Objective : Although the detection of a positive margin is widely known to be closely linked to local recurrence of breast cancer in breast-conserving therapy, methods for intraoperatively evaluating resected margins during breast-conserving surgery are not necessarily standardized. In the present study, we investigated the usefulness and drawbacks of intraoperative stump imprint cytology (hereafter, stump cytology), which is used in our departments.
Subjects and methods : Among a total of 308 patients who underwent breast surgery between 2005 and 2007, we investigated 160 patients who underwent breast-conserving surgery as well as stump cytology with regard to their results on stump cytology in addition to permanent tissue samples.
Results : Stump cytology had a sensitivity of 70.0%, specificity of 97.1%, and a diagnostic accuracy of 93.8%. Six false-negative and four false-positive results were obtained. A total of 18 patients had a positive result on stump cytology, while eight patients had cancer based on the permanent tissue samples prepared from additionally resected parts. The directions of positive results on stump cytology were papillary (n=16), lateral (n=5), and opposite the papilla (n=2).
Conclusion : These findings suggest that stump cytology is a simple and useful method for intraoperatively evaluating margins during breast-conserving surgery.

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Background......The report on the long term follow up of breast cancer in which axillary lymph node dissection (ALND) is spared because of negative sentinel lymph node biopsy (SLNB) indicates about 1% recurrence rate of cancer in the axillary lymph nodes (ALN). However, no detailed reports regarding the recurrence of cancer in the ALN are present so far. We studied this time the recurrence of cancer in the ALN after negative SLNB.
Materials and Methods......Among 670 cases of SLNB of breast cancer performed between Jan. 2000 and Dec. 2007, 566 cases showed negative results, and therefore ALND were spared. During the average follow up period of 40 months, 9 cases (1.6%) of recurrence of cancer in the ALN were observed. In these 9 cases, a study was done regarding to the background factors, treatment modalities and prognosis.
Results......Histopathological study revealed the presence of scirrhous carcinoma in all cases. Histological grade of malignancy was grade 3 in 6 cases (67%) and in 5 cases (56%) vascular invasions were seen. In 6 cases (67%), hormone receptors were negative. Recurrences occurred in average of 16.1 months and ALND were performed in all cases. In 4 cases, more than 7 ALN metastases were involved and in all cases supraclavicular lymph nodes or distant metastases were seen. In 5 cases with less than 3 ALN metastases, only one case showed supraclavicular metastasis and received radiation therapy resulting in CR and all the cases are alive without cancers.
Conclusion......The risk factors for the ALN recurrence were histological grade, presence of vascular invasions and negative hormone receptors. ALN recurrence with multiple positive nodes are prone to have other sites metastases and radiation therapy or chemotherapy should probably be indicated.

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Interstitial pneumonia is a potentially fatal complication after surgery. Between April 2003 and March 2007, 182 patients underwent thoracotomy for esophageal cancer-related diseases in our hospital. Of these, 7 (4%) developed interstitial pneumonia. In this study, we studied the backgrounds, treatments and prognoses of these 7 patients. We found that all were men (mean age : 67 years) with history of smoking. Five had undergone esophagectomy for esophageal cancer, one had gastric tube cancer and received a distal gastrectomy using the left thoracoabdominal approach, and one had a gastric tube-lung fistula and underwent bypass surgery using the right colon. They all received steroid-pulse therapy, after which the steroid dose was gradually reduced. In four cases, however, pneumonia shadows redeveloped, and three (43%) died in hospital of interstitial pneumonia. In two of the patients who died, the dose of steroid was re-increased again after reduction, and two had received chemoradiotherapy. All three suffered from malmutrition and MRSA infection in their sputum. It has been suggested that cases with malnutrition or MRSA infection, and cases treated with pre-operative chemoradiotherapy or repeated steroid therapy are the coses leading to poor prognoses when interstitial pneumonia develops after sugery for esophageal cancer-related disease.

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The aim of this study was to evaluate the safety of early oral feeding in patients after distal gastrectomy for gastric cancer. Since 2005, we introduced early oral feeding clinical path in 66 patients undergoing Roux -en Y reconstruction after distal gastrectomy for gastric cancer. They were scheduled to remove nasogastric tubes immediately after surgery ; to start drinking in the morning of the 1^st postoperative day ; to start thin rice gruel from the morning of the 2^nd or 3^rd day. As a result, all patients were able to remove nasogastric tubes and to start drinking, 3 patients were not able to start oral intake because of abdominal distention (n=2) or anastomotic hemorrhage (1), 8 patients stopped eating because of rest stomach dilatation (3), abdominal distention (2) or fever (3). Namely, 55 patients (83.3%) were able to follow the early oral feeding clinical path schedule perfectly. The incidence of complications including nausea, vomiting, abdominal distention (10), fever (5), anastomotic leak (0), pneumonia (1), ileus (4) was low. Postoperative early oral feeding can be carried out safely on patients after distal gastrectomy.

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A 1-year-old boy presented with a left submandibular mass which started to enlarge gradually from six months after birth. When he was first seen at the hospital, the mass showed an elastic soft tumor, 3cm in diameter, without signs of inflammation and tenderness. Ultrasonography revealed a cystic mass including a high echoic lesion inside. There were no findings in the oral cavity. We diagnosed the tumor as submandibular ranula. Needle puncture was unsuccessful because of viscous content. We injected OK-432 into the cyst after draining the transparent and gelatinous content from a small skin incision. The mass recurred two months later. As the former treatment was determined to be ineffective the cyst was removed surgically by collar incision. The mass was present close to the salivary glands and progressed toward the oral cavity. The cyst wall was thin without epithelial lining, but stratified squamous epithelium, keratinized substance and hair follicles were found in a small part of the cyst wall. The pathological diagnosis was dermoid cyst. In this case, the basic structure of the cyst was submandibular ranula and the skin tissue was considered to be an abberated origin.

