In this study, the liver blood flow and effect of PGE1 administration were evaluated after vascular clamping of the hepatic hilum in a hepatic resection. We examined 27 hepatectomized cases (6 normal liver and 21 cirrhotic liver). These case were divided into 4 groups : PGE1 administered (n=3) and control (n=3) in normal liver, PGE1 administered (n=12) and control (n=9) in cirrhotic liver. Liver blood flow (ml/min/100 g) was compared at the following time points ; just before, during, and just after vascular clamping. In the normal liver, blood flow after declamping recovered immediately to the previous value in both the PGE1 administered and control groups with no significant difference. In the cirrhotic liver the blood flow after declamping did not recover to the previous value in the control, and was still significantly low ; meanwhile it returned to the previous value only in the PGE1 administered group.
In liver cirrhosis blood flow maintenance after vascular clamping was very difficult, and continuous injection of PGE1 seemed to be effective.

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Introduction : Surgical treatment is an accepted remedy for patients with inguinal hernia ; however the appropriate treatment strategy for patients with inguinal hernia during pregnancy remains obscure. Patients and Methods : Among 1032 patients who had undergone herniorrhapy from 1996 through 2006, a total of 14 patients (1.4%) diagnosed as having inguinal hernia during pregnancy were enrolled in this study. We evaluated retrospectively the clinical characteristics, surgical procedures, and clinical outcomes of patients with inguinal hernia during pregnancy. Results : Inguinal hernias were diagnosed at the median time of 19-weeks of gestation. All 14 patients had a complaint of inguinal bulging or pain. Twelve patients underwent herniorrhaphy during pregnancy (median : 25-weeks of gestation) : one patient underwent herniorrhaphy at the same time as the cesarean section ; and one patient underwent herniorrhaphy eight days after delivery. Marcy's repair herniorrhaphy was performed on eight patients, and Lichtenstein's repair herniorrhaphy was performed on six patients. No patients had complications with the pregnancy or delivery, nor had recurrences of hernia after the herniorrhaphy. Conclusion : We concluded that surgery for patients with inguinal hernia during pregnancy is safe and feasible. Surgery should be considered for patients suffering from the symptoms of inguinal hernia.

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Extra-anatomical bypass (EAB) is selected as an alternative for anatomical bypass (AB) in the treatment of chronic arterial occlusive disease, when AB is inappropriate because of age, history of abdominal surgery or other high risks.
From 1989 to 2005, we experienced 91 surgical reconstructions for chronic arterial occlusive disease. EAB was performed in 36cases (39.6%) (axillo-femoral bypass 18 cases and femoro-femoral crossover bypass 18 cases). The patient age ranged from 52 to 82 years old, and the mean age was 70 years old, male-female ratio being 32 : 4. Duration of operation and hospitalization, graft patency, and postoperative complications were compared between EAB-group and AB-group. Indication of EAB was severe calcification of the aorta, history of previous laparotomy, high age or other high risks. Postoperative evaluation was performed by magnetic resonance angiography, ankle brachial arterial pressure index and other examinations. In the EAB group, there was no major postoperative complications or operative deaths except a few regional lymphorrhoea and subcutaneous hematoma.
Primary and secondary 3-year patency rates were 88.2% and 94.4% in femoro-femoral bypass, and 88.9% and 94.1% in axillo-femoral bypass respectively. Late deaths were observed in 3 patients in axillo-femoral bypass and 2 patients in femore-femoral bypass (5 in total), but no relation was suspected to EAB.
In conclusion, we consider that EAB is an effective alternative for patients with high age and other high risks guaranteeing better quality of life.

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A 46-year-old female patient noticed a tumor in her right breast since Feb. 2007 and came to our clinic in May 2007. An elastic hard, well circumscribed tumor of about 5 cm in diameter was palpable in the AC area of the right breast with a 2 cm diameter size lymphnode in the right axilla. Mammographic study confirmed the diagnosis of category 4. Ultrasonographic study revealed a relatively well circumscribed, non-homogeneous tumor over the right AC area. A diagnosis of cancer was made by a needle biopsy and a right modified radical mastectomy and axillary lymphnode dissection were performed. Pathological study of the resected specimen revealed a rosette arrangement of the tumor cells by HE staining and immunohistochemical study revealed positive synaptophysin and CD56, leading to the diagnosis of large cell neuroendocrine carcinoma (LCNEC). LCNEC is rare and definite treatment strategy has not been established and prognosis of the disease is not clear yet. We report the case here with some review of the literatures.

