Purpose: To improve prognosis, we evaluated preoperative factors for treating colorectal perforation and potentially fatal factors and postoperative complications. Methods: Subjects were 35 persons undergoing emergency surgery for colorectal perforation between January 2004 and August 2008. We analyzed preoperative factors of age, complications, perforation cause and site, white blood cell count, creatinine, prothrombin time, base excess, body temperature, blood pressure, APACHE II score, time from perforation onset to surgical intervention, ascites, and surgical procedure. We then analyzed potentially fatal postoperative complications for mortality. Results: Overall mortality was 23% (N=8) for which significant predictive factors in univariate analysis were creatinine, prothrombin time, base excess, body temperature, blood pressure, APACHE II score, and ascites. Multivariate logistic regression analysis, however, showed only the APACHE II score to be significantly associated with mortality (relative risk 1.89, p=0.005). Mortality in those with an APACHE II score of ≥20 was 83%, compared to 10%, in those with an APACHE II score of <20 (p=0.001). Postoperative mortality increased significantly from zero in those without the postoperative infection such as intraperitoneal infection, bacteremia or pneumonia to 53% in those with the infections (p<0.001). Mortality increased significantly from 13% in those without disseminated intravascular coagulation (DIC) to 80% in those with it (p=0.006). Conclusions: The APACHE II score is significantly predictive in those with colorectal perforation. And, it indicated that successful management of the postoperative infections could reduce mortality.

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We report a rare case of pregnancy involving esophageal achalasia complicated by severe anemia and fetal distress due to a huge submucosal hematoma. A 32-year-old pregnant woman admitted for hematemesis and severe anemia sufferd loss of conciousness, causing fetal distress. Computed tomography and endoscopic examination detected esophageal dilation, submucosal esophageal hematoma, blood pooling in the esophageal lumen, and lower esophagus tortuosity. Emergency surgery involved a Caesarean section, Heller myotomy with Dor fundoplication, and gastrostomy. The postoperative course was uneventful, with the patient discharged on post operative day18, and the premature infant after a 3-month stay in the neonatal intensive care unit.

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Glycogen storage disease type Ia (GSDIa) is a congenital metabolic disorder often associated with multiple hepatocellular adenomas. We report a case of adenomas with internal bleeding requiring hepatectomy twice. A woman diagnosed with GSDIa when one year old was later found to have multiple hepatocellular adenomas and followed up thereafter. At age 18, she was seen for sudden upper left abdominal quadrant pain and fever and diagnosed with adenoma with internal bleeding in the left lateral segment. Hepatic selective transcatheter arterial embolization (TAE) for preventing rupture failed to relieve pain and fever, so we conducted lateral segmentectomy to alleviate symptoms and due to the possibility of malignancy. Three years later, we partially resected her liver due to growing adenomas with internal bleeding. Liver transplantation is a radical treatment for multiple hepatic adenomas in GSDIa. We found adenoma resection useful because liver transplantation was hardly a possibility due to Japan's dire donor shortage. Careful follow-up is especially important to subjects in their 30s due to potential malignancy.

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A 55-year-old man who had undergone transarterial embolization (TAE) elsewhere for hepatocellular carcinoma (HCC) evidenced by a S1 liver lesion (2 cm in diameter) in May 2004 was seen for right hypochondrial pain in August 2005. Abdominal computed tomography (CT) showed a hematoma of the gallbladder, diagnosed as acute hemorrhagic cholecystitis requiring cholecystectomy. Clots had accumulated of clots in the gallbladder and the mucosa was mildly inflamed. He suffered back pain, melena, and jaundice in November 2005, and endoscopic retrograde cholangiopancreatography (ERCP) showed hemobilia. Abdominal contrast CT showed a mass (3 cm in diameter) having ill-defined border in the caudate lobe. Based on HCC recurrence suspected, we conducted intraoperative cholangioscopy used for hemobilia and observed a tumor embolus proceeding from the bile duct branch of Spiegel's lobe into the left branch of the intrahepatic bile duct. Based on a diagnosis of HCC invasion to the bile duct, we totally resected the left hepatic and caudate lobes. Although few cases develop hemobilia due to HCC invasion to the bile duct, this should be considered in HCC follow-up.

