Anterior anal fistula in female is usually low inter-sphincter fistula. Since the sphincter muscle and tension are thin in anterior side of the anus in female, attention should be paid not to damage them in surgical operation. We report here clinical utility of modified seton in surgical operation for anterior anal fistula in female. Between January 2010 and December 2012, we experienced anterior anal fistula in five female patients (24-45 years old). Their complaints were perineal pain, anal pain, and/or purulent discharge. The primary opens of fistula were located in and around the anterior dentate line, and fistula tracts extended anterior. In two patients, inflammation and abscess were affected the perineal and genital region. A rubber band was placed and tied after dissection out of the fistula tract from the secondary open to the sphincter muscle, according to the modified seton. Operation duration was 14 minutes in average, and hospital stay was 4 days. Anal fistulas were cured after surgery without any morbidity or relapse. In conclusion, the modified seton would be useful in surgical operation for anterior anal fistula in female.

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Purpose: Recent studies have reported that glycated albumin (GA) levels have can be used to monitor blood glucose control. Because the half-life of albumin is shorter than that of erythrocytes, serum GA levels better reflect shorter-term glycemic control status than glycated hemoglobin (HbA1c). We measured serum GA levels in patients who underwent surgery and analyzed the relations of such levels to preoperative co-morbidity to examine whether serum GA levels are a useful preoperative risk factor. Methods: We studied GA levels, preoperative co-morbidity, laboratory findings, and surgical procedures in adults who underwent surgery. Patients were divided into 2 groups according to whether the GA level was ≥16.5% (GAH group) or <16.5% (GAN group). Results: The study group comprised 1,258 patients. Preoperative co-morbidity of coronary artery disease occurred in 28.4% of the GAH group (n=225) and 6.5% of the GAN group (n=1,033). Preoperative co-morbidity of cerebrovascular disease occurred in 16.0% of the GAH group and 5.1% of the GAN group. There were significantly more of these preoperative co-morbidity (p<0.01) in the GAH group than in the GAN group. Conclusions: The measurement of GA levels can facilitate the early detection of diabetes mellitus in surgical patients and can also contribute to the management of perioperative complications.

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Here we present the usefulness of noninvasive reduction of obturator hernia. We studied 47 of 464 of, our and other reported cases from 2007 to 2013 in Japan. A total of 26% cases were noninvasively reduced by compression with an ultrasonic probe and manual compression, and we then checked if intestinal incarceration was reduced using imaging. These patients underwent radical surgery, electively or without general anesthesia, or minimally invasive treatment such as an inguinal approach or a laparoscopic technique. Morbidity was significantly decreased after noninvasive reduction compared with the other technique. If there is no evidence of obvious intestinal ischemia, noninvasive reduction of obturator hernia could be the first choice and a minimally invasive option for elderly patients.

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A 54-year-old female underwent resection of esophageal cancer. Because of the final diagnosis of Stage Ⅱesophageal cancer, 5-fluorouracil (5-FU) and cisplatin were chosen for adjuvant chemotherapy. After 2course of adjuvant chemotherapy, we found out a cervical lymph node reccurence. Treatment with 5-FU/cisplatin chemotherapy was restarted. On 4 course day 7, the patient presented with neurological disorders including anarthria and cerebellar ataxia. Brain MRI revealed leukoencephalopathy. After cessation of 5-FU and cisplatin, neurological symptoms diminished over 2 days. At the same time, the abnormal MRI findings are almost disappeared. Drug-induced leukoencephalopathy is known to be caused by various anti-neoplastic agents. 5-FU and cisplatin are key drugs of the several chemotherapy for solid cancer, so it is thought that we took the possibility of neurologic complications such as the leukoencephalopathy.

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Introduction: Umbilical metastasis from malignant tumors is called Sister Mary Josephʼs Nodule (SMJN), and is assumed as a sign of poor prognosis. Herein, we report one case of SMJN from breast cancer that we detected during an operation for intestinal obstruction.
Case: A 74 year-old woman. The patient had been diagnosed as having carcinoma of the breast on the right side and undergone right mastectomy and axillary lymph node dissection at the age of 65 years. She visited our hospital with the chief complaint of abdominal pain. Based on careful physical examination, she was diagnosed as having ileus due to obstruction of the small intense and was scheduled for surgery. During the surgery, evidence of malignant peritoneal dissemination with a large number of peritoneal nodules was found, and masses were also recognized in the umbilical region and small intestine. Therefore, resection of the umbilical mass and partial resection of the small intestine were performed. Histopathological examination showed umbilical metastasis and dissemination to the small intestine from breast cancer. After consulting with the patient and her family, we decided to observe the patientʼs progress under best supportive care (BSC); the patient died 168 days after the first medical examination.
Conclusion: SMJN is a rare disease, however, the possibility of SMJN should be considered in patients detected to have changes in the umbilical region during routine medical work.

