Purpose: Number of psychiatric disorder patients who undergoing medical treatment is increasing in Japan. We retrospectively studied the impact of coexisting psychiatric disorders on the perioperative management of surgery for gastric and colorectal cancer. Patients and Methods: Subjects were consecutive 381 patients undergoing surgery for gastric and colorectal cancer between January 1998 and March 2005.Of these, 61 had psychiatric disorders (disorder group: DG), while, 320 patients did not complicated with psychiatric disorders (non-disorder group: NG). Results: The proportion of patients screened by annual medical checkup was significantly lower in the DG group than in the NG group. Overall morbidity in gastric surgery was 38% in the DG group and 28% in the NG group, and 30% in the DG group and 33% in the NG group in colorectal surgery. Mortality rate was zero in both groups. In gastric surgery, the median postoperative hospital stay was 30.5 days in the DG group and 25 days in the NG group, and in colorectal surgery, 22 days in the DG group and 24 days in the NG group. No significant differences between groups were seen in, morbidity, mortality, or length of postoperative hospitalization. Postoperative intravenous injections of psychotropic drugs, temporary physical restrictions, and resistance to medical treatment were studied as episodes associated to psychiatric complications. These three psychological episodes were significantly higher in the DG group than in the NG group. Conclusions: Although additional response to postoperative psychiatric complications was needed, the perioperative risk of gastrointestinal surgery in psychiatrically disordered patients was essentially equivalent to non-disordered patients.

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Purpose: We studied the postoperative infection after hepatectomy based on the risk factors in the CDC guideline and the results of perioperative culture. Patients and methods: Subjects were 80 patients undergoing hepatectomy from January 2003 through June 2005. We cultured nasal discharge and gastric juice obtained preoperatively and sputum, bile, and ascites obtained one day after surgery. We studied the frequency of postoperative infection and risk factors. Results: Bacteria were detected in 27% of nasal discharge, 59% of gastric juice, 52% of sputum, 19% of bile, and 5% of ascites. Postoperative infection occurred in 15/80 cases (19%), and 11 of 15 bacteria detected from infected site were identical to bacteria detected before and 1 day after surgery. Univariate analysis suggested that significant risk facters for postoperative infection were positive culture in sputum, bile, and ascites (p<0.05). Factors associated by multivariate analysis with postoperative infection included gender, glucose intolerance, liver fibrosis, operation time, and positive culture (p<0.05). Conclusions: Our results suggest that patients with liver cirrhosis may be at high risk for postoperative infection. Perioperative positive culture in sputum, bile, and ascites is the risk factor for postoperative infection, and this information of perioperative culture may be useful in appropriate selection of antibacterial agents against postoperative infection.

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We report a case of MRSA empyema successfully treated after surgery for spontaneous esophageal rupture. A 60-year-old man reporting abdominal pain after vomiting was diagnosed left pneumothorax and pleural effusion based on chest radiography. The day after onset, he suffered septic shock and was admitted. Thoracic drainage showed cloudy brown effusion, necessitating emergency thoracotomy under a diagnosis of esophageal rupture. The left wall of the lower esophagus was perforated and was repaired with direct sutures. Circulatory failure disturbed additional covering, and the patient suffered multiple organ failure after surgery. On postoperative day (POD) 1, irrigation with saline solution was started twice a day. Because MRSA was identified from pleural effusion and pus in the wound on POD 13, we started irrigation with increased saline solution and general antibiotics for MRSA. MRSA became negative in the pleural effusion on POD 30 and in the wound on POD 44. Pleural effusion became aseptic on POD 58, and the thoracic drainage tube was removed. The patient was discharged ambulatory on POD 108. Postoperative esophageal radiography and endoscopy confirmed a cure, and CT confirmed that left pulmonary volume was preserved. Regular irrigation with large amounts of saline solution is thus effective.

