AIM: To investigate the benefits of introduction of laparoscopic appendectomy (LA) in a community hospital.
PATIENTS AND METHODS: The subjects of the study were 56 patients who underwent appendectomy for acute appendicitis from June 2003 to January 2005 in Kokura Memorial Hospital. Before March 2004, all patients underwent open appendectomy (OA). We introduced LA in April 2004 and from that point onwards almost all the cases underwent LA, except for the initial few cases. Operating time, wound infection, postoperative fever, the time to the first flatus, time of use of postoperative analgesics, and the length of postoperative hospitalization were evaluated.
RESULTS: Of the 56 patients enrolled in the study, 35 underwent OA and 21 underwent LA. The operating time for LA was longer than that for OA (mean ± S.D.: 81 ± 37 vs. 58 ± 21 min, p<0.01). However, the rate of wound infection was lower (37% vs. 0%, p<0.01), and the hospitalization was shorter (9.0 ± 6.1 vs. 5.7 ± 3.4 days, p<0.05) for LA. There were no significant differences in other factors.
CONCLUSION: The introduction of LA into a community hospital can reduce wound infection and shorten hospitalization. Thus, we recommend use of LA in community hospitals.

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Purpose: We studied the effect of keishi–bukuryo–gan (KBG), also known as cinnamon and hoelen formula, on subcutaneous hematoma following varicose vein surgery.
Materials: Subjects were 192 persons undergoing varicose vein surgery using InvisiGrip^TM in Aisei Hospital from November 2007 to April 2009. Of these, 45 were administered 7.5 g/day of KBG and wore an elastic compression bandage for 7 days postoperatively, while 147 used an elastic bandage alone. Seven days postoperatively, we compared subcutaneous hematoma scores between groups.
Results: No significant differences were seen between groups.
Conclusion: After varicose vein surgery, the use of elastic bandages alone and of elastic bandages with KBG helped prevent subcutaneous hematomas in the two groups studied, although no significant differences were seen between groups.

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A 40–year–old man seen elsewhere two days before for loss of appetite (anorexia), fever, and neck swelling was brought to our hospital by ambulance due to decreased consciousness. Sudden respiratory arrest in the emergency room then necessitated nasal intubation, computed tomography (CT) on admission indicated erythema, ambilateral neck swelling and gas patterns in all cervixes, yielding a diagnosis of septic shock due to a deep neck abscess and gas formation. Whole–body control was implemented using 0.3–0.9 gamma of norepinephrine, but contrast–enhanced CT detected an abscess in the prevertebral space on hospital day (HD) 3, when the man's general status had stabilized. Incision and drainage were done on HD 3 and 5. The infection was combined Pseudomonas aeruginosa and an anerobic gram–negative coccus, requiring washing with doripenem (DRPM) and clindamycin (CLDM) on HD 32. The right mandibular wisdom tooth was removed on HD 64. The final diagnosis was a deep neck abscess with gas formation due to odontogenic infection of the wisdom tooth. Early detection of abscess formation by contrast–enhanced CT may have been lifesaving because of optimal incision and drainage and the use of appropriate antimicrobial agents.

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A 79–year–old postmenopausal woman was seen for a hard mass 5.0 cm in diameter resembling breast cancer in the upper outer left–breast quadrant. Mammography showed asymmetrical density and ultrasonography revealed an irregular hypoechoic lesion with posterior acoustical shadowing. Contrast–enhanced computed tomography (CT) detected no focal enhanced lesion in the thickened left breast, but contrast–enhanced magnetic resenance imaging (MRI) showed gradual patchy lesion enhancement. Despite the initial breast cancer diagnosis, we found imaging inconsistent with typical breast cancer. The woman had been treated for Type 2 diabetes mellitus for 45 years, so her clinical history and the inconsistency yielded a final diagnosis of diabetic mastopathy. This was confirmed histologically following incisional biopsy. Diabetic mastopathy may be difficult to distinguish from breast cancer, but can be correctly diagnosed before surgical biopsy through accurate medical examination, interview, and imaging diagnosis.

