Aim: Prospective studies were conducted to improve hospital mortality for gastrectomy in stomach cancer patients by assessing risk factors for hospital death. Subjects: Subjects were 690 patients from 1991 to 2000 who underwent gastrectomy for gastric cancer at our department of surgery. The first 6 years of research (1991-1996) were analyzed to find risk factors for hospital death retrospective by and the next 4 years de-voted to prospective study (1997-2000) to verify risk factors for hospital death revealed by the retrospective study. Results: Hospital mortality was 6.7%(46 subjects; 32 men and 14 women averaging 65±9 years of age) during the first 6 years. Patients dying surgery numbered 13 cases with an average hospital stay of 33±60 days. Total-gastrectomy deaths numbered 24 (11%). Distal-gastrectomy deaths numbered 18 (5.3%). Gasro-enterostomy deaths numbered 2 in hospital. Exploratory lobotomy deaths numbered 2 in hospital. Ten-tative risk factors for hospital death in surgery were thus, 1) pre-operative complications with poor perform-ance status, 2)<40 of the PNI nutrition index before operation, 3) cases for the neo-adjuvant chemotherapy, 4) cases with data of over twice much for tumor markers or cases with elevation of the FDP, 5) supposed cura-tive C (no curativity for gastric cancer) operation. Strict indications for operation (no more than 2 risk factors as shown in above criteria) contributed to the improvement for hospital death rate in next period of the study subjects. Highest death causes for the hospital death was carcinomatosis, numbered 19 (45%) in first period and 6 (67%) in second period, respectively and post operative complications were the second causes, num-bered 22 (52%) in first period and 2 (20%) in seconds period. Avoidance for the operation in patients with potential operative complications and potential operative carcinomatosis (possible curative C patients) led bet-ter survivals. Conclusions: The selection of indications for gastrectomy depending on risk factors helps the decrease hospital death. Further reducing hospital death requires the introduction of scoring for risk assess-ment of operative indications or pre operative procedures.

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Purpose: We have been performing jejunal pouch double-tract reconstruction (PDT) to improve the QOL of patients after total gastrectomy, and this study examined the safety and efficacy of the PDT method. Method: The clinical results of the PDT method (72 patients) performed between May 2001 and March 2004 were compared with the results of the Roux-en Y method (R-Y)(84 patients) that was being performed con-ventionally. Results: PDT operation time was longer than R-Y operation time, but the difference was not sig-nificant. The overall frequency of postoperative complications of PDT and R-Y was almost the same. Compli-cations regarding reconstruction occurred in 9.7% of the PDT cases, and 13.1% of the R-Y cases (not signifi-cant). Body weight one year after operation as a percentage of preoperative weight was 97.5% in the PDT group (40 patients) and 88.9% in the R-Y group (32 patients), and the increase in weight was better in the PDT group (p<0.05). There were no significant differences in the responses to a questionnaire about meals or in to-tal cholesterol values, serum albumin values, or lymphocyte counts one year after the operation. Conclusions: PDT does not increase complications compared with R-Y; recovery of postoperative body weight is bet-ter; and PDT is concluded to be an effective procedure.

