[in Japanese]

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Since 1996, we have omitted axillary lymph node dissection for the elderly patients with breast cancer older than 75 years, and have administered tamoxifen as an adjuvant therapy. From 1990 through 2000, a total of 119 elderly patients were operated on for breast cancer except those with N1b and further. We classified these 119 patients into two groups; 47 patients treated from 1990 to 1995 were assigned to group A and 72 patients from 1997 to 2000, to group B. Axillary lymph node dissection was performed in 68% of the group A patients and 24% of the group B patients. There were no significant differences between the two groups in ER positivity, histology, age, the incidence of bilateral breast cancer and another cancer. The mean follow up time was 50 months in group A, versus 29 months in group B. Compared with group A, there were more patients performed breast conservative therapy, and less patients experienced relapse in group B. Survival rate for 5 years was 56.5% in group A, versus 91.3% in group B. These results suggest a possibility that, for the elderly patients with breast cancer, we can expect favorable therapeutic outcomes by administering tamoxifen instead of performing axillary lymph node dissection.

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This study was designed to clarify the postoperative QOL and gastric emptying in reconstruction procedure using gastric tube after proximal gastrectomy for upper gastric cancer. Subjects were 15 cases undergone this reconstruction method. The indications were early cancer located near the E-C junction without the indication of wedge resection, and advanced cancer located in the upper portion in high risk cases. In this method, the dissection of lymph node was limited in No1, 2, 3, 7, and the length of gastric tube was 20-25cm.
The patient's QOL was evaluated in terms of the changes in oral intake and body weight, symptoms, findings of gastrofiberscopy and gastric emptying by acetaminophen. The volume of oral intake and body weight recovered to preoperative levels one year after the operation in 8 out of 15 cases. The postprandial heavy feelings were observed in one case, but no bezoar was observed in this method. Endoscopic findings of reflux esophagitis were present in three out of 12 cases. This method showed a rapid gastric emptying function samely as distal gastrectomy with Billroth's I reconstruction.
In conclusion, the method of reconstruction using gastric tube after proximal gastrectomy for upper gastric cancer was easy and simple, and the postoperative QOL was well-preserved.

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In order to determine the optimal conservative treatment for patients with postoperative adhesive small bowel obstruction (PASBO), a series of 140 patients of this disease were treated without a nasointestinal tube for initial 48 hours between April 2001 and March 2002. Some patients of them who were suspicious of strangulated small bowel obstruction underwent surgery. We compared the therapeutic outcomes of them with those of 132 patients of this disease treated with a nasointestinal tube for initial 7 days between January 1999 and December 1999 (control group). No mortality was recorded in both groups. The resolution rate with conservative treatments and the rate of postoperative complications were not significantly different between two groups. However, prolonged conservative treatment entailed a delay of diagnosis for patients with strangulated small bowel obstruction in the control group. Furthermore, length of hospital stay in the studied group was shorter than that in the control group (p<0.01). Therefore, the optimal period of conservative treatment for patients with PASBO should be 48 to 72 hours. With regard to the patient's quality of life and length of hospital stay, there was no advantage of long tubes over short tubes in patients with PASBO.

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The incidence of postoperative hepatic metastasis within five years was statistically analyzed in 144 patients undergone a curative resection for advanced colorectal cancer in our department. Liver metastasis occurred in 23 (15.9%) out of the 144 patients, and these 23 patients were analyzed to identify values for clinicopathologic factors and their subcategories. Significantly higher frequencies were noted in patients demonstrating the following factors: (1) preoperative serum level of CEA antigen>30ng/ml (p<0.01); (2) tumor size>60mm in the great dimension (p<0.05); (3) undifferentiated histological type (p<0.01); (4) depth of tumor invasion (p<0.05); (5) postive lymph node metastases (p<0.01); (6) positive lymphatic invasion (p<0.01); (7) positive venous invasion (p<0.01). These factors were analyzed by Hayashi's quantification theory, and high risk group for liver metastasis after curative resection for colorectal cancer was identified by guantifying these factors. Of the 23 patients, 20 (87%) patients were identified to belong to high risk group. Since this guantification of factors is made on limited factors which can be easily obtained in many hospitals, it contributes to identify the high risk patients. In these high risk groups, careful postoperative management would be mandatory, thereby improving prognosis of the patients with colorectal carcinoma.

