Laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis in a patient with situs inversus totalis: A case report.

Situs inversus complicates diagnosis and treatment due to the mirrored organ placement in relation to normal anatomy. This report describes a 78-year-old female patient with situs inversus totalis who underwent laparoscopic cholecystectomy and laparoscopic common bile duct exploration for cholecystolithiasis and choledocholithiasis. Utilizing the "French mirror technique" for port placement, the surgeon adeptly mirrored standard maneuvers with a 2-mm needle forceps in the left hand and a 5-mm forceps in the right in a reversed anatomical setting. This technique maintained familiar hand movements, despite the patient's unique anatomy. The surgeon applied transcystic ductal bile duct exploration, using choledochoscopy for duct exploration and a basket catheter for stone removal. Laparoscopic cholecystectomy and common bile duct exploration through the transcystic ductal route are viable and effective for patients with situs inversus.

Application of a novel surgical difficulty grading system during laparoscopic cholecystectomy.

BACKGROUND: Prevention of bile duct injury and vasculo-biliary injury while performing laparoscopic cholecystectomy (LC) is an unsolved problem. Clarifying the surgical difficulty using intraoperative findings can greatly contribute to the pursuit of best practices for acute cholecystitis. In this study, multiple evaluators assessed surgical difficulty items in unedited videos and then constructed a proposed surgical difficulty grading. METHODS: We previously assembled a library of typical video clips of the intraoperative findings for all LC surgical difficulty items in acute cholecystitis. Fifty-one experts on LC assessed unedited surgical videos. Inter-rater agreement was assessed by Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS: Except for one item ("edematous change"), κ or AC exceeded 0.5, so the typical videos were judged to be applicable. The conceivable surgical difficulty gradings were analyzed. According to the assessment of difficulty factors, we created a surgical difficulty grading system (agreement probability = 0.923, κ = 0.712, 90% CI: 0.587-0.837; AC2  = 0.870, 90% CI: 0.768-0.972). CONCLUSION: The previously published video clip library and our novel surgical difficulty grading system should serve as a universal objective tool to assess surgical difficulty in LC.

Intraoperative holography navigation using a mixed-reality wearable computer during laparoscopic cholecystectomy.

BACKGROUND: Mixed-reality technology, a new digital holographic image technology, is used to present 3-dimensional (3D) images in the surgical space using a wearable mixed-reality device. This study aimed to assess the safety and efficacy of laparoscopic cholecystectomy using a holography-guided navigation system as an intraoperative support image.In this prospective observational study, 27 patients with cholelithiasis or mild cholecystitis underwent laparoscopic cholecystectomy between April 2020 and November 2020. Nine patients underwent laparoscopic cholecystectomy with 3D models generated by a wearable mixed-reality device (laparoscopic cholecystectomy with 3D models) and 18 underwent laparoscopic cholecystectomy with conventional two-dimensional images (laparoscopic cholecystectomy with 2D images) as surgical support images. Surgical outcomes such as operative time, blood loss, and perioperative complication rate were measured, and a four-item questionnaire was used for subjective assessment. All surgeries were performed by a mid-career and an experienced surgeon. RESULTS: Median operative times of laparoscopic cholecystectomy with 3-dimensional models and 2-dimensional images were 74.0 and 58.0 minutes, respectively. No intraoperative blood loss or perioperative complications occurred. Although the midcareer surgeon indicated that laparoscopic cholecystectomy with 3-dimensional models was "normal" or "easy" compared with 2-dimensional images in all cases, the experienced surgeon rated 3-dimensional models as more difficult in 3 (33%) of 9 cases. CONCLUSION: This study provides evidence that laparoscopic cholecystectomy with 3-dimensional models is feasible. However, the efficacy of laparoscopic cholecystectomy with 3-dimensional models may depend on the surgeon's experience, as indicated by the different ratings provided by the surgeons.

Preoperative diagnosis of a gastric extremely well-differentiated adenocarcinoma: A case report.