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Purpose: Herbal medication Dai-Kenchu-Tou is clinically effective in postoperative ileus. We studied the effi-cacy of rehabilitation with Dai-Kenchu-Tou after colorectal surgery. Patients and methods: Subjects were 98 patients (average age 67.9, male: female=47: 51) undergoing a colorectal surgery between 2000 and 2003. We analyzed open surgery (OS) and laparoscopic surgery (LS) separately. Patients were divided into a Dai-Kenchu-Tou (DKT) group (n=24 (OS), n=16 (LS)) and a Traditional group (TRAD)(n=51 (OS), n=7 (LS)). We excluded those with anastomosis leakage and infections. Patients were scheduled to have the NG tube and start drinking on postoperative day (POD) 1.The DKT group was started on Dai-Kenchu-Tou on POD 1 or 2.Liquid was started after first flatus. Every 2 days, we increased diet calorie if no symptoms of ileus or bowel obstruction occurred. Subjects able to intake a 1, 200 kcal diet were discharged. Results: In the OS group, age, gender, location, pathological stage, and operative procedure were similar. Significant differences were observed in the time of first flatus (2.4±0.7days in the DKT group vs. 3.4±1.6 days in the TRAD group; P=0.007) and length of postoperative hospitalization (8.4±1.6 days in the DKT group vs. 12.3±7.1 days in the TRAD group; P=0.009). The incidence of bowel obstruction was 0% in the DKT group vs. 5.8% in the TRAD group. Analysis of variance of postoperative hospitalization showed blood loss (P=0.0002) and Dai-Kenchu-Tou (P=0.0086) to be significant factors. No other factor was significant. In the LS group, no sig-nificant difference was seen in the time of first flatus, length of postoperative hospitalization, or the incidence of bowel obstruction. Conclusions: The use of herbal medicine Dai-Kenchu-Tou after colorectal operation under laparotomy is effective and recommended.

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We report here a case of esophageal cancer complicated by syndrome of inappropriate secretion of antidiu-retic hormone (SIADH) following cisdichlorodiamimnine platinum (CDDP) and 5-FU administration. A 66-year-old male developed dysphasia, and was found with a squamous cell carcinoma of esophagus (T4N1M0). He was treated with CDDP and 5-FU. The serum sodium concentration decreased from 123mEq/l to 105mEq/l after chemotherapy. SIADH was diagnosed on the basis of hyponatremia with corresponding serumhypoosmolality and an inappropriatelu high urinary osmolality due to continued sodium excretion. In our case, SIADH was probably induced by CDDP. Fluid restriction and sodium supplement resulted in an appropriaterise in the serum sodium level to 126mEq/l in 3 days.

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We report 2 cases of extravasation of fluid that were rare complications of central venous (CV) catheter use. Case 1) A 66-year-old women reporting respiratory distress on day 5 of total parenteral nutrition (TPN). She became progressively hypoxic and acidositic, and had large bilateral pleural effusions and cardiac tamponaderequiring emergency intubation. Chest CT showed free air nearby the tip of the CV catheter in the hydrome-diastinum, so we inferred that the air had been mixed through the bolus injection of drugs. We conducted bi-lateral thoracocentesis (right 2, 300ml, left 980ml) and pericardiocentesis (300ml), and removed the CV cathe-ter immediately. Case 2) A 82-year-old woman reporting dyspnea on day 18 of TPN was found in chest ultra-sonography to have right pleural effusion. Thoracocentesis yielded 350ml of clear fluid, and the dyspnea im-proved dramatically. The glucose concentration of the fluid was 416mg/dl and pleural effusion was blue 30minutes after the injection of Indigocarmine through the CV catheter. After diagnosis, we removed the cathe-ter. Patients both recovered. It is considered that the CV catheter might perforate the vessel wall of superiorvena cava. When a patient suddenly becomes dyspneic and develops pleural effusion during TPN, care givers should suspect life-threatening fluid extravasation requiring immediate thoracocentesis, pericardiocentesis and CV catheter removal.

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A 80-year-old woman admitted with progressive dysphasia and weight loss was found in computed tomographyto have a pulmonary tumor with pleural indentation in the left lower lobe. Bronchoalveolar lavage (BAL) of the lesion led to a cytological diagnosis of adenocarcinoma. Barium and endoscopy showed a circumferentialstricture without mucosal abnormality in the middle third of the esophagus. Cytological studies onspecimens by fine needle aspiration biopsy under endoscopic ultrasonography (EUS-FNAB) defined adenocarcinomasimilar to cytological findings in the BAL specimen. These facts strongly suggested that the esophagealtumor had metastasized from the lung. She was diagnosed with Stage IV lung cancer. Because of her ageand poor renal and respiratory function, she underwent esophageal stenting. Distant metastasis in lung canceris rare in the esophagus, with only 19 cases including ours, reported thus far in Japanese literatures. Thedismal prognosis makes the flexible metallic stent a good treatment option for such patients.

