In order to compare the clinical outcome of laparoscopic appendectomy (LA) to conventional open appendectomy (OA), we retrospectively reviewed the clinical records of patients who had undergone appendectomy from 2001 to 2009 at Sendai red cross hospital. Of them, 154 had undergone LA, in which 9 patient were converted to the open procedure after laparoscopy, and 86 OA. According to the degree of inflammation based on pathological examination, LA and OA groups were divided into three subgroups (catarrhal, phlegmonous, and gangrenous), and compared these groups for background factors and clinical findings. Gangrenous subgroups include complicated appendicitis with or without perforation, localized abscess, or disseminated peritonitis. There was no significant difference in the operation time. The incidence of complications in LA group was significant lower than that in OA group. In addition, the incidence of superficial surgical site infection in LA group was significant lower than that in OA group, especially in gangrenous cases. In gangrenous cases, for postoperative hospitalization and start of oral intake, significantly better results were seen in LA group than in OA group. Our findings indicate that LA is useful in treating acute appendicitis, especially complicated cases.

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Introduction: Although pancreaticoduodenectomy is performed for elderly patients, its safety among elderly patients has not yet been verified. Objective: To investigate the safety of pancreaticoduodenectomy for elderly patients. Subjects: Participants comprised 27 patients who underwent pancreaticoduodenectomy between March 2007 and October 2011, classified by age into Group O (≥75 years old; n=9) and Group Y (≤74 years old; n=18). Methods: Intra- and perioperative outcomes were compared between groups. Results: No significant intergroup differences were observed in blood loss or operative time. No significant intergroup differences were found for preoperative lymphocyte count, C-reactive protein level, or leukocyte count. Use of fresh frozen plasma was more frequent in Group O (p<0.05). No significant differences were seen in frequency of postoperative complications such as pancreatic fistula or delayed gastric emptying. Compared to Group Y, Group O showed a lower albumin level on postoperative day 14 (p<0.05) and a higher body temperature on postoperative day 7 (p<0.05). Conclusion: While normalization of nutrition condition and body temperature and inflammatory findings tended to be delayed in Group O compared to Group Y, no differences were observed for surgical outcomes or complication rates. Pancreaticoduodenectomy appears safe for elderly patients.

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Due to population ageing, the number of elderly patients with malignant bone and soft tissue tumours including metastatic bone tumours has been increasing. We herein describe the means and ideas to improve therapeutic outcome of the elderly patients with such tumours. When the tumour is curable, wide excision of the lesion should be performed as a general rule. However, when wide excision is too invasive for the elderly, less invasive surgery may be performed with adjuvant intra- or post-operative radiotherapy, or with photodynamic therapy. Heavy particle beam therapy may be performed instead of surgery. Adjuvant chemotherapy may be performed for primary malignant tumours after due consideration of the patients’ general conditions. When the tumour is incurable, the final goal is to improve the patients’ ADL and QOL. Metastatic bone tumour is the typical case, most of which is accompanied by pathological fracture. Internal fixation, usually followed by radiotherapy, is performed for pathological fracture of long bones to improve ADL. Since postoperative deterioration of ADL is the most serious matter in elderly patients, commencing rehabilitation exercise in early stage after surgery is mandatory.

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Background.
The aim of this retrospective study was to determine the effect of age on the outcome of hepatic resection in octogenarian patients with hepatocellular carcinoma (HCC).
Methods.
Data of 845 primary and recurrent HCC patients who underwent curative hepatectomy were studied. The surgical results of the elderly group (≥80 years of age; n=59) and the younger group (<80 years of age; n=786) were compared.
Results.
The patients in the elderly group displayed significantly more comorbid conditions, including hypertension and cardiovascular diseases preoperatively and higher nutritional risk than those in the younger group (p < 0.05). Although the rate of transfusions of packed red cells were significantly lower, the rate of postoperative delirium were significantly higher in the elderly group than in the younger group. However, there was no significant difference in the duration of postoperative hospital stay. The long-term prognosis of the elderly group patients was almost identical to that of the younger group patients after primary and repeat hepatectomy.
Conclusion.
Hepatectomy is a viable treatment alternative with satisfactory surgical outcome for HCC even in patients aged 80 years or older, but preoperative evaluation of comorbid conditions or nutritional risk and management of postoperative delirium are necessary.