INTRODUCTION: Gastric adenocarcinomas with low grade atypia may be difficult to diagnose as gastric cancer by preoperative biopsy. We report an extremely well-differentiated adenocarcinoma (EWDA) of the stomach which appeared like a submucosal tumor diagnosed by preoperative endoscopic submucosal dissection. PRESENTATION OF CASE: A 70-year-old male was referred with a 3-month history of a submucosal-appearing lesion in the gastric wall found on endoscopy. Biopsies of the lesion were performed and were inconclusive for neoplasia. Endoscopic ultrasonography showed a low echoic tumor growing into the fourth layer of the gastric wall. It was difficult to identify the tumor by repeat biopsy. Endoscopic submucosal dissection of the lesion was performed and revealed adenocarcinoma, and laparoscopic total gastrectomy was performed. Histopathologic evaluation showed that the tumor was stage IIA (T3N0M0). There is no recurrence 12 months after resection. DISCUSSION: Gastric EWDAs are rare lesions, accounting for 0.6% of all gastric cancers. It is difficult to diagnose gastric EWDA especially if it appears like a submucosal tumor. This lesion was finally diagnosed by endoscopic submucosal dissection. CONCLUSION: Endoscopic submucosal dissection may facilitate establishing the preoperative diagnosis of a tumor thought to be a gastric EWDA based on its endoscopic appearance and pathological findings.

Pathological complete response after intraperitoneal paclitaxel and systemic combined chemotherapy in a patient with peritoneal metastases from gastric cancer: a case report.

BACKGROUND: Despite recent progress in systemic chemotherapy, the prognosis of patients with peritoneal metastases from gastric cancer is still poor. Efficacious intraperitoneal and systemic combination chemotherapy regimens to treat patients with peritoneal metastases have recently been developed. CASE PRESENTATION: A 74-year-old man with gastric cancer T4b (transverse mesocolon) N3 M1 (peritoneum) received combination chemotherapy with intraperitoneal administration of paclitaxel, intravenous oxaliplatin, and oral S-1. Eight courses of combined chemotherapy had remarkable anti-tumor effects on the primary lesion, lymph node metastases, and peritoneal metastases. Total gastrectomy with regional lymph node dissection was performed. Pathological examination revealed no viable tumor cells in the resected specimens. After gastrectomy, the patient received 25 courses of the same chemotherapy without oxaliplatin and has no evidence of recurrence 24 months later. DISCUSSION: Therapeutic approaches including systemic chemotherapy, extended resection, and heated intraperitoneal chemotherapy have been used to treat patients with peritoneal metastases. Repeat therapy with intraperitoneal paclitaxel has been used recently. Intraperitoneal administration of paclitaxel results in prolonged retention in the peritoneal cavity with effects against peritoneal metastases. Repeated administration of paclitaxel does not cause adhesions in the peritoneal cavity. When combination chemotherapy is effective, salvage gastrectomy is a promising option with minimal morbidity and mortality. CONCLUSION: Combined chemotherapy with intraperitoneal paclitaxel and systemic chemotherapy followed by gastrectomy is a promising strategy for patients with advanced gastric cancer and peritoneal metastases.

Combined subtotal gastrectomy and splenectomy after partial splenic embolization for a patient with gastric cancer and immune thrombocytopenic purpura: A case report.

INTRODUCTION: Immune thrombocytopenic purpura is an acquired thrombocytopenia. Preoperative management of thrombocytopenia is important in patients with gastric cancer. Partial splenic embolization can be effective for patients with thrombocytopenia, but could lead to ischemic necrosis of the remnant stomach when performing subtotal gastrectomy with splenectomy. PRESENTATION OF CASE: The patient is an 84-year old woman evaluated for anemia. Endoscopy revealed an advanced gastric cancer with bleeding. The patient also had immune thrombocytopenic purpura with a platelet count <50,000/µL. Administration of platelets did not increase the platelet count. Partial splenic embolization was performed followed by administration of high-dose immunoglobulin. The platelet count was over 50,000/µL preoperatively. The patient underwent combined subtotal gastrectomy and splenectomy, followed by an uneventful course. DISCUSSION: Patients with immune thrombocytopenic purpura and advanced gastric cancer can have anemia. Partial splenic embolization has been used to treat patients with refractory immune thrombocytopenic purpura as an alternative to splenectomy. Preoperative partial splenic embolization and high-dose immunoglobulin therapy resulted an increased platelet count in this patient. Elderly patients with gastric cancer have a high risk of postoperative complications. Patients with gastric cancer undergoing total gastrectomy have an impaired postoperative quality of life compared to those who undergo subtotal gastrectomy. We performed a subtotal gastrectomy and splenectomy as a function-preserving operation, completed safely by maintaining blood flow to the remnant stomach. CONCLUSION: Partial splenic embolization is effective for patients with immune thrombocytopenic purpura and gastric cancer. Combined subtotal gastrectomy and splenectomy is achieved by preserving blood flow to the remnant stomach.