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We reported here a 55-year-old woman with uterine metastasis from breast cancer detected by instrumental FDG-PET/CT after mastectomy for right breast cancer (invasive lobular carcinoma, pT2, pN1, pM0, stageIIB, estrogen receptor (ER) (+), progesterone receptor (PgR) (+)). At the age of 53, she under went left axillary lymph node dissection for contra-lateral lymph node metastasis followed by endocrine-therapy of aromatase inhibitor. One and a half year after the surgery, a serum tumor marker (CEA) had gradually elevated. FDG-PET/CT revealed a pale increased uptake of radioisotope in the uterus and MRI demonstrated an enhanced diffuse enlarged uterus. Endometrial tissue specimens revealed suspicion of uterine metastasis of poorly-differentiated adenocarcinoma. Hysterectomy and adnexectomy were performed, and histopathological findings revealed diffusely infiltrative carcinoma, ER (+) and PgR (+), compatible with uterine metastasis from lobular carcinoma of right breast. Twenty-one months after the surgery, she has survived and is under treutmcnt with chemotherapy for skeletal and peritoneal relapses without major complaints.

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A 35-year-old female presented with a palpable mass, 1.9 cm in diameter, located in the inner upper quadrant of the left breast. Mammography showed an indistinct mass. On ultrasound, an irregular-shaped, hypo-echoic lesion was noted. MRI showed a high intensity tumor with peripheral enhancement. The tumor was diagnosed as an invasive ductal carcinoma, possibly a scirrhous carcinoma based on pathology of a needle core biopsy. The patient had breast-conserving surgery with a sentinel lymph node biopsy. The specimen contained a solid, yellowish-brown tumor. On histopathology, the tumor was found to be composed of overt carcinoma, a direct transition to a cartilaginous matrix without an intervening spindle cell zone or osteoclastic cells was noted. Matrix -producing carcinoma is an extremely rare subtype of metaplastic carcinoma. We report a Japanese MPC case and review other Japanese MPC cases.

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A 45-year-old female had a synovial sarcoma located in the left femoral region resected a year before being admitted due to lung metastases. After the first pulmonary resection, due to repeated pulmonary metastases five more resections were performed over a ten-year period. After having six complete resections, yet another metastasis was detected in the left main bronchus. Since, for this metastasis a left pneumonectomy was necessary to be able to do a complete resection, endobronchial laser therapy followed by chemotherapy was selected in order to avoid a left pneumonectomy. The patient was doing well nine months after chemotherapy, although she had residual tumor. Lung metastasis is a significant prognostic factor for synovial sarcoma. It is essential to treat lung metastasis by complete resection while preserving as much pulmonary parenchyma as possible. However, therapies other than surgery should be considered especially when pneumonectomy is contraindicated due to limited pulmonary reserve or when surgery would be difficult to do due to the presence of pleural adhesions related to previous thoracotomies.

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A 54-year-old male with cough, chest pain, and dyspnea was diagnosed as having a right tension pneumothorax. Although chest drainage was instituted, the patient had a persistent air leak. Wedge resection of the lung was done during Video-Assisted Thoracic Surgery. An 8-mm nodule was found in the resected lung parenchyma. Based on the histology, a large cell neuroendocrine carcinoma was diagnosed. Therefore, a right upper lobectomy with lymph node dissection was performed ; no remnant cancer tissue nor lymph node metastasis was noted. This paper deals with a case of primary lung cancer found incidentally during surgery for spontaneous pneumothorax.

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Toxic shock syndrome (TSS) is a severe vigorous multisystemic disorder resulting from a Staphylococcal exotoxin. To date, seven cases of TSS following gastrectomy have been reported in Japan. This report describes a rare case of toxic shock syndrome after gastrectomy.
A 68-year-old man, with IIc type gastric carcinoma at the upper body of the stomach by a medical check-up, was admitted to our hospital and underwent distal gastrectomy with level 2 lymph nodes dissection. Despite prophylactic administration of CEZ for postoperative 3 days, remarkable increases in the white blood cell count and CRP and high fever were noted on the first postoperative day, followed by hypotension on the 3rd p.o.d.when the patient went into shock. CRP was changed to PAPM/BP, but he developed DIC and ARDS on the 4th p.o.d.. Erythroderma around the surgical wound was noted on the 5th p.o.d.. Methicillin resistant staphyrococcus aureus was cultured from the surgical wound and was identified the presumed etiologic agent in the patient's life-threatening illness, toxic shock syndrome toxin-1 (TSST-1) producing from the nasal cavity. Culture of the infected wound yielded MRSA that had produced TSST-1. The patient recovered fully with supportive care, antibiotics, and surgical debridement of the surgical wound. Early recognition and prompt aggressive symptomatic treatments based essentially on fluids administration, appropriate intravenous antibiotics may avert the significant morbidity with TSS.

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A case of gastrointestinal stromal tumor of the stomach presented ball valve syndrome in herein described. An 80-year-old woman with vomiting, abdominal fullness and melena was admitted to our hospital. Abdominal computed tomography scans visualized a tumor 5 centimeters in diameter in the duodenal bulb. Gastrointestinal endoscopy revealed that the elevated lesion was incarcerated into the duodenal bulb, and endoscopic reduction of the impaction was unsuccessful. The whole body of the tumor was unrevealed. Endoscopic ultrasonography showed the tumor originated from the fourth layer of the stomach. At surgery, we incised the anterior wall of the pyloric antrum and comfirmed that the tumor was a submucosal tumor. We reduced the tumor into the the stomach by hands, and performed a distal gastrectomy. Pathologically, the tumor, which measured 5 centimeters in diameter, was a gastrointestinal stromal tumor originated from the proper muscular layer and was positive for c-kit and negative for smooth muscle actin and S-100 protein on immunostainings. Gastrointestinal stromal tumor of the stomach was diagnosed with certainty.

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A 63-year-old woman was admitted to the hospital because of vomiting of blood.
Enhanced abdominal CT disclosed a huge tumor at the left upper abdomen and left pleural effusion. Biopsy was performed and the histopathological diagnosis was gastrointestinal stromal tumor. Because of huge size and invasion, resection was thought to be difficult. Administration of imatinib 400mg/day was started since January 2006. Pleural effusion disappeared by the end of two months, and the tumor reduced its size about 30% in 7 months after start of the treatment. Over 100weeks, the effect of imatinib was observed. However, under consideration of development of late resistance to imatinib, resection was thought to be optimum if possible. So surgery was done in January 2008, and the resected specimen was 1360g, including the spleen and portion of the stomach. The patient was discharged from the hospital 3 weeks after the operation. As adjuvant chemotherapy, imatinib 400mg/day has been administered after surgery.