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A 56–year–old woman diagnosed with left breast cancer, as T4bN1M0 stage IIIB (squamous cell carcinoma; ER negative, PgR negative; HER2 3+). Underwent 12 weekly paclitaxel and trastuzumab cycles and achieved partial response (PR). After completion, cycle 12 she was admitted with a 38°C fever, cough, and sore throat 8 days afterward, followed the next day by dyspnea. SpO2 was 93% and bilateral lower lung fields. fine crackling. Chest CT showed ground–glass density with partial infiltrates in bilateral lung fields, and KL–6 had increased to 694 U/mL, yielding a diagnosis of interstitial pneumonitis reguiring steroid pulse therapy. She became afebrile the day after pulse therapy and reported no marked symptoms. Drug–induced interstitial pneumonitis was suspected and a drug lymphocyte stimulation test for paclitaxel and trastuzumab, showed negative results. Total mastectomy with axillary lymph node dissection was done on day 23 after admission. Postoperative trastuzumab was cautiously reinstituted with no recurrent interstitial pneumonitis, resulting in paclitaxel being considered causally related.

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We report three cases of local postoperative breast cancer recurrence found in diffusion–weighted MRI (DWI). Case 1: A 42–year–old woman undergoing breast–conserving surgery for right–breast cancer 3 years and 4 months earlier was shown in DWI to have a high round signal area in the remaining breast. This was diagnosed as ipsilateral recurrence due to mastectomy. Case 2: An 88–year–old woman undergoing left mastectomy for breast cancer 8 years and 6 months earlier was shown in DWI to have a mass shadow in the left chest wall exhibiting a high signal. This was diagnosed as regional lymph node metastasis due to resection. Case 3: A 69–year–old woman undergoing left mastectomy with sentinel lymph node biopsy 10 months earlier was shown in DWI to have a mass shadow in the left chest wall exhibiting a high signal. This was diagnosed as lymph node metastasis due to lymph node dissection. These three women, whose recurrence was found thanks to DWI MRI, remain well without recurrence as of this writing, demonstrating the usefulness of DWI MRI in detecting local recurrence early.

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A 64–year–old woman reporting a bloody left–breast nipple discharge was not found in mammography or ultrasonography to have a palpable mass or other abnormality. Nipple discharge Cytology findings were benign. Mammary ductography, however, showed a duct stricture and peripheral dilation of the duct. The in ability to deny malignancy necessitated lobular duct segmentectomy. Histopathological findings showed solid and papillary ductal carcinoma in situ (DCIS). Tumor cells had numerous fine eosinophilic granules in eosinophilic cytoplasm and nuclei were polarized in HE staining. Cytoplasmic tumor cell granules reacted positively to chromogranin A and most tumor cells reacted positively to synaptophysin. Tumor cells were positive for both ER and PgR. The final diagnosis was neuroendocrine DCIS– a differential diagnosis to be considered in cases of bloody nipple discharge without other evident abnormalities.

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A 66–year–old female patient underwent laparoscope assisted total gastrectomy with retrocolic Roux–en–Y reconstruction for early gastric cancer, and she complained of abdominal pain and vomiting on the 12th postoperative day. Fluoroscopy revealed dilatation and obstruction of the efferent loop. Abdominal computed tomography also showed dilatation of the afferent loop in addition to that of the efferent loop. Conservative therapy using a decompression tube was ineffective, and a reoperation was undertaken on the 21st postoperative day. Laparoscopy revealed that the efferent loop, including part of the jejuno–jejunostomy, had herniated through the mesenteric defect of the transverse mesocolon and caused an obstruction. The efferent loop with part of the jejuno–jejunostomy was pulled out from the mesenteric defect, and the intestinal loop was repositioned laparoscopically. The subsequent operative manipulations were performed laparoscopically. Part of the jejuno–jejunostomy was resected because it was noted to be strictured due to adhesion. The stump of the afferent loop was anastomosed side–to–side with the efferent loop, and both stumps of the efferent loop were anastomosed end–to–end. The efferent loop was then securely fixed by suture onto the transverse mesocolon, and the mesenteric defect was closed. The postoperative clinical course was uneventful, and the patient was discharged on the 21st postoperative day.
It is important to bear in mind the possibility of internal hernia in patients who develop bowel obstruction unresponsive to conservative therapy after laparoscope assisted gastric resection with Roux–en–Y reconstruction.

