[in Japanese]

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Background and Aim : The guidelines for the treatment of colorectal cancer were published in 2005 in Japan, and may have changed adjuvant chemotherapy regimens and indications. The aim of this study was to examine the influence of the guidelines on adjuvant chemotherapy for colorectal cancer.
Methods : Questionnaires regarding adjuvant chemotherapy were sent to member hospitals of the Hyogo Colorectal Cancer Surgery Group (HCCSG) in 2008. The results were analyzed and compared with those obtained in 2004.
Results : 1) The number of institutes with a common regimen had increased. 2) Adjuvant chemotherapy for elderly patients had increased. 3) Adjuvant chemotherapy for stage I or II patients had decreased. 4) Oral chemotherapy had increased compared with intravascular chemotherapy. 5) The duration of adjuvant chemotherapy had shortened.
Conclusion : Adjuvant chemotherapy for colorectal cancer patients has been improving due to modifications based on the guidelines for the treatment of colorectal cancer. Therefore, these guidelines are thought to be useful for clinical practice based on evidence-based medicine.

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We retrospectively evaluated data from 346 patients with 387 primary inguinal hernias (272 indirect hernias and 115 direct hernias) repaired by the mesh plug method between January 2000 and August 2006, to examine the characteristics of recurrence following this type of hernioplasty. The patient' ages ranged from 21 to 87 (median, 65) years, and the ratio of males to females was 315 to 31. Five recurrences were confirmed in four patients (1.3%), all of whom were male. The ages of these patients at the primary repair ranged from 61 to 77 (median, 69). The interval between the initial surgery and recurrence ranged from 10 to 78 (median, 17) months. The types of hernias at primary repair included two indirect hernias (recurrence rate, 0.7%) and three direct hernias (2.6%). Re-operative findings showed dislocation (n=2) or deformity (n=1) of the onlay patch, migration of the plug (n=1), and a combination of dislocation of the patch and migration of the plug (n=1). The recurrent lesions were repaired by the mesh plug method again (n=3) or the Lichtenstein method (n=2). The recurrence rate after the mesh plug hernioplasty in our series, although acceptable, may be further reduced by firm fixation of the plug and the onlay patch.

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Background : Uncrossmatched-red cell concentrate (UCM-RCC) can easily cause ABO-incompatible transfusion in the management of lethal massive bleeding with hemorrhagic shock. Methods : We experienced 15 patients with gastrointestinal hemorrhage who underwent UCM-RCC transfusion (17 series and 80 units). In our institution we perform UCM-RCC transfusion to patients who are in refractory hemorrhagic shock over after 2,000 ml of bolus infusion and who cannot wait the report of crossmatching. Results : The volumes of transfused UCM-RCC ranged from 2 to 10 units for a case with the mean of 5.3 units, and less than 6 units in 93 % of all cases. Type O UCM-RCC transfusion without blood typing test (BTT) was performed in 7 cases. Type O UCM-RCC transfusion after only 1 BTT was performed in 4 cases, and non-O group specific UCM-RCC transfusion after only 1 BTT was performed in 4 cases. The mean of the worst values of systolic pressure, pulse rate, shock index (pulse rate/systolic pressure), and base excess before UCM-RCC transfusion were 76.9 mmHg, 117.5/minutes, 1.69, and -9.61 mEq/l, respectively. Disturbance of consciousness was noted in 8 cases. Two cases were non survivors (13 %). No ABO-incompatible transfusion and no transfusion related complications occurred. Conclusions : Rapid type O UCM-RCC transfusion is useful and safe in emergency UCM-RCC transfusion for gastrointestinal bleeding. We should require less than 6 units of UCM-RCC as a first request in managing gastrointestinal bleeding.

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The patient was a 58-year-old woman who had been undergoing dialysis at a local clinic for chronic renal failure caused by diabetic nephropathy. From November 2005 a rapid increase in serum intact PTH levels was observed, and the patient was referred to our department as her condition could not be managed at the Department of Internal Medicine. Based on further tests, surgery was indicated for secondary hyperparathyroidism, and the patient underwent total parathyroidectomy with autotransplantation into muscles in the right forearm (PTx) in December 2005. Although the postoperative course was favorable, serum intact PTH levels increased again from around October 2007 and a tumor gradually formed on the transplantation site on the right forearm. The patient returned to our department after her serum intact PTH exceeded 700 pg/ml in April 2008. No remnants of the ectopic parathyroid gland were observed, and serum intact PTH levels in blood collected from the right (operated) arm was 19300 pg/ml, which was approximately 16-fold greater than that for the left arm. The patient was thus diagnosed with recurrence caused by autograft growth and underwent resection under local anesthesia. Serum intact PTH levels rapidly returned to normal following surgery. We report the present case of recurrence occurring approximately two years after PTx with reference to literature.

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Parathyroidectomy was done in three patients with primary hyperparathyroidism during pregnancy. One case was diagnosed as primary hyperparathyroidism with hypercalcemia and had surgical treatment in the third trimester. The two other cases were diagnosed with neonatal tetany and had surgical treatment after delivery. Primary hyperparathyroidism during pregnancy is generally associated with a high risk of maternal morbidity, neonatal tetany, and fetal death. If hypercalcemia is detected, during pregnancy or neonatal tetany occurs, it is mandatory to rule out primary hyperparathyroidism.

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The patient was a 25-year-old unmarried woman. She had noticed a lump in a medial region of the left areola in December 2004, which spontaneously disappeared. However, the lesion relapsed during menstrual period. Although a family physician advised her conservative observation, she visited our clinic for further examinations in February 2005. Not only physical examination but also ultrasonography suggested that the mass under the left areola was likely to be an abscess. A needle aspiration failed to obtain pus, but cytology of the smear was negative for malignant cells. There was not nipple retraction but a slight inflammatory sign such as redness alone. Thus surgical excision or drainage was reserved. She revisited us in early March, when inflammatory process was exacerbated with menstruation. Ultrasonography revealed an enlarged abscess collection. Then incision and drainage were performed. Thereafter she had recurrence of subareolar abscess repeatedly. In July pus drainage from the nipple due to compression was noted. A 3-0 nylon thread was inserted through a fistula and drawn out from the nipple. The thread was ligated there in a loop and left in place. The operation was performed in September under general anesthesia. The fistula was removed as far as possible using the strand of nylon thread as guide, and affected lactiferous duct in the nipple was open and curetted. No relapse has been observed in 3 months after operation.

