Objective : To study the adverse events associated with neoadjuvant chemotherapy (NAC) used for esophageal cancer, and the factors relating to them. Method : The data of 25 patients who had NAC consisting of 5FU and cisplatin followed by curative resection for advanced thoracic esophageal cancer in our department from July 2007 to February 2009 were analyzed. Adverse events that were grade 3 or 4 which were recorded according to NCI-CTC version 3.0 were retrospectively retrieved. Results : Grade 3 or 4 adverse events of occurred in 10 patients (40%). Neutropenia was observed in 9 ; 3 of these patients developed febrile neutropenia. Compared to the 15 patients without adverse events which were grade 3 or 4, 10 with grade 3 or 4 adverse events were : older (mean 64 years versus 56.8 years, p=0.02), had a lower BMI (mean 19.3 versus 22.4, p=0.04), and had a higher rate of IVH during NAC (5/10 (50%) versus 2/15 (13%), p=0.08). The three patients with febrile neutropenia all had IVH. Conclusion : NAC at standard dose intensity frequently causes grade 3 or 4 adverse events in elderly patients, and in patients with a nutritional disorder.

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Using chemiluminescence method (CL method), we counted the ability of neutrophil's free radical relense (CL counts) in both esophagectomy and gastrectomy patients during postoperative period. CL counts in patients who underwent esophagectomy without doing chemotherapy or chemo-radiation therapy before surgery (un-treated esophagectomy group) were significantly higher than those in the gastrectomy group. It was considered that esophagectomy might be more invasive than gastrectomy.
We performed esophagectomy 4 weeks after the completion of preoperative treatment such as chemotherapy or chemo-radiation therapy. A comparison study between those treated and un-treated groups suggested no significant difference in CL counts during postoperative period. It was suggested that we could safely perform operation without entailing risks of postoperative immunological dysfunction in this period when the neutrophil function had improved.
CL counts in patients who developed postoperative infection after esophagectomy (infected group) were significantly higher than those in the non-infected group on and after the second postoperative day, and there were no significant changes between the infected and non-infected groups in WBC and CRP counts.
We thus consider that this CL method would serve as a good guide in detecting postoperative infection early in esophagectomy patients.

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We performed immediate breast reconstruction using autologous free dermal fat flap followed by irradiation to the breast in a total of 11 patients with breast cancer in whom breast-conserving therapy was difficult. Their postoperative courses were satisfactory and they had not experienced infection and necrosis of the flap Postoperative MRI examination confirmed that the blood flow had resumed only in the periphery of the flap, but no blood flow was seen in the center part of the flap and the size of the flap had become smaller than that when it had been collected. Core needle biopsy showed that fatty tissue of the flap had dropped while its tissue structure had been kept intact, of which histological features were compatible with those of coagulation and necrosis of the tissue due to decreased flap perfusion. The cosmetic evaluation of the reconstructed breast was rated as an average score of 10.0 according to the Sawai group's criteria of the Japanese Breast Cancer Society. The postoperative flap was felt hard in many cases, but good outcomes were gained in all cases in terms of the lowest hanging point of the breast, location of the nipple, and balance between the right and left breasts.
Autologous free dermal fat flap is an easier and less invasive breast reconstruction method than myocutaneous flap and implant methods. It requires no positioning changes of the patient and can be performed not only by plastic surgeons but also by general surgeons.

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Spontaneous rupture of the esophagus occurs rarely, and its mortality rate is relative high if it is lately diagnosed or treated. The patients whose ruptures are small and general conditions are stable can be candidates for conservative therapy, however, surgery is generally indicated for the disease. We here report two cases of spontaneous rupture of the esophagus which were well treated with omentopexy under the video-assisted thoracoscopic surgery.

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We performed laparoscopy-assisted percutaneous endoscopic gastrostomy (LAPEG) in three patients in whom we had been unable to place a standard percutaneous endoscopic gastrostomy (PEG). The laparoscopic approach provided direct visualization for accurate PEG placement, while avoiding injury to other organs. Based on our experience, we recommend LAPEG as a safe and effective alternative to open surgical gastrostomy when PEG is not possible.

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An 18-year-old woman, who had been diagnosed as having Marfan syndrome, annuloaortic ectasia, aortic regurgitation, and mitral valve prolapse at 2 years of age, consulted a pediatrician complaining of left back pain. The patient was found to have a pneumothorax and a pleural effusion on chest X-ray. Tube thoracotomy was performed, and 800 ml of a bloody effusion was drained out. Although hemostasis was obtained, the air leakage continued. Thus, the patient was admitted to our department for surgical treatment. Bullae were detected at the apex of the left lung on computed tomography. After evaluation of the patient's cardiac function, the patient underwent thoracoscopic surgery. Fibrous adhesions with neovascuarzation and bullae were seen in the apex of the left lung. A thoracoscopic bullectomy was performed, and the patient's postoperative course was uneventful. The patient was discharged on the fifth postoperative day. It is important to avoid perioperative cardiovascular events in patients with Marfan syndrome who undergo surgery. Therefore, in patients with Marfan syndrome who require surgery for pneumothorax or hemopneumothorax, a cardiovascular evaluation using ultrasonography should be performed before surgery. The essential point of perioparative management in patients with Marfan syndrome is to avoid an elevation or a rapid change in the blood pressure.

