(Purpose) The aim of this study was to elucidate the trends in colorectal cancer by analyzing surgical colorectal cancer cases treated at our institution

(Methods) Between 1965 and 2011, 4,887 patients with colorectal cancer underwent surgery at our institution. We divided the 47-year period into ５ periods.

(Results) The median age of patients undergoing surgery during the last 20-year period was increased by approximately 10 years.

During the 2000 to 2011 period, the proportion of patients older than 75 years was more than 20％, a more than ２-fold increase compared to the cases of the 1990 to 1999 period.

The incidence of right-sided colon cancer began increasing from 1980.

The proportion of patients with type ０ carcinoma within the mucosa and Stage 0 cancer increased during the 1990 to 1999 period, but decreased during the 2000 to 2011 period.

The outcomes of Stage Ⅰ and Stage Ⅱ cases were similar for all periods.
The survival rate of Stage Ⅲ and Stage Ⅳ patients was higher during the 2000 to 2011 period than during the other periods.

(Conclusion) Our results reflected an aging society, the introduction of medical checkups, prevalence of total colonoscopy, and improvements in endoscopic resection and chemotherapy.

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Background; We evaluated usefulness of single incision laparoscopic cholecystectomy on therapeutic outcome, incisional pain, and cost. Methods; The subjects were 154 patients who underwent either single incision laparoscopic cholecystectomy (n=27) or conventional laparoscopic cholecystectomy (n=127) at Jikei University Hospital. We retrospectively assessed duration of operation, perioperative complications, incisional pain by the Numeric Rating Scale, hospital stay after operation, and cost of operative devices of single incision laparoscopic cholecystectomy as compared to conventional laparoscopic cholecystectomy. Results; Duration of operation, hospital stay after operation of single incision laparoscopic cholecystectomy were 113.8±41.1 minutes (mean±SD) and 3.4±1.8 days, which were comparable to those of conventional laparoscopic cholecystectomy. Incidence of perioperative complication of single incision laparoscopic cholecystectomy, and conventional laparoscopic cholecystectomy were 1 of 27 cases (3.7％) and 2 of 127 cases (1.6％). Post operative pain score was no significant difference to those of conventional laparoscopic cholecystectomy. Total price of operative devices of single incision laparoscopic cholecystectomy (146,000yen) was more expensive than those of conventional laparoscopic cholecystectomy (105,200yen). Conclusions; Single incision laparoscopic cholecystectomy needs less number of incisions, and its therapeutic outcomes are comparable to that of conventional laparoscopic cholecystectomy. Reduction of cost seems important for single incision laparoscopic cholecystectomy to become a standard therapeutic procedure for gall bladder diseases.

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Purpose: The possibility of the early detection of all the intestinal tract layer necroses of an operation which are adapted absolutely was examined from the clinical characteristics of non occlusive mesenteric ischemia: NOMI. Inclusion and methods: It was aimed at 11 examples by which it was diagnosed as NOMI from the abdominal CT imaging and the operative findings with intestinal resection from January, 2006 to August, 2011. 11 examples were classified pathologically into the intestinal tract membrane necrosis group and all the intestinal tract layer necrosis group, and clinical examination view, outcome, etc. were evaluated, respectively. Results: The average age among 11 examples was 78 and one example was died. All the intestinal tract layer necrosis group tended to present a peritoneal irritation symptom, and it seemed that the serum CRP value tends to show high. Conclusions : A peritoneal irritation symptom and the serum CRP value can serve as a key of early detection in all the intestinal tract layer necrosis cases.

