Objective: Malignant tumors of the small intestine are uncommon. There are few reports of clinical reviews, therefore, we analyzed the data of cases of small intestinal malignant tumors operated at our hospital.

Methods: We conducted a retrospective analysis of zed the clinical and pathological characteristics of cases of small intestinal malignant tumors operated at our institution from June 2007 to October 2016.

Results: There were 26 cases. The mean age was 66.0 ± 14.0 years and 16 of the patients were female. Of the 26 cases, 25 had symptoms, as follows: abdominal pain in 14 cases, vomiting in 5 cases, palpable abdominal tumor in 3 cases, lower blood in 2 cases, and anemia in 1 case. Preoperative diagnosis could be established in 9 cases. The tumor was located in the jejunum in 14 cases, in the ileum in 9 cases, and the tumor location was unknown in 3 cases. Histologically, 9 cases were diagnosed as gastrointestinal stromal tumor (GIST), 6 as malignant lymphoma, 6 as metastatic small intestinal tumor, and 5 as small intestinal cancer.

Conclusion: Small intestinal malignant tumor may cause intestinal obstruction or perforated peritonitis, carry a poor prognosis and should be included in the differential diagnosis of such condition.

Objectives: The present study was performed to examine operative cases of perforated diverticulitis and to consider the corresponding treatments.

Methods: In the 10-year period from January 2007 to December 2016, 20 cases of perforated sigmoid diverticulitis were treated surgically in our hospital. We examined the background factors, physical findings, preoperative diagnoses, surgical findings, and postoperative courses.

Results: Twenty patients with sigmoid colon diverticulitis, eleven males and nine females with a median age of 67.5 years (25 to 87 years), were included in the analysis. Preoperative complications included chronic kidney failure, including post-transplantation failure in 4 cases (20%), among others. Surgery was performed using open methods, including 15 patients who underwent the Hartmann procedure and 5 patients who underwent colon resection or suture closure with stoma construction. Among the postoperative complications, stoma dropout, deep venous thrombosis with pelvic abscess formation, pneumonia, and wound dehiscence were detected in one case each. Postoperative polymyxin-direct hemoperfusion (PMX-DHP) was effective in 2 cases (10%). No deaths occurred.

Conclusions: For perforated sigmoid diverticulitis, we performed colon resection or suture closure with stoma construction by open methods. The postoperative course was relatively favorable.

We retrospectively analyzed the clinical outcomes of unresectable metastatic colorectal cancer patients who received late-line therapy. We collected medical records data from 41 patients who underwent late-line treatment with regorafenib and / or trifluridine / tipiracil (TFTD) between July 2013 and December 2016. There were no significant differences in overall survival and progression-free survival of patients who first received regorafenib (n=25) vs. those who first received TFTD (n=16). Nineteen patients who received both of regorafenib and TFTD experienced significantly longer overall survival than 22 patients who only received one drug (median: 20.8 months vs. 6.4 months, p= 0.02). Our data suggest that administration of both regorafenib and TFTD as late-line chemotherapy for colorectal cancer may prolong patient survival times.

Radical resection for esophageal cancer is a highly invasive operation, and patients often develop serious postoperative complications, such as arrhythmias; therefore, perioperative care for such complications is particularly important. In our case series, among 141 patients who underwent radical resection for esophageal cancer, 19 developed tachyarrhythmias. The rate of occurrence of tachyarrhythmias was higher in patients with electrocardiographic abnormalities or circulatory diseases before the operation (p = 0.0001, 0.006). Landiolol hydrochloride, a short-acting β1 selective blocker, was administered in 12 of the 19 patients, and sinus rhythm was immediately restored on the electrocardiogram in 10 of the 12 patients. Neither reduction of the blood pressure nor deterioration of the respiratory status was observed. For controlling perioperative tachyarrhythmias in patients with esophageal cancer, we consider landiolol hydrochloride as a safe and effective drug, and its use is expected to increase.

