The purpose of the present study was to determine the recurrence rate of symptoms suggesting acute appen-dicitis following conservative therapy and feasible CT findings for prediction of recurrence from follow-up ofconservatively treated cases in which thediagnosis of acute appendicitis was confirmed by CT. Subjects and Methods: Between December 1997 and June 2002, we studied 233 patients diagnosed with acute appendicitisconfirmed by CT. Follow-up of at least 6 months was done in the 62 cases treated conservatively. Results: 1) Recurrent right lower abdominal pain was recognized in 14 (33%) of 43 patients treated conservatively andwhose follow-up was completed; appendectomy was done in 9 (21%) and histological examinations of surgi-cally resected specimens showed acute appendicitis in 8 (19%). 2) No significant difference was seen betweenrecurrent and non recurrent cases in the development of positive fecal stones or elevated CT values aroundthe appendix on CT at initial conservative treatment. Appendix enlargement exceeding 9mm in diameter orascites was recognized in CT at initial conservative therapy more often in recurrent than non recurrent cases.
Summary: The recurrence rate of acute appendicitis diagnosed by CT following conservative therapy was19-33%. Caution must therefore be exercised regarding the possible recurrence of acute appendicitis afterconservative therapy in cases with enlarged appendix or ascites on CT at the initiation of conservative ther-apy.

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Background: Evaluation of anorectal function clinically, structurally and functionally in patients with faecalincontinence should ensure appropriate and individual treatment.Methods: Two hundred and twenty-six pa-tients with faecal incontinence were reviewed regarding disease history, results of anorectal physiologicaltests and anal ultrasonography.Results: The mean age was 54 and 191 patients (85%) were female.Sixty-twohad passive faecal incontinence only (PI); 49 urge faecal incontinence only (UI); and 115 had both passiveand urge faecal incontinence (PUI).Patients with PI had a significantly higher voluntary contraction pressureand less external sphincter abnormalities than UI or PUI.The structural abnormalities of the internal and ex-ternal anal sphincters identified on anal ultrasonography were significantly associated with a low maximumresting pressure and a low voluntary contraction pressure, respectively.The causes identified for this faecalincontinence were: 90 idiopathic; 76 obstetric injury; 36 internal anal sphincter degeneration; 20 anal sur-gical injury; 6 rectal prolapse; and 9 miscellaneous.Conclusion: The anal sphincter structure as demon-strated by ultrasonography was closely related to the anorectal function as determined by anorectal physi-ological tests and the observations from these were reflected in the range of patient reported symptoms. Analultrasonography and anorectal physiological tests are useful tools, enabling us to identify the mechanisms andcauses of faecal incontinence in at least 60% of the patients.

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A 63-year-old woman admitted for a common cold and leg edema was found to have advanced gastric cancerwith nephrotic syndrome. Serum albumin was 1.8g/dl and uric protein volume was 3.4grday on admission.After albumin and FFP was administered for 3 weeks, total gastrectomy was conducted and albumin and FFP administration continued postoperatively. The postoperative course was unremarkable. About a monthpostoperatively, serum albumin gradually increased, and uric protein volume decreased. Careful pre-andpostoperative management is important in gastric cancer with nephrotic syndrome. If membranous nephropathyis histologically diagnosed before surgery, possible remission of nephrotic syndrome can be expected aftergastrectomy.

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A 81-year-old man with cerebral infarction admitted for persistent vomiting and marked abdominal distension was found in abdominal X-ray to have marked gastric dilation, and enhanced CT showed portal venous gas and marked dilation of the duodenum proximal to the superior mesenteric artery with collapsed distal intes-tine, confirming the diagnosis of superior mesenteric artery syndrome presenting with acute gastric dilation and portal venous gas. The patient was treated conservatively with nasogastric suction and total parenteral nutrition. Although, he suffered from aspiration pneumonia, he responded rapidly to treatment. On hospital day 5, gastric dilation and portal venous gas had improved and the aortomesenteric angle was reduced in CT examination. On hospital day 6, an upper gastrointestinal series revealed gastric emptying and a narrowed segment at the third portion of the duodenum with proximal distension. Because of dysphagia and dysmas-esis, the patient underwent enteral feeding via nasojejunal tube extending beyond the site of obstruction and into the proximal jejunum on hospital day 12, and was discharged on hospital day 19. Superior mesenteric ar-tery syndrome with acute portal venous gas may thus be improved by conservative treatment.

