Mondor's disease is a relatively rare benign disease which is characterized by thrombophlebitis of the subcutaneous vein in anterior chest wall. It involves a painful subcutaneous cord caused by breast surgery, trauma, and muscular overactivity. We experienced 19 cases of Mondor's disease during the last 16 years.
All patients were women and the ages ranged from 25 to 69 years (mean: 46.8) From an anatomic point of view, subcutaneous cords were found mainly in the thoracoepigastric vein and all cases had some ipsilateral disease. The identified potential etiologies were unknown causes in eight cases, postoperative breast biopsy in five cases, benign breast tumor in three cases and breast cancer in two cases. All cases of the breast cancer were associated with non-palpable tumor, which accounted for about 10% of all 19 cases. Common symptoms included sudden appearance of painful subcutaneous cords or furrows in the skin which run vertically or transversely. The symptoms spontaneously relieved without any treatment about one or two months after the onset of the symptoms except two cases associated with breast cancer.
In patients presenting with Mondor's disease, mammography and ultrasonography should be conducted because of the possibility of underlying breast cancer.

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A series of 27 patients under went venography through the ipsilateral cubital vein in pacemaker implantation at pacemaker generator exchange. Of these 27, revealed complete obliteration of the subclavian vein, including 1 in which venous obliteration extended to the left vena innominate. One of the obliteration of the subclavian vein required additional insertion of a transvenous pole, but ipsilateral puncture was thought possible as a result of venography, so the pole was inserted by puncturing a central portion of the ipsilateral subclavian vein.
In cases of venous obliteration involving the left vena innominate, ipsilateral addition of a pole is not possible. It is thought useful to preced operation with ipsilateral venography.

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We clinicopathologically studied gastric cancer patients with tumor thrombus in the left gastric vein. Of 362 gastric cancer patients operated on from 1991 to 2000, 10 (2.8%) developed tumor thrombus in the left gastric vein, which remained in 8; existed continuously from the left gastric vein to the splenic vein in 1; and existed continuously from the left gastric vein to the splenic/portal stem veins in 1. Gastric cancer predominantly occupied the upper or middle stomach and most were elevated, including 7 type 3. All 10 patients showed advanced gastric cancer with SS or more invasion; histological types including poor differentiation in 6 and differentiated in 4 patients; significant vascular infiltration; high α-fetoprotein (AFP) in 2; and liver metastases in 6. Resection with curability B was conducted in 2. Prognosis included nonrecurrent survival 24 months postoperatively in 1; tumor bearing survival at 6 months postoperatively in 1; and cancer death within 2 years postoperatively in 8. Resection may thus improve prognosis.

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We report a consecutive series of 37 patients undergoing surgery for ampullary carcinoma at our institute between January 1977 and December 2000, whose complication with other malignancies was analyzed as for its clinical aspects and occurrence by external comparison. Mean follow-up lasted 50 months (range: 0.1-190 months). Seven (19%) of 37 patients had at least 1 other tumor. The expected cancer occurrence using person-years method among the 37 was 1.4. The probability of observing 7 or more patients was assumed significantly small (p=0.0006). Of the 7 with at least 1 other tumor, 4 are alive, while 3 died: 1 from cardiac disease and 2 from other carcinomas. Multiple tumors were confined to the colon, rectum, and stomach. Our results suggest that patients with ampullary carcinoma are at increased risk of developing other cancers and should be carefully montitored over the long term to help ensure a positive prognosis.

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A series of 50 resected cases of hilar bile duct carcinoma were subjected to a study of elucidating the appropriate lymph nodes dissection according to the local extent of the tumor by exploring the status of lymph node metastasis. Five-year survival rate of patients without lymph node metastasis and that with nl metastasis were 15.3%, and 14.3%, respectively. Each one patient surviving more than 5 years was recorded in both patient groups. No patient with n2 or n3 metastasis survived beyond 17 months. The most frequent site of lymph node metastasis was No.8 (a, p), followed by 12b and 12p. N3 lymph node metastases were rare. Jumping metastases were found in No. 5 and 6 (suprapylolic or infrapylolic lymph node). As for appropriate lymph node dissection according to the extent of the tumor, D2 is recommended for the standard dissection, and No.5 and 6 lymph nodes should be resected besides. When lymph node metastasis is found in N2 or N3, we should not perform extended resections.

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A 51-year-old woman was referred to our hospital with a diagnosis of ductal carcinoma of the breast which was made by a fine needle aspiration biopsy under ultrasound (US) guidance at another hospital. After admission, mammography was not helpful for the diagnosis. US showed the lesion 8mm in diameter with an unclear border and a large depth width ratio in the left upper lateral quadrant. No lymphnodes were involved. No distant metastases were demonstrated neither by CT scan nor by bone scintigraphy. The patient was diagnosed as having stage 1 (T1N0M0) breast cancer. We performed a conservative surgery on February 14, 2000, and added radiation theraphy. The pathological report finally showed tubular carcinoma (pure type) of the left breast. Nuclear malignancy of the epithelium cells was low and a single layer of the epithelium cells formed well-shaped small open ducts and apical snouts. This type of cancer is commonly seen in pre-menoposal woman. The prognosis of it is comparatively good, however, coexisting benign diseases such as sclerosing adenosis and blunt duct adenosis are often seen in such patients, so that the differential diagnosis is important.

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A 48-year-old woman noting a mass in the left breast was referred to us. Palpation, US, MMG, and ABC yield a diagnosis of T2aN0M0 stage II breast cancer. Macroscopic examination showed a solid tumor 40×30mm in diameter at a section surface. Histologically, the tumor was invasive ductal carcinoma including cartilaginous and osseous metaplasia. ER and PGR were negative. Breast cancer with cartilaginous and osseous metaplasia is a special type of invasive carcinoma, whose incidence is very rare. Only about 60 such cases have been reported in Japan. We discuss clinical features and prognosis.