Maternal impacts and perinatal outcomes after three types of bariatric surgery at a single institution.

PURPOSE: Bariatric surgery is widely known to improve pregnancy outcomes and to increase the risk of having small for gestational age neonates. However, the specific causes of neonatal growth restriction are still unclear. This study aimed to investigate the impacts of bariatric surgery on pregnancy and perinatal status at a single institution. METHODS: 24 women delivered singleton births among the 193 reproductive-aged women who underwent bariatric surgery. We classified the surgery into three types: laparoscopic adjustable gastric banding (LAGB; n = 6), laparoscopic sleeve gastrectomy (LSG; n = 5), and malabsorptive surgery (MS; n = 13), and investigated the pregnancy complications and perinatal impacts. RESULTS: The median maternal weight gain after LAGB was 12.5 kg (LSG 6.9 kg, MS 9.0 kg). Gestational hypertension was observed in half of the women who underwent LAGB, but in none of those who underwent MS. No significant difference in neonatal birth weight was observed between the LAGB (median 3272 g) and LSG (median 3005 g) groups. The maternal impact after MS was a remarkable decrease in hemoglobin during prepregnancy (median 1.9 g/dl). About 69% of women developed gestational anemia after MS, and their neonatal birth weight was the lowest (median 2660 g). However, the birth weight of neonates delivered by mothers without anemia after undergoing MS was similar to that of those delivered by mothers after undergoing other types of bariatric surgery (median 3037 g). CONCLUSIONS: Maternal anemia after MS may lead to low neonatal birth weight, which could be attributed to the large-scale reduction in maternal micronutrient levels.

Correction to: Preoperative Weight Loss and Operative Outcome After Laparoscopic Sleeve Gastrectomy.

In Table 2 on p. 2517 the heading for Group 3 should read as follows.

Non-exposed endoscopic wall-inversion surgery for pediatric gastrointestinal stromal tumor: A case report.

Gastrointestinal stromal tumors (GIST) in patients under 18 years of age are classified as pediatric GIST. Pediatric GIST are extremely rare, and there are no reports of laparoscopic-endoscopic cooperative surgery for these lesions. We report the use of non-exposed endoscopic wall-inversion surgery as a laparoscopic-endoscopic cooperative surgery-related procedure for the treatment of a pediatric GIST. The case involved a 17-year-old male patient who presented with anemia and was found to have a bleeding gastric tumor. The tumor was resected transorally using the non-exposed endoscopic wall-inversion surgery technique. No gene mutation of c-Kit or Platelet-Derived Growth Factor Receptor α (PDGFRα) was found, and the final pathological diagnosis was epithelial-type GIST due to a succinate dehydrogenase abnormality. Follow-up included a CT scan every 4 months. No recurrence has occurred to date.

A black adrenal adenoma with high FDG uptake on PET/CT scan in a patient with esophageal carcinoma: A case report.

INTRODUCTION: Black adrenal adenoma (BAA) is a rare, benign adrenal lesion with a black or brown appearance. This is the first report of this lesion in a patient with a synchronous esophageal cancer and highlights the importance of considering a false positive finding on a Positron Emission Tomography (PET) scan, which might otherwise preclude resection. PRESENTATION OF CASE: A 73-year-old male was diagnosed with mid-esophagus carcinoma. Computed tomography scan revealed an enlarged left adrenal gland. Plasma adrenocorticotropic hormones levels were normal. To characterize the adrenal lesion, a PET scan was obtained which showed high uptake of 18F-fluoro-2-deoxy-d-glucose (FDG), consistent with a metastasis, suggesting T3N2M1, clinical stage IV esophageal cancer. After two courses of neo-adjuvant therapy, sub-total esophagectomy and left adrenalectomy were performed. The adrenal tumor was soft, and black in color, diagnosed as a BAA on histology. The pathologic stage of the esophageal cancer was T3N0M0, Stage II. Six months after surgery, he is alive without recurrence. DISCUSSION: High FDG uptake by an adrenal lesion on PET scan, as in this patient, usually suggests a metastatic lesion. Although rare, patients with esophageal cancer and adrenal metastases have been reported to have long-term survival, so it is important to characterize an adrenal lesion when found. CONCLUSION: Most adrenal lesions with high FDG uptake are malignant, but BAA is also positive on PET scan. Although rare, BAA should be considered in patients with solitary adrenal lesions with high uptake on PET scan, even in the presence of a malignancy.

