[in Japanese]

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We retrospectively studied 125 patients with local breast cancer recurrence treated between 1977 and 1999 at Ohmoto Hospital. Multiple regression equation (the prognostic index) was made of prognostic indicators determined by some analyses. The prognostic index (PI) was 5.550-0.034×patient age at initial surgery-0.682×clinical stage of tnm+0.025×disease-free interval (months)-0.821×recurrence site (site point)+0.853×secondary surgery (No: 0, Yes: 1). The disease-free interval was the most effective factor in this index. The 5-year survival from local recurrence was 100% for Grade I (PI≥4.5), 62.4% for Grade II (2.5%le;PI<4.5), 19.4% for Grade III (2.0≤PI<2.5), and 6.6% for Grade IV (PI<2.0). This classification of the prognostic index had definite prognostic significance.

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We compared the thoracoscopic sternal elevation for funnel chest (Nuss' procedure) with conventional sternal elevation. Subjects were 60 patients with funnel chest-52 boys and 8 girls averaging 6 years of age-undergoing conventional sternal elevation (CSE) before July 1999 and 26 patients-24 boys and 2 girls averaging 8 years and 6 months of age-undergoing Nuss' procedure after August 1999. The operating time and blood loss in Nuss' procedure (138±39 min and 16±11 g) were significantly less than those of CSE (299±61 min and 170±206 g). Days before returning home after Nuss' procedure (8±3 days) were significantly shorter than after CSE (13±4 days). The cosmetic results of Nuss' procedure were more satisfactory than those of CSE, since, in addition to sufficient elevation of the concavity, operative scars were smaller. We noted hemothorax, injury of the intrathoracic artery, skin necrosis and shift of a steel bar in 5 of the CSE patients. Lung injury during surgery, lung injury and a foreign body in the thoracic cavity due to a broken wire, shift, or flipping of a bar occurred in 4 of the Nuss' procedure patients. We recommended use of a stabilizer for fixation of the bar, since in 3 of 5 patients whose bars were fixed with wires, wires broke and caused complications. The rate of complications did not, however, differ significantly between the 2 procedures. Though Nuss' procedure was recognized to be minimally invasive, more experience and work is required to dicrease complications.

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We retrospectively studied 17 cases of nonocclusive mesenteric ischemia in terms of clinical features, diagnosis, and therapeutic outcomes. Their mean age was 73 years ranging from 56 to 90. There were 13 patients (76%) with cardiovascular diseases, three with diabetes mellitus, and two with chronic renal failure. Inciting factors included a use of digitalis and/or diuretic agents in five patients, major surgery in three, hemodialysis-induced hypotension in two, sepsis in two, and hemoconcentration in two. Preoperatively, 11 patients went into circulatory shock. Contrast-enhanced computed tomographic scans conducted in 12 patients disclosed lack of bowel-wall enhancement without mesenteric artery occlusion. Mesenteric angiography and intra-arterial vasodilator therapy were perfomed pre-or post-operatively in two patients. Ischemia/infarction involved both the small and large bowels in nine patients, small bowel in six, and unsalvageable pannecrotic bowel in two. Overall mortality including operative and hospital death was 56%. These poor outcomes were associated with preoperative circulatory shock, receiving adrenergic agents, and massive bowel necrosis. The perioperative administration of prostaglandin E₁ contributed to favorable outcomes. To improve the dismal results for nonocclusive mesenteric ischemia, recognition of patients at high risk, the early diagnosis using computed tomography, and the treatment with vasodilator and minimal bowel resection are essential.

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We studied the clinical features of an incisional hernia following running mass closure of abdominal midline incisions using absorbable synthetic monofilament sutures. Subjects were 588 cases followed up at least 1.5 years. Incisional hernia was recognized in 22 cases (3.7%): within 3 months after surgery in 4, between 3 and 6 months in 6, between 6 and 9 months in 4, between 9 and 12 months in 3, exceeding 1 year in 4. Herniation started around the umbilicus in 55% of cases with an incisional hernia, and around a suture knot in 38%. Synthetic monofilament suture absorption at the hernial incision was considered negligible. Caution should therefore be paid when suturing around the umbilicus during running mass closure of abdomen.

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We have treated 7 cases (4 males, 3 females) of acute arterial obstruction of the upper extremity during a 2-year period. The age of the patients ranged from 61 to 91 years, with a mean age of 77.3 years. Symptoms included coldness in 6 cases, pain in 3, paresis in 2 and paresthesia in one. The site of obstruction was on the left side in 3 cases and on the right side in 4 cases. The involved arteries were the subclavian artery in 2 cases, the axillary artery in one, the brachial artery in 2, and the radial artery in 2. Thrombolytic therapy was performed in all cases. This therapy was effective in 4 cases. In the other 3 cases, either a percutaneous transluminal angioplasty, thromboembolectomy using a Fogarty catheter, or a bypass operation was performed. No complications were experienced. Although thromboembolectomy is recomended as the primary therapy for acute arterial obstructions, thrombolytic therapy may be easier, less invasive and effective.