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Cancer arising in the ectopic breast tissue is rare. This paper presents a case of apocrine carcinoma of the ectopic breast tissue in the left axillary region. A 66-year-old woman was seen at the hospital because of a left axillary tumor. An excisional biopsy of the tumor revealed apocrine carcinoma without connection to the proper mammary gland. There were no other primary legions in a general exploration and clinical findings were also suggestive of breast cancer. A wide local resection with lymph nodes dissection was carried out. After the operation, a rapid swelling of the left breast occurred. A modified radical mastectomy was performed with a suspicion of a progress of cancer to the mammary gland or latent breast cancer. Histological study of the excised mammary gland revealed no apparent malignancy. She is doing well without any evidence of recurrence, as of 10 months after the second operation.

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Invasive lobular carcinoma has a distinctive metastatic pattern compared with invasive ductal carcinoma. It has a higher tendency to metastasize to the stomach, intestine, ovary, peritoneum and retro-peritoneum. We report a rare case of invasive lobular carcinoma which metastasized to the stomach and ovary. A 46-year-old woman was seen at the hospital because of lower abdominal pain at defecation and epigastralgia at hunger. She also had a right breast mass. Radiological and endoscopic examinations showed bilateral ovarian tumors, multiple gastric ulcers and a linitis plastica lesion in the stomach. A biopsy specimen obtained from the stomach showed poorly differentiated adenocarcinoma. Simple mastectomy, total gastrectomy and bilateral oophorectomy were performed. Histological examination revealed that the gastric tumor spreaded between submucosal layer and serosa, and that both gastric and ovarian tumors were identical with the breast cancer. In the treatment of invasive lobular carcinoma, a systemic examination of the patient is mandatory taking its distinctive metastatic pattern in consideration.

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A 51-year-old woman was admitted to the hospital for close exploration and treatment of palpitation and disagreeable sensation on the chest. Before this admission, she visited another hospital because of chest pain and was found having a tumor in the left ventricle on an echocardiography; thereafter her palpitation and chest disagreeable sensation persisted. Cardiac catheter revealed no lesions in the coronary arteries. Cardiac CT scan visualized no tumor, but an echocardiography showed a left ventricular tumor about 10mm in diameter. At surgery, the left ventricle was longitudinally incised under extracorporeal circulation, and then an edematous tumor 8mm in size localized in the ventricular septum was excised together with cardiac muscle adhesive to the tumor. Histopathologically it was myxoma. The postoperative course was uneventful without any complications. The patient was discharged from the hospital.
Left ventricular myxomas are extremely rare compared with left atrial myxomas. Besides, those with the diameter of less than 10mm present difficulty in identification on CT, because hard blood flow in the left ventricle causes disarranged flow of a contrast material; and IL-6, CRP, and eryhrocyte sedimentation rate in those patients sometimes are in normal ranges.
Consequently echocardiography might be most advantageous in diagnosing left ventricular myxoma.

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A 51-year-old man performed a distal gastrectomy with D2 lymph node dissection for gastric cancer 2 years earlier was referred to the hospital because of general fatigue. The laboratory data revealed liver dysfunction. Ultrasound cardiography showed significant pericardial effusion and heart failure due to cardiac tamponade. Pericardial drainage was performed and carcinomatous pericarditis was revealed from a cytology. Adjuvant chemotherapy (TS-1: 100mg/day p.o.×4 weeks) was started after the pericardial drainage and pericardial effusion was controlled. Six months later bilateral pleural effusion and dyspnea were recognized. Thoracic drainage offered the diagnosis of bilateral carcinomatous pleuritis. For left pleural effusion which could not be controlled, pleural adhesion therapy by OK432 was conducted. Four months later, right pleural effusion became significant and uncontrolled. The patient died three years later after the resection of gastric primary lesion. Autopsy revealed prominent carcinomatous lymphangitis in the abdominal and thoracic paraaortic region without other abdominal and distant organ metastasis.

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A case of chronic traumatic thoracic aneurysm of the descending thoracic aorta after a blunt chest injury, which is relatively rare, is reported. A 26-year-old woman who had been suffering from major depression attempted suicide by felling from seventh floor on May 3, 1998. She had multiple injuries including multiple costal fractures, bilateral hemothoraxes, pelvic fracture, and ruptured bladder. Conservative treatments such as transfusion and chest tube drainage were conducted initially. On May 22, she was operated on to repair the pelvic fracture and ruptured bladder. She had two other operations because of pelvic osteomyelitis. A routine chest X-ray examination on November 5 demonstrated an enlargement of the aortic notch. Enhanced CT scan revealed an aneurysm of the descending thoracic aorta. On December 1, she underwent a resection of the aneurysm and a prosthetic graft replacement. The postoperative course was uneventful. Traumatic rupture of the thoracic aorta demands prompt diagnosis and surgical therapy. It is rare that such a patient can escape from death due to the rupture in an acute phase and thereafter an aneurysm of the thoracic aorta is formed chronically like our case. In instances in which rupture of chronic traumatic thoracic aneurysms occur, surgery is recommended immediately after making the diagnosis.

