Cyclic Hypervalent Iodine-Induced Oxidative Phenol and Aniline Couplings with Phenothiazines.

C-H/N-H bond functionalization for direct intermolecular aryl C-N couplings is a useful synthetic process. In this study, we achieved metal-free cross-dehydrogenative coupling of phenols and anilines with phenothiazines using hypervalent iodine reagents. This method affords selective amination products under mild conditions. Electron-rich phenols and anilines could be employed, affording moderate-to-high yields of N-arylphenothiazines. Aniline amination proceeded efficiently at 20 °C, a previously unreported phenomenon.

Detection of Shunting Into Pulmonary Artery on Multidetector Row Computed Tomography Arteriography Before Bronchial Arterial Embolization: A Preliminary Study.

OBJECTIVE: The aim of this study was to investigate the diagnostic performance of detecting systemic arterial pulmonary circulation shunts on multidetector row computed tomography arteriography (MDCTA). METHODS: Thirty-five consecutive bronchial artery embolization sessions with preprocedural MDCTA were performed for 32 patients and 35 sessions. The MDCTA studies with computed tomography value of pulmonary trunk visually lower than that of ascending aorta were defined as "diagnostic MDCTA." Angiographic studies and "diagnostic MDCTA" were evaluated, respectively, for shunting into pulmonary artery. Based on the results of angiographic studies, diagnostic performance of "diagnostic MDCTA" was evaluated. RESULTS: The rate of diagnostic MDCTA was 63% (23 of 35). On "diagnostic MDCTA," sensitivity, specificity, and positive and negative predictive values for detecting shunts were 83% 100%, 100%, 94%, respectively. CONCLUSIONS: Systemic arterial pulmonary circulation shunts were detected on "diagnostic MDCTA" with high sensitivity and specificity.

Amyotrophic lateral sclerosis associated with pleuroparenchymal fibroelastosis.

An autopsy case of sporadic amyotrophic lateral sclerosis (ALS) associated with pleuroparenchymal fibroelastosis (PPFE), a rare form of idiopathic interstitial pneumonia, is reported. The patient, a 76-year-old man, presented with shortness of breath and dyspnea and died of progressive respiratory failure after a clinical course of 9 months. Muscle weakness and motor disturbance were mild, and the diagnosis of ALS was not established until one month prior to death. He had serum IgM-kappa monoclonal gammopathy (IgM: 1,232 mg/dL). Autopsy demonstrated ALS of the lower neuron-predominant type. The density of motor neurons in the spinal anterior horn showed a moderate decline, and many remaining neurons contained round inclusions that were immunoreactive for pTDP-43 (phosphorylated transactivation responsive DNA-binding protein of 43 kD) and ubiquitin. Betz cells and the pyramidal tracts were well preserved. The lung showed typical features of PPFE predominantly affecting the upper lobe: fibro-hyalinous thickening of the visceral pleura, a marked increase and aggregation of elastic fibers in the subpleural zone, and intra-alveolar collagenous fibrosis with an increase of elastic fibers in the alveolar septa. Although the complications from interstitial lung diseases including PPFE in ALS patients are usually regarded as incidental, PPFE is clinically important because of its markedly adverse influence on the clinical course. IgM-monoclonal gammopathy is another notable finding in the present case, which is occasionally seen in ALS patients, and the pathogenesis of PPFE is also considered to be associated with immunological derangements.

Validation of an assessment tool: Estimation of Postoperative Overall Survival for Gastric Cancer.

BACKGROUND: Benchmarking of long-term surgical outcomes has rarely been attempted. We previously devised a prediction model for assessing the outcome of late survival after surgery, termed the Estimation of Postoperative Overall Survival for Gastric Cancer (EPOS-GC). This study was undertaken to validate EPOS-GC in an external data set. METHODS: A retrospective cohort study was conducted in 11 cancer care hospitals in Japan, analyzing a consecutive series of patients who underwent elective gastric cancer resection between April 2007 and March 2009. EPOS-GC consists of three tumor-related variables and three physiological variables. The primary endpoint was postoperative overall survival. The observed-to-expected (O/E) ratio of 5-year survival rates was defined as a metric of quality of care. The sample size for O/E was determined as 42. RESULTS: We included 2045 patients for analysis. The median (95% confidence interval) follow-up time was 5.1 (1.2-6.8) years for censored patients. Although EPOS-GC demonstrated a good discriminative power (Harrell's C-index, 95% confidence interval: 0.80, 0.79-0.83), the calibration plot revealed that EPOS-GC underestimated 5-year survival rates in the high-risk group. Therefore, we recalibrated the model with Cox's regression analysis. The recalibrated EPOS-GC showed a good calibration, preserving the high discriminative power (C-index, 95% confidence interval: 0.80, 0.78-0.82). The O/E among hospitals according to the recalibrated EPOS-GC ranged between 0.87 and 1.27. The O/E correlated with hospital volumes (Spearman's correlation = 0.76, n = 11, p = .006). CONCLUSION: EPOS-GC with recalibration can convey risk-adjusted quality assurance regarding late survival following gastric cancer resection.