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A 65–year–old man diagnosed in April 2005 elsewhere with gastric cancer underwent chemotherapy following abdominal computed tomography (CT) showing enlarged paraaortic and left supraclavicular lymph nodes. After CDDP+CPT–11 and TS–1+CDDP treatment, enlarged lymph nodes disappeared but not the primary lesion. The man was referred to our hospital in July 2006 for surgery— total gastrectomy and D2 dissection done in August 2006. Postoperative histopathological examination indicated pT2 (MP), tub2, N1 (#3), M0, Stage II. Despite weekly postoperative PTX therapy using TS–1+CDDP, the man's CEA increased to 318.2 ng/ml and abdominal CT showed paraaortic lymph adenopathy recurrence in April 2007. Since HER2 protein was overexpressed in primary tumor immunostaining, he was treated with trastuzumab at (2 mg/kg/week), after which CEA decreased, becoming normal at 2.5 ng/ml in December 2008 with no CT evidence of recurrent lesions, yielding a diagnosis of CR. As of January 2011, neither reelevated CEA nor recurrent lesions were detected, resulting in long–term remission in gastric cancer lymph node metastasis after trastuzumab monotherapy.

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We report a case of double gastric and colon cancer associated with multiple cancers operated on synchronously—a case that, to our knowledge, had not been previously seen in the literature.
A 75–year–old man referred for dizziness was found in laboratory data to be severely anemic (Hb 6.9 g/dL). Gastrofiberscopy showed a type 3 tumor in the middle stomach and a granular protrusion at the gastric antrum. Colonofiberscopy showed a type 2 tumor at the S/D junction, a type 0–I tumor at the Ra, and LST at the proctus. EMR was done for the two rectal tumors. Distal gastrectomy and partial colectomy were done for gastric and colon cancers. Postoperatively, the antral gastric lesion diagnosed preoperatively at gastric adenoma was diagnosed by a pathologist as early gastric cancer (m). We concluded this case as involving triple cancer, including two multiple cancers of the stomach and colorectum. The man has remained recurrence–free in the 1.5 years (18 months) since surgery.

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In Crohn's disease (CD), active terminal ileitis may expand to the diverticulum but usually does not impact on clinical decision–making. We detail an original surgical approach in a woman with perforated diverticulitis and CD.
Case presentation
We report the case of a 53–year–old woman with chronic renal failure admitted for lower right abdominal pain, fever, and an abdominal abscess. Computed tomography (CT) showed active ileocecal inflammation and fluid collecting in the right iliac fossa suggesting intestinal perforation. In addition to localized ileitis and ileocecal colitis, ileocaecal resection for diverticulitis perforation showed a 3×3 cm abscess. Pathologically, the surgical specimen showed transmural inflammation with granulomas and perforation of the end of the diverticulum.
Conclusion
CD of the ileum may result in intestinal diverticulitis and perforation.

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We report a case of primary mucinous adenocarcinoma of the appendix diagnosed by mucocele. An 83–year–old woman seen for a lower right abdominal cystic lesion was found in laboratory tests to have mild inflammation and elevated serum CEA and CA19–9. Ultrasonography and computed tomography (CT) showed a cystic mass 10 cm in diameter in front of the cecum and surrounded by inflammation.
We diagnosed the mass as primary appendiceal neoplasm or abscess, conducting right hemicolectomy. The resected specimen showed mucinous discharge from the appendiceal orifice and a cyst communicating with the appendix. The pathological diagnosis was primary mucinous adenocarcinoma of the appendix.

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A 64–year–old woman diagnosed elsewhere with sigmoid colon cancer was found in abdominal magnetic resonance imaging (MRI) to have a 6–cm mass consisting of solid and cystic components suggestive of right ovarian cancer. She underwent sigmoid colectomy, total hysterectomy, and bilateral adnexectomy.
Immunohistochemical staining for the resected specimen showed colon cancer and an ovarian tumor with the same staining properties negative for CK7 and positive for CK20, yielding a definitive diagnosis of metastatic ovarian cancer from colon cancer. Colon cancer metastasizing to the ovary is rare, with a frequency of 1.6–6.4%. We report a case of sigmoid colon cancer with synchronous ovarian metastasis, together with a review of the literature.