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We report a case of many lesions of aortic arch branches successfully treated by intravascular treatment combined with bypass operation.
A 63-year-old man was admitted to the hospital because of dizziness. The right and left margin blood pressure of the upper limbs was 34mmHg. A close examination revealed 50% stenosis of the internal carotid artery, 90% stenosis of the bottom of the left common carotid artery, occlusion of the left external carotid artery, and 50-75% stenosis of the left subclavian artery. A two-step approach to operation was employed for the patient. In the first operation, a stent was inserted into the left subclavian artery. In the second operation, a left subclavian artery-common carotid artery bypass was performed using a saphenous vein graft. The patient's postoperative course was uneventful and he was discharged from the hospital on the 16th postoperative day. Intravascular treatment for many lesions of aortic arch branches using a stent ofters minimum invasion and resultant better QOL of the patient. This regimen may be of great value.

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A 34-year-old man, who had been diagnosed as having von Willebrand's disease (vWD) of type IIA, was seen at the emergency clinic of this hospital because of an abrupt onset of anal bleeding and hematemesis. Upper gastrointestinal examination revealed bleeding from the upper portion of the body of the stomach. Hemostasis was made. Three days later, the patient complained of feeling of heaviness in the chest. A chest X-ray film disclosed right pleural effusion. A thoracic drain was inserted, when a bloody discharge was seen. Discharge did not decrease in amount thereafter, so that the patient was referred to the surgical department. An emergency operation was performed, when active bleeding was seen from a bulla at the apical segment and also from a portion of adherence of the chest wall. Resection of the bulla was done and hemostasis by way of electro cautery was obtained on the chest wall.
It is known that vWD is a disease with bleeding tendency, but it actually designates a group of heterogeneous diseases of various types. Symptoms and therapies vary by the type of each disease. The diseases are inherited to interfere the primary hemostasis and can be aggravated by bleeding, so that hemostasis must be made as early as possible if bleeding occurs.

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We reported a case of acute pulmonary embolism (PE) after a right upper lobectomy for pulmonary cancer. A 59-year-old woman was admitted to the hospital because of primary right lung cancer. Right upper lobectomy and ND2b dissection were performed. Two days after the operation, she developed sudden loss of consciousness and hypoxia. Lung blood flow scintigram showed multiple perfusion defects at the bilateral lung fields. Anticoagulant and thrombolytic therapies were started immediately under a diagnosis of acute PE. The patient's life was successfully saved by these therapies for 7 days. Anticoagulant and thrombolytic therapies are of great value in the treatment of acute PE and intermittent pneumatic compression stockings offer an effective prevention for acute pulmonary embolism.

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Lung cancer is prone to metastasize to other organs in an early stage due to its anatomical characteristics. However, metastasis to the stomach is uncommon, and patients in whow metastatic lesions in the stomach are detected and excised while they are alive are very rare. We encountered a patient with lung cancer who underwent an excision of metastatic lesions in the stomach. A 70-year-old man who had undergone a right upper lobectomy for G-CSF producting large cell of the lung 2 months earlier was admitted to the hospital because of fever and systemic malaise. An upper gastrointestinal series and a gastroscopic examination showed a Borrmann I-like lesion on the greater curve of the stomach. Gastroscopic biopsy specimen of the mass showed large cell carcinoma. Because the lesion was judged to be resectable by an abdominal CT, the patient underwent a total gastrectomy. Pathological examination of the excised material revealed that the lesion was large cell carcinoma with the depth of se without metastatic lesions in lymph nodes. The patient received 3 courses of adjuvant chemotherapy with decetaxel and CDDP after the operation. The patient has been in good health, as of 28 months after the operation without any evidence of recurrence.

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A 61-year-old man was seen at the hospital because of sensation of food sticking in his throat at meals. Endoscopic study revealed a stricture over the entire circumference of the esophagus at the lower end of the esophagus which tended to bleed and was negative for Lugol staining. Barium meal disclosed a type 2 tumor 6cm in size at the lower thoracic esophagus. With a diagnosis of esophageal cancer, a total excision of the thoracic esophagus with a retrosternal gastroesophagostomy was performed. It was 6.0×4.0cm in size, T3, N1, M0, Stage III. Since the tumor was histopathologically small-cell cancer, postoperative radiation therapy (40Gy/16times; supraclavicular and mediastinam) was given. The postoperative course was uneventful and the patient was discharged from the hospital. He has been free from any signs of recurrence and strictly followed in our clinic, as of 4 years 8 months after the operation.
Although the frequency is low, small-cell cancer of the esophagus has a high malignant potential and a poor diagnosis. In a review of the literature, all patients with esophageal cancer survived for 2 years or more had undergone combined therapies including operation, chemotherapy and radiotherapy. This paper deals with the long-term surviving patient without any signs of recurrence after an excision of the foci followed by radiation therapy.

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A 64-year-old man was admitted to the hospital because he was pointed out to have an elevated lesion of the esophagus by an upper gastrointestinal endoscopic examination at a medical check up. A diagnosis of biopsied material was poorly differentiated squamous cell carcinoma of the esophagus. Total resection of the thoracic esophagus with reconstruction was performed with a diagnosis of esophageal cancer of Mt, T1b, N0, M0, StageI. The resected specimen showed a 20×20mm unevenly elevated lesion with slightly depressed parts. The histopathological diagnosis was esophageal basaloid-squamous carcinoma, pT1b, pN0, pStageI, and curability pA. The tumor was 0-I sep macroscopically and had an invasion depth pf pSM. The postoperative course was uneventful. The patient was discharged from the hospital on October 12, 2000, and is strictly followed in clinic. So far 72 cases of this carcinoma have been reported in Japan. It is believed that basaloid-squamous carcinoma of the esophagus has a poor prognosis compared with squamous cell carcinoma, however, long-term survivors after the carcinoma in an early stage have been increasingly reported. Consequently this patient requires further careful follow up the course of his clinical course.

