We studied whether the lymph node metastasis rate indicates the lymph node metastasis grade in 149 subjects with Dukes C colon and rectosigmoid cancer undergoing curative surgery. We alse analyzed the relationship between the metatstasis rate and survival. When the cases were classified into the metastasis rate of less than 20% and those of 20% or more, the survival difference was significant. When the cases were classified into 4 groups by the metastasis rate (less than 20% / 20% or more) and pN1 / pN2 or pN3, survival in those with a metastasis rate of <20% and pN1 was significantly better than others. Multivariate analysis showed that the lymph node metastasis grade was an independent prognostic factor regardless of whether the Japanese classification or metastasis rate was used as the metastasis grade. Using the lymph node metastasis grade together with the metastasis rate enables prognosis to be predicted in lymph node metastasis.

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Objectives: We studied inguinal hernia surgical classification status following classification revised by the Japanese Hernia Society.
Methods: The Shiga Hernia Society prospectively collected and analyzed data on 327 adults with inguinal hernia between May and October 2009.
Results: Of the 327, 308 were assessed by surgeons as I–1 (5.2%), I–2 (46.1%), I–3 (14.0%), II–1 (5.2%), II–2 (6.2%), II–3 (14.0%), III (4.2%), and IV (2.6%). Type I classification varied considerably among facilities. I–1 type was 1.6% based on the new classification presumed based on hernia orifice diameter. Of surgical procedures, tension–free accounted for 89%, including direct kugel (DK) (49%), mesh plug (MP) (23%), and prolene hernia system (PHS) (16%). In type I, the greater the hernia orifice diameter, the less PM was used. In type II, DK and PHS were used more often than PM.
Conclusions: new classification and mesh type and size suggest that the new classification is likely to be used as an inguinal hernia repair guideline, but the incidence of hernia classification differed among facilities even under the new classification, indicating that the Japan and Shiga Hernia Societies must provide more precise information on the new classification and hernia orifice diameter diagnosis.

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A 54–year–old woman undergoing hemodialysis (HD) three times weekly since 1991 for chronic renal failure (CRF) was seen in June 2009 for a left–breast mass. A left–breast cancer diagnosis (T2N0M0, Stage IIA) necessitated partial resection and sentinel node biopsy. Histopathology indicated papillotubular carcinoma with 23–mm–diameter infiltrate, f, ly0, v0, nuclear grade 2, n (0/2), ER negative (0%), PgR negative (5%), and HER2 (0). The woman was informed of failed risk reduction by dosage reduction and consented to adjuvant epirubicin/cyclophosphamide (EC) therapy. Dose levels were based on case reports of similar disease. Epirubicin is metabolized 80% by the liver but not removed via HD, so the 90 mg/m² dose was reduced 20%. Cyclophosphamide is hepatically metabolized and removed via HD, but decreases CYP3A4 metabolization, so we used a reduced 600 mg/m² minus 25% dose. EC therapy on non–HD days consisted a four–cycle 3–week course, which was completed without serious adverse events, although cycles 3 and 4 were each prolonged one week due to delayed leukocyte count recovery. Particular caution is required in recovery delay from myelosuppression because such delays are rarely seen in healthy persons. EC therapy is, nevertheless, safe in those undergoing HD because dosage can be reduced based on depressed renal excretory and drug–metabolizing function.

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We report a rare case of esophageal schwannoma. A 75–year–old man admitted with mild dysphagia was found in gastrointestinal endoscopy to have an submucosal esophageal tumor covered with normal mucosa. Chest–abdominal computed tomography (CT) showed a well–demarcated homogenous mass on the right anterior wall of the lower thoracic to abdominal esophagus. Based on a diagnosis of esophageal submucosal tumor, we conducted lower esophagectomy with proximal gastrectomy for a 45× 32× 40 mm tumor. Microscopically, the tumor consisted mainly of vaguely palisaded spindle cells with nuclei mildly varying in size and shape. Immunohistochemical staining was positive for S–100 protein and negative for c–kit, h–caldesmon, and α–SMA, yielding a diagnosis of benign esophageal schwannoma.

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A 74–year–old man seen for anemic symptoms was found in abdominal computed tomography (CT) to have small–intestine wall thickening and an enlarged mesentery lymph node. Positron emission tomography (PET) showed a 4 cm tumor near the left pelvic intestinal tract. Double–balloon endoscopy showed a circumferential hemorrhagic type 2 tumor in the upper jejunum diagnosed as moderately differentiated adenocarcinoma based on site biopsy. The man was also diagnosed with primary small–intestine cancer and underwent partial small–intestine resection, local lymph node dissection, and functional end–to–end anastomosis. Histopathological findings yielded a final diagnosis of type 2 papillary adenocarcinoma, ly2, v1, pSS, pN1, sP0, sH0, and pM0. The postoperative course was satisfactory and he was discharged on postoperative day 12.