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We report a case of malignant gastrointestinal stromal tumor (GIST) of the stomach with dissemination respondingto postoperative administration of imatinib mesylate and enabling survival without recurrence for21 months. A 49-year-old woman hospitalized for upper abdominal pain was found in abdominal CT to have aprotruding tumor about 10cm in diameter at the lumen of the gastric body. During surgery done after the tumorwas diagnosed as of gastric origin, multiple disseminated tumors were detected in the bilateral diaphragmand abdominal wall. The main gastric tumor was resected by partial gastrectomy and all disseminatedtumors resected where possible. Histopathologically, the main and disseminated tumors consisted ofspindle cells with oval nuclei. The tumor was diagnosed as uncommitted malignant GIST. Although the firstchoice for treating GIST is surgery, imatinib mesylate may be effectively administered as neoadjvant chemotherapypostoperatively and in recurrent cases.

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A 75-year-old man admitted for fever, general fatigue, and loss of appetite in June 2002 had been treated forlung carcinoma by right lobectomy in June 2001 and partial gastrectomy 8 month later elsewhere. Histopathologicalexamination showed poorly differentiated squamous cell carcinoma in the lung and a metastatic lesionin the stomach. An upper gastrointestinal series and gastroscopy showed a protruded lesion in the gastriccardia. Suspecting malignant GIST or a metastatic tumor, we conducted proximal partial gastrectomy.Histopathologically the tumor had metastasized from lung carcinoma. Immunohistochemical staining withanti-G-CSF monoclonal antibody was positive in the lung stomach and preoperative serum G-CSF was abnormallyhigh. The diagnosis was relatively rare G-CSF-producing metastatic gastric cancer. A mesenteric tumorof the transverse colon growing for a short time was resected in December 2002. Histopathological examinationand Immunohistochemical staining with anti-G-CSF monoclonal antibody showed similar results. G-CSFproducinglung carcinoma with gastric metastasis has a dismal prognosis, and surgical treatment must becarefully selected considering the patient's quality of life.

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When pancreatoduodenectomy is conducted in a patient with celiac axis obstruction, the blood flow to theliver becomes an important consideration. We report a case of carcinoma of the papilla of Vater with celiacaxis obstruction, for which pancreatoduodenectomy was done safely without reconstruction of blood circulation.A 75-year-old woman admitted for general fatigue and right hypochondralgia was found in endoscopicexamination to have carcinoma of the papilla of Vater. Visceral angiography showed extensive collateral bloodflow to the hepatic artery and splenic artery via dilated pancreatic arcades and the dorsal pancreatic arteryfrom the superior mesenteric artery. A lateral view of 3D reformation of enhancement abdominal CT showedceliac axis obstruction necessitating surgery. We found a stricture at the celiac axis and we detached it, butpulsations of the common hepatic artery were not visible. Monitoring with ultrasonic flowmetry showed thatthe common hepatic artery had an efferent blood flow after test-clamping gastroduodenal artery, which issupposed to be from the dorsal pancreatic artery. We conducted pancreatoduodenectomy safely without reconstructionof blood circulation.

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A 76-year-old man admitted for tarry stool and suspected of duodenal poorly differentiated adenocarcinoma infiberscopic biopsy underwent pylorus-preserving pancreaticoduodenectomy in which surgical findingsshowed a duodenal tumor, 5 jejunal tumors, and mesenteric lymph node metastasis. Histopathological findingsof positive immunohistochemical staining for KIT showed these tumors to be gastrointestinal stromal tumors (GIST). One month postoperatively, he suffered cramps and was diagnosed with multiple brain metastases.Although treated with whole-brain radiation and medicated with imatinib mesylate, he died 6 months aftersurgery. This extremely rare case involved GIST accompanied by lymph node and brain metastasis, suggestingthe multiple modality of GIST.