Purpose： The standard operation for inguinal hernia in adults is tension-free repair. Surgical site infection complicating this operation is uncommon; however, once it occurs, it may be difficult to cure. We analyzed the effect of antibiotic prophylaxis on the rate of occurrence/control of SSI associated with this operative method and present the results herein.

Method: We divided 88 cases that underwent surgery for unilateral primary inguinal hernia (mesh repair) from October 2011 to July 2015 at our hospital into a group that received antibiotic prophylaxis (prophylaxis(+) group; 33 cases) and another that did not receive antibiotic prophylaxis (prophylaxis(-) group;55 cases), and compared the incidence of SSI between the two groups. We also compared the background characteristics such as the age, degree of obesity, duration of surgery, and amount of bleeding between the two groups.

Results: There were no significant differences in the background factors between the two groups. Although SSI was found in three cases of the prophylaxis(-) group, the difference in the incidence of SSI between the two groups was not statistically significant.

Conclusion: Although there was no significant difference in the incidence of SSI between the two groups, the incidence rate of SSI tended to be lower in the group that received antibiotic prophylaxis.

Retropharyngeal hematoma is a rare and life-threatening due to the rapid progression of airway obstruction. We herein report a case of exacerbation of retropharyngeal hematoma after initial improvement.

We report the case of a 93-year-old woman who presented to the emergency department complaining of anterior neck swelling. She was diagnosed as retropharyngeal hematoma without a preceding traumatic injury or coagulopathy. Computed tomography (CT) scan showed a hematoma extending from the retropharyngeal to the superior mediastinal space and slight extravasation near the right vertebral artery. She was conservatively managed at the intensive care unit, with improvement in neck size. On post-admission day 21, she suddenly developed dysphagia followed by dyspnea, her oxygen saturation decreased rapidly, and emergency tracheostomy was performed. A CT scan revealed exacerbation of the retropharyngeal hematoma. Twelve days after exacerbation, she moved to the general ward because her condition became stable. On post-admission day 60, she developed bacterial pneumonia, which worsened her respiratory condition. On post-admission day 80, she died of bacterial pneumonia.

On encountering elderly patients with retropharyngeal hematoma-associated airway obstruction without preceding traumatic injury or coagulopathy, airway management and monitoring for hemorrhage are essential.

Descending Necrotizing Mediastinitis (DNM) is a fatal infection that typically arises from an upper respiratory tract infection or odontogenic infection. Although the mortality rate was high in the past, advances in medicinal care have improved the treatment outcomes. The patient was a 38-year-old male who was referred to our hospital with the diagnosis of cellulitis in the left neck and mediastinal abscess by his local doctor. On the same day, drainage was carried out in the deep neck and superior mediastinum. Treatment with antimicrobial agents targeting any resident flora in the oral cavity was initiated, along with intensive care, including intubation. Contrast-enhanced CT on day 7 of the disease day revealed a persistent abscess in the left neck and thrombosis of the left internal jugular vein. Upon confirmation of disappearance of the abscess and thrombus, the patient was discharged on day 27 after disease onset. Herein, we report, along with a review of the literature, a case of DNM associated with infectious thrombosis of the internal jugular vein.

A 50-year-old man visited our hospital while complaining of a left-sided chest pain and right ankle pain after falling from a height of 1.5 m. A chest X-ray showed multiple fractures of the left ribs, a left pneumothorax, and a fracture of the lateral malleolus of the right ankle. Chest tube drainage was performed for the pneumothorax. On the 3rd hospital day, the chest tube was removed. Immediately after the removal of the chest tube, he began complaining of chest pain and dyspnea. A chest CT showed a massive hemothorax. An emergency operation was performed. A large amount of hematoma and blood was seen in the left thorax. Bleeding at the edge of the fractured 7th rib was also observed. After the removal of the hematoma, hemostasis was performed. He was discharged on the 15th postoperative day without complications. Hemothorax after chest trauma is not a rare complication, but delayed hemothorax is uncommon. Here, we report a patient who experienced a massive hemothorax after the removal of a chest tube and provide a review of the applicable literature.