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The aim of this study was to evaluate the effects of preoperative transarterial chemoembolization (TACE) prior to microwave coagulation therapy (MCT) for hepatocellular carcinoma (HCC) with intratumoral portosystemic shunts. ICG R15 and ^99mTc-GSA (LHL 15, functional liver volume) evaluated before and two or three weeks after TACE in 11 HCC patients with portosystemic shunts (shunt (+) group), and in 21 HCC patients without portosystemic shunts (shunt (-) group), Levels of ICG R15 after TACE significantly decreased in shunt (+) group. LHL 15 in shunt (+) group tended to increase after TACE. Although the functional liver volume in shunt (-) group decreased significantly following TACE, no significant change found in shunt (+) group. No major complications occuurred in both groups and no significant differences were recognized in survival between the two groups. In conclusion, these results indicate that TACE prior to MCT is useful for increments of effective hepatic blood flow in HCC patients with intratumoral portosystemic shunts, without deterioration of the functional liver volume.

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We discuss the long-term results of endoscopic sphincterotomy (EST) in patients with choledochocele, a rare congenital biliary dilatation. Subjects were 2 men and 3 women aged 63 to 96 years (mean: 81.2 years) diagnosed by endoscopic retrograde cholangiopancreatography showing cystic dilatation of the terminal common bile duct (CBD). In all with cholangitis, we conducted EST to relieve biliary stagnation. A 96-year-old man with ampullary cancer arising in the cele had an endoprosthesis and died 14 months later. In the other 4, the cele was disappeared and symptoms were ameliorated. They remain alive without cholangitis or pancreatitis during follow-up of 35-110 months (mean: 64.6 months). Pancreatobiliary stagnation in the cele may induce malignant changes. Once EST relieves stagnation, the frequency of carcinogenesis is reduced, potentially rendering surgical resection unnecessary. Due to the possibility of malignant changes already induced before EST, however, the ampullary mucosa should be meticulously observed for at least several years even after EST.

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Of a series of 38 patients resected t2 gallbladder carcinoma in the hospital, prognostic factors and modes of recurrence were investigated in terms of the histological findings, especially paying attention to the subserosal cancer infiltration such as deapth (ss1, 2, 3) and type (INFα, β, γ) of cancer infiltration, and the combined classification (ssINF A, B, C). The present study revealed that lymph node metastasis (n), ss and INF were significant prognostic factors, and the combined classification was more valuable significant prognostic factor than n, ss and INF. From an analysis of the recurrent patients died of liver metastasis, extended cholecystectomy with hepatic resection of S4a and S5 should be performed for the patients with hinf positive, ssINF-B and -C infiltration to the gallbladder bed. From another analysis of the recurrent patients died of lung metastasis or malignant stenosis of the hilar bile duct, the extrahepatic bile duct should be resected with lymph node dissection for the patients with cancer infiltration to the neck of the gallbladder.

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We recently experienced a patient with gstric metastasis from breast carcinoma which is relatively uncommon. A 52-year-old woman, who had a history of undergoing a mastectomy for left breast cancer 4 months earlier, was seen at the hospital because of anemia and anal bleeding. Endoscopic examination of the upper gastrointestinal tract showed multiple elevated lesions with slight erosion at the gastric body. Endoscopic and histologic findings were compatible with gastric metastasis from the breast cancer. The patient died of primary cancer 8 months after the mastectomy. We should pay careful attention to possible occurrence of gastric metastasis in patients with advanced breast cancer, if they complain of gastric symptoms and anemia.