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We report a rare case of gastric lipoma with hemorrhagic ulcer. A 55-year-old man admitted for further examination of an abnormal shadow in a routine upper gastrointestinal (GI) tract series was found in endoscopic examination to have a 3cm semipedunculated submucosal tumor on the anterior wall of the lower gastric body. Endoscopic ultrasonography showed a soft homogenous hyperechoic mass limited to the third layer, and diagnosed as gastric lipoma. We suggested that he have a check up every six months, but he did not follow through. Two years later, he was readmitted for dyspnea and found in endoscopic examination to have a 5cm semipedunculated submucosal tumor with an ulcer on the anterior wall of the lower gastric body. CT showed a 5cm low-attenuation mass in the lower gastric body composed of fat. We performed partial gastrectomy. Gastric lipoma with hemorrhagic ulcer formation during follow-up is rare, and only six cases have, to our knowledge, been reported in Japan.

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A 24-year-old man with severe peritonitis due to traumatic splenic and gastric rupture was saved by emergency decompression laparotomy after refractory shock, abdominal compartment syndrome (ACS), cardiac arrest, and disruption of the suture line for gastric rupture by cardipulmonary resuscitation. Because resuture or resection and synchronous reconstruction was thought to be difficult, we conducted peritoneal lavage, drainage, and temporary abdominal closure with sealed continuous high-pressure aspiration based on damage control (DC). After correcting metabolic dysfunction in the ICU, we conducted permanent abdominal closure by planned reoperation on postoperative day 3. We should consider ACS in patients with severe peritonitis with shock as a lethal factor and should pay attention to intra urinary-bladder pressure, respiratory and circulatory condition, and urination. Only rapid decompression laparotomy based on damage control can save these patients. Although DC is abnormal strategy following insufficient surgical management only preparing for correction of metabolic crisis in ICU, it is necessary and useful and we should be prepared to implement this strategy under all emergency conditions.

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A 76-year-old who had been an outpatient of psychosurgery for apoplexy was admitted in an emergency for hematemesis. Upper gastrointestinal endoscopy showed a nodular tumor with mucin at the anterior wall of the middle of the stomach, a gross granular tumor at the posterior wall, a minimal granular polyp under the EG junction, and multiple hyperplastic polyps from the upper to middle stomach. Histopathological findings of biopsy specimens showed Group V adenocarcinoma in the nodular and granular tumors, and Group II adenoma in the granular polyp. We conducted total gastrectomy with D1+β lymphadenectomy. Final pathological findings showed tumors in the middle stomach to the moderately differentiated adenocarcinoma, sm2, and the granular polyp under the EG junction to be well differentiated adenocarcinoma, m. All lesions originated from the hyperplastic granular epithelium of the stomach. Multiple hyperplastic polyps appeared to occur to canceration might acquire to oncogenic potential. We must therefore consider all polyps of the stomach for resection.

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A 62-year-old man referred for bloody stool due to sigmoid colon cancer was found in endoscopy to have granular changes in the mucosa at the upper gastric antrum. Biopsy yielded a diagnosis of extramedullatory plasmacytoma of the stomach. Positron emission tomography with 16 F-fluoro-2-deoxy-D-glucose (FDGPET) identified tumors in the stomach and colon necessitating total gastorectomy and sigmoidectomy. Macroscopic examination showed granular changes with mucosal thickening. Pathological findings showed diffuse proliferation of plasma cells limited to the lamina propria mucosae and no lymph metastasis. Immunochemically, IgA and κ were positive. The colon tumor was diagnosed as well-differentiated adenocarcinoma. He has remained disease-free during 6 months of follow-up.

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Though gastric wall perforation can happen as a complication of endoscopic submucosal dissection (ESD), but no report exists, to our knowledge, of peritoneal dissemination caused by perforation during ESD. We report a case of stage IB gastric cancer causing peritoneal dissemination 1 year after perforation during ESD. An 80year-old man with an abnormality found in a medical examination and diagnosed with gastric cancer was found in endoscopic ultrasonography to have massive tumor invasion to submucosal layer of stomach. ESD was conducted and gastric wall perforation was detected and endoscopically treated with endoclips, followed 1 month later by curative gastrectomy. One year after surgery, he noticed hard spot of abdominal wall diagnosed by computed tomography and biopsy as metastatic tumor. The tumor extended into the abdominal cavity, which contained nodules of all sizes. The diagnosis was peritoneal dissemination of gastric cancer. Six months later, he died of peritonitis carcinomatosis.