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Fibromatosis of the breast is a distinctive lesion defined as a group of nonmetastasizing fibrous tumor, but it tends to invade locally and recur after surgical excision. A 20-year-old woman was referred to the hospital because of a left breast mass. When she was first seen, an ill-defined and elastically firm tumor, 9.0×8.0 cm in size, occupying the entire left breast was recognized, and an elastically firm tumor, 3.0×2.0 cm size, was also recognized at the right breast. Bilateral phyllodes tumors were diagnosed and wide-excisions were performed. Histologically, fibromatosis of the breast was diagnosed. Immunohistochemical analysis showed that ERα and PgR were negative, and that positive cells for Ki-67 were scattered in the tumor tissue. Fibromatosis of the breast which is prone to recur locally despite a benign disease might require careful determination of resected area and strict observation of the patient's clinical course after surgery.

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A 49-year-old woman who had been noticed a left axillary tumor since 30 years earlier, was referred to the hospital because the tumor started to grow 5 years before, became 25 cm diameter, and overlaying skin had changed to red with inflammatory change. After admission, CT and MRI showed multi-nodular tumor with cystic degeneration, and pathologic findings for needle biopsy specimen indicated benign interstitional tumor. The tumor was removed and the pathologic diagnosis was phyllodes tumor of borderline malignancy. Local recurrence occurred 2 months after the resection, A wide resection was performed again and a defect was reconstructed with a lattisimus dorsi musculocutaneous flap. The phyllodes tumor arising from the ectopic axillary mammary gland is extremely rare. This rare case also suggests the biological nature of phyllodes tumor.

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In performing breast conservative surgery, if a greater deal of tissue is removed, a problem from the cosmetic standpoint naturally arises with increasing frequency. It becomes prominent in instances in which a breast tumor is present in the lower areas of the breast. So we have used a laparoscopically harvested omental flap with vascular pedicle to a defect of the breast tissue at breast conservative surgery, with favorable outcomes. It took only about one hour to harvest an omental flap with the pedicle laparoscopically. The size of the surgical wound on the abdomen was about the same as that made at laparoscopic cholecystectomy.
We think that this operative procedure can be a useful method in performing breast conservative surgery for a tumor situating in the lower area of the breast and demanding a great deal of breast tissue to be removed.

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A case of adenoid cystic carcinoma of the breast, which was diagnosed by aspiration biopsy cytology, is reported. A 52-year-old woman was seen at the hospital because of a left breast tumor and pain. On clinical examination, there was an elastic hard, movable and well-defined tumor with the diameter of 1.5cm in the D area of the left breast. Mammography showed an oval mass with circumscribed margin and the tumor was diagnosed as categoly 3. Ultrasonography showed a low echoic lesion with oval shape. Aspiration biopsy cytology showed clusters of small atypical epitherial cells that surrounded mucoid balls, and we diagnosed this tumor as adenoid cystic carcinoma. A breast conserving operation with axillary lymph node dissection was performed. Histologically, this tumor was characterized by cysts with a cribriform pattern, and was diagnosed as adenoid cystic carcinoma of the breast. None of the 15 axillary lymph nodes contained matastasis. Perineural space invasion which might cause breast pain was seen. This disease is very rare but histological findings are very charactaristic. It is important to know those histological findings of this disease in order to make the accurate diagnosis before operation.

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A 73-year-old woman was seen at the hospital because of abdominal pain. There were previous histories of undergoing a radical mastectomy for right breast cancer at the age of 58, a laparotomic cholecystectomy for cholelithiasis at the age of 63, a partial pneumonectomy for lung metastasis of breast cancer at the age of 67, and an extended total hysterectomy for uterine cancer at the age of 70. The patient was admitted to the hospital with a diagnosis of adhesive ileus on February 4, 2001. Ileus symptoms were almost relieved by a long tube, but a 2cm narrowing covering the entire ileum at the ileocecal region was disclosed on imaging methods. A tumor of the small intestine at the ileocecal region was diagnosed and an ileocecal excision was performed on March 8. Histopathological study revealed that the tumor was small bowel metastasis of breast cancer.
A study of 135 autopsied cases of breast cancer with metastasis had reported that gastrointestinal metastasis accounted for 8.9% of all metastasis of breast cancer. Small bowel metastasis of breast cancer has hardly posed clinical problems so that this case is thought to be very rare.

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It is known that inflammatory recurrence of breast cancer after breast conserving treatment has a poor prognosis. Reported here in is a patient with breast cancer in whom inflammatory recurrence after breast conserving treatment was successfully treated by weekly Trastuzumab-Paclitaxel therapy and a mastectomy. A 55-year-old woman undergone a breast conserving treatment for left breast cancer 20 months earlier developed inflammatory recurrence in the left preserved breast. CEF therapy and taxane infusion were ineffective. Inflammatory skin change expanded to the contralateral breast. HER2 receptor expression of the lesion was positive immunohistochemically. Weekly administration of Trastsuzumab and Paclitaxel was started. The skin lesion shrank remarkably after 4 weeks. At the end of 12th course, the skin lesion vanished. After 20th course, skin biopsy revealed no malignant cells. No adverse side effects were seen. On January 24, 2002, the left preserved breast was removed. No residual cancer cells were found microscopically. The patient is well without treatment.