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A 56-year-old woman who had a choroidal metastasis from breast cancer is reported. She had undergone a breast conserving operation with radiotherapy for left breast cancer in 1996. Lymph node metastasis in 1996, local recurrence in 1997 and multiple liver metastases in 2001 were found and she received chemotherapy. She was referred to the hospital because of blurring of vision in her left eye. Serous retinal detachment and flat tumor 1.3cm in diameter were found in her left eye fundus. She was diagnosed as having metastatic choroidal carcinoma. We recommended radiotherapy so as to improve her quality of life, but she rejected. Since patients with breast cancer have turned out to survive for a long time with recent multimodal treatment, patients who experience choroidal metastasis from breast cancer will increase.

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We report two cases of cystic and bullous disease in young women. Case 1: A 28-year-old woman was admitted for a cystic lesion found in chest X-ray and chest computed tomography. Bullectomy was conducted for a giant bulla. Case 2: A 27-year-old woman was admitted for a cystic lesion on chest CT. Segmentectomy of the right right basal segment was done. Histological findings led to a diagnosis of multiple bronchiolus cysts. These bullous and cystic disease are rare in young women.

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A 52-year-old woman was admitted to the hospital because of persisting back pain. She had undergone a radical modified mastectomy for right breast cancer at 49 years old and a left upper lobectomy for lung cancer at 51 years old. Abdominal computed tomography revealed each one tumor about 20mm in diameter in the pancreas head and tail. Endoscopic retrograde cholangiopancreatography revealed stenosis of the main pancreatic duct in the head and dilatation in the body and tail. The tumors were suggestive of malignancy by a cytology of pancreas juice. We diagnosed the case as multiple pancreas metastasis from breast or lung caner and performed a distal pancreatomy and a splenectomy. Histologically the excised tumors consisted of well differentiated squamous cell carcinoma and partially differentiation to adenocarcinoma. Compared with previous pathological findings of lung cancer, these pancreatic tumors were compatible with pancreas metastasis from lung cancer. After the operation her back pain disappeared, and she has remained well with other recurrence as of 1 year and 3 months. Although pancreas metastasis had poor prognosis, we should consider aggressive surgery that might prolong prognosis and improve quality of life in some cases.

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A 76-year-old man seen at another hospital because of dysphagia and a body weight loss was referred to the hospital with a diagnosis of a lower esophageal tumor. On admission, the white blood cell count was 18, 300/mm³, which thereafter increased to 27, 900/mm³ and at the same time his body temperature increased to 38°C. Blood granulocyte-colony stimulating factor (G-CSF) was 101pg/ml and IL-1 and IL-6 also showed high values. Because he had impaired renal function, a thoracotomic transdiaphragmatic esophagectomy was performed. Pathological diagnosis was so-called carcinosarcoma, pT1b (SM) pN0M0, and stage I. After the operation, the white blood cell count and high fever were normalized and G-CSF decreased to less than 10pg/ml. The tumor was positive in an immunohistological staining for anti-G-CSF antibody. The definite diagnosis of G-CSF producing tumor was thus made.

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So-called carcinosarcoma of the esophagus is rare malignant neoplasm composed of carcinoma and sarcomatous components. We described a case of multicentric “so-called carcinosarcoma” of the esophagus, together with a review of the literature.
A 60-year-old man was admitted to the hospital because of dysphagia. Esophageal X-ray examinations and upper gastrointestinal series revealed a large polypoid lesion in the middle intrathoracic esophagus. We performed surgery on a two-step approach because the patient's general condition was poor. Surgical procedures included a total thoracic esophagectomy and dissection of chest lymph nodes, followed by reconstruction of the esophagus using a gastric tube and dissection of abdominal and cervical lymph nodes.
A macroscopic view of the resected specimen showed two elevated tumors, 13.5×5.0 cm and 2.0×2.0 cm in dimension, respectively. Microscopic examination revealed that the tumor consisted of squamous cell carcinoma with plemorphic cell with sarcomatous stroma. And a transitional area between the two elements was tecognized histopathologically. The patient was diagnosed as having so-called carcinosarcoma of the esophagus.

