Purpose: The aim of this study was to investigate the possible association of peristomal granulomas（PG）and parastomal hernia（PSH）and other clinical factors, and to determine whether PSH associated with PG causes various symptomatic complications. Methods: We retrospectively identified 145 patients who had undergone rectal resection and descending or sigmoid permanent colostomy in our hospital between September 2002 and July 2010, and compared patients with PG (n = 26) and without PG (n = 119) with regard to clinical factors, including PSH. Patients with PG consisted of 17 patients accompanied with PSH, and 9 patients who did not have PSH. We then defined connected PG formation as having 3 or more granulomas connected along the peristomal mucosa-skin junctional line, and determined whether PSH was an associated factor with connected and symptomatic PG formation or not. Results: In multivariate analysis, PSH (P = 0.018), and BMI at the time of operation ≧23.5 (P = 0.035) were factors significantly related to PG. Stoma height of skin level (P = 0.052) may also be a related factor to PG. BMI at the time of operation and stoma height were also found to be associated significantly with PSH. PG with PSH were more frequently connected (P = 0.004) and symptomatic (P = 0.039) than PG without PSH. Conclusions: PSH is a factor significantly associated with PG. PSH is significantly related to symptomatic and connected PG. Treatment or prevention of PSH should be taken into consideration to avoid symptomatic PG refractory to conservative treatment.

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A 51-year-old woman admitted for abdominal discomfort was found to have a 12 cm superficial esophageal squamous cell carcinoma and a submucosal cardiac tumor by esophago-gastrointestinal endoscopy. We diagnosed the submucosal tumor as a huge metastasis of right cardiac lymph node. She then underwent total thoracic esophagectomy with 3 field lymphadenectomy. The huge stomach tumor was diagnosed as an intramural metastasis to the stomach 53×44 mm. Final pathological findings were superficial esophageal carcinoma with tumor depth of muscularis mucosae with an intramural metastasis to the stomach and 10 lymph node metastases including the common hepatic arterial node. Immunohistochemical analysis revealed that high expression of the lymphangiogenic factor was observed in the primary tumor. She had abdominal lymph node recurrence 9 months postoperatively although postoperative adjuvant chemotherapy had been administrated. She received chemotherapy and chemoradiotherapy for the recurrent disease; however she died 29 months after the operation. To the best of our knowledge, there are only 3 reported cases of mucosal esophageal carcinoma with an intramural metastasis to the stomach.

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We present a case of a neuroendocrine carcinoma (NEC) of the liver. A 66-year-old Japanese woman was admitted to our hospital with epigastric pain. Computed tomography revealed an 89×76 mm low density mass occupying most of the right lobe the liver with occlusion of the right portal vein (VP3) and right and middle hepatic vein (Vv2). Under a preoperative diagnosis of intrahepatic cholangiocarcinoma, extended right lobe hepatectomy, common bile duct resection, lymph node dissection, and hepatico-jejunostomy were performed. The histological findings were consistent mainly with NEC cells and adenocarcinoma cells in the intrahepatic bile duct. Both components were immunohistochemically positive for synaptophysin. Systemic chemotherapy (gemcitabine) for metastasis to the lung, liver and bone was ineffective and the patient died 6 months after surgery. Several cases of NEC of the liver have been reported, but this is the first reported case of NEC of the liver coexistent with intrahepatic cholangiocarcinoma. This case suggested that intrahepatic cholangiocarcinomas associated with the histological nature of NEC of the liver.

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The patient was a 69-year-old man. In August 2002, abdominal computed tomography (CT) revealed an enhanced lesion 4 cm in diameter in S5/6 segments. Hepatocellular carcinoma was diagnosed by fine needle aspiration (FNA) biopsy. He underwent right lobectomy of the liver. Eight years after the hepatectomy, an intrapubic mass lesion (6 cm in diameter) was detected by CT. We suspected the lesion to be peritoneal recurrence of HCC, gastrointestinal tumor, angiosarcoma, or malignant fibrous histiocytoma. Whole-body positron emission tomography imaging revealed no other lesion. Tumor extirpation was carried out in October 2010. A histological examination of the resected nodule demonstrated the peritoneal dissemination of the hepatocellular carcinoma. This seems to be a rare case of FNA related to peritoneal dissemination.

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A 64-year-old man had been followed up because of alcoholic liver injury. Multiple liver tumors were detected on abdominal computed tomography (CT) and abdominal ultrasonography (US) and he was admitted to our hospital. There were three tumors. The tumors in S3 and S6 werer enhanced but the tumor in S8 was not enhanced on dynamic CT. Fine needle biopsy of the S8 tumor of the liver revealed adenocarcinoma. Left lateral segmentectomy and partial resections of S4, S5, S6, and S8 were performed. Pathological examination revealed double primary liver cancer of hepatocellular carcinoma (S3, S6) and intrahepatic cholangiocarcinoma (S4, S5, S6, S8). Lung metastasis and cervical lymph node metastasis were found 20 months after the operation. Though we performed chemotherapy, this patient died 3 months later. Concomitant hepatocellular carcinoma and intrahepatic cholangiocarcinoma is rare. We report a very rare case of double cancer without hepatic C virus and B virus infection.