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Spindle cell carcinoma of the breast is a rare variant of breast cancer. We report a rare case of spindle cell carcinoma with a rapid growth. A 41-year-old female noted a rapid growing mass in her left breast. Fine needle aspiration cytology led to a diagnosis of breast cancer. PET-CT revealed tumor which size was 4cm in her left lung. Vacuum assisted biopsy of the breast and CT-guide biopsy of lung was performed. Then she got a diagnosis of spindle cell carcinoma of the breast with lung metastasis. After 35 days after confirmed diagnosis, she passed away because of rapid progression of lung metastasis.

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Median arcuate ligament syndrome (MALS) is a rare cause of abdominal pain and weight loss, which is likely caused by compression of either the celiac artery (CA) or plexus by the median arcuate ligament. A case of MALS in a 25-year-old female with severe postprandial pain and weight loss is herein described. An imaging study demonstrated the abnormal “stealing” of the blood flow from the superior mesenteric artery (SMA) circulation through the pancreaticoduodenal arcade to the hepatic circulation, which was corrected by laparoscopic dissection of the MAL followed by percutaneous transluminal angioplasty (PTA) of the CA.

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We report 2 cases of lung cancer with combined resection of partial sternum. Case1: A 44-year-old man became aware of a painful anterior chest wall tumor and was diagnosed with lung squamous-cell carcinoma of the right upper lobe. After preoperative chemo-radiotherapy, median sternotomy was performed. Right upper lobectomy and chest wall resection of right upper quarter of the sternum were carried out. A chest wall defect was reconstructed by ePTFE sheet. Case2: A 71-year-old woman became aware of a painful chest wall tumor and was diagnosed with lung squamous-cell carcinoma of the left upper lobe. Median sternotomy was performed. Left upper lobectomy and chest wall resection of left upper quarter of the sternum were carried out. A chest wall defect was reconstructed by ePTFE sheet. This procedure proved to be satisfactory for maintaining respiration and local control of the lung cancer.

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An 80-year-old Japanese woman was referred to our hospital with anemia and abdominal distress. Upper gastric endoscopy revealed Barrettʼs esophagus, 20cm in length from the esophagogastric junction, and a type 1 tumor including poorly differentiated adenocarcinoma. Colonoscopy revealed type 2 advanced tumor including tubular adenocarcinoma in the transverse colon. These tumors were resected simultaneously using subtotal esophagectomy and right hemicolectomy. Postoperative recovery was uneventful and the patient was discharged 35 days after surgery. Histopathologic diagnoses were Barrettʼs esophageal adenocarcinoma (Mt-1 T1bN0M0-Stage I) and colon carcinoma (T-2 T3N0M0-Stage Ⅱ). Both tumors were completely resected. In Japan, the prevalence of long-segment Barrettʼs esophagus appears extremely low and the incidence of double cancer of the colon is about 5%. We report herein a case of esophageal adenocarcinoma against a background of long-segment Barrettʼs esophagus accompanied by adenocarcinoma in the transverse colon, with complete surgical resection at the same time.

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A 64 year old man was taken to an emergency room in our hospital with syncope and melena in August, 2012. An urgent upper gastrointestinal endoscopy was done. Submucosal tumor with ulceration and blood clot existed in middle part of the stomach accompanied with an early gastric cancer near it. Another submucosal tumor was represented in upper site of the stomach. We have diagnosed simultaneous existence of gastrointestinal stromal tumor (GIST) and early gastric cancer. Total gastrectomy with lymphadenectomy and resection of the spleen were performed. Histopathological and immunohistochemical study showed the both of submucosal tumors were GIST, which indicated positive for KIT and CD34. Histology of the early gastric cancer was poorly differentiated adenocarcinoma. The patientʼs postoperative course was doing well, then he was discharged from the hospital on the 17^th postoperative day. Coexistence of GIST and gastric cancer represents about 0.29 percent of resected gastric cancer, and only 29 cases have been reported in the Japanese literature. We report this case here because simultaneous existence of GIST and gastric cancer with pre-shock onset due to gastrointestinal hemorrhage is uncommon.

