We measured telomerase activity (TA) in patients with breast diseases and investigated the relation of TA with the progress of breast cancer, especially with clinico-pathological effects of arterial infusion chemotherapy. Telomeric repeat amplification protocol (TRAP) was used for detection of TA in 86 breast diseases including 103 breast lesions. In 17 patients with locally advanced breast cancer who received pre-operative chemotherapy with adriamycin and 5FU through an arterial infusion pump for 2 weeks, the values of TA were measured before and after the chemotherapy. Positive TA rates were 92% in cancers, 86% in metastatic sites, 50% in fibroadenomas, and 25% in normal tissues. TA increased with an increase in the frequency of lymph nodes metastasis and an advance of the clinical stage. In the 17 patients received chemotherapy, TA values decreased in all tissues taken from them after surgery compared to the pre-operative values. Although no statistically significant correlation was seen between high TA value in breast tissues before the chemotherapy and pathological effects of it, more excellent pathological effects were noted with an increase in the TA values. On the other hand, we recognized statistically positive correlations between the TA values in the preoperative tissues and clinical regression rate after the chemotherapy (p<0.05). It is suggested that breast tissues pre-operatively showing high TA values might respond well to the chemotherapy.

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With a recent increase in associated use of screening mammography for breast cancer, non-palpable lesions with only finding of fine calcification have been increasingly detected. From April 1998 to March 2002, a total of 45 patients have undergone stereo guided biopsy for fine calcification as category 3, 4 and 5 diagnosed by screening mammography, without any findings on palpation and ultrasonography. Of them, 17 patients had malignancy (37.8%) including five with non-invasive cancer (29.4%) and 12 with microinvasive cancer. Detecting rates of cancer in each category were as follows: category 3: 20.0% (2/10), category 4: 31.0% (9/29), and category 5: 100% (6/6). Although no lymph nodes metastases were seen in 14 patients performed lymph nodes dissection, one case with microinvasive cancer revealed distant metastases 23 months after surgery.
Non-palpable lesions with finding of fine calcification on screening mammography, without any findings on ultrasonography include many non-invasive cancers. It is expected that screening mammography for younger women will increase to detect non-invasive cancer.

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We evaluated the effect of preoperative pulmonary physical therapy with exercise training in esophageal cancer surgery. The 54 subjects were retrospectively divided into 2 groups, i.e., 40 with and 14 without preoperative pulmonary physical therapy. Postoperative hospital stays numbered 29.9 days in the preoperative group and 67.9 days in the nonpreoperative group (p=0.02). The incidence of postoperative respiratory complications was 28% in the preoperative group and 43% in the nonpreoperative group. To evaluate postoperative respiratory complications, we divided 34 patients retrospectively into 3 groups based on 21 with no complications (NC group), 8 undergoing preoperative physical therapy with respiratory complication (preoperative + RC), and 5 nonpreoperative physical therapy patients with respiratory complication (nonpreoperative + RC). Postoperative hospital stays were 20.1 days in the NC group, 31.3 in the preoperative + RC group, and 69.4 in the nonpreoperative + RC group. Medical expenses were 1.3 times higher in the preoperative + RC group and 1.8 times higher in the nonpreoperative + RC group, compared to the NC group. Pre-and postoperative pulmonary physical therapy with exercise therapy thus effectively prevented pulmonary complications and shortened postoperative hospital stays lowering medical expenses.

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This study was designed to elucidate changed in clinicopathological features of synchronous multiple cancer of the stomach with time. Subjects were 388 cases of multiple gastric cancer resected at the hospital from 1981 to the end of 2000. These subjects were divided into the first one decade from 1981 (138 cases) and the latter one decade (250 cases) for comparison of clinicopathological changes with time. Multiple gastric cancers undergone gastrectomy or surgical local resection accounted for 6.9% of all primary gastric cancers (n=2, 006) in the first one decade; versus 10.3% (n=2, 475) in the latter one decade, showing an increasing tendency with time. In the latter one decade, the most significant increase was noted in patients in those fifties, followed by those in seventies. In recent years, the incidence of patients with advanced cancer for main lesion increased in comparison with it in the first one decade. The number of cases with more than three lesions was sixty (24.0%) in the latter one decade, and there was a tendency of increase compared with the first one decade (15 cases, 10.9%). As for the location of main lesion, 55 cases (11.0%) had tumors located at the U area in recent years, that remarkably increased from that in the first one decade (0.8%). In conclusion, we must be careful to indicate more limited surgery for patients with gastric cancer, because of the increase in the incidence of synchronous multiple gastric cancer included early accessory lesions at the U area. At the same time, the postoperative intensive examination of the remnant stomach should not be lacked.

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To clarify factors improving the condition of anastomotic leakage that is one of the severe postoperative complications of colorectal cancer, we retrospectively examined consecutive 675 patients undergoing ordinary or emergency operation for colorectal cancer at this hospital for the past 12 years. In this study, we also examined the correlation between ileus and anastomotic leakage, particularly whether preoperative insertion of a retrograde decompression ileus tube was useful for the prevention of anastomotic leakage. Anastomotic leakage occurred in 47 patients (7.0%). Male, preoperative ileus, cancer of the lower part of rectum and lymph node metastasis were risk factors of anastomotic leakage. Of 34 patients treated conservatively, there was a significantly negative correlation (p<0.001) between the day of the onset of anastomotic leakage and the day of beginning of oral intake. Of the 47 patients experienced anastomotic leakage, eight patients underwent reoperation, but after the reoperation, all patients had a good postoperative course. Five out of the 47 patients with anastomotic leakage (10.6%) died in the hospital. The mortality rate in the patients with anastomotic leakage was significantly higher than those without episodes of anastomotic leakage (hospital death 1.9%). We were able to decrease the incidence of anastomotic leakage as well as emergency operations for patients with colorectal cancer presented with ileus, by inserting a retrograde decompression ileus tube.