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Background and Objectives:The increasing average age of the Japanese population has significantly increased the number of elderly patients undergoing surgery for hepatocellular carcinoma (HCC). We aimed to compare the results of hepatectomy for HCC in patients aged ≥80 years, 75–79 years, and <75 years. We reviewed ten recently published reports of elderly patients who underwent surgery for HCC.

Methods:(1) Clinicopathological data and outcomes for 24 super-elderly patients, 59 elderly patients, and 515 younger patients who underwent hepatectomy for HCC between 1992 and 2010 were retrospectively compared. (2) We searched for recently published reports in the English literature using PubMed with the key words ‘elderly’, ‘hepatocellular carcinoma’, and ‘hepatectomy’.

Results:(1) There were no significant differences among the three groups in terms of operative morbidity, hospital death, disease-free survival, or overall survival. Super-elderly and elderly patients had a significantly higher incidence of postoperative delirium compared with non-elderly patients. Five of 8 super-elderly patients and 6 of 16 elderly patients died of non-HCC-related conditions. (2) Most reports classified patients aged 70 years or older as elderly. There were no significant differences between elderly and non-elderly patients in terms of operative morbidity, hospital death, disease-free survival, or overall survival in the ten reports reviewed.

Discussion:The short-term and long-term outcomes of surgery for HCC were similar in super-elderly, elderly, and younger patients. It is suggested that super-elderly and elderly HCC patients have the same indications for surgery as non-elderly patients.

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The resident of our department consists of the sent from some universities and our hospital original resident. Thus, it may be very important to show justice in training to maintain the motivation of each resident. It is considered important to give chances to perform surgery sufficiently and fairly, and our department makes arrangements to ensure that, in principle, the residents, using the minimum criteria established based on the levels of surgical procedures, perform surgery by rotation. By creating a table called a “victory list” and ensuring that all medical staff can confirm the order of performing surgery as well as the number of previous surgeries, we maintain fairness and openness. The resident (5 years post-graduation) who are currently receiving training have performed 410 surgeries over 2 years and 10 months, including 45 gastrectomies, 65 colorectal resections (3 laparoscopies), 54 cholecystectomies (26 laparoscopies), 4 hepatectomies, and 4 pancreaticoduodenectomies. Although they will perform surgeries by rotation for patients with highly-advanced cancer or a concomitant disease as well, the incidence of complications are comparable to those found in other hospitals. The residents accept this system as favorable, and a well-developed training program that maintains their motivation is conducted. Additionally, the attending doctors need to acquire higher-level skills of surgery and perioperative management, and all members of our department including the residents show growth.

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Jikei University School of Medicine has established videoscopic surgery training program in 2004. In order to obtain operating privilege for videoscopic surgery, each surgeon has to take the courses in the program. The participant of this program became the residents primarily recently. Therefore, the program is operating as educational program of the residents now. In our institution, junior residents participate in this program with training initiation. And they receive the authorization of the operator qualification by all means when they become senior resident. By the results of the questionary survey, the program got an affirmative evaluation from residents. This program is expected to improve the fundamental knowledge and technical skills of residents who conduct videoscopic surgery.

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Background:A pre- and post-graduate training program for young surgeons passing surgeons specialized in gastroenterology has been developed in our department and affiliated hospital.
Details of the program are as follows:

1）Pre-graduation clinical education:In addition to usual lectures, clinical education based on a laparoscopic surgery simulator and a digestive endoscopy training model is provided. Students start their training as a surgical assistant, and those who are regarded as sufficiently prepared experience lapatomy under the supervision of the advisor.

2）Surgical skill training seminars:Weekend-seminars are held for fifth- and sixth-grade students to improve their incision and suture techniques, and for residents to increase their intestinal anastmosis skills. Laparoscopic surgery training seminar for medical officers or those desiring to become them also take place on a regular basis.

3）Post-graduation training in affiliated hospitals:Students are trained mainly in medical facilities performing a large number of surgeries, while receiving guidance on academic conference presentations and paper creation.