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This paper presents a rare case of metachronous double cancer of the liver and esophagus, in which esophageal cancer was radically resected 13 years after a hepatic anterior segmentectomy for hepatocellular carcinoma (HCC). A 71-year-old man, who had a history of undergoing a hepatic anterior segmentectomy for HCC 13 years earlier, was admitted to the hospital because of dysphasia. Barium swallow study and an endoscopy revealed well defined ulcerative type of moderately differentiated squamous cell carcinoma 4cm in diameter in the middle third of the esophagus. Esophagectomy was performed on August 30, 2000. Because the patient was associated with liver disfunction and hepatitis c virus infection, a laparotomy was preceded. As the liver damage was mild, an esophagectomy with lymph node dissection (D2) and a posterior mediastinal reconstruction using the stomach were performed. Histologically the esophageal cancer was in Stage IV a, with a curability of pB. The postoperative course was uneventful. The patient is in a good condition without any signs of recurrence. In the patients with double cancer involving HCC, histologic stage of the HCC often becomes the determinant prognostic factor. However, when HCC can be treated curatively like in this case, the second cancer should be treated curatively, if the patient's liver function permits it.

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A 35-year-old woman was seen at the hospital because of abdominal pain and vomiting. Intestinal obstruction was diagnosed on close examination, and an emergency operation was performed on the same day because of prominent clinical symptoms. During operation, there emerged ascites, and thickening and narrowing of the intestinal wall about 210cm to the terminal ileum, an oral side intestine from which dilated. A partial excision of the small intestine was performed. Cytodiagnosis of the ascises revealed numerous eosinophile. Histopathologic study of the excised intestine revealed eosinophile infiltrating to the full thickness. So eosinophilic gastroenteritis was diagnosed.
Eosinophilic gastroenteritis that is characterized by infiltration of eosinophile to the gastrointestinal wall, is a relatively uncommon entity. So far over 120 cases have been reported in the Japanese literature, and of them only 32 patients incluing this patient were operated on as far as we could review. This paper presents a case of eosinophilic gastroenteritis with eosinophilic ascites which was treated by operation, together with some bibliographical comments.

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A 68-year-old man undergoing hemodialysis for a renal failure due to polycystic kidney (PCK) was pointed out having gastric cancer and underwent a gastrectomy. PCK is transmitted as an autosomal dominant trait and ends up uremia. In patients with PCK, the bilateral kidneys massively enlarge by numerous cysts. PCK is expected to have a good prognosis compared with other diseases causing renal failure, because heart failure is relatively rare in PCK due to mild degrees of anemia and preservation of urinary output. But at operation, enlarged kidneys can occupy the procedure field, and once the cystic wall is injured we need a nephrectomy for an uncontrolled bleeding. Rarely, perinephric or retroperitoneal hematona may occur after the operation due to a rupture of the renal cyst. Cerebral aneurysm, heart vulve disorder, and diverticula in the colon are often coexistent with PCK so that we should pay attentions to them in periopetative period. PCK patients account for about 3% of all patients on hemodialysis. In general, hemodialysis patients are more prone to gain some malignant disease, especially gastrointestinal carcinoma. Regular survey of the GI tract must be made for such patients.

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A 72-year-old man with hemophilia A complicated by massive hemorrhage from advanced gastric cancer was performed a radical operation by infusing a preparation of recombinant factor VIII (octocog alfa), and the hemostatic control was successfully made during and after the operation. The activity of factor VIII on admission was 16%. Distal gastrectomy with D2 lymph node dissection was performed with continuous infusion of the recombinant factor VIII (octocog alfa). Total volume of intraoperative hemorrhage was 670g, and no blood transfusion was aquired. The patient was transfused the recombinant factor VIII continuously with the 11th postoperative day to keep the range of activity of factor VIII within 60-80%. Total suture was removed on the 9th postoperative day. The continuous transfusion of the recombinant factor VIII has no risk of infection with any viruses and no adverse effects on the immune system. With the use of the therapy, surgery for patients with hemophilia A can be performed effectively and safely. This therapy will be increasingly used to offer useful perioperative hemostatic control for patients with hemophilia A.

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A 49-year-old woman was seen at the hospital because of lower abdominal pain. She had had two laparotomies for appendicitis and cholelithiasis, respectively. After admission, the patient was given analgesics and followed. The abdominal pain gradually intensified and 6 hours after admission, abdominal distension on the right flank and muscle guarding in the right lower quadrant appeared. Abdominal CT scan revealed gathered ileus intestines in the right side of the retroperitoneum and ascites. Strangulation ileus was diagnosed and an emergency operation was performed. Upon laparotomy, the entire small intestines were impacted in the right side of retroperitoneum to be strangulated with the Treitz' ligament as a hernia orifice. The ileum, an efferent loop, presented severe congestion and a change in color, but the change was normalized when the ileum was soaked in warm physiological saline after it was reduced. So no intestinal resection was performed, and the hernia orifice was closed by sutures. The postoperative course was uneventful.
Paraduodenal hernia is so rare that only 87 cases have been reported in the Japanese literature as far as we could review, and it presents difficulty in diagnosis preoperatively. In this case, characteristic findings should have been revealed on imaging, but it was difficult to differentiate the disease from ileus due to adhesion because of the patient's previous histories of undergoing laparotomies.