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A 66-year-old man presented with abdominal distention. Abdominal computed tomography (CT) showed a huge tumor 25cm in diameter that was suspected to directly invade the transverse colon and the pancreas. The patient was given neoadjuvant chemotherapy with imatinib (400mg/day) to reduce the risk of surgery and to promote functional preservation. After 24 weeks of treatment, CT revealed massive degeneration of the tumor. Sleeve resection of the stomach with partial resection of transverse colon was performed. The tumor invaded only the transverse mesocolon, and curative resection was possible without rupture. The patient postoperatively received adjuvant chemotherapy with imatinib, and there has been no evidence of recurrence as of 18 months after surgery.

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A 78-year-old man underwent distal gastrectomy for gastric cancer on September 2007. Abdominal computed tomography showed a mass lesion near the transverse colon, and CEA increased, thus he was diagnosed as having colonic metastasis of gastric cancer. After chemotherapy was started, the mass lesion became unclear, however tumor markers repeated a pattern of increase and decrease. Symptoms of ileus were shown on January 2012, therefore an operation was performed. As for the operation view, colorectal cancer was suspected, and transverse colon resection was performed. Histological examination revealed adenocarcinoma (tub, pSE, and pN0), CK7+, CK20-, CdX2-, HER2+, which was the same as the primary gastric cancer. Finally it was diagnosed as metastatic colonic cancer of gastric cancer.

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An 85-year-old man presenting with jaundice and a right upper abdominal mass was admitted. He had a history of distal gastrectomy with Billroth-Ⅱ reconstruction for gastric cancer. Computed tomography revealed a locally advanced tumor in the head of the pancreas, which invaded the third portion of the duodenum. Marked dilatation of the stump of the duodenum and intrahepatic hepatic bile duct were confirmed. Percutaneous transhepatic biliary and duodenal drainage were immediately performed via the papilla of Vater to treat acute cholangitis and prevent impending rupture of the duodenum. After the improvement of cholangitis, a duodenal metallic stent 22mm in width was placed in the stenotic site (length, 40mm) of the duodenum via the route used for percutaneous transhepatic biliary drainage. The malignant stenosis and jaundice improved, without complications. Oral intake was begun the day after stenting, and the stent remained patent during the patient's life.

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A 62-year-old woman had upper abdominal pain for two days. Abdominal CT showed pneumoperitoneum and fluid collection around the duodenum. Esophagogastroduodenoscopy revealed discharges out of juxtapapillary duodenal diverticulum. Then she underwent emergency operation under the diagnosis of perforated duodenal diverticulitis. We dissected the duodenum to find the perforation site, but were unable to detect it. The perforation site was thought to be hard to close surgically, and we decided to finish the operation by leaving drains there. After the operation inflammation had turned down, however, small amount of discharge had kept on coming out of the drain. Fistulogram showed a shadow defect in the diverticulum suggesting an enterolith, and esophagogastroduodenoscopy revealed an enterolith in the duodenal diverticulum. Endoscopic lithotomy was attempted in vain, then the patient underwent reoperation. The enterolith was removed, and plication of the duodenal diverticulum was performed. The enterolith was a true enterolith. There are 89 domestic case reports of perforated duodenal diverticulum, and 28 of those had enteroliths. Because most of true enteroliths are X-ray lucent and could be missed like our case, we must confirm existence of enteroliths in duodenal diverticulum.

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A 78-year-old woman had undergone surgical resection of a gastrointestinal stromal tumor (GIST) of the jejunum. A second intestinal resection proceeded one year later and therapy with imatinib mesylate was started due to recurrence in the superior mesenterium. However, the tumor recurred in the superior mesenterium at four years after the first operation. At that time, the patient elected to continue with internal imatinib mesylate rather than endure further surgery. The local tumor obviously increased in size and hepatic metastasis appeared at seven years after the initial surgery. The disease had progressed locally and the metastasis seemed completely resectable. We applied a curative operation comprising partial resections of the jejunum, duodenum, and hepatic segment 7. Genetic analysis of resected specimens showed that the imatinib mesylate had been effective. Considering that the patient had a history of poor compliance with medication, internal administration of imatinib mesylate was resumed. However, metastases were discovered in the thoracic vertebra at three months after the last operation. Thus, bisphosphonate was also administered internally, and MRI findings one month later showed that this combination therapy had stabilized the metastases. Appropriate therapeutic intervention should be considered even for rare bone metastasis, especially in long-term survivors of highly malignant, recurrent GIST.