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We report a 28-year-old woman with granulomatous mastitis (GM) and erythema nodosum (EN). Post partum, the patient developed a painful, elastic hard mass located in her right breast. On histology, granulomatous mastitis with erythema nodosum was diagnosed. She was treated with oral steroids, antibiotics, and surgical drainage. The skin lesions improved rapidly. The breast lesion improved gradually ; it disappeared five months after the start of treatment. Based on a review of the literature, 6 cases of GM with EN have been reported in Japan.

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Ductal adenoma (DA) consists of the proliferation of benign epithelial cells and it is a comparatively new histologic type added to the “General Rules for Clinical and Pathological Recording of Breast Cancer” (the 16th edition) in the field of “Classification of Breast Tumors Histological”. It is a rare histologic type, The peak incidence is around 50 years. It presents similar findings to those of carcinomas on palpation and diagnostic imagings, and is easily misdiagnosed as scirrhus carcinoma or ductal adenocarcinoma. We here present a case of male ductal adenoma excised.
A 61-year-old man was admitted to the hospital with the chief complaint of a right breast tumor. A core needle biopsy was enforced twice because breast ultrasonography revealed findings suggestive of malignanacy. The diagnosis was intraductal papilloma. However, benign male mammary gland diseases are extremely rare, and we performed lumpectomy after informed consent was gained from him. The excised specimen was 20×12×10mm in dimension, and the histopathological diagnosis was ductal adenoma, and no malignant findings were noted.

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We report two cases of pseudoangiomatous stromal hyperplasia (PASH) of the breast which is a rare entity. Patient 1, a 46-year-old woman was seen at the hospital because of a tumor of the right breast. A 25×25 mm, movable tumor was felt in the upper outer quadrant of the right breast. A possibility of malignancy could not be ruled out from results of ultrasonography and mammography, and aspiration biopsy cytology was class IIIb. Patient 2, a 34-year-old woman, had a 20×15 mm well movable tumor in the lower outer quadrant of the left breast. Results of ultrasonography and aspiration biopsy cytology suggested fibroadenoma which showed a tendency to increase. We excised these tumors under local anesthesia. Pathological examination revealed that the lesions were characterized on histology by the presence of anastomosing slit-like spaces embedded in a thick fibrous stroma. Stromal spindle cells lacked atypia and were immunohistochemically positive for vimentin, alpha-smooth muscle actin, and CD34. Thus the histopathological diagnosis of the lesions was PASH of the breast in both cases.

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A 48-year-old woman was pointed out to have calcifications of the right breast on a screening mammography and had a check up in our Hospital. We observed that the small round calcifications were clustered and classified Category 3. Vacuum-assisted biopsy (Mammotome) specimen of approximately 3 mm in diameter demonstrated dilatation of the mammary ducts and pool of mucin, including small gritty calcifications and was diagnosed that she had a mucocele like tumor (MLT). So we performed a wide excision including the calcifications. The excised specimen showed no malignancy, and the final diagnosis was benign MLT. We present a case of MLT which was diagnosed by a Mammotome before the operation. This is a rare case and so far there is no domestic report like this.

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The patient was an 85-year-old woman who had undergone a surgery for breast cancer at age 63. When she visited a clinic with a chief complaint of dyspnea, chest x-ray showed a possible left pleural effusion. She was referred to our hospital for the further evaluation and management. On admission thoracentesis was performed, and the cytology of the pleural effusion was diagnosed as Class V (adenocarcinoma). As dyspnea resolved she was discharged and followed up as an outpatient. However, scattered small skin spots on the left anterior chest and enlarged lymph nodes of the left axilla were noted 10 months after. Biopsy of the skin lesion revealed metastatic skin cancer (consistent with adenocarcinoma, metastatic breast cancer). She lives with no impairment in her activities of daily living one year after the event of pleural effusion, and is followed up as an outpatient receiving letrozole.

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In January, 2007, a 69-year-old woman whose younger sister and eldest daughter had had breast cancer required a right breast partial excision (Bp+Ax) for breast cancer. The pathological diagnosis was a acirrhous carcinoma, n0, ER(+), PR(-), and HER2(1+). AI was given after EC chemotherapy. The patient noted a left breast abnormality in February, 2008 but, only reported it in May. A mastectomy (Bt+Ax) of the left breast was done in June, 2008. The pathological diagnosis was a solid-tubular carcinoma, n0, ER(-), PR(-), and HER2(3+). The characteristics of the second cancer were quite different from the first. The left breast cancer had developed during the early stage of hormonal therapy given after chemotherapy for the initial right breast cancer. It is important to evaluate the contra-lateral breast at the time a cancer located in one breast is diagnosed.

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We report a case of pulmonary lymphangioleiomyomatosis (LAM) with repeated pneumothorax and chylothorax in a short period.
A 19-year-old woman with dyspnea and right chest pain was admitted to our hospital. Chest CT revealed multiple bullae in bilateral lungs, with suggestion of LAM. She was treated with chest tube drainage and was discharged with an uneventful course. She had recurrent right pneumothorax twenty days later, and underwent a video assisted thoracoscopic surgery (VATS). The thoracoscopic view showed multiple bullae of various sizes. She underwent bullectomy and ablation of the bullae. Microscopic examination revealed LAM in the resected bullae. Recurrent right pneumothorax and left chylothorax developed 34 and 66 days later, respectively. Bilateral pleurodesis and diet restriction were useful, and she was discharged with a good response. She has experienced no pneumothorax for 20 months since the last discharge without the treatment with GnRH analogue.
The cause of repeated pneumothorax and chylothorax in a short time is unknown. It is important that the establishment of diagnosis and early treatment via VATS be performed for pneumothorax with suspected LAM. Pleurodesis to intractable pneumothorax due to LAM is controversial for possible later lung transplantation, and needs further consideration.