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In 2009, The Japanese Hernia Society (JHS) classification was revised. We surveyed 366 patients who underwent surgery for inguinal hernia in three years in our hospital. (Methods) We analyzed the date based on a frequency of each classification type of all sites, male and femal, and the recurrence cases. (Results) We show below a number and frequency of the JHS classification type of all sites. Ⅰ-1:48 sites (13.1%),Ⅰ-2:177 sites (48.4%), Ⅰ-3:39 sites (10.7%), Ⅱ-1:25 sites (6.8%), Ⅱ-2:12 sites (3.3%), Ⅱ-3:18 sites (4.9%), Ⅲ:33 sites (9.0%), Ⅳ:13 sites (3.6%), Ⅴ:0 sites(0%). Ⅰ-1 ratio was higher than expected because it included a judgment mistake. In the recurrence case, Ⅱ-1 types and typeⅢwere observed a lot. In the woman case, typeⅢaccounted for about 40%. （Conclusion） For typeⅠ, it is necessary that the revised contents will be clearly known . TypeⅡ-1 and Ⅲ are important classification types from the viewpoint of prevention of the recurrence. In female cases, we should always check for the presence of enlarged femoral ring because the type Ⅲ is often in the female inguinal hernia.

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This work was supported by the Research Grant for Longevity Science from the Ministry of Health, Labour and Welfare, Japan



Delirium is the disease with decline of consciousness, cognitive function, esthesia, and/or attention. It is easy to diagnose as postoperative delirium (POD) in patients with typical symptoms, such as confusion with hallucination or disorientation in early after operation. However, in some cases, it is difficult to diagnose in the patients have lethargy or depression as POD. Various scales are used for diagnosis for this disease. In literature, the incidence of POD is vary from 4 to 87 %. Pain, anesthesia and medication are well known risk factors.

In, Department of Surgery, National Center for Geriatrics and Gerontology, the incidence of POD in operative patients with elective surgery was 73.9 % in mature subjects (80+). Older age, low preoperative MMSE, low preoperative JNCS and history of erethism or executive hyperaction are among the risk factors of POD.

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Background:Deep pressure ulcers in Stage Ⅲ or Ⅳ remain intractable despite continuation of conservative treatment for several months or years.

Surgical risk and issues associated with surgery are meaningful concerns; however, less-invasive reconstructive surgery may lead to improved patient quality of life even in the elderly. The author described the latest mode of reconstructive surgery and its perioperative management of pressure ulcer derived from experiential data regarding sacral pressure ulcers.

Objective:To evaluate the effect of flap surgery in elderly patients presenting with sacral pressure ulcers.

Methods:From 1998 to the present, two types of flap surgery were conducted in 125 cases involving sacral pressure ulcers. Outcome was evaluated based on complete healing rates.

Results:Two primary surgical procedures, which transitioned from the pedicled flap to the perforator flap, were performed:pedicled flaps were employed mainly in the “First stage”, whereas perforator flaps were utilized in the “Second stage”. The rate of primary healing, e.g., complete surgical wound healing achieved within three weeks post-operatively, among the three age groups was compared. Differences were not statistically significant; however, healing rates in the elderly displayed relative gain in the “Second stage” group.

Conclusion:A minimally invasive procedure is desirable particularly in the elderly; additionally, perioperative management is mandatory in order to improve the healing rate. Preventive management of pressure ulcers, including general and local management, is also important following surgical intervention.

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(Background) Esophagectomy for esophageal cancer is one of the most invasive surgical procedures. With the recent rapid aging of society, we frequently encounter elderly patients with esophageal cancer. The purpose of this study was to evaluate the surgical strategy for esophageal cancer in elderly patients aged 75 years or older.

(Methods) Between 2006 and 2011, we performed curative esophagectomy in 226 patients, including 33 patients who were aged 75 years or older (elderly group) and 193 patients who were aged less than 75 years (non-elderly group). The clinical results of patients in elderly group were compared with those of patients in non-elderly group.

(Results) With regard to coexisting diseases before esophagectomy, were observed pulmonary dysfunction, cardiac disease and cerebrovascular disorder at high rates in the elderly group. In the elderly group, the rate of synchronous cancer before esophagectomy was 24.0%, the invasion depth of the main lesion was T1 or T2 in 51.6%, and the main tumor was located in the lower esophagus in 72.7%. With regard to surgical approach, left thoracotomy or laparotomy were used at high rates in the elderly group. There were no significant differences between the two groups in mortality, morbidity or clinical outcome.