A 77-year-old woman with a long history of esophageal hernia and consequent difficulty in swallowing, presented with progressively worsening dysphagia and elected to undergo hernia repair. An elective laparoscopic esophageal hernia repair was planned. Preoperative computed tomographic examination revealed a huge esophageal hernia with an upside-down stomach, that is, an organoaxial volvulus, wherein the stomach had almost entirely entered the mediastinum. The hernia orifice was repaired with a laparoscopic running suture, and Nissen fundoplication was performed. No recurrence has been observed until 18 months postoperatively. Esophageal hernia is common, especially among middle-aged women; however, cases of hernia with an upside-down stomach are rare. Such cases can sometimes develop fatal complications, for example, necrosis and perforation of the stomach. Thus, early treatment intervention is needed. As a prolapsed stomach and wide esophageal hernial orifice can be treated laparoscopically, laparoscopic surgery is useful in such cases.

The patient was a 70-year-old man. During follow-up for chronic pancreatitis, he was found to have branch-duct intraductal papillary mucinous neoplasm (IPMN) in the head of the pancreas. In accordance with the cyst size and presence of an internal solid component, subtotal stomach-preserving pancreaticoduodenectomy with pancreatogastrostomy was performed. The lesion was diagnosed by histopathology as an IPMN. Upper gastrointestinal endoscopy performed 2 years after the surgery revealed a submucosal 0-I tumor measuring approximately 30 mm in diameter in the posterior wall of the middle part of the gastric corpus, which was diagnosed by biopsy as an adenocarcinoma. Findings of upper gastrointestinal endoscopy and computed tomography indicated that the pancreas-stomach anastomosis and type 0-I tumor were separated by a distance of 3 cm by intervening normal mucosa; the tumor was thus diagnosed as a remnant gastric cancer, and local resection was performed. The patient has been followed up without recurrence for 5 years after the pancreaticoduodenectomy and 3 years after the local gastric resection. Although long-term survival can be expected in patients with IPMN after pancreaticoduodenectomy, some cases of newly occurring metachronous multiple primary cancer in the residual stomach have been reported. Therefore, careful postoperative follow-up focusing on the residual stomach is important.

A 75-year-old woman was admitted to our hospital several times over the past several years for acute gastric dilatation. She presented with similar symptoms each time. Abdominal CT demonstrated gastric dilatation, and the stomach appeared upside-down, with the antrum and pylorus superior to the fundus and proximal body. After decompression with a nasogastric tube, her symptoms resolved and she resumed oral intake. In the present admission, she presented with abdominal distension again, and a nasogastric tube was inserted for decompression. The gastric contents were bloody, and gastrointestinal endoscopy was performed, which demonstrated bloody debris and gastric volvulus. Bleeding was found to originate from the fundus, which was controlled by clipping. However, endoscopic detorsion of the volvulus was not successful, and emergency laparotomy was performed. The hepatoduodenal ligament was found to be defective and the duodenum was not fixed. Transomental hernia was identified, with strangulation of the gastric body. After detorsion of the volvulus, the defect of the omentum was repaired and gastropexy was performed. The patient had a good postoperative course, and has remained free from recurrence for the past 5 years. To the best of our knowledge, this case is the first case of idiopathic gastric volvulus accompanied by a defect in the hepatoduodenal ligament and transomental hernia reported in the Japanese literature.

A 63-year-old female patient admitted to another hospital for generalized fatigue 2 months ago was referred to our hospital for further management after being diagnosed as having anemia. Examination revealed a submucosal tumor in the second portion of the duodenum, which was diagnosed as a duodenal GIST (gastrointestinal submucosal tumor). Partial resection of the duodenum was performed, with jejunal serosal patch used for the repair procedure. Histopathological examination of the resected specimen revealed a duodenal GIST. Gastrointestinal endoscopy performed 12 months after the operation showed scarring of the patched lesion. At 29 postoperative months, no signs of recurrence were observed, and the patient was in a favorable condition. We usually employ jejunal serosal patch repair in cases of duodenal trauma. This method appears to be useful and worthy of consideration also in patients with duodenal tumors.