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A 31-year-old man had been diagnosed as iron deficiency anemia at 27 years of age, and gastrointestinal endoscopy at the time revealed numerous small and large polyps at the gastric angles and in the antrum. The pathological diagnosis was juvenile polyps of the stomach, and a further study revealed adenocarcinoma in a small area of the lesion. Piecemeal endoscopic mucosal resection was performed, and recurrence of a polypoid lesion and atypical epithelium were found around the scar after the follow up of about 3 years. Distal gastrectomy and lymph node dissection was performed. Juvenile polyposis is generally recognized as characterized as benign hyperplastic polyps, but its malignant potential has recently been noted. Generally total gastrectomy is recommended for juvenile polyposis of the stomach. Local resection or distal or proximal gastrectomy may be used to treat localized lesions.

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The present patient, a 60-year-old female, had a total gastrectomy and pancreatosplenectomy with a Roux-en-Y reconstruction due to gastric cancer in 1997. The pathologic diagnosis was signet ring cell carcinoma, T3 (SE), N1, M0, Stage IIIA, curativity B. Adjuvant chemotherapy with doxifluridin (600 mg/day) was given for 5 years. There were no signs of recurrence during adjuvant chemotherapy. In April 2007, the patient was admitted with dysphagia ; she had lost 10 kg in the previous 6 months. She was diagnosed as having a passage disorder due to recurrent gastric cancer. Surgery was done in May 2007 ; it was found that the tumor had disseminated and had grown over the jejunum, which had been anastomosed ; the surrounding organs were also involved. Esophagojejunectomy, lateral segmentectomy of the liver, and transverse colectomy were performed. On histopathology, the tumor was diagnosed as disseminated signet ring cell carcinoma. Currently, the patient is being given adjuvant therapy, and there is no evidence of recurence. Signet ring cell carcinoma of the stomach tends to relapse early as dissemination. Reports of recurrence occurring more than 10 years after the initial surgery are rare. This report also includes a review of the relevant literature.

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An 82-year-old man was admitted to our hospital for lower extremity edema and dyspnea. Laboratory examination on admission revealed hypoproteinemia (serum total protein 5.0g/dl, serum albmin 3.0g/dl). His urinalysis was normal. Upper GI series, and endoscopic examinations demonstrated a giant tumor on the lesser curvature of upper middle portion of the gastric body. The surface was villous and easy bleeding. In spite of high calorie parenteral nutrition and administration of albumin, his hypoproteinemia did not improve at all (serum total protein 3.9g/dl, serum albmin 2.1g/dl). He was diagnosed as having protein-losing gastric cancer, and a partial resection of the stomach was performed. Histopathological findings showed that general stage of the disease was stage IA with invasion depth of m, n0, ly0, v0 showing villous growth. The leg edema, dyspnea and hypoproteinemia improved remarkably after the operation and no recurrence was found during 7 years of postoperative course. Protein-losing gastric cancer is rare in Japan, most of these cases were treated with distal gastrectomy or total gastrectomy because of tumor size. Our case is the second partial resection of the stomach reported in Japan.

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A 77-year-old woman presented with abdominal pain, nausea and vomiting. Abdominal x-ray and ultrasonography revealed some dilated loops of small bowel. The patient was admitted with the diagnosis of small bowel obstruction. Abdominal computed tomography revealed a partially calcified mass about 3 cm in diameter in the dilated small bowel loop, just to the left of the cavitas pelvis. Gastrographin contrast study of the ileus tube showed ileus of small bowel, and with a preoperative diagnosis of small bowel obstruction, a laparotomy was performed. At operation, an oval hard mass obstructing the ileum about 4 cm in diameter was palpated at 60 cm proximal to the terminal ileum. A partial ileoresection was done, and the mass was removed. A yellow-brown enterolith which measured 4.5×3.5×2.0 cm was extracted. Chemical analysis revealed that the enterolith contained mainly deoxycholic acid. Postoperatively, an upper gastrointestinal x-ray series and gastroscopy were performed that showed the presence of diverticula in the third part of the duodenum and enteroliths in each of them, and normalcy of the gallbladder. For the reasons mentioned above, the diagnosis of small bowel obstruction secondary to a duodenal diverticular enterolith was made.

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Churg-Strauss syndrome is a relatively rare disease that is characterized by bronchial asthma, eosinophilia, and periarteritis nodosa-like symptoms. We report a churg-Strauss syndrome case with a ruptured inferior pancreaticoduodenal artery aneurysm. A 49-year-old female was on oral steroid treatment due to Churg-Strauss syndrome. She developed abdominal pain. On examination, the entire abdomen was tender. On contrast-enhanced CT, a hematoma in the retroperitoneum and bleeding in the abdominal cavity were noted. The diagnosis of a ruptured inferior pancreaticoduodenal artery aneurysm was made, and embolization was immediately done. The patient was then treated conservatively. The patient's general condition improved, and she was started on full meals, but began vomiting. A diagnosis of duodenal obstruction was made, and she was treated conservatively. However, there was no improvement, and surgery was performed. Based on the intraoperative findings, removing the hematoma would have been difficult ; thus, a gastrojejunostomy was done. To the best of our knowledge, there have been no reports in Japan of Churg-Strauss syndrome complicated by abdominal cavity bleeding.

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A patient, 40-year-old female, was admitted on an emergent basis with the diagnosis of perforation of the duodenal diverticle. CT study revealed a wide spread retroperitoneal emphysema extending from around the inferior vena cava immediately below the diaphragm down to the pelvis, but there was no retention of fluid. Blood study did not reveal the elevation of the markers of inflammation. The conservative management with no oral intake, intravenous infusion of fluid, continuous aspiration through nesogastric tube, antibiotics and administration of proton pump inhibitors was successful. Perforation of duodenal diverticle is a relatively rare pathology and there is no consensus of its treatment. We report here a successful case of conservative treatment for the perforation of duodenal diverticle and evaluated the indication of this type of treatment. If the contamination of the retroperitoneal cavity is severe, an operation should probably be performed, but in case the contamination is not severe and start of the treatment is prompt, a conservative treatment chould be possible. In case the inflammatory reaction gets worse with deterioration of the general condition, an immediate laparotomy with drainage procedure may be necessary.

