Introduction: The effects of fecal diversion in intractable anorectal complications of Crohn's disease are controversial. Materials and Methods: We studied the efffects of fecal diversion in 42 patients with Crohn's disease (24 men and 18 women) with intractable anorectal complications. Indications for fecal diversion involved with complex perianal fistula (36 patients), anorectal stenosis (22), ano- or rectovaginal fistula (11), rectal fistula (3), perirectal (intrapelvic) abscess (2), rectoperineal fistula (1), and rectourethral fistula (1). Results: After diversion, symptoms improved in 31 of 42 patients, remained unchanged in 4, and worsened in 3. Four patients, improving initially had later recurrence. All rectal fistulas, intrapelvic abscesses, rectoperineal fistulas, and rectourethral fistulas healed, as did 26 of 36 complex fistulas, but most anorectal stenosis and ano-(or recto-) vaginal fistulas did not. Despite improvement, 15 of 16 patients with closure of stoma had recurrent anorectal complications and required rediversion. Overall, only 4 had restored intestinal continuity. Ten needed proctectomy, and 28 remained with fecal diversion. Conclusions: Fecal diversion improves the symptoms of anorectal complications but does not result in healing anorectal lesions and seldom restores intestinal continuity.

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We report an extremely rare case of poorly differentiated gastric adenocarcinoma with totally cornified squamous cell carcinoma in metastatic focus. A 59-year-old man seen for abdominal pain and distention and admitted for closer examination of an epigastric tumor was found in gastric endoscopy to have a defective extension from the corpus to the antrum of the stomach. A histological diagnosis of poorly differentiated adenocarcinoma was made based on the biopsy specimen. A swollen No.4d lymph node 4cm in diameter was suspected in abdominal CT, necessitating total gastrectomy, partial resection of the transverse colon, cholecystectomy, and ρ-Roux-en-Y reconstruction. Although histologic ally the gastric cancer was poorly differentiated adenocarcinoma, the histologic type of metastatic lymph nodes and metastatic focus developing later was cornified squamous cell carcinoma. Pathological autopsy showed no squamous cell carcinoma components as a primary focus in organs, including the esophagus, lung, and testis. We strongly suggest that this rare case indicates the possibility of poorly differentiated adenocarcinoma transformed into cornified squamous cell carcinoma in metastatic focus or in the process of metastasis.

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A 74-year-old man admitted for appetite loss was found in gastrointestinal fiberscopy to have an elevated tumor with an ulcer on the upper third of the stomach. Pathological examination of the biopsied specimen yielded a diagnosis of gastrointestinal stromal tumor. Multiple liver metastases were suspected from abdominal computed tomography. Deeming curative surgery not possible, we started treatment with imatinib mesylate at a dose of 400mg/day. After 18 weeks of treatment, the primary tumor, but not liver metastases, showed partial response. Because of severe interstitial pneumonia, we conducted proximal gastrectomy and partial hepatectomy. Histological exploration showed that most of the primary tumor was replaced by fibrotic tissue and some cells remained. Although the recurrence of liver metastases was detected 6 months after surgery, it showed cystic change after chemotherapy with imatinib mesylate. The patient remains alive 13 months postoperatively.

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We report a case of gastrointestinal stromal tumor (GIST) of the duodenum with liver metastasis. A 50-yearold woman admitted for appetite loss and abdominal pain was found in upper gastrointestinal endoscopy to have a tumor with ulceration at the 2nd portion of duodenum. Abdominal computed tomography showed a mass 10cm in diameter involving the duodenum and a low-density mass in the liver, necessitating pyloruspreserving pancreatoduodenectomy and hepatectomy. Histopathologically, the tumor arose from the proper muscle layer of the duodenum, and was positive for c-kit and negative for CD34, S100 protein, and SMA on immunostaining. The tumor was diagnosed as combined malignant GIST.

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Solitary hepatic tuberculoma is rare and difficult to diagnose, making it often diagnosed as hepatocellular carcinoma. Almost all cases have been resected due to such in accurate diagnose. We report a case of solitary tuberculoma. A 60-year-old man was found in abdominal ultrasonography and computed tomography (CT) to have a low-density mass in the right hepatic lobe. Magnetic resonance imaging (MRI) and angiography were incondusive. We undertook right hepatic lobectomy. Histopathologically, the tumor showed granuloma with caseous necrosis, so we diagnosed the tumor as solitary tuberculoma.