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A 60-year-old man developed a productive cough. Prior to developing this symptom, he had had routine annual medical exams, and no abnormalities had been observed on chest radiographs. However, in January 2007, he began having frequent episodes of coughing that were productive ; chest radiograph abnormalities were seen in April 2007. A bronchial sponge biopsy done at another hospital revealed Class II cytology, and the patient was referred to our hospital for further examination and treatment. A sponge biopsy performed at our hospital revealed Class IV cytology. Since lung cancer was suspected, the patient underwent a right anterior axillary thoracotomy and a right lower lobectomy via a thoracoscope. After surgery, a definitive diagnosis of pulmonary mucosa-associated lymphoid tissue lymphoma was made. A preoperative diagnosis of this disease tends to be difficult to make, and a standard treatment regimen has not yet been established. Therefore, surgery is not only useful for initial treatment, but also aids in making a definitive diagnosis and provides information for making additional treatment decisions.

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We treated a patient with lung adenocarcinoma that had a cystic cavity. A 75-year-old man had an egg-sized cystic cavity in the left upper lobe on chest X-ray and CT. It was thought that the patient had an infectious disease, but he was afebrile, and an examination of the blood showed no inflammatory reaction. Bronchoscopic biopsy revealed lung adenocarcinoma in the cystic cavity. Therefore, a left upper lobectomy was performed via video assisted thoracoscopic surgery (VATS). The resected specimen included a cystic cavity and the tumor surrounded the bronchus that was considered the drainage bronchus. The cavity had developed due to a check-valve mechanism created when the invading tumor surrounded the bronchus. Lung cancer should be considered in patients with a cystic cavity in the lungs.

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A 78-year-old female was urgently admitted with a diagnosis of ileus which occurred just after the fourth exchange of PEG, which had been initiated one year and nine months prior due to a swallowing disturbance caused by Alzheimer's disease diagnosed when the patient was 77 years old. A diagnosis of gastrocolonocutaneous fistula was confirmed based on further examinations. To treat the fistula the PEG bumper and tube were removed under endoscopic guidance. After confirmation of fistula closure, the PEG was remade surgically. If a fistula does not develop a break a gastrocolonocutaneous fistula may not be found, and the patient may not develop any symptoms.

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We report a case of gastrointestinal tumor (GIST) of the stomach, which was difficult to differentiate from cystadenocarcinoma of the pancreas, in an 82-year-old woman. She was admitted to our hospital complaining of epigastralgia and vomiting. Abdominal contrast-enhanced CT scan showed a heterogeneously enhanced tumor and cyst, located between the posterior gastric wall and pancreatic body. MRCP revealed complete pancreatic duct obstruction. FDG-PET showed abnormal accumulation only in the left upper quadrant mass. These findings suggested cystadenocarcinoma of the pancreas rather than GIST of the stomach. At laparotomy, we diagnosed an extragastric growing type GIST with invasion to the pancreatic body by frozen section, then performed a partial resection of the stomach and distal pancreatectomy. Histological findings included spindle cells with a storiform pattern and numerous mitoses (more than 10/50HPF). Immunohistochemically, the tumor was positive for c-kit and CD34, but negative for SMA, S-100 protein and desmin. In addition, she was diagnosed as having GIST of the stomach with high malignant potential, but no signs of recurrence have been observed to date, 14 months after the operation.

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A 64-year-old male had received postoperative chemotherapy with S-1 for 12 months following macroscopically curative gastrectomy (R1) for stage IV gastric cancer with positive peritoneal seeding. Nineteen months after the resection, She felt something wrong with her umbilicus and an abdominal CT scan revealed the emergence of liver metastases and an umbilical nodule. Although the umbilical tumor seemed to disappear once after the sequential chemotherapy composed of S-1 for 3 months, biweekly irinotecan plus cisplatin for 8 months, and weekly paclitaxel for 7 months, the nodule started to increase in size again and caused umbilical pain afterwards, which required the resection of the umbilical tumor 23 months after the emergence of it. Pathological studies revealed moderately differentiated adenocarcinoma located in the subcutaneous region of the umbilicus, which was diagnostic of Sister Mary Joseph's nodule. To date, the patient has been alive for 44 months since the emergence of the Sister Mary Joseph's nodule, bearing liver metastases.

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We report a case of long-term survival without recurrence following resection of hepatic and pulmonary metastases from gastric cancer. A 62-year-old man had a total gastrectomy for gastric cancer with lymph node metastases. 15 months later, he had a partial hepatectomy for a solitary 6.0 × 5.0 cm hepatic metastasis in S4. 26 months after the hepatectomy, he had a partial pulmonary resection for a solitary 2.3 × 2.0 cm lung metastasis in the right lung (S4). He has remained tumor-free for 90 months after the pulmonary resection. It is likely that patients with a solitary and metachronous hepatic metastasis are good candidates for surgical resection. Furthermore, a long survival after pulmonary resection of a solitary, nodular type of lung metastasis after hepatic resection for hepatic metastasis of gastric cancer can be expected.