4）Board Certified Surgeon in Gastroenterology:After sufficiently preparing to obtain a Board Certified Surgeon in Gastroenterology in related hospitals for 7 to 8 years after graduation, graduates return to the medical office of the university to choose their sub-specialties. The final goal of this program is to obtain a Board Certified Surgeon in Gastroenterology; at present, all of 19 test-takers obtain it since 2007.

Future perspective:Recently, the number of those desiring to become medical officers seems to be increasing again, suggesting the positive effect of this program. Further studies may be necessary to develop and promote pre- and post-graduation training systems.

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In surgical training, it is very important to maintain the balance between providing training to young surgeons and maintaining surgical quality. In this study, we investigated the safety and efficacy of laparoscopic cholecystectomy (LC) performed by an attending doctor along with young surgeons. The patient background and intraoperative and postoperative factors were compared between 2 groups:the R group, in which LC was performed by an attending doctor and 2 young surgeons, and the S group, in which LC was performed by the same attending doctor with 1 young surgeon and another attending doctor. The operation time in the R group was longer than that in the S group, especially in normal cases without cholecystitis. However, no significant intergroup differences were found in preoperative patient characteristics, intraoperative blood loss, and postoperative outcomes. Young surgeons can actively participate in LC, and it is more feasible for them to assist the attending doctor during the procedure.

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As in general hospital, it is very difficult for education in laparoscopic coloproctectomy to guarantee the quality of operation, we introduce our strategy. The trainee can operate the cases of cecum, ascending colon, sigmoid colon and recto-sigmoid colon, the cases of benign or malignancy which are not exposed to intra-peritoneal space without lymph nodal metastasis, and the cases without severe obesity and adhesion. Before operate the patient, the trainee has to prepare the actual operative procedure and the technical attention by textbook and DVD made by director who has the license from the Japan Society of Endoscopic Surgery , and has to have the experience of 20 operative cases of laparoscopic cholecystectomy and 30 assistant cases of laparoscopic coloproctectomy. Our standard procedure with small incision (glove method with 3 reusable trocars) adding 2 (5mm and 3mm) trocars on the abdominal wall is routine in detail. The trainee can be allowed to operate within 1 hour in addition to the operation time by the director, and add the trocars on the abdominal wall in case of difficulty. There is no difference concerning the operative results of malignancy between the director’s 210 cases since having license and trainee’s 126 cases since commencing the training. The pursuit of low invasiveness is compatible with education in the laparoscopic coloproctectomy.

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More than 20 years have passed since introducing thoracoscopic esophagectomy in Japan. Although this procedure is performed in various institutions, there are few reports of a training system for this procedure. From April 2010, we introduced the thoracoscopic esophagectomy in the left lateral position with pneumoinsufflation and we contrived the procedure and developed a training system for thoracoscopic esophagectomy. Our training system, comprises a step-by step training process, in which, the surgeons first learn the basics such as handling of laparoscopic forceps and the characteristics of the endoscopic surgery. At the training for operator, we advanced the operative fields from laparoscopic procedure to the upper mediastinum step by step. Although the reports about the usefulness of the thoracoscopic esophagectomy increased, the development of a training system is necessity for the widespread and the standardization of this procedure.

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Panitumumab (Pmab) which is a fully human monoclonal antibody against the epidemal growth factor reseptor (EGFR) has been used in USA since septmber 2006 and in Japan since april 2010. EGFR inhibitors, such as Pmab are used as highly effective therapies for Kras wild type advanced colorectal cancer. Although EGFR inhibitors are generally well tolerated and do not increase the classical adverse events of chemotherapy, they induce a skin toxicity that occurs in more than 80％ of patients. We report the reviews of clinical trials with Pmab and outcomes (effect and skin toxicity) in Toyonaka municipal hospital.

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OBJECTIVE:Skin Toxicity is a predictable adverse event of anti-EGFR chemotherapy. The aim of this study is to evaluate the role the assessment sheet, which we developed and introduced in 2011 to check the adverse events associated with chemotherapy.

METHODS:We analyzed 44 consecutive patients with colorectal cancer treated with chemotherapy including cetuximab and panitumumab from 2009 to 2011. The patients were divided into two groups:before the introduction of the assessment sheet or after that. Skin toxicity was graded by the current National Cancer Institute-Common Toxicity Criteria (NCI-CTC).