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We report a very rare case of chyrulia following biliary and abdominal surgery. A 58-year-old woman undergoing right lobectomy with bile duct and portal vein resection and reconstruction after percutaneous transhepatic portal vein emborization for gallbladder cancer with infiltration to the right hepatic artery, portal vein and bile duct was discharged on postoperative day (POD) 26 without major complication so she was readmitted for dehydration, electrolyte imbalance, and chyrulia on POD 50, discharged again after symptomatic therapy, then readmitted for shortness of breath and appetite loss. Left pelvic kidney urine was normal, but right pelvic kidney urine included 2+proteinuria/2+sugar in split renal function, spouting of chyrulia from the right ureter closest at cystoscopy. Filarial antibody was negative. Based on a diagnosis of chyrulia due to lymphorrea at the right pelvis due to gallbladder cancer surgery influence, she underwent unilateral stripping of the right renal pedicle. Postoperatively, hyponatremia, proteinuria, and urine dullness disappeared and ascites and edema were relieved. To the best of our knowledge, only one such case have been reported in the Japanese and English literature.

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We report a case of solid pseudopapillary tumor (SPT) of the pancreas, a 59-year-old woman seen for an abdominal mass initially diagnosed as a pancreatic tumor underwent subtotal pancreatectomy. The tumor was diagnosed pathologically as SPT, immunostaining show low galection-3 expression, reportedly indicating poor prognosis. Careful follow-up including computed tomography (CT) found liver metastasis two years and three months later necessitating partial liver resection. The second tumor was diagnosed pathologically as liver metastasis from SPT. Despite a generally good prognosis, metastasis occurs in about 15% of SPT cases, although no consensus has been reached on the malignant potential of SPT. Galectin-3 is thus a useful marker of malignant potential.

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Hereditary spherocytosis, which causes hemolytic anemia, jaundice, and splenomegaly is often treated by splenectomy, and recurrence is rare due to the dispersion of the spleen or accessory spleen remnants. We report a case of laparoscopic resection of the accessory spleen for the recurrence of hereditary spherocytosis 17 years after splenectomy. A 21-year-old woman had underwent splenectomy and cholecystectomy for hereditary spherocytosis and cholelithiasis at the age of 4. She was seen for jaundice at the age of 21. Three-dimensional computed tomography showed an 8 cm tumor and spleen scintigraphy showed high accumulation in the pelvis. Based on a diagnosis of hereditary spherocytosis recurrence due to a large accessory spleen in the pelvis, we conducted laparoscopic resection of the accessory spleen. She was discharged on postoperative day 6 without complication. Hereditary spherocytosis thus may, in cases, recur in the presence of accessory spleens.

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We report a case of encapsulated peritoneal sclerosis (EPS) requiring surgery three years after renal transplantation. A 54-year-old man treated by peritoneal dialysis for 14 years underwent cadaveric donor renal transplantation. Three years after the transplant, the patient developed intestinal obstruction resulting from EPS. Emergency surgery showed the small intestine to be encapsulated in white fibrous tissues. Enterolysis with resection of the white capsule relieved the intestinal obstruction, and the man was discharged 13 days after operation. Basic EPS treatment includes bowel rest, steroids, and immunosuppressive agents, but the pathological response is poor. Some reports discuss the exacerbation of EPS after kidney transplant, despite the administration of steroids and immunosuppressive agents. This fact should be kept in mind in follow-up for kidney transplant recipients with a history of peritoneal dialysis.

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Most Bochdalek hernias are observed in infancy, and adult cases are very rare. We report such a case perforating the small intestine in an adult suffering serious clinical complications. A 72-year-old woman admitted for nausea, abdominal pain, underwent emergency surgery for a left diaphragmatic hernia with small-intestine incarceration and thoracic cavity perforation. A defect in the left diaphragm was diagnosed as a Bochdalek hernia entered by 40 cm of the ileum in the left chest. Hernia strangulation caused a 15 mm punch in the thoracic cavity, necessitating partial small-intestine resection including the perforation site. The diaphragmatic defect was closed with interrupted sutures and herniation repaired by closing the left Bochdalek foramen. Such subjects should undergo surgery as soon as possible after diagnosis.