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We report a case of gastrointestinal stromal tumor (GIST), which was diagnosed as an ovarian tumor preoperatively. A 67-year-old woman was found to have a pelvic tumor suspected of an ovarian tumor in computed tomography and magnetic resonance imaging, and her serum level of CA125 was elevated. In laparotomy, a dumbbell-like shaped tumor 20cm in diameter was found to being attached on the mesenteric side of the small intestine, approximately 20cm apart from the Treitz ligament. Partial resection of the jejunum containing the tumor was performed. Histopathologically, spindle-shaped tumor cells arranged in a fascicular pattern and immunohistochemically positive for KIT, were found, and the tumor was communicated with the proper muscle layer of the jejunum. The tumor was diagnosed as GIST of the small intestine with extraluminal growth. Our case is the thirteenth reported in Japan to have been diagnosed preoperatively as an ovarian tumor, but shown postoperatively to be GIST of the small intestine.

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A nonagenarian female admitted with epigastric pain and fever. She had a past history of common duct stone which had been treated by EST. Abdominal CT scan revealed a huge common duct stone causing dilatation of the common bile duct. Conservative treatment was chosen, according to the patients preference. Abdominal CT scan was performed, according to the appearance of nausea and vomiting. The CT scan showed a gallstone which had moved from the common bile duct into the short bowel, causing short bowel obstruction. We diagnosed it as gallstone ileus and inserted the long intestinal tube for treatment. No improvement was shown on the seventh day after insertion, so operation was considered. To confirm the location of the gallstone, abdominal CT scan was performed just before surgery. It revealed no short bowel obstruction, and revealed that the gallstone had moved into the rectum, therefore the operation was canceled. We report an elderly case of gallstone ileus which successfully recovered by conservative treatment. Evaluation by CT scan when clinical changes are seen, seemed to be useful for gallstone ileus to determine treatment plans including operation, especially in elderly patients.

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The patient was 69-year-old woman who had been diagnosed with polymyositis and had been receiving oral prednisolone at 10mg/day over the long term. She was referred to the emergency department for abdominal pain. Abdominal computed tomography demonstrated extra-intestinal free air. We suspected upper gastrointestinal perforation, and performed a laparoscopic examination. Redness and perforation were identified in the ileum, so ileal resection was performed. Pathological study revealed that the perforation had been caused by cytomegalovirus (CMV) enteritis. Perforation of the gastrointestinal tract by CMV infection is rare, and carries a poor prognosis because CMV infection predominantly develops in immunosuppressed patients.

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A 40 year-old man was brought into our hospital with chief complaints of upper abdominal pain and vomiting. He was diagnosed with intestinal obstruction from the findings of plain abdominal X-ray and enhanced abdominal computed tomography. After ileus tube was inserted, abdominal symptom improved. The terminal ileum stenosis was detected by the imaging. On the 7^th days from the ileus tube insertion, laparoscopic surgery was performed. During laparoscopic observation, Meckelʼs diverticulum was seen at about 50cm proximal side to the terminal ileum and the small intestine adhered to Meckelʼs diverticulum. After removal of the adhesion, resection of Meckelʼs diverticulum and partial small intestine were performed. His postoperative course was uneventful. Adult symptomatic Meckelʼs diverticulum is relatively rare, and itʼs difficult to be diagnosed preoperatively. Laparoscopic surgery is effective and feasible for intestinal obstruction of unknown origin.

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A 60-year-old woman was admitted to our hospital for examination of hepatic tumors. Abdominal computed tomography indicated ascending colon cancer and multiple liver metastases, while colonofiberscopy did not reveal a tumor in the ascending colon but detected sigmoid colon cancer. Thus, sigmoid colon resection and ileocecal resection were performed for diagnosis and treatment. On histology, the sigmoid colon cancer was diagnosed as an undifferentiated adenocarcinoma, and the terminal ileal tumor was diagnosed as a neuroendocrine tumor (NET). Postoperatively, the patientʼs serum serotonin level was high, suggesting that the liver metastases had originated from the NET. Because neuroendocrine cell tumor of the terminal ileum is rare, particularly when accompanied by advanced sigmoid colon cancer, we chose to report this case along with a review of the literature.

