Aim: The mode of rectal amputation, i. e abdominoperineal [Miles], sacroabdominal [SA], abdominosacraland abdominosacroabdominal [ASA], is based on repositioning for the surgical approach. Miles requires nointraoperative repositioning, but hemostasis from the prostatic or vaginal posterior wall is often difficult. Weidentified the significance of intraoperative repositioning in those undergoing SA rectal amputation. Patients and methods: Subjects were 134 consecutive rectal cancer patients undergoing rectal amputation, whichmode was Miles (70 cases) or SA (64 cases), at our institution from April 1998 to March 2007.Operating time, intraoperative blood loss and postoperative hospitalization were recorded and analyzed. Results: Although SA required more time for repositioning, operating time was statistically shorter than that for Miles (315.1±8.6 vs. 365.6±10.5 minutes, p=0.0004). Mean operating time in those cases of which performed lateral pelvicnode dissection, was statistically prolonged in enforcement cases (p=0.028). But the dissective rate amongthese two groups was similar. Intraoperative blood loss of SA was statistically less than that for Miles (790.9±69.4 vs. 1, 338.0±164.1ml, p=0.0035). Conclusions: Intraoperative repositioning for patients undergoing rectal amputation helps reduce blood loss and operating time. We would like to utilize actively intraoperative repositioning for adequate patients undergoing rectal amputation, and to hand over a younger surgeon in the future.

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A 71-year-old woman, taking methotrexate for rheumatoid arthritis, lost consciousness after falling while bathing. After recovering consciousness, she reported severe chest pain and dyspnea, and was found in chest CTto have left hydropneumothorax and thickening of the lower thoracic esophagus, although no other traumaticlesions were detected. Left thoracic drainage indicated saburra. Esophageal endoscopy confirmed perforationof the lower thoracic esophagus. Emergency thoracotomy showed that the left wall of the lower thoracicesophagus had ruptured for 3.5cm. The perforation was closed directly followed by irrigation and drainage.Postoperative esophageal radiography showed neither anastomotic leakage nor stenosis. Although the patientsuffered from wound infection and insufficient daily activity postoperatively, she was discharged as ambulatory on postoperative day 58. The mechanism of esophageal rupture in this patient was considered to be asudden increase in luminal pressure of the esophagus due to falling, because no symptoms which led to increase in intraabdominal pressure were noticed before losing consciousness and falling. Esophageal ruptureshould therefore be considered in patients with blunt trauma.

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A 63-year-old man diagnosed with esophageal cancer in July 2002 had pathological findings of welldifferentiated squamous cell carcinoma (SCC) of clinical stage II (I MtUtLt, T3-4, N2) based on Japanese Guidelines for clinical and pathological studies on esophageal carcinoma. Direct invasion to the left main bronchus was suspected, necessitating chemoradiotherapy (5-FU, cysplatin for 2 series) and radiotherapy (RT)(65Gy). In December 2002, his response was complete recoverly (CR) for the tumor and partial recovery (PR) for lymph node metastasis. In September 2003, a mucosal irregularity of the entire esophageal wall circumference detected 40-45cm distal from the fore-tooth that was not dyed by Lugol iodine solution was diagnosed as esophageal cancer. Another round of RT and chemotherapy (FP) was done, but a clinical evaluation of no change (NC), necessitated endoscopic mucosal dissection. The pathological finding was squamous cell carcinoma.(m1, ly0, v0) In August 2004, the findings of carcinoma of the hypopharynx necessitated partial pharyngectomy and lymph node dissection. In January 2006, detection of an elevated submucosal tumor like lesion in the cardiac part of the stomach was found in fine-needle aspiration to be SCC, necessitating proximal gastrectomy in April 2006, and pathological findings of moderately differentiated SCC with severe venous invasion. This tumor appeared to have arisen through hematogenous metastasis from the first esophageal cancer.

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Cervical esophageal adenocarcinoma arising from heterotopic gastric mucosa is rare, with only 16 cases reported, to our knowledge, in Japan. A 35-year-old man reporting odynophagia and hematemesis after drinking alcohol and examined in upper gastrointestinal endoscopy was found to have a tumor at the cervical esophagus. Histologically, biopsy specimens indicated adenocarcinoma. Computed tomography showed swelling of cervical and superior mediastinal lymph nodes. He was treated with esophagectomy with right thoracotomy. Histopathological examination of the resected specimen showed papillary adenocarcinoma with invasion to the submucosa and lymph node metastases. Carcinoma was diagnosed as arising from heterotopic gastric mucosa because of its continuity.