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The diffusely diseased left anterior descending coronary artery (LAD) remains a challenge for both interventional cardiologists and cardiac surgeons. We report 7 cases of coronary artery bypass graft surgeries (CABG) for the diffusely diseased LADS with long onlay patch bypass graftings. The left internal thoracic artery (LITA) was used to reconstruct the LAD in all patients. The operations were performed using cardiopulmonary bypass in 4 cases and the off-pump technique in 3 cases. The LAD incision length was 2.5-6.0 cm. One emergent case was lost due to cerebral infarction. The patency of all the grafts was confirmed by angiographic examination. Coronary artery reconstruction with onlay patch grafting using the LITA for a diffusely diseased LAD seems to be reproducible.

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An 87-year-old man suspected of infected aneurysm of the iliac artery was successfully treated. Bleeding from arterial stump after removing infected arterial wall is well known complication and is associated with high mortality. We removed the infected arterial wall and reinforced the arterial stump using autologous fascia lata. The patient was discharged without reinfection or bleeding. His condition has remained uneventful for 31 months after the surgery. It could be effective to reinforce arterial stump by using autologous fascia lata for infected aneurysm.

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We report a case of inflammatory myofibroblastic tumor (IMT) arisen in the lung, a rare entity, in which surgical treatment was performed. The case involved a 15-year-old man who was pointed out a 5-cm sized tumor shadow in the right upper lobe of the lung by a chest x-ray film at a medical checkout when he had entered a high school. Following close exploration at the department of respiratory internal medicine in our hospital, he was referred to our department for the purpose of surgery with a suspicion of myofibroblastic sarcoma in the right upper lobe of the lung. Since the tumor was adjacent to the middle lobe and was an incomplete segment, right upper and middle lobectomy was performed. The histopathological diagnosis was IMT. However, the removed cells revealed metaplasia and p53 positive, indicating that his disease might be prone to recurrence and metastasis compared to usual IMTs. Thus further careful observation of the clinical course would be necessary. The postoperative course was uneventful and he was discharged from the hospital on the 13^th postoperative day.

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The case was a 60-year-old man. Upper gastrointestinal endoscopy in a screening examination revealed the gastric wall to be externally compressed. Abdominal computed tomography showed a solid mass about 7 cm in diameter mainly in the back space of the pancreatic body and tail to the posterior gastric wall. The tumor had a clear border with the pancreas and adrenal gland. Its feeding artery was not obvious on abdominal angiography. We diagnosed it as retroperitoneal tumor and performed an operation because the tumor mainly existed in the retroperitoneum under the pancreas, though we also considered gastrointestinal stromal tumor (GIST) with external growth of the gastric wall. On operative findings, the tumor pressed the pancreas forward and connected with the serosa of the posterior gastric wall with a short stalk. The tumor was resected with an edge-shaped resection of the stomach. Histologically, the tumor consisted of spindle-shaped cells. Immunohistochemical staining showed positive c-kit and CD34, and negative SMA and S-100 protein, so we made a diagnosis of GIST. To the best of our knowledge, this is the first report of such a development in the GISTs growing out of the gastric wall with a pedicle. This was a case of gastrointestinal stromal tumor of the stomach with very rare growth difficult to preoperatively differentiate from a retroperitoneal tumor with some bibliographical comments.

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A 74-year-old woman was found to have wide adenoma in the middle gastric body by gastrofiberscopy for screening in September, 1998. In consideration of cancer in adenoma, diagnostic endoscopic mucosal resection was performed in April, 1999, and the pathological diagnosis was gastric adenoma. The tumor had been followed by endoscopy once a year until May, 2005, as a result of which both biopsy diagnoses were Group III. In January, 2007, when the patient was hospitalized by cholecystitis, the gastric tumor had obviously grown, and it was diagnosed as papillary adenocarcinoma by biopsy. We conducted total gastrectomy, regional lymphadenectomy and cholecystectomy. Although the gastric tumor was a huge mass of type 1 macroscopically, it was diagnosed as a lesion within the mucosal layer, v0, ly0, n0 pathologically. In recent years, various knowledge has been gained about the malignant transformation risk factor of gastric adenoma. In this case we felt it necessary to try aggressive endoscopic excision for adenoma with high malignancy.