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The patient was a 34-year-old male who came to our hospital with chief complaints of melena and dizziness. Blood study revealed the presence of anemia and an emergent upper gastrointestinal endoscopic study revealed a bleeding ulceration in an elevated lesion in the descending segment of the duodenum 2cm orally from Vater's papilla. Since it was not possible to stop the bleeding, a surgical excision of the tumor was performed 2 days later. Pathological study of the specimen revealed an ectopic pancreas of Heinrich I type. A small artery and capillary dilatation was present in the base of the ulcer. Surgical treatment was thought to be necessary for the bleeding from a submucosal tumor of the duodenum if a conservative management was not successful. Ectopic pancreas is asymptomatic in most of the cases and usually found incidentally in surgically excised specimens or at autopsies. We report here a recently experienced rare case of bleeding from an ectopic pancreas.

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A 59-year-old man complaining of right hypochondralgia was admitted to our hospital with a suspicion of diverticulitis. Temporary improvement was gained by using antibiotics, however, restarting diet exacerbated this symptom. Therefore exploratory laparotomy was performed. There was an intraperitoneal inflammatory tumor involving a part of the jejunum and transverse colon. The resection of the tumor with partial jejunectomy and transverse colectomy was performed. Abscess formation was noted inside of the tumor and in the tumor, a toothpick was found penetrating from the jejunum. Penetration of the small intestinal wall by the toothpick was diagnosed.
Penetration of the digestive tract by a toothpick is rare and sometimes it becomes difficult to diagnose unless we know the history of accidental ingestion. Penetration of a foreign body should be considered as one of the causes for acute abdomen of unknown origin.

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The patient was a 56-year-old woman suffering from SLE for about 32 years. She visited our hospital with the chief complaint of lower abdominal pain. Since free air in the abdomen was detected by abdominal X-ray and CT scanning, perforation in the lower digestive tract was diagnosed, and laparotomy was performed. Retention of pyoascites was observed in the abdominal cavity and a perforation was detected in the lower ileum. Partial resection of the ileum with the perforated site was performed. Microscopic examination of the resected small intestine disclosed marked necrotizing vasculitis of small and medium-sized arteries with fibrinoid degeneration and inflammatory cell infiltration in and around the affected blood vessel walls were noted.
The patient survived the first operation, but the perforation of the colon and the different segment of the ileum occurred in different times and died due to the development of MOF.

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A 59-year-old male complaining of abdominal pain was admitted to our hospital with a diagnosis of intestinal obstruction and underwent conservative therapy. Melena occurred on the 2nd hospital day and emergency colonoscopy revealed ischemic changes of the sigmoid colon. Ischemic colitis of the sigmoid colon was diagnosed and the conservative therapy was resumed. Temporary symptomatic remission was gained, but restarting diet induced abdominal pain and abdominal distension again. Abdominal x-ray film showed small intestinal obstruction, so that a long tube was inserted. Abdominal CT scan showed thickened wall of the small intestine, but his symptoms subsided and he was discharged from the hospital on the 30th hospital day. However lower abdominal pain recurred, and he was readmitted to the hospital and underwent laparotomy on the 7lst day after the onset of the symptom. At the operation, the small intestine about 15 cm in length and about 150 cm distant from the Treitz'ligament was flared up and firm, but no signs of embolization were observed at the mesentery. A 60cm-long portion of the small intestine including the edematous portion was resected. The resected small intestine revealed thickened wall with redness and fibrosis in the submucosal layer microscopically, and it was diagnosed as ischemic enteritis.
We report a rare case of ischemic stenosis of the small intestine associated with ischemic changes of the sigmoid colon.

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A 73-year-old male was admitted with an ileus and an abdominal wall abscess. His past medical history included alcoholic dementia and abdominal surgery due to a gastric ulcer at 56 years of age. The patient was given decompression therapy using a long ileus tube ; the ileus improved within one week. Although the abdominal wall abscess was incised and drained, the treatment was not successful. Thus ileus recurred along with signs of a strangulated obstruction. Emergency surgery was done. During surgery, a strangulated intestinal ileus due to an adherent band between the abdominal wall and the ileum located 50cm from the ileum end on the antimesenteric side was found. The adherent band connected the abdominal wall abscess to the ileum. The band was cut, the strangulated intestinal obstruction was corrected without resection, and the abdominal abscess was removed. The patient's postoperative course was uneventful. In pathology the abscess wall and the small bowel wall were clearly demarcated. It is likely that the abdominal abscess originated in the small bowel diveticulum. We present a very rare case of an abdominal wall abscess caused by an small bowel diverticulum associated with a strangulated ileus due to a band located between the abscess and the ileum. A review of the literature is also provided in this paper.

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We report a case of bleeding from Meckel's diverticulum diagnosed by intra-operative endoscopy. A 52-year-old woman was admitted to our hospital for gastrointestinal bleeding of unknown origin. Computed tomography, conventional endoscopy, angiography and double balloon enteroscopy (DBE) from the mouth showed no apparent bleeding site. DBE from the anus and enterography revealed a Meckel's diverticulum but showed no obvious bleeding site. A minimal laparotomic operation was done. No prominent bleeding site of the small intestine was discovered by intra-operative endoscopy, and the Meckel's diverticulum was resected. The Meckel's diverticulum revealed the heterotopic gastric mucosa but no active ulcerative lesion. However, the bleeding has not recurred. Finally, it was concluded that the prominent bleeding site was the Meckel's diverticulum.

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A 51-year-old man was admitted to the hospital because of abdominal pain and nausea. Laboratory data on admission revealed a slight increase in the white blood cell count. Abdominal CT scan showed a target like sign, and intussusception was suggested. Because he showed a slight degree of inflammation and had no symptoms of peritonitis, we gave an antibiotics and observed the condition of the patient. On the next day, the abdominal pain disappeared and the leukocytosis was relieved. Abdominal CT scan on the same day did not visualize intussusception, and showed a tumor like lesion in the small intestine. We diagnosed it as small intestine tumor and performed laparoscopy-assisted operation on the 3rd hospital day. Operative findings included dilatation about 40 cm in diameter and redness at the lower jejunum. Partial resection of the small intestine including the redness lesion was performed. The resected specimen showed two simple ulcers of Ul-III.
This time, we report the case in which we perfomed the laparoscopy-assisted surgery for intussusception caused by simple small intestinal ulcer and got a good result.

