Purpose:Perforation occurs more often with appendiceal diverticulosis than with acute appendicitis;thus, confirming a diagnosis of appendiceal diverticulosis is critical. We compared the clinicopathological features of 12 appendiceal diverticulosis cases (3 confirmed preoperatively) and 321 acute appendicitis cases (excluding catarrhal) and investigated the pathological features specific to appendiceal diverticulosis.
Methods:Over a 7.5-year period, 12 of 392 patients with appendiceal disease were diagnosed with appendiceal diverticulosis (3 confirmed preoperatively). Findings from physical examination, abdominal ultrasonography and/or computed tomography, surgery, and histopathology were statistically analyzed.
Results:Onset age was significantly later for appendiceal diverticulosis than for acute appendicitis (p = 0.0176) (average, 54.3 years). Perforation occurred more frequently with appendiceal diverticulosis (p < 0.001). There were no significant gender differences. Moreover, 11 patients had appendiceal diverticulitis. The average preoperative white blood cell count and C-reactive protein levels were 11929/µL and 7.15 mg/dL, respectively. Appendectomy (6 cases), partial cecal resection (4), and ileocecal resection (2) were performed. Pseudodiverticula were confirmed histopathologically in all cases (mesenteric, 10;bilateral, 2). Six patients suffered perforations. The average number of diverticula was 2.5.Conclusions:Excision is recommended when appendiceal diverticulosis is suspected or the presence of acute appendicitis is unclear.

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We performed first screening of Lynch syndrome (LS) using Amsterdam criteria Ⅱ (ACⅡ) and Revised Bethesda guidelines (rBG) from medical records, including 893 colorectal cancer patients who underwent colectomy in our institute, and analyzed the usefulness and problems for ACⅡ and rBG . The most frequent cancer related to LS was gastric cancer (23 cases) except colorectal cancer in a proband and first- or second-degree relatives. Of 893 patients, 146 patients were determined as candidates of LS by rBG, while no patients were satisfied with all the subjects of ACⅡ. The age at diagnosis of cancer in almost first- or second-degree relatives was missed in medical charts. If we know that correctly, the number of candidates of LS using ACⅡ and rBG as first screening increase up to ３ patients (0.3％) and 87 patients (9.8％), respectively. In conclusion, we recommend rBG for first screening to detect candidates of LS in clinical practice, keeping in mind that hearing the age at diagnosis of cancer in first-degree relatives is essential.

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We investigated 2,090 cases of colorectal cancer involving 168 cases of colorectal cancer with invasion into adjacent organs (SI/AI). Histological diagnosis of invasion matched in 40.8％ of cases. Lesion location in order of decreasing prevalence was the sigmoid colon, ascending colon, and cecum. Extracolonic invasion frequently involved the abdominal wall, small intestine, and urinary bladder. A definite difference was not noted in the frequency between well or moderately differentiated adenocarcinoma and, mucinous adenocarcinoma or others. No significant difference was seen in the survival rate between pathological SI/AI and pathological SS/SE/A, but prognosis of pathological SI/AI was worse than that of pathological SS/SE/A in Stage Ⅲ and prognosis of laparoscopic surgery was worse than the open surgery in macroscopic SI/AI. In Cur A cases, hematogenous reoccurrence accounted for more than half of the recurrence cases.

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Purpose:The aim of this study was to identify the prognostic factors of Stage Ⅳ colorectal cancer, by investigating the clinicopathological features.
Materials and Methods:A total of 115 patients with Stage Ⅳ colorectal cancer who received treatment from August 1999 to August 2009 at Yokohama Minami Kyosai Hospital were enrolled. The clinicopathological data of the patients were retrospectively evaluated.
Results:The median follow-up period was 14.2 months. The 5-year survival was 9.9％ in the study group as a whole. Univariate analysis for 5-year survival identified six factors;age (≦75 years old vs ≧76 years old), depth (ss/a vs se/si/ai), resection of the primary tumor, curability, chemotherapy, and the number of non-curative factors (1 vs 2,3). Multivariate analysis for 5-year survival identified two independent factors;curability (hazard ratio [HR], 3.53;95％ CI, 1.84-6.77;p<0.001), and chemotherapy (HR, 2.87;95％ CI, 1.78-4.63;p<0.001).
Conclusion:Curative B resection including preoperative chemotherapy and aggressive chemotherapy are thought to improve a prognosis of Stage Ⅳ colorectal cancer.