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A 58-year-old womam, who was performed mitral valve replacement (MVR) 26 years earlier, was admitted to the hospital because of her prosthetic mitral valve failure. She had been diagnosed as having chronic hepatitis type C 8 years before admission. Her laboratory data showed thrombocytopenia (platelet 3.4×10⁴/mm³) due to hpersplenism. Concentrated platelets were transfused before cardiac catheter examination, but the number of platelets did not increase. Thus, a splenectomy was performed before cardiac surgery in expectation of improvement of thrombocytopenia. As a result, the number of platelets increased up to 16.0×10⁴/mm³ on the next day, and 20.5×10⁴/mm³ at the time of cardiac surgery on day 21 after the splenectomy. Re-MVR was performed without any operative complications. We conclude that splenectomy before cardiac surgery for the patients with thrombocytopenia due to hypersplenism is useful for hemostasis, especially control of bleeding in the acute phase after operation.

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A case of pulmonary lymphangioleiomyomatosis (LAM) with spinal neurinoma in a 26-year-old woman is reported. The patient had a previous history of bilateral renal angiomyolipoma (AML). Since May 1994, she had experienced five episodes of right pneumothorax, for the second episode of which was treated by a thoracoscopic surgery, and two episodes of left pneumothorax, as well. This time, the patient was admitted to the hospital because she had the third episode of left pneumothorax in September 2000. Chest CT scan visualized multiple cystic changes on the bilateral lung fields. LAM was suspected and a thoracoscopic biopsy was conducted in October 2000. Histopathological study showed hyperplasia of smooth muscle tissue on bronchiole wall and alveoli. The biopsied material was weakly positive for smooth muscle actin, and positive for both HMB-45 and progesterone receptor. Consequently LAM was diagnosed. Furthermore, the patient's back pain was aggravated after the operation and a spinal magnetic resonance imaging scan showed thoracic intraductal extramedullary tumor. The tumor was removed and the diagnosis of neurinoma was made.
No cases of LAM with neurinoma have been reported as far as we could review and this case is presented here because it is thought valuable.

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A 74-year-old man, who suffered injury to his back in minor collision with an automatic lawn mover driven by other person during mowing along the reilway, was brought into the hospital by ambulance. The wound was 25 cm in length and reached to the thoracic cavity, at where the muscles and ribs were cut. The left lung was observed through the wound. We initiated an emergency operation under general anesthesia and observed the thoracic cavity. There were no injuries to the heart and large vessels, but an injury with the width of 8 cm and depth of 2 cm was present in the left lower lobe of lung (S6). The injury was resected and sutured by using as automatic suture machine, and the opened chest was closed after sufficient levage of the thoracic cavity and chest wall wound. The postoperative course was uneventful and the patient was discharged from the hospital on the tenth postoperative day.

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A 75-year-old man who had undergone a left thoracoplasty 30 years earlier was brought into the hospital by ambulance because of fractures of the right 3rd through 9th ribs due to on blunt chest wall trauma at a traffic accident. Concavity in the right lateral chest wall with paradoxical movement was observed. Chest CT scan revealed right hemopneumothorax, lung contusion and severe deformity of the right-side thorax.
We performed operation through a right posterolateral incision and the fifth intercostal thoracotomy. Three fissures of the right lewer lobe were revealed which were closed by a direct sutures. The fractured ribs were fixed with stainless wires. His postoperative course passed without difficulty. We think that the emergency operation performed immediately after injury was successful.

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A 72-year-old woman with a ten-year history of an esophageal diverticulum presented with mild dysphagea was admitted to the hospital for surgery because of recent exacerbation of the symptom and enlargement of the diverticulum. Non-Zenker's diverticulum was suspected from a preoperative esophagoscopy that disclosed a pedicle of the diverticulum projecting to the left side at the height of the 4^th and 5^th cervical vertebrae. During surgery, we confirmed the diverticulum projecting from between longitudinal muscles on the left side of the esophageal wall at the tail side of cricopharyngeal muscle. Furthermore, preoperative examination of esophageal intraluminal pressure revealed that the cooperative movement during swallowing was kept intact. Thus only a diverticulectomy was performed and no incision in the cricopharyngeal muscle was made.
There have been no signs of a relapse of esophageal diverticulum, as of one year after the operation, but we have to follow the patient carefully for probable relapse.

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A 55-year-old man was admitted to the hospital because of dysphagia. Esophagogastrogram and endoscopic examination showed esophageal cancer (MtUt, 3 type, 12cm in length) and gastric cancer (M, IIa+IIb, 3cm in diameter). Computed tomography offered a suspicion of esophageal cancer infiltrating to the right lung (S₆) and right lower bronchus. He underwent radiation (40Gy) and chemotherapy (CDDP, 5'-DFUR) preoperatively. He had fever and from pneumonia 2 weeks after radiochemotherapy. Esophagogram showed an esophago-bronchial fistula (B₆). We inserted a covered expandable metallic stent (EMS) successfully in the esophagus and resultantly improved the pneumonia. On the 19th days after EMS insertion, a subtotal esophagectomy, a right lower lobectomy of the lung and a total gastrectomy were performed. Histological examination of esophageal cancer showed well differentiated squamous cell carcinoma, pT₃, pN₀, stage II. The patient received postoperative chemotherapy, but he died of mediastinal recurrence and multiple bone metastasis 11 months after the operation.
It is thought that insertion of a covered EMS for esophageal cancer with esophagobronchial fistula is helpful for the treatment of pneumonia, and serves as a useful measure prior to a radical operation.