A 68-year-old man visiting a neighborhood clinic with a history of epigastric pain and generalized fatigue was diagnosed as having anemia and referred to our hospital for further examination. Abdominal computed tomography revealed a tumor in the small intestine and invagination caused by the tumor. Colonoscopy also showed an ileal tumor. Histologically, the findings of the biopsy specimen were consistent with the diagnosis of leiomyosarcoma of the small intestine. The invaginated small intestine involving tumor was surgically resected. The tumor cells were immunohistochemically positive for desmin and α SMA; the tumor showed a high Ki 67 index. The tumor was finally diagnosed as leiomyosarcoma of the small intestine. There has been no local or distant recurrence until date, 28 months after the surgery.

The patient was a 69-year-old female with cecal cancer, with a single subcutaneous metastasis. After the operation for the cecal cancer and nonmalignant tumors of the uterus and ovaries, the patient received 8 courses of capecitabine alone. One year eleven months later, a subcutaneous tumor appeared in the left anterior chest wall. It was a slow-growing tumor, and we performed complete resection of this tumor two years four months after the first operation. Histopathological examination of the resected specimen revealed the diagnosis of subcutaneous metastasis from the cecal cancer. After the second operation, no chemotherapy was administered, and the patient remains alive at one year. Skin and subcutaneous metastases from visceral cancers appear to be a part of systemic metastasis in cases of advanced cancer. The prognosis is generally poor, although cases of long-term survival have been reported. Reported herein is one of those patients that showed prolonged survival after surgical resection. We think that the patient will hopefully show a good prognosis as the lesion was a single skin or subcutaneous metastasis that was slow-growing.

The patient was a 68-year-old male who had undergone subdural-peritoneal shunt implantation at another hospital for a chronic subdural hematoma. Ten years later, he visited our hospital complaining of fever. An abdominal CT showed that the S-P shunt tube had penetrated into the descending colon. A head MRI showed a brain abscess in the right frontal lobe and right subdural abscesses, which were thought to have been caused by retrograde infection by intestinal bacteria. In the first operation, the brain abscess and subdural abscesses were enucleated and the subdural shunt tube was removed. In the second operation, the peritoneal shunt tube was removed and the descending colon was repaired by laparoscopic surgery. The treatment proved safe and successful.

A metastatic tumor of the umbilicus is called “Sister Mary Joseph Nodule”, and patients with this tumor show a poor prognosis. Sister Mary Joseph nodule is a rare occurrence, and there are few case reports. We report a case of colorectal cancer in which the patient first presented with the metastatic tumor in the umbilicus. A male patient visited a neighborhood clinic because of a bleeding umbilical tumor, which he had first noticed about three months earlier. At first, the umbilical tumor was diagnosed as omphalitis, and the patient was referred to our hospital. We performed biopsy of the umbilical tumor, and the findings revealed an adenocarcinoma. Abdominal CT showed wall thickening in the descending colon. Therefore, we performed lower gastrointestinal endoscopy, which revealed a colorectal tumor in the descending colon. We performed biopsy of the tumor and the findings were consistent with adenocarcinoma. Based on these results, we diagnosed the umbilical tumor as a metastasis from the colorectal cancer. We performed umbilical resection and colectomy, and the postoperative course was uneventful. After the operation, the patient received chemotherapy. This case serves to emphasize that in a patient presenting with an umbilical tumor, we must consider the possibility of Sister Mary Joseph Nodule, and perform a detailed examination to detect malignancy.