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Bladder and sexual dysfunction are potential problems after rectal excision. The aim of this study was to prospectively evaluate bladder and sexual dysfunction in male patients with rectal cancer who were treated using fully robotic techniques. Between September 2011 and April 2012, 8 consecutive patients scheduled to undergo a fully robotic resection for the treatment of rectal cancer were prospectively included in this study. The patients were asked to complete validated, self-administered questionnaires regarding their urinary and sexual function before surgery and 3, 6, and 12 months after surgery. Urinary function deteriorated postoperatively in only one of the 8 patients. None of the patients required permanent or intermittent catheterization. Erectile and ejaculation function had returned to the preoperative sexual status at 6 months after surgery. None of the patients were erectile dysfunction or were experiencing retrograde ejaculation at 6 months after surgery.

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We report a case of chylothorax that occurred after esophagectomy for esophageal cancer. A 62-year-old man was diagnosed with lower thoracic esophageal cancer and underwent right thoracolaparotomy subtotal esophagectomy. After initiating enteral nutrition on postoperative day 3, the fluid in the chest tube turned a milky color and drainage increased to 1,080 ml per day. The patient was diagnosed with chylothorax and treated using octreotide acetate. This caused the drainage to decrease, but the condition was not cured. On postoperative day 22, we performed video-assisted direct suture repair of the leakage area of the thoracic duct. After the surgery, the drainage markedly decreased, and the thoracic tube was removed on day 13 after the second surgery. Chylothorax after esophagectomy with large amounts of chylous fluid is difficult to treat. However, therapy is usually based on the treatment guidelines for regular chylothorax. We, therefore, collected and analyzed case reports on chylothorax after esophagectomy from Japan to determine a treatment strategy for such cases. The results indicated that octreotide acetate should be administered after beginning total parenteral nutrition. However, if the drainage does not decrease to less than 500 ml within a few days, then immediate surgery should be considered.

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A 38-year-old woman was referred to our hospital in August 2002 complaining of a right breast tumor. Ultrasonography revealed a heterogeneous tumor of irregular shape measuring 17mm in the right breast. Aspiration biopsy cytology showed “suspicious for carcinoma”, we underwent excisional biopsy and gave the tumor diagnosis of breast neuroendocrine carcinoma (NEC).
We performed additional right breast conserving surgery and axillary lymph nodes dissection (T1N0M0 StageⅠ). Immunohistochemical staining was positive for estrogen and progesterone receptors, and HER-2 negative. The patient received radiation therapy (50Gy) and hormonal therapy(tamoxifen) as adjuvant therapy.
Three years and six months after the operation, she was diagnosed local recurrence and performed the right mastectomy. Immunohistochemical staining of the recurrence tumor showed the same figure as the primary breast NEC. Postoperatively, she received hormonal therapy with tamoxifen and LH-RH agonist.
Ten years after the primary operation, she was pointed out a solitary liver tumor with enhanced-CT. In another hospital, she was submitted left lateral partial hepatectomy. Postoperative immunohistochemical staining showed the almost same figure of the primary breast NEC, we diagnosed the liver tumor as metastasis of breast cancer. She has received chemotherapy with paclitaxel up to now.

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The case pertains to a 68-year-old man. A close investigation was carried out due to a chief complaint of difficulty swallowing, with type 2 squamous cell carcinoma observed around the entire circumference of the lower intrathoracic esophagus. The stage was cT3 cN2 cM0 cStage Ⅲ. An untreated aortic arch aneurysm (a saccular aneurysm measuring 36 mm in diameter) was observed upon CT imaging of the thoracoabdominal region. Stent graft interpolation was carried out following the commencement of nutrition administration by intubation feeding from the nose. FP therapy (5FU 600 mg/m², CDDP 60 mg/m²) was commenced as preoperative chemotherapy; however, this was terminated after one round due to the observation of Grade 3 diarrhea and renal dysfunction. Excision of the lower intrathoracic esophagus, posterior mediastinal gastric tube reconstruction, and jejunostomy were carried out. No.106recL and 106tbL were not dissected because these were found to have strongly adhered to the circumference of the aorta upon intraoperative observation. No complications were observed during or after surgery and the patient was discharged from the hospital 15 days following surgery. The histopathological outcome was pT3 pN1 (1/29) pM0 Stage Ⅲ and the histological response evaluation of chemotherapy was Grade 1a.