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A 71-year-old man was diagnosed as having a recurrent gastric cancer with peritoneal dissemination and umbilical metastasis. He was started on combination chemotherapy with TS-1 plus cisplatin (CDDP). On the 7th day after the administration of the first course of CDDP chemotherapy, the patient became drowsy ; laboratory studies revealed a serum sodium level of 108 mEq/l, a serum chloride level of 70 mEq/l, a plasma osmolality of 218 mOsm/kgH₂O, a urine sodium level of 127 mEq/l, and a urine osmolality of 533 mOsm/kgH₂O. The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) induced by chemotherapy using CDDP was diagnosed. Fluid restriction and sodium supplementation were started. On the 3rd day after the start of SIADH treatment, the serum sodium concentration rose to within normal limits, and the patient's consciousness disorder had almost fully resolved. The serum sodium concentration has to be frequently checked during S-1 plus CDDP chemotherapy for gastric cancer treatment due to concerns about SIADH.

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We report a case of non-traumatic duodenal intramural hematoma. A 48-year-old male complaining of vomiting was referred to a local doctor and then admitted to our hospital. At the time of admission, his blood pressure was low. Blood gas analysis revealed remarkable metabolic alkalosis. Abdominal computed tomography showed marked expansion of the stomach and an approximately 6×8cm inhomogeneous tumor at the second and third portions of the duodenum. Upper gastrointestinal series revealed duodenal stenosis. Stenosis was thought to be due to a submucosal occupying lesion. MRCP revealed sclerosis of the main pancreatic duct. The common bile duct was slightly dilated and the intra-pancreatic bile duct was stenotic, though no irregular change of the bile duct wall was recognized. Therefore, we diagnosed a duodenal gastrointestinal tumor of the duodenum. One month after admission, he underwent pancreaticoduodenectomy. The resected specimen showed an intramural hematoma arising from the duodenal muscularis propria. Severe atrophy and fibrosis were recognized in parenchymal pancreatic tissue. Thus, the pathological diagnosis was intramural hematoma of the duodenum with chronic pancreatitis. Heavy drinking and chronic pancreatitis may have been causal factors in our case. Non-traumatic adult cases such as our patient are rare. The preoperative diagnosis of hematoma allowed surgery to be avoided in our case. Thus, preoperative diagnosis is clearly important.

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We describe a case of a neuroendocrine tumor of the accessory papilla of Vater. A 37-year-old woman was admitted due to a tumor located in the duodenum which was found during a routine medical checkup. Duodenal endoscopy showed a slightly depressed submucosal tumor, measuring 10 mm. Computed tomography showed an enhanced tumor in the descending portion of the duodenum. Endoscopic ultrasonography revealed that the tumor invaded the muscularis propria. A pylorus-preserving pancreatoduodenectomy was done. On pathology, a diagnosis of a neuroendocrine tumor with a glandular pattern involving the accessory papilla of Vater was made ; reactivity to chromogranin A and somatostatin antibody was found on immunohistochemical analysis. The nuclear fission index was very low (<2%). The tumor was 7 mm in diameter and invaded to the muscularis propria layer. On microscopy, a lymph node metastasis was seen.

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A 28-year-old woman with a 15-year history of Crohn's disease was admitted to the hospital because of severe stenosis of the transverse colon and an abscess of the abdominal cavity. Ultrasound cardiography demonstrated thrombus with apex of CV port in the right atrium and severe pulmonary hypertension. Additionally, pulmonary thromboembolism was demonstrated by chest CT scan and RI schintigraphy. She was diagnosed as having Crohn's disease with ASA classification IV. After an anticoagulant therapy for 3 weeks, she was performed subtotal colectomy and ileostomy under the preparation of percutaneous cardiac pulmonary system. She had an uneventful postoperative course with no remarkable complications and went back to her works 3 months after the operation. The anticoagulant therapy was maintained after the operation and a chest CT scan taken on the 1st postoperative year showed disappearance of thrombus.
The patient having inflammatory bowel disease with thrombus associated with CV port in the right atrium or pulmonary thromboembolism is so rare. Thromboembolism is a critical complication and strongly influential factor at the selection of treatments for Crohn's disease.

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We report a case of gastrointestinal stromal tumor (GIST) with intussusception of the small intestine. A 30-year-old man was admitted to hospital with abdominal pain and vomiting. Abdominal CT scan demonstrated a mass of the small intestine located in the pelvis. Surgery confirmed the presence of intussusception. An invagination of the ileum, 42 cm in length, located about 10 cm proximal to the terminal ileum was found ; it was caused by an elastic hard tumor. Ileocecal resection was perfomed. On histology, proliferation of spindle-shaped mesenchymal cells was noted. Tumor cells were partially positive for c-kit, positive for CD34, negative for α-smooth muscle actin, and negative for S-100 protein. The tumor was diagnosed as a GIST. GIST with intussusceptions of the small intestine is extremely rare. GIST should be considered in the differential diagnosis of intussusception.

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A 62-year-old man was admitted to our hospital because of severe lower abdominal pain and pyrexia. Abdominal CT scan showed an approximately 8cm-sized cystic lesion with air and fluid occupying from the navel to slightly caudad area. The patient was operated on with a diagnosis of perforative peritonitis. Upon laparotomy, the tumor with bleeding was demonstrated in the small intestine which was about 170cm distal from the Treiz's ligament. In addition a perforation was found at a normal part of the vowel near the tumor. Two parts in the small intestine including the tumor were excised. The immunohistological findings showed positive for CD34 and C-kit, and the lesion was diagnosed as gastrointestinal stromal tumor of the small intestine.