Low density neutrophils (LDN) in postoperative abdominal cavity assist the peritoneal recurrence through the production of neutrophil extracellular traps (NETs).

Many types of immune cells appear in peritoneal cavity after abdominal surgery. In patients who underwent laparotomy due to gastric cancer, peritoneal lavages were obtained before and after surgical procedure. Cells were recovered from intermediate layer after Ficoll-Hypaque centrifugation and analyzed for phenotypes and functions, especially focused on low density neutrophils (LDN). The number of CD66b (+) LDN with mature phenotype was markedly elevated in postoperative as compared with preoperative lavages. Short term culture of the purified LDN produced many threadlike structures positive for SYTOX, nucleic acid staining, as well as histone and myeloperoxidase, suggesting the NETs formation. Human gastric cancer cells, MKN45, OCUM-1 and NUGC-4, were selectively attached on the NETs, which was totally abolished by the pretreatment of DNAse I. Intraperitoneal (IP) co-transfer of the LDN with MKN45 in nude mice strongly augments the metastasis formation on peritoneum, which was strongly suppressed by the following IP administration of DNAse I. Many NETs-like structures were detected on the surface of human omental tissue resected by gastrectomy. NETs on peritoneal surface can assist the clustering and growth of free tumor cells disseminated in abdomen. Disruption of the NETs by DNAse might be useful to prevent the peritoneal recurrence after abdominal surgery.

Preoperative Weight Loss and Operative Outcome After Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Use of a preoperative diet before bariatric surgery to improve postoperative complications and weight loss has been reported. However, evidence supporting this diet for laparoscopic sleeve gastrectomy (LSG) is insufficient. We aimed to investigate postoperative outcomes influenced by preoperative diet before LSG. METHODS: This study included 247 patients who underwent LSG after preoperative weight management. They were classified according to preoperative weight changes (group 1, weight gain; group 2, 0-3.0% total weight loss (TWL); group 3, 3.1-5.0% TWL; group 4, >5.1% TWL) and investigated for early postoperative complications and weight loss at 1 year. RESULTS: There were 37 patients in group 1, 79 in group 2, 64 in group 3, and 67 in group 4. There were no statistical differences in initial physical status among the 4 groups. The median BMI declined to 27.6 kg/m2 in the entire group. Although the average %TWL during the combined preoperative and postoperative periods showed no statistical differences (P = 0.69), the average %TWL during the postoperative period decreased gradually as the extent of preoperative weight loss increased (P = 0.01). The early postoperative complication rate for the entire group was 6.9%; it tended to be lower as the extent of preoperative weight loss increased. However, a multiple logistic regression model demonstrated that the preoperative diet was not a statistical predictor of reduced early postoperative complications (P = 0.28). CONCLUSION: The extent of preoperative weight loss statistically affected postoperative weight loss. A preoperative diet might have minor advantages in reducing the risk of early postoperative complications.

Long-Term Outcomes of Bariatric and Metabolic Surgery in Japan: Results of a Multi-Institutional Survey.

BACKGROUND: The number of bariatric procedures performed in Japan is increasing. There are isolated reports of bariatric surgery, but there have been no nationwide surveys including long-term data. METHODS: We retrospectively reviewed data for patients who underwent bariatric and metabolic surgery throughout Japan and reviewed outcomes. Surveys were sent to ten institutions for number of procedures, preoperative patient weight and preoperative obesity-related comorbidities, and data at 1, 3, and 5 years postoperatively. Improvement of type 2 diabetes mellitus at 3 years after surgery was stratified by baseline ABCD score, based on age, body mass index, C-peptide level, and duration of diabetes. RESULTS: Replies were received from nine of the ten institutions. From August 2005 to June 2015, 831 patients, including 366 males and 465 females, underwent bariatric procedures. The mean age was 41 years, and mean BMI was 42 kg/m2. The most common procedure was laparoscopic sleeve gastrectomy (n = 501, 60 %) followed by laparoscopic sleeve gastrectomy with duodenojejunal bypass (n = 149, 18 %). Laparoscopic Roux-en-Y gastric bypass was performed in 100 patients (12 %), and laparoscopic adjustable gastric banding was performed in 81 (10 %). At 3 years postoperatively, the remission rate of obesity-related comorbidities was 78 % for diabetes, 60 % for hypertension, and 65 % for dyslipidemia. Patients with complete remission of diabetes at 3 years postoperatively had a higher ABCD score than those without (6.4 ± 1.6 vs 4.2 ± 2.0, P < 0.05). CONCLUSIONS: Bariatric and metabolic surgery for Japanese morbidly obese patients is safe and effective. These results are comparable with the results of previous studies.