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A 57-year-old women complaining of abdominal pain and back pain was referred to our hospital. Abdominal CT scan showed a giant mass adjacent to the liver, the stomach and the pancreas which was 23cm in diameter and consisted of cystic and solid components. 3D-CT angiography indicated that the left gastric artery and right gastroepiploic artery were the feeding arteries of the tumor. These findings suggested that the tumor was GIST of the stomach. Operation finding revealed the tumor originated from the stomach and total gastrectomy was performed. The resected specimen was 23×20×12 cm in size and weighed 2,800g. Immunohistochemical analysis showed that the tumor was positive for c-kit and CD 34. Based on these findings, the tumor was diagnosed as GIST of the stomach. She is alive with no signs of recurrence during 3 years and 2 months after surgery without administration of Imatinib. Molecular genetic study revealed insertions in the distal part of KIT exon 11, which is a rare mutational subtype and has a favorable clinical course. We herein report a case of giant cyst-containing GIST of the stomach, together with a review of the literature of 17 cases of giant GIST of the stomach in Japan.

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We report an adult case of idiopathic gastric volvulus successfully treated by laparoscopic gastropexy. A 24-year-old woman with mental retardation referred to our hospital because of abdominal pain, vomiting and abdominal distention. Abdominal computed tomography revealed mesentero-axial volvulus of the stomach. The endoscopic detorsion was attempted, but it resulted in failure. However, by the decompression with a nasogastric tube, we succeeded in detorsion two days later. In the case with the mental disease it is considered that the recurrence rate is relatively high, because of aerophagia and chronic dilatation of stomach or colon^1）. Her parents hoped the preventive operation worrying about the future of the daughter. Then we performed laparoscopic gastropexy. Operation was done with 3 ports, and gastropexy was made with three lines running sutures. Postoperative course was uneventful. 1 year after surgery, there has been no recurrence. The recurrence rate of idiopatic gastric volvulus is fairly high. Therefore the preventive operation should be considered as one of the treatment options, especially in the case with mental disease. The fixation method by some lines running sutures may be the useful procedure, because it is possible to fix the wide range of the stomach to the abdominal wall.

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There are few reports about sequential laparoscopic surgery for simultaneous gastric and rectal or sigmoid colon cancers. And this sequential laparoscopic surgery has not been compared with conventional open surgery adequately regarding the short-term postoperative quality of life (QOL). A 61-year-old man, who was diagnosed as having simultaneous gastric and rectal cancers, underwent a sequential laparoscopic surgery of distal gastrectomy and low anterior resection. To assess whether the short-term postoperative QOL of this patient was superior to that of a sequential open surgery or not, some perioperative statuses were compared between this case and the group of 14 cases who underwent open surgery for simultaneous gastric and rectal or sigmoid colon cancers in our hospital. As a result, the blood losses of this case were less than a median of these 14 cases. Furthermore the postoperative beginning days of flatus and those of diet were earlier and the hospital stays were shorter than a median respectively. Although this operation required long time, a sequential laparoscopic surgery might be considered as cosmetically favorable and minimally invasive compared with a conventional open surgery. This procedure might be expected to improve the short-term postoperative QOL dramatically.