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We report a case of neuroendocrine carcinoma of the duodenum. A 76-year-old man came to our hospital, complaining of dizziness. Laboratory data showed anemia. Abdominal CT revealed a 3-cm mass on the ventral side of the pancreatic head, and duodenoscopy showed a 4-cm elevated lesion with ulceration in the first part of the duodenum. Biopsy showed a malignant epithelial neoplasm of the duodenum. Partial duodenectomy and excision of a metastatic lymph node was performed for a preoperative diagnosis of a duodenal cancer with a metastatic lymph node, and followed by adjuvant chemotherapy with tegafur. Immunohistochemical analysis showed positive staining for chromogranin and synaptophysin. The definitive diagnosis was neuroendocrine carcinoma of the duodenum. The patient has survived for more than 36 months after surgery with no signs of recurrence.

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Carcinoma of the papilla of Vater may cause clinical symptoms, but acute pancreatitis as a presenting symptom is rare. We report a case of carcinoma of the papilla of Vater presenting with severe acute pancreatitis. A 58-year-old man referred for sudden epigastric pain was found to have a serum amylase concentration markedly elevated at 3, 680IU/l. Abdominal computed tomography (CT) scan showed an enlarged pancreas throughout the pancreatic head to pancreatic tail with peripancreatic fluid collection, yielding a diagnosis of severe acute pancreatitis (Stage 2). He underwent intensive care including arterial injection treatment. We attempted endoscopic retrograde cholangiopancreatography to determine the cause of the acute pancreatitis, but failed. Duodenoscopy showed redness and concentration of the folds at the papilla of Vater, and the biopsy specimen showed adenocarcinoma, necessitating pylorus-preserving pancreaticoduodenectomy with abdominal lymph node dissection. The pathological diagnosis was pT3 pN0 Stage III, well-differentiated tubular adenocarcinoma of the papilla of Vater based on the Japanese classification of biliary tract carcinoma. The man remains well without recurrence 15 months after surgery.

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A 65-year-old man admitted for a hemorrhagic gastric ulcer but no fever and laboratory data showing normal liver function except for slightly elevated ALP and γ-GTP and negative serology for hepatitis B and C was found on US examination to have a 5cm diameter tumor of the hepatic right lobe near the hepatic hilum. In contrast-CT, only the tumor margin was enhanced. Portography via the superior mesenteric artery showed the right branch of the portal vein to be completely occluded. Percutaneous needle biopsy under ultrasonic guidance showed the presence of inflammatory but not malignant cells. The tumor, diagnosed as inflammatory hepatic pseudotumor, necessitated right hepatectomy. Pathological findings for the resected specimen were compatible with those of the preoperative diagnosis. He has been followed up for 5 years without sign of recurrence. Inflammatory hepatic pseudotumor is relatively rare and its etiology inconclusive. Surgical treatment should be selected for the cases with the tumor near the hepatic hilum to prevent the occurrence of complications including portal vein or obstructive jaundice.

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We reported two rare cases of intraperitoneal rupture of gas-containing pyogenic liver abscesses. Case 1: A 52-year-old man admitted with a high fever and abdominal pain and diagnosed with panperitonitis showed marked tenderness and muscle defense in the entire abdomen on admission. Abdominal computed tomography (CT) indicated a gas-containing liver abscess, ascites, and free air in the abdominal cavity. Laboratory data indicated severe diabetes mellitus with BS of 544mg/dl and HbA1c of 11.3%. We conducted emergency drainage under laparotomy. Klebsiella pneumoniae was detected from the abscess fluid. Case 2: A 65-year-old man who had undergone stenting for common bile duct stenosis due to advanced pancreatic cancer and admitted with a high fever and abdominal pain showed abdominal irritation. Abdominal CT showed gas-containing liver abscesses, ascites, and free air in the abdominal cavity. He was diagnosed with panperitonitis due to rupture of the liver abscess, necessitating emergency drainage under laparotomy. Lactococcus species was detected from the abscess fluid. The postoperative course of both men was uneventful and their liver abscesses gradually diminished.