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An 85–year–old man seen locally for abdominal pain starting in early morning in July 2005 was found in abdominal plain radiography to have an intestinal obstruction, and referred for hospitalization the same day. On admission, he showed right abdominal tenderness and an abdominal mass was palpated. Abdominal computed tomography (CT) showed a 3 cm lower right abdominal mass with mesenteric arteries and veins continuous with this lesion in a spiral—the so–called “whirl sign.” A diagnosis of small intestine tumor with small intestinal volvulus necessitated surgery that day. Laparotomy showed a small discolored dark–red tumor 10 cm from Treitz′ ligament. This tumor had caused the small intestine to rotate 360° with the superior mesenteric vessels as the rotational axis. Torsion was released and the small intestine partially resected. Histopathologically, the diagnosis was gastrointestinal stromal tumor (GIST) of the small intestine with a maximum diameter of 5.7 cm. Immunostaining showed the tumor was positive for c–kit (+), CD34 (+), SMA (+), and S–100 (+). The man remains recurrence–free 5 years after surgery.

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Hepatic portal venous gas is a rare but important radiographic finding that is frequently associated with intestinal ischemia and high mortality. Here we report two cases. Case 1 was an 84–year–old man with respiratory failure and hypotension. Enhanced abdominal computed tomography (CT) revealed intraperitoneal effusion and gas in the branches of the portal vein in the peripheries of the liver. An emergent laparotomy was performed. A long section of the small intestine was necrotic, and 270 cm was resected. Pathological findings revealed ischemic enteritis. The patient died the day following surgery. Case 2 was a 78–year–old man who had hematemesis and melena. Enhanced abdominal CT revealed intraperitoneal effusion, intramural bowel gas, and intrahepatic portal venous gas. A long section of the small intestine and large intestine was discontinuously necrotic and about 300cm was resected. The patient died from acute myocardial infarction on the 12th day after surgery. Hepatic portal venous gas, particularly when associated with pneumatosis intestinalis, is an important finding suggestive of bowel ischemia. Clinicians must carefully distinguish ischemic from non–ischemic cases.

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Case 1: A 36–year–old man admitted for lower right abdominal pain underwent appendectomy based on a diagnosis of appendicitis. The microscopy diagnosis was appendiceal adenocarcinoma in situ.
Case 2: An 81–year–old man with metastatic renal cell carcinoma treated using multikinase inhibitor and referred for fever and abdominal pain underwent appendectomy based on a diagnosis of appendicitis. A perforation was found in the appendiceal tip. Pathological examination showed adenocarcinoma in situ around the perforation. Because early vermiform appendix carcinoma is rare, we report these cases with a review of the literature.

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We report a case of cecal perforation by a transanal decompression tube in a subject suffering from obstructive ascending–colon carcinoma. An 86–year–old woman admitted for colon obstruction due to advanced ascending–colon carcinoma had a transanal decompression tube placed in the ascending colon through colonoscopy. Despite temporary symptomatic relief, she developed fever and abdominal pain relapse 2 days later. Abdominal computed tomography (CT) suggested cecal perforation by the decompression tube from the presence of free air in the abdominal cavity. Emergency laparotomy confirmed a cecal perforation with a 5 mm hole and type 2 ascending colon carcinoma. Right hemicolectomy was conducted following intaraperitoneal irrigation. She was discharged without morbidity 16 days after surgery. Transanal decompression tube use in colon obstruction therefore poses risks such as hemorrhage and intestinal perforation. Immediate surgery is recommended provided that ileus is relieved.

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A 51–year–old man admitted for a left lower abdominal tumor and pain was found in gastrogaphin enema to have a sigmoid colon stricture and diagnosed with well–differentiated adenocarcinoma based on pathological biopsy findings. Postadmission abdominal computed tomography showed an abdominal wall abscess, yielding a diagnosis of sigmoid colon cancer with an abdominal wall abscess. We conducted sigmoidectomy with abdominal wall resection and abdominal wall reconstruction using a fascia lata tensor muscle skin flap. Resection for colon cancer with direct invasion to abdominal wall or formation of abscess sometimes have required wide rang resection of the abdominal wall and its reconstruction. Surgery was conducted in cooperation with the plastic surgery department, with a good outcome.