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A 62-year-old man with a long-standing history of dysphagia and anemia was admitted to our hospital with symptoms of severe dysphagia and general weakness. Laboratory analysis revealed a typical iron deficiency anemia. Gastrointestinal x-ray and endoscopic examinations showed a membranous stenosis in the upper esophagus, which suggested an esophageal web and a Borrmann type 1 tumor on greater curvature of the gastric body which was proved to be a moderately-differentiated adenocarcinoma by endoscopic biopsy. Under a diagnosis of gastric cancer with Plummer -Vinson syndrome, the patient underwent radical subtotal gastrectomy with D2 nodal dissection. Macroscopically, the resected stomach contained a Borrmann type 1 cancer in the body. Pathological findings demonstrated atrophic change of the gastric mucosa and a lesion of papillary adenocarcinoma. The patient had an uneventful postoperative course, and his dysphagia and iron deficiency anemia have recovered by oral administration of iron therapy.

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A 49-year-old woman under internal treatment for ulcerative colitis (UC) was found to have anemia in the course of the disease and was referred to our department because advanced gastric cancer was diagnosed by upper gastrointestinal endoscopy. Introduction of preoperative chemotherapy was considered for gastric cancer due to suspected lymph node metastasis and disseminated lesions by preoperative examinations, but surgery was performed because it was clarified that her anemia had been caused by gastric cancer. Laparotomy disclosed that her UC involved the entire colon and was moderately active, and it just begun to be manageable by internal treatment. Thus we did not employ total colectomy.
Although little cases of UC associated with gastric cancer have been reported so far, such associated cases will be increasingly reported in future with an increase in numbers of patients with UC. Therapies differ from case to case according to each pathologic condition of UC or gastric cancer. Many UC patients have been given long-term steroid therapy or large doses of steroids when gastric malignancy is detected, so that perioperative management should include supplementary administration of steroids and some strategies for complications. This case in which we were able to manage the perioperative period safely is presented here, together with some bibliographical comments.

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Bleeding from diverticula of the duodenum is rare and difficult to be diagnosed. This is a rare case which showed the usefulness of angiography in diagnosis of bleeding from a duodenal diverticulum.
A 64-year-old man was brought into our department by ambulance because of an abrupt episode of massive melena. Despite an endoscopy at another hospital, the origin of bleeding could not be identified in the stomach, duodenum, and colon. A repeated endoscopy revealed acute bleeding from the eroded mucosa in a duodenal diverticulum in the 3^rd portion. Endoscopic clipping was unsuccessful. Emergency angiography disclosed extravasation of the contrast material from a branch of the inferior pancreaticoduodenal artery, and then hemostasis was made by embolization with coils. The patient was discharged from the hospital on the 11^th postoperative day. Rebleeding has not occurred.

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We report an extremely rare case of small cell carcinoma of the ampulla of Vater. A 72-year-old Japanese female, who had been followed due to chronic hepatitis C, was referred to our hospital with a diagnosis of carcinoma of the ampullary region according to the pathological findings of endoscopic biopsy specimens. An operation of pancreatoduodenectomy reconstructed by a modified Child's method was performed with lymph node dissection. The detailed histological and immunohistochemical examination revealed that the tumor was identical to extrapulmonary small cell carcinoma combined with tubular epithelial differentiation and that neuroendocrine differentiation was clarified by chromogranin A immuno-staining. This tumor was smallest ever reported in the Japanese literature, and involved no lymph node. It is well known that this disease has an extremely poor prognosis. Although the present tumor was very small and had no metastatic lymph node, she died of progressive hepatic metastases one year after the surgery. A standard chemotherapy for gastrointestinal small cell carcinoma should be established.

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A 49-year-old man was admitted for abdominal pain and vomiting. Abdominal distention and tenderness was observed, but muscular defence was not remarkable. Plain X-ray of the abdomen showed multiple air-fluid levels in the dilated small intestine, and an abdominal computed tomography (CT) showed an extended intestinal tract and ascites. Strangulated ileus could not be ruled out and an emergency operation was conducted. Upon laparotomy, we found moderate amount of chylous ascites, and the small intestine was twisted and rotated about 360° clockwise by mesenteric torsion. The necrosis of small bowel was not present, so reduction of torsion was performed. This case did not revealed anatomical abnormalities nor malformation, and the patient was diagnosed as primary small bowel volvulus. It is rare, and 47 cases, including ours, have been reported in Japan. For diagnosis, abdominal CT is useful. It is also reported. Small intestine may develop rapid necrosis and can go into shock and cautions are required in not missing the timing of surgery.