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The patient was a 72-year-old woman who was diagnosed with papillary thyroid carcinoma by another physician and underwent a total thyroidectomy and cervical lymph node dissection. She visited a local physician presenting a cough. Chest x-ray conducted by the physician indicated a nodular shadow, and therefore was referred to our hospital. Surgery was performed because of a growing tendency of the shadow. The patient was diagnosed with lung cancer based on intraoperative rapid diagnosis, and underwent a right lower lobectomy and lymph node dissection (ND2a). Postoperative pathology showed it to be a well-differentiated, distinctly cornified squamous cell carcinoma with four intratumoral micropapillary carcinomas. Similar papillary carcinoma microlesions were scattered in the normal lung tissue apart from the main tumor. Immunostaining found that squamous cell carcinoma and papillary carcinoma were positive for cytokeratin staining, and that only papillary cell carcinoma was positive for thyroglobulin staining. According to this result, they were diagnosed as primary lung squamous cell carcinoma with thyroid papillary carcinoma metastasis complication. As this is a rare condition, we report it with bibliographic consideration.

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We often have great difficulty in treating flail chest and the life prognosis of the patient depends on shortening of the therapeutic duration. Although common therapies for the disease are internal and external fixations, flail chest can occur with multiple traumas frequently so that we have employed less invasive internal fixation as the first choice of therapy. However, the method has provided various adverse events such as pneumonia due to long-term mechanical ventilation, with inevitable tracheostomy, and iatrogenic hepatic impairment due to long-term administration of a sedative. In order to avoid these inconvenient events, a new therapeutic method of the internal fixation associated with Nuss method has been employed since 1999. For that, the duration of respiratory management has been shortened and the patients have been able to facilitate their earlier reentry into society. In this study three male patients and two female patients, with a mean age of 41 years old, were enrolled. Causative traumas were fall in 2 cases, traffic accident in 2, and closed chest heart massage in the remaining one case. The average duration of internal fixation combined with Nuss method was 5.6 days, and the average duration when a respirator was used was 10.2 days. No adverse complications with the associated Nuss method occurred.

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Thymic MALT lymphoma is rare. Only approximately 30 cases have been reported in Japan. We treated a patient who developed thymic MALT lymphoma during Sjögren's syndrome treatment. We report this case along with a discussion of the relevant literature.
The patient was a 47-year-old woman. She had been treated as an outpatient for Sjögren's syndrome since January 1998. In February 2002, she stopped treatment for personal reasons. In June 2004, she presented with recurrent arthralgia affecting multiple joints. The chest CT scan revealed a mediastinal tumor. In August 2004, a thymectomy was performed, since a thymic malignant lymphoma or a multilocular thymic cyst was suspected.
Postoperatively, on pathology, infiltration of tumorous lymphocytes into Hassall's body (lymphoepithelial lesions) was noted. The cells were positive for CD20 on immunostaining, both κ and λ globulin chains were detected. Therefore, MALT lymphoma of thymic origin was diagnosed. Adjuvant chemotherapy was given after surgery. The patient has been doing well and has not had any reccurence during 4 years of follow-up.

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The patient was a 59-year-old man who presented with hematemesis. Endoscopy revealed a bloody tumor in the middle esophagus. On admission, anemia and leucocytosis were found. The serum granulocyte-colony stimulating factor (G-CSF) level was high by enzyme immunoassay test. The patient had an esophagectomy via a right thoracotomy and a stomach tube reconstruction via a laparotomy (Ivor Lewis operation). On histopathology, well-differentiated squamous cell carcinoma that was for anti-G-CSF antibody positive on immunostaining was diagnosed. On pathology, the tumor was pT3, pN1, and pM0 : stage III according to the TNM classification. The serum G-CSF level dropped to within normal limits after the operation. Despite adjuvant chemotherapy, the patient had a lymph node recurrence that was treated with chemoradiotherapy. He died as a result of multiple lung metastases 4 years after the operation. Esophageal G-CSF producing carcinoma might have an aggressive behavior and, there fore, should be treated using multi-modal therapy.

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We experienced a case of spontaneous rupture of the esophagus complicated by pulmonary abscess with inflammatory arteriorrhexis.
An 85-year-old man visited a local physician because of anorexia and cough. On chest radiography, pulmonary abscess was suspected, and antibiotic therapy was started. The treatment was ineffective and he was referred to our hospital for further examination and medication. Upper gastrointestinal endoscopy showed no abnormality, but the gastrografin swallow showed extravasation from the esophagus which led us to the diagnosis of mediastinitis caused by spontaneous rupture of the esophagus. Emergency operation was performed. We found a longitudinal tear, 1cm in length, in the left side of the lower esophagus and then started drainage using a T-tube. On postoperative day (POD) 14, massive hemorrhage was seen through the thoracostomy tube and emergency operation was performed again. We found arteriorrhexis caused by inflammation of the descending aorta. It was difficult to control the bleeding, and so we selected fenestration drainage. Seven days later, the patient died of massive hemorrhage from the arteriorrhexis. Spontaneous rupture of the esophagus in elderly people often become serious because it lacks typical symptoms and test findings, with resultant delayed diagnosis. In selecting therapies for them, allowance must be made for the extent of invasiveness of the therapies.