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This paper reports a 57-year-old man with gastric cancer who developed leukoencephalopathy during administration of carmofur after gastric resection, which almost subsided after the drug was withdrawn. The patient underwent a total gastrectomy with Roux-en Y reconstruction and group 4 lymph nodes dissection for gastric cancer on April 28, 1997. Administration of carmofur was started in the outpatient clinic on July 1, and the patient was readmitted to the hospital because of disturbance of consciousness on August 31. Carmofur-induced leukoencephalopathy was diagnosed. Carmofur was withdrawn immediately after admission, and we had to observe his clinical course because of no available therapy. After a transient life-threatening condition, the patient's symptoms gradually subsided and almost complete cure was attained 152 days after the onset of symptoms. It is important for carmofur-induced leukoencepaholopathy to keep the disease in mind at the beginning of administration; to prevent the onset of the disease; and to take a persistent attitude to the treatment no to give up to the end once it occurs.

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Leiomyoma is the most frequent submucosal tumor of the esophagus. But esophageal leiomyomas associated with calcification are rare. A 66-year-old man was admitted to the department because of an abnormal lesion on his esophagogram at a physical check-up. Esophagoscopy showed a protruding lesion in the middle of thoracic esophagus and it was diagnosed as leiomyoma by a bowling biopsy. Esophagography and a chest CT scan visualized pronounced calcification in the tumor.
Thoracoscopic enucleation of the leiomyoma of the esophagus was performed. Intraoperative findings showed that the tumor was situated in the submucosal layer. It was resected and the defect was closed with layer to layer. The resected specimen was 4×1.5cm in size and on the section, almost part of the tumor was occupied with yellowish white calcification. Histological diagnosis was leiomyoma. Thoracoscopic resection was found to be useful for the enuclealation of leiomyoma associated with calcification.

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We report a case of left paraduodenal hernia (LPDH) that was preoperatively diagnosed by computed tomography (CT) and upper gastrointestinal series (UGI) and underwent an elective surgery. A 50-year-old man was admitted to the hospital because of left upper abdominal pain and postprandial vomiting as “unknown subileus”. There was slight tenderness in the left upper quadrant of abdomen. CT showed the looped small intestine with converging mesenteric vessels in the left upper abdomen. Both before and after intestinal obstructions were relieved by conservative treatment. UGI demonstrated the looped jejunum associated with stenosis of its proximal and distal ends. These findings were considered to represent LPDH. Elective surgery revealed a hernia sac with the hilus 4cm in diameter to the ligament of Treitz. The hernia contained the 40cm-long, non-ischemic jejunum. This patient underwent closure of the hernia hilus. In patients with intestinal obstruction, differential diagnoses should include LPDH. It may show characteristic CT and UGI findings.

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A 48-year-old man undergone a total gastrectomy for gastric leiomyosarcoma and histlogically diagnosed as low grade malignant tumor 7 years before was admitted to the hospital because of an abdominal tumor. As a result of various examinations, a large metastatic liver tumor occupying the entire left lobe was diagnosed, and a left lobectomy of the liver was performed on September 12, 2000. Histological examination revealed that the degree of malignancy in the metastatic site was higher than that in the original site. Multiple liver matastases in the residual liver appeared 3 months after the operation. Despite hepatic arterial infusion chemotherapy, he died 13 months after the operation.
There have been 28 cases of gastric leiomyosarcoma with hepatectomized liver metastasis in the Japanese literature. This is rare case because the metastic liver tumor could be resected after a long time 7 years, had elapsed following the initial operation. This case also suggests that there is a possibility of liver metastasis of gastric leiomyosarcoma even if the primary trmor is small and diagnosed as low grade malignancy, so that long-term observation is necessary.

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A 74-year-old woman treated for chronic renal failure due to anemia was found in gastric endoscopy to have a pedunculated polyp prolapsing into the duodenal bulb. Histopathologically, it was well-differentiated adenocarcinoma, necessitafing distal gastrectomy with D1 lymph node dissection. She was discharged on postoperative day 13 after the operation. This case is presented together with the analysis of 58 reported cases gastric cancer prolapsing into the duodenum from 1982 to 2002.

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Sometimes we have great difficulty in making diagnosis for gastric cancer appeared as a submucosal tumor in morphology in the course of its progress. We report such a case of medurally carcinoma of the stomach which demanded about 3 years until we made the definite diagnosis by following endoscopic pictures in a 57-year-old woman.
The patient underwent EMR for m carcinoma of the lesser curvature at the angular notch in November 1996, when a submucosal tumor like elevation an about 1 cm in diameter was also found on the posterior wall of the upper middle portion of the gastric body adjacent to the lesser curvature. A biopsy of the elevation was reported to be Group I. Thereafter periodic follow-up studies with upper gastric endoscopy were conducted. In July 1999, the elevated lesion increased to about 1.5 cm in diameter and its biopsy disclosed Group V, poorly differentiated adenocarcinoma. Endoscopic ultrasonography revealed the tumor with the invasion depth of SM3. Considering the site of the tumor, a total gastrectomy (D1+β) was performed. Histopathologically it was poorly differentiated adenocarcinoma and early stage of medurally carcinoma of the stomach with lymphoid stroma. The patient's postoperative course was uneventful. There have been no signs of recurrence, as of 37 months after the operation.