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A 78-year-old woman whose fecal occult blood test was positive was referred to the hospital after she was pointed out having a huge duodenal polyp on an upper gastrointestinal x-ray examination at another hospital. Upper gastrointestinal endoscopic examination and an abdominal CT scan showed giant duodenal lipoma. It was difficult to observe this tumor fully by an endoscope, and a surgical resection was performed for the treatment of the duodenal polyp. At the serosal surface of the anterior wall of the duodenal bulbus, a yellowish and round serosal elevation due to the lipoma was observed. The lipoma attached to this serosal elevation as a narrow base of the tumor and it was growing toward the duodenal lumen as a semi-pedunculated polyp. The tumor was 5×3.5×3.5cm in size and had mucosal erosion. Microscopically, the tumor was lipoma. As the outside of this intraluminal lipoma was covered with only the serosa, the origin of this giant duodenal lipoma was thought to be from fat tissue in the subserosa. Three cases of duodenal lipoma, that were thought to be from fat tissue in the subserosa, were reported in Japan among the 104 Japanese case reports of duodenal lipoma.

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A 64-year-old man being monitored for anemia was found on computed tomography to have a tumor in the abdominal cavity. This tumor was diagnosed as a gastrointestinal stromal tumor at laparotomy. Partial jejunal resection was conducted and intestinal reconstruction made by functional end-to-end anastomosis (FEEA) with a linear cutter device. Massive delayed intestinal bleeding occurred on postoperative day (POD) 9, and the patient went into shock on POD 10. Emergent abdominal angiography showed pooling and extravasation near the FEEA site. Emergency laparotomy was done and the jejunum including the FEEA site was partially resected. Bleeding was controlled and no rebleeding occurred in the 1 year since surgery. FEEA site bleeding was diagnosed in postoperative pathological findings.

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A 60-year-old woman admitted was to the hospital because of abdominal pain and vomiting. Physical examination revealed severe tenderness in the abdomen with peritoneal sign. Abdominal CT scan demonstrated a whirl-like pattern of distended small intestinal loops converging toward the point of torsion, and of tightly twisted mesentery around the point of torsion. An emergency operation was performed with a diagnosis of small bowel volvulus. Abdominal exploration revealed a gangrenous small bowel twisted 270 clockwise rotation. After detorsion, the extensive gangrenous small bowel was resected and an end-to-end anastomosis was performed. Because of the absence of a predisposing anatomical abnormality, the patient was diagnosed as having primary small bowel volvulus. Reports of primary small bowel volvulus in adults is few. Abdominal CT scan may provide useful information to diagnose this disease.

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Two cases of Crohn disease with an intractable intestinal fistula after an operation for acute appendicitis are reported.
Case 1: A 32-year-old man was diagnosed as having an intestinal fistula 54 days after an operation for acute appendicitis, and was conservatively treated. After he experienced repeated aggravation and remission, a fistulography revealed communication between the ileum and rectum. Partial excisions of the ileum and rectum were performed approximately 1.5 years after the initial operation. Crohn disease was diagnosed on postoperative histopathological findings.
Case 2: A 26-year-old woman was diagnosed as having an intestinal fistula 47 days after an operation for acute appendicitis. Conservative therapy was unsuccessful. Ileocecal excision was performed about 3 months after the initial operation and Crohn disease was diagnosed postoperatively. Their postoperative courses were uneventful, and no signs of recurrence of the fistula have been demonstrated. In both cases, the histological features of excised appendix at the initial operation was compatible with those of appendicitis, but findings suggestive of Crohn disease were gained by a reexamination in Case 2.
Intestinal fistula after an operation for acute appendicitis occurs in an extremely low incidence. If the disease affects young patients and is intractable, Crohn disease must be kept in mind as a probable differential diagnosis.

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A 76-year-old woman was admitted to our hospital because of repeated bloody stool, the bleeding site not detected and anemia for 6 months. Gastroscopy, colonoscopy, and upper gastrointestinal series failed to confirm any bleeding site, so abdominal angiography was ordered. Superior mesenteric arteriography showed a dilated vein from the early arterial phase to the venous phase and small intestinal endoscopy visualized a small nodular elevation resembling a submucosal tumor in the jejunum 30cm from Treitz's ligament, leading to the diagnosis of arteriovenous malformation (AVM). We conducted laparoscopic surgery. Since the tumor lesion was not detected from the serosal side, intraoperative intestinal endoscopy was introduced and the lesion was detected from the mucosal side. The jejunum including the portion 10cm long was pulled out of the abdomen through the minilapatomy and resected. The postoperative course was good and no anal bleeding recurred. Laparoscopic surgery with the use of intestinal endoscopy is thus effective for treating intestinal AVM.

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A case of intussusception caused by carcinoma of the terminal ileum is reported. A 57-year-old woman was admitted to the hospital because of ileus. Abdominal computed tomography and an ileography by a long tube offered a suspicion of intussusception and a caecum tumor. Emergency operation was performed. An ileocecal tumor 6cm insize was present at 8cm from the teminal ileum, with the intussusception in its oral side. After the intussusception was repaired by Hatchinson's method, the ileocecal resection including 50cm ileum and lymph nodes dissection were performed. Pathologically, the ileum tumor was diagnosed as carcinoma with lumph node metastasis, type 1, well differentiated adenocarcinama, and depth of SS. This case of ileum carcinoma causing intussusception is thought rare.

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We report a case of metastatic malignant melanoma to the small intestine presented with intussusception. A 76-year-old woman was admitted to the hospital because of abdoninal pain and vomiting on December 19, 1999. The patient had been diagnosed as having malignant melanoma of the scalp in 1987, and experienced subcutaneous metastasis of the whole body in 1998 and brain metastasis in 1999. Abdominal CT scan revealed target sign which is typical finding of the intussusception. She underwent an emargency operation and the intussusceped jejunum was resected. The resected matarial disclosed three polypoid lesions. Histological study indicated malignant melanoma (amelanotic type). Nine months after the operation, she died of brain metastasis. Our case is 18th reported case in our country.