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A 44-year-old man complaining of heartburn was referred to the hospital for close exploration of an esophageal elevated lesion found at another hospital. Barium esophagograms revealed a slightly elevated lesion with surrounding mucosal irregularity of the lower thoracic esophagus. Endoscopic examination revealed reddish and rough mucosa with maple-leaf-like shape on the oral side of squamo-columnar junction, and an elevated lesion with a central depressed component. Biopsy specimens sampled from the main lesion was diagnosed as well differentiated adenocarcinoma and this case was diagnosed as adenocarcinoma arising from the short segment Barrett's esophagus. Distal esophagectomy and a proximal gastrectomy without thoracotomy was performed. Histological examination of the resected specimen showed Barrett's epithelium in the lower esophagus, and well-differentiated adenocarcinoma limited in mucosa (IIa+IIc, m, ly1, v0, n0, 12×7 mm) in it. Postoperative course was uneventful, and no recurrence has been observed over 2 years. The case of adenocarcinoma arising from the short segment Barrett's esophagus, which has recently attracted clinical attentions is reported together with a review of the Japanese literature.

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A 62-year-old man with appetite and body weight loss undergoing esophagography was found to have an uneven filling defect 8 cm long at Lt to Ae of the esophagus. Endoscopic examination showed an uneven nodulaous, protruding, infiltrative tumor 37 cm from the incisors to the esophagogastric junction. Biopsy of the tumor showed basaloid-squamous carcinoma, necessitating right transthoracic subtotal esophagectomy with dissection of mediastinal and abdominal lymph nodes. The resected specimen showed an 8×6.5×3 cm combined type 1p with a type 3 lesion. The histopathological diagnosis was esophageal basaloid-squamous carcinoma with a stage grouping of pT3, pN1, pIM0, ly1, v0, pStage 3. Basaloid carcinoma of the esophagus is rare and thought to have greater malignant potential than squamous cell carcinoma. We review 41 cases of advanced basaloid carcinoma, including ours, reported in the Japanese literature.

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A 79-year-old man was admitted to the hospital because he was pointed out having gastric cancer and hepatic impairment. Upper gastrointestinal fluoroscopy and endoscopic study disclosed type 3 gastric cancer on the lesser curvature of the upper and middle portion of the stomach. Abdominal CT scan showed # 12 lymph node metastasis and tumor embolism at the portal trunk, but SOL was not especially confirmed though the hepatic parenchyma was revealed as slight uneven staining. During preoperative examinations, the patient went into shock after hematemesis and anal bleeding so that an emergency total gastrectomy with splenectomy was performed for hemostasis. Histopathologically, it was well differentiated adenocarcinoma with a strong tendency of vascular invasion, tumor invasion depth of se, intermediate type, INFβ, ly3, and v2. The patient rapidly went into DIC state and died of hemorrhagic shock on the next day. Autopsy revealed metastases to the liver, bone marrow, prostate, and lymph nodes of the hili of the lung and liver, other than portal tumor embolism. Based on the autopsy findings, he died from suddenly progressed hepatic failure due to hepatic metastasis and portal tumor embolism as well as hemorrhagic shock associated with DIC. The hepatic metastasis which could not be demonstrated by preoperative CT was found to be diffuse metastasis of tumor cells which forms no tumor. In all metastatic foci including hepatic metastasis, tumors looked like small cell carcinoma. On immunohistologic stainings, the primary foci and portal tumor embolism which manifested well differentiation were negative for chromogranin A and CD56 (NCAM) stainings, but periportal lymph nodes and hepatic metastasis were positive. On H-E stainings, there were areas showing vascular forming tendency. We consequently considered that dedifferentiation to small cell carcinoma in metastatic foci from well differentiated adenocarcinoma of the primary foci might occur.