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A 37-year-old man ungiong detailed examination of an elevated lesion in the duodenum was found in upper gastrointestinal endoscopic examination to have a giant pedunculated polyp covered with normal duodenal mucosa in the bulb. After CT, MRI and endoscopic ultrasonography, we conducted endoscopic polypectomy. The resected 35×25×25mm specimen was pathologically diagnosed as Brunner's gland hyperplasia. The pa-tient was discharged without complication at day 11 after the treatment and he has no sign of local recurrence for one year.

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A 57-year-old woman admitted for right hypochondoralgia had normal laboratory data and tumor markers and was negative for hepatitis virus type B s-antigen and type C antibody. Ultrasonography showed ex-tremely hypoechoic hepatic tumors of 8.3×6.5cm in diameter at segment 6 and 1.7×1.5cm at segmen 8.Drip-infusion cholangiography computed tomography showed highly dense straight vasculature in the S8 tumor, considered to be the biliary duct. Needle biopsy specimens showed undifferentiated carcinoma, necessitating extended right hepatectomy. We found no abdominal splenomegaly or lymphadenopathy, and tumors ap-peared localized in the liver. Microscopic findings of resected specimens showed tumors to be composed of round lymphocyte-like cells. CD 20 protein was positive immunohistochemically, leading to a diagnosis of pri-mary non-Hodgkin's hepatic lymphoma type B. To ensure definitive diagnosis, we should first consider pri-mary lymphoma differentially, then conduct immunohistochemical staining with biopsy specimens.

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A 77-year-old woman admitted for liver dysfunction was found in abdominal ultrasonography to have a 16×9mm polyp in the gallbladder. A color doppler ultrasonography suggested that the polyp had a pulsating blood flow. Abdominal enhanced CT enhanced the lesion, confirmed by angiography showing tumor staining. We conducted open cholecystectomy because it was difficult to differentiate this lesion from cancer. Pathologi-cally, the polyp was inflammatory with rich vessels in the interstitium. This case shows that measurement of maximum blood flow with the ultrasonic doppler flowmeter, is useful. Cholesterosis in the gallbladder mucosa is likely related to pathogenesis of an inflammatory polyp.

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A 49-year-old woman admitted for general fatigue and right hypochondralgia was found in. Preoperative CT to have a relative hypervascular tumor in the gallbladder fossa. MRI showed low intensity in T1 and high in-tensity in T2 imaging. Tumor marker test showed high AFP-L3. She underwent surgery under a preopera-tive diagnosis of HCC or mixed HCC, but was diagnosed intraoperatively as gallbladder carcinoma, necessitat-ing radical resection with regional lymph node dissection. The analysis of lectin affinity electrophoresis of AFP showed AFP-L2 and AFP-L3 bands, suggesting non hepatoma malignancy. We concluded that gallblad-der carcinoma should be considered if we observe AFP-producing liver tumors next to the gallbladder. Lectin affinity electrophoresis of AFP is thus helpful in differentiation between HCC and AFP-producing gallbladder carcinoma.

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A 61-year-old man referred for a diagnosis of obstructive jaundice on February 3, 2001, was found in further examination to have unresectable hilar cholangiocarcinoma invading the portal vein and hepatic artery. We inserted an expandable metallic stent into the portal vein on April 4 for portal stenosis caused by invasion and into the common bile duct through the right anterior brunch for biliary stenosis on May 2. After follow-up for 24 months without any remarkable change, the man developed nausea and vomiting. Endoscopy showed stric-ture of the prepyrolic region due to extramural compression. Insertion of a third stent into the gastrointestinal stricture effectively enabled the man to eat orally. Unfortunately, be died of peritonitis carcinomas after being followed up as an out-patient with good QOL for 26 months after the first stenting.