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A 76-year-old man admitted June 18, 2001, for epigastric pain was found in gastrography and gastroendoscopic examination to have a Borrmann 3 tumor occupying the gastric antrum up to the middle of the stomach. Biopsy examination suggested a preoperative diagnosis of poorly differentiated gastric adenocarcinoma. Computed tomography (CT) showed regional lymph node metastasis, but no liver metastasis. We conducted distal gastrectomy with regional lymph node dissection on Jnly 3. Tumor cells in the resected specimen stained positively in Grimelius, chromogranin A, and NSE staining. The tumor was diagnosed as gastric neuroendocrine cell carcinoma. Although the prognosis of this disease is very poor, the patient remains alive and recurrence-free 1 year and 3 months after surgery.

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A 66-year-old man referred for diffuse abdominal pain, nausea and vomiting. Emergency laparotomy underwent under a diagnosis of ileus by based on computed tomography (CT) findings. Operative findings showed intestinal gangrene and a swollen mesenterium. Massive thrombus was found in the mesenteric vein. The affected bowel was resected with end-to-end anastomosis. On postoperative day (POD) 2, he experienced of severe abdominal pain and CT showed edema of the small intestine and ascites. Reoperation showed recurrent thrombosis and the previous surgical procedure was repeated. The remaining small intestine was 65 cm long. Immediately after surgery, we started anticoagulation therapy. The patient recovered well and was discharged on POD 44. Coagulation studies showed no abnormality and we considered this a case of primary thrombosis.

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We report a rare case of bowel necrosis due to dissection of the superior mesenteric artery with portal gas, which was successfully saved by surgery. A 71-year-old woman was admitted to the hospital because of appetite loss. On the next day, she vomited severely and had hypotention. The abdomen was board-like. An abdominal X-ray film and an abdominal CT scan showed dilatation of the small intestine, portal gas and gas in the intestinal wall. With a diagnosis of ileus and panperitonitis, the patient underwent an emergency operation. Operative procedures included an extensive small bowel resection, a right hemicolectomy, a jejunostomy and a colostomy. She recovered uneventfully and was transferred to another hospital on the 30th postoperative day.

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A 30-year-old man complaining of abdominal pain was admitted to the hospital with a diagnosis of ileus. Despite conservative therapy, ileus symptoms worsered. Emergency operation was performed. At laparotomy, we found a 20cm reddness of the small intestine 110cm from the terminal ileum and partially white debris. A partial excision of the small intestine was performed. Macroscopic findings revealed diffuse edematous change of the mucosa and the ulcerative lesion with prominent redness. Histopathological findings revealed eosinophilic inflammation and larvae of the family Anisakidae in submucosal tissue. Anisakiasis of the small intestine is a relatively rare disease and often presents difficulty in preoperative diagnosis. We report a case of anisakiasis of the small intestine presented with symptoms like intestinal obstruction.

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We report a case of alimentary ileus-like condition due to ‘mochi’ persisted for 3 months with resultant perforation of the small intestine causing generalized peritonitis.
A 66-year-old man who had a previous history of undergoing a gastrectomy was admitted to the department of internal medicine in our hospital because of abdominal pain on December 18, 2001. Conservative therapy with a diagnosis of ileus was successful and the patient was discharged from the hospital. Thereafter he had occasional abdominal pain and was seen at the hospital because the abdominal pain became severe since the morning of March 29, 2002. Peritoneal signs were present in the abdomen. Abdominal CT scan visualized ileus image, intraabdominal free air, and a dense food mass with the longer diameter of 4 cm in the ileum. When we reviewed another abdominal CT scan performed in December, the similar food mass had been visualized. From these findings, a laparotomy was performed with a diagnosis of intestinal perforation with generalized peritonitis resulting from alimentary ileus-like condition persisted for 3 months. During surgery, we found a piece of ‘mochi’ impacted in the ileus and a perforated portion in the jejunum situating 180 cm oral side of the mass. The patient developed septicemia after the operation, but was successfully saved by intensive therapy.
This case is presented here because it is extremely rare that alimentary ileus-like condition persisted for 3 months resulted in small bowel perforation.

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An 85-year-old woman underwent a laparoscopic cholecystectomy and a choledochotomy for choledocholithiasis. During surgery, subfascial emphysema was confirmed in the upper and lower abdomen of the right side than center of abdomen, but the operation was continued because the emphysema did not enlarge. At the end of operation, we inserted a drain in the abdomen from a 10mm port site on the right flank. The drain was withdrawn on the fifth hospital day, the abdominal wall bulged in agreement with the emphysema part under the fascia that broken out during the surgery, and the patient went into an ileus state on the seventh hospital day. We recognized the prolapsed bowel in the out side of abdominal wall on an abdomen CT scan conducted on the 15th hospital day and operation was performed on the same day. At laparotomy, the prolapsed hernia opening was the 10mm port site, the small intestine of 40cm into under the fascia, and a part of the small intestinal wall necrotized. There have been no reports on port site hernia impacted in the subfascial emphysema confirmed at laparoscopic cholecystectomy for choledocholithiasis in the Japanese literature as far as we could review. This case, consequently, is thought to be very rare.