OUTCOME:91% of the patients developed skin toxicities:the rate of grade-1 / -2 / -3 was 41% / 32% / 18% respectively. There was no difference in the rate of skin toxicity between before and after the introduction of assessment sheet, however, the patients developing grade-3 skin toxicity were reduced in the group with assessment sheet.

CONCLUSIONS:Assessment sheet to check the adverse events associated with chemotherapy might help reducing maximum skin toxicity. It seemed chiefly because the common understanding of the adverse events between patients and medical staff made early and adequate management.

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We report here the management of skin toxicity induced by epidermal growth factor receptor (EGFR)-targeted monoclonal antibodies (MAbs) administration in our institute. Thirty patients treated advanced colorectal cancer with EGFR-targeted MAbs were retrospectively analyzed for antitumor effect, time to treatment failure (TTF), and skin-related toxicity. Cmab was administrated to 27 patients, and Pmab was administrated to 6 patients. Overall response rate was 24.2% (8 PR; 4 SD; 19 PD; NE 2), and disease control rate was 36.4%. Skin toxicity of all grades was observed in 23 cases with Cetuximab and in 5 cases with Panitumumab, respectively. Grade 3 toxicity of skin reaction was observed in 3 cases. No patient was interrupted their treatment with EGFR-targeted MAbs by skin toxicity. TTF was 4.7 months in all case. Treatment for advanced colorectal cancer with EGFR-targeted MAb was tolerated with acceptable efficacy under interdisciplinary team approach with trained pharmacists and nurses in our institute.

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[Purpose] To evaluate the therapeutic results of Panitumumab (P-mab) treatment in 19 cases of unresectable advanced/recurrent colorectal cancer treated from December 2010 to March 2012 in our department.
[Method] The first, second, third, and fourth therapeutic lines included 3, 8, 6, and 2 cases respectively. According to the administration regimen, 13, 4, and 2 cases were treated with FOLFIRI + P-mab, mFOLFOX7 + P-mab, and P-mab alone, respectively.
[Results] The therapeutic outcomes were complete response, partial response, stable disease, progressive disease, and not evaluated in 0, 1, 2, 12, and 4 cases, respectively. The response rate was 5.3%, and the tumor control rate was 15.8%. The median survival time was 9.74 months. Skin toxicity, infusion reaction, hypomagnesemia, and persistent dizziness were seen in 7 (G1: 3 cases, G3: 4 cases), 1, 1, and 1 case, respectively.
[Conclusion] The therapeutic results of P-mab were not necessarily good. Additionally, skin toxicity associated with anti-epidermal growth factor receptor monoclonal antibodies occurred frequently. Skin toxicity considerably reduce the quality of life of patients and might result in decreased drug compliance. Therefore, close follow-up not only by the outpatient physician but also through collaboration with dermatologists, pharmacists and nurses is considered necessary.

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We report the results of surgical treatment for esophageal perforation at our institution. We examined 13 cases of esophageal rupture from 2002 to 2012. The subjects were 11 men and 2 women, and the mean age of the group was 66.9. For each case, we clinically analyzed operation type, complications, and patient survival. Spontaneous esophageal rupture occurred in 10 cases, esophageal perforation of Bechet disease occurred in 1 case, and esophageal perforation of a thoracic aortic aneurysm occurred in 2 cases. Two cases of esophageal rupture from a thoracic aortic aneurysm resulted in death. Esophageal rupture associated with thoracic aortic aneurysm results in a poor clinical outcome and is often fatal.

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Introduction : Tension-free mesh repair has become a standard operation for both inguinal and ventral hernia repair. Ventralex^Ⓡ, a dual mesh, is a polypropylene mesh coated with ePTFE, and is designed for a rather small ventral hernias, such as umbilical and port-site hernia. We report clinical outcome of hernia repair by Ventralex^Ⓡ.