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We present a case of elderly onset membraneous stenosis of the duodenum which is thought extremely rare.
An 83-year-old woman was referred to the department of internal medicine in our hospital on November 13, 2001, because of weight loss, poor appetite, and occasional vomiting which started in September of the year. She had been taking oral non-steroidal analgesics for rheumatoid arthritis for 8 years. Close examinations demonstrated a whole-circumferential stenosis at the descending portion of the duodenum. Since conservative therapy was unsuccessful in relieving passage disturbance and endoscopic dilatation was inapplicable, the patient was recommended surgery. Upon laparotomy, no cicatrical deformity of the duodenum was present, and the stenotic portion was extramurally felt as cordlike thickening of the wall at the descending portion of the duodenum. The portion was longitudinally incised, and on palpation of the lumen from the incision, at least two membraneous stenoses were felt in the vicinity of the part transitional region from the descending to horizontal portions of the duodenum. Considering the number of stenoses and the patient's age and physical activities, a gastrojejunostomy was performed.

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A 37-year-old woman suffering from left upper abdominal pain after dinner on April 17, 1999 was admitted to another hospital on April 18 because the pain intensified. A fist-sized lump with tenderness was palpated in the left lower abdomen on admission. But the lump disappeared after the patient vomited during the night and the pain was relieved. On April 19, ileus due to paraduodenal hernia was suspected from abdominal X-rays and CT scan, and the patient was referred to our hospital for elective surgery. At surgery performed on April 20, a hernia opening 2cm in diameter was present in the right side of the Treitz's ligament, through which about a 90cm leugth of the jejunum had invaginated into the mesenterium of transverse colon. The jejunum entered into the hernia cavity was returned to the normal position, and the opening was closed. She developed adhesive ileus after the operation but it improved without further operation. She was discharged from the hospital on May 16.
A case of paraduodenal hernia, that is a rare inner hernia, is here reported, together with a study of similar cases in Japan.

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We report a case of Meckel diverticulum without ectopic tissue in an elderly patient presented with anal bleeding.
A 76-year-old woman complaining of anal bleeding pointed out anemia at elsewhere was referred to the hospital for close examination. No bleeding site could be localized by both lower and upper gastrointestinal endoscopic studies. So intestinal fluoroscopy was conducted that revealed a 6×4cm Meckel diverticulum with ulcers about 30cm oral to the terminal ileum. Hemorrhage caused by the diverticulum was diagnosed and a partial excision of the ileum including the Meckel diverticlum was performed. On the resected material, sporadically scattered ulcers were observed which were considered probable cause of anal bleeding. However, no ectopic tissue was present in the diverticulum on a histopathological study. Since bleeding from Meckel diverticulum without ectopic tissue rarely occurs, we present the case together with some bibliographical comments on the genesis of ulcerative hemorrhage.

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We report a case of perforative ulcer of the small intestine induced by a nonsteroidal antiinflammatory drug (NSAID), which is rare in Japan, with a review of the literature. A 69-year-old man was admitted to the hospital because of sudden onset of continuous abdominal pain after treatment with a diclofenac sodium suppository (150300mg/day) for a pain from recurrent ureteral cancer. Since abdominal computed tomography revealed the presence of free air and ascites, the patient was diagnosed as having panperitonitis caused by gastrointestinal perforation and underwent an emergency surgery. At laparotomy, a perforative ulcer and a deep ulcerative lesion were observed at the anti-mesenteric site in the terminal ileum. We performed a wedge resection of the ileum for both lesions. Histological examination of the lesions revealed only non-specific ulcer and no evidence of malignancy. After the surgery, NSAID was withdrawn and he has been free from recurrence of ileal ulcer for three months until his death of primay diseas.