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A 56-year-old man with dysphagia and found in endoscopic examination to have an ulcerative lesion in the inferior thoracic esophagus was diagnosed with adenocarcinoma from a biopsy specimen, necessitating esophagectomy. Histologically, the resected tumor showed poorly differentiated adenocarcinoma, which presented with features of medullary carcinoma with lymphoid stroma. This particular histological type of carcinoma, such as breast and gastric, has been reported to be related to better prognosis and to be associated with Epstein-Barr virus (EBV) infections in gastric carcinomas. Cases of esophageal cancer are rare, however, and their pathogenesis remains to be clearfied. No positive signs of EBV were detected in tumor cells in our case. Immunohistochemically, the expression of HLA-DR antigen was evident in cancer cells, suggesting that HLA-DR antigen expression in esophageal cancer with lymphoid infiltration is thought to be associated with long-time survival. The patient has survived for more than 12 months after surgery with no signs of recurrence.

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A 59-year-old man admitted for abdominal pain and tenderness and muscular defense in the upper abdomen, was found in blood examination to have an increased inflammation reaction, a liver and renal function disorder, and increased creatine kinase. Computed tomography showed significant thickening of the gastric wall and slight abdominal dropsy. Based on a clinical diagnosis of peritonitis, we undertook exploratory laparoscopy. The presence of hemoperitoneum and ischemic change in the gastric wall necessitated gastroin testinal endoscopy, which in turn showed defluxion of the gastric mucosa, ulceration and necrotic change. Based on a diagnosis of gastric necrosis, we conducted total gastrectomy. Pathological examination showed moderately differentiated adenocarcinoma and tumour invasion to the muscularis propria. Neutrophilic leukocytes were seen in all layers and formed an abscess. Transmural necrosis was seen in part of stomach, presumably due to infection from the cancerous ulcer.

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A 75-year-old woman with a sense of a full stomach was found in endoscopy of the upper digestive tract to have a submucasal tumor in the anterior wall of the duodenal bulb extending into the gastric antrum showing a cushion sign. Abdominal CT showed a 67×66mm clear fatty density lesion in the duodenal bulb and the gastric antrum. Based on a diagnosis of lipoma arising in duodenal bulb, we coducted laparoscopic-assisted distal gastrectomy. The resected tumor was 12.0×6.5×3.0cm, wide-based and covered with duodenal serosa. The tumor in the duodenal bulb and antrum was histologically confirmed to be lipoma originating in the submucosa. Giant duodenal lipoma exceeding 50mm in maximum diameter have only been reported in 5 times in Japan and 9 times abroad. Only two have been treated by laparoscopically assisted resection of the duodenal lipoma in Japan.

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A 72-year-old woman who underwent upper gastrointestinal endoscopy for epigastric discomfort was found to have a protruding lesion in the fourth part of the duodenum, upon admission diagnostic imaging studies showed no evidence of distant metastasis or lymph node enlargement, and tumor marker values were normal. Biopsy results indicated adenoma with moderate to severe atypia, but because of the lesion. s 40mm diameter, adenocarcinoma could not be ruled out necessitating surgery. Lymph nodes were submitted for rapid pathological diagnosis intraoperatively, and results confirmed the absence of metastasis, so we conducted a partial duodenectomy, The pathological diagnosis was very well-differentiated 40mm×25mm adenocarcinoma, T1N0M0 stage I. Reports of early-stage primary cancer of the fourth portion of the duodenum are very rare, and we induce a discussion of the literature.

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We report a case of a malignant primary solitary fibrous tumor (SFT) of the liver. A 38-year-old woman admitted for abdominal pain was found in abdominal computed tomography (CT) to have a mass with enhancement below the liver and ascites necessitating emergency laparotomy due to intraperitoneal bleeding from the mass. Bleeding was stopped, and the mass was found to be a hepatic tumor of segment 6. the tumor was not ruptured, and we guess the origin of intraperitoneal bleeding was ovarian hemorrhage. Partial hepatectomy yielded a histopathological diagnosis of SFT. The postoperative course was uneventful, but the woman died 11 months after surgery due to multiple liver and bone metastasis. Primary SFT of the liver is very rare, with only 27 cases, including our own, reported worldwide. Malignant cases are even rarer than primary hepatic SFT.