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A 70-year-old woman was found in gastrointestinal series and gastrointestinal fiberscopy studies to have type 3 advanced gastric cancer in the middle and upper stomach. Abdominal computed tomography showed No.3 Lymph node metastasis and multiple liver metastases in liver segment 2 (9mm in a diameter), segment 3 (9mm in a diameter) and segment 8 (22mm in a diameter). We started chemotherapy using TS-1 plus CDDP. TS-1 (80mg/m²/day) was orally administered for 3 weeks followed by a drug-free 2 weeks period and CDDP (60mg/m²) was administered intravenously on day 8 as 1 course. After 4 courses of chemotherapy, abdominal computed tomography showed solitary 8mm liver metastasis only in liver segment 8. Therefore, we conducted total gastrectomy with lymph node dissection (D2), reconstruction by R-Y anastomosis, partial hepatectomy (S8) and cholecystectomy. No recurrence was seen in the 1 year and 6 months after surgery. This case suggests that chemotherapy is effective against advanced gastric cancer with multiple liver metastases.

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A 54-year-old male admitted to the hospital because of black stool and high grade anemia was found to have a huge neoplasm in the bulb of his duodenum using a gastroendoscope. Abdominal CT and MRI scans revealed a neoplasm about 5cm in diameter. It was difficult to grasp the whole image of the tumor by the gastroendoscopy and to resect the large tumor via gastroendoscopy. Therefore, the tumor was extirpated under laparotomy with intraoperative gastroendoscopy. The tumor was 6.5×2.5×2.0cm with Brunnerʼs gland hyperplasia, which had a stalk on the duodenal bulb. The patientʼs postoperative course was uneventful. There is an increasing number of reports of tumors arising from Brunnerʼs gland, but the diagnosis and treatment of these tumors is still unclear. We analyzed the pertinent literature regarding Brunnerʼs gland hyperplasia, hamartoma, adenoma, and carcinoma.

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We present two case reports of non-occlusive mesenteric ischemia with different outcomes.
Case1 : A 78-year-old woman visited our hospital complaining of left lower abdominal pain. The patient received laparotomy fifty-four hours. The operative findings revealed the ischemic change of whole small intestine and large part of colon necrosis. The resection of necrotic colon and colostomy were performed. The re-operation was carried out due to necrosis of the residual colon, all of the small bowel and the gallbladder. The patient was died six days after the second surgery.
Case2 : An 81-year-old woman visited our hospital complaining of lower abdominal pain and vomiting. The patient underwent emergency laparotomy due to necrosis of large part of the colon except rectum and a part of the small intestine twenty-five hours after admission. The patient discharged from hospital one year after the operation. Two cases with different outcome and past reports suggest the time from the onset to the operation and abdominal findings are the most important factors. The earlier diagnosis using laparotomy and following immediate operation for necrotic bowel are important if the bowel necrosis is suspected, and aggressive re-operation for bowel necrosis after first operation should be considered.

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A 32-year-old female visited the hospital complaining chiefly of abdominal pain and swelling. Her medical history showed she had undergone five previous laparotomies and had repeatedly complained of the same symptoms each year for the past ten years. While she was being treated conservatively after being diagnosed with intestinal obstruction, she expressed a desire to undergo surgical treatment because her symptoms were gradually beginning to appear more frequently. Preoperative tests suggested an adhesion of the small intestine to the midline wound and she was diagnosed with intestinal adhesion. Laparoscopic dissection of the intestinal adhesion was performed using small-diameter forceps. Surgical findings indicated that a section of the small intestine that curved directly below the midline wound and adhered to it was causing the intestinal adhesion. Therefore, only laparoscopic dissection was performed. The patient was discharged on the 5^th hospital day and no relapse of intestinal obstruction symptoms or abdominal pain has appeared one year and two months later. We used small-diameter forceps in the treatment of a case of intestinal adhesion and found that small-diameter forceps help to enhance cosmetic outcome and increase patient satisfaction. However, they should be used with a sufficient understanding of their advantages and disadvantages.

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A 37-year-old man visited our hospital because of nausea, vomiting, and epigastric discomfort. A giant mass was pointed out in the lower abdomen on abdominal CT. Gastroscopy and colonoscopy revealed no lesions. Abdominal US, CT, MRI and angiography revealed a hypovascular giant solid mass of approximately 16cm in diameter in the lower abdomen. Laparotomy was performed with a suspicion of tumor originating from the mesentery. Operative findings showed a white solid tumor, measuring 16.5×９×９cm in the mesentery of the terminal ileum with adhesion to the ascending colon. The tumor also involved other parts of the small intestine. The resected tumor had smooth surface with elastic hard consistency. Histopathological and immunohistochemical diagnosis was mesenteric fibromatosis. The tumor was considered to have originated from the mesentery of the terminal ileum. To our knowledge, only a few cases have been reported as mesenteric fibromatosis without concomitant familial adenomatous polyposis (FAP) or history of open surgery.

