Background:The long–term outcome of hepatocellular carcinoma resection is influenced by factors related to the tumor and to underlying liver disease. Its prognosis is worse in those with antibody–positive hepatitis C virus than surface–antigen–positive hepatitis B patients. Optimum surgical resection in those with hepatitis C–limited versus anatomic–remains controversial.
Methods:We compared clinical profiles, surgical results, and long–term survival in 2 groups from among 326 patients with hepatitis C virus undergoing curative hepatocellular carcinoma resection between 1992 and 2006–i.e. 271 undergoing limited resection and 55 undergoing anatomic resection of at least one Couinaud subsegment completely removing the tumor–containing portal area.
Results:Although those undergoing limited resection had significantly worse preoperative liver function than those undergoing anatomic resection, the postoperative liver function of the limited resection group was significantly better. Mortality and morbidity did not differ significantly after either surgery. Disease–free and overall survival were similar, as were intrahepatic tumor recurrence and patterns.
Conclusions:Anatomic resection provides no significant benefit to those with hepatitis C virus infection and hepatocellular carcinoma. and should not be done unless technically necessary. In those with a limited hepatic functional reserve, tumor removal preserving liver parenchyma should take priority over more extensive resection.

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We investigated whether a significant difference existed between subjects with a history of laparotomy (lap group) and without (nonlap group) and whether there are significant differences in the presence of systemic inflammatory response syndrome (SIRS) or the sequential organ failure assessment (SOFA) score between patients with simple ileus and those with strangulation ileus in the nonlap group. Of 66 subjects undergoing surgery for ileus from January 2001 to December 2006, 12 were in the nonlap group and 54 in the lap group. Of those in the nonlap group, 6 had strangulation ileus and 6 simple ileus. Significant differences were seen in heart rate, PaCO₂, base excess, creatine phosphokinase and muscular defense between those with strangulation ileus and simple ileus in the nonlap group. Both lap and nonlap groups, diffcred significantly in SIRS and SOFA incidence between strangulation and simple ileus, suggesting that SIRS and SOFA scores may be useful in diagnosing strangulation ileus in the nonlap group.

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Urachal sinus, which is usually a pediatric concern, should involve immediate umbilical reconstruction to avoid aggravating cosmetic considerations.
We report four cases of urachal cyst resection and immediate umbilical reconstruction.
Our work embraced three types of reconstruction–skin suturing with anchoring to a white line, autologous skin grafting, and a skin bolster suture.
Immediate umbilical reconstruction with skin grafting maintains a deep, long–term umbilical depression, and results can be as satisfactory through the work of a general surgeon compared to the complex skin flaps that specialists may imprese.

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We encountered a patient with regional advanced breast cancer who was resistant to chemotherapy and in whom it was difficult to control hemorrhage from the tumor, who showed satisfactory response to interdisciplinary oncotherapy, including transcatheter arterial embolization(TAE). This case is reported herein. The patient was a 55–year–old female patient who presented with the chief complaint of a tumor mass in the right breast. Initial examination revealed an adult fist–sized tumor mass in area A of the right breast. Needle biopsy(histodiagnosis)reverled the diagnosis of infiltrating ductal breast carcinoma. Chest CT revealed multiple pulmonary metastases. The patient was administered systemic chemotherapy; both the tumor and metastatic lesions showed little decrease in size(SD)when epirubicin and cyclophosphamide were used in the combination treatments. Chemotherapy with docetaxel, paclitaxel and trastuzumab was continued, however, each time the drugs were administered, the tumor increased in size (PD) and massive hemorrhage from the tumor, which necessitated admission to the hospital, was observed. The patient was considered to be an unsuitable candidate for tumor resection, and TAE was conducted via the internal thoracic and lateral thoracic arteries. With further addition of radiation and cryotherapy, marked decrease of the tumor size was seen, and the hemorrhage subsided. Regional interdisciplinary oncotherapy, including TAE, is useful for the treatment resistant locally advanced breast cancer, taking into consideration the patients′QOL.

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Ductal adenoma resembles ductal carcinoma clinically and pathologically. We report a case of ductal adenoma requiring differentiation from ductal carcinoma. A 40–year–old woman with a 1.5×1.0 cm tumor in the internal upper quadrant of the left breast was found in mammography to have a 1.5 cm elliptical high–density area with partially microserrated margins.
Ultrasonography showed a 9×8 mm very–low–echoic lesion with a high D/W ratio. Fine–needle aspiration cytology (FNA) showed epithelial cell clusters preserving two–cell glandular structures. Core needle biopsy showed epitheliosis, but the diagonosis was indeterminate. To determine the diagnosis, we conducted incisional biopsy, and histological examination showed ductal adenoma with epithelial proliferation preserving a two–cell glandular structure.