Patients and Methods : From December 2005 to September 2009, 31 patients underwent Ventralex^Ⓡ repairs for ventral hernia in our hospital. With skin incision just above the hernial orifice, the sac was dissected and laparotomy was performed. Adhesion around the hernia orifice was detached minimally, and Ventralex^Ⓡ was inserted into the abdominal cavity. The edge of the hernia orifice and the straps of four stitches were fixed by 2.0 polypropylene sutures and the excess strap was excised.

Results : Mean operating time was 53 minutes and mean post operative hospital stay was 4.6 days. Only one patient needed conservative therapy for seroma, and no recurrence of hernia has been identified with a mean follow-up period of 24 months.

Conclusion : Ventralex^Ⓡ repair is a easy, safe and effective technique for ventral hernia.

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A 67-year-old man who was admitted for dysphagia underwent an esophagogastroduodenoscopy and was found to have a protruding tumor (type 1. 15 cm in diameter) in the lumen of the cervical and upper thoracic esophagus. The tumor was diagnosed as an esophageal carcinosarcoma, and a video-assisted thoracoscopic surgery involving a subtotal esophagectomy, lymph node dissection, and antesternal reconstruction was performed. Macroscopically, the resected specimen measured 150×55×50 mm in dimension. A pathological examination revealed esophageal carcinosarcoma and squamous cell carcinoma. The patient was discharged on the 25th postoperative day without any complications. Here, we report our experience performing video-assisted thoracoscopic surgery with laryngeal preservation for the treatment of a carcinosarcoma of the cervical and upper thoracic esophagus.

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We experienced the advanced gastric cancer with the peritoneal dissemination which became resectable by the pre-operative chemotherapy and reached clinical CR (Complete Response) state by the additional post-operative chemotherapy.
A 66 year-old man with advanced gastric cancer was diagnosed as unresectable due to tight local invasions and diffuse dissemination at first laparotomy (T4b, N3, M1 PER cy+, Stage Ⅳ). We applied 4 cycles of S-1+cisplatin to this case, and found clinical PR (Partial Response) which enabled non-curative total gastrectomy at second laparotomy and intraperitoneal infusion catheter placement was added. The resected tumor was moderately differentiated tubular adenocarcinoma overexpressing HER2 (Human Epidermal Growth Factor Receptor 2) protein. We selected S-1+paclitaxel i.v. and i.p.+trastuzumab combination therapy for residual disseminative cancers. This effected conspicuously for exterminating the intraperitoneal lesions. At the present time, the patient continues this treatment and have no evidence of progression.

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Recently, laparoscopic surgery has rapidly spread, so laparoscopic gastrectomy is performed for not only malignant disease but also submucosal tumor. We herein report a case with gastric lipoma of 8 cm in size removed by laparoscopic gastrectomy. A 74-year-old man presented with epigastric discomfort. Endoscopy of upper digestive revealed a giant submocosal tumor in the antrum of the stomach. Abdominal computed tomography and magnetic resonance imaging showed a large tumor in the stomach, which consisted of fat tissue. Based on a diagnosis of lipoma in the antrum of the stomach, we conducted laparoscopy-assisted distal gastrectomy. The pathological findings of tumor showed no lipoblast cells, so the tumor was finally diagnosed as gastric lipoma. Gastric lipoma resected by laparoscopic surgery is rare and to our knowledge, only five cases had been reported in Japan. In these five cases, only two cases had more than 5cm tumor in size. Our case had a biggest tumor among those six cases. Laparoscopic surgery for large gastric lipoma is useful treatment and is supposed to be performed widely.

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Desmoid tumor of the small bowel mesentery is rare. We report herein a case of desmoid tumor of the mesentery of the small intestine. A 55-year-old man with an abdominal tumor was referred to us based on a diagnosis of abdominal tumor. Abdominal ultra-sonography, CT, magnetic resonance imaging, and angiography showed a relatively discrete abdominal tumor. Surgery was performed under a presumptive diagnosis of a mesenteric GIST of the small intestine. The resected specimen showed a white solid tumor measuring 14×12×８cm tumor. Pathologic examination showed differentiated fibroblasts and copious collagen fibers, without karyomitosis. The tumor was negative for CD34, c-kit, NSE, S-100, α-SMA, Desmin and Calretinin. Based on these findings, we established a diagnosis of the mesenteric desmoid tumor of the small intestine. The patient has been followed postoperatively for two years and there has been no sign of recurrence, to date.