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A 26-year-old woman with epigastralgia admitted after an upper gastrointestinal series showed a submucosal tumor with ulceration in the antrum, strongly requested laparoscopic surgery. Through adequately informed consent, we conducted a totally laparoscopic distal gastrectomy with Billroth-I reconstruction. The 3.5×3.5×1.8 cm tumor was 2 cm from the pylorus ring. A diagnosis of leiomyoma was made based on histopathological examination. She was discharged on postoperative day 17. We report this as the first case of gastric submucosal tumor of leiomyoma resected by totally laparoscopic distal gastrectomy.

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We report a case of peritoneal recurrence of gastric cancer presented with saccular tumors of inguinal hernia 31 months after surgery for Krukenberg metastasis from gastric cancer. A 46-year-old woman underwent a radical operation for hernia in January 2002, when 31 months had passed after a removal of Krukenberg tumor. On the tip of the removed hernia sac, a yellowish white and soybean-sized solitary nodule was present. It was histopathologically diagnosed as peritoneal recurrence of gastric cancer. In this case no multiple nodules in other area of the peritoneum were seen and there have been no signs of recurrence as of 5 months after the second operation. Accordingly, it is etiologically inferred that free cancer cells in the abdomen due to the previous surgery had implanted to the hernia sac and proliferated there. Sometimes making the diagnosis of peritoneal recurrence is difficult in cases without clinical symptoms such as ascites and without changes in imagings and tumor markers. In such cases, this extremely rare mode of peritoneal recurrence, the presence of a tumor at a hernia sac, must be kept in mind in making the diagnosis.

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A 47-year-old man was seen at the hospital because of abnormal findings of the duodenum pointed out at a medical checkup. Upper gastrointestinal endoscopy showed a protruded lesion with the diameter of 15 mm and a shallow concave at the center. With a biopsy, carcinoid tumor was diagnosed. On an ultrasonographic endoscopy, the depth of tumor invasion was thought to be “sm”. No hepatic metastasis and periduodenal lymph node swelling were visualized on an abdominal CT scan. A pylorus preserving pancreatoduodenectomy was performed with a diagnosis of a carcinoid tumor of the accessory papilla Vater of the duodenum. Histopathologically, it was a 14×13 mm carcinoid tumor of the accessory papilla Vater of the duodenum, with the tumor invasion depth of “sm”, and three positive nodes were present at the lymph node 14d.
Since there are some cases of carcinoid tumor of the accessory papilla Vater of the duodenum with positive lymph nodes compared to a small diameter of the tumor like in this case, radical surgery with lesional lymph node dissection like pancreatoduodenectomy would be desirable.

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We report a pancreaticoduodenal arterial aneurysm probably formed by hemodynamic stress compasating for stenosis of the celiac axis.
A 48-year-old woman with epigastralgia was found to have an inferior pancreaticoduodenal arterial aneurysm 3cm in diameter. Arteriography showed retrograde blood flow in the common hepatic artery, suggesting an increase in blood flow through the superior mesenteric artery. She underwent an operation in which we released a compression by cutting the median arcuate ligament following an aneurysmectomy. Three months later, an arteriography revealed an improvement of the celiac arterial stenosis and antegrade blood flow in the common hepatic artery. A pancreaticoduodenal arterial aneurysm associated with celiac arterial stenosis is relatively rare but rupture cases have been reported. Decompression of the celiac axis and aneurysmectomy should be performed electively in order to avoid disastrous rupture.

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We report a patient with advanced primary duodenal bulb cancer diagnosed incidentally prior to gallstones surgery. A 56-year-old woman seen to treat cholecystolithiasis with cholecystitis was found in preoperative screening with upper gastrointestinal endoscopy to have duodenal bulb cancer, necessitating distal gastrectomy with regional lymph node dissection, Billroth II reconstruction, and cholecystectomy. Macroscopically, the 3.2×2.5 cm tumor appeared to be Borrmann 1 and was located in the upper wall of the duodenal bulb. The histological diagnosis was poorly differentiated adenocarcinoma without invasion of the serosa or lymph node involvement.
Duodenal cancer generally requires pancreaticoduodenectomy, but other surgical procedures may be considered in duodenal bulb carcinoma without serosal invasion. We discuss optimal resection for duodenal bulb cancer in lymph node metastasis based on areview of the literature.