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An 81-year-old man visited our hospital with chief complaints of nausea and vomiting. The abdominal symptoms were mild, and examinations other than CT showed no evidence of abnormalities. Abdominal CT revealed that the small intestine had invaginated into the right colon and its wall had thickened to show “a target appearance.” These findings led to a diagnosis of ileocecal intussusception into the ascending and transverse colon with strangulation ileus, and the patient underwent emergency surgery. Laparotomy showed distension of the large intestine with the intussusceptum and small bowel volvulus at the ileocecal junction. The intussuscepted intestine was reduced into the ascending colon, and right colectomy, including the twisted small intestine, was performed. The resected specimen showed no organic lesions, but revealed that a 30cm segment of the ileum had undergone hemorrhagic necrosis. We speculate that the mobile cecum induced intussusception with secondary small bowel volvulus. In adults, intussusception is most often due to an organic lesion, and the idiopathic form is rare. This case is very rare in that the intussusception was not associated with an organic lesion, and was complicated by small bowel volvulus.

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A 78-year-old man who had undergone hemodialysis for 8 years for chronic glomerulonephritis had been receiving calcium polystyrene sulfonate (CPS) for hyperkalemia for 6 years. He presented to our hospital with sudden onset abdominal pain and was prescribed a sedative. Due to recurrence of the abdominal pain on the next day, he again visited our hospital. A chest radiography and an abdominal computed tomography (CT) scan indicated the presence of intra-abdominal free air. Thus the patient was diagnosed with gastrointestinal perforation and underwent an emergency operation. Hard fecal masses were observed in the large intestine. The perforated sigmoid colon was resected, and Hartmannʼs procedure was performed. An additional operation was performed due to perforation of the descending colon on postoperative day 6. However, he died 40 days after the second operation. On histopathological examination, basophilic staining indicating the presence of numerous CPS crystals was noted in the perforated region. Constipation is a well-known major adverse effect in patients undergoing CPS treatment. As intestinal perforation has been reported in patients receiving CPS, it should be considered in patients who present with an acute abdomen, and who have been undergoing treatment with CPS.

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One case of early carcinoma of the ileum is described in which a definitive diagnosis was obtained preoperatively based on a lower gastrointestinal tract endoscopic biopsy, allowing radical surgery to be performed. An 89-year-old man presented with repeated diarrhea and stomach pain. No abnormalities were noted during upper alimentary tract or lower gastrointestinal tract endoscopy, while abdominal CT indicated intussusception in the ileocecal area, but the symptoms subsided and the patient was only observed. Later the symptoms occurred again and lower gastrointestinal tract endoscopy was repeated, and a single neoplasm was noted in the ascending colon, which was biopsied and found to be cancerous. The patient was transferred to this hospital with a diagnosis of colon cancer, but after a barium enema the intussusception subsided, and the diagnosis was changed to ileac cancer. The patient underwent partial resection of the ileum and lymphadenectomy. Histopathological examinations showed a tumor in the ileum around 20cm from the Bauhin valve on the entry side, measuring 7.2×5.7cm, of which 5％ was adenoma carcinoma including well differentiated tubular adenocarcinoma. The carcinoma was located within the lamina propria, and therefore it was categorized as T1, N0, M0, Stage I according to the TNM classification.