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A 62-year-old woman visited our hospital because of a righ lower abdominal pain and redness of skin around an operation scar. She had recieved an appendectomy 52 years previously. An abdominal X-ray and CT scan revealed a high density mass, similar to a fecal stone in the right lower abdomen. We suspected acute appendicitis with a fecal stone but thought that her appendix had been resected. Antibiotics were administrated, and conservative clinical treatment and observation were performed. The next day, her symptoms worsened and an operation was performed. An appendix remnant showing a phlegmonous change was adhered to the abdominal wall. An appendectomy was performed.
In patients presenting with a right lower abdominal pain, acute appendicitis may be possible even in cases when appendectomy has already been performed. Stump appendicitis is very rare. Ultrasonography is considered to be useful for the diagnosis of acute appendicitis, but a CT scan was more useful in the present case.

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A 33-year-old man was seen at the hospital because of melena and abdominal pain. Interstinal radiography with the use of an enema detected sigmoid cancer. In June, 1999, the patient underwent a sigmoidectomy. An examination of the excised specimen revealed the tumor to be poorly differentiated adenocarcinoma, se, ly2, v0, n2, ow(-) and aw(-). Intestinal radiography with use of an enema conducted at a periodic examination 20 months after the surgery disclosed a constriction in the descending colon. An anastomotic stenosis was suspected and a colonoscopy was conducted. Consequently, a lesion affecting the entire periphery was found in the descending colon 10cm orally from the anastomotic site. A biopsy revealed the lesion to be signet ring cell carcinoma, and the patient underwent a left hemicolectomy in March, 2001. Histopathologically, the tumor was signet ring cell carcinoma, ss, ly1, v0, n1, ow(-) and aw(-). Most histological types of colonic tumors are adenocarcinoma of high or intermediate level differentiation, and signet ring cell carcinomas account for only 1% of all colonic cancers. A case of signet ring cell carcinoma of the colon developed 20 months after the treatment of poorly differentiated colonic cancer is presented in metachronous multiple cancer, together with a review of the literature.

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A 56-year-old man was admitted to the hospital because of vomiting. There were previous history of undergoing colectomies for transverse colon cancer and ascending colon cancer, 12 years and 9 years before admission, respectively. Imaging studies revealed a liver tumor in S4-5, which caused ileus by direct invasion of the hepatic tumor to the ileum. A laparotomy revealed that the tumor invaded the ileum, gallbladder, and first portion of duodenum. Tumor clearance was achieved by a liver resection with combined resections of the surrounding organs. Lymph node dissection of the hepatic hilum was also performed, because a metastatic node was recognized at the cystic duct. Microscopic examination of the liver tumor showed moderately differentiated adenocarcinoma compatible with the metastasis from the previous ascending colon cancer. The cut ends of specimen were free from invasion. There have been no signs of recurrence for 25 months after the last operation. To the best our knowledge, this is the first case of liver metastasis causing ileus by direct invasion to the ileum. Hepatic metastasis from colonic cancer commonly occurs within 5 years after colectomy for the primary cancer. This case in which hepatic metastasis occurred after more than 9 years had elapsed is rare. Surgical intervention seems to be an acceptable management strategy for treating liver metastasis invading the neighboring organs.

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We experienced a case of rectal cancer in a young adult with X-linked agammaglobulinemia (XLA). The patient was a 25-year-old man who had been often suffered from respiratory infections in his childhood. After diagnosed as having XLA, he had been treated with periodic intravenous gamma globulin at the department of internal medicine in our hospital. Carcinoma of type 2 in gross appearence in the rectum presented with anemia. When he was admitted to the hospital, chronic bronchitis and bronchiectasis were associated. After treatment for respiratory infecion with antibiotics and additional gamma globulin, we performed a low anterior resection of the rectum with aseptic manipulation. Postoperatively, he received respiratory physical-therapy, antibiotics, and additional gamma globulin. Postoperative course was uneventful. We consider that the control of preoperative infection, aseptic manipulation and supplement of gamma globulin are critical for perioperative care of patients with XLA.

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This paper presents a case of cap polyposis which is a new concept of the disease. A 21-year-old man was admitted to the hospital because of bloody stool lasting for over recent 3 years. He had been suspected having a villous tumor at the rectum by other doctor. He had a past history of undergoing a rectal polypectpmy with the chief complaint of bloody stool at the age of 14. Barium enema showed a whole circumferential lesion covering about 6-7cm from the anal verge and multiple elevated lesions on its surface. Colonoscopy showed multiple polypoid lesions covered with whitish exudate with intervening normal mucosa. In a histopathological examination of the specimens obtained by a transanal polypectomy, it was covered with a ‘cap’ of fibrous granulative tissue and diagnosed as inflammatory hyperplastic polyp. Based on these findings, we diagnosed the case as cap polyposis and dicided to observe conservatively. Thereafter his symptom almost vanished and no aggravation was revealed at a follow-up examination conducted 2 months after the treatment.

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We report a case of nonoclusive mesenteric ischemia accompanying pneumatosis intestinalis in which portal venous gas was observed only in the early stage after onset. A 69-year-old female brought to our hospital in a state of alcoholic drunkenness was found on the abdominal CT on admission to have a dendriform image of intrahepatic portal venous gas on the surface of bilateral hepatic lobes. The portal venous gas image was found to have disappeared in the abdominal CT conducted 7 hours after admission. Since abdominal findings were relatively mild, the clinical course was monitored without surgery. When abdominal CT was conducted again on the day after admission, the portal venous gas image was not noted but emphysema was observed within the small intestinal wall. Enteral necrosis was suspected and we undertook emergency surgery. The ileum about 1.5m in length from about 15cm oral to the end of the ileum showed an unfavorable color, and the area was partially necrotic, necessitating an ileectomy. Pulsation of the superior mesenteric artery was clearly palpable. The oral side of the resected specimen exhibited extensive mucous necrosis, and U-IV ulcers were sporadically present on the anal side. Multiple thrombi were noted in the lumen of small vessels in the intestinal wall and mesenterium, and cystoid emphysema was noted extensively in the submucosal layer.