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Intestinal arteriovenous malforation (AVM) is relative rare as a cause of gastrointestinal bleeding. And in the case of a small lesion of the small intestine, it is often difficult to localize the lesion precisely. We report two cases of resected intestinal AVM using a microcatheter placed near the bleeding site by selective mesenteric angiography before operation to localize the lesion precisely.
(Case 1) A 62-year-old woman was admitted to the hospital because of massive melena. Abdominal angiography revealed a small hypervascular lesion in the ileum. To localize the lesion precisely, a microcatheter and a microcoil were inserted and maintained near the bleeding site before operation. By injection of indigocarmine through the catheter and abdominal X-ray examination, we localized the lesion and performed a local segmental resection of the ileum.
(Case 2) A 34-year-old man was admitted to the hospital because of massive melena and dizziness. Laboratory data showed severe anemia (Hb 4.8g/dl). Dynamic CT and abdominal angiography revealed a marked dilatation of the 1st. jejunal artery. A microcatheter was inserted and maintained into the 1st. jejunal artery before operation. After confirming the lesion by transcatheter staining with indigocarmine macroscopically, a short segment of the jejunum was resected.

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A 62-year-old man admitted to the hospital because of right shoulder pain was found to have a right adrenal tumor 6 cm in diameter on computed tomography (CT) and magnetic resonance imaging (MRI) scan. He was sent to other hospital for an endocrinological examination which revealed no abnormal findings, so a laparoscopic biopsy was conducted. Histopathological diagnosis was a metastatic tumor and he was sent to the hospital again. A movable tumor was palpable in the lower abdomen and an abdominal CT scan showed a tumor 10 cm in diameter similar to the right adrenal tumor. With a diagnosis of a small intestinal tumor and metastasis of the right adnenal gland, we conducted a resection of the small intestinal tumor and a right total adrenalectomy with the right lobe of the liver and right kidney. Macroscopically, the small intestinal tumor showed ulceration on the mucosal side, hematoma, and multiple small abscesses, and the right adrenal tumor was spongiform with hemorrhage. Immunohistochemical findings showed positive c-kit and focally positive SMA. Gastrointestinal stromal tumor was diagnosed. The tumor relapsed in a short time after the surgery and advanced rapidly. We inferred that the patient had a highly malignant gastrointestinal stromal tumor.

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A case of primary T cell lymphoma of the small intestine with perforated peritonitis is reported.
A 55-year-old woman was admitted to the hospital because of the sudden onset of right lower abdominal pain. Before operation, we made a diagnosis of peritonitis due to inflammation or a tumor of the ileum based on physical findings and the wall thickening of the ileum end by computed tomography. At an exploratory emergency laparotomy, we found severe perforation of the ileum and performed an enterectomy and drainage operation. The diagnosis after the operation was primary T cell lymphoma of the small intestine with perforation. Postoperative course was stable and chemotherapy was started, but she died seven months after the operation.
A clinicopathological study was made on eight cases of lymphoma of the small intestine with perforated peritonitis diagnosed during emergency laparotomy in the hospital during the recent 40 years. Pathologically, all cases were of non-Hodgkin lymphoma. Regardless of methods of operations, the prognosis was very poor. We were able to give chemotherapy after operation to four cases and obtained good response in only two cases. It is considered that we had better select short enterectomy and drainage operation for these patients and start chemotherapy or radiation therapy after saving their lives.

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A 38-year-old man was referred to the hospital because of lower abdominal pain. Barium enema, colonoscopy and CT scan showed a tumor of the appendix. Biopsy specimens from the lesion gave a pathological diagnosis of as non-Hodgkin lymphoma, which was characterized by diffuse large cell type. With the diagnosis of primary malignant lymphoma of the appendix, we performed a right hemicolectomy and D3 lymph nodes dissection. The tumor was immunohistologically diagnosed as B cell lymphoma. Regional lymph nodes involvement was histopathologically proved. Following systemic chemotherapy with 2 courses of CHOP, he has been free from recurrence as of 24 months after the operation. We report herein the rare case of primary malignant lymphoma of the appendix, together with a review of some previous Japanese reports.

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A clinicopathological study was made on 11 cases of mucocele (eight cases of adenoma and three cases of adenocarcinoma) of the appendix treated at the hospital in the recent 16years and 5months. They were from 42 to 83 years old, and the male-to-female ratio was four to seven. The most common complaint was lower abdominal pain in six cases including two cases in which a tumor was palpable. Two cases were asymptomatic when the lesion was detected. With a recent progression in the imaging diagnosis, correct preoperative diagnosis was successfully made in five out of eight cases of adenoma. The three cases of adenocarcinoma were diagnosed as peritonitis carcinomatosa (peritoneal pseudomyxoma) before surgery. The most common operative procedure was appendectomy in six cases including one case undergone an appendectomy with a partial resection of the small intestine, followed by ileocecal resection in four cases including one case in which an omental resection was associated, and partial cecectomy in one case. As for prognoses of eight patients with adenoma, one patient with adenoma associated with gastric cancer died of cancer, but the remaining seven patients are doing well. Of three patients with adenocarcinama, two patients died as of 3 months and 17 months after the operation, respectively, and the remaining one patient is still alive as of 9 months after the operation.