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The patient was a 19-year-old male, who was brought to his private physician by an ambulance on Sept. 19th, 2007, with the complaint of epigastric pain which gradually increased its intensity. Ascites was found to be presented by an abdominal CT and peritoneal irritation sign was also noticed, and the patient was admitted to our hospital on emergency basis. Systolic blood pressure was 80 mmHg and pulse rate was 90 / m and the patient looked pale when admitted. Intra-peritoneal bleeding was suspected to be due to rupture of the short gastric artery by an abdominal CT, causing hemorrhagic shock and an emergency operation was performed. Copious amount of blood was present in the peritoneal cavity and the bleeding point was found in the short gastric artery on the posterior wall of the gastric body and upper pole of the spleen. Partial gastrectomy including the above mentioned area was performed. The patient could be weaned from the ventilator on the first postoperative day and showed gradual recovery. Pathological study with Elastica van Gieson staining revealed abnormal rupture of the media of the arteriole and the findings were thought to be compatible with fibromuscular dysplasia (FMD). Rupture of aneurysm of the short gastric artery in a young patient is quite rare among mesenteric artery aneurysms, therefore we report the case with some review of the literatures.

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We report a case of eosinophilic gastroenteritis of predominant subserosal layer.
The laboratory data revealed eosinophilic-predominant leukocytosis of 30% or more, and massive ascites was noted.
Because ileus symptoms did not improve, we performed emergency operation without making the correct preoperative diagnosis. During the operation, thickened small bowel wall with stenosis on the ileum end was confirmed, and we performed ileocolectomy including the ileum by 40cm in length on the oral side of the ieocecal valve.
Histopathologically diffuse infiltration of eosinophils was recognized in the subserosal layer predominantly, and it was diagnosed as eosinophilc gastroenteritis. Thus steroid therapy was started, and symptomatic remission was attained. Fortunately, postoperative complications such as anastomotic leakage did not occur in our case.
However, it must be remembered that we could not save the patient after severe complications once occur following thoughtless laparotomy without the clear recognition of eosinophilic gastroenteritis.
It is important not only to bear this disorder in mind in diagnosing any gastrointestinal diseases but also to recognize the difference in the symptoms and the examination data among 4 subtype categories.

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The patient was a 61-year-old female, who had multiple bilobar hepatocellular carcinoma for which a transcatheter arterial embolization (TAE) was performed in July, 2007. She had repeated TAE in Oct. for a new disease in segment S6. Anemia (Hb 6.2g/dl) was found around that time and an endoscopic upper gastrointestinal study was performed, which revealed an easily bleeding tumor, typeI, on the posterior wall of the lesser curvature of the body of the stomach. Pathological diagnosis of the biopsied specimen was poorly differentiated adenocarcinoma and a total gastrectomy was performed in Nov., 2007. Postoperative pathohistological study revealed bile producing cells in the tumor, positive AFP immunostaining, and extensive venous vascular infiltration and tumor cell thrombosis. Accordingly a diagnosis of hematogenous metastasis of hepatocellular carcinoma to the stomach was established.
Hematogenous metastasis of hepathocellular carcinoma to the stomach is relatively rare. Only 30 cases, including ours, have been reported in Japan. We experienced a successful surgical resection of hematogenous metastasis of hepatocellular carcinoma to the stomach and report here with some review of the literatures.

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We report here in an extraordinary case of superior mesenteric artery (SMA) aneurysm caused by segmental arterial mediolysis (SAM) with concomitant left renal angiomyolipoma (AML) and pulmonary lymphangioleiomyomatosis (LAM). A 32-year-old woman presented at the urological outpatient clinic of our hospital with erythrocyturia. Abdominal computed tomography (CT) and abdominal angiography examination revealed a saccular aneurysm arising from the base of the SMA and a tiny aneurysm from the posterior inferior pancreaticoduodenal artery. A 14 cm left renal AML was also observed. Chest CT showed multiple cysts suggesting LAM. We surgically removed the aneurysm from the bifurcation region of the SMA and concurrently performed left nephrectomy including the AML. Pathological findings from the resected aneurysm showed SAM and the huge left renal tumor was histologically diagnosed as AML.

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A 58-year-old man was admitted to the hospital for close exploration of anal bleeding in July 2008. On the second hospital day he developed cardiopulmonary arrest temporarily due to massive anal bleeding. After resuscitation, a contrast-enhanced abdominal CT scan showed extravasation of contrast material into the jejunum, and bleeding from the jejunum was diagnosed. Emergency angiography was thus performed. Bleeding from the periphery of the 3^rd jejunal artery was identified and arterial embolization was carried out. On the 3^rd hospital day, we decided to perform emergency partial resection of the small intestine including the bleeding lesion. It was supposed that we might have to have difficulty in identifying the lesion during surgery, so that angiography was performed again immediately before surgery. Marking with a microcoil was conducted at the periphery of the jejunal artery from where the bleeding was seen on the day before, and then laparotomy was done. Intraoperative fluoroscopic study identified the coil was present at the small bowel mesentery, about 60 cm apart from the Treitz' ligament. The small intestine by 60 cm in length including the lesion was resected. A 1.4×1.0 cm elevated lesion was seen on the mucosa at the center of the resected material. The histopathological diagnosis was arteriovenous malformation of the small intestine. Multiple organ failure was developed after the operation, but, following intensive care, the patient was discharged from the hospital on the 44^th postoperative day without any sequela.

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A 74-year-old woman was seen at the hospital because of upper abdominal pain. There was a previous history of undergoing laparotomy. When she was first seen, abdominal distension and mild degree of peritoneal irritation sign were noted. Following abdominal CT scan and ultrasonography, adhesive postoperative small bowel (strangulation) obstruction was diagnosed and an emergency operation was performed. After the obstruction was resolved, the patient developed intestinal obstruction again which needed re-operation. During the second operation, we recognized that more serious adhesions than those seen at the first operation developed. Considering a possible risk of causing intestinal obstruction again, a gastrostomy was created during the surgery and an intestinal splinting tube was induced and placed at the ileum about 30cm proximal to the ileum end. Despite resolution of the obstruction performed twice, intestinal obstruction recurred postoperatively, so that balloon dilatation method was conducted at the obstructing segment, which might cause the obstruction, through the gastrostomy using a guidewire. Non-operative resolution of the obstruction was thus done.
With this novel method using an intestinal splinting long tube and a balloon catheter that has not been reported so far, we have succeeded in conservative therapy of adhesive postoperative small bowel obstruction.