Preliminary Results: Can Dual-Energy Computed Tomography Help Distinguish Cardiogenic Pulmonary Edema and Acute Interstitial Lung Disease?

OBJECTIVE: We compared iodine concentration in pulmonary ground-glass opacity on iodine density images of contrast-enhanced chest dual-energy computed tomography (DECT) between patients with cardiogenic pulmonary edema (CPE) and acute interstitial lung disease (AILD). METHODS: Five of 12 patients who underwent contrast-enhanced chest DECT to exclude pulmonary embolism were clinically diagnosed with CPE and 7, with AILD. We compared the mean CT value on monochromatic images at 65 keV and iodine concentration on iodine density images between the affected and normal areas. RESULTS: The mean iodine concentrations were comparable between the affected and normal areas (P = 0.3048) in patients with CPE and were significantly higher in the affected than in the normal areas in those with AILD (P < 0.0001). CONCLUSIONS: Measurement of iodine concentration in pulmonary ground-glass opacity of contrast-enhanced chest DECT has the potential to help distinguish CPE and AILD.

Preoperative Risk Factors for Conversion of Laparoscopic Cholecystectomy to Open Cholecystectomy and the Usefulness of the 2013 Tokyo Guidelines.

To identify predictive factors for conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy performed for mixed indications as an acute or elective procedure. We retrospectively analyzed the data of 236 consecutive cases of LC performed in our department between January 2012 and January 2015, and evaluated preoperative risk factors for conversion and the usefulness of the 2013 Tokyo guidelines (TG2013) for diagnosing acute cholecystitis. The conversion rate in our series was 8% (19/236 cases). The following independent predictive factors of conversion were identified (p≤0.04): previous upper abdominal surgery (odds ratio (OR), 14.6), pericholecystic fluid (OR, 10.04), acute cholecystitis (OR, 7.81), and emergent LC (OR, 15.8). Specifically for patients with acute cholecystitis defined using the 2013 Tokyo guidelines, use of an antiplatelet or anticoagulant drug for cardiovascular disease (p=0.043), previous upper abdominal surgery (p<0.031) and a resident as operator (p=0.041) were predictive factors. The risk factors for conversion identified herein could help to predict the difficulty of the procedure and could be used by surgeons to better inform patients regarding the risks for conversion. The TG2013 can be an effective tool for diagnosing acute cholecystitis to make informed clinical decisions regarding the optimal procedure for a patient.

Metachronous colorectal carcinoma with massive submucosal invasion detected by annual surveillance in a Lynch syndrome patient: a case report.

BACKGROUND: Lynch syndrome is the most common form of hereditary colorectal carcinoma. It is characterized by the presence of germline mutations in DNA mismatch repair genes. Mutation carriers have a lifetime risk of developing colorectal carcinoma of approximately 80%. Current treatment guidelines recommend periodic surveillance for colorectal carcinoma in patients with Lynch syndrome. However, the optimal interval between colonoscopies has not yet been determined. CASE PRESENTATION: We describe a 54-year-old man with Lynch syndrome who was undergoing annual colonoscopy surveillance for the development of colorectal carcinoma. At 54, 57, 59, and 60 years old, a colonoscopy showed high-grade dysplasia and adenoma. Therefore, endoscopic mucosal resection was performed. At 61 years old, a colonoscopy showed metachronous colorectal carcinoma with massive submucosal invasion. He subsequently underwent laparotomy for colorectal carcinoma. CONCLUSIONS: Annual surveillance using colonoscopy can detect colorectal carcinoma at an early stage, leading to reduced mortality. However, some patients might require a laparotomy, as was the case here. More frequent colonoscopic surveillance might be necessary to avoid surgery for colorectal carcinoma in Lynch syndrome patients with multiple risk factors for interval cancer.