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A 50-year-old woman with abdominal pain and a suspected biliary disorder was found in enhanced abdominal CT to have a nodular tumor 3cm in diameter in the body of the gallbladder, swollen lymph nodes in the hepa- toduodenal ligament that were suspected to have invaded the head of the pancreas, paraaortic lymph nodes (No.16b1) swollen to 1cm in diameter, and the right hepatic artery compressed by a swollen lymph node at the hepatic hilum. ERCP showed pancreaticobiliary maljunction without dilation of the common bile duct, a filling defect in the gallbladder, and a compressed common bile duct, leading to a diagnosis of advanced gall-bladder carcinoma with paraaortic lymph node metastasis and necessitating right hepatic lobectomy and pan-creaticoduodenectomy with regional and paraaortic lymphadenectomy. Histologically, the cancer was papil-lary adenocarcinoma with a depth of ss, lymph node Nos. 8p, 12b, 12p, 14, and 16b1 was positive and stage IVa.A pancreatic fistula was identified postoperatively. The woman was discharged on postoperative day 49, and is doing well without any sign of recurrence 3 years and 7 months later.

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A 50-year-woman reporting general fatigue and found in abdominal ultrasonography to have a 1cm tumor in the body of the pancreas was suspected of pancreatic endocrine tumor because of contrast medium enhanced in CT. Abdominal MRI showed a low-intensity mass in the pancreatic body both in T1 and T2-weighted imag- ing unusual for an endocrine tumor. Serum CA19-9 was markedly elevated at 1, 459.2U/ml, necessitating re- section because pancreatic ductal carcinoma could not be ruled out. Histologically, the well-circumscribed tu- mor consisted of nests of endocrine tumor cells embedded in prominent fibrous stroma. The strong fibrosis ap- peared to cause the low intensity in T2-weighted MRI. The tumor had focally evident ductal structures and close contact with endocrine tumor cells. Immunohistologically, tumor cells were positive for chromogranin A and glucagon, but were negative for insulin, gastrin, and somatostatin. The ductal component was immunore- active to CA19-9. The tumor was definitively diagnosed as nonfunctioning pancreatic endocrine tumor. Patho- logical findings in this case support the idea of pancreatic duct epithelia were differentiating into endocrine cells and ductal structures.

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A 44-year-old woman underwent left nephrectomy with resection of retroperitoneal tumor (leiomyosarcoma) on April, 1997. Subsequently, recurrence was diagnosed and she underwent partial hepatectomy of S2 and S4 on early in February, 2000, and lateral segmentectomy of the liver on middle of December, 2001. Both of the resected liver tumors were diagnosed as histologically metastases from leiomyosarcoma. On late in July, 2002 she was admitted with abdominal pain, and abdominal computed tomography (CT) showed tumor, 2cm in di- ameter, in the tail of the pancreas. Distal pancreatectomy with splenectomy was carried out on late in August, 2002 and also histologically diagnosed as metastases to the pancreas. She has been alive 12 months postopera- tively without relapse. This case was very rare and we did find a few reports in which cases of resection of the pancreatic metastasis from soft-tissue sarcoma with or without other organ metastases could expect conse- quence in the long-term survival. Resection may one of treatments for cases like this diagnosed as pancreatic metastasis.

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Superior mesenteric artery (SMA) thrombosis is difficult to correct without early diagnosis. A 65 year-old man with brain infarction, myocardial infarction, and diabetes mellitus was admitted for epigastralgia. Although blood laboratory tests revealed increased white blood cells and CRP, but no serious pain, so we could not diag-nose his SMA thrombosis early. Enhanced CT revealed mesenteric artery occlusion. Surgery was done 44 hours after symptom onset. The small intestine was already infarcted. We resected most of the small intestine, leaving 50cm of the jejunum, and resected the right colon. Seven days after surgery he suffered right hypo-chondriac tenderness. Blood laboratory tests revealed increased white blood cells and CRP again. Abdominal angiography showed complete SMA occlusion. Continuous per-catheteric thrombus aspiration successfully got most of the thrombi. To the best of our knowledge, this is only the sixth case of SMA thrombosis treated with per-catheteric thrombus aspiration procedure in Japan.