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The patient was a 73-year-old woman who was examined at our hospital for abdominal pain. Abdominal computed tomography (CT) revealed a cystic lesion in the pelvis suspected to be continuous with the intestinal tract. Pelvic abscess was diagnosed and conservative treatment resulted in marked reduction in the size of the abscess cavity and improvement of the inflammatory reaction. Contrast study of the small intestine showed a shadow of an elevated tumor in the small intestine approximately 1 m from the ligament of Treitz, leading to a diagnosis of small intestinal tumor with pelvic abscess. Partial resection of the small intestine was performed laparoscopically. As the tumor was observed in the small intestine approximately 1 m from the ligament of Treitz, the portion of the intestinal tract including the tumor was resected outside the abdominal cavity following endoscopic isolation. Histopathological examination provided a definitive diagnosis of GIST originating in the small intestine with abscess formation. When treating GIST, it is important that complete resection including the capsule is performed while avoiding capsule rupture. In cases of small intestinal GIST with abscess formation such as in the present patient, conservative treatment to reduce the abscess cavity prior to resection was thought to enable both safe and complete resection to be performed.

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A 78-year-old female was admitted to hospital due to lower abdominal pain. Abdominal CT scan showed a pelvic cystic mass and a swollen appendix. Under a pre-operative diagnosis of acute appendicitis with a pelvic abscess, an appendectomy and drainage were performed. Histopathological examination revealed a moderately differentiated adenocarcinoma invading the subserosa in the proximal appendix and a goblet cell carcinoid located at the distal portion of the appendix. Due to the presence of the adenocarcinoma in the proximal margin of the resected appendix, a right hemicolectomy with D3 dissection were performed. Only one case of primary adenocarcinoma of the appendix with goblet cell carcinoid has been previously reported in Japan.

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A 61-year-old man admitted to the hospital because of scybalous stool had no noteworthy abdominal findings. A submucosal tumor 2 cm in diameter was found at the transverse colon by fiberoptic colonoscopy. He underwent laparoscopic-assisted transverse colectomy with a suspicion of GIST of the transverse colon. Microscopically, the submucosal tumor consisted of Anisakis body and hyperplastic nodule. Anisakiasis is an infection of the stomach, less frequently the small intestine, and rarely, of other organs. This case of Anisakiasis of the transverse colon which lacked recognizable acute abdominal symptoms is rare, and it is inferred that larvae of the family Anisakidae might naturally have died and been absorbed.

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An 88-year-old woman who had previous histories of interstitial pneumonia and angina pectoris was seen at the emergency clinic in our hospital because of vomiting and abdominal pain. There was strong tenderness in the entire abdomen. Abdominal CT scan showed a markedly dilated gallbladder, and serum CEA was elevated to 361.7ng/ml. We started conservative therapy with a diagnosis of acute cholecystitis, but eventually performed laparotomy for intensifying abdominal pain 3 days later. The operative findings showed the gallbladder without inflammation and necrotic changes from the descending colon to the sigmoid colon. We performed left hemicolectomy and transverse colostomy. Serum CEA level normalized to 2.4ng/ml on the 13th hospital day and the patient was discharged on the 21st hospital day. Although the mechanism of elevated serum CEA is still unknown, it is necessary to consider that ischemic colitis can cause elevation of serum CEA, especially in aged patients with acute abdomen with arteriosclerosis.

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We report a rare case of lipomatosis of the sigomoid colon in a 50-year-old women. She presented with intermittent abdominal pain and was admitted to our hospital. She underwent emergency CT scan, which revealed sigmoid colon wall thickening and inflammation of the peripheral fat in adittion to a 6cm stool. An exploratory laparotomy showed impaction of the stool in the inflamed wall of the sigmoid colon. A Hartmann's procedure was subsequently performed. The diseased colon specimen revealed multiple submucosal tumors up to 40mm in diameter. The histopathological diagnosis was submucosal lipomatosis of the colon. The patient's abdominal pain and the pathological findings identified were considered to be unrelated.

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Lipoma of the large intestine has been said to be rare so far, but reported cases are increasing along with the common use of endoscopy. One resected case of a giant lipoma of the sigmoid colon that was found by invagination prolapsing through the anus is presented in this paper together with a review of literature. The patient was a man in his sixties who visited our hospital with a complaint of a tumor prolapsed through the anus. A yellowish, elastic soft tumor 8 cm in diameter with bleeding was noticed prolapsed. The tumor was manually reducible. A pedunculated lipoma of the sigmoid colon was diagnosed through various tests after admission to hospital. Since the complication of invagination was also found, Hutchinson's method and partial sigmoidectomy was performed with laparotomy. Histopathological findings revealed proliferation of adipocytes lobulated by fibrous tissues in the submucosa, and lipoma of the large intestine was diagnosed. Only 6 cases of lipoma of the large intestine that prolapsed from the anus including our case have been reported in Japan, and thus it is suggested that these cases are extremely rare.

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A 23-year-old woman who had an operation and chemo-radiation therapy for a neuroblastoma of the left adrenal gland at the age of five months developed a fever and left hypochondralgia when she was 22 years old. A splenic abscess was noted. Percutaneous drainage was done, but the splenic abscess recurred. There was no recurrence of the neuroblastoma. Conservative therapy was unsuccessful and a laparotomy was performed. Operative findings included a bulky mass at the splenic flexure which involved the spleen, pancreas tail, and jejunum. Colectomy at the splenic flexure was performed with co-resection of the spleen, pancreas tail, and jejunum. The surgical specimen showed mucinous carcinoma of the splenic flexure which invaded the spleen. This case was considered to be an radiation-induced secondary colon cancer.