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We report a rare case of double cancer involving the breast and lower bile duct resected simultaneously and completely. A 66–year–old woman seen for a left breast mass and scheduled for breast cancer surgery suffered jaundice and surgery was postponed. ERCP showed the lower bile duct to be stenotic, and bile duct biopsy showed well–differentiated adenocarcinoma. Based on a diagnosis of double left breast and lower bile duct cancer, we later conducted simultaneous left breast–preserving surgery and pylorus–preserving pancreaticoduodenectomy. She remains recurrence–free in the 18 months since surgery.

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We report a case of rare mediastinal lymph node metastasis in rectal cancer diagnosed postoperatively by mediastinoscopic biopsy, although preoperative FDG–PET/CT suggested physiological accumulation. Case:A 63–year–old man with rectal cancer was found in preoperative FDG–PET/CT to have no apparent p metastasis to other organs but had slight FDG accumulation in mediastinal lymph nodes. Assuming this accumulation to be physiological, we conducted abdominoperineal rectal resection. Pathological findings showed poorly differentiated adenocarcinoma accompanied by lymph node metastasis and marked vascular invasion, necessitating adjunctive chemotherapy. performed. Repeat PET/CT showed no change in accumulation in mediastinal lymph nodes. When he was admitted 3 weeks later for a fever of 40°C, chest CT showed no lung–field abnormalities but enlarged mediastinal/hilar lymph nodes. Soluble IL–2 receptor was high at 1,630 U/ml. Lymphoma could not be excluded, so we conducted mediastinoscopic lymph node biopsy. Biopsied tissue resembled the primary rectal cancer lesion, excluding lymphoma. Despite chemotherapy, the man died of carcinomatous lymphangiosis. Conclusion:The possibility of mediastinal lymph node metastasis should be considered even in those with rectal cancer, and mediastinoscopy proactively done in suspecious cases.

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A 44–year–old woman seen for right back pain was found in chest computed tomography (CT) to have right pleural thickening. She underwent right chest–wall resection and reconstruction, resulting in a postoperative diagnosis of desmoid tumor of the chest wall. Desmoid tumors are rare and histopathologically benign, but tend to recur locally at a high rate. Treatment is surgical excision. A desmoid tumor arising from the chest wall necessitates chest–wall reconstruction, so the treatment strategy requires possible postoperative adjuvant therapy for incomplete resection. Treatment must both maintain quality of life (QOL) and effectively prevent local recurrence or metastasis. Careful long–term follow–up is also required.

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A 61–year–old woman experiencing pharyngeal discomfort after mistakenly ingesting a fishbone and developing neck pain four days later was found in computed tomography (CT) to have transitional pharyngoesophageal calcification found in endoscopy to be a fishbone, which was removed with forceps. CT thereafter showed fluid retention with air bubbles at the left side of the cervical esophagus. Anticipating drainage from the perforation, we observed it serially fixed with a staple. After 8 days of conservative treatment, we conducted drainage after CT showed that the amount of fluid retention had increased. The retained fluid was purulent. The perforation was no longer identifiable. Following a favorable postoperative course, she was discharged on postoperative day 14.

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We report two cases of spontaneous esophageal perforation alleviated in early primary repair. Case 1 was a 69–year–old man who developed esophageal perforation followed vomiting after drinking. Chest computed tomography (CT) showed mediastinal emphysema confirmed by upper gastrointestinal endoscopy, necessitating primary repair with a fundic patch 11.5 hours after onset. No postoperative leakage occurred. Case 2 was a 76–year–old man who vomited and developed perforation during endoscopic therapy. Chest CT showed mediastinal emphysema necessitating primary repair with a fundic patch 4 hours after onset. The postoperative course was uncomplicated. Some studies have related prognosis to the length of the interval between spontaneous esophageal perforation onset and treatment. Some have reported that a fundic patch added to primary repair reduced postoperative leakage. Our two cases suggest that early diagnosis and surgery were effective in treating spontaneous esophageal perforation.

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We report a case of systemic disseminated metastases from superficial esophageal carcinoma five years after curative surgery demonstrating significant differences between clinical diagnosis and autopsy findings. A 77–year–old woman underwent subtotal esophagectomy with lymph node cleansing for esophageal carcinoma in December 2003. Histologically, the tumor was moderately differentiated squamous cell carcinoma (SCC) stage I (T1b, N0). She developed lower abdominal pain and vomiting in April 2008 and a 3 cm tumor was palpated with tenderness under the surgical scar. Abdominal computed tomography (CT) indicated an incarcerated incisional hernia, a tumor of the small intestine, or peritonitis carcinomatosa, necessitating emergency surgery. Laparotomy showed no findings of peritonitis carcinomatosa, so we conducted wedge resection of the small intestine including the tumor. Pathological examination showed poorly differentiated SCC metastasis. Despite rapidly accumulated postoperative ascites and pleural effusion, CT showed no tumor. After the woman died on postoperative day 43, autopsy findings showed diffuse metastases to the pleural and peritoneal membrane, diaphragm, mesenterium, heart, lung, liver, uterus, lumbar spine, urinary bladder, and multiple lymph nodes without forming a tumor mass.

