Introduction: The effect of subcutaneous Penrose drain (PD) insertion in superficial surgical site infection (s-SSI) has not been reported comprehensively. To evaluate effectiveness, we implanted the PD subcutaneously in all cases at high s-SSI risk. Materials and Methods: From April to August 2008, all cases at high s-SSI risk, i.e.) classified into wound class III or IV, or II accompanied by at least 20-mm-thick subcutaneous fat, were subjected to subcutaneous PD implantation and checked for s-SSI occurrence based on risk, wound class, and their totality, followed by comparison with the incidence from November 2007 to March 2008. Results: From April to August 2008, 50 high-risk subjects had a s-SSI incidence of 8.0%. Previous s-SSI incidence from November 2007 to March 2008 was 42.6%. Prophylactic subcutaneous drainage thus significantly decreased in high-risk patients at high risk (p<0.001) and in each classified group and totality, i.e.) ClassII: 9.18% vs. 1.87%, p=0.044, ClassIII: 32.0% vs. 6.90%, p=0.032, ClassIV: 50.0% vs. 10.0%, p<0.001, total: 9.91% vs. 1.97%, p<0.001. Conclusion: The Penrose drain, costing just a few dollars, demonstrates definite potential as an effective means for preventing s-SSI.

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A 71-year-old woman admitted for gastric ulcer, pyloric stenosis, and severe anemia was found in upper gastrointestinal X-ray to have prolapse of the gastric antrum and duodenum into the mediastinum. Abdominal computed tomography (CT) showed the pancreatic head to have herniated into the mediastinum. Her symptoms were temporary relieved by gastrointestinal endoscopy. But liver dysfunction developed, drip infusion cholangiography (DIC)-CT showing bile duct dilation. Under a diagnosis of bile duct obstruction and intractable ulcer due to incarceration of the gastric antrum, duodenum, and pancreatic head of pancreas, we closed the hernia defect after determining that a portion from the gastric antrum to the second portion of the duodenum with the pancreatic head of pancreas was incarcerated in the paraesophageal hiatus. The woman was discharged 12 days after surgery and had no recurrent symptoms in the 30 months after surgery.

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We report a case of bleeding from a diverticulum in the fourth portion of the duodenum detected by multidetector computed tomography (MDCT). A 78-year-old woman undergoing hemodialysis for chronic renal failure twice a week produced coffee-ground-like vomitus during dialysis and her blood pressure dropped, necessitating emergency upper gastrointestinal endoscopy. We found no bleeding source in the esophagus, stomach, or first and second portions of the duodenum, but fresh blood regurgitated from the anal end. In 64-row MDCT, a slightly hypodense 40 mm mass was found in the fourth portion of the duodenum with adjacent extravasation. The patient's vital signs had not been stabilized despite a blood transfusion, so we conducted emergency laparotomy to resect a diverticulum with hematoma and closed the excision site by suture. Diverticulectomy and primary closure is minimally invasive and optimal in the surgical management of duodenal diverticular bleeding, and contrast-enhanced MDCT is useful in diagnosing suspected acute gastrointestinal bleeding.

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A 57-year-old man with von Recklinghausen's disease (VRD) admitted for occult blood, examination was found in colonoscopy to have an ascending colon tumor, comfirmed to be adenocarcinoma by the biopsy spesimen. Abdominal computed tomography (CT) showed a solid tumor on the third portion of the duodenum, necessitating partial duodenal resection and right hemicolectomy. The duodenal tumor was immunohistochemically positive for KIT and CD34, but genomic c-kit gene analysis showed no apparent mutations. These results suggest that the pathogenesis of gastrointestinal stromal tumors (GIST) in VRD patients differs from that in non-VRD patients. Although VRD is often complicated by neurogenic tumors, GIST has been recently reported to occasionally occur in VRD patients, who should therefore be systemically examined with special attention paid to the gastrointestinal tract.

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We report the case of 50-year-old man presenting abdominal fullness and general fatigue, in whom a cystic liver tumor was detected by ultrasound screening. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a multilocular cystic liver tumor with a thrombus in the common bile duct. We conducted extended left and caudal hepatic lobectomy with extrahepatic bile duct resection. The cut surface of the resected specimen showed a multilocular and honeycomb like cyst. Pathological findings confirmed adenocarcinoma intermingling with adenoma on the cyst wall occurring in the fatty liver with fibrosis. This was compatible with a hepatic cystadenocarcinoma, type II-A in Group A, according to Kawarada's classification. The relationship of fatty liver and hepatic cystadenocarcinoma remains unclear, however we suspect that liver fibrosis could be a carcinogenetic factor.