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We reported a case of double hepatic cancer with type C liver cirrhosis. A 69-year-old man was admitted to treat the liver tumors, a 60mm tumor in segment 6 and a 15mm tumor in segment 8. The S6 tumor showed early enhancement with delayed wash-out and the S8 tumor enhancement from the early to late phases. Se-rum PIVKA-II was elevated at 2, 640AU/ml. Liver damage was grade B. He was treated with transcatheter arterial chemo-embolization to shrink the S6 tumor and then with microwave coagulation, and underwent he-patectomy for the S8 tumor. The S6 tumor was diagnosed histologically as hepatocellular carcinoma and the S8 tumor as cholangiocellular carcinoma. The man remains well and free of tumor recurrence 51 months after therapy.

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A 78-year-old man admitted for right hypochondralgia and back pain was found in blood tests to have ele-vated LDH and in abdominal CT and MRI to have an enhanced right adrenal gland tumor 15×10cm in diame-ter with direct invasion to the right kidney and liver suspected. Angiography showed tumor staining from the right inferior adrenal artery. The IVC was dislocated by the tumor and collateral vessels had developed. Under a diagnosis of malignant adrenal tumor, we resected the right hepatic lobe and the right kidney en bloc with the tumor. The resected specimen weighed 1.3kg, and showed a whitish solid elastic hard mass with di-rect invasion to the right hepatic lobe and the right kidney. The tumor was diagnosed histopathologically as malignant lymphoma, diffuse mixed B-cell type. The patient was discharged on postoperative day 29 and underwent 4 courses of postoperative CHOP treatment. He remains alive and well without evidence of recur-rence 2 years after surgery. We suggested that his case emphasizes the importance of rapid diagnosis and in-tensive therapy in primary adrenal lymphoma.

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A 38-year-old woman admitted for jaundice and treated for acute lymphocytic Leukemia was found in abdominal ultrasonography and abdominal computed tomography to have a mass in the pancreas head. Based on her history, we diagnosed intraperitoneal relapse of leukemia and conducted cholecystectomy and lymphadenectomy. Microsopically. The gall bladder was confirmed to have gangrenous cholecystitis and lymph nodes showed the metastasis of leukemia. The woman died about 1 year after sugery due to meningial infiltration.

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A 61-year-old man with epigastralgia and fever and found to have a liver tumor was found in dynamic CT to have a low-density tumor in the lateral segment and partly in the medial segment of the liver. The periphery was gradually irregularly enhanced. Tumor markers were within normal limits. Suspecting cholangiocarcinoma, we conducted left hepatic lobectomy with lymph node dissection on April 7 2003. Histopathological examination showed sarcomatous and tubular structures joined by a transitional form. We diagnosed it as cholangiocarcinoma with sarcomatous change. The patient had an uneventful postoperative course but died of liver metastases on January 15 2004. Cholangiocarcinoma with sarcomatous change is very rare. We report a case and review it in light of 13 reports in the Japanese literature.

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Omental granuloma, also called a Braun tumor, rarely causes intraabdominal bleeding. A 58-year-old man transfered by ambulance due to severe epigastralgia with muscular defense was found in physiological examination to be in hemorrhagic shock. Abdominal computed tomography showed intraabdominal effusion and a mass in the gastric wall, strongly suggesting intraabdominal bleeding caused by intraabdominal rupture of the submucosal gastric tumor. Laparotomy confirmed the abdominal cavity to be filled with zanguinous effusion and a round mass adhering to the gastric wall and transverse colon and having a partically torn capsule. Because the mass could not be differentiated from malignancy, we conducted distal gastrectomy and partial resection of the transverse colon. Postoperative histopathology showed no apparent neoplastic component in the resected specimen but did show inflammatory granulation tissue. Because the patient had no history of abdominal surgery, the precise tumor cause remains unclear. This is, to our knowledge, only the second such report in Japan describing omental granuloma accompanying intraabdominal bleeding.