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A patient, 75-year-old male, had a segmental resection of the jejunum for a small intestinal tumor in Sept. 1994 and histopathological diagnosis of the tumor then was leiomyosarcoma. The patient was regularly followed by CT studies and in April 2007 he came to our hospital because of a subcutaneous tumor around the umbilicus. A detailed study revealed multiple tumors in the peritoneal cavity and umbilical subcutaneous area. A specimen from the umbilical area was biopsied and at the same time the previous operative specimen was pathologically studied. Spindle and polygonal type cells in bundle form proliferations were observed and showed positive c-kit in immuno-staining. Accordingly the diagnosis of recurrence of small intestinal GIST was made. A radical resection of the tumor was deemed impossible and so administration of imatinib mesilate 300mg/day was immediately started and the dosage was increased to 400mg/day without decrease of the size of the tumor. The patient died in generalized deterioration. Recurrence of this type of tumor 13 years after the initial operation is rare and we report it here including the analysis of its form of recurrence with some review of literatures.

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This paper deals with a case of perforation of the appendix due to a fish bone, together with 48 cases of foreign objects of the appendix reported during recent ten years as well as 27 reported cases of appendicitis or appendiceal perforation due to fish bones.
A 56-year-old man with a 2-day history of right lower abdominal pain was referred to the hospital. Abdominal ultrasonography and abdominal CT scan showed a swollen appendix and a dot-like structure in the lumen of appendix. Thus appendectomy was performed with a diagnosis of acute appendicitis with enterolith. It disclosed that the entire appendix had swollen and a fish bone 2.5cm in length had penetrated the end of the appendix.
Foreign objects of the appendix are frequently caused by fish bones in our country and are prone to perforation. Preoperative diagnosis of appendicitis or appendiceal perforation due to a fish bone is often difficult, however, the presence of a fish bone must be considered if some linear structure is demonstrated by abdominal imaging studies. Further, in diagnosing a patient complaining of right lower abdominal pain with an abdominal tumor, we must keep in mind that an ingested fish bone may cause perforation of the appendix and form an inflammatory tumor.

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A 56-year-old male patient with complaint of upper abdominal pain was admitted to our hospital with the diagnosis of acute peritonitis. Acute appendicitis was suspected by a CT study of the abdomen and the patient was first treated conservatively. On the 7^th day of admission SMV thrombosis was discovered by a CT study and continuous intravenous heparin infusion was started. On the 12^th day of admission pain in the right lower quadrant of the abdomen increased and on the 13^th day a laparotomy was performed with ileocecal resection. Pathological diagnosis was gangrenous appendicitis. The postoperative course was uneventful and oral warfarin treatment was continued. On the 136^th postoperative day SMV thrombosis was found to have disappeared by a CT study. SMV thrombosis is relatively rare disease and its diagnosis is sometimes delayed because of lack of specific symptoms. In case complicated with appendicitis, the thrombosis could progress as inflammation worsens and could cause bowel necrosis. It is important, therefore, to make its early diagnosis and start appropriate control of inflammation. Our case presented here did not cause bowel necrosis, but the inflammation progressed under conservative management. In such a case, an aggressive surgical treatment for the original disease should be undertaken without delay.

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A 75-year-old male was admitted to our hospital complaining upper abdominal pain. Abdominal CT scan visualized a cystic lesion 12×6×6cm in diameter with partial calcification on the wall. The tumor existed between the gall bladder and the cecum, lying on the back of the ascending colon. Preoperative diagnosis was retroperitoneal neurogenic tumor or mesenteric cyst. However, the operative diagnosis was mucinous cyst adenoma of the appendix. We performed right colectomy considering malignant potential from its size. No malignant findings were revealed by histological examination.

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The patient was a 77-year-old man who had suffered sudden lower abdominal pain during a bowel movement. Abdominal computed tomography showed marked dilatation of the sigmoid colon which contained massive amounts of stool, and ascites. The patient underwent emergency laparotomy for generalized peritonitis, suspecting perforation of the sigmoid colon. During the operation, a laceration 4cm in diameter was found at the sigmoid colon, and 400 ml of intra-abdominal bleeding was also noted. Neither perforated lesion nor tumorous changes were recognized. On microscopic examination, both ischemic change and a split muscle layer from the colon serosa were observed. The chronic ischemic colitis due to feces might have been the consequence of the laceration of the sigmoid colon which occurred during the bowel movement.

