Purpose : In this study, three-dimensional computed tomography lymphography (3D-CTLG), a recently developed technique using a contrast medium in sentinel lymph node biopsy (SLNB), was evaluated in terms of efficacy.
Materials and Methods : A mixture of 1-2.5 ml of iopamidol and 0.5 ml of 1% xylocaine was injected subareolarly in 51 patients with operable breast cancer. Within two minutes after the 15-30 sec gentle massage of the injection sites, 1.25 mm-thick cross-sectional CT images of the breast and axilla were taken. These images were reconstructed into 3D images to identify the location, size and number of the sentinel lymph nodes (SLN). All the subjects underwent dye-guided SLNB with a backup axillary dissection. The accuracy of the procedure was evaluated pathologically.
Results : In the first ten cases, we failed to obtain stabilized results due to lack of experience with the procedure. In the remaining 15 cases, with increased experience, the identification rate was 100% and the false-negative rate was 0%.
Conclusion : The 3D-CTLG, allowing easy and accurate identification of SLN, is an appropriate procedure for visualizing SLN and lymphatic vessels. A concurrent use of the dye-guided method with the 3D-CTLG is useful for SLNB.

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We present a series of nine patients with adrenocortical carcinoma (ACC) treated at our institution from 1981 to 2005. All patients presented with hormonal excess, including three with primary hyperaldosteronism, two with virilization, and four with Cushing's syndrome. ACC was suspected preoperatively in all of the patients because CT and/or MRI showed irregular shaped masses that were enhanced heterogeneously. Preoperative stages were as follows ; Stage I in two patients, II in three, III in two, and IV in two. Operation was performed for Stage I to III patients (n=7). O,p'-DDD (Mitotane) was used for two patients in Stage IV and one patient who had recurrence after the operation. The median survival was 39 months of these seven patients operated on, two patients in Stage I and II are currently disease free, three experienced recurrence, and the remaining two died. Other two patients who were not operated on died. Repeated resections of distant metastases in one of the Stage II patients led to a long-term survival for 87 months after the first operation. All Stage III patients died shortly after the recurrence. O,p'-DDD was not effective. Stage I and II patients had better prognosis than Stage III and IV patients. When the locally controlled early stage patient developed distant metastasis, repeated resections of these lesions provided a long-term survival.

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Objective : Tension free repair for inguinal hernia has been demonstrated to have minimal complications and a low recurrence rate. There are many reports on the use of the procedure for unilateral hernia, but few on the simultaneous use of the procedure for bilateral inguinal hernia. In this study we investigated the characteristics of bilateral inguinal hernia and compared for the safety between simultaneous bilateral inguinal hernia repair and unilateral repair.
Methods : We retrospectively reviewed medical records of consecutive 899 adult patients who had repaired inguinal hernia in the hospital from January 1993 to September 2003. And we comparatively examined the characteristics complications after the operation, and recurrence rate, by dividing them into group A (153 patients with bilateral inguinal hernia) and group B (743 with unilateral inguinal hernia).
Result : Ten percent of the patients who complained of unilateral hernia had bilateral hernia. The types of the hernias included indirect hernia in 76% of group B, bilateral direct hernia bilateral indirect hernia, and mixed type in 45%, 30%, and 25% of group A, respectively. No significant differences were noted between the two groups in postoperative hospitalization (A : 3.6days, B : 3.2days), postoperative complication (A : 1.8%, B : 1.3%), and recurrence rate (A : 6.8%, B : 3.6%).
Conclusion : In the treatment of unilateral inguinal hernia, physical examination to confirm the presence of contralateral hernia is very important, and simultaneous repair for bilateral inguinal hernia is safe.

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We report a case of systemic multiple abscesses with Group B streptococci (GBS). A 68-year-old woman was admitted to our hospital with continuous pain in the right foot and hip. Computed tomography and magnetic resonance imaging showed multiple abscesses in the right stenoclavicular joint, mediastinum, right thoracic cavity, pelvic cavity and right hip. An abscess and blood culture yielded GBS organism. With a local drainage, abscesses of the right stenoclavicular joint and hip were improved. Despite the use of antibiotics, abscesses in the mediastinum, thoracic cavity, and pelvic cavity developed. Successful management was accomplished with an appropriate surgical drainage. The patient was discharged at the 118^th day. She had a neurogenic bladder and had repeated urinary tract infection. It suggests that the primary infection might be UTI. Systemic multiple abscesses is rare, but it is associated with significant mortality. No definitive treatment has been established, but we suggest that the adequate surgical drainage led to a good outcome.

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We report a rare case of pseudoangiomatous stromal hyperplasia (PASH) of the breast, diagnosed as breast fibroadenoma preoperatively, in a 28-year-old woman. The patient seen at our hospital because of a right breast tumor had a well movable tumor 30×25mm in diameter in the A area of the right breast on palpation. Results of ultrasonography and aspiration biopsy cytology suggested fibroadenoma. We excised the tumor under local anesthesia. The tumor dimensions were 35×25×20mm. Vimentin, alpha-smooth muscle actin, desmin, and CD34 were positive in the stromal cells on immunohistochemical studies. Consequently, the histopathological diagnosis of the lesion was PASH of the breast. Most patients have favorable clinical courses after the excision.