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Case 1:A 57-year-old man was admitted to our hospital because of reccurent abdominal pain and melena. Through various tests we detected large tumor about 6cm in diameter with fat density in sigmoid colon and it associated with invagination. Single incision laparoscopy-assisted sigmoidectomy was performed. Case 2:An 89-year-old man was admitted to our hospital because of severe bowel obstruction. Abdoninal enhanced CT scan showed 2 cm tumor with fat density in small intestine associated with invagination. Single incision laparoscopy-assisted partial resection of small intestine was performed. In these cases resected material was histopathologically diagnosed as lipoma. Single incision laparoassisted surgery is minimally invasive, offers cosmetic benefits, and can be used in the treatment of intestinal lipoma associated with invagination.

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Intussusception occurs commonly in children but is relatively rare in adults. Intestinal obstruction in adults occurs primarily in the small intestine, rarely affecting the large intestine. Intussusception of the large intestine is often caused by colon cancer, but it is considered unlikely to occur in portions of the colon fixed to the retroperitoneum, such as the descending colon. The case of a 90-year-old man with intestinal obstruction caused by descending colon cancer who was treated surgically is reported. The underlying tumor was type 2 and 2.5 cm × 2.0 cm in size, which was thought to be small compared to previous reports. The intussusception was attributed to abnormal peristalsis caused by age-related tissue dysfunction.

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Colon perforation by a migrated biliary stent is a rare late complication of endoscopic biliary stenting. We describe a case of a 74-year-old woman with double sigmoid colon perforation and pelvic abscess due to migration of plastic biliary stent. One year ago, endoscopic biliary stenting was performed for cholangitis due to choledocholisiasis at another hospital. Since she presented acutely with abdominal pain and pyrexia for two days, abdominal x-ray and CT scan were performed and demonstrated a migrated stent in the sigmoid colon and a huge pelvic abscess. Emergency laparotomy found double sigmoid colon perforation by a migrated plastic stent and a huge abscess between the sigmoid colon and the dorsal uterus. Hartmannʼs procedure and peritoneal drainage were performed. Although the endoscopic biliary stenting is a relatively safe procedure, such late complications as stent migration and perforation should always be kept in mind carefully.

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We describe here the case of a 75-year-old woman who underwent emergency laparoscopic surgery for recurrent hemorrhages caused by diverticulosis of the right colon with subsequent anemia. At admission, physical examination revealed stable vital signs, and the abdomen was soft, non-tender, and non-distended. The hemoglobin level was 10.6 g/dL. No fresh blood clots were observed in the right colon lumen on colonoscopy. Ileocecal resection was planned; however, at 10 days after hospital admission, the patient presented with severe gastrointestinal bleeding; the hemoglobin level decreased to 7.2 g/dL, with the subsequent development of hemorrhagic shock. Blood transfusion (4 U of blood) was immediately performed; however, a second episode of massive hematochezia occurred after emergency angiography. Therefore, an emergency laparoscopic right colectomy was performed for resection of the diverticulosis of the right colon, followed by reconstruction with end-to-end anastomosis. The patient remained asymptomatic at 8 months of follow-up.

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We report our therapeutic experience of perirectal abscess due to rectal damage injured by glycerin enema. A 73-year-old female was admitted to the hospital because of perianal pain and fever after a glycerin enema, which had been used for treatment of constipation. She was diagnosed as having a rectal damage and perirectal abscess by pelvic CT and colonoscopy. A loose seton was placed at the site of damage in the rectum. We successfully treated her by this therapeutic approach without laparotomy. We think this method of therapy is useful and less-invasive.