Synchronous coexistence of liver metastases from cecal leiomyosarcoma and rectal adenocarcinoma: A case report.

Multiple liver tumors represent a challenging condition for abdominal surgeons both in the selection of technique and the rarity of diagnosis. There are no case reports on co-existence of liver metastases from both intestinal leiomyosarcoma and adenocarcinoma. The patient described in this report successfully underwent resection of both primary lesions and liver metastases in combination with chemotherapy. As for the leiomyosarcoma, the primary cecal lesion was revealed more than three years after the patient's first visit. Peritoneal, lymph-node, and lung recurrences were observed afterward, and thus surgeries on those regions were performed. Pathologically, the peritoneal and lung recurrences comprised leiomyosarcoma and the lymph-node recurrence was diagnosed as adenocarcinoma. Despite newly discovered multiple lung recurrences and regional lymph-node metastases, the patient lived a normal life for 73 mo after the initial operation based on multidisciplinary therapy. He ultimately died of liver failure due to invasive lymph-node recurrence from the rectal adenocarcinoma, in addition to multiple lung recurrences from the leiomyosarcoma. Hepatic recurrence did not occur in this patient's case, which appears to be one reason for his long-term survival.

Evaluation of surgical treatment for incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy: single center results.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the accepted standard management for benign gallbladder disease. LC rarely results in a diagnosis of incidental gallbladder carcinoma (IGBC). The aim of our study was to report our experience with IGBC diagnosed during or following LC. METHODS: Between January 2008 and January 2015, 352 patients underwent LC at Iwakuni Clinical Center. Among these patients, 8 (2.3%) were diagnosed with IGBC. We evaluated their characteristics, surgical related variables, histopathological findings and surgical outcomes. RESULTS: Patient median age was 71 (range 49-88) years, and 3 out of 8 were female. All patients with IGBC were Japanese. The grade of cancer was as follows: pT1a (3 cases), pT2 (4 cases) and pT3 (1 case). Two patients with pT2 disease underwent radical surgery. The median follow-up time of these patients was 24 (range 11-80) months. All patients are still alive and two of three patients who refused radical surgery have developed recurrence (liver metastases and recurrence in the peritoneum). CONCLUSIONS: Although the number of cases was small, the results of this study further support the suggestion that gallbladder carcinoma may be curable if diagnosed as IGBC at an early stage. If the cancer has reached an advanced stage, radical surgery should be performed.

Granulocyte Colony-Stimulating Factor-Producing Gallbladder Cancer.

We report a case of a granulocyte colony-stimulating factor (G-CSF)-producing gallbladder tumor associated with fever in a middle-aged female. Preoperative blood analysis showed leukocytosis with elevated levels of C-reactive protein and G-CSF. We resected the liver at S4a＋S5, with regional lymph node dissection and partial resection of the duodenum. Histology revealed undifferentiated carcinoma with spindle and giant cells and papillary adenocarcinoma. Immunohistochemistry revealed Stage IIIB G-CSF-producing gallbladder cancer. Postoperatively, leukocyte and serum G-CSF levels decreased to within normal limits. Adjuvant gemcitabine chemotherapy was administered for 16 months, and she has been recurrence-free for 48 months.

Changes over time in milk test results following pancreatectomy.