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Encapsulating peritoneal sclerosis (EPS) is a complication of continuous ambulatory peritoneal dialysis (CAPD). Adhesion of peritoneum undergoing fibrosis causes bowel dysfunction with associated abdominal pain, nausea, and vomiting. We report 5 EPS patients -4 men and 1 woman- aged 28 to 67 years. All were treated with total parenteral nutrition (TPN) and corticosteroid therapy, but 4 eventually required surgery, i.e. adhesional lysis, with also requiring resection of a segment of the ileum difficult to remove. Although the immediate postoperative course was uneventful, 1 patient needed additional surgery to remove a parahepatic cyst encapsulated by residual sclerosing peritoneum 8 months after initial surgery. All 4 surgically treated now undergo hemodialysis and are free of abdominal symptoms. Surgical treatment of EPS should be con-ducted at an appropriate stage of disease, and if possible, adequate, meticulous decortication of all sclerosing peritoneum is recommended.

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The symptoms of a 55-year-old man admitted elsewhere for nausea and abdominal pain, diagnosed as ileus, did not improve despite insertion of a long tube. Upon transfer to our hospital, he reported severe nausea, and ab-dominal X-ray examination showed stomach dilation and tube tension. Ultrasonography and CT showed the small intestine telescoping over the tube and parts suspected of intussusception. Conservative therapy by tube withdrawal reduced symptoms and CT showed no abnormalities after withdrawal. Use of a long tube in conservative therapy for ileus may cause intussusception, such attempts in conservative therapy should not aggravate the underlying illness.

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We report 2 cases of incarcerated internal hernia of appendix epiploica of the sigmoid colon and a small intesti-nal mesentery. Case 1: A 65-year-old woman admitted for abdominal pain and vomiting underwent conserva-tive therapy using a long tube. Intestinal contrast studies through the tube and CT showed obstruction of the small intestine at the lower abdomen on day 4 after symptom onset. On day 6, we conducted surgery. The small intestine was incarcerated 130cm proximal from the terminal ileum into a 2.5×2.5cm defect in the ap-pendix epiploica of the sigmoid colon. When the appendix epiploica was resected and ileus relieved, no necro-sis was seen and no intestinal resection was needed. Case 2: A 19-year-old woman admitted for upper ab-dominal pain and vomiting was found in CT to have ascites and obstruction of the small intestine at the lower abdomen on day 2 after symptom onset. Surgery was done under a preoperative diagnosis of strangulated ileus. The small intestine was incarcerated 10cm proximal from the terminal ileum into a small intestinal 3.0×3.0cm mesenteric defect. After ileus was relieved, the necrotic ileum was resected and the defect in the small intestinal mesentery sutured closed. Incarcerated internal hernia of the appendix epiploica of the sigmoid co-lon has been reported only once in the Japanese literature to the best of our knowledge, and incarcerated in-ternal hernia of a small intestinal mesentery in more than 15 years have amounted to only 32 cases in Japan. It is thought that preoperative diagnosis of internal hernia is difficult, but intestinal obstruction in a patient with-out history of undergoing surgery should be suspected of a possible internal hernia and we should not miss the opportunity for operation.

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Small bowel cancer in Crohn's disease is reportedly increasing, but remains extremely rare in Japan. We report a 44-year old woman with adenocarcinoma of the terminal ileum who underwent total colectomy and ileoanal anastomosis 10 years earlier for preoperative diagnosis of ulcerative colitis and had been treated for Crohn's disease, diagnosed when she was 35 years old, using 5'-ASA, predonisolone, and azathioprin. She reported left side hip pain and was admitted on August 19, 2003, for further examination. Small bowel cancer detected in the ileal pouch had developed to about 10cm size in diameter. She underwent abdomino-perineal resection of the ileal pouch and anus and chemotherapy. The curatively resected tumor had no lymph node involvement and no recurrence has been seen as of this writing. Because small bowel cancer may occur in Croh n's disease or ileal pouch, regular follow-up is recommended.

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A 70-year-old man admitted for tarry stools was found in blood tests to be anemic and have markedly high tumor markers. Gastroduodenal fiberscopy showed a type 2 tumor in the second portion of the duodenum, found to be moderately differentiated adenocarcinoma on biopsy. CT showed a tumor around the right wall of the duodenum invaginating the transverse colon. Another tumor was apparent in the spleen. The barium enema showed complete obstruction of the hepatic flexure of the transverse colon. Angiography showed that a nutrient tumor vessel had branched from the middle colic artery, strongly suggesting transverse colon cancer. We conducted pancreaticoduodenectomy, right hemicolectomy, and splenectomy, and when a hepatic tumor became evident during surgery, partial hepatectomy. Transverse colon cancer with formation of a duodenocolic fistula with splenic and hepatic metastasis was the definitive diagnosis. Although peritoneal and hepatic metastasis led to death 30 months postoperatively, long-term survival for colon cancer patients with a duodenocolic fistula may be achieved by the radical excision described above.