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A 66-year-old man visited our hospital with a chief complaint of anal hemorrhage. Endoscopic examinations of the lower gastrointestinal tract indicated carcinoma of the upper rectum, and a low anterior resection (D3) was carried out. The tumor was situated 10cm from the anal verge. The tumor perforated the mesorectum. Total mesorectal excision (TME) was performed on the anal canal and lateral lymphnode dissection was carried out. The histopathological diagnosis was adenosquamous carcinoma. In addition, there was an endocrine cell carcinoma with a rosette formation and various forms of organization were present. Theories about the genesis of adenosquamous carcinoma have been advocated. We report herein on the genesis and clinicopathological findings of adenosquamous carcinoma.

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A 74-year-old woman was admitted to our hospital for treatment of rectosigmoid colon cancer. Abdominal CT showed two hypovascular tumors, one, 10 mm in diameter, was located in segment 8 and the other, 5 mm in diameter, was located at segments 6 to 7 of the liver. These tumors were not detected on abdominal ultrasonography. Synchronous metastatic tumors of colon cancer were diagnosed. Thus surgery was performed. These tumors were not detected on operative ultrasonography. However, a tumor was palpated in segment 8, and a limited resection which included the lesion was performed. On pathohistology, the colon lesion was found to be a well differentiated adenocarcinoma with a metastatic lymph node, and the liver tumor was a nodule of aggregated lymphocytes that formed a lymphoepithelial lesion. On immunohistochemistry, lymphoma cells were positive for CD20 and CD5, but negative for CD10. Therefore, a hepatic lymphoma of mucosa-associated lymphoid tissue (MALT) was diagnosed. A primary hepatic MALT lymphoma is rare. It is important to differentiate this entity from metastatic hepatic tumors in patients with carcinoma in other organs.

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We report a case of huge hepatocellular carcinoma detected after childbirth in a 39-year-old woman. She had felt persistent upper abdominal swelling after childbirth, and a liver tumor was pointed out by a primary care doctor. So she was referred to our hospital. Close examination showed a huge 13cm-sized hepatocellular carcinoma occupying the entire left lobe of the liver. Considered the primary to avoid tumor rupture, laparotomy was performed on a semi-urgent operation referral to our department. Self-destruction of the tumor had already confirmed by the bloody ascites in the abdominal cavity, and we performed left lobectomy of the liver and a partial resection of S8. The resected tumor was poorly differentiated hepatocellular carcinoma of infiltrative type. She had good postoperative course and was discharged on day 10. Currently as of the 11th month after the surgery, she has been on chemotherapy. Malignancy, especially hepatocellular carcinoma, during pregnancy is very rare. Since rapidly growing tumors might be caused by the pregnancy-associated hormones such as estrogen, we conducted an immunohistochemical study of the resected specimen in this case.

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A 59-year-old woman developed icterus and pruritus. She had a history of liver dysfunction, and on US a thickned gallbladder wall and stones in the neck of gallbladder were noted. ERCP showed stenosis of the right hepatic duct starting from the common biliary duct ; ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed focally increased FDG uptake. Surgery was performed given the diagnosis of Mirizzi syndrome-complex and the possibility of biliary tract cancer. A cholecystectomy, choledochectomy, and a hepaticoenterostomy were performed. Histological findings showed only inflammatory changes without any signs of malignancy. The patient was discharged but had to be readmitted sixth months later due to the presence of jaundice. Although percutaneous transhepatic cholangiography (PTC) showed stenosis and sclerosis of the right hepatic duct and the intrahepatic bile duct, drainage was successful in alleviating her jaundice. Based on immunohistochemical studies of a postoperative liver biopsy specimen and of a salivary gland biopsy specimen a final diagnosis of IgG4-related sclerosing cholangitis was made. The patient is now well controlled with steroids ; there have been no recrudescences.

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A 63-year-old woman was noted to have an asymptomatic cystic liver tumor on follow-up abdominal ultrasonography due to being positive for hepatitis B virus antigen. Computed tomography and magnetic resonance imaging revealed a cystic tumor 5cm in diameter with an internal tuberculum in the left hemiliver. The serum levels of all tumor markers were within normal ranges. Aspiration biopsy was not undertaken, to avoid dissemination of tumor cells in the abdomen, and a left hemihepatectomy was performed. In the resected specimen, an encapsulated cystic mass, with mucinous fluid and a white tuberculum in a part of the cystic wall, was found. Histologically, the inner layer of the cyst wall was lined with a single layer of columnar epithelium with partial papillary proliferation and slightly differentiated cells. The intermediate layer was composed of dense mesenchymal stroma, with estrogen and progesterone receptors identified by immunohistological examination, but was free of malignant components. From these findings, the tumor was diagnosed as hepatobiliary cystadenoma with ovarian-like stroma. Since diagnosis of a cystic liver tumor is difficult and hepatic cystadenoma is a rare neoplasm with possible malignant formation, complete tumor resection is essential.