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We report a case of unresectable advanced esophageal cancer in which intentional intensity–modulated radiation therapy (IMRT) alleviated clinical symptoms and quality of life (QOL).
A 54–year–old man diagnosed with unresectable advanced esophageal cancer and passage disorder in the middle to lower thoracic esophagus was found in computed tomography (CT) to have multiple lung, liver, brain, and distant lymph node metastases. We conducted IMRT against the primary lesion and left supraclavicular lymph node metastasis and stereotactic gamma–knife radiotherapy against brain metastases. IMRT dramatically reduced tumors and markedly improved the passage disorder. Stereotactic radiotherapy markeadly reduced left supraclavicular lymph node and brain metastases. These were followed by systemic S–1 and hepatic arterial infusional chemotherapy using cisplatin. In short, liver and lung metastases skrank to where the man′s long–term condition stabilized, leading to acceptable QOL.

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An 82–year–old woman seen for appetite loss and general malaise was found in blood tests to be severely anemic, and in gastrointestinal fiberscopy to have a hemorrhagic tumor of the lesser gastric curvature. Computed tomography (CT) showed a laterally spreading gastric tumor directly invading the liver. Based on a preoperative diagnosis of invasive gastric cancer with liver invasion, we conducted surgery, finding the tumor directly invading the liver and the left diaphragm, necessitating total gastrectomy, lateral segmental hepatic resection, and Roux–y anastomosis. The postoperative course was uneventful and the woman was discharged on postoperative day (POD) 17. The pathological diagnosis was gastric adenosquamous cell carcinoma with significant liver invasion. The woman died seven months later due to disease recurrence.

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A 78–year–old woman followed up for sarcoidosis involving the eyes and lymph nodes developed anemia 3 years and 5 months after initial diagnosis. Upper endoscopy to determine why showed an ulcerative lesion on the greater curvature of the gastric antrum. Biopsy showed moderately to poorly differentiated adenocarcinoma. Chest computed tomography (CT) showed swollen supraclavicular and mediastinal lymph nodes. Abdominal CT showed swollen lymph nodes around the celiac artery, at the left renal hilum, and around the abdominal aorta. Based on a diagnoses of gastric cancer and lymph node swelling due to sarcoidosis, we conducted distal gastrectomy and Billroth I reconstruction with D1+αlymph node dissection. Intraoperative findings showed multiple swollen gastric lymph nodes. Inter operative pathological findings for suprapyloric lymph nodes showed sarcoidal epithelioid cell granuloma. Pathological examination showed moderately differentiated tubular adenocarcinoma (tub2), 0–IIa+IIc, 57×45 mm, pT1(SM2), pN1, CYX, ly2, v2, med, INFβ, fStageII. Dissected lymph nodes along the lesser curvature and infrapyloric lymph nodes showed the coexistence of a sarcoid nodule and adenocarcinoma. The woman is doing well and recurrence–free 17 months after surgery.

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We report 3 cases of Y–loop obstruction after total gastrectomy and Roux–Y reconstruction. Case 1:A 64–year–old man seen for abdominal pain was found in computed tomography (CT) to have Y–loop dilation. Operative findings showed a stenotic jejunojejuno anastomosis, which was widened to eliminate the obstruction. Case 2:A 69–year–old seen for abdominal pain was found in CT to have Y–loop obstruction caused by an internal hernia. Operative findings showed a fistula at the back of the main loop, corrected by repositioning the intestine and fistula closure. Case 3:A 69–year–old man seen for nausea was found to have the Y–loop bent at the jejunal feeding tube insertion point. We reinserted it into the duodenal site. The tube drained the Y–loop contents, correcting the occlusion. Y–loop obstruction, while rare, may develop in many different situations, requiring prompt correction and careful checking via CT.

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A 78–year–old woman seen for melena was found in abdominal computed tomography (CT) to have a pancreatic head tumor and dilated bile and main pancreatic ducts. ERCP showing the lower bile and main pancreatic ducts, to be stenotic led to a tentative diagnosis of pancreatic head carcinoma. Colonoscopy showed a type 2 sigmoid colon lesion for which biopsy indicated sigmoid colon adenocarcinoma. Gastrointestinal endoscopy showed a 0–IIc lesion of the gastric angle for which biopsy indicated gastric adenocarcinoma. Based on a diagnosis of synchronous triple pancreas, stomach, and sigmoid colon cancer, we conducted curative pancreatoduodenectomy with sigmoidectomy. To the best of our knowledge, a case of synchronous triple cancer including the pancreatic head is rare, and we discuss its radical resection.