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We report an extremely rare case of internal hernia incarcerated into the mesenteric gap between a gastrojejunostomy and Braun anastomosis after Billroth II gastrojejunostomy. A 76-year-old man who had undergone gastrectomy 40 years earlier and seen for vomiting and regular abdominal colic pain but without metallic sounds or muscular defense was found in abdominal computed tomography to have an almost completely dilated small intestine, suggesting strangulated ileus. Emergency surgery showed almost all of the small intestine to be dilated and dark red. We repositioned the incarcerated intestine by feeding it toward the terminal ileum. The incarcerated intestine fit into the mesenteric gap between efferent and afferent loops taking the form of an internal hernia. No bowel resection was required. The hernia orifice constructed by the mesenteric gap was closed by suturing.

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We report successfully treating a rare case of recurrent solitary tumor in the rectovesical extraperitoneum. A 68-year-old man undergoing right hemicolectomy for ascending colon cancer in 2001 was found in pelvic computed tomography in October 2003, conducted to evaluate a tumor marker increase, to have a 16 mm tumor behind a seminal vesicle touching the rectum. Endoscopic biopsy showed well-differentiated submucosal adenocarcinoma, necessitating low anterior resection. Surgical findings indicated the tumor had invaded to Rb of the rectum, but, showed nothing unusual in the rectovesical pouch. Microscopic findings in the resected specimen suggested invasion from outside the intestinal wall because rectal mucosa was intact. The man has shown no sign of recurrence in the more than 5 years since the last surgery.

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We report an extremely rare case of solitary thyroid metastasis from the rectum. A 65-year-old woman undergoing low anterior resection for rectal adenocarcinoma was given a definitive pathological diagnosis of moderately differentiated adenocarcinoma, pT2 (ss), pN1, stageIIIa. Postoperatively, she underwent adjuvant chemotherapy 5 cycles with UFT/UZEL. Ten months later, computed tomography (CT) showed a low-density left thyroid gland nodule with swollen cervical lymph nodes. Fine-needle aspiration biopsy of the nodule showed carcinoma cells, necessitating thyroidectomy and modified neck dissection based on a diagnosis of primary thyroid carcinoma. Histological examination showed that the thyroid adenocarcinoma had metastasized from the rectum. No involvement of regional lymph nodes was seen. Postoperative physical and imaging examinations found no evidence of metastasis. Although metastasis to thyroid gland is recognized in autopsy studies, tumor metastasis localized in the thyroid gland is clinically uncommon.

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We report treating a solitary fibrous tumor originated in the transverse colon mesentery by laparoscopically. A 72-year-old man admitted for an abdominal mass was found in enhanced computed tomography (CT) to have a 6 cm solid mass adjacent to the transverse colon. An artery branching from the middle colic artery fed a tumor. T1-weighted magnetic resonance imaging (MRI) showed a homogeneous low-intensity mass. Laparoscopic surgery conducted for a suspected mesenchymal tumor arising from the transverse colon found that the tumor had originated in the transverse colon mesentery. We resected the tumor laparoscopically. Histologically, the tumor consisted of spindle cells presenting a "patternless pattern." The labeling index was 6.8%. Immunohistochemical staining was positive for CD34 and bcl-2 and negative for c-kit, α-SMA, vimentin, and desmin. The tumor was definitively diagnosed as a benign solitary fibrous tumor of the transverse colon mesentery.

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Adult rhabdomyosarcoma rupture is rare. A 21-year-old man seen for abdominal pain and constipation was found in abdominal computed tomography (CT) and magnetic resonance imaging (MRI) to have a large pelvic tumor with abdominal pain and distension rapidly worsening. CT showed considerable ascites and laboratory findings indicated anemia. In emergency surgery based on a diagnosis of tumor rupture, we found intraabdominal hemorrhaging and mucinous discharge and conducted abdominoperineal resection. Parts of the tumor adhering to the prostate and urinary bladder had to remain in the abdomen. The histopathological diagnosis was embryonal rhabdomyosarcoma. One month after surgery, metastases detected in the liver and lung have completely disappeared after chemotherapy and radiation. At present, 15 months after surgery, the man remains alive without disease recurrence.

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