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An 80-year-old woman was admitted to our hospital because of anterior chest pain. There were past histories of diabetes mellitus, hypertension, and unstable angina pectoris. When she was first seen, she showed serious anemia due to melena. Despite gastrofiberscopy, colonscopy, and enteroclysis, the bleeding source was unclear. We suspected a small intestinal lesion, and performed double-balloon enteroscopy. A submucosal tumor with an erosive top was found, and this tumor was considered to be the bleeding source. After percutaneous transluminal coronary angioplasty (PTCA) to treat unstable angina due to intestinal hemorrhage, partial excision of the ileum was performed. The pathological diagnosis was ectopic pancreas of HeinlichII.
We present a case of adult ileal ectopic pancreas confirmed by double-balloon enteroscopy.

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It is known that von Recklinghausen's disease (R's disease) is occasionally associated with gastrointestinal tumors such as neurofibromas and carcinoids. Lately, gastrointestinal stromal tumors (GISTs) in patients with R's disease have been reported with an increasing frequency. We present a case of multiple GISTs of the jejunum associated with R's disease.
A 53-year-old woman with R's disease was admitted to our hospital because of tarry stool and vomiting. Abdominal CT scan revealed a tumor 7cm in diameter in the pelvic cavity, and the tumor was found to be fed by the superior mesenteric artery by abdominal angiography. Laparotomy was performed with a diagnosis of GIST of the small intestine. At surgery a 7cm- and a 2cm-sized tumors were present in the upper jejunum and a 1cm-sized disseminated nodule, in the omentum. Partial resection of the jejunum and removal of disseminated nodule of the omentum were performed. The resected specimes were immunohistochemically positive for KIT and CD34, and were diagnosed as GIST.
A total of 25 cases of GIST with R's disease including out case have been reported in the past decade. Clinicopathological features are discussed, together with a review of the literature.

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A 46-year-old man complaining of abdominal pain was referred to the department of surgery from the department of internal medicine in our hospital with a suspicion of an intraabdominal tumor. No abnormal findings were revealed by endoscopic study. Abdominal CT scan showed a 6cm-sized tumor with an enhancement effect in the lower abdomen and fluid in the pelvic cavity as well. The patient was operated on with a diagnosis of an intraabdominal tumor on November 22, 2004. At surgery there were bloody ascites, about 150ml, in the abdominal cavity and an outgrowing tumor in the ileum at about 210cm distant from the Treitz' ligament. We noted some clots attached to the tumor and a small amount of hemorrhage from it. Thus the tumor was determined to be the bleeding source. Partial resection of the small intestine including the tumor with end-to-end anastomosis was performed. Immunostaining resulted in positive reaction only to c-kit, and thus gastrointestinal stromal tumor (GIST) of the small intestine was diagnosed. The patient has been doing well, as of approximately 3 years after the operation.

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IN December of 1994 a 65-year-old woman underwent her first operation for small intestinal tumor, and the case was diagnosed as a smooth muscle sarcoma. In Aug. 1997, hepatectomy was performed for a liver mass, which was diagnosed as a metastasis. In Nov. 2000, multiple metastases in the omentum were excised and diagnosed as CD34-positive GIST. Laparoscopic lymphnode-dissection of the right common iliac artery was undertaken, in June of the next year, and it was metastasis of the GIST. In July 2002, A tumor appeared in liver S7, and radio frequency thermal therapy (RFA) was conducted twice. A tumor appeared in liver S8, and, in August 2004, a partial liver resection was enforced. In Feb. 2007, an operation was undertaken with the diagnosis of right ovary tumor, She is living now in March, 2008 and is under observation while receiving imatinib on an outpatient basis. There are many reports of aggressively performing radical operations for patients with a long time between their first operation and recurrence. We intend to perform radical operations for later recurrences as much as possible.

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A 59-year-old woman visited the emergency clinic in our hospital because of abdominal pain and vomiting was admitted to the hospital with a diagnosis of intestinal obstruction on May 3, 2007. Symptomatic remission was attained by placing a gastric tube, and the tube was removed. Intestinal obstruction recurred on the evening of May 9, so that a long tube was inserted. The tip of the tube reached to the ascending colon in a few days and her clinical course was observed with clamp. However intestinal obstruction recurred again. Adhesive intestinal obstruction or intestinal obstruction due to a small bowel tumor was diagnosed, and surgery was carried out on May 17. It disclosed an invagination of the ileum ranging 20cm in length at a portion about 100cm proximal to the terminal ileum which was led by a tumor. Partial resection of the small intestine including the tumor was thus performed. Histologically proliferation of oval-shaped or short spindle-shaped mesenchymal cells was noted. Immunological staining was done, and gastrointestinal stromal tumor (GIST) was resultantly diagnosed. The patient has been free from recurrence and is strictly followed in the clinic, as of 11 months after the operation.
In the treatment of intestinal obstruction of unknown origin, a possibility of a small bowel tumor such as a GIST must be kept in mind.

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The patient was a 73-year-old male who showed positive occult blood test of stool and was found to have an elevated lesion in the ileum 5 cm orally from Bauhin's valve by a colonoscopic study. For the further investigation of the lesion, a double balloon small intestinal endoscopic study was performed and a diagnosis of carcinoid tumor was made by a biopsy. An ileocolic resection with lymph nodes dissection was performed. The patient has been followed at our outpatient clinic but no signs of recurrence are seen up to now. Small intestinal carcinoid is one of the difficult pathologies to make preoperative diagnosis depending on the site of origin. We experienced this time a case of carcinoid diagnosed preoperatively by a double balloon small intestinal endoscopy and report it here with some review of the literatures.