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A 44-year old female patient visited our hospital with lower abdominal pain. Computed tomography (CT) scan revealed the inflammatory thickening of the sigmoid colon wall, and with a diagnosis of diverticulitis, conservative therapy led to temporary recovery. One month later, the diverticulitis recurred with persistent mildly elevated inflammatory reaction. The serum carcinoembryonic antigen (CEA) level was 8.7 ng/ml at the time of the first consultation, and then it increased to 13.4 ng/ml 2 months later and 16.3 ng/ml 4 months later. Both gastrografin enema and colonoscopy were insufficient for making any diagnosis. Additional CT scan and positron emission tomography (PET) were performed for assessing the elevated CEA level, but there were no other findings except the thickening of the sigmoid colon wall with accumulation of fluorodeoxyglucose (FDG) in the same region. Surgery was performed based on a diagnosis of refractory diverticulitis and the possibility of colon cancer. During laparotomy, inflammatory changes were observed around the sigmoid to recto-sigmoid colon, and then high anterior resection was performed. Histopathologically, there were multiple diverticuli with inflammation with no malignant findings. CEA immunoreactivity patterns were observed in the epithelia and the surrounding neutrophils. The elevated level of CEA was due to the diverticulitis, based on its normalization after surgery.

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A 79-year-old woman was admitted to our hospital for neoadjuvant chemotherapy against an advanced sigmoid colon cancer with a bladder invasion and lung metastasis after placement of a sigmoid colonostomy at the referring hospital. A biopsy of the tumor before chemotherapy revealed well-differentiated adenocarcinoma. Computed tomography showed a huge tumor occupying the pelvic cavity and directly invading the urinary bladder, with regional lymph node metastases, right pyelectasia and a lung metastasis. The patient received FOLFOX4 with bevacizumab as adjuvant chemotherapy. After 6 courses of the regimen, enhanced computed tomography revealed no tumor in the pelvis, and improvement of the right pyelectasia. The patient underwent elective sigmoidectomy, and then partial lung resection for lung metastasis. Histopahological examination revealed a pathological complete response of both primary colon cancer and lung metastasis. The patient received adjuvant chemotherapy with S-1 and remains well without any evidence of recurrence of cancer more than one year after operation.

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A 63 year-old female was admitted to our hospital because of abdominal pain and abdominal distension. Tenderness was recognized in the upper and lower abdomen. Abdominal X-ray and abdominal computed tomography revealed massive dilatation of the total colon and rectum. However, no organic disease was noted on colonoscopy, so a diagnosis of Ogilvie syndrome was made. The patient did not improve on conservative medical treatment, and an artificial anus was created in the dilated ascending colon. We reviewed 5 cases of Ogilvie syndrome involving dilated intestine extending to the rectum.

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We repot a case of solitary splenic metastasis from descending colon carcinoma without any other distant metastasis at 4 years after the primary surgery. A 75-year-old man underwent descending colectomy for descending colon cancer with occlusive ileus. Postoperative adjuvant chemotherapy (LV/5-FU) was carried out for 1 year. At 4 years after the primary surgery, serum carcinoembryonic antigen (CEA) was extremely high and abdominal enhanced CT scan showed a low-density mass in the spleen. No other lesion was found in gastroduodenoscopy and colonfiber. As metachronous solitary metastasis was suspected, a splenectomy was performed. Postoperative histological diagnosis confirmed splenic metastasis from descending colon cancer. He has no sign of recurrence at present, 4 years and 8 months after splenectomy. Since a solitary splenic metastasis form a colon cancer is extremely rarely, this case is presented with a review of the literature.

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It has been difficult to cure complex anal fistulas, for which we have performed a modified seton. Crohnʼs disease is sometimes associated with complex anal fistula. A 20-year-old female complained anal pain and prulent discharge. Physical examination showed a deep anal fissure and secondary orifices around the anus. CT revealed complex anal fistulas. The fistula was cured by a modified seton technique. Frequent diarrhea developed 2 years after the cure, and diagnosed as Crohnʼs disease. The disease was remitted with mesalazine. She has been well without any recurrence for 4 years after surgery. For anal fistula in Crohnʼs disease, surgical indication has been limited to the patients with abscess despite of medical treatment. Although seton method provided favorable results, seton was placed for long-term drainage. Recently, new drugs improved the treatment. For anal fistula, combination of the drugs and surgery would be promising. We devised a modified seton, placed in the primary orifice and abscess with preserving the sphincter muscle after excision of the secondary fistula tract, maintaining the anal shape and function. The present case showed sign of Crohnʼs disease after cure of complicated anal fistula by a modified seton technique. She has been well without any recurrence.