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A 35-year-old woman found a mass in her left breast 6 months after delivery of her second baby in April 2006, and a month later she noticed a sudden diffuse swelling of her left breast with erythema. She stopped lactation and visited our hospital. We found a movable mass, measuring 10×9cm in size, with an erythema above the mass in her left breast. The mass was detected by both mammography and breast ultrasonography. Ultrasonography also revealed enlargement of a lymph node in her left axilla. We diagnosed it as diffuse large B cell lymphoma by core needle biopsy for the palpable mass of her left breast and fine needle aspiration biopsy for the swollen axillary lymph node. We report this rare case of primary malignant lymphoma which developed in a lactating breast and treatment for it during breast feeding.

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Male breast cancer is rare. We experienced a case of primary male breast cancer following endocrine therapy for prostate cancer. An 88-year-old man underwent surgery for prostate cancer in 2000. After surgery, LH-RH agonist and antiandrogens were administered. In 2003, he was admitted to us with gynecomastia and left breast tumor. He was diagnosed as having breast cancer by means of needle biopsy. Left mastectomy with lymph node dissection was performed. Histologically the mass was diagnosed as invasive ductal carcinoma, papillo tubular carcinoma. After the surgery, he was given chemotherapy and endocrine therapy. Local recurrence occurred 8 months after the operation.

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In spite of stanching by an astriction or an alginic acid, re-bleeding from a skin-invading lesion of advanced or recurrent breast cancer often occurs and sometimes it results in advanced anemia. Therefore, patients are often compelled to limit daily life, and their quality of life declines. To achieve stable stanching, local excision or radiation treatment is necessary. However, because of their bad general condition and their pre-treatment history of radiation, it is difficult to give these treatments to advanced or recurrent breast cancer patients. This time, we report two cases in which stable stanching was attained by fixing a bleeding lesion using 3% formalin liquid. This method involves soaking a bleeding lesion in 3% formalin liquid using an ostomy appliance, and it can be done easily in the ward. In the two cases, we achieved stable stanching for about 2 months, without serious side effects. Therefore, we consider that the 3% formalin fixation therapy is a valid method to improve QOL of advanced or recurrent breast cancer patients.

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A 58-year-old man on hemodialysis was seen at the hospital because of fever and abdominal pain. There was peritoneal sign in the upper abdomen. An abdominal CT scan showed free air in the omental bursa, mediastinal emphysema, and subcutaneous emphysema of the neck. Upper gastrointestinal endoscopy revealed ulcer scar on the lesser curvature of the upper body of the stomach, but no perforation was identified. A possibility of perforation of the lower gastrointestinal tract could not be ruled out, so that a laparotomy was performed. A small amount of turbid ascites and free air were present in the omental bursa. The gastric body was adherent to the retroperitoneum, showing scartissue replacement. No abnormalities were noted in the other gastrointestinal organs, and then abdominal drainage alone was performed. The patient showed little improvement in inflammatory findings after the operation. Another CT scans of the chest and abdomen demonstrated abscess formation in the mediastinum. Thoracoscopy-assisted mediastinal drainage was thus conducted on the 21^st postoperative day. The right lower lobe of the lung firmly adhered to the mediastinal pleura which demanded a small thoracotomy about 8cm in length which enabled to open the abscess cavity.
Mediastinal abscess associated with gastric perforation like this case in rare. We report this case of mediastinal abscess with gastric perforation in which thoracoscopy-assisted drainage was useful, together with some bibliographical comments.

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A 39-year-old man who was born cerebral palsy but was able to eat by mouth without any problems developed vomiting after a supper in the middle of August 2006. He was brought into the hospital by ambulance because his vomiting persisted foe more than 24 hours and bloody vomits were noted. When he was first seen, there was a bulge in the upper abdomen. Abdominal x-ray examination disclosed siginificant dilatation of the stomach and dendriform gas in the liver. Abdominal CT scan also showed prominent dilatation of the stomach, intrahepatic portal gas and intrahepatic venous gas. We attempted to insert a gastric tube but failed in. Accordingly the tube was inserted under fluoroscopy and decompressed. Symptomatic remission was attained temporarily, but his abdominal pain was aggravated and he went into shock. An emergency operation was performed that revealed mesenterioaxial volvulus of the stomach and necrotic change on the gastric wall of the upper portion of stomach. Hence total gastrectomy was performed.
Gastric volvulus is a relatively rare entity, and so far no cases of the disease associated with hepatic portal venous gas have been reported. This time we experienced a patient with gastric volvulus with hepatic portal venous gas, which is considered to be a pathologic sign carrying poor prognosis, whose life was successfully saved by early diagnosis and surgical therapy.

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Acute peritonitis caused by omental metastasis is rare. We report a case of gastric cancer with omental metastasis causing acute peritonitis. A 76-year-old man was admitted to our hospital with lower abdominal pain in December 2006. On admission, he had tenderness with Blumberg's sign in the lower abdomen. Laboratory findings showed inflammatory reaction. An enhanced abdominal CT scan showed ascites and thickened greater omentum in the pelvic cavity. He received conservative treatment, but abdominal pain worsened, so emergency laparoscopy was performed under a diagnosis of acute peritonitis. The greater omentum was extensively adherent to the abdominal wall. The abdominal wall was inflamed. A moderate amount of serous bloody ascites was found in the pelvic cavity. A partial resection of the greater omentum was performed through the mini-laparotomy site. Macroscopic findings of the greater omentum showed that four tumors, almost 4cm in diameter, were present. Microscopic findings of the greater omentum showed metastasis of adenocarcinoma. Postoperative upper gastrointestinal endoscopy showed a Borrmann type 4 gastric cancer. Therefore, we diagnosed the omental tumor as metastasis of gastric cancer.