(Discussion) Owing to the development of new procedures using thoracoscopy and small incisions, the surgical strategy for esophagectomy has been extended in elderly patients. However, elderly patients aged 75 years or older with esophageal cancer have high rates of comorbidity and synchronous cancer. In order to achieve similar outcomes in these patients as in those aged less than 75 years, it is necessary to carefully select patients who are candidates for esophagectomy. We think that a family environment which can secure the patient's quality of life is essential.

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Background/Aims: The aim of this study was to determine the effect of age on the outcome of liver resection in hepatocellular carcinoma (HCC).

Methods: 91 HCC patients who underwent liver resection were studied. The surgical result of the younger group ( <80 years old) and the elderly group (≧80years old) were compared.

Results: In the elderly group, the patients were 81.2 years old on average comparable in their liver damage of grade A. Two patients were positive for HBsAg and four were positive for HCVAb, while the others were negative for both HCVAb and HBcAg (non-B non-C type). Four patients had extra-hepatic malignancies. Operative procedure consists of partial hepatectomy in 4 patients, subsegmentectomy in 4 and bisegmentectomy in 2. Postoperative complications, including delirium, ascites and bile leakage, were not so sever in all patients. There is no hospital death and the average duration of postoperative hospital stay was 23.8 days.

Conclusion: The present results suggest that surgical resection for hepatocellular carcinoma in the elderly patients is possible to perform safely by adequate assessment and operation.

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Purpose: We discuss about the factors for early discharge after pancreaticoduodenectomy (PD) in patents older than 80 years. Methods: 12 cases that underwent PD in which patients older than 80 years of age were retrospectively reviewed. The patients were divided into two groups; those who could be discharged within 30 days after PD and those discharged more than 30 days after PD. Results: There were no differences in age,gender,diagnosis, comorbidity, operative procedure, reconstruction method of remnant pancreas, method of the remnant main pancreatic duct, operative time, blood loss, delayed gastric emptying, surgical site infection, postoperative complications, enteral nutrition, postoperative hospital stay, hospital death. The participation of the experienced surgeon of PD is significantly more frequent and pancreatic fistula is significantly less in the patients who could be discharged within 30 days after PD. Conclusions: For early discharge of the patients over 80 years after PD, participation of experienced surgeon of PD and prevention of pancreatic fistula are important.

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Purpose: We investigated the effectiveness of Juzen-taiho-to for adverse effects of chemotherapy for advanced or recurrent gastric cancer patients, retrospectively.

Subjects and Methods: Thirty-one patients with advanced or recurrent gastric cancer were administered Juzen-taiho-to and some anti-cancer agents. We investigated adverse effects of chemotherapy and Juzen-taiho-to.

Results: Hematological adverse effects were improved in 64.7％ and non-hematological were also improved in 70.0％ patients.

Conclusions: Juzen-taiho-to would be effective agent that served to reduce adverse effects of anti-cancer agents.

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We performed combination hepatectomy three cases for multiple cancers in bilateral lobes of the liver. Combination hepatectomy were performed as follows: case 1; combination of pure laparoscopic hepatectomy and hepatectomy under thoracolaparotomy, case 2; combination of pure laparoscopic hepatectomy and hand-assisted laparoscopic hepatectomy and case 3; combination of laparoscopy-assisted hepatectomy and minimum invasive hepatectomy. Operation time and blood loss were 9 hours 10 minutes and 2,200 g in case 1, 5 hours 59 minutes and 250 g in case 2 and 8 hours 35minutes and 900 g in case 3, respectively.　Post operative courses were uneventful and no complications were occurred. Discharge was allowed on postoperative day 14 in case 1, 5 in case 2 and 7 in case 3.
In case of multiple tumors in bilateral lobes of the liver, we should consider multiple approaches for each tumors including laparoscopic approach. If we could not resect all of the tumors by pure laparoscopic approach, we may choice the optimal approach from multiple approaches according to intraoperative findings. Our experiences indicated that combination hepatectomy contributed to achieve less invasive surgery for multiple liver tumors than ordinary hepatectomy under laparotomy.