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Duplication of intestine is an extremely rare anomaly of the gastrointestinal tract, and it occurs in various sites of the intestinal tract. So far cases of this anomaly accompanied with inflammation have rarely been reported, accounting for 8.6% of all cases reported. We present a case of duplication of intestine presented with an intraabdominal abscess.
A 69-year-old male was seen at our hospital because of intermittent lower abdominal pain. Abdominal ultrasonography and CT scan showed thickening and calcification of the small intestinal wall. He was admitted for close exploration. It seemed that there was a foreign body like a fish bone in his intestinal tract, because he miss-swallowed it two days before admission. Despite fasting and treatment with antibiotics, the inflammation became worse, and we performed surgery. There were a firm mass about 5 cm in length in the abdominal cavity and intestinal wall-like structure in the mesentery of the jejunum. We diagnosed the case as duplication of intestine and performed partial resection of the small intestine including the duplicated intestine. On the resected material, intestine like structure was present along the small intestine. The pathological diagnosis was tubular duplication of intestine.
This case is of duplication of intestine presented with inflammation and associated with ectopic gastric mucosa and ectopic pancreatic tissue, which is rare and the sixth report in Japan.

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We treated a case of acute abdomen caused by inflammation of an ileal duplication. A 39-year-old man presented with lower abdominal pain and was diagnosed as having acute appendicitis. His physical findings were suggestive of acute appendicitis with localized peritonitis. Abdominal CT scan showed a normal appendix, and severe inflammation of the ileum. Emergency surgery was performed given the diagnosis of acute peritonitis due to inflammation of the ileum. An ileal diverticulum with its own mesenterium was found on the mesenteric side, 60 cm proximal to Bauhin's valve. Inflammation was present in the area where the diverticulum adhered to the adjacent ileum ; the diverticulum and adjacent ileum were resected. On pathology, the cystic lesion was lined with mucosa and aberrant gastric mucosa ; its wall consisted of a smooth muscle layer. Ileal duplication was diagnosed. Alimentary tract duplication is relatively rare in adults, and the preoperative diagnosis is difficult to make. This diagnosis should be considered in patients with an acute abdomen with of unknown etiology.

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We report a case of small intestinal endometriosis with perforation. A 42-year-old female was admitted to the hospital because of abdominal pain. She had been treated with endocrine therapy for suspected small intestinal endometriosis since 2 years earlier and had had several boats of intestinal obstruction treated conservatively. This time no etiologic lesion was identified by close exploration, but she developed perforative peritonitis. Emergency operation was thus performed. Operative findings showed perforation of the ileum at a part of 5cm distal from the ileum end, and ileo-cecal resection was performed. Resected specimen revealed endometrial glands and fibrotic change in the all layer of the ileum and the pathological diagnosis was endometriosis of the ileum. Endometriosis can occur in various sites of the entire gastrointestinal tract, but the common sites are the rectum and sigmoid colon and the small intestine is uncommonly involved. Furthermore small intestinal endometriosis commonly presents with intestinal obstruction or anal bleeding and rarely with perforation. We report this case, together with some bibliographical comments.

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A 66-year-old woman developed fever and lower back pain. Abdominal computed tomography revealed a tumor located at the third lumbar vertebra. On tumor biopsy, a malignant lymphoma (diffuse large B cell type) was diagnosed. The patient was given THP-COP (pirarubicin hydrochloride, cyclophosphamide, vincristine sulfate, predonisolone) therapy. After the third chemotherapy cycle, the patient complained of abdominal pain. On abdominal computed tomography, perforative peritonitis was diagnosed. During emergency laparotomy a perforation of the jejunum was noted. A partial jejunal resection was performed. On histology, inflammatory cell infiltration and organized thrombi in the subserosal blood vessels around the perforated site were noted ; therefore, the perforation was likely secondary to ischemia.

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A 57-year-old male was admitted due to vomiting. On enhanced abdominal CT ; a 3-cm mass was found in the jejunum ; the feeding artery was the third jejunal artery. Endoscopy revealed a complete obstruction related to tumor located in the jejunum 40 cm distal from Treitz's ligament. A biopsy was obtained ; on histology an adenocarcinoma was diagnosed. Partial small bowel resection with D2 lymph node dissection was done. Histopathological examination revealed a mucinous adenocarcinoma originating in the jejunum. According to TNM classification, the cancer is stage II, pSS, int, INFα, ly1, v1, pN0 (0/28), CY0. The patient is doing well one year after surgery. Mucinous adenocarcinoma is histologically rare. The feeding artery was identified by enhanced CT. Thus, the appropriate lymph node dissection could be chosen preoperatively. The endoscopic biopsy was useful in making the diagnosis.

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A 72-year-old man was referred to our hospital because of melena and anemia. Gastroscopy and colonoscopy failed to identify the bleeding source. Abdominal computed tomography with gastrografin showed a diffuse thickening of the small intestinal wall. A small bowel series demonstrated a circumferential apple-core lesion of the upper jejunum. After a tumor with bleeding in the small intestine was detected by capsule endoscopy, a double-balloon endoscopy revealed a tumor at the upper jejunal wall 40 cm from the Treitz ligament. Pathological analysis of the biopsy sample confirmed adenocarcinoma. Tumor markers were in normal ranges. We conducted an operation under a diagnosis of primary cancer of the small intestine. During surgery, no liver metastasis, peritoneal dissemination, or lymph node metastasis was observed and a partial jejunectomy was performed. The resected specimen revealed a circular type 2 tumor, measuring 57×29 mm. Histopathological examination of the resected tumor revealed well-differentiated adenocarcinoma with tubular adenoma components in a part of its periphery. The patient is doing well 13 months after the surgery without any signs of recurrence and his tumor markers remain within the normal ranges.
Primary jejunal cancer with adenoma components is rare and this case suggests a relationship between adenomas and carcinomas of the small intestine.

