Introduction: Bile duct carcinoma is known to spread intraepithelially with high frequency, but biological features remain to be clarified. To differentiate clearly among biological features of the intraepithelial spread portion (IESP) and the invasive portion (IP), we studied the number of argyophilic nucleolar organizer region proteins (AgNOR), Ki-67 positive rate (Ki-67 PR), and p53 overexpression (p53 score). Methods: We stained 20 bile duct carcinoma specimens with antihuman p53 protein monoclonal antibody, antihuman Ki-67 protein monoclonal antibody by streptavidin-biotin immunoperoxidase, and AgNOR by Ploton's 1-step method. Results: Ki-67 PR was 21.5% in IESP and 20.2% in IP. AgNOR in IP was significantly larger than in IESP (IESP: 2.2, IP: 3.3, p=0.0012). Nuclear p53 immunopositivity was observed in 8 of 20 patients (40.0%) in IESP and 13 of 20 (65.0%) in IP. Cases of p53 positive stain in IP were also observed mostly in IESP. Conclusion: No difference in proliferative activity was seen between IESP and IP. This suggests that the cell kinetics of IESP are lower than in IP and that p53 overexpression plays a part in the early of carcinogenesis.

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Purpose: We determined whether the discriminant formula of multivariate analysis is useful for early diagnosis of strangulation ileus. Methods: Subjects were 39 patients undergoing laparotomy under a diagnosis of bowel obstruction from 1994 to 1999. Based on operative findings, they were divided into a strangulation group (St group, n=11) and a simple obstruction group (Sim group, n=28) and were compared for physical findings, laboratory data, and radiological imaging. Factors leading to a diagnosis of strangulated obstruction were clarified and the discriminant formula by multivariate analysis calculated. We studied the formula prospectively, and its usefulness in diagnosis. Result: Cases with peritoneal irritation sign numbered 6 (54.5%) in the St group (p≤0.001), whose average Pco2 was significantly higher than that in the Sim group.(34.58 vs. 41.20mmHg; p≤0.001). The St group had a significantly higher frequency of ascites and lack of the to and fro sign than the Sim group (p≤0.001, p≤0.05). All patients in the St group had ascites, wall thickening, and decreased enhancement, while the frequency of findings in the Sim group was 20.0%(p≤0.001) for ascites and 30.0% for wall thickening but no decreased enhancement. Multiple regression analysis showed independent factors in the diagnosis of strangulated obstruction to be peritoneal irritation sign, collection of ascites (US or CT), and Pco2. The discriminant formula was as follows: Y=0.48×Peritoneal irritation sign (1/0) +0.31×Collection of ascites (1/0)-0.052×Pco2 (mmHg) +2.12 (1: positive, 0: negative). In the prospective study of this formula, all instances exceptfor a false-negative example in the St group, all instances can be classified and sensitivity calculated to be 85.7%, specificity 100%, and accuracy 91.7%, indicataing the formula's usefulness. Conclusion: Strangulated obstruction was identified by the peritoneal irritation sign, Pco2<35, and the existence of ascites. The discriminant formula was thus useful in early diagnosis of strangulated obstruction.

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Ball valve syndrome is defined as a clinical manifestation in which a gastric tumor intussuscepts into the duodenum and obstructs the pylorus. We report a case of ball valve syndrome in which leiomyosarcoma arising from the upper part of the stomach intussuscepted into the duodenum. A 65-year-old man reporting vomiting. Developed massive anal bleeding with hypovolemic shock after being hospitalized. Endoscopy and radiography showed that leiomyosarcoma of the stomach intussuscepted into the duodenum. Necessitating partial stomach resection. Histologically, the excised specimen was diagnosed as leiomyosarcoma. The postoperative course was uneventful and he has shown no sign of recurrence in the 2 years since surgery.