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Crohn's disease is an inveteratus and non-peculiar inflammatory disease that has a potential to occur in all the alimentary canal and shows a tendency of increasing recently in this country. There are many cases of Crohn's disease associated with severe complications such as fistula, stenosis, and perforation. However it is rare that the disease is complicated by liver abscess and iliopsoas abscess. So for seven cases of Crohn's disease complicated by liver abscess and 34 cases complicated by iliopsoas abscess have been reported in Japan. It is thought that Crohn's disease complicated by both abscesses is very rare. We report such a very rare case in a 24-year-old man, who was successfully treated by percutaneous drainage for iliopsoas abscesses and fragmentation for ruptured liver abscess associated with Crohn's disease of colon.

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Infectious colonic necrosis is a rare inflammatory bowel disease. A 63-year-old man with diabetes admitted for abdominal pain showed abdominal guarding on physical examination and mucosanguineous diarrhea. Abdominal computed tomography (CT) showed marked thickening of the sigmoid colon. Under a preoperative diagnosis of peritonitis due to diverticulum, we conducted an emergency laparotomy that showed partial necrosis of the sigmoid colon necessitating partial resection and colostomy. Histopathological examination showed no deverticulum, but numerous large rod Gram-positive bacilli in the sigmoid colon wall consistent with clostridium, indicating colonic necrosis caused by bacteriological infection. We suggest that chronic constipation in diabetic patients may indicate genesis of infectious colonic necrosis.

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We report a case of an abscess of the inguinal and scrotal region resulting from an intramesenteric perforation of the sigmoid colon. A 64-year-old man, who had a relapsed left inguinal hernia for 2 years following a previons operation for bilateral inguina hernia, presented with a 1-day history of swelling and pain in the left groin and scrotum and fever. The groin and scrotum markedly swelled, and were erythematous and tender. The patient was diagnosed as having incarcerated inguinal hernia, and a surgical operation was performed. Upon dissecting the swollen spermatic cord, infected necrotic tissue, abscess and faeces were encountered. No strangulated bowel was found. Laparotomy revealed an intramesenteric perforation of the sigmoid colon which caused the abscess. Resection of the sigmoid colon and debridement of the left spermatic cord were performed. Histopathological evaluation showed neither carcinoma nor diverticulum. The patient was discharged from the hospital 57 days after the operation. A possibility of colocectal perforation must be kept in mind in diagnosing a patient presented with a swelling of the inguinal and scrotal region with inflammatory findings.

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A 76-year-old man was admitted to the hospital because of dizziness and tingling in November 2000. Examination of the blood revealed 6.8 g/dl hemoglobin, indicating prominent anemia. Lower gastrointestinal endoscopy disclosed a solitary circular protruded lesion, with an about 15 mm in diameter and vivid red in color. Abdominal angiography visualized dense and macular accumulation of contrast material in the branch feeding the middle portion of ascending colon from the ileocolic artery. No other lesions which might cause anemia were present, and the case was diagnosed as bleeding due to angiodysplasia of the ascending colon associated with severe iron deficiency anemia. A laparoscopic assisted partial resection of the ascending colon was performed. The postoperative course was uneventful. There have been no signs of bleeding and anemia, as of 23 months after the operation.

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A 76-year-old woman was admitted to the department of orthopedics in our hospital because of fever, difficulty in walking and left side abdominal pain. On the next day after admission, she was enrolled in another course as an emergency patient in a shock state.
Abdominal plain X-ray film showed multiple bubble around the desending colon, and an abdominal CT scan showed extensive emphysema around the left hip joint. An emergency surgery was performed under a diagnosis of retroperitoneal abscess. A postoperative barium enema and an abdominal CT scan showed retroperitoneal perforation of a diverticulum of the colon.

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A 52-year-old woman was admitted to the hospital because of left lateroabdominal pain. There were previous histories of undergoing a low anterior resection of the rectum for rectal cancer 10 years 2 months before admission, and thereafter undergoing pulmonary resection for lung metastasis three times, resection (2 times) and gamma knife treatment (6 times) for brain metastases. In addition she received radiotherapy for pulmonary metastasis 5 months before admission. After admission, a plain CT scan disclosed a tumor with petechial calcification at the pancreatic tail. The center of the tumor was not enhanced on an enhanced CT scan. Magnetic resonance imaging san showed low intensity on T1-weighted image and iso-intensity spotted with high intensity parts on T2-weighted image. Endoscopic retrograde pancreatography revealed occlusion of the main pancreatic duct and disappearance of acinus at the pancreatic tail. From these findings, a resection of the pancreatic body and tail with a sprenectomy was performed with a suspicion of malignant pancreatic tumor. The removed tumor was 4.0×3.1×3.0cm in dimension and the section was yellowish white in color. It was moderately differentiated adenocarcinoma. Since there were no lesions in the main pancreatic duct and peripheral pancreatic ducts and the tumor had many similar histopathological findings to those of primary foci of the rectum and metastatic foci of the lung and brain, pancreatic metastasis of rectal cancer was diagnosed.
So far few reports on pancreatic metastasis of rectal cancer have been reported, and hence this rare case is presented here.