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We report a case of sigmoid colon cancer with intussuception prolapsing through the anus treated with transanal resection.
A 90–year–old woman observed but not treated at her own request for four years after being diagnosed with sigmoid colon cancer was seen for a tumor prolapsing through the anus accompanied by anal pain. Physical examination confirmed intussusception prolapse, with the tumor in the lead. The tumor was diagnosed on biopsy as moderately differentiated adenocarcinoma. Pelvic computed tomography (CT) indicated a multilayered structure in line with these findings. Chest and abdominal CT showed multiple pulmonary and liver metastases necessating partial transanal resection of the sigmoid colon without lymph node dissection using a circular stapler. After resection and autosuturing, the intestine was entered naturally through the inside of the pelvic cavity. The woman had no complications, and was discharged on postoperative day 21.

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The patient, a 40–year–old multiparous woman, was in the 29^th week of gestation when she complained of left lower abdominal pain. Colonoscopy was performed in another institution, revealing discontinuous geographical redness and edematous swelling in the lower rectum, as well as narrowing of the lumen from the rectosigmoid to the sigmoid colon. Crohn's disease was diagnosed on the basis of the findings, the clinical course, and the fact that skin tags were also present. However, the following day, the inflammatory findings and abdominal pain worsened, and the patient was referred to our hospital, since NICU management for the baby was considered necessary. A CT scan did not show any clear abscess formation nor free air, but panperitonitis was diagnosed on the basis of the abdominal findings, and emergency surgery was thus performed. Caesarean section was performed first. Copious amounts of white moss–like adherent and contaminated ascites were observed centred on the sigmoid colon, and it was concluded that minor leakage had caused the peritonitis. We decided priority the life of the patient, palliative stoma was created at the splenic flexure of the transverse colon. Both the mother and the baby had good postoperative courses.

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We report a case of non–B/C hepatocellular carcinoma (HCC) treated with central hepatectomy after coronary artery bypass grafting (CABG) using right gastroepiploic artery (RGEA) grafting.
A 54–year–old–man was referred for a hepatic tumor 8 cm in diameter 5 years after undergoing CABG using the RGEA. Enhanced abdominal computed tomography (CT) showed a hypervascular liver tumor at segments 4 and 8 with a compressed middle hepatic vein and RGEA grafting to the diaphragm along the left hepatic falciform ligament. Because hepatitis B and C markers were negative with high serum PIVKA–II, the tumor was diagnosed as non–B/C HCC. Central hepatectomy was done without injuring the RGEA graft or adversely affecting morbidity. The man has remained without recurrent disease in the 7 months after surgery.

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Managing abdominal aortic aneurysm together with gastrointestinal malignancy is controversial. We report a case of bile duct cancer and abdominal aortic aneurysm treated by endovascular aneurysm repair, then pancreaticoduodenectomy. A 72–year–old man admitted for icterus and diagnosed with bile duct cancer and an abdominal aortic aneurysm (AAA) 52 mm in diameter first underwent endovascular aneurysm repair (EVAR) for AAA, then pancreaticoduodenectomy 22 days later. The postoperative course was uneventful. We thus found pancreaticoduodenectomy following EVAR safe for treating subjects with AAA and bile duct cancer for a short period.

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We report laparoscopic cholecystectomy (LC) in a subject with a body mass index (BMI) exceeding 50— the first such report, to our knowledge, on this procedure.
A 44–year–old man with a history of diabetes and with a BMI of 51 was seen in September 2009 at the emergency outpatient unit for upper abdominal pain. Detailed examination yielded a diagnosis of gallstone–related acute pancreatitis. Admitted on the same day, the man concomitantly developed a false pancreatic cyst but was discharged in 1 month. In December 2009, he underwent LC for biliary calculi. Intraoperative findings included increased subcutaneous fat. An extra–long trocar was used to access the abdominal cavity. Due to the high omental fat level, 5 ports were required to maintain the surgical field. The pneumoperitoneum pressure of 10 mmHg enabled surgery. Postoperatively, 20,000 units/day of heparin were administered to prevent thrombi from forming. No complications arose and the man was discharged 5 days postoperatively.