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We report a case of blind loop syndrome (BLS) with hemorrhage from a blind loop intestinal ulcer after a side-to-side iliotranseversocolostomy following a transection of the ileum. A 66-year-old man was admitted to the hospital because of melena. The patient had undergone a surgery for acute appendicitis at the age of eight, and then additional surgery 3 times due to postoperative ileus. Roentgenography of the small intestine and a colonoscopy revealed anastomosis between the tansverse colon and small intestine. Hemorrhage due to BLS was diagnosed and the patient was operated on. The ileum had been incised 20cm from the Bauhin's valve on the oral side. The ileum on the oral side was anastomosed side-to-side with the transverse colon 15cm from the incised end on the oral side. After a right hemicolectomy as well as a resection of the blind loop intestinal tract, an end-to-end iliocolostomy was performed. The resected specimen showed a simple ulcer in the blind pouch of the ileum. Hemorrhage may occur in a blind loop intestinal tract after a prolonged interval following a side-to-side anastomosis of the intestinal tract. In the presence of such a past history, we should watch for melena on long-term follow-up.

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Blind pouch syndrome and blind loop syndrome after surgery are comparatively rare. We studied five patients with blind pouch or blind loop syndrome after surgery who required surgical treatment in the hospital in an eleven-year period from 1990 to 2001. They were three men and two wemen. Their ages ranged from 52 to 72 years, with an average of 63.8. Their first operations were performed 3244 years before admission, with an average of 38.6. The long durations had passed. The first operations in three patients were permormed for acute appendicitis. All patients were performed reoperations for ileus and after diseases after the first operation. Then their blind pouchs or blind loops were created. Their chief complaints were abdominal pain in four patients. Two patients had anemia due to digestive bleeding in one and normocytic-normochromic anemia in the remaining one. We were able to diagnose blind loops in three patients, but were not in two, including one undergone an emergency operation for digestive perforation and the other diagnosed as adhesion ileus. We performed resection of the blind pouchs and blind loops in the all patients.

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Lipoma of the colon is a relatively rare benign neoplasm found in middle-aged or elderly patients and more frequently in womem. We report a case of lipoma of the sigmoid colon partially protruding from the anus, accompanied by a brief bibliographical discussion.
A 37-year-old man reporting an anal mass suffered from protrusion of a ping-pong-ball-sized mass from the anal canal at defecation. No anal bleeding was seen and the mass was easily reinserted into the rectum. Colonoscopic examination showed 6 cm tumor with a stalk in the sigmoid colon. Gastrographin enema studies showed a tumor about 6 cm in diameter in the rectosigmoid region. Abdominal computed tomography showed a fatty tissue like low-density mass in the rectum. At laparotomy, palpation of the sigmoid colon showed a mobile endoluminal tumor, necessitating partial sigmoid colon resection. Macroscopically, the tumor was 14×8×7 cm with a large 6 cm stalk. The pathological diagnosis was lipoma.
The present case is noteworthy because the patient was young and male, the tumor was large, and the anal mass was the chief symptom. This diagnosis may indicate the need for laparoscopy-assisted surgery if lipoma is found, although we conducted the laparotomy because the tumor was large and malignancy could not be rule out.

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We had great deal of difficulty in treatment of obstructive colitis and enteritis due to fecal ileus detected at an emergency operation for peritonitis in a 51-year-old woman without previous history of undergoing a laparotomy.
The patient was seen at the hospital because of pain in the entire abdomen. She had been suffered from constipation lasting for one week. There were signs of generalized peritonitis. Upon laparotomy, fecal ileus was disclosed and the necrosed sigmoid colon due to fecal mass was confirmed. An open colostomy was made at the descending colon. Prolonged symptoms of peritonitis after the operation demanded another laparotomy, when necrosed portions were found in the descending colon and ileum. Obstructive colitis with obstructive enteritis was diagnosed. After the necrosed intestines were resected, a transverse colostomy and an ileostomy were made. The patient recovered with postoperative therapies with CHDF and PMX, and, about 10 months later, underwent closures of the ileostomy and transverse colostomy.
Etiologically obstructive colitis is caused by cancer in most cases, and it is very rare that fecal ileus causes the disease. This case of obstructive colitis caused by fecal ileus is thought significant from standpoint of its association of obstructive enteritis which is also very rare. We have difficulty in making the correct intraoperative diagnosis of obstructive colitis and enteritis, and should strictly follow the postoperative clinical course.

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A 29-year-old woman experienced abortion in September 2000 visited to the patient's internal doctor because of lower abdominal pain persisting after abortion. Her stool guaiac tests were positive, and she was referred to the department of gastrointestinal medicine in our hospital and underwent colonofiberscopic study. The study disclosed a type I tumor occupying the entire lumen of the transverse colon near the hepatic flexure, and it was impossible to insert an endoscope from the site to oral side. As a result of a biopsy, moderately differentiated adenocarcinoma was diagnosed. After systemic exploration, a right hemicolectomy with dissection of group 3 lymph nodes was performed on January 15, 2001. On the resected material, the tumor was 7×5×4 cm in dimension, type 1, moderately differentiated adenocarcinoma, ss ly1, v1, n3 (+) P₀H₀M(-), and stage IIIb. After chemotherapy with CDDP, 5FU, and isovoline following the operation, the patient was discharged from the hospital. The patient has been free from recurrence at present and is followed in the outpatient's clinic.
This case which involved a young woman after abortion who complained of persistent lower abdominal pain has made us see the importance of conducting close examinations considering possible malignancies including colorectal cancer.