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We report two cases of septic shock in which plasma endotoxins were detected by a novel endotoxin detection method, named endotoxin scattering photometry (ESP) method. Case1: An 85-year-old female was diagnosed with peritonitis caused by sigmoid colon perforation. The patient presented with septic shock after Hartmann’s procedure. Reduction in the elevated endotoxin levels was observed accompanied with the improvement of hemodynamic condition by standard treatment. A temporal elevation of endotoxin at POD3 was observed by ESP but not by turbidimetric method, relating with a decreased blood pressure and requirement of catecholamine. Case2: Since a 73-year-old man with necrotic pancreatitis presented with septic shock, a direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX) was employed. Plasma endotoxins measured by ESP method were markedly reduced by PMX. This reduction of endotoxin measured by ESP method but not by turbidimetric method was related with the improvement of hemodynamic condition. In conclusion, since the alteration in plasma endotoxin measured by ESP method could be in parallel with the improvement of patient’s condition, ESP method may be able to sensitively evaluate endotoxins than the widely used ordinary turbidimetric method. Further study needed to clarify the diagnostic significance of ESP method.

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A 35-year-old man had undergone ventriculoperitoneal (VP) shunt placement and chemoradiotherapy for pineal tumor-associated hydrocephalus at 19 years of age, and had shown no disease recurrence. In February 2010, he experienced disturbed consciousness and gait impairment, and visited a local clinic. A cranial CT scan revealed hydrocephalus, and he was referred to the department of neurosurgery of our hospital. Plain X-ray examination of the head showed VP shunt catheter disconnection, and abdominal plain X-ray examination and CT scan revealed that the VP shunt catheter had disconnected and migrated into the peritoneal cavity. The patient underwent single port laparoscopic removal of the catheter. Single incision laparoscopic surgery is considered to be minimally invasive and useful in the present case.

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We report two cases of women who were diagnosed with breast cancers after the onset of nephrotic syndrome (membranous nephropathy). Case 1 was a 46-year-old woman with proteinuria and hyperlipidemia. Invasive ductal carcinoma was found in her right breast during malignancy screening after she was diagnosed with membranous nephropathy by renal biopsy. We performed a breast conserving surgery and axillary lymph node dissection and then hormonal therapy was administered as adjuvant therapy. The patient has been disease-free for 9 years since and her nephrotic syndrome was resolved completely 2 years after the surgery. Case 2 was a 53-year-old woman with leg edema, proteinuria, hypoalbuminemia and hyperlipidemia. Scirrhous carcinoma was found in her right breast during malignancy screening after she was diagnosed with membranous nephropathy by renal biopsy. We performed a mastectomy and axillary lymph node dissection. Histological diagnosis was invasive ductal carcinoma with involvement of 14 axillary lymph nodes. Chemotherapy and hormonal therapy were administered as adjuvant therapy, but bone metastasis was discovered 1 year and 5 months after the surgery. She died 4 months later and nephritic syndrome did not resolved throughout.

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The lymph node metastasis of gastric cancer has its own specific metastatic route to the regional lymph nodes. The skip metastases of gastric cancer defined as the presence of extraperigastric lymph node involvement without the detection of proximal lymph node metastasis. The skip metastasis was rarely found in early stage gastric cancer.

A 78-year-old female admitted to treat a Type 1 cardiac gastric cancer. On preoperative diagnostic work up, the paraaortic lymph node swelling were pointed out by CT and it confirmed by PET. The total gastrectomy with standard D2 dissection of regional gastric lymph node was performed to treat the cardiac tumor and paraaortic lymph node sampling was also performed simultaneously. A total of 14 perigastric lymph nodes were dissected. The pathological examination revealed that all of the dissected perigastric regional lymph node was negative for metastasis whereas the paraaortic lymph node found a metastasis of the gastric cancer. As the result, present case explained as T2 (MP), N0, M1 (LYM) according to the 14^th edition of Japanese classification gastric carcinoma.