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A 62-year-old man reporting jaundice found in cholangiography to have a clear-margined oval shadow defect at the end of the common bile duct diagnosed by frozen section as poorly differentiated carcinoma underwent pancreaticoduodenectomy. Pathological studies showed relatively homogenous cells with solid growth and immunohistochemical analysis positive staining for CD-56,; yielding a definitive diagnosis of small cell carcinoma of the common bile duct, Stage III (pT3pN0M (-) ). Tegafur/uracil administered as adjuvant chemotherapy for a year has resulted in the man's survival without recurrence in the 5 years since surgery. Small cell carcinoma and adenoendocrine cell carcinoma of the bile duct are highly malignant diseases with a dismal prognosis and median survival of just 9.5 months. Fortunately, they are also rare and, to the best of our knowledge, this is only the 32nd case reported in the Japanese literature.

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An 83-year-old man with B-cell chronic lymphocytic leukemia diagnosed 13 years earlier but not treated because thrombocythemia was mild and developing splenomegaly 4 years later, was admitted for sudden-onset left lateral abdominal pain with no history of trauma in October 2008. Abdominal computed tomography showed bleeding in the abdominal cavity with splenic rupture, necessitating splenectomy. We found a huge 1950 g 18×12×7.5 cm splenomegaly and bloody ascites. Pathological examination showed the invasion of B lymphocytes that were CD-20 positive in the red pulp. The man had no complications except for hyperleukocytosis caused by chronic lymphocytic leukemia. He was discharged on post operative day 12. He still is not administered medication and his platelet value remains within the normal range.

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We report a case laparoscopy-assisted surgery for adult duplicated ileal perforation. A 38-year-old man seen in an emergency for sudden abdominal pain onset was found in palpation to have severe abdominal tenderness with rebound tenderness and guarding. Abdominal enhanced computed tomography (CT) showed an inflammatory cystic-like tumor in the left abdomen near the navel and very small amount of free air diagnosed as panperitonitis due to Meckel's diverticulum perforation and requiring urgent laparoscopic surgery that day. Laparoscopy showed a perforated diverticulum with a cystic-like tumor about 80 cm from the ileum toward the mesenteries, necessilating partial ileal resection and appendectomy. The diagnosis was a duplicated ileum with ectopic gastric mucosa inside the cyst-like duplication, but having no pathologically detectable continuity with the intestinal tract. No ectopic gastric mucosa was seen in the consecutive diverticuli but the wall was perforated.

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Pouchitis-the most common complication of total proctocolectomy and anal ileal-pouch anastomosis for ulcerative colitis-is effectively treated in most patients by antibiotic ciprofloxacin or metronidazole therapy, In some cases, however, pouchitis is refractory to these antibiotics. We detected Clostridium difficile toxin A in the feces of three patients suffering from antibiotic-refractory pouchitis whose mucosal inflammation was ameliorated by oral vancomycin treatment. C. difficile should therefore be considered in antibiotic-refractory pouchitis, which requires appropriate medication.

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A 74-year-old man seen elsewhere for positive occult blood in the stool detected during a municipal health examination was suspected from lower gastrointestinal endoscopy of having malignant lymphoma of the ascending colon and referred to us. Physical examination showed no superficial lymph nodes to be palpable, but barium enema and lower gastrointestinal endoscopy showed a type 1 tumor 2 cm in diameter in the ascending colon. Immunohistochemical staining of biopsy specimens yielded a diagnosis of extramedullary plasmacytoma. Fluorodeoxy glucose positron emission tomography (FDG-PET) showed marked accumulated FDG in the lesion but no evidence of metastasis, necessitating laparoscopic ileocecal resection with D2 lymph node dissection. The histopathology of the resected tumor showed diffuse proliferation of plasma cells producing κ chains, with an intramural invasion to the muscularis mucosae. No lymph node metastasis was found. At 18 months after surgery, the man shows no evidence of metastasis or relapse and is being treated as an outpatient. Extramedullary plasmacytomas originating in the large intestine are extremely rare; with only 5 patients, including ours, having been reported in Japan. Our patient is also considered as the first case of extramedullary plasmacytoma reported anywhere in the world to have been treated by laparoscopic ileocecal resection. This case is discussed with reference to the literature.