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A 62-year-old female was referred to our hospital for further examinations of an abdominal mass in her right hypochondrium. Upper gastrointestinal examination showed a submucosal tumor (SMT) with a major axis of 8 cm at the lower third of the stomach. Abdominal CT revealed a heterogeneous tumor with extra-gastric growth. The specimens obtained through EUS-FNAB indicated suspicious carcinoma. A diagnosis of primary gastric cancer with SMT like morphology was made, and laparotomy was performed. During the operation, the mass lesion was identified as a well-delineated round tumor originating from the stomach, showing extramural growth and distal gastrectomy with transvevse colectamy and wedge resection of the pancreatic head was performed. The surgical specimen disclosed a tumor (8×7×6 cm) covered with normal gastric mucosa and growing ettra-gastrically. Histopathological examination demonstrated that the tumor consisted of carcinoma and was not continuous with the gastric epithelium. The results of immunohistological examination suggested a tumor originating from the ectopic pancreas or ectopic liver tissue.

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A 59-year-old male previously diagnosed as having Behçet's disease and Crohn's disease was admitted to the hospital because of abdominal pain. Early gastric cancer was detected by upper gastrointestinal endoscopy and endoscopic submucosal dissection (ESD) was performed. Intraoperatively, gastric perforation occurred, and ESD was discontinued. Emergency abdominal CT scan showed free abdominal air and hepatic portal venous gas (HPVG). Total gastrectomy was done immediately because abdominal pain persisted.
There is no remarkable differences in pathologic condition between ESD related perforations with or without HPVG. However, there have been few reports on HPVG after ESD which became serious and hence more intensive observation would be required for these cases.

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A 48-year-old female with right epigastralgia and severe anemia was admitted to our hospital for detailed evaluation of an abdominal mass. Abdominal CT showed a giant mass 20 cm in diameter with well-enhanced areas and a low-density area on the ventral side of the right kidney. Celiac angiography revealed that the tumor was hypervascular and the lower 2/3 side of the tumor was fed by the posterior superior pancreaticoduodenal artery and the 1/3 upper side of the tumor by the right hepatic artery. Upper gastrointestinal series showed compression of the 2nd portion of the duodenum and no abnormal lesions on the mucosal side of the stomach and duodenum. Under a diagnosis of retroperitoneal tumor, we conducted surgery. At laparatomy, the tumor was connected to the 2nd portion of the duodenum with a small node protruding from the tumor without attaching to the retroperitoneum. The tumor was easily removed with partial resection of the 2nd portion of the duodenum and freeing of adhesion to the liver bed and omentum. Histopathologically, the tumor arose from the proper muscle layer of the duodenum, and was positive for c-kit and CD34 and negative for S-100 protein and SMA on immunostaining. Then the tumor was diagnosed as GIST of the duodenum. A duodenal GIST over 20 cm in size and mimicked from retroperitoneal tumor very rare. We report our case with a review of the literature.

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We report a case of CA19-9 producing duodenal cancer, which presented with an initial symptom of obstructive jaundice. A 68-year-old woman complaining of brown urine and heart burn was admitted to our hospital. Laboratory data showed elevated serum levels of bilirubin, hepatobiliary enzymes and CA19-9 (425.2U/ml), and an abdominal computed tomography scan revealed tumor of the pancreatic head, 2cm in diameter. Pancreaticoduodenectomy was performed under a diagnosis of carcinoma of the pancreatic head after reducing jaundice. Histopathological examination showed primary duodenal cancer, which invaded the pancreas. Cancer cells were stained by immunohistochemical staining against CA19-9. In most cases, patients with primary duodenal cancer presenting with obstructive jaundice have advanced tumors because of pancreatic invasion, however, aggressive surgical treatment may result in a good prognosis.

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A 55-year-old man undergoing a routine physical examination in July 2005, was found to have a type 0-III tumor in the second portion of the duodenum by endoscopy. Duodenal cancer was diagnosed. Pancreatoduodenectomy with D1 dissection was performed in August 2005. Histopathologic examination showed a well-differentiated tubular adenocarcinoma, sm2, n0, ly1, v0, CEA subsequently increased to 358 ng/ml, and abdominal CT and PET-CT images showed swelling of the paraaortic lymph nodes. Recurrence of the duodenal cancer was diagnosed in June 2006, and administration of TS-1 (120 mg/day) was begun. A savere cough developed, and chest CT images showed pulmonary lymphangitis carcinomatosa. Paclitaxel (130 mg/week) and CPT-11 (80 mg/week) were added in August 2006, but the patient died of respiratory failure in February 2007. Duodenal cancer is rare, and there is no established chemotherapy protocol. Although the adenocarcinoma was an early-stage and well-differentiated tumor, the pulmonary lymphangitis carinomatosa was rapidly progressive. It is necessary to establish a therapeutic strategy for treatment of duodenal cancer.