Five-Year-Results of Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass for Weight Loss and Type 2 Diabetes Mellitus.

BACKGROUND: Laparoscopic sleeve gastrectomy with duodenojejunal bypass (LSG-DJB) has been designated as a novel bariatric surgery procedure. This combination of sleeve gastrectomy and proximal intestinal bypass theoretically offers an effective and prolonged anti-diabetes effect. This is a follow-up of our institution's previous report on the short-term effects of LSG-DJB on type 2 diabetes mellitus (T2DM), which a 68.7 % remission (HbA1c <6 % without diabetes medication) rate 1 year after surgery. The aforementioned result was comparable to the reported remission rates of laparoscopic Roux-en-Y gastric bypass. However, the durability of remission remains unknown. OBJECTIVE: The objective of this study is to investigate the medium-term (up to 5 years) effects of LSG-DJB on weight loss and T2DM. METHODS: In this analysis, consecutive 120 patients (female to male ratio = 61:59, mean age = 44.8 years) with T2DM who underwent LSG-DJB from April 2007 to November 2013 and were followed up beyond 1 year were included. The preoperative mean body weight and BMI were 105.7 kg and 38.5 kg/m2, respectively. The mean HbA1c and fasting blood glucose values were 8.9 % and 194 mg/dL, respectively. The mean duration of T2DM was 7.3 years. Fifty-five patients (46 %) were being treated with insulin prior to surgery. RESULTS: The follow-up rate was 97.5 % at 1 year, 73.3 % at 3 years, and 50.0 % at 5 years. The mean body weight was 74.9 kg at 1 year, 76.8 kg at 3 years, and 72.8 kg at 5 years (p < 0.001, compared to the baseline). The mean percent of total body weight loss (%TWL) was 28.9, 28.6, and 30.7 % at 1, 3, and 5 years, respectively. Remission of T2DM was achieved at 63.6, 55.3, and 63.6 % at 1, 3, and 5 years, respectively. Among those who achieved diabetes remission at 1 year, 10.8 % of them experienced recurrence during the subsequent follow-up period. CONCLUSION: Although recurrence of T2DM is observed in some patients over time, LSG-DJB is an effective procedure for achieving significant weight loss and improvement of glycemic control, and the effects seem to be durable up to 5 years.

Boerhaave's syndrome in a patient with an upside down stomach: A case report.

INTRODUCTION: Spontaneous esophageal perforation, or Boerhaave's syndrome, is a life-threating condition which usually requires emergent surgery. An upside down stomach is defined as a gastric volvulus in a huge supradiaphragmatic sac. In general, this condition can result in ischemia and perforation of the stomach. This is the first report of a patient with Boerhaave's syndrome and an upside down stomach. CASE PRESENTATION: A 79-year-old woman presented with sudden epigastric pain following hematemesis. Evaluation of the patient showed both an esophageal perforation and an upside down stomach. Surgical drainage and irrigation of the mediastinum and pleural cavities were undertaken emergently. Due to the concurrent gastric volvulus, a gastrostomy was placed to fix and decompress the stomach. The patient had an uneventful hospital course and was discharged. DISCUSSION AND CONCLUSION: Boerhaave's syndrome is a rare but severe complication caused by excessive vomiting, due to a sudden elevation in intraluminal esophageal pressure resulting in esophageal perforation. Acute gastric volvulus can result in ischemia and perforation of the stomach, but has not previously been reported with esophageal perforation. The most likely mechanism associating an upside down stomach with Boerhaave's syndrome is acute gastric outlet obstruction resulting in vomiting, and subsequent esophageal perforation. Perforation of the esophagus as well as perforation of the stomach must be considered in patients with an upside down stomach although both upside down stomach and Boerhaave's syndrome are rare clinical entities.

Stenosis after use of the double-stapling technique for reconstruction after laparoscopy-assisted total gastrectomy.