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The patient was a 54-year-old man, who had a long history of type 1 diabetes mellitus for 33 years. Simultaneous pancreas-kidney transplantation was performed from a cadaveric donor in 2006. Prophylaxis with intravenous ganciclovir was done for 8 days posttransplantation due to CMV mismatch combination (seropositive donor to seronegative recipient). On postoperative day 27, diarrhea occurred and he was CMV antigenemia-positive. After resuming intravenous GCV, diarrhea disappeared and data of CMV antigenemia went into remission. Thus, he was discharged on postoperative day 55. However, he was rehospitalized because fever and explosive diarrhea on the fifth day after discharge. Colonoscopy showed multiple scattered reddish spots on the rectum from the cecum. Pathological examination of the reddish mucosa immunohistochemically revealed CMV-positive cells, so the diagnosis of CMV colitis was confirmed. The risk of CMV disease is the highest among CMV-seronegative recipients of a graft from seropositive donors on pancreas transplantation. Strong prophylaxis for CMV and careful monitoring were required.

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A 77-year-old woman complaining of nausea and vomiting was referred to the department of internal medicine of our hospital. Abdominal plain radiograph showed abnormal calcification of the right abdomen, and abdominal CT scan revealed well-thickened colonic wall and nodular calcification. Colonoscopic examination disclosed purple-blue edematous mucosa from the cecum to transverse colon. In view of these findings, she was diagnosed phlebosclerotic enteritis and has been given conservative treatment. Since the treatment proved ineffective, laparoscope-assisted surgery was performed in December 2002. Phlebosclerotic enteritis was confirmed by histopathological findings. The postoperative course was uneventful, and she is doing well without recurrence 5 years after surgery.

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A duodenocolic fistula caused by colon-diverticulum is rarely reported. We experienced such a case of fistula, which was diagnosed with symptoms of gastro-duodenal ulcer, as a turning point. The patient was a 71-year-old man who also had symptoms of gastro-duodenal ulcer 4 years earlier. He was afebrile, but his CRP and white cell count were high in the laboratory examination. Abdominal CT showed a tumor-like and abscess-like lesion at the ascending colon, and edematous hypertrophy of the descending duodenal wall. Abdominal CT 6 months before on admission also had revealed the same findings. Upper and lower barium examination revealed a fistula of the descending duodenum and the ascending colon, which seemed to communicate with each other. Upper and lower endoscope examinations showed no tumor, but there was colon oppression from the outside. The fistula, ascending colon, and partial duodenal wall were resected surgically. Pathological findings revealed no malignant lesion, and it seemed that the fistula was possibly caused by inflammation and the abscess induced from the diverticulum.

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A patient, 81-year-old female, came to see her private physician with complaints of fever and right lower abdominal pain. The patient was admitted to our hospital with possible diagnosis of acute appendicitis. Physical examination revealed a fist sized tumor accompanied with tenderness and peritoneal irritation sign in the right lower quadrant of the abdomen. A flat plate of abdomen revealed a tumor like shadow with irregular consistency. A CT study revealed a cystic tumor with ring like peripheral calcification with long diameter of about 60 mm, connecting to the lumen of the ascending colon. Diagnosis of a giant diverticulum of the colon was made and ileocecal resection was performed on the following day. Histopathological study revealed lack of muscular layer in the diverticulum and was diagnosed as pseudodiverticulum with severe inflammation. This is the report of our experience of surgical resection of diverticulum of the ascending colon which was difficult to differentiate from acute appendicitis. We report this case with some review of literatures.

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Diverticulitis of sigmoid colon with colovesical fistula is rare. Laparotomy was the standard surgery, but cases of laparoscopic surgery are reported in recent years. We experienced 5 cases of laparoscopic surgery for fistulized diverticulitis between 1998 and 2006. There was no conversion case to laparotomy. The mean operative time was 194 minutes. The mean hospital stay after surgery was 14.6 days. There was no mortality. Postoperative morbidity consisted of one ureterostenosis and one subcutaneous abscess. In our cases, the bladder wall required no sutures or staplings. Laparoscopic surgery is safe and could be carried out even for diveticulitis of sigmoid colon with colovesical fistula.