The explanation of the skip metastasis is different from the 14^th edition and previous classification. We should be attention about this concern to compare the skip metastasis between previous and new cases.

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A 52-year-old woman was referred to our hospital with complaints of nausea and bulging abdomen. Gastrointestinal fiberscopy revealed the villous tumor on the first to second portion of the duodenum and the histological examination resulted in group Ⅳ. The distance from the distal tumor margin to papilla of Vater was approximately 4 cm and from endoscopic ultrasonography we determined that the depth of the tumor was mucosa. From these observations, we diagnosed this patient as an early duodenal carcinoma of the duodenal bulb then decided to perform a surgical resection of the duodenum considering that complete endoscopic resection would be difficult. In other words, the carcinoma was still at the early stage and reductive surgery became more of an option rather than to take pancreaticoduodenectomy approach; distal gastrectomy and partial duodenectomy was performed. In order to take functionally conservative approach towards papilla of Vater, we inserted C-tube into the cystic duct and the dye was injected. After closing the duodenal stump, we confirmed the constant flow through the papilla of Vater during an intraoperative cholangiogram. Additionally, to avoid the duodenal stump leakage, we fixed the C-tube in the common bile duct and covered the duodenal stump with the omentum. The histological finding showed well differentiated tubular adenocarcinoma in adenoma and the stage in UICC category was T1N0M0, Stage Ⅰ. Three years and six months has past after the surgery however the patient is still alive with no recurrence.

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An 83-year-old female patient visited our hospital with the chief complaint of pus discharge from the operation wound of an appendectomy performed when she was 17 years old. The patient was admitted to the hospital due to ileus. Barium enema showed irregular stenosis at the cecum, however, no communication was observed from the skin to the cecum based on fistulography. An Abdominal computed tomography scan showed a tumor 50 mm in size located in the ileocecal region and invading the abdominal wall just below the wound. A diagnosis of cecal cancer invading the abdominal wall was made, and a right hemicolectomy was performed with excision of the abdominal wall including the operative wound of the appendectomy and D3 lymph node dissection. Pathologically, the tumor was tub1, SI (abdominal wall), ly0, v0, N0, and fStage Ⅱ. The patient received curative pathological resection (pCurA). No signs of recurrence have seen in the 5 years since the operation. A case like the present one may be considered to be rare, in which cancer invasion was detected in a patient with the chief complaint of pus discharge from a previous operative wound.

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We report a case that received a pancreatico-duodenectomy for metacronous pancreas head metastasis of ascending colon cancer. The patient was a 68-year-old man who received right hemi-colectomy with regional lymphadectomy and partial hepatectomy in January 2005. Pathological examination revealed moderately differentiated adenocarcinoma (type2, pSi-duodenum, ly0, v2, pN1, pH1, sP0, cM0). At three years after the first operation, enhanced CT showed pancreas head lymph node swelling. He received FOLFIRI and FOLFOX chemotherapy. However, at 43 months after the first operation, CT revealed the enlarged lymph node. At 45 months after the first operation, a lymphadectomy of pacreas head was performed. The resected lymph node contained well-differentiated adenocarcinoma with viable cells. At 48 months after the first operation, CT showed pancreas head metastasis again. Chemo-radiation therapy reduced pancreas head metastasis in size. But the metastasis re-grew on CT at 53 months after the first operation. Therefore he received the pancreatico-duodenectomy to aim the curative resection at 54 months after the first operation. Successfully he has no recurrence at 34 months after the last operation.