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Advanced gastrointestinal stromal tumor (GIST) with multiple liver metastases was successfully resected after pharmacological debulking with imatinib. A 47-year-old man with a huge gastric GIST with multiple liver metastases considered irresectable was administrated 400 mg/day of imatinib. The tumor responded dramatically but a resistant clone appeared 8 months later. A small mass was detected inside one of the liver lesions that had changed to a shrunken cystic mass. In subsequent surgery, we successfully treated all tumors with total gastrectomy, partial hepatic resection, and hepatic radiofrequency abrasion (RFA). The resected specimen showed viable cells of a new liver lesion. Genetic analysis of the tumor revealed 2 mutations in KIT gene and 1 mutation in platelet-derived growth factor receptor-α(PDGFRA) gene. Since only surgery can potentially cure the disease, advanced GIST patients on imatinib therapy should be closely monitored for resistant lesions and surgery should be considered repeatedly to improve outcome.

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A 87-year-old man seen in an emergency for sudden onset upper right quadrant pain, coffee-ground vomiting and a medical history of hypertension was found to have tenderness and muscle guarding in the upper right quadrant. Laboratory data showed WBC 23, 700/μl, CRP 22.28mg/dl, and severe inflammation. Plain abdominal X-ray showed marked gastric dilation. Abdominal computed tomography showed widespread hepatic portal venous gas in the liver and portal venous gas in the gastric border vein, splenic vein, and superior mesenteric vein, and gas imaging in the gastric wall. The gallbladder was distended and edematous and showed fluid collection around the gallbladder. We conducted emergency laparoscopic exploration for gastrointestinal necrosis or possible acute cholecystitis, then laparoscopic cholecystectomy under an intraoperative diagnosis of acute perforated necrotic cholecystitis. Postoperative gastroduodenal endoscopy showed multiple erosions with an ulcer in the gastric subcardia and antrum of the stomach. The man was definitively diagnosed with acute perforated necrotic cholecystitis combining broad portal venous gas due to an acute gastric mucosal lesion and gastric dilation and discharged on postoperative day 16.

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A 54-year-old woman admitted for epigastralgia and fever, was found in abdominal ultrasonography (US) to have cholecystitis due to cholecystolithiasis. Laboratory data on admission showed serum CA19-9 to be extremely high at 26, 780U/ml. Antibiotics reduced inflammation and serum CA19-9 fell to 10, 060U/ml. Because no other examinations suggested the presence of a malignant tumor, the elevated serum CA19-9 was due to cholecystitis. Serum CA19-9 dropped significantly lower to 49U/ml after laparoscopic cholecystectomy. Histopathological findings showed severe inflammation in the gallbladder wall, and immunohistological staining of CA19-9 was strongly positive at the epithelium of Rokitansky-Aschoff sinus. Serum CA19-9 may be high in benign disease, but is usually within 100U/ml, with cases up to 10, 000U/ml extremely rare. An analysis of cases with high CA19-9 indicates that the main factor in elvated serum CA19-9 in cholelithiasis is biliary tract inflammation.

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We report a rare case of double bile duct with calculus. A 71-year-old woman admitted for abdominal pain was found in abdominal ultrasonogy and CT to have a common bile duct stone. Upper gastrointestinal endoscopy showed that the bile flowed into the upper body of the stomach. ERCP delineated defects in the common bile duct and the statue of ectopic bile duct. In operative findings, a statue of ectopic bile duct lay between the liver hilus and the lesser curvature of the stomach in the lesser omentum. Cholangiography in the operation revealed that double bile duct diverged from left hepatic duct. Calculus occurred in a common bile duct and the ectopic bile duct, necessitating cholecystectomy, choledochotomy, and ectopic bile duct resection with partial gastrectomy. Histopathological finding of the double bile duct showed that the double bile duct was not aquired duct but also congential duct. A double bile duct is rare, and a case in which calculus is recognized in the ectopic bile duct is very rare.