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We report a very rare case of gangrenous cholecystitis which was caused by herniation of the gallbladder through the foramen of Winslow with severe torsion. An 86-year-old woman in a geriatric health services facility had high fever and upper abdominal pain 5 days before admission. She was initially treated with antibiotics at the facility, but exacerbation of the abdominal pain led her being referred to our hospital for further treatment. Abdominal ultrasonography revealed a large distended gallbladder with an edematous wall, but no stones. Abdominal CT showed the herniated gallbladder through the foramen of Winslow with a whorled appearance at the neck of the gallbladder. We suggested the possibility of herniation of the gallbladder through the foramen of Winslow with torsion, and emergency surgery was performed. Operative findings showed the Gross type-II floating gallbladder which had gangrenous changes and herniation through the foramen of Winslow and 450° clockwise torsion, the so-called complete type, at the neck. Cholecystectomy was performed. Her postoperative course was uneventful and she was discharged 18 days after surgery and returned to the facility.

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We report a rare case of granular cell tumor of the common bile duct. A 62-year-old woman who underwent total gastrectomy, lymph node dissection, Roux-Y reconstruction, and splenectomy for gastric cancer in December, 2007 was found to have a palpable tumor, 8 mm in diameter, in the middle common bile duct during surgery and confirmed after additional examination. An enhanced CT scan of the abdomen showed a round tumorous lesion in the middle common bile duct without bile duct wall thickness. Cholecystectomy, choledocholithotomy, and choledochoduodenostomy were conducted based on a preoperative diagnosis of a common bile duct tumor in March, 2008. The lesion was a yellowish-white submucosal tumor. Immunohistochemical study of the resected specimen confirmed granular cell tumor of the common bile duct. Postoperative progress was uneventful with no recurrence till the present. The occurrence of granular cell tumor in the biliary tree is extremely rare and, to the best of our knowledge, our case is only the fifth of such cases reported in Japan.

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Total pancreatectomy for invasive ductal carcinoma is rare. A 59-year-old man presented with upper abdominal pain in May, 2010. Abdominal CT revealed multi-focal tumors in the pancreatic head, body, and tail. Our diagnosis was pancreatic cancer, so we performed total pancreatectomy. Pathologic diagnosis was invasive ductal carcinoma, T3N0M0 Stage III. All tumors were connected with pancreatic intraepithelial neoplasia (PanIN). There was the possibility of independent tumors in each nodule, but these continued through the lesion in the epithelium, and a single lesion seemed to have formed multiple nodules because all of these were the histologically same.

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A 74-year-old man was admitted to Ogaki Municipal Hospital with a chief complaint of anemia. Abdominal enhanced CT showed 13 cm expansive growing tumor in the left upper abdomen. The borderline between the pancreas body and the tumor was unclear and the dilatation of the main pancreatic duct was seen. In the portal vein, filling defect suspected of tumor thrombus was seen. MRCP showed interruption and dilatation of the main pancreatic duct. Given these, we diagnosed acinar cell carcinoma or endocrine tumor of the pancreas with tumor thrombus extending into the portal vein and distal pancreatectomy with portal vein replacement, right hemicolectomy and jejunectomy was performed. Pathological diagnosis was acinar cell carcinoma. During follow up, multiple liver metastases was found after 3 months. We treated this by systemic chemotherapy of Gemcitabine or S-1 but he died of cancer after 9 months. Patients with acinar cell carcinoma extending into the portal vein have poor prognosis and need to be treated by chemotherapy after surgery, however, standard treatment has not yet been established.

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A 79-year-old man presented to the emergency department with abdominal pain. He had tenderness in the left side of the umbilicus. Enhanced abdominal computed tomography showed thickening of the small intestinal wall in the lower left abdomen with a small amount of adjacent free air. The fat tissue around the small intestine also revealed a high density area suspecting inflammation. Under the diagnosis of peritonitis, due to intestinal perforation, an emergency operation was performed. We resected a part of the jejunum with the abscessed greater omentum at about 180 cm from the ligament of Treitz. The resected specimen showed a mass lesion 3 by 7 cm with ulcer and perforation at the base of the ulcer. Histopathological findings revealed densely increased numbers of monomorphic medium-sized lymphoma cells infiltrating into all layers of the intestine and lymphoepithelial lesion. Immunohistochemically, the lymphocytes were positive for CD3, CD8 and CD56 and negative for CD4, CD20 and EBV-encoded small non-polyadenylated RNA-1 in situ hybridization. We diagnosed type II Enteropathy-associated T-cell lymphoma (EATL) . The postoperative course was uneventful and he was discharged on postoperative day 8. He had a recurrence of type II EATL and died 62 days postoperatively.

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A 54-year-old woman presented with chief complaints of hemorrhagic stool and anemia. Lower endoscopy following admission revealed advanced stage II rectal cancer. Contrast-enhanced CT showed a filling defect in the inferior mesenteric vein, and tumor embolism was suspected. On laparotomy, a hard, cord-like mass was palpated continuously from directly under the tumor to the periphery of the inferior mesenteric vein. After first ligating the inferior mesenteric vein, lower anterior resection with hysterectomy was performed. The pathological diagnosis was mucinous carcinoma with a depth of invasion of a2, and no lymph node metastases were observed. Tumor embolism was seen in the inferior mesenteric vein. On abdominal CT performed 8 months later, a low density area, 2 cm in size, was detected in the left medial segment (S4) of the liver, and the medial segment of the liver was resected. The liver tumor was a mucinous carcinoma, diagnosed as liver metastasis of rectal cancer. Following surgery, the patient was given combination chemotherapy with FOLFOX4 plus bevacizumab for approximately one year and followed-up. Liver, lung, and adrenal metastases developed following the conclusion of chemotherapy, but all were resected. The patient was still alive 4 years and 2 months after the initial surgery.

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