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We report 4 cases of traumatic duodenal injury–3 in traffic accidents and one in a collision. Individual injury classifications were IIb (D3, rp), IIa (D4, rp), IIc (D4), and IIb (D2). We conducted simple closure, duodenal diverticulization, and tube jejunostomy in the 3 cases of IIa and IIb and duodenal diverticulization and duodenojejunostomy by Roux–en–Y and tube duodenostomy in the case of IIc. In cases with poor imaging, diagnosis may be delayed and complications such as anastomotic leak increase. Surgical choice must thus be based on the degree of injury and interval until surgery.

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Superior results have been reported in treating pediatric duodenal ulcer perforation. We report such a case, in which conservative therapy was begun 2 days after onset. A 13–year–old man admitted for epigastralgia was found in X–ray imaging to have free abdominal air 2 days after onset. Although abdominal muscular guarding was absent, serum C–reactive protein was elevated at 15.4 mg/dl. Abdominal computed tomography confirmed a diagnosis of duodenal ulcer perforation. When conservative therapy had reduced symptoms, he was permitted to eat on hospital day (HOD) 8. Gastroduodenal endoscopy on HOD 16 showed ulcer scars on the duodenal bulb and the man was discharged on HOD 17. Helicobacter pylori (H. pylori) infection was diagnosed and successfully eradicated. Duodenal ulcer perforation should be considered as a differential diagnosis in pediatric patients with acute abdomen. Examination for H. pylori infection is mandatory in pediatric patients with duodenal ulcer perforation, and eradication should be done as soon as practicable.

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A woman in her 60s with a 6–year history of systemic sclerosis admitted for acute abdominal pain with muscular defense was found in abdominal computed tomography (CT) to have free air in the abdomen, necessitating emergency surgery under a diagnosis of acute peritonitis.
We found torsion of the total small intestine and pneumatosis cystoides intestinalis, due to systemic sclerosis, but no perforation. Ischemic change to the bowel was slight, so we repositioned the bowel and completed the operation.
Several reports have shown that conservative treatment for pneumoperitoneum due to systemic sclerosis is more efficacious than surgery, which has high mortality. Rare cases such as our case, however, require emergency laparotomy.

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A 65–year–old woman admitted for abdominal fullness and idiopathic ascites was found on admission, to have free air in the abdominal cavity, abdominal distension, digestive tract obstruction and ascites, but no findings of peritonitis. At her urgent request, we conducted emergency laparotomy, but found no gastrointestinal perforation and the cause of free air and ascites was unknown. When the same thing occurred one year later, we recognized pneumatosis cystoides intestinalis through computed tomography(CT), Raynaud′s phenomenon, and anticentromere antibodies (+), yielding a definitive diagnosis by skin biopsy of systemic sclerosis. Thereafter, she benefitted from medical therapy.
Diagnosing systemic sclerosis complicated by pneumatosis cystoides intestinalis due to free air in the abdominal cavity and ascites enabled us to avoid unnecessary surgery. We also concluded that symptomatic treatment for gastrointestinal symptoms was important.

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We report a patient with a ruptured middle colic artery aneurysm who underwent emergency surgery. The patient was a 47–year–old woman who visited our hospital with a chief complaint of abdominal pain. She developed shock during examination, and was immediately admitted to the ICU. On admission, plain abdominal CT demonstrated a large mass in the left upper abdominal cavity. On the third day after admission, the Hb level dropped rapidly. Emergency contrast–enhanced CT revealed rupture of the middle colic artery aneurysm ; therefore, emergency surgery, including hematoma removal, aneurysm resection, and partial transverse colectomy, was performed. Pathological examination of the aneurysm showed segmented arterial mediolysis (SAM).

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Multiple cancer incidence in the colon is higher than in other organs and is being increasingly detected as examination advances arise. Type 4 colon cancer is rare and its prognosis dismal. We report a case of type 4 ascending colon cancer and type 2 sigmoid colon cancer. A 69–year–old man having a Cypher drug–eluting stent to treat cardiac infarction and could not have his anticoagulants reduced. Seen in September 2007 for abdominal fullness and pain, he was found in colonoscopy to have type 4 ascending colon cancer and type 2 sigmoid colon cancer. Enhanced computed tomography (CT) showed massive liver metastasis to the left lobe, a small nodule in the anterior right pulmonary lobe segment and multiple lung metastases. Progressive anemia and ascending colon stenosis necessitated right hemicolectomy and anterior rectal resection in November 2007, during which diffuse peritoneal dissemination was also found. He was treated postoperatively using irinotecan combined with fluorouracil and leucovorin therapy (FOLFIRI), and remains alive in the 20 months since surgery.