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A 51-year-old female patient with idiopathic portal hypertension (IPH), splenomegaly and pancytopenia had received internal treatments including a partial splenic embolization (PSE), but no remission was attained. A splenectomy was performed in April 2002. The patient's postoperative course was uneventful, however portal vein thrombosis was recognized on an abdominal computed tomography (CT). The patient was immediately given danaparoid sodium. This drug was very effective, and the portal vein thrombosis disappeared within four months. Danaparoid sodium is a new drug for deep venous thrombosis (DVT). pulmonary embolism (PE), and heparin-induced thrombocytopenia (HIT) in the Western countries. Although both warfarin and heparin require careful maintenance of anticoagulant activity danaparoid sodium does not. Because of a low risk for bleeding tendency with a use of danaparoid sodium, this drug can be expected to be very useful for treating thrombosis.

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Obstructive jaundice due to a benign, non-parasitic liver cyst is rare. We report a case of obstructive jaundice caused by a large liver cyst, which was successfully treated by a dome resection. A 73-year-old woman presented with obstructive jaundice and appetite loss. Abdominal CT and ultrasonography visualized a large hepatic cyst 13×9cm in diameter and intrahepatic bile duct dilatation. After a percutaneous transhepatic cholangio drainage for the right intrahepatic bile duct, a dome resection was carried out because a possibility of malignancy could not be ruled out. Post operative clinical course was uneventful. Liver enzyme levels returned to normal range and jaundice disappeared. The patient has remained healthy without symptoms.

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A 28-year-old woman diagnosed with cholelithiasis and reporting acute severe right upper quadrant pain was found in biochemical blood studies to have increased liver enzyme. Upon laparoscopy, the patient was diagnosed with Fitz-Hugh-Curtis syndrome and cholelithiasis based on violin-string-like adhesion between the liver surface and peritoneum and serological positivity for Chlamydia IgA, IgG antibody. With Chlamydia infection on the increase, Chlamydia should be checked for and the liver surface carefully observed in laparoscopy involving young women.

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We report an operated case of slow growing pancreatic cancer which had been followed as a pancreatic cyst elsewhere for 9 rears and 4 months. A 67-year-old man who had been followed at another hospital with a diagnosis of diabetes mdllitus and a pancreatic cyst since July 1992 was referred to the hospital because of a liver tumor on November 8, 2001. Abdominal CT scan revealed a cyst at the pancreas tail 35 mm in longer diameter and a liver tumor 15 mm in diameter. Ultrasonography-guided fine needle biopsy suggested that the liver tumor was cholangiocellular carcinoma. He was operated on with a diagnosis of cholangiocellular carcinoma and a pancreatic cyst on December 11, 2001. We performed a distal pancreatectomy with a splenectomy and a limited resection of segment 8 in the liver. Histologically, the pancreatic cyst was malignant islet cell tumor and the hepatic tumor was metastasis from the pancreas tumor. Because we often have difficulty in making the correct preoperative diagnosis for pancreatic cysts, all the cystic tumors must be treated by surgical resection, unless they are definitely diagnosed as pseudocysts.

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A 63-year-old man presenting left upper quadrant discomfort was found by his personal physician to have a splenic mass upon echography. Computed Tomography showed a low-density mass with calcification. The mass showed iso-intensity in T1-weighed images and low intensity in T2-weighed images. Angiography showed a hypovascular mass. Splenectomy was done on June 1, 1999. The spleen weighed 345 g and the whitish-yellow, solid, well-circumscribed, firm mass was 6×4cm. Microscopic examination showed psoriasis fibrous granuloma by proliferation of plasma cells, and the mass was diagnosed as an inflammatory pseudotumor of the spleen.

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A 53-year-old man, whose operation under a diagnosis of a retroperitoneal tumor was sustained because his blood pressure increased at an intraoperative biopsy of the tumor at another hospital, was referred to the hospital with a diagnosis of pheochromocytoma. The diagnosis was made based on abnormally high levels of blood and urinary catecholamines and histopathological findings. On admission to the hospita, an abdominal ultrasonography, CT, and magnetic resonance imaging scans showed a tumor dosal to the liver, and infiltration into the inferior vena cava was suspected. No abnormalities were found in the bilateral adrenals. A removal of the extra-adrenal pheochromocytoma with a partial excision of the inferior vena cava was performed. The excised tumor was 6×6×5 cm in diameter and 66 g in weight, with multinodular surface and segmented section. Histopathologically, tumor cells showed honeycomb proliferation, and infiltration into the surrounding fatty tissues and venous invasion were also seen, which were indicative of malignancy. From these findings, extra-adrenal malignant pheochromocytoma was definitely diagnosed. After the operation, blood and urinary levels of catecholamines immediately decreased into normal ranges. The patient's postoperative course was uneventful and he was discharged from the hospital on 19^th postoperative day.
Extra-adrenal malignant pheochromocytoma reportedly accounts for about 4% of all pheochromocytomas, but its criteria for diagnosis are not necessarily clear. We report this rare case of extraadrenal pheochromocytoma, together with some discussion in terms of differentiation between benign and malignant lesions.