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A 53-year-old woman who had been treated for rheumatoid arthritis (RA) with steroid, methotrexate and NSAIDs visited to our hospital with abdominal pain in February 2004 . The emergency operation was performed under diagnosis with the perforation of sigmoid colon and the multiple ulcers of the transverse and the descending colon. Left hemicolectomy and colostomy was performed. Postoperative colonoscopy revealed multiple ulcer scars of remaining colon. Closure of colostomy and remaining colectomy was performed. After operation, treatment of RA was resumed with steroid and NSAIDs. Seven years after, she was admitted to our hospital with abdominal pain and the emergency operation was performed under diagnosis with the perforation of the remaining large bowel. The local resection of rectum was performed against the perforation of the distal colon at the ileo-colo anastomosis. Drug-induced perforation was suggested because histopathological examination revealed no special finding. We herein reported a case of twice perforation of the large bowel during treatment for rheumatoid arthritis with the review of literature.

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A 61-year-old man underwent curative abdominoperineal resection with lateral lymph node dissection for anal canal mucinous adenocarcinoma at our hospital. Histopathological findings were pA, pN0, pH0, pP0, pM0, pStage Ⅱ, curA on the Japanese Classification of Colorectal Carcinoma, the seventh edition. Five years after the surgery, he complained of perineal pain and CT/MRI scans revealed a substantial recurrent tumor in the pelvis, measuring 90mm in diameter without other metastatic lesions. On the diagnosis of local recurrence of anal canal mucinous adenocarcinoma, we performed total pelvic exenteration (TPE), to eradicate the tumor in an en bloc fashion. He was discharged on the 25^th postoperative day without intra- and postoperative complications. Histopathologically, the specimens showed mucinous adenocarcinoma suggesting local recurrence of the primary tumor, and the radial margin was negative for cancer. The patient is doing well without any re-recurrence 28 months after TPE. Colorectal mucinous adenocarcinoma is a poor prognostic disease, compared with differentiated adenocarcinoma, and most of local recurrence arises within three years. We report a case of local recurrence of anal canal mucinous adenocarcinoma at five years after the initial surgery with good course and survival after TPE.

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The patient was a 66-year-old woman who had undergone abdominoperineal resection for a rectal GIST at 58 years of age. Based on the size and mitotic index of the lesion, it was diagnosed as a high-risk GIST. Abdominal ultrasonography 7 years later showed a tumor measuring 1.5 cm in diameter in the right lobe of the liver. Dynamic computed tomography showed that the tumor was slightly enhanced by contrast medium during the arterial phase and hypodense during the venous phase. We suspected a liver metastasis of the GIST on the basis of the core needle liver biopsy findings, and the patient underwent hand-assisted laparoscopic liver resection. Since the resected tumor contained malignant spindle cells that immunostained CD34-positive, we diagnosed it as a liver metastasis of the rectal GIST. The postoperative course was uneventful, and 18 months have passed with no evidence of tumor recurrence.

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A 73-year-old woman presented to a clinic with right upper abdominal pain. Abdominal ultrasonography indicated the presence of cholecystolithiasis, and the patient was referred to our hospital for surgery. During laparoscopic cholecystectomy, a nodular lesion, 6×3 mm in size, was noted on the serosal surface of the body of the gallbladder. No communication was noted between the liver and the nodular lesion; however, the color of the nodular lesion was identical to that of the main liver. Pathologically, the surface of the nodular lesion was found to be covered with a smooth fibrous capsule, and the Glissonʼs sheath and central vein were seen, thus illustrating the normal structure of a liver lobule. The lesion was therefore diagnosed as ectopic liver. Ectopic liver is a rare anomaly of the liver. Most patients with ectopic liver are asymptomatic, and is usually detected incidentally on the serosal surface of the gallbladder during surgery or laparoscopy.