A 45-year-old male who had been treated conservatively for sigmoid colon diverticulitis presented with ileus. A transanal ileus tube was inserted to treat the ileus and then perform laparoscopic surgery. On the following day, the patient’s condition worsened and an emergent operation was performed. The tip of the ileus tube had entered the ileum through a coloileal fistula. We performed sigmoidectomy and ileocecal resection, with a double-barrel ileostomy. Sigmoid diverticulitis causes fistula formation with the surrounding organs, and a few cases of development of a coloileal fistula have been reported. Transanal drainage is a common technique for treating ileus associated with lesions of the rectum or sigmoid colon. In the X-ray obtained after the insertion of the ileus tube, the transanal ileus tube was not detected in the ileum. Fistula formation must be kept in mind when transanal drainage is performed for ileus caused by colon diverticulitis.

A 33-year-old woman with recurrent lower abdominal pain related to her menstrual cycles consulted a local doctor for infertility treatment. Abdominal computed tomography revealed a tumor in the sigmoid colon, and she was referred to our hospital for evaluation. Histopathological examination of an endoscopic ultrasound-guided fine needle aspiration biopsy revealed endometrial glands and stroma within the sigmoid colon. We made the clinical diagnosis of endometriosis of the sigmoid colon, and performed laparoscopic surgery. The operative findings showed several blueberry spots on the surface of the pelvic wall. We ablated most of the blueberry spots and removed a chocolate cyst from the right ovary. Macroscopic examination of the resected specimen revealed stenosis with adhesion and bending by the mass-forming endometriosis was seen at the sigmoid colon. A partial sigmoidectomy was performed. A histopathological examination revealed endometrial glands and stroma from the submucosa to the subserosa of the sigmoid colon.

Case 1: A 60-year-old male patient, who was diagnosed as having sigmoid colon cancer, underwent laparoscopic excision of the sigmoid colon. Since the development of a disseminated tumor in the mesentery proper was suspected, based on the results of a CT examination performed during the postoperative follow-up period, we performed a partial resection of the small intestine and surgical removal of the tumor. Pathologically, the resected tumor was diagnosed as an intraabdominal desmoid tumor.

Case 2: A 47-year-old male patient, who was diagnosed as having rectal cancer, underwent a laparoscopic low anterior resection. Since lymph node metastasis of the tumor at the dissection site of the superior rectal artery was suspected, based on the results of a CT examination performed during the postoperative follow-up period, we performed a tumorectomy. Pathologically, the resected tumor was diagnosed as an intraabdominal desmoid tumor.

Intraabdominal desmoid tumor is a relatively rare disease that develops as a consequence of mechanical stimulation during abdominal surgery. The onset of intraabdominal desmoid tumor following laparoscopic surgery, which is believed to be characterized by less mechanical stimulation, is rare. Herein, we report our experience treating 2 cases of intraabdominal desmoid tumors that developed after laparoscopic surgery for colorectal cancer.

Intestinal malrotation is a congenital anomaly caused by the abnormal rotation and fixation of the gut during embryogenesis. We herein report a case of rectal carcinoma with intestinal malrotation in an adult. A 51-year-old woman was admitted for an additional resection of rectal carcinoma after an endoscopic mucosal resection (EMR). An abdominal contrast-enhanced CT examination was performed to visualize the EMR-treated area because of the presence of endoscopic clips in the lower abdomen. Moreover, the superior mesenteric vein was located to the left of the superior mesenteric artery. Based on these findings, we diagnosed the patient as having a rectal carcinoma with intestinal malrotation. Thus, the patient underwent a laparoscopic high anterior resection with D2 lymph node dissection. The postoperative course was uneventful. Abdominal contrast-enhanced CT was useful for preoperative diagnosis, enabling laparoscopic surgery to be performed in a patient with intestinal malrotation.

A 72-year-old woman underwent colonoscopy due to a positive fecal immunohistochemical test. A 0-Ⅱa+Ⅱc type tumor, measuring 25 mm in diameter, was identified in the anterior wall of the lower rectum. The tumor showed a VN-type pit pattern and non-lifting sign on endoscopy, and the patient was diagnosed as having invasive cancer involving the submucosal layer. Preoperative computed tomography (CT) revealed situs inversus totalis. We performed laparoscopic low anterior resection with D2 lymph node dissection and covering transverse colostomy. Preoperative three-dimensional CT angiography for blood vessel mapping, CT colonography, and image training enabled safe performance of the laparoscopic procedure.