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We report a case of stenosis of the first portion of jejunum caused by adhesion with transmesocolonic hiatus, although the pre-operative diagnosis was difficult. A 72-year-old man with abdominal distension visited our hospital. Upper gastrointestinal endoscopy revealed no abnormal mucosal finding, and the fiber was not passed through the jejunum because of strong crookedness of the duodenum near the Treitz ligament. Although no neoplastic lesion was able to be pointed out by abdominal CT and MRI, the possibility of intestinal stricture by a neoplastic disease could not be ruled out, so an operation was performed after the examination on the 26th. Laparotomy showed the jejunam was adhered to the retroperitoneum, and revealed a defect about 3 cm in diameter in the mesentery of the transverse colon. It was thought that crookedness of the jejunum was produced as a result of inflammatory adhesion, while the intestinal tract went in and out of the hiatus. Although it is a comparatively rare disease, it was thought that this is one of the diseases which should be kept in mind in the differential diagnosis of an unknown ileus of the upper jejunum.

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We experienced a case of ischemic stricture of the small intestine, presented with subileus symptom, in which we could observe the stricture lesion with colonoscopy. The patient was an 82-year-old man who had had multiple cerebral infarctions and atrial fibrillation and was a smoker for a long time. An abdominal radiograph showed findings of small intestinal ileus, and abdominal enhanced CT scan revealed hypertrophy and edema of the small intestine at the ileum-end, without regional lymph node swelling. Colonoscopic observation disclosed no ulcer and no tumor in the colon, but the severe stricture encircling the lumen at 15 cm oral side from the ileum-end, and inflammatory erosion and mucosal redness at the anal side of the stricture lesion were observed. Microscopic examination of a biopsy of the stricture lesion showed nonspecific inflammatory findings, without malignant and granulomatous findings. Judging from these clinical findings, we diagnosed this lesion as ischemic stricture of the small intestine. No improvement of subileus symptom could be attained with conservative treatment after admission, and then partial resection of the stricture lesion was conducted. Histological and macroscopic findings of the lesion provided the most likely diagnosis of ischemic stricture of the small intestine, with insufficient evidence.

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A 55-year-old woman admitted to our hospital because of melena and palpitation showed almost normal laboratory results except Hb of 4.8g/dl and serum value of CEA of 25.5ng/ml. To search the origin of hemorrhage, upper gastrointestinal endoscopy and colonoscopy were performed, but the origin of hemorrhage was unknown. Radiography of the small intestine showed a mass on the jejunum. Pelbic CT scan showed a 45mm mass in the left side of the pelvis, when no connection between the mass and the bowel was clearly seen. Because the mass was considered to be origin of hemorrhage, laparotomy was performed. A submucosal tumor was found in the jejunum 160cm apart from the ligament of Treitz. Partial resection of the jejunum by 20cm in length was performed. The pathological findings revealed that the submucosal tumor had arisen from theproper muscle, and gastrointestinal stromal tumor (GIST) with mesenteric lymph node metastasis was diagnosed because an immunohistochemical study revealed c-kit, CD34 and vimentin positive. CEA stain performed additionaly resulted in that the tumor cells were not stained, but the jejunum mucosa near the tumor were stained. This case is considered to be precious in suggesting that GIST is related to a rise of a tumor marker that has not been reported so far.

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A 72-year-old man with hepatitis C was admitted to our unit due to lt. abdominal pain and palpable tumor. CT findings revealed an intra-abdominal mass 88mm in maximum diameter. A small intestinal fiberscope revealed a full circumferential ulceration of the jejunum and B cell lymphoma was confirmed pathologically. Because the mass was invasive and huge, chemotherapy was applied at first instead of surgery. An R-CHOP regimen of four sessions successfully resulted in a definite tumor reduction, but the stricture of jejunum remained so laparoscopic-assisted jejunostomy was performed. Pathological findings disclosed no residual variable lymphoma cells in the specimen. In the case of intestinal tumor, laparotomy has been used to obtain biopsy samples for diagnosis. We report a case of small intestinal malignant lymphoma that was diagnosed preoperatively by small intestinal fiberscope and then was successfully resected by a less invasive surgical procedure.

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A 57-year-old man was admitted to the hospital for close exploration because his fecal occult blood test was positive. Colonoscopy showed a protruding lesion with a concave at the end of the ileum about 4cm proximal from the ileocecal valve. Endoscopic ultrasonography performed consecutively using a fine probe disclosed rupture of the third layer. A biopsy suggested adenocarcinoma. Combined with findings of barium enema study, primary ileal cancer with the tumor invasion depth of MP was diagnosed preoperatively, and laparoscopy-assisted resection of the ileocecal region with D3 lymph node dissection was performed. The histopathological diagnosis was well differentiated adeocarcinoma, invasion depth of m, n0, and histological Stage 0.
Primary small intestinal cancer is a comparatively rare entity, and no consensus on the diagnosing methods and therapeutic guidelines has been established as yet. In this case we selected lymph node dissection according to cecal cancer because the lesion was present at the end of the ileum, and further we were able to perform a less invasive and effective resection with laparoscopic assistance. In the diagnosis, however, this was the case which made us realize keenly the difficulty in diagnosing the stage of small intestinal cancer preoperatively.