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Retroperitoneal xanthogranuloma is relatively rare. We report a case of retroperitoneal xanthogranuloma adhered to the left sciatic nerve. A 56-year-old woman was admitted to the department of gynecology in our hospital because of a tumor in the pelvic space pointed out at mass-screening for uterine cancer. With a preoperative diagnosis of peduncular uterine myoma or ovarian tumor, the patient was operated on. The tumor, 8×7×5 cm in dimension, was present in the pelvic retroperitoneal space. The tumor compressed the rectum to the right side. The tumor adhered to the sacrum and left sciatic nerve, but the dissection itself was not difficult. Total resection of the tumor was performed. Histopathologically, it was diagnosed as xanthogranuloma. The patient is alive without any signs of recurrence, as of 1 year and 5 months after the operation.

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A 56-year-old man was referred to the department because of lower abdominal pain. Abdominal ultrasonography revealed ascites, and an abdominal CT scan demonstrated a concentric whorl-like structure and left inguinal hernia. Emergency operation was performed under a diagnosis of mesenteric volvulus with left inguinal hernia. At surgery, a dark-red omental mass with torsion, entering into a left inguinal hernia sac, was detected. Another patient, a 50-year-old man, was referred to us with a suspicion of acute appendicitis. An abdominal CT scan showed a large fat density mass with concentric linear strands and right inguinal hernia. Laparotomy was performed under a diagnosis of secondary omental torsion, revealing a dark-red omental mass with clockwise torsion, entering into a right inguinal hernia sac. The omentum was resected at its normal side in both cases. It might be possible to reach the correct diagnosis from the characteristic appearance on abdominal CT.

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We report a rare case of desmoplastic small round cell tumor, with difficulty in diagnosis. A 38-year-old man was seen at the hospital because of abdominal fullness. Imaging procedures revealed a giant tumor of the ometum and peritoneum, and much ascites. Poorly differentiated adenocarcinoma of unknown origin with carcimatosa peritonitis was diagnosed by cytological analysis on aspirate from the ascites. With the aim of tumor reduction, an exploratory laparotomy was performed. The tumor of the omentum was partially excised. On the 19th postoperative day, DSRCT was diagnosed by immunohistochemical studies. Recently, a 5-year survival rate of 35% was reported for DSRCT treated with preoperative chemotherapy. We scheduled the same chemotherapeutic regimen, but the patient died of respiratory fuilure on the 50th postoperative day. For the diagnosis of an intra-abdominal tumor of unknown origin like this case, rapid and correct biopsies including open incisional biopsy and laparoscopic biopsy are mandatary.

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A 64-year-old man was admitted to the hospital because of epigastralgia. He was diagnosed as having early gastric cancer by upper gastrointestinal endoscopy. Abdominal computed tomography showed a solid tumor with marginal enhancement at the pancreatic head. Angiography revealed tumor hypervascularity and encasement of the pancreatic artery. A pancreaticoduodenectomy and a total gastrectomy were performed. The pancreatic tumor was histologically diagnosed as adenosquamous carcinoma. Adenosquamous carcinoma of the pancreas is relatively rare. Synchronous double cancer of adenosquamous carcinoma of the pancreas and gastric cancer like in this case has not been reported in the Japanese literature to our knowledge. This first case is presented here.

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An 82-year-old man was admitted to the hospital because of an abdominal mass and anorexia. Abdominal ultrasonography (US) and CT scan revealed an infrarenal type abdominal aortic aneurysm 7.6×10 cm in dimension. Upper gastrointestinal endoscopic examination revealed type 3 advanced cancer at the antrum and type IIc cancer at the middle body of the stomach. In adittion advanced cancer of the upper rectum was detected by barium enema. One-stage operation was carried out for the concomitant infrarenal abdominal aortic aneurysm and double advanced cancer of the stomach and rectum. In this case, a resection and grafting of the aneurysm preceded a distal partia gastrectomy and a Hartmann's operation. The postoperative course was uneventful without graft infection. He is doing well without signs of recurrence as of six months after the operation. We report that the one-stage operation is possible for abdominal aortic aneurysm with synchronous cancer of the upper and lower gastrointestinal tract under a careful attention to prevent graft infection.

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A 61-year-old man complained of epigastric pain and diagnosed as having gastric cancer at elsewhere was referred to the department of internal medicine in our hospital. After admission, close exploration of the digestive organs demonstrated carcinoma of the esophagus, stomach, and descending colon. Abdominal CT scan showed hepatoma. Triple cancer with hepatic metastasis was diagnosed. After systemic chemotherapy, a total gastrectomy, a left hemicolectomy, and a partial hepatectomy (S5) were performed. After the operation, the hepatic tumor was diagnosed as hepatocellular carcinoma, and the definite diagnosis was made as synchronous quadruple cancer. Radiotherapy was conducted for the esophageal cancer.
Pathologically, the esophageal cancer was moderately differentiated squamous cell carcinoma (at a biopsy); the gastric cancer was moderately differentiated tubular adenocarcinoma, T2, N1, and Stage II; the colonic cancer was well differentiated adenocarcinoma, sm, n (-), and Stage I; and the hepatic cancer was moderately differentiated hepatocellular carcinoma, T2, N0, M0, and Stage II.
We tend to select more invasive surgeries for treatment of multiple carcinoma, but in this case, minimal invasive surgery could be performed by combining with chemotherapy and radiotherapy, with an uneventful postoperative course.

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