AIM: To investigate changes over time in, and effects of sealing technology on, milk test results following pancreatectomy. METHODS: From April 2008 to October 2013, 66 pancreatic resections were performed at the Iwakuni Clinical Center. The milk test has been routinely conducted at the institute whenever possible during pancreatectomy. The milk test comprises the following procedure: A nasogastric tube is inserted until the third portion of the duodenum, followed by injection of 100 mL of milk through the tube. If a chyle leak is present, the patient tests positive in this milk test based on the observation of a white milky discharge. Positive milk test rates, leakage sites, and chylous ascites incidence were examined. LigaSure™ (LS; Covidien, Dublin, Ireland), a vessel-sealing device, is routinely used in pancreatectomy. Positive milk test rates before and after use of LS, as well as drain discharge volume at the 2(nd) and 3(rd) postoperative days, were compared retrospectively. Finally, positive milk test rates and chylous ascites incidence were compared with the results of a previous report. RESULTS: Fifty-nine milk tests were conducted during pancreatectomy. The positive milk test rate for all pancreatectomy cases was 13.6% (8 of 59 cases). One case developed postoperative chylous ascites (2.1% among the pancreatoduedenectomy cases and 1.7% among all pancreatectomies). Positive rates by procedure were 12.8% for pancreatoduodenectomy and 22.2% for distal pancreatectomy. Positive rates by disease were 17.9% for pancreatic and 5.9% for biliary diseases. When comparing results from before and after use of LS, positive milk test rates in pancreatoduodenectomy were 13.0% before and 12.5% after, while those in distal pancreatectomy were 33.3% and 0%. Drainage volume tended to decrease when LS was used on the 3(rd) postoperative day (volumes were 424 ± 303 mL before LS and 285 ± 185 mL after, P = 0.056). Both chylous ascites incidence and positive milk test rates decreased slightly compared with those rates from the previous study. CONCLUSION: Positive milk test rates and chylous ascites incidence decreased over time. Sealing technology may thus play an important role in preventing postoperative chylous ascites.

Value of E-PASS models for predicting postoperative morbidity and mortality in resection of perihilar cholangiocarcinoma and gallbladder carcinoma.

BACKGROUND: It has previously been reported that a general risk model, Estimation of Physiologic Ability and Surgical Stress (E-PASS), and its modified version, mE-PASS, had a high predictive power for postoperative mortality and morbidity in a variety of gastrointestinal surgeries. This study evaluated their utilities in proximal biliary carcinoma resection. METHODS: E-PASS variables were collected in patients undergoing resection of perihilar cholangiocarcinoma and gallbladder carcinoma in Japanese referral hospitals. RESULTS: Analysis of 125 patients with gallbladder cancer and 97 patients with perihilar cholangiocarcinoma (n = 222). Fifty-six patients (25%) underwent liver resection with either hemihepatectomy or extended hemihepatectomy. The E-PASS models showed a high discrimination power to predict in-hospital mortality; areas under the receiver operating characteristic curve (95% confidence intervals) were 0.85 (0.76-0.94) for E-PASS and 0.82 (0.73-0.91) for mE-PASS. The predicted mortality rates correlated with the severity of postoperative complications (Spearman's rank correlation coefficient: ρ = 0.51, P < 0.001 for E-PASS; ρ = 0.47, P < 0.001 for mE-PASS). CONCLUSIONS: The E-PASS models examined herein may accurately predict postoperative morbidity and mortality in proximal biliary carcinoma resection. These models will be useful for surgical decision-making, informed consent, and risk adjustments in surgical audits.

Surgical resection of splenic metastasis from the adenosquamous gallbladder carcinoma: A case report.

INTRODUCTION: Splenic metastasis of gallbladder carcinoma is extremely rare. Specific anatomical, histological, and functional properties of spleen are believed to be responsible for the rarity of solitary splenic metastasis. PRESENTATION OF CASE: We present the case of a 62-year-old female who developed metachronous splenic metastasis of adenosquamous carcinoma of the gallbladder. We performed central bisegmentectomy of the liver for gallbladder carcinoma. The patient subsequently presented 3 months later with isolated splenic metastasis and liver metastasis. Splenectomy and partial hepatectomy was performed at this time. Histological examination confirmed metastatic adenosquamous carcinoma of the gallbladder. No signs of recurrence were observed at 3 months after the second surgery. DISCUSSION: Although splenectomy provides a potential means of radical treatment in patients with isolated splenic metastases, it should be performed with caution as splenic metastatic lesions may represent the initial clinical manifestation of systemic metastases at multiple sites. In this case, radical surgery was performed following the confirmation of no new unresectable metastatic lesions or systemic dissemination. CONCLUSION: This is the first report on the adenosquamous splenic metastasis from the gallbladder carcinoma. Curative resection may be the treatment of choice for prolonging survival in patients with the splenic metastasis of gallbladder carcinoma.

Preliminary study of surgical audit for overall survival following gastric cancer resection.