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We report a case of metachronous liver metastasis from ascending colon cancer. The patient was a 73-year-old man who received a right hemicolectomy with regional lymphadenectomy including the group 3 lymph nodes in August 2009. Pathological examination revealed a moderately differentiated adenocarcinoma (sType2, pSE, ly0, v2, pN2, sH0, sP0, cM0). Eight courses of modified FOLFOX 6 were administered as adjuvant chemotherapy. In May 2010, computed tomography (CT) revealed a mass in segment 5. and liver metastasis was diagnosed. The patient received radiofrequency ablation therapy in July 2010. However, CT in May 2011 showed a mass in the anterior segment of the liver, and re-growth of liver metastasis was diagnosed. We re-examined the resected specimens in August 2009 after immunohistochemical staining. The specimens stained positive for EGFR and K-ras wild type. The patient received modified FOLFIRI therapy with panitumumab. The liver metastasis shrank after eight courses of chemotherapy, and the serum carcinoembryonic antigen level decreased to the normal range. In November 2011, he received a partial hepatectomy of sub-segment 5. The postoperative course was uneventful, and the patient was discharged on 10th day after operation. An additional four courses of modified FOLFIRI with panitumumab were administered. There has been no evidence of recurrence since the last operation.

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We report a case of adenosquamous carcinoma of the sigmoid colon with synchronous multiple liver metastases. A 51-year-old man was admitted to our hospital complaining of constipation and melena. A biopsy specimen histologically revealed a well differentiated adenocarcinoma. He was diagnosed as having an advanced sigmoid colon cancer with multiple liver metastases based on imaging findings. Sigmoidectomy was performed for the relief of symptoms like bleeding and stenosis. Macroscopically, the type 2 tumor had across section 3.5×3.0cm and was located in the sigmoid colon. Histological findings showed an adenosquamous carcinoma invading the subserosa. He postoperatively received chemotherapy (FOLFOX). However, the patient died 35 days after surgery because of respiratory failure and liver failure.

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We experienced a case that intractable fistula after postoperative anastomotic leakage was able to close with new endoscope treatment device, OTSC^® (Over the Scope Clip) system. A 70s man reported, fistula after postoperative anastomotic leakage that developed two years ago was intractable for conservative treatment. After conservative treatment, fistula was closed with OTSC^® system under endoscopic and fluorography control. There were no major complications, and the abscess disappeared in the pelvic CT. In the fifth month after the procedure, there is no recurrence of the pelvic abscess. The rectal postoperative anastomotic leakage site is thickens by fibrosis for inflammation. Therefore it is very hard to be closed down by the conventional metallic clip. The new clip device OTSC^® can deliver big size of metallic clip, and can close down for the intractable fistula. From 2011, insurance cover this new device. OTSC^® is one of the new treatment choices of the anastomotic leakage or intractable fistula.

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A man in his 30s was admitted to our hospital with a diagnosis of intestinal obstruction. He had been admitted to hospital three times for intestinal obstruction, but had no history of abdominal surgery. The symptom was improved by conservative treatment and endoscopy revealed a stenosed lesion. For the purpose of diagnosis and treatment, laparoscopic surgery was done. Laparoscopy identified Meckelʼs diverticulum in the small intestine, and it was adhered to the retroperitoneum. He was diagnosed as having intestinal obstruction caused by adhesions due to the Meckelʼs diverticulum. A small laparotomy was placed and a part of small intestine including the Meckelʼs diverticulum was resected. His postoperative course was uneventful. He had no recurrence of intestinal obstruction after that. Meckelʼs diverticulum should be kept in mind as a cause of intestinal obstruction. Laparoscopic surgery is useful for this disorder.

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A 51-year-old man was admitted to our hospital because of abdominal pain. A physical examination showed severe tenderness, rebound tenderness and muscle defence throughout the entire abdomen. A diagnosis of panperitonitis was made and an emergency operation was performed. At laparotomy, there were slight purulent ascites and Meckelʼs diverticulum 8 cm in size on the antimesenteric side about 70 cm from the ileocecal valve. The apex of Meckelʼs diverticulum was covered with pus and was adhered with other small intestine. A resection of Meckelʼs diverticulum and drainage of the intraperitoneum were performed. Histologically, it was diagnosed as Meckelʼs diverticulitis with heavy neutrophilic infiltration throughout all layers. Meckeʼs diverticulum is rare, but its complications may occasionally cause acute abdomen.