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Emphysematous cholecystitis is a variant of acute cholecystitis characterized by intraluminal and intramural gas of the gall bladder. Several reports of emphysematous cholecystitis have been associated with pneumobilia, although it is rare. Portal venous gas is generally detected under different abdominal conditions, including infarcted bowel, but portal venous gas caused by emphysematous cholecystitis is extremely rare. We discuss a rare case of emphysematous cholecystitis associated with pneumobilia and portal venous gas. A 79-year-old man with general fatigue and appetite loss was found on physical examination to have diffuse abdominal tenderness with severe tenderness in the upper right quadrant. Abdominal computed tomography showed gas in the gall bladder and its wall, pneumobilia, and portal venous gas without findings in other abdominal viscera, including the bowel. Based on a diagnosis of panperitonitis caused by emphysematous cholecystitis, we conducted emergency open cholecystectomy. The patient had to spend several days in the intensive care unit thereafter, but the postoperative course was essentially uneventful.

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We report a case of spontaneously ruptured anaplastic carcinoma of the pancreas. A 59-year-old man seen for abdominal pain was found in abdominal ultrasonography and computed tomography (CT) to have a tumor of the pancreatic body and multiple metastatic liver tumors. He was admitted due to exacerbated symptoms. Abdominal CT showed a rapidly expanding tumor and marked ascites. Exploratory needle aspiration showed hemorrhagic ascites, necessitating emergency surgery under a diagnosis of intraabdominal hemorrhage. During surgery, we found bleeding from a ruptured tumor and conducted distal pancreatectomy. The pathological diagnosis was anaplastic carcinoma of the pancreas. Despite postoperative chemotherapy, the man died of cancerous cachexia on postoperative day 18. Anaplastic carcinoma thus may cause spontaneous rupture during rapid tumor enlargement.

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A 25-year-old woman seen for abdominal pain that decreased after taking medicine was sent home but returned the next day when pain recurred and intensified. After admission, pain intensified with peritoneal irritation. Abdominal computed tomography (CT) showed swollen small intestines, and laboratory studies showed a severe pancytopenia. Emergency laparotomy showed an omphalomesenteric duct remnant between the peritoneal umbilicus and the ileum. The small intestine was twisted around the duct and the other part of the small intestine was entrapped. An internal hernia caused an intestinal obstruction. Few such reports have been made in adults, but this possibility should be considered as a possible cause of intestinal obstruction in patients not having undergone previous abdominal surgery.

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We report a case of mucinous cystadenoma of the appendix with intussusception. A 46-year-old woman came to our hospital because of abdominal pain and diarrhea. Ultrasonography revealed a target sign and multidetector computed tomography showed a multiconcentric ring sign in the transverse colon, and a diagnosis of intussusception induced by a cystic mass was made. A gastrografin enema showed a crab-claw-like area with-out filling in the proximal transverse colon. After reduction of the intussusception by means of a gastrografinenema, a hemispheric protrusion persisted, and no gastrografin entered into the ileum. Iliocecal resection was performed. The appendix was swollen to 7.5×3cm in size, and proximal end of the appendix had invaginated into the cecum. The pathological diagnosis was mucinous cystadenoma of the appendix. Coronal reconstruction CT was helpful in making the diagnosis of intussusception.