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The patient, a 78-year-old man, had a right nephrectomy for right renal cell carcinoma in April 2006. From about May 2008 he became aware of anorexia and staggering. Blood test showed Hb 6.7 g/dL and marked anemia. Lower gastrointestinal endoscopy revealed elevated lesions in the ascending colon, and the results of CT, barium enema and small intestine series revealed intussusception at two sites probably due to small intestinal tumor. Laparoscopic partial small bowel resection was performed for the two sites. Tumors were observed in the jejunum 80 cm from the Treitz ligament and in the ileum 28 cm upstream from the ileocaecal valve. They were histopathologically diagnosed as clear cell carcinoma that metastasized from renal cell carcinoma. While metastases to the lung, mediastinal lymph nodes, scalp and brain have been found, he is presently surviving 5 months after surgery. We report the case with bibliographic discussion.

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A 71-year-old woman complaining of lower abdominal pain and abdominal distention was seen at the hospital 2 days after the onset of the pain. When she was first seen, recognizable peritoneal irritation sign was absent. Abdominal ultrasonography showed edema encircling the lumen of the sigmoid colon. Based on physical findings, acute colitis was diagnosed and a drug for controlling intestinal function was prescribed. Thereafter her clinical course had been observed until the 28th day after the first visit, when she was seen at the hospital again because of persisting abdominal symptoms. Lower gastrointestinal endoscopy performed for a suspected lesion of the sigmoid colon disclosed a toothpick (about 65mm in length) stuck in the wall of the sigmoid colon at a portion about 25cm proximal to the anus. The toothpick was removed using an endoscopic forceps per anus. A contrast enhanced CT scan of the abdomen following the removal of the toothpick showed an intra-pelvic abscess, but the inflammatory findings were not so severe. Thus the patient was given drip infusion of antibiotics and administration of the drug for controlling intestinal function on an ambulant basis. Thereafter her clinical course was satisfactory, and the inflammatory findings became negative on the 35^th day after the removal of the foreign body, leading to the termination of treatment.
Lower gastrointestinal perforation due to a toothpick is comparatively rare and this case is reported here, together with some bibliographical comments.

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A 52-year-old woman was admitted to the hospital because of pain in the right flank. She was diagnosed as having acute right colonic diverticulitis and treated conservatively. But her condition did not improve with conservative treatment and she developed acute peritonitis. Emergent laparotomy was thus performed. The Cecum and ascending colon swelled up and changed in color to dark-red. We performed right hemi-colectomy. The resected specimen showed geographic ulcerative lesions, but there were no diverticula. After temporary improvement, she developed acute peritonitis again and went into septic shock on the 13th day after the laparotomy. Re-operation was performed, and we found the transverse and sigmoid colons swelled up and changed in color to dark-red like the last time. We resected the transverse and sigmoid colons. The resected specimen showed geographic ulcerative lesions and Entamoeba histolytica trophozoites were identified in this specimen. Amebic colitis was diagnosed and administration of metronidazole was started. After that, her condition improved immediately.
The diagnosis of amebic colitis is difficult. We should pay attention to E. histolytica infection in the differential diagnosis of refractory ulcerative colitis since it has been increasing in Japan recently.

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Case 1 : A 74-year-old female with a colostomy was admitted due to abdominal pain. CT scan revealed her a parastomal hernia along with an ileus : Simple closure of the fascia defect was performed via an intraperitoneal approach. Case 2 : A 79-year-old female with a colostomy was admitted due to abdominal pain. During emergency surgery, the orifice of the hernia was found to be inside the stoma, and incarceration of the intestine was noted. The orifice, which lacked fascia, was simply closed. There was no recurrence in either of the two cases after surgery. Case 3 : An 83-year-old male with an ileal conduit developed an ileus secondary to a parastomal hernia of the conduit. The orifice of the hernia was closed using a composite mesh. The patient developed an infection in the membrane 3 years after the operation. He refused surgery. The patient was conservatively treated and a fistula developed. An artificial mesh should be used with care. The simple closure of a fascia defect is adequate to repair a parastomal hernia if the fascia defect is not very wide.

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We report herein a case of resectable rectal gastrointestinal stromal tumor (GIST). The patient was a 78-year-old female suffering from hematochezia.
Colonoscopy revealed a giant rectal tumor in the lower rectum with central ulceration and bleeding. Abdominal computed tomography (CT) showed that the tumor occupied the lesser pelvic cavity. She was referred to our hospital, upon which endoscopic coagulation therapy was prescribed. Based on the biopsies specimen, the tumor was diagnosed as a rectal gastrointestinal stromal tumor. Colostomy was subsequently performed and imatinib mesylate therapy started as the tumor was unresectable.
After 23 months of imatinib mesylate therapy, the patient was readmitted to our hospital due to relapse of hematochezia. Tumor size had reduced and she was able to undergo radical tumor resection.
The present findings suggest that imatinib mesylate therapy may allow radical tumor resection in cases of unresectable GIST.

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An 80-year-old woman, who had undergone colostomy for advanced rectal carcinoma with invasion to the uterus, vagina and sacrum three months before, was admitted to the hospital because of high fever, pain and swelling in the buttocks. Pelvic CT scan revealed a tumor in the rectum and widespread abscess cavity from the perianal area to the right calf. Fournier's gangrene caused by penetration of rectal carcinoma was diagnosed and wide drainage operation was immediately carried out. Then she received administration of antibiotics as well as debridement and irrigation every day. On the 19^th post-operative day, closure of the wound and skin grafting were performed. After the second operation, she made a good recovery and was transferred to another hospital on the 63rd post-operative day.
Fournier's gangrene is a specific type of necrotic fascitis. It is rare that rectal carcinoma causes Fournier's gangrene and only 9 such cases with rectal carcinone have been reported so far. We thus report this case with a review of the literature.

