Background: A perforation is a serious, potentially fatal complication of gastroduodenal ulcers. The incidence of perforated gastroduodenal ulcers has not decreased, althoughugh evidence shows a decrease in the surgery for gastroduodenal ulcers after an H2-receptor blocker is used. We studied risk factors related to operative mortality in perforated gastroduodenal ulcer patients. Methodology: From January 1983 to August 2001, 92 patients with perforated gastroduodenal ulcers underwent emergency surgery at our clinic. We studied; performance status (PS), medical illness, preoperative risk factor, surgical procedure, and postoperative morbidity. Results: Factors correlating significantly with mortality were age (p=0.0036), PS (p<0.0001). perforation size (p=0.0008), the time from onset to operastion (p=0.016), severe preoperative complication in either the liver (p=0.0008) or kidney (p<0.0001), and active malignancy (p=0.0059). Mortality in patients with postoperative complications such as anastomotic leakage (p<0.0001) or bleeding inthe gastrointestinal tract (p=0.0008) was significantly high. No significant correlation was seen between mortality and surgical procedure. Multivariate analysis indicated that a patientk's likelihood of death could be predicted using 5 variables: preoperative risk factor, postoperative anastomotic leakage/bleeding in the gastrointestinal tract, PS, perforation size, and the time from perforation to operation. A significant correlation was also seen between preoperative condition and postoperative anastomotic leakage/bleeding the the gastrointestinal tract. Patients outcome after operation for a perforated ulcer thus depends on preoperative condition of the patient and appears to be independent of surgical procedures.

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A 13-year-old girl admitted for a left-upper abdominal mass was found in abdominal ultrasonography and computed tomography to have a heterogeneous mass on the tail of the pancreas, 80mm in diameter, Abdominal magnetic resonance imaging showed high intensity in T2 weighted imaging, and abdominal angiography showed a hypovascular tumor without invasion to the splenic artery. We found splenic vein obstruction and collateral blood flow via the left gastroepiploic vein. Endoscopic retrograde cholangiography and pancreatography showed compression and flection of the main pancreatic duct of pancreatic body and tail without interruption. She was operated on to remove a solid cystic tumor of the pancreatic tail. The capsulated tumor showed no other organ invasion but the splenic artery and vein were adhered tightly due to inflammation, and collateral blood flow via the left gastroepiploic vein involved obstruction of the splenic vein. We conducted spleen-preserving distal pancreatectomy with splenic vein resection. The resected specimen was a 90×90×85mm tumor with a small lobular pattern and slit but without cystic area. The tumor was confirmed to be sold cystic tumor in microscopically and immunostaining. Such a case is rare and offers insights into diagnosis and surgical procedures because, despite being benign, the tumor obstructed the splenic vein and caused collateral blood flow formation.

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A 55-year-old woman with stage IV b pancreatic body and head carcinoma undergoing pancreatic tumor resection and postoperative irradiation experienced recurrence at the left cervical lymph node and underwent radiation therapy. She has remained diseasefree in the 8 years since surgery. It seemed that the long time survival reasons were the surgical resection for no residual tumor and postoperative irradiation. This shows that patients with stage IV b pancreatic carcinoma and progressive local or lymphatic spread but no liver metastasis or venous invasion, may experience long time survival after pancreatic tumor resection and postoperative irradiation.

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A 60-year-old man with upper abdominal pain admitted June 3, 2001, was found in ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) to have diffuse dilation of the dorsal pancreatics duct. Endosdcopic retrograsde pancreatography (ERP) showed pancreas divisum. Conservative therapy was ineffective and no stenosis of hte accesory papilla was found in ERP, so we conducted side-to-side pancreaticojejunostomy. Four weeks after surgery, the man was idscharged. Side-to-side pancreaticojejunostomy is an alternative surgical therapy for dorsal pancreatitis complicated by pancreas divisum.

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An 18-year-old woman with intraluminal duodenal diverticulum (IDD) and chronic obstructive pancreatitis suffered occasional nausea and had a 6-year history of episodes of increasingly upper abdominal pain. Upper gastrointestinal radiography showed a pocket-like lesion extending caudally in the second portion of the duodenum. Magnetic resonance cholangiopancreatography revealed stricture of the main pancreatic duct at the pancreatic head and upstream dilation. A preoperative diagnosis of IDD and chronic obstructive pancreatitis was made, necessitating excision of the IDD at duodenotomy and a Roux-Y lateral pancreaticojejunostomy. Symptoms completely disappeared and pancreatic exocrine function recovered to within normal ranges. In the literature, 18 cases of pancreatitis combined with IDD have been reported thus far and most were treated with excision of the IDD surgically or endoscopically. In our case, pancreaticojejunostomy was needed to eliminate pancreatitis, because stricture of the pancreatic duct was present at the fusion of forsal and ventral pancreatic ducts. Such strictures have been reported mostly associated with congenital anomalies. We concluded that chronic obstructive pancreatitis with IDD was caused by incomplete fusion of the pancreatic ducts.

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Stercoral perforation of the colon is rare, and is usually found in the rectosigmoid region. We report stercoral perforation of the ascending colon. A 77-year-old man, who had a right lower lobectomy 9 months previously for lung cancer, was admitted due to pneumothorax, and a chest tube was put in place. He suffered sudden abdominal pain 2 days after admission. Abdominal radiography showed free air under the diaphragm. Abdominal computed tomography (CT) showed impressive dilation of the ascending colon, which contained massive amounts of stool. We conducted emergency laparotomy for generalized peritonitis, suspecting stercoral perforation of the colon. Several oval perforations were discovered on the anterior wall of the ascending colon, and feces were found iin the peritoneal cavity. We conducted right colectomy and reanastomosis. Histopathologically, necrosis and several perforations were identified in the resected ascending colon. The patient's postoperative course was uneventful except for temporary delirium, and he was discharged on postoperative day 15.

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Metastasis to the ovary is relatively rare after colorectal cancer surgery. We report 2 cases of ovarian metastasis requiring oophorectomy after curative colonic cancer resection. Case 1, a 27-year-old premenopausal woman, underwent resection for descending colon cancer based on a histological diagnosis of n1, curative A. Six months after surgery, bilateral ovarian tumors were found, necessitating bilateral oophorectomy and hysterectomy under a histological diagnosis of bilateral ovarian metastasis from colon cancer. She died of carcinomatous peritonitis and hepatic metastasis 18 months after colon cancer surgery. Case 2, 39-year-old premenopausal woman, underwent resection of descending colonic cancer, diagnosed as n1, curative A, histologically. Eleven months after surgery, a ovarian tumor was found and she underwent bilateral oophorectomy, under a histological diagnosis of right ovarian metastasis from colonic cancer. She remains well 19 months after colon cancer surgery. Both cases were premenopausal, diagnosed as lower advanced colon cancer with lymph node metastasis. We must follow up such patients and be on the outlook for ovarian metastasis from colorectal cancer. We review cases of ovarian metastasis necessitating oophorectomy after curative colon cancer resection in the Japanese literature.

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An 84-year-old woman visited with abdominal pain and vomiting was admitted with a diagnosis of ileus. Rectal cancer was found 18 cm from the anus by colonoscopy, so her colonic ileus was due to the tumor. An ileustube was inserted into the colon from the anus and drainage started. Surgery was postponed due to liver dysfunction, but emergency surgery was done due to susected diffuse peritonitis due to colonic perforation. Surgery showed the rectum had been perforated caused by a Press Through Package (PTP) at the oral side of cancer, necessitating Hartmann's operation. Although 5 cases of colonic perforation have been reported in Japan, ours is the first of rectal perforation by PTP.

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