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We report a case of lower bile duct cancer with de novo non-invasive pancreatic cancer and small intraductal papillary mucinous neoplasm (IPMN). A 75-year-old man saw locally for elevated fever and jaundice in September 2003 was found liver function tests to have obstructive jaundice. ERCP showed severe stenosis of the lower bile duct, dilation of the upstream bile duct, and fine irregularity in the body of the pancreatic duct. Abdominal CT showed a dilated intraheptic biliary duct and small cysts in the pancreatic body. Cytology of bile juice showed class IV diagnosis highly suspicious of adenocarcinoma. Based on the diagnosis of lower bile duct cancer, we conducted pancreaticoduodenectomy with lymph node dissection and reconstruction using Imanaga's method. Microscopically, papillary adenocarcinoma was seen in the lower bile duct. de novo noninvasive papillary adenocarcinoma 2mm in size and changes of IPMN and mucosal cell hyperplasia in the main pancreatic duct and intraductal papillary mucinous adenomas 10mm in size in the branch of the pancreatic duct were found. Non-invasive pancreatic cancer is difficult to diagnose early, but fine abnormalities in ERCP or CT as seen in our case may lead to an early diagnosis of non-invasive pancreatic cencer.

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We report a rare case of intraductal papillary mucinous neoplasm localized in the ventral pancreas associated with pancreas divisum. A 74-year-old man was admitted for further examination of a cystic lesion in the pancreatic head. Ultrasonography and computed tomography showed a multilocular cystic lesion in the pancreatic head. MRCP suggested a cystic lesion with pancreas divisum. ERCP via the major papilla showed only the cystic lesion, and it was unsuccessful via the minor papilla. The size of the cystic lesion, which was greater than 3cm, and the presence of a mural nodule greater than 5mm suggested a malignant neoplasm. Subtotal stomach-preserving pancreaticoduodenectomy with D2 lymph node dissection was performed. The pathological diagnosis of the resected specimen was intraductal papillary mucinous adenoma. Since to our knowledge only four cases of intraductal papillary mucinous neoplasm with pancreas divisum have ever been reported, we report our case and discuss it.

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Isolated pancreatic injury is rare in blunt abdominal injury. We report two cases of blunt isolated pancreatic injury due to domestic violence. Case 1: A 24-year-old woman presenting with a crushed epigastric region, alert and complaining of epigastric pain. Abdominal CT showed contusions and a rupture of the pancreas parenchyma. Endoscopic retrograde pancreatography (ERP) demonstrated main pancreatic duct injury. This case was diagnosed as “type IIIa pancreatic injury ”. In emergent surgery the pancreas parenchyma, including the main pancreatic duct was completely transected on the left border of the superior mesenteric vein. Considering that the patient had acute pancreatitis and DIC preoperatively, we undertook two-staged pancreatojejunostomy, which is for preservation of pancreatic function and external drainage of pancreatic juice to prevent pancreatic fistula. No abnormalities in both internal and external secretion of the pancreas were documented for 1.5 year after the second operation. Case 2: A 28-year-old woman presenting with blunt trauma, alert and complaining of upper abdominal pain after being kicked violently to the epigastric region and left abdomen. Abdominal CT scan showed a low-density area in the body of the pancreas, but no main pancreatic duct injury was found in ERP and MRCP. Under a diagnosis of type II pancreatic injury, we decided to observe without operation. Blunt pancreatic injury due to domestic violence must be suspected and evaluated based on the degree and location of impact.

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Pancreatic serous cystadenoma is benign and does not invade the pancreatic duct, but occasionally causes pancreatic stenosis by compression, making it sometimes difficult to discriminate from a malignant tumor. We report a case of this disease causing pancreatic duct stenosis. A 55-year-old woman reporting appetite loss and having serum amylase of 798IU/l and CEA of 8.4ng/ml was found in abdominal computed tomography and magnetic resonance image to have a 1cm pancreatic mass and endoscopic retrograde cholangiopancreatography showed pancreatic duct stenosis at the mass site. Abdominal angiography showed no abnormalities. Distal pancreatectomy with splenectomy was done based on a diagnosis of pancreatic tumor in which malignancy could not be denied. The resected specimen showed a 10×12mm white solid mass containing small microserous cysts and found microscopically to be serous cystadenoma. Most cases of this disease with pancreatic duct stenosis involve a tumor at the pancreatic head and body and smaller tumors as complicated pancreatitis, making malignancy difficult to diagnose.

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We report two cases of old intraabdominal hematoma preoperatively presenting as a malignant solid tumor. Case 1: A 58-year-old man hospitalized for a 7cm left subphrenic tumor found in ultrasonography underwent surgery, although the tumor was not clearly linked to the gastric muscular layer in endoscopic ultrasonography, because the tumor was large and suspected of being a gastric submucosal tumor or splenic tumor in abdominal CT and MRI. Case 2: A 50-year-old man hospitalized for a 2cm pancreatic tumor found in abdominal MRI underwent surgery even though tumor markers, blood sugar, and insulin were within normal range, because we could not exclude the possibility of a pancreatic tumor. The definitive diagnosis was old hematoma in both cases. Although neither case was symptomatic and each had a history of abdominal trauma, the old hematoma should be considered as differential diagnosis in the case of intraabdominal tumor with central bleeding or peripheral calcification.