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We report a patient with an ileal lipoma manifested by acute abdomen who underwent single incision laparoscopic tumor resection. A 24-year-old male visited the emergency outpatient clinic of our hospital due to right lower abdominal pain. Abdominal CT revealed a lipoma (23 mm in size) in the ileum near its terminal part. Lower gastrointestinal endoscopy showed a lipoma hanging into the ascending colon. Endoscopic reduction of the lipoma to the ileum side was performed. The tumor was considered to have caused abdominal pain, involve the risk of developing intussusception, and regarded as an indication for resection. Since endoscopic resection was difficult, elective surgical resection of the tumor was decided. Since this tumor was benign and developed in a young male, single incision laparoscopic tumor resection was performed. This surgical technique is minimally invasive and esthetically excellent, and may be the optimal surgical method for benign tumors in the young.

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A 60-year-old Japanese woman was admitted because of abdominal pain. She had a history of liver cysts which had been followed. Computed tomography at the admission demonstrated intraluminal bleeding of a cyst in posterior segment of the liver. Transcatheter arterial embolization to the artery of posterior segment was made, and aspiration of the intracystic fluid was performed. Although no radiological or cytological malignancy was demonstrated, serum CA19-9 range was 4,028 ng/mL. The etioology of intraluminal bleeding of simple liver cyst are unsettled because of scarcity, and the patient was scared of rebleeding. After informed concent, laparoscopic deroofing of the cyst and coagulation of the vessel bleeded. Histopathologic examination demonstrated the cyst wall consisting serous epithelium with no malignancy, and serum CA19-9 range was dramatically decreased. The patient was discharged, and uneventful. As above-mentioned, litte is knwon about intraluminal hemorrhage of the simple cyst because of small number of the cases. Some investigators assume the inflammation or degeneration of the adjacent vessel. Postulating a mistake of differential diagnosis from cystic malignancy and rebleeding of the cyst, we believe that laparoscopic fenestration and hemostasis with intraoperative pathologic examination would be better option at this moment.

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We report our experience with three cases of hepatectomy for intrahepatic stones which occurred after extrahepatic bile duct excision and reconstruction (biliary diversion) for congenital bile duct dilatation. Case 1:A 62-year-old man. He underwent lithotripsy operation for intrahepatic stones two years after biliary diversion. At 16 years after the operation, left hepatectomy was done for recurrent intrahepatic stones. Case 2:A 32-year-old woman. She underwent biliary diversion for intrahepatic stones at 20 years after cholecysto-jejunostomy. At 9 years after the operation, lateral segmentectomy of the liver was performed for recurrent intrahepatic stones. Case 3:A 56-year-old man. He underwent lithotripsy operation for intrahepatic stones at 10 years after biliary diversion. At 12 years after the operation, extended right hepatectomy was performed for recurrent intrahepatic stones of the bilateral lobe and cholangiocarcinoma. Hepatectomy seems to be a good indication for recurrent hepatiolithiasis, because all of the current cases had piled-up stones which obstructed dilated biliary tract. Careful course observation is needed for intrahepatic stones after biliary diversion for bile duct dilatation, because intrahepatic stones recur repeatedly and could be complicated by cholangiocarcinoma of the liver. Hepatectomy is a useful treatment for recurrent intrahepatic stones which occurred after biliary diversion operation.

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Background: Umbilical metastases known as Sister Mary Josephʼs nodule (SMJN) occur rarely. Pancreatic cancer presenting as an SMJN is a rare phenomenon.

Case: An 73-year-old woman with 2 month history of exudation and inflammation in the umbilical region. We performed the outpatient care, so inflammation was gradually improved. However omphalitis was repeated, a painful tumor was gradually increased to about 20mm in diameter. Computed tomography revealed a 40mm diameter tumor located in the pancreatic body, in addition to a 20mm diameter umbilical tumor. Umbilical tumor was performed a biopsy and diagnosed as adenocarcinoma.

The patient received S-1 for chemotherapy. She died 12months from the first medical examination.