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A 52-year-old woman with colon cancer with multiple liver metastasis involving the caudate lobe underwent a partial resection of the sigmoid colon, followed by an implantation of hepatic arterial infusion system. After then, pharmacokinetic modulating chemotherapy (PMC), which consists of continuous i. a. (or i. v.) infusion of 5-FU over 24hrs for one day a week at 1, 000mg/body and an oral dose of UFT 450mg/day for 5days per week, was given to the patient. After repeated i. a. and i. v. PMC alternatively every week for about 3 months, metastatic liver lesions were all remarkably reduced during 6 months after the first operation. So we were able to perform a partial hepatectomy including the caudate lobe. Extremely few viable cells were found in the hepatic lesions on pathological examination. The patient has been free from recurrence, as of 18 months after the hepatectomy.
We report effective multidisciplinary treatment to multiple liver metastasis from colon cancer involving the caudate lobe, with resultant hepatic resection on a two-step approach.

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Ovarian metastasis from colorectal cancer is rare. We report 2 cases of synchronous ovarian metastasis from colon cancer together with bibliographical comments.
Case 1: A 25-year-old woman admitted to the department of gynecology for a tumor in the lower abdomen underwent surgery based on a diagnosis of left ovarian tumor. During oophorectomy, a tumor was observed in the sigmoid colon, necessitatiny the Hartmann procedure. Histological diagnosis was sigmoid colon cancer with metastasis to the left ovary. Case 2: A 56-year-old woman admitted for abdominal pain and vomiting underwent transverse colon colostomy based on a diagnosis of ileus due to a descending colon tumor. Abdominal computed tomography (CT), after colostomy showed a right ovarian tumor, necessitating left hemicolectomy, total hysterectomy, and oophorectomy. The histological diagnosis was descending colon cancer with metastasis to the right ovary.

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Recently, hepatic portal venous gas has been increasingly reported. It has variety of causes, but paralytic ileus rarely causes the disease. A 39-year-old man with a history of schizophrenia was referred to the hospital because of paralytic ileus accompanied with shock sign. A CT scan of the abdomen-pelvis revealed paralytic ileus and hepatic portal venous gas. Exploratory lapalotomy showed no evidence of ischemic change of the intestine. Remarkable dilatation of the intestine from the stomach to rectum was observed. The intestinal content was aspirated. The postoperative course was uneventful. The inciting factor of HPVG in this case was paralytic ileus due to side effects of an anticholinergic drug.

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Long-term course of cystic tumors of the liver has been unknown as yet. We report two cases of cystic tumor of the liver in which dramatic morphological changes were able to be followed. Case 1: A 51-year-old woman, who had a cystic tumor with a papillary projection of the liver, was treated by a extended left lobectomy of the liver at the hospital. The pathological diagnosis of the resected tumor was intrahepatic bile duct cystadenoma. However, computed tomography (CT) performed 4 years before admission revealed a huge simple cyst in the same area of the liver. The resected tumor was clearly smaller in size than that on the CT scan and the papillary projection in the tumor had been formed during 4 years. Case 2: A 50-year-old man was admitted to the hospital because of a huge cystic tumor with solid compornent which invaded the inferior vena cava, right atrium and mediastinal area. With a diagnosis of unresectable cystadenocarcinoma, he was treated by combination therapy with arterial infusion, radiation and hyperthermia. In spite of our recommendation of close exploration for a small cystic tumor of the liver detected on ultrasonography 7 years before, he had not received further examination until this admission, when the small cystic tumor had grown to be unresectable adenocarcinoma. Periodical checkup should be made against a relatively large cystic lesion of the liver in consideration of a potential development to bile duct cystadenoma or cystadenocarcinoma.

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We experienced a case of hepatocellular carcinoma (HCC) in a patient with hemophilia A associated with human immunodeficiency virus (HIV) infection. A 52-year-old man, who was diagnosed as having hemophilia A in his childhood and was found to be infected both with HIV and hepatitis C virus (HCV) through usage of blood products, was followed in our hospital for liver cirrhosis. Recent abdominal CT scan revealed a low-density area in the segment 6 of the liver. After admission, the patient was diagnosed as having HCC and underwent operation. Because of hypersplenism associated with liver cirrhosis, we performed a splenectomy as well as a partial resection of the liver. For the control of patient's coagulation, platelet concentrate and factor VIII products were preoperatively transfused to the patient. In addition, fresh frozen plasma and factor VIII products were daily administered for a week after the operation. Because of the low CD4 lymphocytes count (144/ul), the patient had a risk of opportunistic infection. But he had no complication after the operation, and left our hospital on the 19^th postoperative day. The life expectancy of HIV-infectee persons has dramatically improved due to the progression in antiretroviral therapies, so that we will have more chance to encounter HCC patients infected with HIV. In such cases, we should consider perioperative care of the patients as well as protection of medical stuffs against HIV infection.