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We report a case of anastomotic recurrence following surgery for submucosally invasive colon cancer. A 78-year-old man diagnosed with submucosally invasive cecal cancer underwent laparoscopy-assisted ileocecal resection with D2 lymph node dissection and functional end-to-end anastomosis. UFT and oral leucovorin administration was initiated as adjuvant chemotherapy after discharge, which the man continued for 6 months as an outpatient. One year postoperatively, however, regular colonoscopy identified anastomotic type 2 tumor recurrence along the staple line, necessitating partial colon resection involving the anastomosis. Few cases of anastomotic recurrence after surgery for submucosally invasive colon cancer have been reported in the Japanese literature. Effective measures against anastomotic recurrence following the implantation of exfoliated cancer cells are thus required following surgery for submucosally invasive colon cancer, and regular postoperative colonoscopic examination is a vital part of such follow-up.

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We report a case of intussusception with cancer-induced rectal perforation. A 86-year-old woman admitted for sudden abdominal pain onset, vomiting, and abdominal distention was found on rectal examination through the anal canal to have a soft rectal mass. Computed tomographic (CT) showed ascites, intraperitoneal free air, and a rectal mass with intussusception. Based on a diagnosis of intussusception and tumor-induced rectal perforation, we conducted emergency laparotomy. The peritoneal cavity confained dirty fluid, the rectal tumor, and upper-rectum intussusception. Repositioning the intussusception by Hutchinson's method revealed a perforation in the anterior rectal wall, necessitating Hartmann's operation, peritoneal lavage, and drainage. Intussusception with perforation caused by rectal cancer is very rare, so we present this case with some bibliographical comments.

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We report a case of rerupture of an aneurysm of the middle colic artery caused by segmental arterial mediolysis (SAM), a rare nonartherosclerotic nonimflammatory arteriopathy. A 56-year-old man admitted for abdominal pain was found in Abdominal computed tomografhy (CT) to have an intraabdominal hemorrhage, treated conservatively, and discharged. Three weeks later, he was readmitted for melena and loss of consciousness. Abdominal CT showed that the clearly bordered 95×64 mm tumor had come in contact with the transverse colon. We also found that contrast medium had extravasated to the tumor. Angiography showed that the left branch of the middle colic artery was bead-shaped and an aneurysm had formed there. We attributed these findings to SAM. Attempted arterial embolization was not successful, so we conducted emergency surgery, finding that the tumor, which was in diameter, 9 cm indeed contacted the transverse colon under the splenic flexure. We resected the colon and the tumor, which we concluded was a pseudoaneurysm, whose rupture toward the colonic lumen caused melena.

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Pulmonary pleomorphic carcinoma is rare but its prognosis is poor. We reported a case of abdominal metastasis of pleomorphic carcinoma regrowing within 3 weeks after resection. A 50-year-old man, who had undergone radical resection for pulmonary pleomorphic carcinoma 5 months earlier and admitted for anorexia and fatigue, was found in abdominal computed tomography to have a left upper quadrant mass suspected of being a gastrointestinal tumor. Worsening tumor hemorrhaging and symptoms necessitated emergency open surgical tumor resection. The pathological diagnosis was omental pleomorphic carcinoma metastasis. Although we completely resected the tumor macroscopically, it regrew to the preoperational size on postoperative days (POD) 19. The tumor grew continuously and at POD 46, the patient died of multi organ failure caused by obstructive jaundice, respiratory failure, and anemia. The former two were due to compression of porta hepatis and diaphragm by the regrowing tumor, the latter was due to intra-tumor hemorrhage.

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We performed laparoscopic-asisted percutaneous endoscopic gastrostomy (LAPEG) in 4 cases in which percutaneous endoscopic gastrostomy (PEG) was difficult. All of the patients were male and had no history of laparotomy. Their mean age was 72.5 years, and ordinary PEG was attempted in all of them, but because there was judged to be a risk of puncturing other organs, we switched to LAPEG. The mean operation time was 36.7 min, and mean blood loss was 3 mL. Wound infection at the site of insertion of the gastrostomy was observed in 1 case, but it was treated conservatively. LAPEG is a superior method that enables gastrostomy to be performed safely and with minimal invasion, and that makes replacement of the gastrostomy tube and routine management easy.

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