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A 22-year-old man required long-term hospitalization for ileus following appendectomy. During treatment, he developed high fever, and blood culture yielded Candida krusei. We assumed that the bacteremia was caused by bacterial translocation because of ileus, therefore antifungul medication was administered. Moreover, mycotic endophthalmitis was diagnosed by funduscopy, and long-term antifungul administration was required. To the best of our knowledge, this is the first case report of mycotic endophthalmitis from ileus in a young adult without underlying disease. Delayed treatment of mycotic endophthalmitis resulted in irreversible visual impairment. In cases of a high fever caused by ileus, mycotic endophthalmitis caused by bacteremia should be considered and an ophthalmologist should be promptly consulted.

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A 59-year-old woman underwent colonoscopy for anemia. The colonoscopy revealed a 10-mm protruded lesion in the cecum from the orifice of the vermiform appendix; a biopsy revealed that the lesion was a tubular adenoma. Furthermore, computed tomography revealed a tumor, 20-mm in diameter, at the vermiform appendix. Due to the possibility of an adenocarcinoma arising in the adenoma, we performed a laparoscopic appendectomy. The histological diagnosis was well-differentiated adenocarcinoma in the adenoma. Therefore, secondary resection of the colon and lymphadenectomy were not performed. There has been no recurrence for 5 years after the laparoscopic appendectomy. Primary carcinoma of the vermiform appendix is rare. It can be difficult to diagnose preoperatively because of exiguous symptoms. Carcinoma of the vermiform appendix is often found by histology postoperatively, although the surgery is performed for the diagnosis of acute appendicitis. The resection range of the colon and lymphadenectomy for early carcinoma remains controversial, and secondary resection after appendectomy should be performed for patients with early carcinoma of the vermiform appendix. This article reports the case of a patient with early carcinoma of the vermiform appendix detected by colonoscopy, who successfully underwent laparoscopic appendectomy, and also provides a review of the available literature.

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A 100-year-old female consulted a local physician due to a positive fecal occult blood test. As abdominal CT examination suggested a tumoral lesion near the transverse colon, she was referred to our department. The coronal view of abdominal CT performed at our hospital revealed circumferential wall thickening from the ascending colon to the hepatic flexure and mild dilation of the intestine on the oral side, but no liver metastasis or ascites was noted. The thickened part had invaginated into the intestine on the anal side, suggesting intussusception. Lower gastrointestinal endoscopy could not reach the tumor due to debris. Based on the above findings, with a diagnosis of right-sided colon cancer complicated by intussusception, laparoscopic surgery was performed. Intraoperatively, the ascending colon was found to have invaginated into the end of the ileum, the intestinal wall was thickened and was difficult to elevate, but right colectomy could be performed under laparoscopy. In the resected specimen, a type I tumor of the cecum had invaginated into the ascending colon, but no intestinal necrosis was observed. Emergency laparotomy is often selected for adult patients with intussusception, but elective and laparoscopic surgery could be performed in the very old patient presented here.

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Some cases of intramesenteric perforated diverticulitis of the colon can be treated by nonsurgical intervention. In our hospital, two patients with intramesenteric perforated diverticulitis of the colon underwent nonsurgical treatment. In both these patients there was no generalized peritonitis, the hemodynamics were stable, feces were not leaking from the colon, and there were no abscesses. Furthermore, lack of exacerbation was confirmed by several follow-up examinations. Both patients were treated successfully with antibiotics. Nonsurgical management of intramesenteric perforated diverticulitis of the colon is an acceptable modality for selected patients.

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A 61-year-old male visited our hospital with complaints of lower abdominal pain and bloody stools 10 months after undergoing superior rectal artery-sparing sigmoidectomy for sigmoid colon cancer. Colonoscopy showed ischemic colitis on the anal side due to anastomosis. Since the patientʼs condition did not react to conservative treatment, we performed abdominoperineal resection. In this case, arteriosclerosis, separated inferior mesenteric vein and chronic progressive scar healing were potential causes of a microcirculation imbalance in the rectum. During the first operation, it might be better to perform inferior mesenteric artery resection. In cases where the inferior mesenteric artery is preserved during lymph node dissection, surgeons must be careful to preserve the inferior mesenteric vein. We herein report a rare case of chronic progressive ischemic colitis that occurred after digestive surgery and discuss the relevant literature.