BACKGROUND: Previous studies for surgical audit have focused on short-term outcomes, such as perioperative mortality. There has been no gold standard how to evaluate quality of care for long-term outcomes in surgical oncology. This preliminary study aims to propose a method for surgical audit targeting long-term outcome following gastrectomy for gastric cancer. METHODS: We prospectively investigated a set of variables relating to physiologic conditions, tumor characteristics and operations in patients who underwent gastrectomy for gastric cancer between June 2005 and July 2008 in 18 referral hospitals in Japan. Overall survival (OS) is the endpoint. Cox hazard regression analysis was used to generate a model to predict OS. The calibration and discrimination power of the model were assessed using the Hosmer-Lemeshow (H-L) test and area under the receiver-operating characteristic curve (AUC), respectively. The ratio of observed-to-estimated 5-year OS rates (OE ratio) was defined as a measure of quality. RESULTS: Among 762 patients analyzed, 697 (91%) completed the 5-year follow-up. The constructed model for OS exhibited a good discrimination power (AUC, 95% confidence interval 0.89, 0.86-0.91), which was significantly better than that for the UICC stage (0.81, 0.77-0.84). This model also demonstrated a good calibration power (H-L: χ(2) = 27.2, df = 8, P = 0.77). The OE ratios among the participating hospitals revealed no significant variation between 0.74 and 1.1. CONCLUSIONS: The current study suggests the possibility of surgical audit for postoperative OS in gastric cancer. Further studies including high-volume centers will be necessary to validate this idea.

Value of general surgical risk models for predicting postoperative morbidity and mortality in pancreatic resections for pancreatobiliary carcinomas.

BACKGROUND: The present study evaluated the utility of general surgical risk models to predict postoperative morbidity and mortality in the specialty field of pancreatic resections for pancreatobiliary carcinomas. METHODS: We investigated Estimation of Physiologic Ability and Surgical Stress (E-PASS), its modified version (mE-PASS), and Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in 231 patients undergoing pancreatoduodenectomy or distal pancreatectomy (Group A). We also analyzed E-PASS and mE-PASS in another cohort of the same procedures (Group B, n = 313). RESULTS: Areas under the receiver operating characteristic curve (AUC) for detecting in-hospital mortality in Group A were moderate at 0.75 for E-PASS, 0.69 for mE-PASS, and 0.69 for P-POSSUM. The predicted mortality rates of the models significantly correlated with severity of postoperative complications (ρ = 0.17, P = 0.011 for E-PASS; ρ = 0.15, and P = 0.027 for P-POSSUM). The AUCs were also moderate in Group B at 0.68 for E-PASS and 0.69 for mE-PASS. The predicted mortality rates significantly correlated with severity of postoperative complications (ρ = 0.18, P = 0.0018 for E-PASS; ρ = 0.17, and P = 0.0022 for mE-PASS). CONCLUSIONS: The present study suggests that the predictive powers of general risk models may be moderate in pancreatic resections. A novel model would be desirable for these procedures.

Early detection of metachronous bile duct cancer in Lynch syndrome: report of a case.

Lynch syndrome is an autosomal dominant disease associated with a high incidence of colorectal, endometrial, stomach, ovarian, pancreatic, ureter and renal pelvis, bile duct and brain tumors. The syndrome can also include sebaceous gland adenomas and keratoacanthomas, and carcinoma of the small bowel. The lifetime risk for bile duct cancer in patients with Lynch syndrome is approximately 2 %. The present report describes a case of Lynch syndrome with metachronous bile duct cancer diagnosed at an early stage. The patient was a 73-year-old Japanese male who underwent a successful left lobectomy of the liver, and there was no sign of recurrence for 2 years postoperative. However, this patient harbored a germline mutation in MLH1, which prompted diagnostic examinations for noncolorectal tumors when a periodic surveillance blood examination showed abnormal values of hepatobiliary enzymes. Although most patients with bile duct cancer are diagnosed at an advanced stage, the bile duct cancer was diagnosed at an early stage in the present patient due to the observation of the gene mutation and the preceding liver tumor. This case illustrates the importance of continuous surveillance for extracolonic tumors, including bile duct cancer, in patients with Lynch syndrome.

Evaluation of modified estimation of physiologic ability and surgical stress in patients undergoing surgery for choledochocystolithiasis.