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In many cases, intestinal malrotation is asymptomatic and incidentally detected in adults. We experienced a case of acute appendicitis with intestinal malrotation in an adult which was difficult to diagnose preoperatively.
A 56-year-old woman was referred to the hospital because of lower abdominal pain high fever, and appetite loss. Abdominal CT scan showed inflammation and suspected abscess in the right pelvic cavity. Although no appendix was visualized, we suspected of acute appendicitis and performed emergency operation. During the operation, intestinal malrotation was demonstrated. The appendix was located at the midline position with forming the abscess, so appendectomy and intrapelvic drainage were performed.
It was retrospectively considered that we should have made the diagnosis preoperatively. We must take this rare disease into consideration in diagnosing acute abdomen.

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We report two cases of mucinous cystadenoma of the appendix with high level CEA in serum. One patient was a 58-year-old woman. She was admitted because of a suspected right ovarian tumor and an increase in serum CEA level. CT, MRI and US revealed a cystic lesion in the right lower quadrant of the abdomen. Ileocecal resection was performed. After the operation the serum CEA level returned to normal. The other patient was a 50-year-old woman. Upon follow-up CT for malignant lymphoma, a cystic growing mass was revealed in the ileocecal area of the abdomen. Partial cecal resection was performed. Postoperatively the serum CEA level decreased to the normal level. Both resected specimens showed a markedly swollen appendix with large quantity of mucin. Histological examinations showed mucinous cystadenoma, and immunohistochemical examinations with antibody to CEA were positive in both cases.
Mucinous cystadenoma of the appendix with high CEA level in serum is a rare disease. To the best of our knowledge, only 38 cases have been reported in the Japanese literature since 1988.

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A 77-year-old woman was referred for close examination of fever, white blood corpuscle, and C-reactive protein occurring during dialysis for chronic renal failure and rheumatoid arthritis at another hospital. From abdomen X-ray and computed tomography (CT) at the time of hospitalization, we diagnosed it as pneumatosis cystoides intestinalis (PCI), but we treated the patient conservatively because there were few abdominal findings. However the patient had a sudden stomach-ache stroke and peritoneal stimulation symptom on the 6th day following hospitalization. We undertook an emergency laparotomy because of free gas and ascites observed on an image. We recognized perforation of the descending colon about the size of the 5th finger with multicystic emphysema in the transverse descending colon mesentery. We conducted a partial colon resection. A pathological diagnosis caused the damage of an intestinal tract wall by gastrointestinal amyloidosis of the colon and then accompanied by PCI. It also resulted in intestinal tract perforation. There are various opinions regarding the generatrix opening of PCI, but this case developed PCI from gastrointestinal amyloidosis. It was an interesting example that eventuated in colon perforation. We thus reported it along with some considerations.

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A 75-year-old female, with a previous history of myocardiac infarction was admitted to the hospital because of abdominal pain after supper. On the next day, her symptoms became severe. Abdominal CT scan showed that the wall of the colon was thin, dilated and was not enhanced. An emergency laparotomy was performed under the diagnosis of acute peritonitis with ischemic colitis. At laparotomy, a portion from the cecum to sigmoid colon was necrotic, and subtotal colectomy was performed. On the postoperative day (POD) 13 she developed intestinal obstruction which was treated conservatively. She was discharged from the hospital on the POD 34. But she was re-admitted to the hospital because of recurred intestinal obstruction on the POD 55. Endoscopic examination revealed ischemic colitis of the residual sigmoid colon. Following unsuccessful conservative therapy, the residual colon was surgically resected. She was discharged 15 days after the second operation.
Gangrenous ischemic colitis spreading to the total colon is rare and carries poor prognosis. Aggressive management with abdominal enhanced CT and emergency operation before endotoxic septicemia has progressed is important to save the patient's life.

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A 71-year-old man on hemodialysis for diabetic chronic renal failure was admitted to the hospital because of aggravation of arteriosclerosis obliterans of the lower limb and then had an abrupt episode of massive anal bleeding. Fiberscopic study of the large intestine disclosed an ulcer lesion with palsatile and sustained bleeding from an exposed vessel in the lower rectum. The most likely diagnosis was acute hemorrhagic rectal ulcer (AHRU). The bleeding on the first hospital day was stopped by clipping, but the bleeding recurred 2 days later, so that tvans-anal hemostasis with suture ligature was performed for the lesion under lumber anesthesia. Thereafter he had recurrent bouts of hemorrhage and finally we had to perform abdominoperineal resection of the rectum. The patient's postoperative course was uneventful for a few days immediately after the operation, however, he developed pulmonary infarction on the 5^th day and died on the 6^th day after the operation.
AHRU is a comparatively rare entity, and a variety of underlying factors participate in the onset of the disease which are risk factors for surgical intervention as well. Accordingly various local treatments are to be the main therapy in achieving hemostasis of the lesions. In this paper we report this case of AHRU in which we had great difficulties in achieving hemostasis and selected abdominoperineal resection of the rectum.

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We present a case of large bowel obstruction caused by an ascending colon cancer impacted with a colonic lipoma. The patient was a 73-year-old woman having complaints of high-grade fever and abdominal pain. Physical examinations revealed severe peritoneal irritation in the right lower abdomen. Plain X-rays showed diffuse small bowel dilatation and a blood test demonstrated high CRP level. CT scan demonstrated segmental wall thickening in the ascending colon, which was impacted with an adjacent tumor having the density of adipose composition. She was suspected as having peritonitis and large bowel obstruction caused by an ascending colon cancer with a colonic lipoma, and so underwent an urgent laparotomy. It was confirmed that there was an impacted colonic lipoma at the ascending colon cancer, which had caused bowel obstruction and perforation of the terminal ileum. The lipoma was microscopically confirmed to be benign and covered with the mucosal layer of adenocarcinoma of the colon.