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A 67-year-old man was found to have swollen cervical lymph nodes. Based on fine needle aspiration cytology a malignant lymphoma was suspected. However, the cervical lymph nodes became non-palpable ; no other lymph-nodes were palpable. On abdominal CT scan, no lymph-node was seen in the abdominal cavity. A papillary protrusion was detected in the fundus of the gallbladder. The patient underwent a laparotomy with a pre-operative diagnosis of carcinoma of the gallbladder. Operative findings included a 50×40 mm papillary tumor in the gallbladder and a 25×20 mm tumor in the jejunum. An extended cholecystectomy with partial resection of the common bile duct, partial resection of the jejunum, and choledochojejunostomy were performed. On histology, a malignant diffuse large B-cell lymphoma was diagnosed. Immunohistochemistry results included negative CD3and CD5 T-cell markers but positive CD10, CD20 and CD79a B-cell markers. The mitotic index was greater than 90%. The patient underwent 8 courses of combined therapy with anti-CD20 monoclonal antibody and CHOP chemotherapy. No recurrence has been noted during 4 years and 10 months of postoperative follow up. Malignant lymphoma of the gallbladder is rare ; it accounts for approximately 0.1% of malignant tumors of the gallbladder. Depending on the type of malignant lymphoma patients may require adjuvant chemotherapy.

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A 42-year-old man complaining of jaundice was referred to our hospital with a suspected diagnosis of pancreatic cancer following examinations at another hospital. Imaging methods revealed a tumor about 4cm in diameter at the pancreas head with suspected invasion into the portal vein. PET-CT showed uptake of fluorine-18 fluorodeoxyglucose (18F-FDG) with the SUV value of 4.7 at the same area as the pancreas head tumor. Accordingly the patient was operated on with the preoperative diagnosis of pancreatic cancer. The histopathological examinations demonstrated no tumor cells at the area where the tumor was present but showed infiltration of inflammatory cells. In addition immunostaining showed IgG4 positive inflammatory cells. IgG4-relating autoimmune pancreatitis was thus diagnosed.
Autoimmune pancreatitis is a pancreatitis in which the participation of autoimmunity is suspected in the onset and it shows uptake of 18F-FDG on PET-CT, so that the differentiation between the disease and pancreatic cancer is important. In the case of a tumor localized in the pancreas, careful attitude would be mandatory to make diagnosis, entertaining the possibility of this disease. This paper deals with a recent case of autoimmune pancreatits in which we had difficulties in making differential diagnosis from pancreatic malignancy due to 18F-FDG uptake on PET-CT, together with some bibliographical comments.

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A lymphoepithelial cyst of the pancreas is a rare benign condition which occurs mainly in middle-aged males. If a diagnosis of lymphoepitehlial cyst can be confirmed before surgery, further treatment would not be needed. However, ruling out malignant disease is extremely difficult, because it often shows features of both multilobular cysts and serum CA19-9 elevation, which can lead to a false diagnosis of mucin-producing neoplasm, resulting in excision in many cases. Two similar cases, both males in their sixties, were treated surgically and are reported and discussed herein.

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A 64-year-old male was admitted to our hospital because an asymptomatic tumor located in the pancreatic tail, was found on computed tomography. Magnetic resonance cholangiopancreatography revealed obstruction of the main pancreatic duct in the pancreatic tail ; there were no abnormal findings in the body or the head of the pancreas. The patient's serum somatostatin and calcitonin levels were elevated. A distal pancreatectomy with aplenectomy was performed. During surgery, a tumor thrombus was found in the main pancreatic duct ; two additional resections were required to obtain a negative margin. The resected specimen included a tumor thrombus in the pancreatic duct that extended 4 cm from the edge of the tumor margin. On histology, the tumor was diagnosed as a well-differentiatied endocrine carcinoma ; it was positive for somatostatin and calcitonin on immunohistchemistry. It is likely that, in this patient, the tumor extended into the pancreatic duct over a rather short period of time. Endocrine tumors which clinically simultaneously produce somatostatin and calcitonin are rare.

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A 26-year-old female visited a nearby clinic because of epigastric pain and was diagnosed as having acute pancreatitis. Abdominal CT scan revealed a cystic tumor 18 mm in diameter at the pancreatic tail. She was referred to our hospital with the diagnosis of pancreatic cystic tumor. Since there were no findings suggestive of malignancy, spleen-preserving resection of the pancreatic body and tail was planned. However, a 1-cm portion of the distal pancreas could not be detached from the spleen. The portion was resected and the stump was sutured. The pathological diagnosis was pancreatic mucinous cystic adenoma. Abdominal CT scan conducted 5 months after the operation revealed ascites, in which the splenic artery could be observed to have penetrated into the spleen. Percutaneous drainage confirmed the diagnosis of late hemorrhage with pancreatic fistula. Emergency angiography showed rupture of a splenic artery aneurysm, and arterial embolization was performed. After the operation, hyperamylasemia persisted for a while but resolved gradually. Splenic infarction was noted in 30% of the spleen, but it was slowly absorbed and disappeared one year after the operation.