BACKGROUND: The incidence of complicated choledochocystolithiasis is increasing with the aging of society in Japan. We evaluated the utility of our prediction rule modified estimation of physiologic ability and surgical stress (mE-PASS) in predicting postoperative adverse events in patients with choledochocystolithiasis. METHODS: A total of 4,329 patients who underwent elective surgery for choledochocystolithiasis in 44 referral hospitals between April 1987 and April 2007 were analyzed for mE-PASS along with postoperative events. The discrimination power of mE-PASS was assessed by the area under the receiver operating characteristic curve (AUC). The correlation between ordinal and interval variables was quantified by the Spearman rank correlation (ρ). The ratio of observed-to-estimated mortality rates (OE ratio) was used as a metric of surgical quality. RESULTS: Postoperative in-hospital mortality rates were 0 % (0/3,442) for laparoscopic cholecystectomy, 0.19 % (1/521) for open cholecystectomy, 1.6 % (1/63) for laparoscopic choledochotomy, 1.1 % (3/264) for open choledochotomy, and 5.1 % (2/39) for plasty or resection of the common bile duct. mE-PASS demonstrated a high discrimination power to predict in-hospital mortality; AUC, 95 % confidence interval (CI) of 0.96, 0.94-0.99. The predicted mortality rates significantly correlated with the severity of postoperative complications (ρ = 0.278, p < 0.0001) and length of hospital stay (ρ = 0.479, p < 0.0001). The OE ratios (95 % CI) improved slightly over time; 1.5 (0.25-9.0) between 1987 and 2000, and 0.40 (0.078-2.1) between 2001 and 2007. CONCLUSIONS: The present study suggests that mE-PASS can predict postoperative risks in patients who have undergone choledochocystolithiasis. mE-PASS may be useful in surgical decision making and evaluating the quality of care.

Spontaneous rupture of a hepatic angiomyolipoma: Report of a case.

A 70-year-old female experienced sudden onset of back pain on the right side and was admitted to our hospital in December 2010. Abdominal computed tomography revealed an S7 hepatic mass measuring 7 cm in diameter accompanied by a subcapsular hematoma. Emergency angiography confirmed the diagnosis of a ruptured hepatic mass, and hemostasis was carried out by embolization of A8 and A7 of the liver. A right hepatic lobectomy was carried out 39 days following transarterial embolization. Although almost all aspects of the tumor were necrotic, residual tumor cells stained positive for HMB-45, and negative for α-SMA, S-100, CD 34, c-kit, CAM 5.2, and hepatocytes. The MIB-1 index was 2 %. Pathological diagnosis was hepatic angiomyolipoma (HAML). The patient has shown no signs of recurrence at 42 months following surgery. Here, we report on this case of spontaneous HAML rupture and discuss therapeutic strategies for HAML and ruptured hepatic tumors.

[Tumor-infiltrating lymphocytes can be used to screen for lynch syndrome - a case report].

Lynch syndrome is an inherited syndrome associated with the development of colorectal and various other cancers. A 65- year-old male underwent a laparoscopic-assisted right hemi-colectomy for ascending colon cancer (cStage II). Histologically, his tumor was diagnosed as a poorly differentiated adenocarcinoma. Lymphocytic reactions, such as tumor-infiltrating lymphocytes (TIL), and Crohn's-like reactions, were observed. Genetic testing revealed the presence of a pathogenic mutation in the MLH1. In the Lynch syndrome, the most frequently observed findings include the accumulation of mutations, and an early onset of familial colon cancer. Although the case presented here did not show the typical clinical findings of Lynch syndrome, histological examination of the lymphocytic reactions proved useful for screening for Lynch syndrome. Herein, we establish the important role of the pathologist in alerting the clinician to the possibility of Lynch syndrome when the findings of TIL and Crohn's-like reactions are detected.

[A case of gastric cancer developed after pylorus-preserving gastrectomy in a patient with lynch syndrome].

Lynch syndrome is an inherited autosomal dominant disorder caused by germ-line mutation of mismatch repair genes, in which a malignant tumor develops at a young age in the colon, endometrium, stomach, or other tissues. A 54-year-old patient with gastric cancer received pylorus-preserving gastrectomy, and a genetic examination confirmed a pathological variation of the MLH1 gene. Five years after surgery, an upper gastrointestinal endoscopy revealed a residual 0 -IIa+IIc gastric tumor approximately 2 cm in size extending from the anastomotic site to the lesser curvature side of the stomach. The remaining stomach was completely removed. The final diagnosis was T1b (SM) N1M0, StageIB gastric cancer. Microsatellite instability was positive, and we attributed the cancer to Lynch syndrome. In Lynch syndrome, the risk of multicentric gastric cancer is higher than normal, and for the initial therapy, preventive total gastrectomy should be considered as an option.