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We experienced a case of choledocholithiasis following a gastrectomy, which was complicated with an external biliary fistula and bilomas.
A 47-year-old man undergoing a distal gastrectomy for duodenal ulcer 15 years earlier was seen at the hospital because of abrupt biliary defluxion from the surgical scar on the abdominal wall. Abdominal CT scan showed multiple bilomas in the liver, a fistula from the skin to abdominal cavity and a calculus in the common bile duct. The largest biloma was about 7.5 cm in diameter and was located in the latelal segment of the liver. Fistulography showed a fistula from the skin to the bile duct and a calculius at the end of the common bile duct. He was operated on with a diagnosis of choledocholithiasis complicated with external biliary fistula and bilomas. During surgery, a fistura was observed from the round ligamet of the liver through the visceral surface of the liver. The gallbladder was extracted, the common bile duct was incised to remove the calculus, and a T-tube was inserted. The fistula on the abdominal wall was excised. A tube was inserted in the fistula of the abdominal cavity, and was exposed to outside the body through other abdominal wall. The patient's postoperative course was unevenful.

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We report a case of xanthogranulomatous cholecystitis (XGC) in which suffering process was successfully observed on computed tomography (CT). A 70-year-old woman complained of fever and hypochondralgia when hospitalized for left traumatic pneumothorax. CT showed no abnormal change of gall bladder (GB) and no stone in biliary tract before cholecystitis. The whole wall of GB showed uniform thickness on day 2, and showed very irregular thickness on day 44. Passage of contrast media was stopped, after a small defect was seen in cystic duct on endoscopic retrograde cholangiography. Cholecystitis was diagnosed from timely change of GB on CT and blood examination. Cholecystectomy was performed and histopathological diagnosis was XGC. Investigation of cholecystitis was uncomplete, for we failed to locate the cystic duct. Detail follow up was thought to be necessary for remained lesion, for XGC was accompanied with gall bladder cancer at high rate.

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We report a case of pancreatic injury that underwent an operation on 3 months after trauma. A 17-year-old man bruised his abdomen in an accident on April 10, 2001. He referred to a doctor and diagnosed with traumatic pancreatic injury. Despite conservative therapy, his serum amylase remained high. He was referred to another hospital and diagnosed in abdominal computed tomography (CT) and other studies with obstruction of the main pancreatic duct. He was referred to us for surgery, conducted on July 11. The pancreatic body and tail were very hard due to obstructive inflammation, necessiting pancreatojejunostomy. His postoperative course was uneventful and he was discharged on postoperative day 19.

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A 17-year-old man seen for epigastric pain had no history of alcoholism or abdominal trauma. He had hyperamylasemia, and ultrasonographic imaging showed a diffuse dilated main pancreatic duct. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiography showed diffuse dilation of the main pancreatic duct, which had smooth, short stenosis at about 30 mm distal to the papilla of Vater. We diagnosed this as erroneous fusion of the pancreas ductal system because of the lack of obvious etiologic factors and the patient age was young.

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A 63-year-old woman was seen at the hospital because of upper abdominal discomfort. An abdominal CT scan showed a tumor 1.6 cm in diameter of the pancreatic head, and at the same time, a variety of anomalies including deficiency of pancreatic body and tail, unnatural run of the portal vein, polysplenia, and absence of vena cava inferior were pointed out. Pancreatic endocrine tumor was suspected on an abdominal angiography. Insulin level was slightly high and gastrins levels were high, but the patient was asymptomatic. With a preoperative diagnosis of a symptomatic islet cell tumor associated with deficiency of pancreatic body and tail, the patient was operated on because a possibility of malignancy could not be ruled out. At surgery, the pancreatic body and tail ware lacked, the portal vein run on the anterior surface of the pancreatic head, and the portal vein, hepatic artery, and common bile duct run on the ventral surface of the duodenum. Intraoperative ultrasonography showed that the tumor was present in the parenchyma of pancreatic head, was 1.5 cm in diameter, and was capsulated, without direct invasion to the surroundings and metastasis. Consequently the tumor was extirpated. On immunological stains, the extirpated material was positive for glucagon, partially and weakly positive for somatostatin, and negative for insulin, with less than 1% of MIB-1 index. The tumor was thought benign and no additional resection was performed.

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External pancreatic fistula due to dehiscence of the pancreatico-jejunal anastomosis remains a critical complication after pancreaticoduodenectomy. We report a case of intractable pancreatic fistula after pancreaticoduodenectomy successfully treated by interventional internal drainage. A 71-year-old man underwent pancreaticoduodenectomy for bile duct carcinoma. After removal of the stent tube inserted into the pancreatic duct, pancreatic juice begun to be discharged from a drain on the pancres, but halted and the fistula healed spontaneously, upon which the man was discharged. One week later, his pancreatic fistula relapsed and he was readmitted for fistulography. Cannulation into the main pancreatic duct and into the jejunal lumen on the opposite side was accomplished and an endoprosthesis was placed to connect the main pancreatic duct and jejunal lumen. These interventional endoprostheses are very useful for treating inactable pancreatic fistula.

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A 76-year-old woman referred with a pancreatic cystic tumor was found in ultrasonography, computed tomography, and magnetic resonance imaging to have a 7 cm cystic tumor in the pancreatic tail suspected of having invaded the stomach. Angiography showed a hypervascular tumor and occluded distal splenic vein. Under a diagnosis of suspected pancreatic cystadenocarcinoma, we conducted distal pancreatectomy, splenectomy, and lymph node dissection. Pathological diagnosis was pancreatic cystadenoma. A 5-year postoperative follw-up has shown no sign of recurrence.