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Volvulus of the cecum is a disease that we uncommonly encounter. This time we have experienced two cases of volvulus of the cecum in patients of great ages over ninety.
A 96- and a 92-year-old man presented with ileus with the chief complaints of abdominal pain and vomiting. Following abdominal CT scanning and barium enema study, an emergency operation was performed with the most likely diagnosis of volvulus of the cecum. In the both patients the fixation of the cecum to the retroperitoneum was poor and the ileocecum had been twisted to becom necrotic. Thus the intestinal resection and reconstruction were performed simultaneously. Their postoperative courses were uneventful. Both patients were aged people over ninety who had almost stayed in bed in an institution with special care units for the aged.
Although the disease is comparatively rare, it is prospected to increase with the recent arrival of aged society. Accordingly it must be kept in mind in making the diagnosis and selecting treatments for aged patients with ileus. At present when intestinal resection can be done safely even for the aged people, the resection of the twisted ileocecum should be the operative procedure of first choice, considering possible postoperative recurrence of the volvulus.

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A 75-year-old man who visited the hospital because of right lower abdominal pain in May 2006 showed remarkably elevated levels of white blood cell counts and CRP in blood examinations. Abdominal CT scan disclosed a tumor shadow with calcification, so that an emergency operation was performed with a diagnosis of acute appendicitis. Laparotomy disclosed a swollen appendix and appendectomy was carried out. The histopathological diagnosis was phlegmonous appendicitis. Degenerated and calcified ova of Schistosoma japonicum were present from the submucosal to subserosal structures, which were considered to be findings of old glanuloma. Postoperative stool examinations for ova and parasites revealed no abnormal findings. The anti-worm body and anti-egg antibodies were negative on ELISA method. Thus old schistosomiasis japonicum was diagnosed and no parasiticide was given to the patient.
As far as we could review the literature from the ichushi web, a total of 19 cases of appendicitis with old schistosomiasis japonicum have been reported in Japan from 1980 to 2006. No new patient with the disease has appeared in this country after 1978 when the last case had been reported. However, some imported cases as well as old cases are reported. We must remain alert for the disease in our daily clinical practice.

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We report a case of acute appendicitis with penetration to the sigmoid colon. The patient was a 76-year-old male who came to our hospital with the complaints of right flank pain and fever of 37°C. A hard tender mass was palpable at right lower quadrant of the abdomen without signs of peritoneal irritation. Blood test showed significant sign of inflammation and an abdominal CT revealed a mass of 8cm in size in the right lower abdomen consisting of conglomeration of the ileum and ascending colon. An intraabdominal abscess caused by acute appendicitis was suspected and antibiotics were administered resulting in significant improvement of the symptoms. Emergent operation was not performed, After the conservative management, an endoscopic study was done which revealed an elevated lesion with a spot of depression in the sigmoid colon 20cm orally from the anus. Lower intestinal image study revealed a lineal communication between the appendix and the elevated lesion of the sigmoid colon. A diagnosis of acute appendicitis with penetration to the sigmoid colon was made and a laparotomy was performed 2 months later. At the laparotomy it was found that a part of the appendix was adhered to the sigmoid colon in fascicular fashion forming a fistula, The presence of malignancy was not suspected and simple appendectomy and division of the fascicular adhesion was done.

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A 36-year-old man was admitted to our hospital because of right back pain and fever. Abdominal CT scan revealed a right psoas abscess, and an operation was performed for drainage by an extraperitoneal technique. The postoperative course of the patient was uneventful. Colonoscopy was performed, and there were no abnormal findings in the right side colon, so the patient was discharged. Six months later, the psoas abscess relapsed. Percutaneous drainage was performed under echoguide. Barium enema revealed a fistula between the perforated site at the tip of the appendix and abscess cavity. An appendectomy was performed, and histological examination showed diverticulum, lacking muscularis propria at the perforated site. There has been only one case report in the Japanese literature on psoas abscess that followed perforation of the appendical diverticulum. We thus reported the case with a review of the literature.

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Endometriosis is a disease in which endometrial tissues grow at locations outside the uterus.
A 36-year-old woman was referred to our hospital because of abdominal pain and vomiting. Laboratory data showed an elevated carbohydrate antigen 125 (CA125). Abdominal X-ray and CT scan showed obstruction of the ileum and the thickened cecum. Placement of a long intestinal tube resulted in symptomatic remission but obstruction of the ileum did not improve. During surgery, we saw that the appendix had swollen and became hard, especially at the tip, and firmly adhered to the ileum causing complete obstruction of the ileum. Thus ileocecla resection was performed. Microscopic findings showed endometrial stroma and glands at the submucosal structure of the appendix, which was compatible with the diagnosis of appendical endometriosis. The postoperative course was uneventful except minor wound infection, and she was discharged from the hospital on the 20th postoperative day.
Cases of appendiceal endometriosis account for about 3% of all cases of intestinal endometriosis. This comparatively rare case is reported here, together with a review of the literature.

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A node was pointed out in the left lung of a 79-year-old woman, and she was followed at our hospital. She started to take α-glucosidase inhibitor (α-GI) one month ago for diabetes mellitus. A follow-up CT scan performed for pulmonary check showed growth of the pulmonary node and a reticular shadow in the whole left lung. The lesion was diagnosed as lung cancer. Additionally, it revealed intra-abdominal free air and intestinal mural air in the right colon. However, there were no apparent findings to suggest gastrointestinal perforation. Therefore, we diagnosed pneumatosis cystoides intestinalis (PCI) with pneumoperitoneum induced by α-GI. The patient's condition was improved by conservative therapy including withdrawal of α-GI. PCI with pneumoperitoneum induced by α-GI is very rare, and only five cases including ours have been reported in Japan. These three of five cases had a history of respiratory diseases, and we suggest that respiratory disease was also involved in the occurrence of PCI with pneumoperitoneum.

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Severe necrotic obstructive colitis is extremely rare. A 71-year-old man was admitted to our hospital due to abdominal pain. Abdominal computed tomography (CT) showed a mechanical ileus due to a tumor in the sigmoid colon. The patient was conservatively treated by a long intestinal decompression tube. However, he suffered a shock 16 hours later after the admission and underwent an emergency operation. On exploration of the intra-abdominal cavity, the color of serosa from the cecum to the sigmoid colon changed to brown. Total resection of the colon was performed. Histopathological examination revealed that the tumor was a well differentiated adenocarcinoma and the whole colon proximal to the tumor became necrotic. It is important to recognize the pathology of this disease for the proper surgical treatment.