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The patient was a 71-year-old male. He had lower right abdominal pain at night. The pain became worse rapidly 12 hours after the on-set of the symptom. He had tenderness in the lower right abdomen. The rectal temperature was 39.1°C, which was relatively high compared with surface body temperature of 37.1°C. The abdominal CT revealed a colon tumor with enlargement of the distal ascending colon. According to the preoperative examination, intestinal obstruction by ascending colon cancer and colon perforation were suspected. On the same day the patient came in, an emergency operation was performed. As the operative findings, a tumor of the ascending colon, measuring 5cm in diameter, with extension to oral side of the colon was discovered. Two longitudinal colonic wall injuries measuring about 10cm were noted on the ascending colon. A large amount of seeds of watermelon and corns was suctioned from the intestinal tract. Right hemicolectomy, with ileostomy and colostomy was performed. No complications occurred in the postoperative course and he was discharged on the 23rd day after the operation.

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A 92-year-old woman was admitted to our hospital complaining of left lower abdominal pain and bloody mucinous attachment on her underwear. The smooth tumor with irregular lesion was partly palpable at the 3 cm oral side from the anal verge. Colonofiberscopy visualized a submucosal tumor with ulcer and a type 2 tumor near the anal verge. Gastrografin enema showed the tumor as a hay-fork sign, and intussusception was not reduced by inflation. We suspected that the mass might cause intussusception. Pelvic CT revealed the low density mass at the lower rectum. Hartmann's operation was performed under a diagnosis of rectal cancer with intussusception.
We present this case with some bibliographical comments, because intussusception caused by rectal cancer is very rare.

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A patient 71-year-old female came to the emergency room of our hospital with the complaint of vomiting and upper abdominal pain. Blood study revealed WBC of 11,100/μl, CRP of 0.5 mg/dl and serum amylase of 1472 IU/L and a diagnosis of acute mild pancreatitis was made and she was treated with pancreatic enzyme inhibitors, antibiotics and intravenous fluid administration. The value of serum amylase came down to normal on the 2^nd day of treatment, but the abdominal pain worsened along with elevation of WBC and CRP value. Abdominal CT revealed a vague tumor shadow of 3×1.5 cm size on the midline of upper abdomen directly beneath the abdominal wall. On the 9^th day of admission this tumor grew to the size of 7×4 cm with low consistency stripe pattern inside. Necrosis of ligamentum teres hepatis was suspected and laparotomy was performed which revealed abscess formation of the inflamed ligament. The culture of the specimen revealed Enterobacter cloacae and histological study revealed necrotic panniculitis. Abscess of ligamentum teres hepatis is classified as acute abdomen, but it is very rarely reported and therefore we report its surgical significance here.

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The patient was a 76-year-old male, who was seen at an another hospital with a complaint of melena. He was diagnosed as Sigmoid colon cancer and hepatic metastases. We only performed sigmoidectomy because his performance status was not good, and hepatectomy seemed to be difficult. After operation, We started a FOLFOX4 regimen. After 8 courses of FOLFOX4, a reduction of hepatic metastases was observed, and it was difficult to continue the chemotherapy due to a side effect. Then we performed hepatectomy. In the histopathology, an adenoma was found in one area, but only necroses and calcification remained otherwise as a result of the chemotherapy. Hepatectomy after chemotherapy seemed to be a useful treatment for unresectable hepatic metastasis.

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A 65-year-old man who had been pointed out to have a liver cyst and pancreatic IPMN was regularly followed at our hospital. Periodic examinations by US detected the irregularity and growth of the wall in the liver cyst. CT and MRI showed the same findings. Then FDG-PET examination resulted that liver tumor showed an upward curve of SUV although no malignant finding was detected on the IPMN. Then we performed left lobe lobectomy of the liver without resection of the pancreatic IMPN. Pathological diagnosis was biliary cystadenocarcinoma with adenoma without ovarian like stroma. Until now he has been well with no evidence such as the recurrence of biliary cystadenocarcinoma and malignant change of IMPN. This case is very rare and there is no report of biliary cystadenocarcinoma with IPMN except our report, therefore we report this case with some bibliographical comments.

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A 64-year-old man was admitted to our hospital because of epigastralgia and pyrexia. An abdominal enhanced CT showed a liver tumor, 7 cm in diameter in segment 4, with portal vein thrombosis in the umbilical portion. Although the presence of high grade fever and positive blood culture for Klebsiella. pneumoniae suggested a diagnosis of liver abscess, serum AFP level of 215ng/ml and PIVKA II level of 777mAU/ml indicated the diagnosis of liver cancer. After the treatment of bacteremia by intravenous administration of antibiotics, an extended left hemihepatectomy was performed with curative intention. After 7 months from the operation, the patient died of recurrent disease with little response to chemotherapy.