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We report a rare case of metastatic colon cancer from carcinosarcoma of the uterus together with a review of the literature. A 67-year-old woman was hospitalized with a complaint of melena. She underwent total hysterectomy and oophorectomy for carcinosarcoma of the uterine corpus 13 years earlier. She was treated with adjuvant chemotherapy for 6 years after surgery. The descending colon was resected under a diagnosis of colon cancer in January 2003. The specimen showed a tumor, 6cm in diameter, growing in the extramural area. HE staining showed poorly differentiated adenocarcinoma which was similar to the primary cancer component of the uterus tumor, although no atypical formation was seen in the mucosal layer. Immunohistochemical study showed cytokeratin, estrogen receptor and CA125 were positive staining, but CD34, C-kit, smooth muscle actin and vimentin were negative. Then the resected tumor in the colon was diagnosed as metastasis of carcinosarcoma from the uterus. Metastatic colon cancer is very rare. No report of colon metastasis derived from carcinosarcoma of the uterus exists to our knowledge.

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Colon perforation usually occurs into the intraabdominal space and causes generalized peritonitis, requiring surgery. Few cases have been reported of penetration of the mesenterium resulting in a favorable outcome. We report a case of stercoral perforation of the sigmoid colon accompanying pneumoretroperitoneum, pneu-momediastinum, subcutaneous emphysema, and intraabdominal free air. A 78-year-old woman admitted for sudden-onset lower abdominal pain, showed muscle guarding and crepitance in the lower abdomen upon ab-dominal examination. Abdominal CT showed massive pneumoretroperitoneum, pneumomediastinum, subcu-taneous emphysema, and intraabdominal free air. Based on a preoperative diagnosis of perforation of the lower gastrointestinal tract, we undertook emergency surgery. A 30mm perforation of the sigmoid colon was found and the mesentery of the sigmoid colon was diffusely expanded by air. Sigmoid colostomy and drainage of the retroperitoneal space were successful. We conclusively diagnosed stercoral penetration of the sigmoid colon into the mesocolon. The patient suffered complications of MRSA enteritis and retroperitoneal abscess, and died of renal failure on postoperative day 41. Such stercoral perforation of the sigmoid colon accompanied by the clinical presentations of emphysematous change and intraabdominal free air, which perforated both sides of the intraabdominal and retroperitoneal space, is extremely rare.

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We assessed the clinical experience and problem of rehabilitation in swallowing disorders following esophagectomy for thoracic esophageal cancer. Postoperative swallowing disorders were studied in 9 thoracic esophageal cancer patients who had undergone esophagectomy with lymph node dissection. Nine with actual or potential swallowing disorders underwent rehabilitation involving (1) anatomical and physiological assessment of organ-related swallowing, bolus movement, aspiration level, safe reclining angle and food safety using videofluorography;(2) repetition of direct and indirect training based on videofluorography assessment;(3) reassessment using videofluorography; and (4) repetition of (1) to (3) until dietetic self-help was possible. Five of the 9 undergoing rehabilitation had paralysis of the recurrent laryngeal nerve, including 1 with paralysis of the bilateral recurrent laryngeal nerves. Eight of the 9 undergoing rehabilitation achieved dietetic selfhelp without severe aspiration pneumonia. Of these 8, mean rehabilitation took 9.6 days and postoperative hospitalization 25.3 days. Mean rehabilitation for the patient with bilateral recurrent laryngeal nerve paralysis took 23 days, and postoperative hospitalization 96 days. Excluding the patient with paralysis of the bilateral recurrent laryngeal nerves, none suffered post-discharge aspiration pneumonia. It is possible that rehabilitation including complementary measures, such as appropriate reclining posture and selection of food consistencies, is effective in postoperative swallowing disorders for thoracic esophageal cancer. The patient who had paralysis of the bilateral recurrent laryngeal nerves required concomitantly greater care.

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