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A 60-year-old female who had undergone high anterior resection of the rectum with D3 lymph node dissection for rectal cancer (Rs) in July 1997 had been followed for the next 5 years with oral UFT chemotherapy. She developed painless swelling on the right side of the neck in September 2002. A thyroid tumor was discovered by cervical ultrasonography, which was diagnosed as papillary cancer by needle biopsy at a local hospital. Preoperative chest X-P and CT scans showed a solitary coin lesion in the lower lobe of the right lung (S₆) and paratracheal lymph node swelling. Right lobectomy of the thyroid with modified radical neck lymph node dissection was performed on December 13, 2002. Thereafter, treatment with PMC (pharmacokinetic modulating chemotherapy : UFTE 450mg/day, 5FU 2,000 mg/48 hr, biweekly) was given for multiple lung metastases. The pathological diagnosis of the thyroid tumor was mucus-producing metastatic adenocarcinoma, the same as that of the lung tumor, suggesting that the rectal cancer metastasized into the thyroid gland and the right lung. The patient had severe pain of the right lower jaw during chemotherapy with a different protocol {CPT-11 80mg/m₂ (day1 and 15), 5FU 500mg/m₂ (day3∼7)}. Biopsy of the ulcer of the gingiva demonstrated moderately differentiated adenocarcinoma, which was the same as both of the thyroid and the lung. Therefore, the primary rectal cancer was judged to have metastasized not only to the thyroid and the lung but also to the right lower jaw. Multiple bone metastases were then detected by bone scintigraphy. The patient died of the disease in August 2003. Recurrence in the form of thyroid metastasis from rectal cancer more than 5 years after excisional therapy is extremely rare, and to our knowledge, this is the 4th report of such a condition reported in the Japanese litercture.

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We experienced a case of old intrahepatic hematoma without any past history of evident hepatic trauma.
A 71-year-old female was referred to our hospital with a diagnosis of ascending colon cancer. An abdominal CT scan and ultrasonography showed a non-enhanced, solid heterogeneous mass in the S7 area of the liver. Since we could not rule out a possibility of liver metastasis, we performed right hemicolectomy with D3 dissection and partial hepatectomy. Pathologically the ascending colon tumor was moderately differentiated adenocarcinoma, and the liver tumor was old intrahepatic hematoma with thick wall.
Only 12 cases of old intrahepatic hematoma have been found in the Japanese literature. This rarely occuring disease should be considered in the differential diagnosis from malignant hepatic tumors such as hepatocellular carcinoma and a metastatic tumor.

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We report a case of liver metastasis from gastrinoma for eighteen years after the initial diagnosis. A 65-year-old male with a 40-year history of epigastric pain was diagnosed as having gastrinoma of the pancreatic head with multiple liver metastasis in 1987. We performed a hepatectomy in August 2005 because the primary tumor had not been identified, however, liver metastasis showed increasing size and number. We should consider that aggressive resection of liver metastasis is able to improve the prognosis of gastrinoma with liver metastasis.

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A 56-year-old man was referred to the hospital because an abdominal CT scan revealed a tumor 5. 5 cm in diameter in S6 of the liver, and liver biopsy indicated poorly differentiated adenocarcinoma. When examined by CTA, the tumor periphery showed delayed filling with contrast material already during the early phase. The area inside the tumor did not show contrast enhancement during the early phase but showed partial contrast enhancement during the late phase. CTAP depicted the tumor as a low density area. The patient was diagnosed as having combined hepatocellular carcinoma and cholangiocarcinoma or cholangiocellular carcinoma and underwent right lobectomy of the liver and excision of hilar lymph nodes. When immunostained, the great part of the tumor was MUC1 positive (cholangiocarcinoma) but a part of it was HepParI positive (hepatocellular component). Both components were transposed each other and coexisted in the tumor. The tumor was thus diagnosed as combined type liver tumor. No lymph node involvement was noted. Six months after the surgery, metastasis to lymph nodes was detected, accompanied by detection of metastasis to bones. Intravenous administration of low dose CDDP + 5-FU was started. AFP and PIVKA II decreased after the treatment. Reduction in lymph node metastases was noted. However, intrahepatic metastasis, showing little contrast enhancement, and lung metastasis occurred. The patient died of hepatic failure associated with the liver cancer 15 months after the surgery.

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A 79-year-old Japanese man was admitted to our hospital with a diagnosis of cholecystolithiasis. Ultrasonography and computed tomography showed cholecystolithiasis with an atrophied gallbladder and thickening of gallbladder wall. In addition, stenosed choledocholith was found Serum level of carbohydrate antigen 19-9 (CA19-9) was 245.9U/ml at admission. An endoscopic sphincterotomy (EST) was done, and the common hepatic duct was found to be stenosed. A cholecystectomy was performed. The pathohistological deagnosis was xanthogranulomatous cholecystitis (XGC). Later, the CA19-9 level decreased to the normal value and the stenosis of the common hepatic duct disappeared.
XGC is a rare inflammatory disease of the gallbladder, and sometimes confused with a malignant neoplasm. Mirizzi syndrome is stenosis caused by compression of the bile duct by a stone leading to inflammation or jaundice of gallbladder. We report a rare case of Mirizzi syndrome caused by xanthogranulomatous cholecystitis.