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A 76-year-old male was found to have an abnormal mass on a routine plain chest X-ray. Further clinical and radiological examinations of the chest lesion suggested the possibility of lung cancer or pulmonary aspergilloma. On colonoscopy, an advanced lower rectal carcinoma was found. The patient was diagnosed as having rectal carcinoma and pulmonary aspergilloma. Under the same anesthetic, both Hartmann's operation for the rectal carcinoma and resection of the lower lobe of the right lung for the pulmonary aspergilloma were performed.
Histopathological examinations of the resected specimens documented moderately differentiated adenocarcinoma of the rectum and an Aspergillus fungus body in the lung cavity. After the operation, the patient developed multiple pulmonary and liver metastases with local recurrence and subsequently died. At the time of death, there were no clinical signs suggestive of pulmonary aspergillosis recurrence. This is the first report describing resection of pulmonary aspergilloma and GI tract carcinoma done under the same anesthetic in a patient in Japan.

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We report a case of rectal cancer with pelvic abscess treated with preoperative chemoradiation therapy.
A 63-year-old man was referred to our hospital because of fever and anal pain. We diagnosed the patient as having advanced rectal cancer with pelvic abscess. After making ileostomy for fecal diversion, we carried out chemoradiation therapy (radiotherapy at a total dose of 40 Gy over 4 weeks and chemotherapy with 5-FU+CDDP during the first week of radiotherapy). The patient tolerated chemoradiation therapy without any adverse effects and relapse of intra-pelvic infection. Colonoscopy prior to radical operation revealed a shrinkage of the tumor. He underwent sphincter-preserving surgery 6 weeks after completion of the chemoradiation therapy, followed by adjuvant chemotherapy (5-FU+LV+oxaliplatin). He has had no recurrence for 12 months after the surgery. Rectal cancer with pelvic abscess entails a high risk of developing local recurrence and hence preoperative chemoradiation therapy is meaningful. Ileostomy prior to chemoradiotherapy was helpful to cure intrapelvic abscess and prevent from its relapse.

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Four cases of anorectal malignant melanoma are reported in this paper. Three patients underwent abdominoperineal resection with lymph node dissection, and one patient underwent low anterior resection with lymph node dissection. All patients received postoperative chemotherapy. Two of these patients survived over five years. The other two patients have been followed for more than one year postoperatively without any evidence of reccurence.
Anorectal malignant melanoma is believed to metastasize by the lymphatic and hematogenic routes in an early phase and to carry poor prognosis. At present no clear notion of standard therapy has been established. Our relatively favorable therapeutic outcomes might be related to postoperative chemotherapy in addition to rectal resection. To improve the prognosis, the establishment of the standard therapy is necessary.

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A 42-year-old man developed a high grade fever and abdominal pain. Abdominal US showed gallbladder swelling and increased wall thickness ; a low echoic area was noted in the liver in S5. Enhanced CT showed gallbladder swelling and a ring enhanced lesion in the liver in S5. A liver abscess was diagnosed, and percutanceous transhepatic abscess drainage was performed. A water-soluble contrast medium was infused through the catheter, and communication with the biliary tract was demonstrated. On microscopically, no echinococcus or Entamoeba histolytica was found in the abscess contents, and bacterial cultures were negative. A liver abscess secondary to the cholecystitis was diagnosed. Laparoscopic cholecystectomy was performed. On histology, no mucosal inflammation was noted in the resected specimen. Therefore, it was thought that the liver abscess had affected the gallbladder. After the operation, amoebic antibody testing was found to be positive, suggesting that the liver abscess was amoebic.

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A 90-year-old male was admitted to the hospital with the chief complaint of fever and vomiting. Close examination established a diagnosis of upper gastrointestinal tract obstruction due to a large liver cyst of 18×15×10 cm causing to develop vomiting and aspiration pneumonia. In view of his age and surgical invasiveness, he was treated with creation of a fistula between the cyst of the liver and the skin under local anesthesia. His postoperative course was uneventful, and he was discharged in good condition on the 41st day after the operation. This case is presented to show the creation of a hepato-cutaneous fistula (marsupialization) to be very useful for the treatment of symptomatic liver cysts in older patients.

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A 43-year-old woman underwent a total gastrectomy under the diagnosis of gastric cancer at 41-years of age. Its pathological diagnosis was T1, N2, H0, P0, CY0, M0, stageII. Two years after the operation, she was found to have a hepatic tumor by a CT scan. CT scan revealed a mass about 7mm in diameter in S3 of the liver. This lesion was rim enhanced in the dynamic study. MRI revealed a low intensity mass on T1 weighted image and a high intensity mass on T2 weighted image. She underwent partial resection of the liver under the diagnosis of metastasis of the gastric cancer. But the resected specimen showed atypical lymphoid cells proliferating in the tumor, and the pathological diagnosis was hepatic MALT lymphoma. Since this case is relatively rare, we report it here with some bibliographical review.

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The patient was a 65-year-old male who had a hepatic resection of S6 for hepatocellular carcinoma. Abdominal CT performed 14 months later revealed a round tumor of 2 cm diameter at the hepatic flexure of the colon and a diagnosis of peritoneal dissemination of the cancer was made. Laparotomy was performed to remove the intra-peritoneal mass. Pathological diagnosis was dissemination of the hepatoccellular carcinoma. During the follow up at out patient clinic multiple intra-hepatic recurrence of cancer was found and TAEs (transcatheter arterial embolization) were performed twice. When the patient was readmitted for the insertion of a reservoir for intra-arterial infusion of chemotherapy, tumors of 3 cm sizes were found on the right side of the ascending colon and in the Douglas pouch and a laparotomy was performed again. Pathological diagnosis of the specimen was hepatocellular carcinoma. Intra-hepatic arterial administrations of chemotherapy were repeated for the intra-hepatic recurrences with good control of the cancer. The second removal of the disseminated tumors two years after the first recurrence of the dissemination was performed. The edge the resected specimen was free of cancer and no distant metastasis of the cancer was found with good general condition of the patient. This experience indicated a possible favorable long term result with satisfactory QOL of the patient even in case of intra-peritoneal dissemination of hepatocellular carcinoma by the management with control of the original cancer, chemotherapy and local surgical resection of the intra-peritoneally disseminated tumors.