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We present a case of splenic sarcoidosis, which is a relatively rare entity.
A 71-year-old woman, who had been observed clinical course of nodules in the spleen on an abdominal CT scan after surgery for pulmonary sarcoidosis, underwent a splenectomy because the splenic nodules gradually became large and multiple.
There have been 12 cases of splenic sarcoidosis in the Japanese literature, and five out of the 12 cases underwent a splenectomy because a possibility of primary splenic malignancy could not be ruled out and were pathologically diagnosed as splenic sarcoidosis after the operation. In the remaining seven cases without surgery, splenic sarcoidosis was diagnosed by liver biopsies due to associated hepatic lesions. It is believed that splenic sarcoidosis spontaneously cures in 80-90% of the patients and follows chronic course in the rest. The problems might lie in therapeutic methods for the disease with a propensity to grow and become multiple. The therapies include steroid regimen and surgery. In this case, we selected surgery because the patient's general condition was stable when the splenic tumor increased, no other lesions were present, and a possible primary splenic tumor could not be ruled out. It is thought that such a case might be a candidate for surgery in terms of making the definite diagnosis.

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We encountered a patient with paraganglioma near the left adrenal gland associated with total situs inversus. A 74-year-old woman was referred to the department because of a tumor in contact with the left adrenal gland and situs inversus accidentally detected by abdominal ultrasonography (US). Abdominal US, CT, and magnetic resonance imaging revealed total situs inversus and a well-delineated tumor 3 cm in diameter, cranial to the left kidney and medial to the posterior segment of the liver. The blood and urinary catecholamine levels were abnormally high, and MIBG scintigraphy showed accumulation in the region of the left adrenal gland. With a tentative diagnosis of pheochromocytoma in the left adrenal gland, the tumor was resected. Surgical findings included left-sided liver, right-sided stomach, total situs inversus, and a hard tumor, 5 cm in diameter, cranial to the left renal vein. Histopathologically, the tumor was diagnosed as paraganglioma originating in the retroperitoneum near the adrenal gland based on clear borders between the tumor and adrenal tissue. The catecholamine levels were normalized after the operation. No signs of recurrence have been observed as of 9 months after the operation. There have been no case reports of paraganglioma with total situs inversus in the Japanese literature.

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We report a case of serous surface papillary carcinoma (SSPC) of the ovary associated with panperitonitis and malrotation of intestine. An 80-year-old woman was admitted to the hospital because of persistent abdominal distension. On admission, laboratory findings showed leucocytosis and an increased plasma CRP level. Abdominal CT and magnetic resonance image scans revealed a massive fluid retension in the entire peritoneal cavity, tumorous lesions in the left lower peritoneal cavity and malrotation of intestine. In the aspirated ascites specimen, adenocarcinoma cells were detected. On another ascites aspitation, a muddy ascites with severe stench was drawn. Since this finding strongly suggested panperitonitis of unknown origin, a laparotomy was performed on the same day. By the operative findings and pathological examinations of frozen sections, the diagnosis of SSPC of the left ovary associated with panperitonitis was confirmed. SSPC is considered specific and rare ovarian carcinoma, which lacks tumorous changes in the ovary itself and invades the greater omentum or the mesenterium, resulting in carcinomatous peritonitis. In addition, SSPC associated with panperitonitis is thought to be very rare.

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A 12-year-old boy was admitted for right lower abdominal pain was found in ultrasonography (US) and computed tomography (CT) to have a mass at the site of tenderness, and laboratory examinations revealed leukocytosis and positive CRP. The mass lesion was suspected of being an abscess near the cecum or terminal ileum, but the tumor was not completely denied. On laparotomy, the swollen appendix and major omentum adhering to it were resected and he was discharged. On postoperative day (POD) 8, he was readmitted for a high fever. Abdominal CT showed an abscess, and a colony of actinomyces was found in the granuloma of the major omentum after a pathological examination. We started conservative therapy for actinomycosis. By day 20 from readmission, the fever had subsided, the abdominal mass had disappeared, and he discharged. Actinomycosis is now rare, but it should be kept in mind when we encounter an abdominal mass with signs of inflammation.

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A 56-year-old man admitted for right upper quadrant pain and loss of appetite was found in palpation to have a mass with tenderness in the right upper quadrant. Laboratory tests showed a white cell count of 13, 000/μl and CRP of 18.4mg/dl. Abdominal echography showed an abscess-like hypoechoic mass 3.2×2.4cm in diameter and a strong posterior echo. After treatment non per os and with antibiotics, clinical symptoms improved and the echo finding changed from a fluid lesion to a solid tumor. For several weeks, the tumor remained in the same size, necessitating surgery because malignancy could not be ruled out. The tumor, together with the partial ileum, partial transverse colon, and partial abdominal wall, were resected due to tumor adhesion to these organs. Histological examination showed omental panniculitis. In Japan. 14 cases of omental panniculitis, including ours, have been reported. Preoperative diagnosis was very difficult, necessitating resection due to possible acute abdomen or malignancy. The change in echography findings was useful in differentiation from a malignant tumor.

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We report a relatively rare case of a retroperitoneal simple cyst with a review of the literature. A 65-year-old man was admitted to the hospital because of a right lower abdominal mass with an increasing tendency. Ultrasonography revealed a hypoechoic mass. On physical examinations, an infant's head-sized, elastic soft, non-pulsative, and unmovable tomor was palpated in the right lower abdmen. Abdominal CT and magnetic resonance imaging scans showed a homogeneous cystic tumor with the diameter of 12cm in the right lower retroperitoneum. With a diagnosis of a retroperitoneal cyst, the cyst was removed under laparotomy. The removed mass was about 900g. In weight with thickened wall and contained light yellow serous fluid. Histopathologically, the tumor was diagnosed as a simple cyst arising from the vein based on an Elastica Van Gieson staining. No malignant cells in the cyst wall were disclosed. His postoperative course was uneventful, and he was discharged from the hospital on the 13th postoperative day. No signs of recurrence of the tumor have been seen.