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An 80-year-old woman with right hypochondralgia consulted a local practitioner and an elevation in hepatobiliary enzymes, a swelling of the gallbladder, and a dilatation of the biliary tract were noted. She was referred to our hospital for further examination. Abdominal enhanced computed tomography (CT) showed a swelling of the gallbladder and dilatation of the intra and extra hepatic biliary tract, but did not show any obvious tumor image. MRCP showed a swelling of the gallbladder, a dilatation of the upper biliary tract, and a V-shaped stenosis of the lower biliary tract. Direct cholangiography through a percutaneous transluminal gallbladder drainage (PTGBD) tube showed the obstruction of the lower biliary tract. An operation was performed because the possibility of malignancy could not be ruled out. We noticed an elastic hard tumor measuring 3.0cm in diameter in the middle and lower biliary tract with severe adhesion to the portal vein and marked swelling of the lymph nodes around the biliary tract. We could not detach the tumor from the portal vein, so a pancreatoduodenectomy with a concomitant wedge resection of the portal vein was performed. The histological diagnosis was an ulcer of the bile duct caused by chronic cholangitis, and no evidence of malignancy was seen. The patient. s postoperative course was good. This case is extremely rare because, to our knowledge, a benign ulcer of the bile duct with chronic cholangitis has never before been reported in the literature.

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We report two cases of eosinophilic cholangitis caused biliary obstruction. Case 1: A 53-year-old woman referred for an abnormal biliary shadow in the liver found in a medical checkup was found in cholangiography to have a local biliary obstruction in the lateral segment of the liver. Suspecting cholangiocarcinoma, we conducted hepatic left lobectomy. Histopathologically resected specimen showed dense eosinophilic infiltration in the obstructive part of the bile duct. The postoperative course has remained uneventful in the 18 months since surgery. Case 2: A 87-year-old woman with right hypochondrial pain, was found in cholangiography to have local obstruction and a stone in the lower bile duct. Histopathological diagnosis from biopsy of this lesion showed dense eosinophilic infiltration but no malignant cell. She was underwent endoscopic biliary dilation and endoscopic stone removal, and has remained symptom-free in the 17 months since surgery. Insofar as we could determine, there were only 18 cases have been reported as eosinophilic cholangitis. Some cases had been conducted invasive surgery for suspicious of malignancy. Recently increase of the clinical reports has made the entity of this disease elucidated gradually, it is thought the treatment with the endoscope becomes subject. Given the need for awareness of this clinical entity and for appropriate diagnosis, eosinophilic cholangitis should be treated by minimal invasion.

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We report a rare communicating accessory bile duct. A 60-year-old woman referred for cholelithiasis surgery was found in laparoscopic cholecystectomy to have a communicating accessory bile duct and in postoperative computed tomography during drip infusion cholecystocholangiography (DIC-CT) and cholangiography showing the aberrant bile duct joined to the anterior inferior duct (B5) and the gall bladder neck. Previous reports suggested that cases of various origins had intermingled. Careful dissection around the gallbladder neck is very important in laparoscopic cholecystectomy.

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A 70-year-old woman bedridden due to cerebral infarction sequela and admitted for abdominal pain and distention had a blood pressure of 83/33mmHg, a heart rate of 88 beats/min, and a body temperature was 35.0°C. Physical examination showed abdominal distension and tenderness, but no peritoneal irritability. Biochemical blood examination showed increased white blood cell (WBC) and C reactive protein (CRP). Abdominal X-ray showed free air. Abdominal CT indicated ascites, hepatic portal venous gas, thickened intestinal wall, and pneumatosis cystoideus intestinalis in the wall of the small intestine. Suspected intestinal perforation due to intestinal necrosis and diffuse peritonitis necessitated emergency laparotomy. Intra-abdominal inspection showed neither intestinal necrosis nor perforation. Following intra-abdominal lavage, cecostomy, jejunostomy, and gastrostomy, nutrition was recovered using enteral nutrition, and she was discharged on postoperative day 94. In this case, we suspected increased intraluminal intestinal pressure due to constipation caused pneumatosis cystoides intestinalis and hepatic portal venous gas through mucosal disruption. Microperforation of the serosa was thought to cause intraabdominal free air.