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We report a case of acute appendicitis resulting from metastatic squamous cell carcinoma of the lung. A 71-year-old man with pain in the lower right abdomen, and a medical history including lobectomy of the right lung for squamous cell carcinoma 12 months earlier had a final TNM stage of the original lung cancer of T4N2 M0. Physical examination showed severe tenderness and a positive Blumberg sign in the right lower abdominal quadrant. The white blood cell count had markedly increased to 22, 000/mm³ and serum C-reactive protein to 9.9mg/dl. Abdomino-pelvic computed tomography showed a mass in the appendix in the right lower abdominal cavity. Acute appendicitis was tentatively diagnosed, necessitating emergency surgery. At laparotomy, the appendix was found to be perforated and to contain dirty fluid. It was also adhering to the ileum through the upper part, necessitating appendectomy and partial resection of the ileum. Pathological examination showed a metastatic, poorly differentiated squamous cell carcinoma-a finding compatible with the history of lung carcinoma resected 12 months earlier in this patient.

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A 60-year-old man underwent unilateral adrenalectomy for a metastatic tumor of the right adrenal gland in November 2002 after CT had shown a high-density tumor in August 2002.In August 1998, ileocolectomy was done for ascending colon cancer without lymph node or distant metastases. In October 2000, right hepatic lobectomy was done for a tumor at hepatic S7.In March 2004, the carcinoma metastasized around the common bile duct. In October 2005, the patient died of intestinal hemorrhage. He had survived 2 years and 11 months since adrenalectomy. Histological examination showed that the colon tumor consisted of moderately differentiated mucinous adenocarcinoma and the three metastases of mucinous adenocarcinoma. Serum CEA was within the normal range before resection of the liver and adrenal metastasis, but increased prior to ileocolectomy and when the carcinoma metastasized around the common bile duct. In Japan, of the 29 cases in which resection of adrenal metastasis due to colon cancer was done, only 7 cases with hepatic resection have been reported.

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Fournier's gangrene is usually caused by an anal fistula, abscess around the anus, or urological disease, but rarely by rectal cancer. We report such a case. A 56-year-old man seen for scrotal swelling and pain and urinary retention was found in pelvic CT to have dirty fat signs and air density in the urethra and scrotum and a tumor in the rectum. He underwent emergency surgery including abscess resection, drainage, and colostomy. Intraoperative biopsy of the rectal tumor showed a well-differentiated adenocarcinoma, resulting in a definitive diagnosis of Fournier's gangrene caused by rectal cancer penetration. Rectal cancer must thus be kept mind as a possible differential diagnosis in Fournier's gangrene.

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Small rectal carcinoids have been detected more frequently with the widespread use of colonoscopy. Most reported rectal carcinoids are less than 20mm in diameter, and the pathological depth of invasion was typically confined to the submucosal layer. However, it is not unusual for these small rectal carcinoids to metastasize to regional lymph nodes and/or to the liver. Here, we report the case of a minute rectal carcinoid, 8mm in diameter, with a huge metastatic obturator lymph node. A 79-year-old woman was hospitalized because of persistent fever and left pretibial edema. Abdominal CT scans demonstrated a large tumor of 13cm in diameter, with intratumoral necrosis occupying the pelvic cavity and compressing the left external iliac vein. With no alternative diagnostic measures available, a percutaneous biopsy was performed and a diagnosis of carcinoid was made. A subsequent colonoscopy revealed a small rectal carcinoid 8mm in diameter and located in the lower rectum to be the primary lesion. We performed a transanal local resection of the primary tumor and simultaneous transabdominal extirpation of the huge pelvic tumor. A pathological examination confirmed that the pelvic tumor was a metastatic obturator lymph node from the rectal carcinoid. No evidence of local recurrence or liver metastasis was seen during the follow-up period. For pelvic tumors of unknown origin, the alimentary tract must be examined to rule out the possibility of metastatic carcinoids.

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A 61-year-old man see for complaining of anal bleeding and pain, and was found in Colonoscopy to have a giant submucosal tumor with central ulceration in the rectum. Computed tomography and magic resonance imaging showed a 12cm heterogeneous mass in the pelvic space invading the prostate. FDG-PET showed abnormal tracer accumulation in the tumor, which was diagnosed as gastrointestinal stromal tumor (GIST) with prostate invasion and resected radically using total perineal exenteration. The resected specimen showed hemorrhagic necrosis of a massive tumor. The mitotic count was 13 per 50 in the high-power field. Immunohistochemical staining detected c-kit and CD34 but was negative for desmin, α-SMA, S-100 protein, and NSE. The tumor was defined as high-risk in risk assessment. We report a case of giant GIST of the rectum resected successfully using total perineal exenteration, following which the patient has remained disease-free for 4 years. Because the risk of the recurrence depends on the operation curability, adequate resection margin is needed for surgical approach for GIST.