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A 42-year-old man was seen at the hospital because of a huge scrotum which started to enlarge since 5 years earlier and was recently pointed out by a friend. The scrotum distended to the size larger than a rugby ball, and the penis was depressed. Bowel movement could be observed on the surface of the scrotum. No symptoms of intestinal obstruction were present, but repositioning of the intestine by hand was impossible. Right not-reduced inguinal hernia was diagnosed. At surgery, large quantities of intestines from the ileum to ascending colon were adherent in a hernia sac. A thickening of the right spermatic cord was noted. The stomach and duodenum were towed close to the hernia opening. The adhered intestines were dissected from hernia sac and were reduced in the abdominal cavity. The posterior wall was reinforced by ileopubic tract repair, and then the colon was fixed over the hernia opening from the abdominal cavity, so that the hernia opening was made to be retroperitoneum. After the operation, respiratory failure and deep vein thrombosis occurred but were relieved. No recurrence of hernia has occurred up to now.

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With a recent progression in imaging technique, clinical reports on preoperatively diagnosed obturator hernia, which had conventionally thought to present difficulty in preoperative diagnosis, has increasingly been reported. We, however, have still great difficulty in diagnosing non-strangulated obturator hernias.
We report a case of non-strangulated bilateral obturator hernia which was diagnosed by herniography and repaired by a laparoscopic operation.
A 75-year-old woman was admitted to the hospital because of repeated abdominal pain and left femoral pain. Ultrasonography and CT scan showed no remarkable findings. From the patient's symptoms we suspect obturator hernia, and herniography was performed. Herniography revealed bilateral obturator hernia, which was radically repaired by a laparoscopic operation.
The combination of herniography and laparoscopic operation is very advantageous in diagnosing and repairing non-stragulated bilateral obturator hernia.

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We report a rare case of obturator hernia forming an intermuscular abscess in the right thigh. An 88-year-old woman reporting appetite loss and right extremity pain was found in palpation to have a hard mass in the medial side of the right thigh that was slightly tender. She had no symptom of ileus. Abdominal radiography showed an abnormal air accumulation around the right obturator foramen and computed tomography showed an abscess between the right pectoneal and obturator muscles. Judging that an abscess had formed due to perforation of the small intestine by an incarcerated obturator hernia, we found, on entering the peritoneal cavity, a Richter incarcerated obturator hernia and partially resected the ileum. The abscess under the pectoneal muscle was opened and drainaged at the right thigh. The femoral wound were left open because anaerobic bacterial infection was suspected. Cultures of pus were positive for Bacteroides fragilis, Klebsiela pneumoniae, and Enterococcus. The postoperative course proceeded uneventfully. Obturator hernia accompanied with femoral abscess is rare, but may lead to severe infectious disease that develops asymptomatically.

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We studied the outcomes of endoscopic lumber sympathetic surgery for plantar hyperhidrosis with the chief complaint of excessive sweating of the plantars. Subjects were seven limbs of four cases. Factors studied were age, sex, family and previous histories of hyperhidrosis, observation time, sites with excessive sweating, operating time, postoperative hospital stay, blocking method, sites where sweating ceased, compensatory sweating sites, and postoperative complications. As a result, this therapy was successful in all cases. No signs of recurrence have been seen for as longest as 40 months of observation time. As for severe complications, transient impaired erection was noted in a male patient. Procedures of this endoscopic lumber sympathetic surgery include to inject 600-800ml of physiological saline solution to a surgical glove to make an artificial retroperitoneum; to maintain it at 8-12mmHg by carbonic acid gas; and then to block an area covering from the lumber sympathetic trunk L2 to L4 by electric or ultrasonic coagulation via 3-4trocars. The locaiton of ganglion is confirmed by intraoperative X-ray examination.
It is demonstrated that the endoscopic lumber sympathetic surgery can be indicated for plantar hyperhidrosis like for palmar hyperhidrosis.

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A 79-year-old woman was admitted to the hospital because of an asymptomatic cystic nodule on the right side of the neck. A computed tomography and a fine needle biopsy of thyroid tumor revealed that the tumor might be metastatic lymph node from papillary thyroid carcinoma. Total thyroidectomy and lymph node dissection were performed. Histologic examination of the resected specimen from the tumor of the right neck revealed moderately differentiated squamous cell carcinoma. This cystic tumor had rich lymphatic follicle like a branchial cleft. The inner wall of this tumor was lined with squamous epithelium and demonstrated that it is gradual transition from benign to malignant. Although a possibility of metastatic tumor was considered, no primary site was discovered on subsequent examinations. This case satisfied three out of the Martin's four criteria for diagnosis of branchiogenic carcinoma. Therefore, this case was diagnosed as double cancer of papillary thyroid carcinoma and branchiogenic carcinoma. In the diagnosis of a thyroid tumor with a cystic lesion of the neck, not only metastatic lymph node from thyroid tumor but branchiogenic carcinoma or other disease should be taken into consideration, even if the primary thyroid tumor was diagnosed as papillary carcinoma before operation.

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