BACKGROUND: The double-stapling technique (DST) for esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien Japan, Tokyo, Japan) is one of the reconstruction methods used after laparoscopy-assisted total gastrectomy (LATG). This technique has potential advantages in terms of less invasive surgery without the need to create a complicated intraabdominal anastomosis. METHODS: From 2008 to 2011, 262 patients with gastric cancer underwent total gastrectomy and reconstruction with a Roux-en-Y anastomosis, and 52 patients underwent LATG with DST. A retrospective analysis then was performed comparing the patients who experienced postoperative stenosis after LATG-DST (positive group) and the patients who did not (negative group). A comparative analysis was performed among patients comparing conventional open total gastrectomy and LATG, and multivariate analysis was performed to evaluate risk factors for the development of anastomotic stenosis. RESULTS: A minor leak was found in 1 patient (1.9 %), and 11 patients experienced anastomotic stenosis (21 %) after LATG with DST. Among the patients with anastomotic stenosis, three (3/4, 75 %) anastomoses were performed with the 21-mm end-to-end anastomosis (EEA) stapler, and eight anastomoses were performed (8/47, 17 %) with the 25-mm EEA stapler. The median interval to the diagnosis of anastomotic stenosis was 43 days after surgery. The patients with stenosis needed endoscopic balloon dilation an average of four times, and the rate of perforation after dilation was 13 %. The clinical and operative characteristics did not differ between the two groups. Anastomotic stenosis after open total gastrectomy occurred in two cases (0.98 %). Multivariate analysis showed that the size of the EEA stapler and the use of DST were risk factors for anastomotic stenosis. CONCLUSION: Esophagojejunostomy using DST with OrVil is useful in performing a minimally invasive procedure but carries a high risk of anastomotic stenosis.

Barrett's esophageal carcinoma consisting of undifferentiated carcinoma and differentiated adenocarcinoma: report of case.

We report on a 53-year-old male with esophageal cancer. He had no evidence of distant metastasis, and received a subtotal esophagectomy. Histopathologically, the tumors were contiguous with Barrett's epithelium. Undifferentiated carcinoma components existed independently of differentiated adenocarcinoma components. Undifferentiated carcinoma was present proximal to the esophagogastric junction. Both tumors had invaded the submucosa and were associated with a prominent lymphoid stroma. Metastasis from undifferentiated carcinoma was found in the paraesophageal lymph nodes. Immunohistochemically, both components were negative for 34bE12 and positive for CAM5.2 and showed nearly identical staining patterns for p53, indicating that the tumors were derived from Barrett's epithelium. Because the undifferentiated carcinoma did not express CK20 or carcinoembryonic antigen, the properties of adenocarcinoma had apparently been lost during the process of tumor cell progression. This is the first report of undifferentiated carcinoma associated with Barrett's esophagus with adenocarcinoma.

A clinicopathological and immunohistochemical study of gastric cancer with squamous cell carcinoma components: a clinically aggressive tumor.

OBJECTIVE: Adenosquamous carcinoma originating in the stomach is an unusual neoplasm with few existing histological studies. This study was aimed to gain insight into the histogenetic and clinicopathological characteristics of gastric cancer with squamous cell carcinoma (SCC) components. METHODS: From January 2001 to June 2010 a total of 1735 patients underwent a resection of gastric cancer. Histopathologically, eight patients had adenocarcinoma containing SCC components, in which the proportion of SCC components was above 25% of the total tumor mass in four patients. The immunohistochemical and clinicopathological characteristics of these eight patients were analyzed. RESULTS: The median survival duration was 22 months. Adenocarcinoma was present at the superficial layer of all tumors and SCC was primarily present at sites with deep invasion. Immunohistochemically, adenocarcinoma components were positive for cytokeratin (CK) 8/18/19 and CK7 in all cases. SCC components were positive for carcinoembryonic antigen and CK7 in more than 60% of patients. Expression patterns of p53 product were identical in both components. SCC components were positive for 34ßE12 and adenocarcinoma components were negative for 34ßE12 in all patients. CONCLUSIONS: SCC components are derived from squamous metaplasia in a pre-existing adenocarcinoma. A gastric adenocarcinoma with SCC components is associated with various patterns of metastasis and both SCC and adenocarcinoma components have the potential for metastasis. Gastric cancer with SCC components is a clinically aggressive tumor.