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We report a case of sigmoid cancer, rectal bleeding and coexisting ITP, in which preoperative treatment with large doses of γ globulin and platelet transfusion enabled surgery to be completed safely. A man in his 90s undergoing detailed evaluation for rectal bleeding was found in colonoscopy to have a circumferential type 3 tumor of the sigmoid colon with bleeding from the site. In his 70s, the patient had been diagnosed elsewhere with idiopathic thrombocytopenic purpura (ITP) and treated for 1 month but discontinued it due to side effects. On admission, his platelet count was 16,000/μL and hemoglobin 6.3 g/dL. Before surgery, he was treated with γ globulin (20 g/day) for 5 days and underwent platelet transfusions. Platelet count improved to 255,000/μL. Sigmoidectomy and D2 lymph node dissection were done without intraoperative problems of hemostasis. Perioperatively, he had no significant bleeding. On postoperative day 2, however, platelet count decreased to 24,000/μL. The subsequent clinical course was satisfactory.

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We report a case of four separate synchronous colon cancer lesions extending from the sigmoid colon to rectum. A 64–year–old man seen in August 2007 for dizziness and anemia was found in colonoscopy to have 3 sigmoid colon cancers lesions and 1 rectal cancer lesion. Repeat colonoscopy in September 2007 and enhance computed tomography (CT) showed no hepatic or lung metastasis. Low anterior resection was done using double stapling with level 3 lymph node dissection. Pathological findings showed a type 1 tumor of the rectum (tub1, 70×85 mm, pSM, ly0, v0), type 2 (tub2, 40×35 mm, pMP, ly2, v2), type 1 (tub1, 85×47 mm, pSS, ly0, v0) and type 1 (tub2, 60×53 mm, pMP, ly0, v1) of the sigmoid colon. Only 1 lymph node metastasis was detected among 61 nodes. No recurrence has been detected in the 24 months since surgery.

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We report a case of locally advanced rectal cancer in a young adult. A 34–year–old woman with a two–month history of abnormal bowel action and genital hemorrhage was found in barium enema and colonoscopy to have advanced rectal cancer with severe stenosis. Computed tomography (CT) showed lower rectal cancer, including the uterus and vagina, and an enlarged left ovary, with neither liver metastasis nor lung metastasis. Miles operation resecting the uterus, bilateral ovary, posterior vaginal wall, and left ureter was conducted in December 2002. Histological examination showed well– differentiated adenocarcinoma invading the uterus, vagina, left ovary, and left ureter, with lymph node metastasis. The woman underwent postoperative adjuvant chemotherapy with 5–FU/l–LV (RPMI regimen) and has remained recurrence–free in the six years since surgery.

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We report a long–surviving case of rectal cancer with synchronous liver and lung metastasis evincing no signs of recurrence in the over 8 years since surgery. A 68–year–old man undergoing anterior rectal resection, partial ileotomy, and partial hepatectomy for rectal cancer with liver metastasis (H1) and direct invasion to the ileum in February 2001 also underwent partial pulmonary resction for a metastatic lung tumor (LM1) in March 2001. He was then administered tegafur at 300 mg a day as adjuvant chemotherapy for one year. As of May 2009, he has shown no signs of recurrence –a rare example of long–term survival may be obtained through surgical resection in rectal cancer with synchronous liver and lung metastases.

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Isolated right ventricular intravitary hepatocellular carcinoma metastasis is a rare condition. A 75–year–old man undergoing extended right hepatic lobectomy for hepatocellular carcinoma 14 cm in diameter 2 years earlier had shown no intrahepatic or distant metastasis. He had been followed up regularly and was generally well. One month before routine computed tomography (CT), he felt mild shortness of breath on exertion and was found in CT to have a large right ventricular intracavitary mass. Serum alphafetoprotein was within normal limits, but serum PIVKA II, a protein induced by vitamin K absence or antagonist–II, had increased. Echocardiography showed an intracavitary mass occupying the right ventricle, strongly suggesting cardiac metastasis from hepatocellular carcinoma. His symptoms were relieved by diuretics and, except for cardiac metastasis, neither intrahepatic nor extrahepatic metastasis was seen in the 2 years until he died of acute renal failure.