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A 77-year-old woman complaining of right hypochondralgia was admitted to the hospital with a diagnosis of cholecystitis. Abdominal CT scans showed a swollen gallbladder, thickened wall, and a gallstone. MRCP visualized no common bile duct (CBD) stone, and showed that the right posterior segmental branch bifurcated from the middle portion of the extrahepatic bile duct, from where the cystic duct bifurcated. Laparoscopic cholecystectomy was performed. Following antegrade dissection of the gallbladder, the cystic duct was transected after applying a clip. Abdominal pain developed on the 3^rd postoperative day. Abdominal CT scan and ERC offered a diagnosis of gallstone pancreatitis and bile leakage caused by impaction of an escaped stone in the papillary portion. Conservative therapy with endoscopic transnasal biliary drainage (ENBD) was started. Improvement of bile leakage was noted on the 5^th day after the initiation of the therapy, and then the ENBD tube was removed on the next day. The patient was discharged from the hospital on the 20^th day after the operation.
It is etiologically considered that the escaped and impacted stone in the common bile duct had led to re-opening of the cystic duct, causing bile leakage. It is important to take careful attitudes for intraoperative maneuvers by entertaining these facts. We here present this case of bile leakage after laparoscopic cholecystectomy caused by a retained CBD stone.

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We report a case of post-cholecystectomy bile leakage from the cystic duct treated by ERBD (endoscopic retrograde biliary drainage). The patient was a 62-year-old male with cholelithiasis who had undergone cholecystectomy in another hospital. On the first operative day, total bilirubin was 2.7 mg/dl, and he complained of hypochondrial pain. On the second day, the pain abated but bile leakage was detected from the site of Penrose drain. Therefore, he was admitted to our hospital. ERCP (endoscopic retrograde cholangiopancreatography) was performed on the sixth operative day in our hospital. Choledocholithiasis was found, and bile leakage from the cystic duct stump was observed. ERBD tube was inserted into the CBD (common bile duct), and the leakage disappeared completely on the fifth day after insertion of ERBD tube. On the sixteenth day after ERBD, EST (endoscopic sphincterotomy) was performed. The patient was discharged on the eighteenth day after ERBD. Bile leakage after cholecystectomy is often reported, but bile leakage caused by CBD stone is rare. Recently, endoscopic treatment such as ENBD (endoscopic nasobiliary drainage) or ERBD is applied in these cases. ENBD requires a nasal tube, whereas ERBD does not. So from the Q. O. L. point of view, ERBD is more acceptable. Thus ERBD should be considered as a method of treatment for management of bile leaks from the cystic duct stump.

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A 61-year-old man was admitted to the hospital because of an abdominal tumor and fever. Abdominal CT scan visualized a huge tumor shadow about 20 cm in diameter at the right abdominal space along with multiple liver metastases. Although it was an inoperable case, we performed a resection of the tumor with a cholecystectomy, partial hepatectomy, pancreatoduodenectomy, and a colectomy for symptom relief. The resected specimen weighted 3,700 g, and the histological examination showed that most areas consisted of undifferentiated pleomorphic cells. On immunostainings, undifferentiated carcinoma originating from the gallbladder was diagnosed. Undifferentiated carcinoma of the gallbladder is comparatively rare, and has the poorest prognosis. We report a case of undifferentiated pleomorphic cell gallbladder carcinoma.

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We report a patient with bile duct cystadenocarcinoma who underwent right lobectomy. A 70-year-old man was admitted to our hospital for further examination of an incidentally detected hepatic tumor. A 4.5cm diameter cystic tumor with papillary projection was detected between the roofs of the anterior and posterior hepatic pedicles by ultrasonography. The margin and the papillary projected area were enhanced by computed tomography using contrast medium. Magnetic resonance cholangiopancreatogram showed a dilatation of the posterior branch of the bile duct. The patient underwent right lobectomy of the liver. The resected specimen demonstrated papillary projections and mucin in the cystic tumor, which was histologically diagnosed as a cystadenocarcinoma, epithelially infiltrating to the adjacent bile duct without ovarian-like stroma. The patient is doing well without any signs of recurrence 10 months after the operation.

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A 79-year-old man treated for hypertension was found to have jaundice. As a result of close examinations, he was diagnosed as having the tumor of ampulla of Vater or lower bile duct. 3D CT angiography showed the aberrant common hepatic artery which ascended on the anterior surface of the pancreas and continued as a normally positioned proper hepatic artery. Also, the gastroduodenal artery was absent. We performed a pylorus preserving pancreatoduodenectomy while carefully preserving this common hepatic artery. If we damage an important artery, critical complications may occur after surgery. Therefore, the preoperative evaluation of the configuration of the hepatic artery and the accurate recognition during operation are considered to be important.