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We present a rare case of superior mesenteric venous thrombosis (SMVT) showing acute abdomen. A 22-year-old man admitted for severe abdominal pain was found in computerized tomography and angiography to have superior mesenteric venous thrombosis. Although anticoagulant therapy was started immediately, aggravated symptoms suggested intestine necrosis. Laparotomy 3 days after admission showed wide-ranging necrosis of the small intestine due to SMVT. About 170cm of the necrotic intestine was resected without anastomosis for fear of the risk of progression of SMVT which might result in necrosis of the remnant intestine. Reoperation 2 days after the first operation showed no necrosis in the remnant intestine. The stumps of the small intestine with the previous operation were anastomosed. The postoperative course was uneventful and he was discharged day 22 after the second operation. The combination of two-staged operation and anticoagulant therapy was successful in treating this patient with massive necrosis of the small intestine caused by SMVT.

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A 40-year-old man with Crohn's ileocolitis and undergoing home parenteral nutrition (HPN) using an implanted port due to malnutrition and intractable enterocutaneus fistula was referred for hospitalization due to loss of consciousness after 1 week of a high-grade fever. Cerebrospinal fluid examination showed bacterial meningitis and positive blood culture of gram-positive cocci necessitating immediate removal of the implanted port for suspected catheter sepsis. CT and magnetic resonance imaging showed brain and splenic abscesses. Because of a severe hemorrhagic tendency, surgical intervention was not selected. After the catheter was removed and intravenous antibiotics administered, his general condition and brain and splenic abscesses improved with conservative therapy alone. Cultures of blood, spinal fluid, and the catheter tip were all positive for Staphylococcus aureus. Both brain and splenic abscess are a rare complications of catheter-related sepsis, but it is important that appropriate instructions on HPN complications and measures be provided to prevent these severe complications

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An 59 year-old-man admitted elsewhere for right low quadrant abdominal pain was transferred to our hospital without reacting to conservative treatment. A barium enema study and colonoscopic examination suggested the presence of a submucosal tumor in the ceacum. Biopsy was group I, but CEA was high and the large tumor was hemmorhagic necessitating right hemicolectomy. Macroscopic ally, the tumor was 9×8cm and was located in the ascending colon and ceacum. The type 3 tumor was covered with normal mucosa and a partial ulcer had formed. Pathohistologicaly, the tumor was almost entirely covered with normal mucosa, with defects of the mucosa in limited areas and the enormous mass accompanied by the abscess from ss over the mesentery. The tumor was diagnosed a modelately differenciated, si, INFγ, ly1, v1 ew (-), aw (-), ow (-), P0H0n0M (-) adenocarcinoma in stage IIIa. Large bowel cancer presenting as submucosal tumor is comparatively rare with only 42 cases reported in Japanese literature. We reported this interesting case with some bibliographical considerations on the mode of development and extension and diagnosis.

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As Japan's population ages, the number of cases of abdominal surgery at advanced ages is increasing. Few reports have been made, however, on laparotomy in people aged 100 years or older in Japan. We report a 104-year-old man who underwent partial colectomy for colon cancer and lived to age 107. After his initial report of abdominal pain was diagnosed as ileus by X-ray examination, he was admitted and enema examination showed an apple core sign at the right colic flexure. A partial resection for transverse colon cancer was conducted under general anesthesia, followed on postoperative day (POD) 6 by dehiscence of an infected wound. After conservative treatment, the wound was resutured under a second round of general anesthesia, which proved uneventful. The man walked preoperatively with a cane and no postoperative mental disorder was observed. After discharge on POD 128, he survived without recurrence 3 years and 8 months until dying of insenescence at the age of 107. We thus believe that elective laparotomy can be safely conducted without severe complications even on patients over 100 years of age.

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A 43-year-old-man seen for lower abdominal pain and frequent diarrehea was found in colonofiberscopy, to have a large circumferential tumor of the rectum. Biopsy showed endocrine cell carcinoma (ECC) necessitating anterior resection with lymphadenectomy. He was, however, diagnosed with local recurrence 14 months after surgery. ECC often occurs in the rectum, has greater malignant potential in lymphatic, vascular, and liver metastasis, and presents the very dismal prognosis of postoperative death 1 year. Surgery alone thus does not appear sufficient, although the condition is rare and requires further study.

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Malignant rhabdoid tumor, first described in the kidneys of infants and children, is very rare and its prognosis extremely poor. Tumors with a similar appearance have been reported in at different extrarenal sites. We report a case of a malignant rhabdoid tumor of the rectum. A 63-year-old man admitted for melena was found on colonoscopy to have a type 1 rectal tumor with bleeding at the Ra portion. Abdominal CT showed a rectal tumor 10cm in diameter with lymphnode metastases. Invasive rectal carcinoma was suspected and Hartmann's operation with lymphadenectomy was performed. Macroscopically, the 10.0×8.4cm type 1 tumor with invasion of serosa was located in the rectum. Pathological findings showed discohesive cells with prominent nucleoli and eosinophilic cytoplasmic inlusions. Immunohistochemically, tumor cells are positive for cytokeratin and vimentin, identifying the tumor as a MRT of the rectum.

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