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A 65–year–old woman undergoing sclerotherapy for esophageal varices was found to have a type 0–IIc cancer lesion in the gastric antrum in follow–up endoscopy and was hospitalized for surgery. She had a 40–year history of primary biliary cirrhosis (PBC). Although ascites was observed on admission, distal gastrectomy with D1+α lymph node resection was done after ascites was controlled. Histologically, well–differentiated tubular adenocarcinoma was observed with no lymph node metastasis. No recurrence of the disease has been noted in the 4 years and 4 months since surgery. Liver biopsy results were consistent with PBC, which is commonly reported in middle–aged women and characterized by destructive inflammation of the intrahepatic interlobular bile ducts. Our case developed gastric cancer 40 years after a diagnosis of PBC. She also has a family history of gastric cancer, so its genetic predisposition may be involved. The possible involvement of impaired immunological defense accompanying autoimmune disease cannot be ruled out. Only a few cases of combined PBC and malignant tumor have been reported in Japan, but any malignant tumor should be performed examined in detail in those with PBC.

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We report a case of hepatocellular carcinoma (HCC) occurring in an elderly person with Crohn′s disease. A 71–year–old man admitted for a right hepatic tumor 2 cm in diameter had undergone blood transfusion during total colectomy and ileostomy construction of the right subcostal space at the age of 45. Hepatitis C infection was pointed out when he was 64. He had since suffered difficulty in stoma care due to a depressed ileostomy. The liver tumor at the edge of subsegment 6 was diagnosed as HCC based on radiological findings, and his liver function was tolerable for hepatectomy. Due to the proximity of the ileostomy to the costal bone arch, transcatheter arterial chemoembilization (TACE) was conducted to suppress tumor growth. Two months after TACE, the ileostomy was relocated to the right lower abdominal wall and partial hepatectomy conducted through a bilateral subcostal incision. The postoperative course was uneventful. Increases in life expectancy are expected to swell the ranks of malignancy–bearing patients with ileo/colostomy, which in turn raises the need for better attention to perioperative stoma management.

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We report a case of cholecystocolonic fistula with confluence stones treated by laparoscopic surgery. A 54–year–old woman admitted for epigastralgia and fever was found in abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) to have gas in the gallbladder with wall thickening and a filling defect of the common bile duct. Based on a diagnosis of emphysematous cholecystitis with confluence stones. Laparoscopic surgery showed the gallbladder to be covered with the omentum and firmly adhering to the transverse colon. The gallbladder was resected with part of the transverse colon using an endoscopic linear stapler. The confluence stones were extracted and a T tube reserved in the common bile duct. The resected specimen showed a fistula between the gallbladder and the transverse colon. The postoperative course was uneventful and she was discharged on postoperative day 9. We conclude that laparoscopic surgery for cholecystocolonic fistula with confluence stones is safe and feasible.

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We report a case intraoperatively diagnosed as Mirizzi syndrome that was actually gallbladder cancer according to postoperative pathology. A 68–year–old woman admitted elsewhere for cerebral infarction and showing increased hepatobiliary enzyme in blood tests was found in imaging to have a 10–cm–plus gallbladder stone, common–hepatic–duct stenosis, and a dilated intrahepatic bile duct, necessitating surgery based on a diagnosis of Mirizzi syndrome. Intraoperatively Calot′s triangle was difficult to mobilize due to severe inflammation, so the gallbladder fundus was partially resected and the gallbladder stone removed. Upon examining the lumen of the gallbladder, we found a preoperatively placed endoscopic biliary drainage (EBD) tube, yielding a diagnosis of fistula between the gallbladder and common hepatic duct. No malignant pathological findings were observed intraoperatively. Cholecystotomy, T–tube placement, and suture repair of the gallbladder were then done. The definitive pathological diagnosis, however, was tubular carcinoma. Given the woman′s general condition, we decided against more resection and are following her up on an ambulatory basis.

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Small–cell carcinoma of the gallbladder is very rare and difficult to treat, having high malignant potential with lymph node metastasis, necessitating postoperative chemotherapy for long–torm survival. We report a case of small–cell carcinoma of the gallbladder. A 64–year–old man admitted for a gallbladder fundus tumor found in ultrasonography was found in enhanced abdominal computed tomography (CT) to have an elevated gallbladder tumor 15 mm in diameter, together with swollen lymph nodes in gallbladder neck and in the hepatoduodenal ligament. Based on a diagnosis of gallbladder carcinoma with lymph node metastasis, we conducted partial hepatectomy with pancreaticoduodenectomy. Histologically, the tumor consisted of small, nodular–infiltrative carcinoma cells, CD56, and synaptophysin positive in immunohistochemical staining. These findings were compatible with small–cell gallbladder carcinoma.