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Extragonadal teratoma originating from the mesentery is extremely rare. A 45-year-old man was found in computed tomography and ultrasonography to have a round, well-encapsulated cystic mass with partial calci-fication in the right abdomen. Serum CEA was 138ng/ml and serum CA19-9 53U/ml, suggesting potential malignancy. At laparotomy, the 9×5cm tumor was located in the mesentery of the ileocecal region. Because it was well encapsulated, we excised the tumor without bowel resection. The histopathological diagnosis of be-nign mature mesenteric teratoma was made postoperatively. Serum CEA and CA19-9 normalized within 2 months of surgery. This is, to our knowledge, the first reported case of mesenteric teratoma with high serum CEA and CA19-9. To diagnose mesenteric tumors, benign mesenteric teratoma should be considered. Be-cause tumor resection is appropriate surgical management for mesenteric teratoma, bowel resection should be avoided to minimize surgical stress.

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We report a very rare case of bilateral Morgagni's hernia preoperatively diagnosed in CT colonography. A 60-year-old woman with dyspnea was found. Chest X-ray to have a tumor shadow with intestinal gas in only the right lower lung field, so we first suspected right diaphragmatic hernia containing the transverse colon. The coronal plane of CT colonography, however, clearly showed the tract of the transverse unnaturally ascending and incarcerated in each bilateral thoracic cavity. Following this, we confirmed bilateral diaphragmatic hernia. We operated abdominally, finding that the transverse colon was incarcerated in the bilateral foramen of Mor-gagni as preoperatively diagnosed. After reducing the colon, we resected hernia sacs, closed the orifices by di-rect sutures of the diaphragm, and patched them using mesh sheet. In Morgagni's hernia, the omentum or co-lon usually herniates to the right thoracic cavity. Bilateral occurrence has been reported in 3.9% of cases. Se-lecting an appropriate surgical approach requires precise preoperative assessment. We found CT colonogra-phy to be easy and effective in diagnosing Morgagni's hernia involving the colon.

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We report a rare case of acute appendicitis in a right femoral hernia. A 90-year-old woman admitted for right groin pain and swelling was found on palpation to have a 6-cm right inguinal mass. Pelvic computed tomography (CT) showed a tubular structure terminating as a blind wedge in the right femoral hernia. Emergency surgery showed gangrenous appendicitis and a periappendiceal abscess in the hernial sac. We completed inguinal exploration with peritoneal drainage, appendectomy, and herniorrhaphy via a MacVay procedure. Despite postoperative wound infection, she was discharged on postoperative day 25. Appendicitis in a hernia is rare. The concomitant inflammatory process is usually caused by extraluminal obstruction of the appendix. Signs and symptoms of acute appendicitis are often overshadowed by findings of an incarcerated hernia. CT is an accurate diagnostic modality in hernia appendicitis. Treatment is always surgical, although the precise procedure to be followed remains controversial.

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We report a case of intussusception caused by hemorrhagic infarction with cecal cancer. A 55-year-old woman admitted for continuous abdominal pain, diahrrea, and appetite loss was suspected in ultrasonography, computed tomography and barium enema examination of obstruction due to intussusception. Laparotomy showed that intussusception was caused by two cecal tumors and the cecum up to the hepatic flexure of the transverse colon was mobile, necessitating ileocecal resection with lymph node dissection. Histopathologically, the tumors involved cancer and hemorrhagic infarction. We surmised that repeated intussusception caused by cecum cancer formed a hemorrhagic infarction that completed the intussusception.