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We reviewed the clinical course of 18 patients with recurrent bone metastases after hepatic resection for hepatocellular carcinoma. We performed 249 operations for 209 patients and then on 151 patients who thereafter had a recurrence. 10 were treated for a liver recurrence, 4 for a synchronism recurrence in liver, and one with a metastatic lung tumor. Only 3 patients had bone metastases without recurrence in liver or lung. Diagnosis was done by CT 10, bone scintigram 12, MR 9, and autopsy 1. 10 patients showed abnormally high results of tumor marker. Symptoms were pain 13, numbness 1, tumor palpating 1, asymptomatic 3, and body paralysis in the lower part of the body in 10 patients. After radiotherapy was performed for 14 patients and symptom relaxation by opioid dosage for 4, the average duration of life after diagnosis was 5.1 months. There was no correlation between the quantity of radiation exposure and the prognosis after radiotherapy. Paralysis in the lower part of the body was accompanied by QOL deterioration and poor prognosis for patients with early diagnosis of vertebra metastasis. Early recurrence with metastases to the bone is a distinct possibility for high-risk patients. Informed consent which takes metastases to the bone into consideration is necessary for patients with recurrence in liver or lung.

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Xanthogranulomatous cholecystitis is an uncommon inflammatory disease of gallbladder and difficult to deffirentiate preoperatively from gallbladder cancer. We experienced a rare case of Xanthogranulomatous cholecystitis (XGC) accompanied by duodenum stenosis. A 51-year-old man was admitted complaining of inappetence and vomiting. An upper GI series showed a duodenum and pylorus stenosis. Abdominal computed tomography revealed a gallbladder with a thickened wall and possible infiltration to the liver and duodenum. The preoperative diagnosis was gallbladder cancer with liver and duodenum invasion. Extended cholecystectomy and gastroduodenostomy was performed. An intraoperative frozen section diagnosis did not reveal any cancer cells. The histological diagnosis of the resected specimens was xanthogranulomatous cholecystitis.

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A 70-year-old man with bile duct cancer underwent pancreatico-duodenectomy in May, 2002. Pathological findings revealed lymph node metastasis and tumor infiltration to the pancreas head. Twenty-three months after surgery, a local recurrence was pointed out and he was treated with gemcitabine (GEM) with his informed consent. However, repeated fever frequently occurred as of January 2005, and abdominal CT revealed the increased massive recurrent tumor and dilated jejunal loop. Since we diagnosed the patient as jejunal loop obstruction due to recurrent tumor, we performed side to side anastmosis of the afferent and efferent loop. After this operation, he underwent treatment with TS-1 for 17 consecutive months. Because ascites increased and ingestion became difficult, the treatment was changed to best supportive care, and he died at April 2007, 58 months after his first operation.

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A 37-year-old woman was seen at the hospital because of epigastric pain. A sharply demarcated tumor 4cm in the maximum diameter involving cystic components in it was present at the pancreas head. The CA19-9 level was high, 135U/ml. A cystic tumor of the pancreas was suggested and total pyrolus preserving pancreatoduodenectomy was performed. Hemorrhage and necrosis were demonstrated on the inside of the tumor and osteoclastic polynuclear giant cells were identified. Thus giant cell type anaplastic ductal carcinoma of the pancreas was diagnosed. The patient has been free from any recurrence, as of 3 years after the operation.
Giant cell type anaplastic ductal carcinoma of the pancreas is relatively uncommon and only 34 cases have been reported in Japan. This case is presented here, together with a review of documented cases in this country so far.

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The prognosis of adrenocortical cancer is poor, and there is not established treatment for progressive and recurrent adrenocortical cancer. We report a case of adrenocortical cancer successfully treated with chemotherapy.
The patient was a 29-year-old woman. She had been treated for malignant lymphoma with chemotherapy at the age of 17. When she was 27 years old, she was referred to the hospital because of a retroperitoneal tumor detected by a CT scan performed for persistent fever. No definite diagnosis was made and thus laparotomy was performed. The tumor was diagnosed as anaplastic carcinoma by an intraoperative rapid histopathological study. We did not perform surgical resection, and started chemotherapy (Etopside+CDDP). But the final histopathological diagnosis was adrenocortical cancer. We thus performed surgical resection after three courses of the chemotherapy. One year four months after the surgery, peritoneum recurrence was detected and the same chemotherapy (Etopside+CDDP) was performed. The tumor of the peritoneum reduced after eight courses of the chemotherapy.