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A 71–year–old woman admitted in May 2005 for a growing pancreatic cyst seen in follow–up was found in abdominal ultrasonography, computed tomography, and magnetic resonance imaging to have a multilocular 68×62×52 mm cystic lesion in the pancreatic tail. The lesion contained cysts a maximum of 3 cm in diameter and blood flow within the diaphragm. Imaging results suggested a mucinous cystic neoplasm (MCN), necessitating resection of the pancreatic tail with splenectomy, followed by two–group lymph node dissection. Histopathological examination of the resected specimen showed cyst contents clear, colorless serous. Flat and cubic tumor cells in a single layer covering the cyst wall were positive in periodic acid–Schiff (PAS) staining. No findings indicated malignancy. The definitive diagnosis was macrocystic (variant) serous cystic neoplasm (SCN). A macrocystic subtype is rarely reported in SCN and should be carefully differentiated from mucinous cystic neoplasm (MCN) and intraductal papillary mucinous neoplasm (IPMN).

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A 39–year–old woman with melena seen for a diagnosis of rectal cancer underwent laparoscopic low anterior resection, during which a tumor 20 mm in diameter was found in the ileum 100 cm proximal to Bauhin′s valve. The ileum was also partially resected to rule out intestinal cancer and metastatic tumors. Postoperative histopathological examination showed ectopic Heinrich type I pancreatic tissue. Ectopic pancreas occurs in organs such as the stomach, duodenum, and jejunum, but rarely the ileum. Ectopic ileal pancreas may occur with intussusception, and is rarely found incidentally during surgery for other reasons. Intraabdominal exploration is difficult during laparoscopic surgery, but appears necessary in eases such as this one.

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A 68–year–old woman admitted for back pain was found in abdominal computed tomography (CT) and magnetic resonance imaging (MRI) to have a low–contrast tumor 13 mm in diameter in the body of the pancreas and a 77 × 50 mm cyst in the splenic hilum, yielding a diagnosis of pancreatic cancer with concurrent obstructive necrotizing pancreatitis and pancreatic pseudocyst. Following laparotomy, a small nodule was found on the liver surface not detected in preoperative imaging, yielding a rapid histopathological diagnosis of metastatic neuroendocrine cancer. The pancreatic tail was resected followed by splenectomy. Histopathological examination showed tumor–cell proliferation in cords and foci, and immunostaining test was positive for chromogranin A and slightly positive for somatostatin and pancreatic peptide (PP). The definitive diagnosis as was differentiated nonfunctional pancreatic endocrine tumor, detailed pathologically as fT3, fN0, fM1, and fStage IVb. Generally, a pancreatic endocrine tumor features intensive imaging contrast reflecting its plethoric nature. The atypical features in this case, however, made it difficult to distinguish the tumors from invasive ductal carcinoma.

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A 78–year–old man seen for jaundice in June 2008 was found to have elevated serum concentration of carcinoantigen 19–9. Endoscopic retrograde cholangiopancreatography showed obstruction of the retropancreatic bile duct. Contrast–enhanced computed tomography (CT) showed a pancreatic head tumor 2 cm in diameter with a slightly enhanced obstructed retropancreatic bile duct. Upper gastrointestinal endoscopy showed gastric cancer (Type 0–IIa+IIc) of the body of the stomach. Based on these findings and a preoperative diagnosis of synchronous double cancer of the pancreas and stomach, pancreatoduodenectomy was conducted with subtotal gastrectomy, regional lymph node dissection (D2), and modified Child reconstruction. Macroscopic findings showed a whitish solid tumor 2 cm in a diameter at the pancreas head with infiltration to the bile duct together with gastric cancer in the middle portion of the stomach. Histologic examination showed the pancreatic tumor to be adenosquamous carcinoma with lymph node metastasis (pT3N1M0 Stage III) and gastric cancer to be moderately differentiated tubular adenocarcinoma limited to the muscle (pT2N0M0 Stage IB). The man underwent chemotherapy with gemcitabine after CT 3 months postoperatively indicated multiple liver metastasis and ascites. After symptoms rapidly worsened, the man died of cancer recurrence 5.5 months after surgery.

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The fentanyl patch is useful in palliative care of gastrointestinal malignancies. A 65–year–old woman undergoing gastrojejunostomy for unresectable pancreatic head cancer began use of a quarter–size trans dermal fentanyl patch (Durotep patch(r) 2.5 mg) 8 months postoperatively, and her pain almost disappeared. She also had inserted a self–expanding metallic biliary stent. She felt no pain with the fentanyl patch alone for a year after patch use started. Billiary stent ingrowth later caused obstructive jaundice, but pain was well controlled by the patch over her 2–plus years of postoperative survival. She died 1 year and 4 months after patch use began. Fentanyl patch use should be started as soon as possible due to its improvement in the quality of life.