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We report a case of squamous cell carcinoma that developed in the ascending colon. The case was a 51-year-old man with lower abdominal pain as the chief complaint. Cancer of the ascending colon accompanied by mul-tiple metastases in the liver was diagnosed, for which right hemicolectomy was performed. In histopathologi-cal examination of the total segmentation of surgical specimen, adenomatous component was detected but adenocarcinomatous component was not, and keratosis was observed, from which moderately differentiated squamous cell carcinoma was diagnosed. The patient was discharged on the day 27 after operation, but died of cancerous cachexia on day 65. As for the development of this disease, carcinogenesis from adenoma was indi-cated because of the involvement of an adenoma element. Because at the time of diagnosis many patients with this disease had already developed remote metastasis, the prognosis is not favorable. Advances in multidisci-plinary treatments are expected to improve the results of treatment.

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A 70-year-old man undergoing total gastrectomy for gastric cancer in August 1998 and subsequent reopera-tion for anastomotic leakage was delay in recovery by a left subphrenic abscess resolved by conservative management. Fourteen years later, he was admitted for incurable interstitial pneumonia. A barium-enema study showed barium passing via the splenic flexure into the bronchi of the left lower lobe but no evidence of colonic malignancy and inflammatory bowel disease, so the colobronchial fistula was attributed to subphrenic abscess as a complication of his last surgery. Because a severe adhesion in his abdominal cavity was expected, not a radical operation but a temporizing operation, colostomy and bronchial embolization were performed. The bronchial fistula was occluded by placing steel coils introduced through an angiographic catheter. His clinical course improved markedly thereafter and he was discharged on postoperative day 23. We report this rare case of colobronchial fistula with a review of the literature.

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A 40-year-old woman 22 weeks and 5 days pregnant suffered right upper abdominal pain. Her history showed that her father had rectal cancer and died of liver failure, and her sister had colon cancer. This family matched the criteria of Hereditary Non-Polyposis Colorectal Cancer (Amsterdam criteria II). Ultrasonography (US) of the abdomen showed liver tumors finally diagnosed as sigmoid colon cancer with multiple liver metastases at 23 weeks and 2 days of pregnancy. After discussion with the patient and her family, we decided to wait until 28 weeks into the pregnancy to ensure a safe delivery, then therapy for cancer would be done. Due to the pa-tient's worsening condition, however, we had to conduct emergency surgery 24 weeks and 4 days into the pregnancy, resulting in fatal death 4 hours postoperatively and the patient's death of multiple organ failure 13 days postoperatively. The treatment of cancer during pregnancy thus requires best selection of therapy based on the many factors attending the particular pregnancy.

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We report an extremely rare case of stercoral perforation of the sigmoid colon presenting as subcutaneous emphysema on admission. A 87-year-old man with a history of cerebral infarction and ongoing severe consti-pation suddenly vomited. In November 13, 2002, he was referred for reduced consciousness and hypotension the next day. Leukopenia, and hepatic and renal dysfunction were confirmed. Computed tomography of the abdomen showed free gas in the abdominal cavity, and emphysema was apparent from the sigmoid mesen-tery to the retroperitonium and mediastinum, with extensive subcutaneous emphysema in the left abdominal and thoracic and cervical regions. Based on these findings, we conducted emergency surgery under a diagno-sis of diffuse peritonitis caused by perforation of the digestive tract. A large volume of contaminated ascites was found in the abdominal cavity and the descending colon, sigmoid colon, and rectum were markedly di-lated. The perforation was located at the dilated sigmoid colon on the medial and dorsal border. The sigmoid mesentery was emphysematous, and a large quantity of caddy stool had leaked into the abdominal cavity. Hartmann's procedure, peritoneal lavage, and drainage were done. Pathological testing of excised tissue showed no diverticuli in the perforated area and, although the stool was not hard, the wall of the sigmoid colon had become necrotic due to severe constipation and the subsequent increase in intestinal pressure.

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