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A 56–year–old man seen for air and fecal matter in the urine was found in abdominal computed tomography (CT) to have gas in the urinary bladder and the sigmoid colon adhering to the bladder. Contrast enema showed bilateral diverticula and a narrowed sigmoid colon segment and contrast medium flow into the bladder. Based on a diagnosis of colovesical fistula secondary to sigmoid colon diverticulosis, we recommended surgery. The man opted, however, for conservative treatment for work–related reasons, so we conducted laparoscopic balloon dilation. Despite temporary symptomatic relief, loorsening fecaluria necessitated sigmoidectomy and partial cystectomy. We concluded that curing colovesical fistula requires surgery.

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We report 2 cases of intramesosigmoid hernia. Case 1: A 44–year–old man seen for abdominal pain had been operated on 20 years earlier for appendicitis. Abdominal plain X–ray and abdominal computed tomography (CT) showed small amount of intestinal gas with air–fluid levels. Conservative therapy using an ileus tube failed to relieve symptoms, necessitating laparotomy 13 days after admission formed and an intramesosigmoid hernia. The strangulated ileum was reserved and the hernia orifice sutured closed. Case 2: A 45–year–old–woman with no history of laparotomy seen for left lower abdominal tenderness was found in plain X–ray to have a small intestinal gas image and fluid. CT showed a small–intestine obstruction of the pelvic cavity, necessitating emergency surgery for suspected strangulated ileus due to an internal hernia. Laparotomy showed intramesosigmoid hernia, the strangulated ileum was preserved, and the hernia orifice sutured closed. Intramesosigmoid hernia is rare, so we review the Japanese literature.

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We report a case of multiple colorectal polyps requiring emergency subtotal colectomy due to intussusception. A 48–year–old woman diagnosed in colonoscopy with multiple colorectal polyps and due to be examined for anemia could not undergo endoscopy due to sigmoid colon adenoma too large to be snared through the proximal colon. Elective surgery was planned but computed tomography (CT) and abdominal pain and fullness yielded a diagnosis of intussusception with a multiple concentric ring sign necessitating emergency surgery. Operative findings showed sigmoid colon intussusception requiring subtotal colectomy for 42 adenomas, starting with a huge protruding 70 × 50 mm tumor. The pathological diagnosis was low–grade tubular adenomas without malignancy.

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We report a rare case of hepatocellular carcinoma (HCC) developing 10 years after sustained virological response (SVR) to interferon therapy in a subject with hepatitis C.
A 70–year–old man with chronic hepatitis C had reached a sustaining virological response in interferon therapy followed by normalized transaminase. A lesion 9 cm in diameter was detected after 15–year medical follow–up at hepatic segment 8/4. Ultrasonography (US) and computed tomography (CT) indicated that the tumor was attached to the right and middle hepatic vein. He underwent extended right hepatectomy and postpercutaneous transhepatic portal vein embolization (PTPE). Pathologically, the diagnosis was moderately differentiated hepatocellular carcinoma (HCC), with, vp₀, vv₀, im₀, and a noncancerous area showing chronic hepatitis. His condition was stable postoperatively, but ascites control was needed. He was discharged on postoperative day 15.

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In cases of spontaneous fistula closure such as reported here, surgical gallstone ileus should be managed carefully, especially in elder and high–risk subjects.
A 79–year–old Japanese man with a history of abdominal aortic aneurysm, dissecting thoracic aorta aneurysm, and cholecystolithiasis referred for abdominal pain and vomiting. Abdominal X–ray and computed tomography (CT) showed intestinal obstruction due to aberrant gallstone and pneumobilia. The diagnosed was gall stone ileus based on these findings, necessitating surgery. The gall bladder adhered firmly to the omentum and the duodenum as confirmed by laparoscopy. Given the man′s comorbidity, age, and surgical risk, enterolithotomy from the ileum alone was done. Gastroduodenal endoscopy showed a large fistula at the anterior duodenal wall with bile excretion. The fistula closed spontaneously asymptomatically and without complications 4 months postoperatively.

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A 67–year–old man admitted in an emergency for severe left backache and left hypochondrium in April 2010 was shown in laboratory data to have elevated serum amylase concentration of 443 IU/L and inflammatory reaction, yielding a diagnosis of acute pancreatitis. Abdominal computed tomography (CT) showed a pancreatic tail cyst 3.2 cm in diameter. Despite symptomatic relief by conservative treatment after admission, his serum amylase concentration and inflammatory reaction persisted. CT on hospital day 12 showed cyst growth and fluid collection in the left infraphrenic space and left pleural cavity. Amylase concentration in left infraphrenic ascites was 55,966 IU/L. Based on a preoperative diagnosis of ruptured pancreatic pseudocyst and gradual cyst growth, we conducted distal pancreatectomy with splenectomy on hospital day 31. Gross examination of the resected specimen showed a coagulum–filled cyst 3.8 cm in maximum diameter. Microscopically, the cyst wall consisted of fibrous connective tissue, with macrophages in cluding hemosiderin scattered within the wall, suggesting cyst rupture by intracystic bleeding. The man′s postoperative course was uneventful and he was discharged on postoperative day 17. Rupture potential should be considered if conservative treatment increases serum amylase concentration and inflammation persists.