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A 57-year-old woman who had been treated for left staghorn calculus in the department of urology in our hospital as an outpatient was seen at our hospital for close exploration because stool guaiac tests were positive at a mass examination. Fiberoptic colonoscopy disclosed a tumor encircling the entire lumen of the descending colon with a part of ulceration. Barium enema showed leakage of barium from the descending colon tumor to the outside of the intestine. Contrast-enhanced abdominal CT scan revealed strongly contracted left staghorn calculus and chronic inflammation in the periphery of the kidney, to which the descending colon which had the thickened wall was adjacent. Accordingly left hemicolectomy associated with left nephrectomy was performed with a suspected diagnosis of a renocolic fistula in which a possibility of malignancy could not be ruled out. During surgery, we saw that the renal arteries and veins had already degenerated and contracted due to severe adhesions from the surroundings of the left kidney to the left diaphragm. Thus we had great difficulties in the identification and dissection between them, and performed an “en-bloc” resection without dissecting the adhesions between the intestine and renal fascia. The resected material showed a fistula from the intestine to the superior calyx. Histopathologically there were the extensively contracted kidney and changes with fibrous proliferation surrounding of it and both acute and chronic inflammatory changes coexisted in the renal pelvis. Hyperplastic change was identified on the colonic mucosa. The patient temporarily developed paralytic intestinal obstruction after the operation, but was discharged very much improved by conservative therapy on the 15^th postoperative day.
Renocolic fistula is a comparatively rare entity and a total of 48 cases, including our case, have been reported in Japan as far as we could review.

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We have experienced a case of metachronous metastasis to the ovary from rectal cancer associated with pseudo-Meigs syndrome.
A 53-year-old woman was seen at the hospital because of abdominal distension, weight gain and appetite loss while she had been treated with chemotherapy for recurrent rectal cancer. She had pleural effusion, ascites and an intrapelvic tumor, and serum levels of CEA, CA19-9, and CA125 were high. Pseudo-Meigs syndrome due to an ovarian tumor was the most likely diagnosis. Her general condition gradually deteriorated due to respiratory dysfunction so that right salpingo oophorectomy was performed to improve short-term prognosis. Histological studies showed cytokeratin 7 negative and cytokeratin 20 positive and then we diagnosed the case as pseudo-Meigs syndrome due to metachronous ovarian metastasis of rectal cancer. After the operation, pleural effusion and ascites disappeared and no re-retention occurred. Chemotherapy was thus resumed, however, her general condition was taking downhill course and she died of primary malignancy 4 months after the operation.
Metachronous ovarian metastasis of colorectal cancer carries poor prognosis. However, in the treatment of a colorectal cancer patient with pseudo-Meigs syndrome, we must be aware of the usefulness of oophorectomy for improvement of the poor prognosis due to respiratory failure.

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Two cases of pyometra are described.
Case 1 : An 86-year-old woman was bedridden due to a right femoral fracture. She developed fever and lower abdominal pain. Abdominal CT revealed free air and ascites in the upper abdomen. Under a diagnosis of acute peritonitis caused by an intestinal perforation, a laparotomy was performed. It was found that the anterior wall of the uterine body was perforated and that pus flowed from the uterus. There were no abnormalities found anywhere along the total length of the intestine. Therefore, a generalized peritonitis due to a perforation of a pyometra was diagnosed. A simple hysterectomy and bilateral salpingooophorectomy were performed.
Case 2 : A 63-year-old woman was bedridden due to sequelae of a brain hemorrhage. She developed abdominal pain and went into shock. Abdominal CT revealed a collection of fluid in the uterus. Under a diagnosis of pyometra, transvaginal drainage was performed. With an aging population the diagnosis of pyometra may increase in Japan. This disease should be kept in mind as a possible cause of acute abdomen in older females.

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A 43-year-old woman was seen at the hospital because of an about 10-year history of swelling at the right side of the pubic bone which had been increasing in size with menstrual pains. When she was first seen, an irregular-shaped, hard submucosal tumor about 5cm in diameter was present in the right side of the pubic bone. Serum CA125 level increased to 72 (U/ml). Ultrasonic study showed a 39.6×23.5×32.3mm hypoechoic area with irregular margin. Abdominal CT scan visualized a heterogeneously enhanced irregular tumor shadow from the right inguinal region to the anterior surface of the pubic bone. Based on her clinical course, ectopic endometriosis was the most likely diagnosis and aspiration biopsy cytology (ABC) of the tumor confirmed the diagnosis of endometriosis. According to her desire, surgical therapy was performed. The tumor had connected to the anterior surface of the pubic bone from the round ligament, and then the tumor with the round ligament was removed. The tumor was 5.5×5×4cm in size and elastic-hard with irregular margin, and the section was solid. Pathological study demonstrated endometrial glands with endometrial stroma in the fibrous tissues, and endometriosis was diagnosed. There has been no recurrence as of 1 year after the operation.
We consider that the patient interview is most important to make the diagnosis of the disease and it must be included in differential diagnoses of inguinal hernia. Besides surgical therapy, other treatments can carry good prognosis to the patient, so that preoperative ABC could be the preoperative examination of choice.

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We report a case of a benign mesosigmoid schwannoma showing high radiotracer concentration on FDG-PET. A 66-year-old woman was admitted for abdominal pain. Computed tomography showed a 5-cm mass in the abdomen ; the FDG-PET examination showed a high radiotracer concentration. Malilgnant lymphoma or abdominal mesenchymal tumor was thought to be the most likely diagnosis. The tumor was resected. The inferior mesenteric artery was involved. On histopathology, the tumor was found to be composed of spindle-shaped cell bundles ; it was S-100 protein-positive, CD34-negative, CD117-negative, and α-SMA-negative. There were no findings suggestive of malignancy. A final diagnose of a benign mesosigmoid Schwannoma was made.