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Case 1 : A 34-year-old man was admitted with a chief complaint of left lower abdominal pain. The diagnosis of intestinal obstruction was made. A contrast study by long tube showed a stenosis at the ileum. An abdominal CT scan revealed an incarcerated small bowel loop at the posterior aspect of the sigmoid mesocolon. A diagnosis of internal hernia related to sigmoid mesocolon was made and an emergency surgery was performed. Laparotomy showed a strangulated intersigmoid hernia. The necrotic ileum was resected and the hernia orifice was closed with sutures.
Case 2 : A 68-year-old man was admitted with a chief complaint of lower abdominal pain. An abdominal CT scan showed the expanded discontinuous small bowel around the sigmoid mesocolon and the loop-shaped small bowel. A diagnosis of intersigmoid hernia was made and an emergency surgery was performed. At laparotomy, the incarcerated ileum was reduced. The bowel was viable and the hernia orifice was closed.
Intersigmoid hernia is a very rare clinical entity. Thirty five cases, including our cases, have been reported in Japanese literature. Contrast study by long tube and abdominal CT scan are useful for the diagnosis of intersigmoid hernia.

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A 72-year-old male who was indicated liver impairment at a medical check-up in August 2006 consulted our hospital. Abdominal CT scan showed a tumor, 5cm in diameter, contacting to the greater curvature of body of the stomach. There were no abnormalities on the gastric mucosa by endoscopic examination. Gastric gastrointestinal stromal tumor was suspected, and the tumor was extirpated by laparoscopic surgery on October 27. The tumor was generated from the transverse mesocolon. Histopathological examination showed proliferation of spindle cells in bundle arrangement, without nuclear fission images. Immunohistochemical studies resulted in c-kit(+), CD34(+), and NSE(+). Thus GIST originating from the transverse mesocolon was diagnosed. We report this rare case of extragastrointestinal stromal tumor (EGIST) together with recent domestic cases and some bibliographical comments.

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Transepiploic hernia is a rare disease in a kind of intraabdominal hernia. This disease lacks specific physical features, making a preoperative diagnosis difficult. From 2003 to 2006, we experienced five cases of transepiploic hernia which could be preoperatively diagnosed by abdominal CT scan and ultrasonography. Three cases were men and two were women ranging in age from 73 to 91 years (mean : 79.2). Abdominal CT scan showed the localized small intestine over the colon and into the omental bursa with dilatation and radial distribution of mesentery. Abdominal ultrasonography showed the anatomic relations of organs and a fat lump which seemed like mesenterium near a hernia hilus.
Even in a case of ileus without a past history of laparotomy, transepiploic hernia should be included in the differential diagnosis. Early diagnosis by abdominal CT scan and ultrasonography is important.

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A patient, 60-year-old female, came to our hospital with complaint of palpable tumor in the left lower quadrant of her abdominal wall. Abdominal echo and CT studies revealed a tumor of 4.0 cm in diameter underneath the left rectus abdominis muscle. Extension of inflammation or infiltration of the mass to the omentum and surrounding tissue was suspected. Biopsy study confirmed the diagnosis of actinomycosis. Excision of the abdominal wall mass along with the omentum adhered underneath was performed. There was no involvement of the bowel nor extention of intraperitoneal inflammation. The culture of the specimen revealed Klebsiella oxytoca only. Histopathological study revealed granuloma and cluster of fungus and the diagnosis of actinomycosis was made. Report of actinomycosis of the abdominal wall is relatively rare in our country and only 16 cases including ours were reported up to now. It is possible to make preoperative diagnosis by biopsy, and so the possibility of actinomycosis should be considered in case of inflammatory abdominal wall mass. Surgical resection is the treatment of choice and selection of antibiotics considering the possible presence of mixed infection is important.

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Two cases of umbilical polyp are reported. Case 1 was of a 2-year and 6-months-old boy who had an moist umbilical swelling since removal of the umbilical cord, and the skin surrounding the umbilicus was eroded. Case 2 was of a 2-year-old girl who had an umbilical polyp-like mass. In both cases, laparotomies were performed, and the tissue underneath the umbilicus was resected. There was no abnormal intra-abdominal structure connecting with the umbilicus. Histological examination of the resected tissue in Case 1 showed ectopic pancreatic tissue and gastric tissue, while Case 2 had large intestinal mucosal tissue. In cases of umbilical granuloma under long-term medical treatment, umbilical polyp must be suspected, and surgery may be required.

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