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We report a case of relatively rare omental torsion diagnosed preoperatively and treated laparoscopically. A 38–year–old woman admitted for lower abdominal pain was found in blood studies to have elevated CRP and in abdominal X–ray to have a calcified pelvic mass. Computed tomography (CT) showed a dense fat mass with concentric strands just below the abdominal wall, suggesting omental torsion. Laparoscopic surgery showed greater omental torsion toward the pelvis and distal omental torsion adhering to uterine myoma. We resected the necrotic omentum and uterine myoma. The postoperative course was uneventful and the woman was discharged on postoperative day 2. Our experience indicates that a laparoscopic approach to omental torsion effectively enables definitive diagnosis and subsequent resection.

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A 74–year–old woman referred on a diagnosis of incarcerated right obturator hernia reported lower abdominal and right groin pain on admission that then subsided. Abdominal computed tomography (CT) did not show the cystic mass between the right pectineus and external obturator muscles identified at the previous hospital, indicating that spontaneous reduction had occurred. Abdominal CT showed a dense nodular shadow between these muscles on both sides, and the woman had a history of left obturator hernia. This confirmed the final diagnosis of bilateral obturator hernia. Elective laparoscopic hernia repair using polypropylene mesh sheet in a transabdominal preperitoneal approach was successful despite ovarian carcinoma laparotomy 15 years earlier and laparoscopy–assisted gastric cancer distal gastrectomy one month before admission. Laparoscopic repair is thus useful in cases such as bilateral obturator hernia associated with repeated attack and spontaneous reduction.

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A 91–year–old woman seen for a gallstone and cholecystitis diagnosis was found on examination to have lower right abdominal redness, distention, and swelling and subcutaneous emphysema from the lower right abdomen to the right axilla. She did not report pain or tenderness. After percutaneous transhepatic gallbladder drainage, computed tomography showed a large abscess in the lower right subcutaneous abdominal space adjacent to the intraabdominal small intestine and widespread subcutaneous emphysema extending to the right thoracic wall. Partial ileal resection and subcutaneous and abdominal cavity drainage showed the ileum to be 60 cm from the terminal ileum adhering to an incarcerated, necrotized, perforated hilar hernia 2 cm in diameter creating a large abscess. The woman suffered postoperative wound infection and venous thromboembolism but was discharged 90 days postoperatively.

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We report a case of sacrococcygeal teratoma with malignant transformation. A 65–year–old woman seen for dull anal sensation from January 2008 was locally examined digitally, and in ultrasound, and referred for detailed examination of suspected rectal submucosal tumor in February.
Colonoscopy showed no mucosal lesion, but computed tomography (CT) and magnetic resonance imaging (MRI) showed 1 10×9 cm cystic tumor in the retrorectal space and another 4 cm in size to the right of the uterus. Diagnosing retrorectal cystic tumor and right ovarian teratoma, we conducted abdominoperinial rectal tumor resection and simultaneous right ovarian tumor resection of the strongly adhering tumor and rectum in April. Histopathology indicated an immature teratoma containing adenocarcinoma. The final diagnosis was sacrococcygeal teratoma with malignant transformation and mature right ovarian cystic teratoma.
Adult sacrococcygeal teratoma, which rare and commonly benign, may become malignant, requiring complete tumor resection and appropriate postoperative treatment.

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Pyomyositis in immunocompromised patients may present only minimal inflammatory changes and thus clinically mimic soft tissue tumour. We report two patients with pyomyositis which was initially suspected to be a soft tissue tumour. Patient 1 was a 64–year–old woman who had pyomyositis at the distal part of the left thigh. She had uncontrolled diabetes mellitus. Causative organism was gram positive rods. Patient 2 was a 54–year–old man who had pyomyositis at the medial head of the gastrocnemius. He had ill–controlled diabetes mellitus. Causative organism was Staphylococcus aureus. Both of them were immunocompromised hosts. They showed minimal inflammatory findings and the swelling of the muscles took the appearance of a soft tissue tumour rather than pyomyositis. The inflammation prevailed beyond the muscle compartment and fluid collection representing abscess were seen on MR images. Patient 1 was treated conservatively and Patient 2 was treated surgically. When needle biopsy is performed for soft tissue tumour–like lesions even with minimal inflammatory changes, not only histological examination but also bacteriological examination should be performed.

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