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A 55 year-old man visited a clinic with frequent bowel habits and bloody stool and was referred to us with a tentative diagnosis of rectal cancer in October, 2010. He was admitted and found to have advanced cancer in the mid and lower rectum. Following colorectal anastomosis, we placed a diverting ileostomy and placed a soft drain in the pelvic space because of distended bowel loops observed during the operation. Postoperatively, anastomotic leakage occured but could be treated with bowel rest and pelvic drainage. At 22 days after operation, just after removal of the drain, massive bleeding occurred from the stab wound of the drain. Emergency angiography with coil embolization was successfully performed for bleeding from the right inferior gluteal artery and right internal pudendal artery. At 32 days after the initial operation, bleeding recurred at the same site. Computed tomography-angiography detected an aneurysm in the left external iliac artery as the origin of recurrent bleeding. Through a retroperitoneal approach, aneurysm resection and simple repair of the left external iliac artery were performed. Thereafter, his postoperative course was uneventful. We assume that the aneurysm reported herein was caused by the long-standing pressure of the drain placed at the time of low anterior resection. Such a reason for drain-related hemorrhage after low anterior resection for rectal cancer has rarely been reported.

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A 53-year-old man was referred to our hospital in January 2009 with a mass in the left neck that he had first noticed in September 2008. Examination revealed swelling of the left swollen lingual tonsils and numerous many swollen lymph nodes in the left side of the neck . MRI and the biopsy of a neck lymph node led to the diagnosis of oropharyngeal cancer (T1-2, N2b, M0, Stage Ⅳ). The patient was treated by neoadjuvant chemotherapy and surgery, followed thereafter by one course of chemotherapy and radiation. At 11 months after the surgery, CT revealed liver metastases. We started chemotherapy; however, the liver metastasis increased in size. Since PET-CT did not reveal any other distant metastasis, we performed partial resection of the medial segment and S8 segmentectomy of the liver. In the pathological findings, it wasn’t contradictory as liver metastasis of squamous cell carcinoma. Because of low incidence of oropharyngeal cancer, report of liver metastasis is rare. We considered in cases with resectable tumors in this patient case, a poor effect of chemotherapy, and surgery may also be an option for treatment.

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We present a case of liver metastases arising from pancreatic neuroendocrine tumor 24 years after the initial resection. The patient was a 64-year-old woman who had undergone pancreatico-duodenectomy for pancreatic neuroendocrine tumor of the pancreas head at 1988. The patient developed acute pancreatitis and was admitted to Hitachi General Hospital as emergency at April 2012. Several imaging examinations showed liver tumors at segment 7. Liver biopsy was undergone to confirm diagnosis of the liver tumors, because it was difficult to clarify diagnosis only from imaging findings. Immunohistochemically, the tumor cells were positive for markers of neuroendocrine such as chromogranin A, synaptophysin, CD56, and parakeratin. Therefore, we suspected the liver tumors as metastases from pancreatic neuroendocrine tumor resected 24 years before. We performed partial hepatectomy. The histological findings were similar to those of the primary pancreatic neuroendocrine tumor resected 24 year before. The longest interval from the resection of pancreatic neuroendocrine tumor to its liver metastases was recorded in this case. We should recognize such a rare type of metastases when it is difficult to confirm the diagnosis of liver tumor.

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A 67-year-old woman underwent laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage for acute cholecystitis. She was discharged shortly, but a month later, came to our hosipital because of right flank discomfort emerged. The abdominal ultrasonography and CT scan revealed abscess cavities with some stone-like shadows in them, at right subphrenic space and Morisonʼs pouch. Morison’s pouch abscess was operated by small incision, and subphrenic abscess was operated laparoscopically, respectively. They both contained some pigmented stones seems to have been spilled from gallbladder at the first operation. Intraabdominal multiple abscess caused by spilled gallstones is relatively rare, and was treated with minimally-invasive surgery.

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The patient was a 52-year-old male taken to a physician by ambulance for sudden epigastralgia and vomiting. On CT, hemorrhagic ascites was noted. Intra-abdominal hemorrhage was suspected, and the patient was transferred to the emergency service of our hospital. At arrival, the blood pressure was 127/84 mmHg, pulse was 71/min, abdominal region was distended, and tenderness and muscular defense were observed mainly in the upper abdominal region. On contrast CT performed at our hospital, HDA was noted in the left region of the stomach. There was no abnormal finding on GIF. Angiography was performed, suspecting visceral aneurysm rupture. Ruptured aneurysm (about ２ cm) of the short gastric artery was suspected based on splenic arterial angiography, and emergency surgery was performed. An aneurysm was observed in the posterior wall of the omental sac in surgery, and it was diagnosed as a ruptured aneurysm of an innominate artery which branched from the splenic artery. Histopathologically, it was an aneurysm accompanied by degeneration of the tunica media, suggesting SAM-induced aneurysm rupture. The postoperative course was favorable, and the patient was discharged ７ days after surgery. We encountered a patient with SAM-induced visceral aneurysm rupture. We report the case with a literature review.