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Transomental hernia often develops into strangulated obstruction, but is difficult to diagnose preoperatively due to lack of specific symptoms. We report a patient with strangulated obstruction due to transomental hernia.
A 74-year-old man was admitted to the hospital because of epigastric pain and vomiting. He had no previous history of abdominal surgery or trauma. There was epigastric tenderness and rebound tenderness. His labs showed elevated white blood cell count and CK. On blood gas analysis, his base excess was decreased at -4.6mEq/L. Abdominal CT scan showed ascites collection, many dilated small intestinal loops with intraluminal air and a strangulated small intestinal loop. Moreover, coronary multiplanar reformation (MPR) showed a hernia orifice, the protruded and strangulated small intestinal loop through the orifice, and engorged mesenteric vessels. A diagnosis of strangulated obstruction by internal hernia was made and an emergency operation was performed. We performed resection of the necrosed portion of the small intestine about 50 cm in length that prolapsed and was strangulated through the hiatus of the greater omantum. The patient was discharged from the hospital 11 days after the operation. Multidetector-row CT (MDCT) examination with MPR is very useful for preoperative diagnosis of internal hernia.

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We report a case of malignant Brenner tumor arising in a 54-year-old woman. She was admitted to our hospital because of upper gastrointestinal tract obstruction. Radiographic examinations demonstrated a giant tumor widely spreading through the retroperitoneal space ranging between the pancreas head including the third portion of the duodenum, the right renal hilum, and tissues adjacent to the left ovary. Pancreaticoduodenectomy along with right nephrectomy were carried out. Histopathological examination gave a diagnosis of adenosquamous cell carcinoma originating from a lower portion of the common bile duct. When she died from the relapsing disease one year after surgery, however, postmortem examinations revealed that most organs in the abdominal cavity were involved in the tumor. The left ovary was moderately swollen and had been replaced by the tumor. Light microscopic examinations including immunohistochemical staining, as well as electron microscopic examination revealed that the tumor had characteristic features consistent with those of malignant Brenner tumor. Brenner tumor is known as a solid ovarian tumor, though the cell lineage remains unresolved. Malignant types of Brenner tumor are very rare, with one third showing extra-ovarian growth, and have an extremely poor prognosis. To date, no effective therapeutic modality has been established yet. Malignant Brenner tumor may thus pose a difficulty in the diagnosis and treatment to surgeons who encounter this tumor.

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A 16-year-old young man was referred to our hospital because of high fever and right lower abdominal pain. He was diagnosed as having retroperitoneal cyst by USG, CT and MRI. With conservative therapy using antibiotics, the symptoms were improved. On the follow-up USG and CT, the retroperitoneal cystic tumor had grown and the right renal pelvis was enlarged, so he underwent an operation for retroperitoneal huge cystic tumor. It was present in the retroperitoneal space which had compressed the right side colon, pancreas head and duodenum to the medial site. A lymphatic about 10 mm in diameter flowed into the tumor. The tumor was fixed to the right testicular vessels and the duodenum. The fixed right testicular vessels were excised with the tumor, and part of the cystic wall, which fixed to the duodenum, was left and cauterized. Pathological findings disclosed that the tumor was composed of three portions of cyst, and no malignant cells. We report a rare case of a huge retroperitoneal cystic lymphangioma.

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This paper deals with a case of a retroperitoneal serous cyst of which lumen was covered with methothelial cells. The patient was a 54-year-old woman with previous histories of undergoing appendectomy and cesarean section. The patient who was asymptomatic was seen at the hospital because she was pointed out a right retroperitoneal cyst at a medical check-up. About 500ml of serous fluid content was aspirated by a puncture of the cyst, and retroperitoneal serous cyst was diagnosed. The cytodiagnosis of the fluid content resulted in class I, but CA125 level was as high as more than 1000U/ml. Abdominal CT scanning performed 2 months later disclosed the remnant of the cyst. Accordingly the cyst was removed. The cyst was present on the dorsal aspect of the right ovarian artery and vein and was easily dissected from the surroundings. Pathologically the lumen of the cyst was covered with one or two layered methothelial cells and was negative for ER and PgR on immunochemical studies. Based on the surgical and pathological findings, the cyst in this case was conceivable to be unilocular peritoneal inclusion cyst which had arisen in the retroperitoneum.

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A 56-year-old man with diabetes mellitus was admitted to our hospital because of high-grade fever and back pain after needle therapy in April, 2007. CT and MRI study showed pyogenic vertebral osteomyelitis and lumbar epidural abscess complicated with bilateral pyothorax. A small incision of part of the diseased skin and intravenous treatment with antibiotics had little effect on the pyothorax and no effect on the lumbar epidural abscess. Neurological para paresis and sensory disturbance of lower legs developed, so a drainage of the residual pyothorax by thoracotomy and an open drainage of lumber epidural abscess were performed. After surgery, the patient has been recovering little by little and is in rehabilitation now. The case was presented together with a review of the literature.

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The patient was a 66-year-old female who had undergone liver transplantation two years previously, with hapatocellular carcinoma of HCV carrier. She underwent a right lower lobectomy for lung cancer six months after the liver transplantation.
One and a half years later, 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed a hot nodule in the left breast and left axillary lymph nodes. She was diagnosed as left breast cancer by a core needle biopsy and a quadrantectomy was performed.
Recently, organ transplantation has increased as a result of the progress of immunosuppression agents.
However, the rate of cancer recurrence after transplantation is rising at the same time. We should pay attention to the usage of anticancer and immunosuppression agents.

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