We report a case of early-onset post-pancreatoduodenectomy (PD) hemorrhage (PPH) caused by a pseudoaneurysm, which was successfully treated by transcatheter arterial embolization to avert fatal hemorrhage. A 75-year-old man with bile duct cancer underwent PD. On the second postoperative day (POD), sentinel bleeding occurred from a drain. Emergency abdominal angiography revealed a pseudoaneurysm in the dorsal pancreatic artery, which was embolized using Lipiodol.

A review of 76 cases of PPH reported previously in the Japanese literature revealed that sentinel bleeding occurred in 54%, a concomitant pancreatic fistula was detected in 63%, hemorrhage from around the pancreatic anastomosis was observed in 66%, and a pseudoaneurysm in 70%, respectively. The median interval time from surgery to PPH was 17 POD (range;1-372 POD). The incidence of early-onset PPH within 7 POD was 16 % among the cases for which data were available.

In conclusion, attention should be paid to sentinel bleeding, even if it is of early onset, so as not to miss cases with potentially fatal PPH.

A 71-year-old man was admitted to our hospital with severe abdominal pain and was diagnosed as having acute pancreatitis. After further examination, he was also diagnosed as having a branch-duct type of IPMN. Since the pancreatic cystic tumor showed some worrisome features and the patient was a heavy drinker, he was given some temperance guidance. Although he completely stopped drinking, the pancreatitis recurred four months later, with the IPMN suspected as the cause of the pancreatitis. We performed subtotal stomach-preserving pancreatoduodenectomy. We injured the right hepatic artery during the operation and sutured it for hemostasis. Postoperatively, a pancreatic fistula developed and the patient presented with chest pain followed by melena on the 16^th postoperative day. Esophagogastroduodenoscopy (EGDS) revealed a small ulcer with an exposed artery in the region of the gastrojejunostomy and clipping was performed for hemostasis. However, melena following chest pain recurred on the 19th, 29th and 32th days, suggesting the existence of an association between the chest pain and melena. Therefore, we performed enhanced chest CT immediately after the patient complained of chest pain on the 37th day, which revealed extravasation from the right hepatic artery into the jejunum． We performed angiography and made the diagnosis of penetration of the right hepatic artery aneurysm into the jejunum. Then, we successfully performed transcatheter arterial embolization of the right hepatic artery.

A 63-year-old woman had been under observation for an intraductal papillary mucinous neoplasm (IPMN) in the pancreatic tail for about a year. Endoscopic ultrasonography (EUS) showed a nodular lesion in the IPMN in the pancreatic tail. Then, a new cystic mass with a nodular lesion in the pancreatic head was also observed. Intraductal papillary mucinous carcinoma (IPMC) in the pancreatic head and tail were diagnosed, and a middle-segment preserving pancreatectomy (MSPP) was performed. The length of the remnant pancreas was approximately 4 cm. Histologically, the tumors in the pancreatic head and tail were due to invasive IPMC. She had no pancreatic fistula and was able to maintain a favorable glucose tolerance. She was discharged from the hospital on the 28th postoperative day. The patient was alive with no signs of recurrence at 14 months after surgery. We herein report a case of MSPP for IPMC in the pancreatic head and tail, with the addition of some bibliographical considerations.