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The case was a 82-years-old man, who had been receiving outpatient treatment at the local hospital because of abdominal pain. He was pointed out liver dysfunction and high elevation of inflammatory reaction and referred to our hospital. At the initial visit, high elevation of inflammatory reaction and slight elevation of hepatobiliary enzymes in the serum were seen. Abdominal plain CT revealed swelling of the gallbladder and a right subphrenic abscess with right pleural effusion. On the same day, percutaneous drainage for the right subphrenic abscess was performed and administration of antibiotics was started. Abdominal MDCT with the abscess cavity filled with contrast medium on the 12^th day after the drainage revealed a fistula from the abscess cavity to the gallbladder and he was diagnosed as having a right subphrenic abscess due to perforation of the gallbladder. After improvement of inflammation, laparoscopic cholecystectomy was performed on the 19^th day after admission. The postoperative course was uneventful, therefore, the drain was removed on the 13^th day. He was discharged on the 17^th day after the operation. Although the therapeutic management for the perforation of the gallbladder with a subphrenic abscess is not established because of its rarity, an elective laparoscopic cholecystectomy after percutaneous subphrenic abscess drainage was possible with less invasion.

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A 53-year-old man was admitted to another hospital because of abdominal pain and underwent laparoscopic cholecystectomy (Lap-C) under a diagnosis of cholecystitis with a gallbladder polyp. The pathological diagnosis was cystic duct carcinoma with invasion to the proper muscle layer and cancer-positive surgical stump. He was referred to our hospital for further treatment. Endoscopic retrograde cholangiography (ERC) revealed pruned-tree appearance in both intra-and extra-hepatic bile duct, and so primary sclerosing cholangitis (PSC) was diagnosed. Extra-hepatic bile duct resection was performed for suspected biliary duct cancer with PSC. On histopathological examination, papillary adenocarcinoma with proper muscle invasion was located in the cystic duct and fibrosis with infiltrating inflammatory cells was found around the bile ducts. Thus it was finally diagnosed as early cystic duct carcinoma complicated by PSC. The postoperative course was uneventful and no recurrence has been detected as of one and half year after the operation.
PSC is difficult to be differentiated from cholangiocarcinoma. In our case PSC was diagnosed based on ERC findings and cystic duct carcinoma was disclosed by Lap-C. Therefore surgical resection should be performed for the exact diagnosis and treatment in case of stenosis of the bile tree.

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A 53-year-old woman was referred to our hospital with the chief complaint of chest tightness. Abdominal CT scan detected a liver cystic tumor having a contrast-enhanced papillary projection. Based on a diagnosis of biliary cystadenocarcinoma, the patient underwent extended right hepatic lobectomy, exicision of the extrahepatic bile duct, lymphadenectomy, and biliary reconstruction. We found communication between the bile duct and the cystic lesion at laparotomy, and pathological examinations did not prove ovarian-like stroma in this case. We therefore diagnosed this case as mucin-producing bile duct cancer. The patient is doing well without any signs of recurrence as of 12 months after the operation.
Mucin-producing bile duct cancer is a relatively rare entity. No concept of the disease as well as its characteristics including differentiation from bile duct cystadenocarcinoma has definitely been established as yet. This case of the disease is reported, together with some bibliographical comments.

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We report the case of a 66-year-old man who presented with abdominal pain and jaundice. Cholangiographic examination done during percutaneous transhepatic biliary drainage (PTBD) revealed a middle common bile duct stenosis, 20 mm in diameter, and a protruded lesion, 2 mm in diameter, located in the lower common bile duct. Subsequently, a pancreaticoduodenectomy was performed since a common bile duct carcinoma was suspected. On Pathology, the circular, flat, diffuse tumor was found to be 23 mm in diameter and was located at the middle common bile duct ; this lesion had poorly and well-differentiated tubular adenocarcinoma findings within the subserosa layer (ss). A circular, flat tumor that was 12 mm in diameter was located at the lower common bile duct ; in this lesion, a well-differentiated tubular adenocarcinoma within the layer fibromuscular (fm) was diagnosed. The two carcinomas were distant from each other, each included intramucosal carcinoma findings. The case was therefore diagnosed as synchronous double cancer of common bile duct carcinoma. To our knowledge, only one previous case of synchronous double cancer of the common bile duct has been reported in the Japanese literature to date.

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A case of metachronous solitary splenic metastasis from cancer of the ascending colon is reported. The patient was a 72-year-old woman undergone right hemicolectomy for cancer of the ascending colon in February 2007. The patient's postoperative course had been uneventful until 13 months after the surgery, when serum CEA level elevated to 5.5ng/ml and splenic metastasis was revealed by CT scan, MRI and FDG-PET examination ; no other distant metastases were seen. Metachronous salitary splenic metastasis of cancer of the ascending colon was diagnosed and splenectomy was performed by laparoscopic operation in March 2008. The operating time was 157 minites and the intra operative blood loss was 87 ml. Histological findings showed moderately differentiated adenocarcinoma compatible with that of the primary tumor. The postoperative course was uneventful and serum CEA level was normalized. There have been no signs of recurrence 6 months after the operation. Splenic metastasis of malignant tumors is relatively rare and the metastasis of colon cancer is extremely rare. So far only 34 cases including ours have been reported in Japan. There are some patients with solitary splenic metastasis from colon carcinoma who survive for a long time, and thus radical surgery would be recommended for such patients.

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A 52-year-old woman, who had been treated with hemodialysis for 32 years, developed hypertention early in the morning and hypotention during hemodialysis. Serum catecholamin levels were elevated, and abdominal CT and MRI showed a left adrenal tumor of 20 mm in diameter. I¹³¹-MIBG scintiscanning showed abnormal accumulations in the left adrenal gland, which was diagnosed as pheochromocytoma. Laparoscopic surgery was performed under continuous hemodiafiltration. During operation, blood pressure transiently decreased, probably because of reduced catecholamines which were removed through the continuous hemodiafiltration. The tumor was resected successfully and she was discharged on the 6th post-operative day uneventfully.

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