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A 42-year-old woman seen for lower abdominal pain and vomiting was found in abdominal computed tomography to have a dilated colon containing much feces at the lower abdomen and an SMV rotation sign, suggesting ileus due to intestinal malrotation. Abdominal symptoms subsided with conservative treatment. Colonoscopy showed stenosis of ascending colon. As abdominal pain recurred after oral intake started, we conducted laparotomy and identified as intestinal nonrotation and found the ileocolic portion incarcerated through the omental opening, which we easily released. We report this case because transomental hernia is not a typical cause of intestinal obstruction with intestinal malrotation.

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A 54-year-old man with a 30-year history of ulcerative colitis (UC) involving the entire colon underwent total surveillance colonoscopy, which showed the presence of a dysplasia-associated lesion or mass (DALM) in the rectum. Since the endoscopically resected DALM was found to be well-differentiated adenocarcinoma, the man underwent total laparoscopic proctocolectomy with an ileal pouch and anal anastomosis in 2006. Pathological examinations including chromogranin A staining of the resected specimen showed multifocal proliferation of endocrine cells in the crypts and multifocal microcarcinoids in the rectal mucosa. The literature contains 26 case reports of pathologically documented carcinoid tumors or microcarcinoids in colons of UC patients. These carcinoids are frequently found in total-colon UC (88%) and in long-term UC patients, hose average morbidity is 13.4 years. Of the 26 patients, 10 (38.5%) developed dysplasia or adenocarcinoma of the colon. It is well documented that long-term UC, especially total-colon UC, is complicated by the development of colorectal adenocarcinoma or dysplasia due to field injuries involving pluripotential stem cells of the colorectal lining induced by chronic mucosal inflammation. Although the incidence of carcinoid tumors or microcarcinoids arising in UC-affected colons is relatively low, microcarcinoids may develop due to reactive phenomena induced by persistent chronic mucosal inflammation, a mechanism similar to that seen in colitic cancer development.

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We report a rare case of colonic ulcers with perforation suspected being induced by aspirin. A 78-year-old woman admitted for episodic lower abdominal pain and vomiting. She was medicated with enteric-coated aspirin due to atrial fibrillation and mitral regurgitation. Her abdomen was rigid and bowel sounds scanty. She was afebrile and abdominal X-ray was normal. Abdominal computed tomography showed inflammation of the sigmoid descending colon and large amounts of ascites. Based on a diagnosis of panperitonitis due to lower intestinal perforation, we undertook surgical exploration. Laparotomy showed a large amount of turbid ascites and sigmoid colon ulcers with a 3mm perforation, necessitating colectomy with colostomy. Microscopic examination showed multiple deep ulcers and nonspecific inflammation of the colon without evidence of Crohn's disease, vascular occlusion, or diverticulitis. The definitive diagnosis was thought to be colonic ulcers and perforation induced by nonsteroidal antiinflammatory drugs (NSAIDs). Recovery was uneventful. After closure of the colostomy, she was discharged in good condition.

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We present a rare case of transmesocolonic hernia in the mesentery of transverse colon. A 74-year-old man undergoing hemodialysis and with no history of surgery was referred for abdominal pain and vomiting. In abdominal computed tomography and gastrographin contrast examination using a long tube, he was found to have complete stricture due to a transmesocolonic hernia in the mesentery of transverse colon. Laparotomy showed an oval hernial orifice about 3cm in diameter in the mesentery of the right transverse colon, with about 10cm of the small intestine invaginated through the opening into the mesentery. The invaginated intestine was reverted by manupulation and had no necrosis, so the orifice was repaired by suture. Transmesocolo-nic hernia in the mesentery of transverse colon is rare, and should be considered a differential diagnosis of ileus under abdominal computed tomography and gastrographin contrast examination.