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Intussusception in an adult is rare and the cause of peritonitis caused by perforation of the colon with intussusception is further rare. We experienced such a rare case and report it here. The patient was a 56-year-old male admitted in a hospital in Dec. 2007 with the chief complaint of abdominal pain. On the 12^th day of admission flat plate of abdomen revealed free air and a diagnosis of bowel perforation was made and the patient was referred to our hospital. When he came to the hospital the consciousness was clear and there was tenderness and some muscle rigidity of the abdomen. Abdominal CT study revealed a perforation of the colon caused by an intussusception of the transverse colon cancer resulting in peritonitis. An emergent operation was performed on the same day, and a perforation of the transverse colon 5cm in diameter towards the splenic flexure was found, and a type II cancer, about 10cm in size was seen exposed into the abdominal cavity from the perforation. Dilatation and edema of the proximal intestine was significant and the nutritional state of the patient was poor, so instead of intestinal anastomosis, simple resection of the ascending, transverse and descending colon and D1 lymph node dissection, ileostomy and drainage of the abdominal cavity were performed. The postoperative course was uneventful and the patient was transferred to the previous hospital without problems.

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The present patient was a 42-year-old woman who developed abdominal bloating in late March 2007. She visited the Department of Gynecology, where she was suspected of having hysteromyoma or ovarian tumor, but was referred to the Department of Surgery for detailed examination of the digestive tract in early April. Sigmoid colon cancer was detected on lower gastrointestinal endoscopy. On the last day of April, the patient visited the emergency department of our hospital with a complaint of severe abdominal pain that had developed in the morning. Based on emergency CT and abdominal paracentesis, the patient was diagnosed with intraperitoneal bleeding caused by tumor rupture and was immediately hospitalized on the same day. Although anemia did not progress following hospitalization, the abdominal pain did not improve and the patient developed bilateral pleural effusion in addition to increased ascites. Due to the gradual deterioration of the patient's condition, emergency surgery was performed in early May. Laparotomy revealed 2 L of hemorrhagic ascites and peritoneal dissemination. Bilateral ovariectomy and Hartmann's procedure for sigmoid colon cancer were performed. Based on pathological examination, the patient was diagnosed with ovarian and disseminated nodules that had metastasized from sigmoid colon cancer.
Although ovarian metastasis from colon cancer has become more commonly reported in recent years, it rarely results in intraperitoneal bleeding. We describe the present patient with reference to literature.

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Umbilical metastasis of malignant tumors, also known as Sister Mary Joseph's nodule (SMJN), is a relatively rare sign with a poor prognosis. In the present study, we report our experience with a case of colon cancer in which umbilical metastasis was observed with a literature review.
The present patient was a 49-year-old woman who underwent right hemicolectomy following diagnosis of ascending colon cancer in December 2004. Although the patient received adjuvant chemotherapy, she developed liver metastasis in July 2005 and underwent enucleation of the hepatic tumor. As liver and lung metastases were observed in May 2006, the patient underwent enucleation of the hepatic tumor as well partial lung resection. In October 2006, umbilical metastasis was observed. Because this metastatic tumor required daily treatment, it was resected in January 2007 with the objective of enhancing QOL. Despite subsequent recuperation at home, the patient died in September 2007 due to respiratory failure secondary to multiple lung metastases.
In patients with SMJN, resection must be considered from the perspective of enhancing QOL depending on metastases to other sites as well as general status. In addition, the possibility of SMJN must be considered during treatment of advanced colon cancer.

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In Janulary 2005, a 79-year-old female had a radical nephrectomy and partial resection of the transverse colon, spleen and pancreas tail due to renal cell carcinoma with transverse colon invasion. She experienced melena 1.4 years after nephrectomy. The descending colon occuluded by the type 1 tumor with necrotic surface was noted on the barium enema study and colonoscopy, hypervascular features were seen on computed tomography (CT) scanning. On biopsy, necrosis and granulation without malignant findings were noted. Suspicious of colon cancer with a lung metastasis, the colon was partially resected, pericolonic lymphnodes were also resected. Postoperative histopathological findings showed that the two tumor had metastasized from a renal cell carcinoma. Metastatic tumors from renal cell carcinoma to the colon are rare ; only 8 cases have been reported in the Japanese literature.

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A 56-year-old female developed melena. On colonoscopy, a submucosal-like tumor was found in the rectum. The tumor appeared to have originated from the uterus or the ovary due to the presence of atypical clear cells in the biopsy specimen. However, the preoperative diagnosis was difficult to make since the patient had a hysterectomy and a bilateral oophorectomy previously. With a provisional diagnosis of a submucosal tumor of the rectum, a low anterior resection of the rectum, along with a regional lymph node dissection, was done. The tumor was located mainly in the submucosal layer, ; ulceration in the rectal mucosa was present. On histology, the tumor consisted of clear cell adenocarcinoma ; endometriosis was noted around the tumor located in the rectal wall. There fore, a diagnosis of endometrioid adenocarcinoma was made. This lesion was considered to have arisen from ectopic endometriosis located in the rectum. Eighteen months postoperatively the patient's condition remains good and there are no signs of tumor recurrence. We report a very rare case of endometrioid adenocarcinoma arising from ectopic endometriosis of the rectum.

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A 57-year-old woman presented with a soft tissue tumor in the right elbow was incidentally found to have a lesion at the hilum of the liver by abdominal CT scan. Dynamic CT scan revealed that the mass was enhanced in the early phase and had pooling of contrast medium in the late phase. The 3D graphy from volume rendering of the CT angio showed encasement of the right hepatic artery (RHA) and sacculus formation at the peripheral side of the encasement and also a loss of blood flow of the RHA at the distal portion to the sacculus. Laparotomy was performed with a preoperative diagnosis of a pseudoaneurysm of the RHA. The pseudoaneurysm was located at the dorsal aspect of the common bile duct and was encapsulated with connective tissues. The intraoperative color dopplar ultrasound sonography (CDUS) confirmed arterial blood flow in the pseudoaneurysm but no stream beyond it. Under the good knowledge of blood circulation around the pseudoaneurysm, we performed arterial ligation. The post-operative course was uneventful and the patient was discharged on the tenth day after the operation. Dynamic CT and CDUS were useful for the diagnosis and decision-making of procedures of the surgery. Arterial ligation is considered to be one of safe treatments for non-emergency cases of hepatic artery aneurysm which require no vascular reconstruction.