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We report a case of a growing gallbladder cyst successfully resected. A small elevated cystic lesion was pointed out at the fundus of the gallbladder in an 80 old man who had undergone gastrectomy for gastric cancer 3 years earlier. This cystic lesion had grown to 13mm in diameter after 1 year of observation. Cholecystectomy showed simple unilocular cyst 13mm in diameter at the fundus of the gallbladder filled with yellow white mucus. Histologically, the inner surface of the cyst was lined by a single layer of columnar and cuboidal epithelium with no dysplasia inside and outside the cyst. The Rokitansky-Aschoff sinus lay scattered around the cyst and the etiology was considered retention cyst due to blockade of the Rokitansky-Aschoff sinus. Although gallbladder cysts are rare, case reports of the disease are recently increasing with improvements in ultrasonic equipment. It is thus necessary to keep this disease in mind as a possible differential diagnosis of a small elevated lesion of the gallbladder.

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A 44-year-old man admitted for acute abdomen was found on physical examination to have signs of peritoneal irritation. Laboratory findings indicated repidly progressive anemia. Abdominal ultrasonography (US) and computed tomography (CT) showed splenic ruputure and intraabdominal hemorrhage.
Emergency laparotomy showed a large amount of coagulated blood in the peritoneal cavity and a ruptured spleen.
The body and tail of the pancreas were firm. After splenectomy, intraoperative US showed a hypoechoic irregular mass in the body of the pancreas suspected of malignancy. Distal pancreatectomy with lymph node dissection showed the resected mass to be a white, firm 27×15×15mm tumor. Histological findings closely resembled small cell carcinoma (SCC) of the lung. Special staining for neuron specific enolase (NSE), chromogranins A, grimelius silver and epithelial menbrane antigen (EMA) were positive. Because further examination of the lung including CT detected no lesion, we diagnosed the tumor as SCC of pancreatic origin. Such SCC is very rare, with only 22 cases reported in the Japanese literature, including our case. After radiotherapy, the patient was discharged without complication and is doing well with no evidence of reccurence 24 months after surgery.

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A 73-year-old man admitted for left flank pain was diagnosed with diverticulitis. After antibiotic administration and starvation therapy, he had remission of abdominal pain and inflammatory blood test responses turned negative, but intermittent abdominal pain remaind. Abdominal enhanced computed tomography (CT) showed a mass lesion in the left abdomen. Surgery conducted January 8, 2002, showed a jejunal tumor 50cm from the Treitz ligament with a 4cm swelling lymph node. The resected specimen showed a type 3 tumor about 30mm in diameter with a 40mm lymph node. The histopathological diagnosis was carcinoid tumor of the jejunum, se, n (+). The patient had recurrent intermittent abdominal pain and CT showed swelling abdominal lymph nodes and no liver metastasis, diagnosed as a rare case of jejunal carcinoid tumor.

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We report a case of malignant lymphoma of the mesentery with intussusception, a disorder that generally has a poor prognosis. A 56-year-old man admitted for abdominal discomfort was found in colonoscopy to have a submucosal tumor of the cecum with a red, sharp margin. Abdominal computed tomography (CT) showed a large 10×10cm isodensity tumor in size located in the left upper abdomen and a smaller 4×3cm tumor demonstrating intussusception in the right lower abdomen. The same region showed significant radioisotope uptake on Ga scintigraphy. The case was diagnosed as malignant lymphoma of the mesentery with intussusception. Surgical intervention consisted of partical resection of the jejunum for the main tumor and ileocecal resection of the terminal ileum for the submucosal tumor. Complete resection was not possible due to residual tumors near Treiz's ligament. Histopathological diagnosis was B-cell follicular lymphoma. Complete remission was achieved with 11 cycles of CHOP adjuvant chemotherapy. Tumor recurrence was detected 20 months after initial surgery, however, and second-line chemotherapy based on the VeMP protocol was administered. The patient is currently alive 22 months following surgery, and it is considered that he better survival.