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A 49-year-old man reported pyrexia and right hypochondrium pain and was hospitalized for shock due to sepsis and disseminated intravascular coagulation (DIC). We recognized a liver abscess S4 with abdominal computed tomography and echography just after admission and conducted percutaneus transhepatic abscess drainage (PTAD). We found anaerobic bacteria breeding pus. The duodenum was contrasted in PTAD cystography after his general condition improved, and a hepatoduodenenal fistula confirmed together with a small ulcer anal to the duodenal bulb in gastroduodenoscopy, but the fistula was not clear. We conducted laparoscopic surgery in abdominal wall lifting, with good results. Reports of hepatoduodenal fistula due to hepatic abscess, have numbered only 10 cases, domestically and overseas, with no report of remedial care by laparoscopic surgery.

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We report a case of solitary liver abscess complicated by early sigmoid colon cancer. A 56-year-old male was admitted to our hospital because of high fever and general fatigue. Abdominal ultrasonography and computed tomography revealed a solitary liver abscess (8×6cm) in the lateral segment of the liver. Antibiotics were ineffective, and percutaneous transhepatic drainage was performed 5 days later. The patient responded well to the drainage, but several days later a blood examination revealed anemia, and several gastrointestinal studies were carried out to determine the etiology of the anemia.
Colonoscopy disclosed early sigmoid colon cancer (Isp), and a sigmoidectomy and hepatic lateral segmentectomy were performed. Pathological examination of the resected sigmoid colon and liver specimens revealed well differentiated adenocarcinoma, sm, infβ, ly(-), v(+), n0 and granulation tissue. The patient has been followed up every 6 months with abdominal US and CT, and at 20 months after the operation, he remains well, with no clinical evidence of recurrent disease.

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A 51-year-old woman was admitted to the hospital the hospital with a suspicion of aneurysm in the splenic artery. It presented with a tumor of the splenic hilus with calcification on a thoracic CT scan. She had a history of undergoing a right partial mastectomy for breast cancer. Splenic angiography showed the aneurysm with a broad neck about Icm in diameter at the site of bifurcation in the upper branch of the splenic artery. She underwent an arterial embolization using the Interlocking detachable coil (IDC^®) for the prevention of the withdrawal of the IDC^® into the peripheral arteries or splenic infarction. We inserted a catheter into the aneurysm and performed a packing of the aneurysm by IDC^® During and after the treatment, no complications were seen. It has been reported that even small splenic aneurysm can easily rupture. Therefore, we must treat it as soon as possible after it is diagnosed. Recently, with a use of interventional radiology less invasive and safe embolization has become available. We think that the procedure might be the first choice of the treatment for arterial aneurysm on a case by case basis.

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We report a case of splenic abscess in childhood associated with Crohn's disease. A 3-year-old girl was admitted to the hospital because of a splenic abscess with protracted enterocolitis. The splenic abscess did not respond to intravenous antibiotic injection therapy. So we inserted catheters into the splenic artery, and antibiotic drugs were administered through the catheters by using interventional radiology (IVR). Thereafter, a splenectomy was performed. There was no intraabdominal infectional complication. Her postoperative course was uneventful at first, but soon she developed necrotizing pyoderma on the right dorsum manus, anal fissure, oral aphtha, and then hematochezia and diarrhea. Crohn's disease was diagnosed with colonoscopic findings and other clinical complications.
As in our case, IVR seems to be an effective treatment for splenic abscess. From the standpoint of preserving the spleen for childhood splenic abscess, IVR is thought to be the therapy of choice. And a pssibility of inflammatory intestinal disease must be kept in mind as an underlying disorder of splenic abscess associated with protracted enterocolitis.
This case is the 40th case of splenic abscess in childhood in Japan. Some discussion on the etiology and management of this disease is also presented.

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We report a case of pheochromocytoma associated with familial von Recklinghausen's disease (VRD). A 52-year-old Japanese woman undergoing emergency surgery for cerebral hemorrhaging at another hospital was found during a check-up after surgery to have hypertension and a large left adrenal tumor. She was referred to us for further examination. She had a familial history of VRD with marked neurofibromatosis and café-au-lait spots on the skin. The tumor was diagnosed as pheochromocytoma by functional examination. Left adrenalectomy relieved her hypertension.
VRD is an autosomal dominant hereditary syndrome featuring neurofibromatosis. Pheochromocytoma shows various clinical symptoms caused by catecholamine oversecretion often associated with intracranial vascular disease. Although these 2 diseases are relatively closely associated, no clear relationship was demonstrated until now. We briefly review and analyze the genetic background of these diseases.

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We report a case of endometriosis in a right external inguinal hernia. A 36-year-old woman was seen at our hospital because of a painful right inguinal mass during menstruation. She had noticed a gradually enlarging bulge and a local tenderness in the right groin. On admission, her physical examination was normal except for a right inguinal mass, 2.0 by 1.5cm in size, which was mobile but was not reducible into the abdominal cavity. Ultrasonography revealed the right inguinal tumor to be a low echoic lesion. Exploration of the mass through a right inguinal incision revealed an indirect inguinal hernia. The hernia sac was found to contain a round, irregular mass that had adhered to the wall of the sac. The mass was easily excised from its surroundings, and the sac was removed after a high ligation, following the usual procedure. Histologic examination of the mass revealed endometrial tissue and stroma surrounded with fibrous tissues. Her postoperative course was uneventful. No signs of recurrence have been seen in the past ten months.