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A 38-year-old woman was admitted to our hospital for treatment of a retroperitoneal tumor associated with epigastric pain. Abdominal ultrasonography showed a hypoechoic mass with clear boundaries and a diameter of 30 mm located dorsal to the pancreas body and to the right of the superior mesenteric artery. The tumor had a low intensity on T1-weighted MRI and a partial high intensity on T2-weighted MRI. Computed tomography showed that the tumor had clear boundaries, a uniform internal density, and a mild delayed enhancement. MIBG scintigraphy showed no accumulation. Findings of gastrointestinal endoscopy and colonoscopy were unremarkable. On the basis of these findings, a retroperitoneal tumor was diagnosed. Upon excision of the retroperitoneal tumor, histological findings showed that it was a ganglioneuroma. The patient made a satisfactory recovery and was discharged on postoperative day 12. The patient remains well with no evidence of tumor recurrence at 1 year after resection.

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The patient was a 62-year-old woman with chronic hepatitis C, who had developed postoperative peritonitis following appendicectomy for acute appendicitis at the age of 15. She visited a local clinic with a chief complaint of epigastric discomfort. Upper gastrointestinal series showed a 0-Ⅱc lesion in the greater curvature of the lower gastric body, and she was referred to the Department of Gastroenterology of our hospital. At that time, the lesion was diagnosed as por2 by biopsy. Abdominal CT showed a solid, enhancing, tumor-like lesion in the proximity of the left side of the inferior mesenteric artery. She was referred to our department for surgery, and underwent laparoscopic distal gastrectomy and schwannoma removal. The operative time was 4 hours and 53 minutes, and blood loss was 24 mL. Her postoperative course was uneventful, and she was discharged on the 10th postoperative day. Since no case has been reported of laparoscopic gastrectomy and concomitant resection of schwannoma in the inferior mesenteric plexus, we report the valuable case.

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Parastomal hernia occurs in more than 30％ of patients with intestinal stoma, and represents a late complication that reduces the quality of life of patients. We report two patients who developed parastomal hernia (>10 cm in diameter) after rectal cancer surgery, and underwent repair with DUALMESH (CORE®), with a favorable outcome. They had stoma created by a transperitoneal approach at the time of abdominoperineal rectal amputation, and the hernial orifices measured 10×8 and 15×7 cm. Since they presented with abdominal pain probably due to the parastomal hernia, they underwent surgery. The hernia was repaired using the Sugarbaker technique. Postoperatively, one patient developed strangulation ileus requiring re-laparotomy, but it was not related to the hernia repair. To date, one year after surgery, the patients have remained free of recurrence, suggesting that this technique is simple and effective.

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We treated two patients with primary malignant bone tumor of the upper limb by intraoperative extracorporeal radiation therapy. Patient 1 was a 53-year-old woman with chondrosarcoma of the right humeral shaft. After wide excision of the humeral shaft, soft tissue on its surface and intramedullary tissue including tumor were thoroughly removed. The bone was washed with physiological saline, irradiated with a dose of 100 Gy, re-implanted at the original site and fixed with a intramedullary nail and two plates. The irradiated autograft fractured 6 months after surgery and developed into non-union. Patient 2 was a 17-year-old boy with osteosarcoma at the proximal part of the left ulna. After wide excision, soft tissue and tumor tissue on the ulnar surface was removed, irradiated with a dose of 60 Gy, re-implanted in the original site and fixed with a plate. The osteotomized site was treated with low-intensity pulsed ultrasound and healed completely. Neither local recurrence nor distant metastasis occurred in both patients.
Non-union, fracture and infection are common complications after reconstruction with intraoperative extracorporeal radiation therapy. However, no local reccurence in irradiated autografts has been reported. This technique is useful in patients in whom artificial implant for reconstruction is commercially unavailable.

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