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We report two cases of ischemic colitis accompanied by elevated serum CEA. The mechanism behind elevated CEA is unknown, but benign conditions that elevate CEA include ischemic colitis. Patient 1: An 87-year-old woman admitted for abdominal pain and vomiting was found to have serum CEA elevated to 62.7ng/ml. Suspecting intestinal obstruction associated with colorectal cancer, we conducted laparotomy, finding necrotic change from the transverse colon to the sigmoid colon but no tumor. Resected specimens following left hemicolectomy and temporary ascending colostomy showed acute gangrenous ischemic colitis but no malignancy. Her serum CEA returned to the normal range 6 days later. Patient 2: A 77-year-old man admitted for septic shock was found to have serum CEA elevated to 25. 0ng/ml. Suspecting malignancy, we conducted colonic fiberscopy, finding an ischemic sigmoid colon but no tumor. After half a year of conservative treatment, his serum CEA gradually decreased to the normal range. Serum CEA is known to occur at high positive rates in patients with malignant tumors.

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A 60-year-old woman admitted for high serum carcinoembryonic antigen (CEA) and a mass 3.7cm in diameter in the left pelvic cavity detected by FDG-PET/CT had undergone endoscopic resection six years earlier for a type 0-Ip sigmoid colon polyp 15mm in diameter pathologically diagnosed as well-differentiated adenocarcinoma with submucosal and lymphatic invasion. Sigmoidectomy with lymph node dissection was not done then due to negative tumor cell margin. Based on her history, preoperative diagnostic imaging, and intraoperative findings, we diagnosed the left pelvic mass as mesenteric lymph node metastasis originating in endoscopically resected sigmoid colon cancer. We then conducted sigmoidectomy with lymph node dissection (D3) resultingin pR0 resection. Because the metastatic lymph node exposed the peritoneal surface of the mesenterium, cytology of a small amount of intrapelvic ascites resulted in a Class IIIb diagnosis. The risk of peritoneal dissemination was considered. In endoscopically resected cases of submucosal invasive colorectal cancer with lymphatic invasion and negative tumor cell margins, we should thus select additional surgery or implement surveillance to detect recurrence at an early stage.

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We report a patient with dilated cardiomyopathy who underwent surgery for rectal cancer under general anesthesia despite ejection fraction of 15%(heart hypofunction). and review perioperative management. A 59-year-old man diagnosed with dilated cardiomyopathy who was seen in the Department of Cardiology outpatient clinic was found to have severe anemia and a positive reaction for fecal occult blood, lower digestive tract endoscopy showed a type 2 rectal carcinoma in the Ra rectal region. After conferring with the Departments of Cardiology and Anesthesiology, we conducted low-position anterior resection and D2 lymph node dissection in October 2006. During surgery, we inserted a Swan-Ganz catheter and an invasive arterial pressure line to evaluate circulatory kinetics while monitoring blood pressure, central venous pressure, pulmonary arterial pressure, and urine volume. The man.s perioperative course was relatively stable without exacerbation of heart failure or complications. Controlling heart failure to some degree in cooperation with other departments and preparing monitors and agents based on accurate preoperative evaluation thus enabled highly invasive surgery under general anesthesia.

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The incidence of treatment-related complications after radiofrequency ablation (RFA) for liver tumors is low, and complications of diaphragmatic burns after RFA are rare. We report a rare post-RFA diaphragmatic hernia involving hepatocellular carcinoma (HCC) in the right subphrenic region. A 78-year-old woman admitted for HCC treatment arising from a cirrhotic liver was found in contrast-enhanced computed tomography to have a solitary HCC 1.5cm at its greatest dimension in Couinaud segment VIII. We conducted percutaneous ultrasound-guided RFA with artificial pleural effusion for a hepatic lesion beneath the right hemidiaphragm. One year later, she suffered coughing and dyspnea followed a few days later by abdominal distension and hepatic encephalopathy. Based on a diagnosis of small bowel obstruction caused by an incarcerated diaphragmatic hernia, we conducted laparotomy, finding an incarcerated ileal loop through a 2cm defect at the right hemidiaphragm adjacent to the previously ablated lesion and necessitating partial resection of the ileum and repair of the diaphragmatic hernia caused by RFA therapy. Clinicians must therefore consider such findings a late complication of RFA for hepatic tumors.

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