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A 68–year–old woman undergoing cholecystectomy with liver resection for gallbladder cancer was treated with adjuvant chemotherapy. Chemotherapy was changed to tegafur–gimeracil–oteracil potassium (S–1) plus gemcitabine (GEM) when multiple liver metastases were found at 8 months postoperatively. This combination was in effective and the tumor grew, so chemotherapy was changed to cisplatin (CDDP) plus GEM, which proved dramatically effective and liver metastases disappeared without solid and tumor size of 1.5 cm metastasis. Metastatectomy was done due to cisplatin–induced renal failure. The clinical course after the second surgery was unevenentful. Histopatholgy showed that the tumor shrank and contained few viable cells.

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Inflammatory pseudotumor, an uncommon cause of primary splenic tumor, is extremely difficult to diagnose. We report two cases of primary splenic pseudotumor treated by laparoscopic surgery and discuss its diagnostic and therapeutic aspects. Case 1: A 66–year–old woman suffered persistent heartburn. Case 2: A 58–year–old man was asymptomatic. Abdominal ultrasonography (US) showed a low echoic mass at the inferior splenic pole 26.2 mm in diameter in case 1 and 28.1 mm in case 2. We conducted Sonazoid^®–enhanced US in case 1, which showed a low echoic lesion in the Kupffer phase with a high parenchymal echo. Laparoscopic surgery was successful in both cases. Splenic hilar exposure was good, with port setup appropriate in both cases. Both recoveries were uneventful. Our cases suggest that laparoscopic splenectomy is minimally invasive in treating splenic tumor, when determining a specific pathological diagnosis.

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A 40–year–old man seen in the emergency room for sudden epigastric pain and fever was found in contrast–enhanced abdominal computed tomographey (CT) to have bowel wall thickening and a superior mesenteric vein thrombus. The man felt no peritoneal irritation, so we considered intestinal necrosis unlikely and administered systemic urokinase and heparin. After 1 month of hospitalization, contrast–enhanced CT indicated intestinal necrosis, necessitating emergency surgery. Laparotomy showed that the ileum had formed a mass and that the intestinal tract had necrosed in the small intestine from 60 cm to the anal side of the Treitz′s ligament to the cecum, necessitating massive small–bowel resection and right colectomy. A protein C antigen deficiency and decreased protein C activity postoperatively led to protein C genetic mutation analysis using direct sequencing. A missense mutation was detected causing amino acid substitution of Met for Ile at position 364. The man shows no evidence of recurrence and is currently being treated with oral warfarin and followed up regularly as an outpatient.

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An 84–year–old woman undergoing uterine cancer surgery and adjuvant radiation therapy 14 years earlier underwent abdominal wall hernia repair using a Bard Composix Kugel Patch^® elsewhere later. The woman was referred because the patch subsequently was exposed to the body surface,causing a skin defect at the lower abdomen midline near the pubis. In surgery to remove the patch, the hernia was also repaired by component separation, but with difficulty. Patch exposure had apparently caused an ulcer to develop because the woman's skin was very thin and had contact with the polypropylene side. Another potential cause was a radiation therapy for skin disorder. With such abdominal wall hernia mesh repair expected to spread, the mesh placement site and skin tissue thickness must be carefully considered to avoid such exposure problems.

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Metastatic tuberculosis abscess is an extremely rare skin tuberculosis. We report such a case and present a review of the literature. An 80–year–old woman with rheumatoid arthritis (RA), diabetes mellitus (DM), right forearm skin tuberculosis, sputum Gaffky No. 1, and PCR–TB (+) confirmed elsewhere in October 2008 was admitted to the tuberculosis ward with miliary tuberculosis. After discharge the following February, asubcutaneous abscess of the right lateral chest, right hip, and back led to a diagnosis of tuberculous abscess based on right buttock puncture. After PSL dose loss and continuously administered antituberculosis drugs, MRI showed no abscess reduction. Surgical resection in January 2010 confirmed the diagnosis. No new tuberculosis lesions were noted, and the woman's condition has remained stable. We thus found surgical resection highly useful for treating metastatic tuberculous abscess.

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