Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas exhibit a wide range of histopathological variation. Epithelial cell adhesion molecule (EpCAM) is a 40 kDa type I membrane protein that is known to be highly expressed in epithelial carcinomas. In this study, we examined immunohistochemical expression of EpCAM in the pancreatic IPMNs in order to clarify its clinicopathological significance. We analyzed 51 cases of surgically resected IPMNs: 32 cases of adenoma; 6 cases of non-invasive carcinoma; 8 cases of minimally invasive carcinoma; and 5 cases of invasive carcinoma. Additionally, these 51 cases were classified into four phenotypes (gastric, intestinal, pancreatobiliary and oncocytic). EpCAM overexpression was found in 16 (31.4%) of the tumor samples. We found five predictive factors of malignancy using the univariate analysis as follows; serum CA19-9 level, main pancreatic duct diameter, presence of mural nodule, phenotype and EpCAM overexpression. In the multivariate analysis, only EpCAM overexpression was identified to be independently associated as a predictive factor for malignancy (odds ratio, 11.039; 95% confidence interval, 1.877-64.919; P-value, 0.008). Our study is the first report to demonstrate that EpCAM overexpression is an independent factor for malignancy; therefore, EpCAM overexpression is thought to be a novel predictor of malignant IPMNs.

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Upside-down stomach (UDS) is a rare type (<5%) of hiatal hernia, often accompanied by organoaxial gastric volvulus. Although surgery is required for most patients, approach method is still controversial. It has been reported that open approach is a standard method in the case of UDS, but recently laparoscopic approach is reported to be useful for the patient without stomach ischemic sign. Here we report the case of UDS successfully treated by laparoscopic surgery. Case presentation: A 57 year-old male patient with hiatal hernia for several years was referred to our institution because of frequent vomiting and UDS. He had no pain and vital signs were stable. Hematological investigations revealed neutrophil dominant elevation of white blood cell count, but CRP was normal in blood biochemistry. An enhanced computed tomography revealed a giant hiatal hernia (Type IV) and whole stomach migrated into posterior mediastinum with organoaxial gastric volvulus, but obviously ischemic signs were not detected. An esophagogastoroduodenoscopy (EGD) showed erosion of gastric mucosa, but no necrotic sign of stomach. From these findings, surgery was thought to be necessary to improve the obstruction of stomach and prevent from necrosis of the incarcerated stomach. However, because of stable general conditions and no ischemic findings, we performed laparoscopic repair of hiatal hernia and Toupet fundopulication. Ischemic change of the stomach was not observed. After stomach withdrawal into the abdominal cavity from the mediastinum, hiatal defect was repaired and fundoplication was performed by Toupet method. After surgery, the symptom and stomach passage obstruction improved and the patient was discharged without no complications. We successfully performed hiatal hernia repair and fundopulication with laparoscopic approach in the case of UDS. If there are no findings obviously indicating gastric ischemia and necrosis on an enhanced computed tomography and an EGD, laparoscopic hiatal hernia repair and fundoplication are considered as a useful method because of its less invasiveness and magnifying effect.

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