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A 60-year-old male with no significant past medical history or trauma visited our outpatient unit for repeated episodes of abdominal pain and distension, persisting over several years, in August 2007. There were no abnormal findings on physical or laboratory examinations. Ultrasonography and abdominal computed tomography (CT) revealed a well defined, heterogeneous cystic lesion measuring 53mm in diameter. Follow-up abdominal CT at two months showed that the cystic lesion had decreased in size. Differential diagnoses of the cystic lesion included mesenteric lymphangioma, alimentary tract duplication cyst, and gastrointestinal stromal tumor. Initial laparoscopic exploration demonstrated immobility of the cystic mass which was located at the root of the mesentery. Open resection of the mass was therefore performed. There were no postoperative complications and the patient was discharged on the fifth postoperative day. Microscopic examination showed no signs of malignancy and the cystic mass was diagnosed as a mesenteric hematoma. We describe herein a case of spontaneous mesenteric hematoma and discuss its clinical features, diagnosis and management.

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A 79-year-old man was referred to our hospital with abdominal fullness, which had appeared in June 2007. Abdominal ultrasonography demonstrated massive ascites, and tumor marker CEA was elevated in serum (50.2ng/ml).
Colonoscopy revealed a type 1 tumor of the sigmoid colon, and pathological analysis of a biopsy sample suggested class 4, highly suspicious of well differentiated adenocarcinoma. Aspiration cytology of the ascites demonstrated the presence of mucin. We performed surgery under the tentative diagnosis of pseudomyxoma peritonei in September 2007.
The abdominal cavity was filled with many mucinous nodules, allowing a definite diagnosis of pseudomyxoma peritonei.
Appendectomy was performed because mucin adhered around the appendix, but there were no abnormal findings in its mucosa. We removed as many mucinous nodules as possible, and sigmoidectomy was also performed.
Histopathological examination of the resected specimen confirmed well differentiated adenocarcinoma with rich mucous lakes in the sigmoid colon tumor. The depth of tumor invasion was SE (exposed serosa), such that the sigmoid colon cancer was considered to be the origin of pseudomyxoma peritonei.
LV/UFT was used as adjuvant chemotherapy, and the patient's performance status has remained good to date. We report this case since the sigmoid colon is a rare origin of pseudomyxoma peritonei, which usually arises from the appendix.

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A 56-year-old male was referred to our hospital because of persistent ileus after reduction of a left inguinal hernia. On admission, although no herniation was observed in the inguinal region, the patient had abdominal bulging and pain. Strangulation ileus was suspected by CT scan because of a partially dilated intestine associated with a thickened wall and hydrocele-like mass seen in a narrow space between the preperitoneal space and scrotum. During emergency surgery, we released the strangulated small intestine via an abdominal approach. A 20 cm portion of the incarcerated intestine fell into the preperitonal space covered with the hernia sac. Intraoperative observation revealed that a herniation ring strangulating the intestine was composed of hypertrophic peritoneum, confirming that the strangulation ileus was oaused by false reduction of an inguinal hernia. Subsequently, the herniation was repaired using the Kugel procedure via an inguinal approach. Here in, we discuss the cause, diagnosis, and treatment of false inguinal hernia reduction which ocours under extremely uncommon conditions.

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We have experienced two cases of late-onset of mesh infection, which was identified when more than 5 years had elapsed after inguinal hernia operations.
Case 1 : A 78-year-old woman who had undergone mesh plug method for right inguinal hernia 5 years earlier, visited our hospital because of right inguinal swelling. Emergency operation revealed mesh infection. Mesh removal and drainage were performed.
Case 2 : A 62-year-old man, who had undergone mesh plug method for left inguinal hernia 8 years earlier, visited our hospital because of left inguinal swelling. He was performed conservative therapy for 6 months with a diagnosis of mesh infection. Because the therapy failed to improve his condition, operation for mesh removal and drainage were performed.
Although we did not perform reinforcement of the posterior wall in both cases, no signs of recurrence of hernia and infection have occurred in these cases.

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Superior lumber hernia is rare and occurs in the superior lumbar triangle. We report a case undergoing successful repair with Bard Ventralex^®. A 71-year-old woman was admitted to our hospital because of a palpable soft mass in the left lower lumbar area. Computed tomography and magnetic resonance imaging showed a superior lumbar hernia. Intraoperatively, the hernia orifice measuring 1.5 cm in diameter was found in the aponeurosis of the transversus abdominis muscle, and fatty tissue protruded from the defect. Because the hernia orifice was small, we used Bard Ventralex^® for repair. Her postoperative course was uneventful and the patient was discharged on postoperative day 5. Bard Ventralex^® was useful for repair of a superior lumbar hernia with a small orifice.

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A 60-year-old man was hospitalized because of a soft mass in the right lower abdominal area. The mass was 3cm in size. Abdominal computed tomography showed prolapsed fat tissue in the right lower abdominal wall. Spigelian hernia or inguinal hernia was suspected. At operation, the hernia orifice was identified beneath the aponeurosis of the external oblique muscles as a slit in the internal oblique muscle. The hernia sac, prolapsed from the orifice, was about 2.5cm in diameter. We diagnosed a Spigelian hernia. A mesh-plug was inserted into the orifice and an onlay patch was fixed to the superior internal oblique muscle.
The postoperative course was uneventful and he was discharged on the 3rd postoperative day. He has been followed for 4 months to date, without recurrence.
Spigelian hernias are very rare. Hernia repair using the mesh-plug method is advantageous because it allows tension-free repair without complications.

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