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An 82-year-old man was admitted to our institution with the complaint of hematochezia and weight loss. Fiberoscopy revealed a 20mm torose tumor and a 30mm Stage 2 tumor in the transverse colon. Biopsy showed spindle cells in both tumors, suspicious for mesenchymal sarcoma. Abdominal ultrasonography and computed tomography demonstrated a solid tumor in the gallbladder, invading the transverse colon. The patient was diagnosed with mesenchymal sarcoma of the gallbladder, with invasion of the transverse colon. Extended cholecystectomy and right hemicolectomy were performed. Histological examination revealed coexistent carcinosarcoma and carcinoma of the gallbladder. The patient was discharged 15 days after surgery.We report a case of coexistent gallbladder carcinosarcoma and carcinoma.

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An 85-year-old man complained of epigastralgia and anorexia. Endoscopy was undergone and there was an ulcerative tumor in the lesser curvature of middle stomach. Pathological findings of the biopsy from the tumor suggested poor differentiated adenocarcinoma. Computed tomography demonstrated a hypovascular tumor, 9 cm in diameter, in the lateral lobe of the liver. The tumor is widely in contact with the stomach. CT angiography showed the tumor was supplied by left gastric artery and left hepatic artery. It was difficult to distinguish advanced gastric cancer with liver metastasis from primary liver cancer invasive to the stomach. We proposed that curability was obtained by operation and total gastrectomy and left lateral segmentectomy was performed. The tumor was invasive to pancreas and resected en bloc including partial pancreas. Histopathology showed that intrahepatic cholangiocarcinoma (ICC) invaded to the stomach. Lymph node metastasis was positive. ICC had recurred 8 months after operation. In small number of cases, it was reported that ICC invasive to other organs is poor prognosis. Therefore, indication for the surgical treatment should be done carefully.

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Long-term survival of patients undergoing resection of pancreatic metastasis from renal carcinoma is frequently reported, but there are few reports on operations for subsequent recurrence in the remaining pancreas. In our patient a solitary pancreatic metastasis was found twice during an 18-year period, necessitating pancreatic resection twice. A woman in her 70s underwent left nephrectomy for left renal carcinoma in 1993. In 2006, 13 years postoperatively, she had a recurrence in the pancreatic head, and underwent pancreaticoduodenectomy. Four years later, two metastases were observed in the tail of the remaining pancreas, leading to distal pancreatectomy. Pathological examination of both metastases showed clear cell carcinomas consistent with the pathological features of the primary lesion. She has remained alive without recurrence for 20 months since the operation. Pancreatic metastases are commonly detected in the terminal phase of cancer, but resection of pancreatic metastasis from renal carcinoma can achieve prognostic improvement for patients. Moreover, because renal carcinoma is characterized by frequent recurrences in the late stage of the disease, follow-up is needed even more than 10 years postoperatively.

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Patients who had a parastomal hernia were treated with laparoscopic hernioplasty using the center band type of the composite mesh.Case 1:39-year-old man who had an ileostomy for Crohn’s disease had torus and skin erosion around the ileostomy. CT scan revealed his parastomal hernia. He was treated with the laparoscopic hernioplasty using the center band type of composite mesh. The center band area coated with the collagen membrane was attached to the ileum and covered a 7cm × 5cm of orifice by the double crown method with 3cm of marginal overlap. The patient has been followed for a year without any recurrence.Case 2:63-year-old man who had received a total cystectomy and had an ileal conduit for his cystic cancer, had a torus around the ileal conduit. CT scan revealed his parastomal hernia. He was treated with laparoscopic hernioplasty using mesh which covered a 6cm × 5.5cm orifice using the double crown method with 3cm of marginal overlap. He has been followed for a half year without any recurrence.

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A 40-year-old woman with a history of three-time pregnancy and delivery visited our department with epigastric pain and a small subcutaneous mass. Multi detector-row computed tomography (MD-CT) revealed a defect in the linea alba with 6mm in diameter and a hernia sac with 10 mm in size. Three dimensional images obtained from MD-CT clearly visualized the fascia defect and the hernia sac. Operation was performed under general anesthesia under the diagnosis as epigastric hernia. The hernia sac was the thinned peritoneum, and the hernia content was the major omentum. After replacing the omentum into the abdominal cavity, the fascia defect was simply sutured including the intact fascia around the defect. Postoperative course was uneventful, and she was discharged on the 2^nd postoperative day. She is free from recurrence for 2 year and 6 months. MD-CT analysis was very useful for the diagnosis in the present study.

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