A 72-year-old woman had undergone subtotal esophagectomy with gastric tube reconstruction for esophageal cancer. In addition, she had been diagnosed as having a branch-duct type of intraductal papillary mucinous neoplasm (IPMN) of the pancreas head. Eight years after the operation, the serum CA19-9 level was slightly elevated. MRCP showed stenosis of the main pancreatic duct, and endoscopic ultrasound showed a low-echoic mass measuring 8 mm in diameter in the narrow segment of the main pancreatic duct near the IPMN. The surgical anatomy of the vessels around the head of the pancreas and the gastric tube was evaluated in reconstructed images of 3D-CT angiography performed preoperatively. To preserve the blood flow to the gastric tube, we performed pylorus-preserving pancreaticoduodenectomy with prevention of the gastroduodenal artery, right gastroepiploic artery and vein, and right gastric artery and vein. Histopathological examination of the resected specimen revealed invasive intraductal papillary mucinous carcinoma (IPMC), plus an intraductal papillary mucinous adenoma. We report a case of IPMC in which gastric tube-preserving pancreaticoduodenectomy was performed safely after esophagectomy.

Some insulinomas are difficult to localize preoperatively and the tumors are often multiple. Herein, we report a case of pancreatic insulinoma in which preoperative localization proved difficult. The patient was a 37-year-old woman who presented with a history of frequent attacks of hyperhidrosis and consciousness disturbance. She was diagnosed as having insulinoma, however, imaging studies failed to enable localization of the tumor. Then, we performed a selective arterial calcium injection test, in which insulin uptake was recognized in the splenic artery and transvers pancreatic artery branching from the gastroduodenal artery. Based on the findings, we estimated that the tumor was localized in the dorsal pancreatic area. We performed distal pancreatomy with intraoperative intermittent insulin monitoring. After resection of the tumor-feeding arteries, we recognized both fall of the insulin levels and elevation of the blood sugar levels. Histopathological examination revealed the diagnosis of pancreatic neuroendocrine tumor (G1, insulinoma). We could estimate that the tumor might be localized in the dorsal pancreas by performing a preoperative SACI test. In addition, intraoperative insulin monitoring was useful for the tumor resection.

A 69-year-old female patient who had undergone total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection for endometrial carcinoma four years earlier, was diagnosed as having sporadic liver and spleen tumors during adjuvant chemotherapy. We decided to perform resection of the liver and spleen tumors, because there were no other metastases. Histopathologically, the tumors were diagnosed as metastases from the endometrial carcinoma. Until now, 9 months after the operation, the patient remains alive without any evidence of disease recurrence.

A 47-year-old woman underwent caesarian section at the age of 23 and 33. Subsequently, she underwent another operation for an umbilical hernia and abdominal-wall tumor of umbilicus when she was 39 years old. Abdominal-wall endometriosis of umbilicus was diagnosed based on the results of pathological examination. There was no post-operative recurrence. At the age of 44 years, two abdominal-wall tumors with cyclical lower abdominal pain were observed in the lower abdominal region. She presented with pain at our hospital and had a palpable abdominal-wall tumor along the caesarian section scar. Tumors were another legions at the age of 39 years. Contrast-enhanced computed tomography revealed that the two tumors had invaded the rectus abdominis muscle. Both tumors were 35 mm in size. Magnetic resonance imaging revealed blood component into tumors. We suspected abdominal-wall endometriosis based on these findings. Core-needle biopsy was not performed due to the risk of re-implantation and dissemination. Surgical excision was used to remove the tumors along with some surrounding tissues. Pathological analysis revealed that the tumors consisted of endometriosis with glands and endometrial stroma. Approximately 79％ of abdominal-wall endometriosis occurs in the operative scar after a caesarian section.　 As there are no treatment guidelines, wide excision with normal tissue surrounding the tumor is recommended.

A 96-year-old woman was brought to our emergency department with a history of right lower abdominal pain of sudden onset. Because the symptoms did not improve, abdominal contrast-enhanced computed tomography was performed; based on the findings, the patient was diagnosed as having strangulation of the small bowel due to a paracecal hernia, and emergency surgery was performed. A 10-cm segment of the ileum was found to be strangulated in the retrocecal fossa. The hernia orifice was opened, and the necrotic segment of the ileum was resected. The postoperative course of the patient was uneventful and the patient was discharged on postoperative day 20. Paracecal hernia is relatively rare, and preoperative diagnosis is often difficult. We report this case with a review of the literature.