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We report here our experience of a single case of retroperitoneal hematoma that occurred during bevacizumab combination chemotherapy for advanced/recurrent colorectal cancer. The patient concerned was a 60-year-old female. Upon presentation with a chief complaint of melena, an investigation performed at our hospital led to the diagnosis of T3N2M1 Stage Ⅳ rectal cancer.
After three courses of chemotherapy with XELOX＋bevacizumab, a lower anterior resection was performed, and then XELOX＋bevacizumab therapy was restarted. On the eighth day after completing the fourth course of chemotherapy, the patient complained of headache and left abdominal pain. A subsequent CT led to the diagnosis of left retroperitoneal hematoma. Conservative medical treatment was performed in the hospital, and the patient was discharged from the hospital 15 days after administration. Serious bleeding as a complication of bevacizumab combination chemotherapy has been reported in Japan in 0.6-1.4% of patients, and in 3-6% overseas; however, this is the first reported example of retroperitoneal hematoma as a complication in Japan or elsewhere. This complication should be noted since it may be serious depending on the degree of bleeding.

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Streptococcal toxic shock-like syndrome (TSLS) is a disease with extremely poor prognosis, and can lead to shock-induced multiple organ failure. The majority of cases of TSLS are caused by the severely pathogenic group A streptococcus, while a number of studies have reported on TSLS caused by other bacteria. We report a case of TSLS due to group G streptococcus.
A 72-year-old woman had been treated with hemodialysis therapy for renal failure from chronic glomerulonephritis since 2006. She underwent pylorus-preserving pancreaticoduodenectomy in September 2013 owing to middle and inferior common bile duct cancer. Thereafter, she was admitted to our hospital because of tarry stool. Under the diagnosis of ulcer at the duodenojejunal anastomosis, we treated her with proton pump inhibitor (PPI). Her consciousness level suddenly deteriorated, and we diagnosed her as disseminated intravascular coagulation (DIC) and septic shock by blood test.
After admission to the ICU, she was treated with antibiotics and immunoglobulin, and blood purification with CHDF and hemoadsorption were started. However, she died of sepsis one day after admission to the ICU. Streptococcus dysgalactiae was detected in the blood, and Gram-positive cocci were observed around vascular access afterward.

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We report a case of long-term survival with advanced pancreatic cancer involving para-aortic lymph node metastasis treated with multidisciplinary therapy. A 56-year-old man had a pancreatic tail carcinoma (30mm in diameter) with para-aortic lymph node swelling. He underwent distal pancreatectomy with splenectomy, transverse colectomy, and adrenalectomy. Pathological findings was papillary adenocarcinoma with #16 lymph node metastasis (pT3 M1: JPS Stage Ⅳb UICC Stage Ⅳ). After surgery, he treated with gemcitabine, S-1, and he survived for 51 months. This case suggest that multidisciplinary therapy can prolong the survival of the advanced pancreatic cancer involving para-aortic lymph node metastasis by the appearance of the effective adjuvant therapy.

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A 74-year-old man was diagnosed with distal pancreatic cancer on May, 2009, and he underwent distal pancreatic splenectomy. Afterward, he received TS-1 adjuvant chemotherapy post-operatively. However, in November 2009, increased CA19-9 level was confirmed and the therapy was switched to gemcitabine (GEM) chemotherapy, starting January 2010. In June 2010, a CT exam indicated worsening local recurrence, and in February 2011, proton therapy was initiated for the local recurrence. The patient experienced vomiting of the stool in July 2011. An upper gastrointestinal endoscopy was conducted. From the results, gastrocolic fistula was confirmed, and the patient was hospitalized. In September 2011, the gastrocolic fistula after the proton therapy is diagnosed, an artificial anus was created in the ascending colon, after which, vomiting disappeared. It was thought that the gastrocolic fistula was closed. In January 2013, the recurrence of pancreatic cancer was confirmed from the biopsy results of the trauma scar tissue of the fistula by upper gastrointestinal endoscopy examination. The patient continued GEM chemotherapy.