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A 62-year-old man with undifferentiated rectal cancer and systemic lymph node metastases underwent chemotherapy with 5-FU, l-LV, and CPT-11. Both lymph node metastases and rectal cancer completely disappeared after 5 cycles of treatment. Rectal cancer recurred locally after 9 months of Complete Response and was resected locally. Five months after local resection, we again resected again local rectal cancer by abdominoperineal resection. The man survived for 3.5 years after the initial chemotherapy. This case is rare in having systemic lymph node metastases of rectal cancer controlled by chemotherapy followed by radical surgery.

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We report two cases of lupus peritonitis. Case 1: a 37-year-old woman diagnosed with systemic lupus erythematosus (SLE) at the age of 20, was admitted for abdominal pain and high fever. Appendectomy was done under a diagnosis of acute appendicitis. Because of histopathological findings that the appendix demonstrated inflammatory cell infiltration around the vessel walls, and with immunohematology, a diagnosis of lupus peritonitis was made. Steroid pulse therapy was started and these abdominal findings disappeared. Case 2: a 36-year-old woman, diagnosed with SLE at the age of 23, was admitted for vomiting and diagnosed with ileus. After 2 days, rebound tenderness appeared. Abdominal computed tomography showed marked thickening of the small intestinal walls and increasing ascites, necessitating a laparotomy for suspected strangulated ileus. During surgery, we found a large amount of yellow transparent ascites and serositis-like reddening and swelling of the entire small intestine, resulting in a definitive diagnosis of lupus peritonitis. Treatment with steroids was started and these abdominal findings disappeared. We surgeon have some chance of examining first for acute abdomen, so must keep lupus peritonitis in mind as a probable differential diagnosis for acute abdomen in patients with previous of SLE.

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A 70-year-old man presented with lower abdominal pain and a hard, 1.0-cm nodule on the upper edge of his umbilicus with a reddish appearance and tenderness. A physical examination showed an advanced carcinoma of the sigmoid colon with no other distant metastases, except for the umbilical one. The patient underwent a sigmoid colectomy and resection of the umbilical tumor. Histopathological examination revealed an umbilical metastasis of a moderately differentiated adenocarcinoma of the sigmoid colon. An umbilical metastasis from an internal malignancy is known as a Sister Mary Joseph nodule (SMJN) and has a very poor prognosis. Most studies show a survival period from the time of diagnosis of less than one year. On the other hand, some reports have concluded that aggressive surgery may improve survival. The possibility of umbilical metastasis from an intra-abdominal malignancy must be kept in mind when an umbilical nodule is encountered.

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Nausea, vomiting, and the feeling of abdominal distension due to bowel obstruction ruin a terminally ill patient'squality of life. Reports indicate that octreotide is effective against these symptoms. Octreotide was approved in an insurance adjustment in October 2004 when it became acceptable for use in general ward patientswith bowel obstruction. We obtained excellent results using octreotide in seven terminally ill patients with bowel obstruction between May 2005 to March 2006. The four men and three women averaged 67.3±11.2 years of age. Primary cancer involved three gastric cancers, and one each of sigmoid colon cancer, ascendingcolon cancer, pancreatic cancer, and idiopathic cancer. Nausea, vomiting, and the feeling of abdominal distension were assessed based on efficacy criteria using the JCOG toxicity scale, and oral intake in five exampleswas attained. After using octreotide, none of the subjects required nasogastric tubes and hydration was decreased. Gastroenterological surgeons should thus consider the use of octreotide as the first choice in inoperableterminally ill patients with bowel obstruction.

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