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In 1998, left nephrectomy for left renal cell carcinoma (pT1bN0M0) was performed . At ８ years after the operation, he had a thoracoscopic right partial pulmonary resection for a lung metastases. He was treated using interferon therapy, but pancreas metastasis was appeared. In May 2008, Sorafenib therapy was started, because the pancreas metastasis was increasing. In February 2010, he was performed gamma knife therapy for brain metastases. He complained hemorrhagic stool in March 2010, 12 years after nephrectomy. Colonoscope showed a submucosal tumor on sigmoid rectum. The lesion was suspected as colon metastasis from renal cell carcinoma. In May 2010, laparoscopic high anterior resection of rectum was performed for control of hemorrhage. Microscopic findings revealed renal cell carcinoma metastasis.

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We herein report that a patient who was unmanageable stoma care due to wound infection and depression of the posterior wall of the stoma improved by stoma reconstruction based on the revised stoma site marking coordinated with wound, ostomy and continence nurse and surgeon.
A seventy-year-old female patient with ovarian cancer who underwent loop transverse colostomy due to diffuse peritonitis with rectal perforation after gynecological surgery was lead to be unmanageable stoma care by the surgical site infection. She was consulted to the wound ostomy and continence nurse and treated with various devices. However, we considered the reconstruction, because of no improvement by conservative treatment. To obtain the sufficient area to contact to the skin and to prevent contamination, the new stoma should be reconstructed at the location more than ３cm distance from the median wound, addition to the consideration of the distance from the iliac crest. We performed the protruded and circular shaped end colostomy with the closure of the anal bowel which located at the 3.5cm distance from the median wound. Since her wound and stoma were well managed independently, her stoma care improved.

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We report 65-year-old woman with a tumor in the rectal wall. Seven years ago, she was operated on for stage Ia endometrial adenocarcinoma. In spite of a CT-guided biopsy, we could not diagnose whether the tumor was primary or metastatic. We performed the surgical operation to diagnose and remove the rectal tumor. The surgically removed rectal tumor was examined by an expert pathologist. It would be the most probable that the rectal tumor was derived from the endometrial adenocarcinoma of uterus. We discuss how does it relapse. We considered that the rectal tumor might be the result of perioperative implantation.

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Case 1 : A 35-year-old woman was admitted to hospital with left lower abdominal pain. Computed tomography showed a cystic mass in the left lower abdomen and dilated small bowel. We diagnosed an internal hernia through the sigmoid mesocolon, and performed emergency laparoscopic surgery at 14 hours after the onset of symptoms. Intraoperative findings showed intersigmoid herniation of the ileum. We did not perform bowel resection because there were no necrotic changes. Simple closure of the hernial orifice was performed.
Case 2 : A 37-year-old man was admitted to hospital with left lower abdominal pain. Computed tomography showed herniation of the small intestine through the sigmoid mesocolon. We diagnosed intersigmoid herniation, and performed emergency laparoscopic surgery at 10 hours after the onset of symptoms. Intraoperative findings showed herniation of the ileum, with a 75 cm length of strangulated bowel. Bowel resection was not required because there were no necrotic changes. Simple closure of the hernial orifice was performed.
In cases of intersigmoid herniation, the strangulated bowel often does not have necrotic changes, even if there were prolonged symptoms. Simple closure of the hernial orifice can usually be performed. We suggest that laparoscopic surgery is a suitable treatment modality for intersigmoid hernia.

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We report a case of strangulated ileus due to internal hernia through a defect of the broad ligament of the uterus treated by reduced port surgery (RPS). A 40-year-old woman was admitted to our hospital with lower abdominal pain and vomiting. An abdominal CT scan revealed enlargement of the small intestine within the pelvis and displacement of the uterus toward the right side. RPS was performed under a diagnosis of internal hernia through a defect of the left broad ligament of the uterus. Since intestinal necrosis developed because of the incarceration through a defect of the broad ligament, operation included resection of necrotic intestine and laparoscopic suture of the defect was performed. RPS is technically feasible in this case and produces a less invasiveness and increased cosmetic benefits.

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