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A 26-year-old woman was found to have pancreatic body mass at another hospital and she was admitted to our hospital. CT showed a poor enhanced mass with a clear boundary in the pancreatic body. MRI showed the pancreatic lesion as a low intensity on a T1 weighted image and a high intensity on a T2 weighted image. A solid pseudopapillary neoplasm (SPN) of the pancreatic body was diagnosed, and laparoscopic spleen preserving distal pancreatectomy was performed. The postoperative course was uneventful, and the patient was discharged from the hospital on the 12^th postoperative day. Laparoscopic spleen preserving distal pancreatectomy is a minimally invasive and useful method for SPN.

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A 32-year-old woman had been seen at another hospital due to the onset of upper abdominal pain. The patient was thereafter transferred to our hospital with a preliminary diagnosis of splenic cyst. Abdominal CT revealed a well-defined and homogeneous cystic lesion measuring 8cm in diameter in the spleen, and the serum CA19-9 level was found to be elevated to 50.5U/ml. No apparent malignancy was identified by imaging, and therefore the final diagnosis was a CA19-9 producing splenic cyst and laparoscopic dome resection was thus performed. The cystic fluid was brownish, and the CA19-9 level in the cystic fluid was elevated to 2,168,500 U/ml. A histopathological diagnosis indicated it to be a true cyst. The serum CA19-9 level was found to decrease to 45.9U/ml after the operation. The patientʼs postoperative course was uneventful, and she was discharged from the hospital on the 8th postoperative day. She is currently doing well without any recurrence at 3 months after surgery. We herein describe a case of a CA19-9 producing splenic cyst that was successfully treated by laparoscopic dome resection.

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A 66-year-old woman underwent laparoscopic low anterior resection and ileostomy for rectal cancer. She had no family history of colorectal cancer, and no polypoid lesions were seen on preoperative colonoscopy. The patient received adjuvant chemotherapy using oral uracil/tegafur (UFT)/oral leucovorin (LV) for 6 months, and then stoma closure was done. Follow-up computed tomography (CT), done 12 months after primary surgery, showed two softtissue density masses around the abdominal aorta and in the mesentery near the ileocecum. We performed laparotomy and investigation of the biopsy revealed the intra-abdominal tumor, and the diagnosis was desmoid. She rejected for operation and the tumor continued to progress. 4 months later operation was performed, and pathological diagnosis showed desmoid. She has shown no sign of reccurence in the 1 year follow-up since surgery. This is a rare case of multiple intra-abdominal desmoid tumors without familial adenomatous polyposis occurring after laparoscopic surgery.

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A 71-year-old female who had been followed in our hospital for Stage IE gastric MALT lymphoma was found to have a 15mm diameter tumor in the retroperitoneal area in July 2011, and the tumor had enlarged to 26mm in diameter by December 2011, as detected during a periodic CT examination.
The tumor came in contact with the left ureter, but with no tissue invasion, and the vasa vasorum on positron emission tomography (PET/CT), there was mild FDG uptake by a tumor (SUVmax 2.3).
The retroperitoneal tumor was resected by laparoscopic surgery in March 2012.
The operation was started with five ports, and the tumor was confirmedat the retroperitoneum, outside of the ureter. After clipping both the superior and inferior vasa vasorum, the tumor was easy to remove. The histopathological diagnosis was leiomyosarcoma, and the size was 46×26×24mm.
Leiomyosarcoma is a rare neoplasm of the retroperitoneum, and it is difficult to diagnose preoperatively. Laparoscopic surgery is useful for the diagnosis and treatment of such tumors.

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An 86-year-old man underwent radical resection of retroperitoneal dedifferentiated liposarcoma. Follow-up computed tomography 2 years after the radical resection revealed a left lung tumor. The histological diagnosis of the resected lung tumor was not a metastatic lung tumor, but a solitary fibrous tumor. Follow-up computed tomography 6 months later revealed a lower-back body wall tumor. The lower-back body wall tumor was surgically resected because it had grown from 1 to 6cm in diameter during the year after its detection. The histological diagnosis of the tumor was lower-back body wall metastasis from the retroperitoneal dedifferentiated liposarcoma. The patient survived without recurrence for 6 months after resection of the metastatic tumor. Surgical resection of a metastatic tumor from retroperitoneal liposarcoma may allow for long-term survival of select patients.

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