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We report an unusual case of an aberrant pancreas with calcifications in the mesentery recognized in abdominal computed tomography (CT). A 54 year-old man admitted for abdominal pain on September 25, 1996, was found in CT to have a mass lesion of the small intestine containing scattered coarse calcifications. Followup CT showed a reduction in size, and abdominal pain improved 2 weeks later. Radiological enteroclysis failed to disclose abnormal findings. He was referred to our hospital for relapsing abdominal pain necessitating laparotomy on November 7, 1996. CT showed the lesion had grown as large as at the first CT. Laparotomy showed the mass in the mesentery located 50 cm on the anal side from Treitz's ligament, necessitating jejunectomy. The specimen revealed a duct with an orifice on the jejunal mucosa connecting the mass with the jejunum. Histochemical and immunohistochemical stains in addition to H.E. staining showed that the mass consisted of acini, islet cells, and ductal system, leading to diagnosis of a group I aberrant pancreas according to Heinrich's classification. It also showed neutrophil infiltration in the calcified aberrant pancreas, suggesting acute chronic pancreatitis responsible for abdominal pain.

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A 79-year-old man diagnosed with a small bowel obstruction was referred for abdominal pain and vomiting. Following up hypertension and brain infarction, he had a history of laparotomy for a rupture of the jejunal mesentric artery and was found on physical examination to have a distended, tympanic abdomen with tenderness of the umbilicus but without rebound tenderness or muscular guarding. No palpable masses were found. Abdominal radiography, ultrasonography (US) and computed tomography (CT) showed a small bowel obstruction. Strangulated ileus was diagnosed preoperatively. Emergency laparotomy showed an ileum 30 cm from the ligament of Treitz 2 m with ischemic change. Pathologically, we diagnosed necrotizing arteritis with fibrinoid necrosis in the mesentery suggestive of polyarteritis nodosa (PN) complicated by ischemic enteritis. Our case fulfills the diagnostic criteria for PN established by the Ministry of Health and Welfare of Japan in 1998. The patient had a smooth postoperative course. PN presenting as acute abdomen is rare. We review 50 patients with PN involving small intestine undergone laparotomy in the Japanese literature.

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A 48-year-old man admitted for abdominal pain had a history of eating raw sardines. Under suspected acute abdomen of unknown origin, we conducted emergency laparoscopic exploration, finding a moderate amount of turbid yellow ascites in the abdominal cavity. Exploration showed induration at the ileum about 250 cm from the of Treitz ligament. After conversion to open surgery, we partially resected the ileum. Resected material showed redness and thickening of the submucosa. Because there no parasites or parasitic ulcerations were found, we made a diagnosis of eosinophilic enteritis.

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We report 5 patients surgically treated rectal carcinoid less than 20mm in diameter. Only 1 had a tumor less than 10mm in diameter, and we performed an endoscopic polypectomy followed by transsacral sleeve resection of the rectum to examine tumor residue. In 4 patients with tumors more than 10mm in diameter, we conducted low anterior resection of the rectum and applied everted rectal stump in 3. Invasion was confined to the submucosal layer in 4 and to the muscular layer in 1. Tumors 13 to 18mm in diameter had a central depression or ulceration in addition to lymph node metastasis, 1 of which had no vascular invasion. Since the risk of lymph node metastasis is relatively high in patients with tumors more than 11mm in diameter, we recommend radical surgery with lymph node dissection, even if no vascular invasion is noted histologically. This is especially important if the tumor has a central depression.

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A 73-year-old man administered prednisolon of 5 mg/day for pulmonary fibrosis was admitted for severe bloody stool. Blood analysis indicated severe pancytopenia, i.e., WBC 2.5×10³/mm₃, Hb 5.9g/dl, and PLT 1.0×10³mm³. Further examination led to a diagnosis of transverse colon cancer associated with idiopathic thrombocytopenic purpura (ITP). Steroid control was inadequate, so we conducted splenectomy and colonectomy with lymphnode dissection (D₂) synchronously by hand-assisted laparoscopic surgery (HALS). The postoperative course was uneventful and he was discharged on 13th postoperative day. Few reports exist about cancer with ITP, and through this case, it appears that splenectomy under HALS is in treating transverse colon cancer assocated with ITP, especially when is necessary other abdominal surgery.

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