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A 63–year–old man admitted for abdominal pain was found in computed tomography to have free air in the abdominal cavity, necessitating emergency surgery under a diagnosis of gastrointestinal perforation. We found air bubbles on the mesenteric side of the jejunum 50–80 cm from Treitz′ ligament. The mesentery showed thickening and was partially ruptured, causing purulent fluid to leak from the defect. Based on a diagnosis of mesenteric abscess perforation due to jejunal mesenteric penetration, we partially resected the jejunum with the thickened mesentery. The resected specimen contained 5 or 6 diverticuli, one of which had penetrated the mesentery, forming a mesenteric abscess. Such abcess perforation is rare, and we report this case with a review of the literature.

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We report a case of primary poorly differentiated squamous cell carcinoma (SCC) presenting as a giant mass in the retroperitoneum. A 41–year–old woman seen for lower left abdominal pain and edema in the left lower leg was found in contrast–enhanced abdomen and pelvis computed tomography (CT) to have a giant mass occupying the left side of the iliopsoas, retroperitoneum, and lower left pelvis. Percutaneous needle biopsy through the back showed the tumor to be (SCC). Careful examination showed no other neoplastic lesion except carcinoma in situ in the uterine cervix. Under a definitive diagnosis of primary retroperitoneal malignant tumor, she underwent surgery. A hard elastic 200 × 80 ×50 mm tumor was found spanning from the lower renal artery branch at the left side of aorta to the left internal and external iliac arteries, including the common iliac artery bifurcation. The surgical tearm, including doctors from orthopedic surgery, gynecology, urology, and cardiovascular surgery, conducted tumorectomy—total hysterectomy, left ovariectomy, removal of the left ureter, and removal of the left internal and external iliac arteries together with the left common iliac vein—urinary diversion, and a left–to–right femoral artery bypass . Low dose cisplatin and 5–fluorouracil therapy and radiotherapy done as the adjunctive therapy failed to be effective, and the woman died of cancer recurrence 5 months after surgery.

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Patient:A 54–year–old man seen for a penetrating injury of the left lateral abdomen and in shock–systolic blood pressure 74mmHg, pulse rate 95/min, respiratory rate 18/min, and body temperature 34.5°C–underwent emergency laparotomy 73 minutes after the event and 30 minutes after admission. Renal injury included the renal hillus and duodenal injury at the end of the 3rd position. Because hemostasis and renal hillus repair were difficult to complete quickly, nephrectomy and simple duodenal closure were completed first. The man presented hypotention, hypothermia, acidosis, and bleeding during surgery, however, so we were forced to conduct gauze packing in postnephrectomy and dissected retroperitoneal areas and to temporarily close the abdomen based on damage control concepts. The man was transferred to the ICU to treat his metabolic crisis, and underwent planned reoperation 50 hours after the first surgery to remove the packed gauze.
Conclusion:Damage control is essentially an escape strategy necessary and useful for patients with massive hemorrhaging, and we should be prepared to implement it under all emergency conditions.

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A 43–year–old woman with no history of laparotomy admitted for intestinal obstruction was found in computed tomography (CT) to have internal hernia of the small intestine from the ventral side to the dorsal side of the left uterine broad ligament. Laparoscopy confirmed the internal hernia through the left broad uterine ligament. The failure of laparoscopic hernia reduction necessitated widening of the broad ligament defect and reduction of viable internal loops after a 5 cm skin incision in the lower abdomen. The defect was closed during laparoscopy. Hernia through such a defect is difficult to diagnose preoperatively and, even if it is diagnosed, intestinal resection is often needed due to impaired blood flow in the incarcerated ileum. Preoperative CT followed by laparoscopic surgery thus proved very useful for treating an internal hernia.

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We report a case of femoral hernia with ovarian incarceration. An 86–year–old woman referred for a left femoral mass and possible left inguinal hernia incarceration was confirmed to have a mass with redness and tenderness in the left inguinal region. No ileal symptoms were noted. Abdominal ultrasonography showed a solid cystic lesion in the left inguinal region continuous in the abdominal cavity. Abdominal computed tomography confirmed these findings. Hernia contents were considered potentially associated with part of the small intestine or ovary, yielding a diagnosis of femoral hernia incarceration, necessitating emergency surgery.
Intraoperatively, a femoral hernia was found whose contents were associated with the left ovary. The absence of ischemic change eliminated any need for resection, so we conducted polypropylene hernia system (PHS) hernioplasty. Incarceration of the ovary, appendix, or other organ should be considered when differentially diagnosisng femoral hernia a symptomatic for ileus in elderly women.

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Spigelian hernia, which occurs in less than 2% of all abdominal wall hernias, is relatively rare. detected A 77–year–old woman seen for a lower right abdominal mass in April 2008 was found in abdominal ultrasound and computed tomography (CT) to have a Spigelian aponeurosis defect, diagnosed as a Spigelian hernia. Repair was done with a Composix kugel patch (S) in October 2008.

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