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Mesenteric hernia during childhood is rare, especially in neonates. Two cases of starangulated ileus due to mesenteric hernia during childhood are reported.
Case 1: A 3-day-old male infant was admitted to the hospital because of vomiting and abdominal distention. Strangulated ileus was diagnosed and an emergency operation was performed. The ileum was strangulated by a defect in the ileal mesentry. After a repair of the strangulated ileus, the ileum was left intact to no necrosis and the hiatus was closed.
Case 2: A 21-month-old female child was admitted to the hospital because of vomiting and bad temper. Abdominal plain X-ray film revealed an abnormal small amount of intestinal gas. Under a diagnosis of starangulated ileus, an emergency operation was performed. The ileum was strangulated by a defect in the ileal mesentry at 19cm from the Bauhin valve. About 1m of the necrotic ileum was resected.
In a review of the literature, a total of 22 neonate cases of mesenteric hernia including our case have been reported so far. Of these 22 cases, only one case was able to be diagnosed preoperatively. It is important to perform a prompt operation as early as possible when it is suspected.

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A 34-year-old man was referred to the hospital for an abdominal tumor, which was detected at another hospital when he visited there because of abdominal pain and diarrhea, on February 1, 2000. A retroperitoneal tumor in the pelvis was revealed by abdominal ultrasonography, CT, magnetic resonance imaging, and angiography. The patient underwent a surgical operation on March 28. The huge tumor was found to fill the almost entire pelvic cavity. It was removed by a transabdominal method. The extirpated tumor was 12×15×9cm in size, 1100g in weight and elastic soft. It had a yellowish white appearance and was well encapsulated on a cut section. It was histologically composed of spindle cells which were arranged in short bundles or interlacing fascicles. The tumor cells showed slight nuclear atypsim but no mitosis. Immunohistochemically, the tumor cells showed a positive stain for S-100 protein, Vimentin, and NSE. The definite diagnosis was benign schwannoma of Antoni type A and B. The postoperative course was uneventful. The patient was discharged from the hospital on 14th hospital day. There have been no signs of recurrence as of 18 months after the operation.

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Patient 1, a 54-year-old man, was admitted to the hospital because of a recurrent retroperitoneal tumor. Six months before admission, the patient was diagnosed as having a retoperitoneal tumor (well differentiated liposarcoma) during a laparotomy for another disease and underwent a tumor resection at another hospital. We successfully removed the tumor 2.3kg in weight. Patient 2, a 77-year-old woman, was found a cystic retroperitoneal tumour during hospitaligation for myocardial infarction. The tumor was removed. Histologicaly, it was schwanoma 1kg in weight. Patient 3, a 71-year-old man, was referred to the hospital because of a recently increasing retroperitoneal tumor. The tumor had been diagnosed at another hospital but the patient let the tumor alone for 17 months, because his left abdominal pain had been relieved. The retroperitoneal tumor 620g in weight (well-differentiated liposarcoma) was removed. Retroperitoneal tumors are apt to be detected as huge masses because they are often silent. In the case of malignant tumor, a risk of recurrence is high so that correct diagnosis and suitable operation are asked to the surgeon.

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Spigelian hernia occurs on Spigelian aponeurosis between the semilunar line from which the fiber of transversus muscle changes to aponeurosis and the lateral margin of the rectus abdominis muscle. We report a case of Spigelian hernia obtaining a clear image by an abdominal CT scan and the resultant preoperative diagnosis.
A 68-year-old woman was seen at the hospital because of abdominal pain and nausea. A 10cm elastic soft mass with tenderness was palpable in the right lower quadrant, and an abdominal CT scan showed the absence of aponeurosis at the lateral margin of the right rectus abdominis muscle and the intestinal tract projecting out of the abdominal cavity. Having opened the abdomen owing to Spigelian hernia, a 6×8cm hernia sac covered with preperitoneal adipose tissue was present directly below the aponeurosis of external oblique muscle. The content was small intestine. The hernia orifice was 2×3cm in size and located on Spigelian aponeurosis of the lateral margin.
Spigelian hernia occurs in an incidence of 2% or less of all primary abdominal wall hernias, and so far 39 cases have been reported in Japan. In this case, the aponeurosis of the internal oblique muscle and transversus muscle were absent, and the CT demonstrating the layer structure and defective site of the abdominal wall was useful for the diagnosis.

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A 79-year-old woman underwent an artificial capital replacement for left femoral neck fracture in January 2001. She had noticed a lateroabdominal tumor at the age of 20 when she had undergone a cesarian section, but she had let it alone. After the replacement procedure, abdominal pain appeared. Abdominal CT scan revealed hernia of the intestine at the left flank, and left lumber hernia was diagnosed. No findings suggestive of strangulation were revealed, and an elastic surgery was performed. At surgery, a longitudinal incision was made from the 12th rib to iliac bone under local anesthesia and on her right side. A hernia opening was 90×85mm in size, and was composed of the 12th rib, erector muscle of spine, internal-external oblique muscle of abdomen, and iliac bone. Extended lumber hernia was diagnosed. No incision was made to the hernia sac, but two EL size and one M size of mesh plugs were inserted and then composix mesh was used as an onlay patch. After the operation, seroma was formed but it was improved by a puncture. The patient was discharged very much improved from the hospital.

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