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This paper present a case of a pseudoaneurysm formed in a biloma after intrahepatic arterial chemotherapy for hepatic metastases of colon carcinoma presented with melena of unknown origin. Right hemicolectomy, cholecystectomy and hepatic arterial catheterization were performed for a 73-year-old man with carcinoma of the ascending colon and multiple liver metastases. Hepatic infarction and intrahepatic biloma were diagnosed 5 months after intrahepatic arterial chemotherapy with 5-fluorouracil (5-FU) and this treatment was changed to systemic chemotherapy with CPT-11. Liver metastases disappeared in one year after this treatment. The patient was followed up without chemotherapy and was admitted to our hospital because of melena. Abdominal CT scan was performed three times after hospitalization with a diagnosis of a pseudoaneurysm and MRI detected its rupture into the biloma. Angiographic embolization with micro coils for the pseudoaneurysm successfully controlled melena. Another pseudoaneurysm of other intrahepatic artery was formed to cause melena 5 months after this treatment and the second embolization controlled it. We should bear in mind that a biloma after intrahepatic arterial chemotherapy can cause repeated formation of pseudoaneurysm in the close intrahepatic artery.

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A 57-year-old man with chronic hepatitis B was referred to our hospital because of the sudden onset of severe abdominal pain. Abdominal CT scan showed enhanced heterogeneous masses measuring about 4.5cm and 2.5cm in diameter in the Spiegel lobe and the segment 8 of the liver, respectively, with a huge hematoma in the omental bursa. Although there was no evidence of extravasation from the tumors on abdominal angiography, the diagnosis of spontaneous rupture of hepatocellular carcinoma originating in the Spiegel lobe was made based on the location of the hematoma. Subsequently, transarterial embolization was performed. After a two-month interval from the episode of rupture, the resection of the Spiegel lobe and partial resection of the segment 8 of the liver were conducted under the diagnosis of multiple hepatocellular carcinoma. The histological diagnosis of the tumor of the Spiegel lobe was moderately differentiated hepatocellular carcinoma with extensive necrosis and hemorrhage. The patient died of recurrence of hepatocellular carcinoma 16 months after the initial surgery.
In a review of 13 cases, including our case, in the Japanease literature, we conclude that hematoma in the omental bursa may be a characteristic finding of ruptured hepatocellular carcinoma in the caudate lobe.

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A 73-year-old man was admitted to the hospital because of epigastric pain with nausea and vomiting. At admission imaging diagnostic methods disclosed a swollen gallbladder with the thickened wall, but there were no emphysematous changes and acute cholecystitis was diagnosed. Conservative therapy with administration of SBT/CPZ at a dose of 1g/day was started, but no clinical remission was attained and remarkable elevations in CRP and CPK were noted. For that another abdominal CT scan was performed about 27 hours after the initial scanning that showed low density areas in the circumference of the gallbladder and intrahepatic bile duct. Thus emphysematous cholecystitis was diagnosed and laparotomic cholecystectomy was performed on the same day. The removed gallbladder was diagnosed as acute gangrenous cholecystitis. A culture of the bile juice yielded C. perfringens, E. casseliflavus, and E. coli which were considered causative microorganisms.
This paper presents our experience with emphysematous cholecystitis which was associated with gas in the bile duct and showed a rapid imaging change, together with some bibliographical comments.

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We report a case of plural port site recurrences of gallbladder carcinoma after laparoscopic cholecystectomy (LC). A 60-year-old man underwent a LC for cholecystolithiasis. After the operation, he was diagnosed as gallbladder carcinoma and received additional operative procedures. During the postoperative follow-up, an abdominal CT showed abdominal wall masses in the port-site of umbilicus and right midclavicular line. Aspiration biopsy cytology showed adenocarcinoma and was diagnosed as port site recurrences. Because of no other recurrences, an abdominal wall resection was performed after 14 months of the additional operation. We removed 3 masses including the abdominal wall from skin to peritoneum of the umbilicus and right midclavicular line port. Another mass was confirmed at the port-site on anterior axillary line during the operation and removed it surgically. Pathologically, the carcinoma was confined to the out-side of the parietal peritoneum in all abscission specimens and the recurrence pattern was extraperitoneal. In our case, it was thought to be a local recurrence without peritoneal dissemination, and radical operation was thought to have been performed.

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A 60-year-old male with gastric cancer had a distal gastrectomy and cholecystectomy ; 9 months later a 1-cm diameter mass with an associated dilatation of the intrahepatic bile duct located at the left lobe of the liver was noted on abdominal CT. The patient was diagnosed as either having a liver metastasis from the gastric cancer or cholangiocellular carcinoma ; a left hemihepatectomy was planned for February 2005. At laparotomy, the right hepatic artery was found to be narrowed at the ligated portion of the cystic duct ; no pulsation was noted. Therefore, it was likely that the right hepatic artery had been injured during the last operation. It was necessary to rebuild the right hepatic artery since there was no arterial blood flow in the liver when the left hepatic artery was clamped. The right hepatic artery was reconstructed and attached to the remnant of the left hepatic artery using an interpositional technique involving the saphenous vein. After confirming that the right hepatic arterial flow was adequate a left hemihepatectomy was done. The patient's postoperative course was uneventful, and he was discharged 13 days after surgery. On histology, the patient's tumor was diagnosed as a cholangiocellular carcinoma.

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A 69-year-old woman diagnosed with biliary cancer was admitted to our hospital. Because she was diagnosed with liver metastases, we started to treat her with gemcitabine as an outpatient. After 148 days of administration, she felt slight muscle weakness in bilateral proximal lower extremity. Subsequently, her muscular signs and symptoms progressed. At 162 days of administration, she was admitted because of muscle pain and muscle weakness in her bilateral proximal lower extremity, pyrexia and oliguria. Investigation revealed increased serum levels of creatine kinase (2565 IU/l), lactate dehydrogenase, aspartate aminotransferase, white blood cell count and C-reactive protein. Although she showed acute renal failure, it immediately improved with hydration, and the creatine kinase level returned to normal range after 5 days. The syndrome gradually improved after the discontinuation of chemotherapy and bed rest with hospitalization. The diagnosis of gemcitabine-induced rhabdomyolysis was supported after the exclusion of other possible diagnoses.

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