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We report a case of larva migrans with ileus which appeared after the patient had eaten raw firefly squids. A 27-year-old man was admitted to the hospital because of vomiting and epigastric pain after eating raw firefly squids. Abdominal X-rays and computed tomography showed dilatation of the small intestin with thickening. The labolatory data showed increasing percentage of eosinocytes. We diagnosed the case as acute abdomen causing intestinal obstruction and laparotomised emergently. These were narrowings with redness and thickening of the jejunum about 10cm and 80cm oral side from the cecum, respectively. Partial jejunectomy including the narrowings was performed. In the removed specimen, we found a kind of parasite on the mucosa. Pathological findings showed eosinocytes infltrating diffusely into the full thickness of the intestine, which were compatible with eosinophilic enteritis. After the operation, anisakis specific IgE antibody was found negative, and we diagnosed the case as ileus due to migration of the Type-X larva of the suborder spirurina which is known to be parasitic on raw firefly squids. Eosinophilic enteritis due to larva migrans should be considered in the diagnosis and treatment of acute abdomen with ileus of known origin.

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A 64-year-old man was admitted to the hospital because of fever, abdominal pain and wheezing. There was tenderness in the left lower quadrant of abdomen. Partial thickening of the small intestine and localized fluid collection in the abdominal cavity were visualized on CT scan. The patient also had infantile asthma in the past. The patient was conservatively treated as having inflammatory bowel disease because his asthmatic attack got worse. But we decided to perform a laparotomy 9 days after admission because of increasing abdominal pain. At surgery, we recognized localized peritonitis with 500 ml-pussy ascites covered by the small intestine, omentum and abdominal wall. The patient was diagnosed as having intestinal perforation due to anisakis through pre and post operative serological examinations. It is believed that anisakis is one of allergens of allergies to foods and causes symptoms of allergies like urticaria. We considered that asthmatic attack in this case might be late asthmatic reaction due to anisakis.

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Small bowel obstruction with bezoars in a gastrectomized patient is rare. We report an operated case of this disease successfully diagnosed preoperatively.
A 51-year-old woman, who had undergone a gastrectomy and Billroth I reconstruction for gastric cancer, was admitted to the hospital as an emergency case with a diagnosis of intestinal obstruction. She had eater several persimmon fruits a week before the onset of these symptoms. After admission an intestinal fluoroscopy revealed a defective shadow in the jejunum due to a mass. Abdominal ultrasonography and CT scan showed the mass containing large quantifies of air component. A diagnosis of ileus due to a bezoar was made and conservative therapy expecting spontaneous discharge was attempted. However, these symptoms persisted even on the 13th day after the therapy, and the patient was operated on. During surgery, an egg sized foreign body which was impacted in the jejunum about 50 cm distal from the Treitz's ligament was removed through an enterotomy. An analysis of the bezoar revealed that 98% of it was composed of tannin acid, and persimmon bezoar was diagnosed. The postoperative course was uneventful and the patient was discharged from the hospital on the 8th postoperative day.

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We studied the relationship between GIST (uncommitted type) and clinicopathologic parameters to clarify its malignancy. From 1991 to 2002, 6 patients with small and large intestinal GIST were studied. GIST sites involved 1 in the duodenum, 3 in the small intestine and 2 in the rectum. Among two with metastasis or recurrence, only one survived more than 5-years. Only surgical resection could cure the disease, and chemoradiotherapy had little impact on the malignant group, which tended to have tumors (more than 5 cm in diameter), extraluminal growth, invasive proliferation, and mitotic figures (≥4/HPF). To assess significance, we will accumulate and follow up cases over the long term.

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A 63-year-old man was admitted to the hospital because of a giant palpable mass and abdominal pain. During hospitalization, he had fever and redness on the anterior abdominal wall. Computed tomography clearly showed an abscess in the anterior abdominal wall and an intraabdominal tumor located in the lower quadrant of the abdomen. Endoscopic examination showed a stenotic lesion in the ascending colon with malignant ulceration, and an enema showed an apple-core-sign. The terminal ileum was not visualized by both examinations. Cancer of the ascending colon complicated by an abscess of the anterior abdominal wall was diagnosed, and an ileocecal resection with a partial resection of the abdominal wall was perfomed. Pathological study revealed moderately differentiated adenocarcinoma containing large quantities of mucinous component. We discussed clinicopathological features of 12 cases of colon cancer complicated by an abdominal abscess reported in the Japanese literature. It is thought that en bloc excision with the anterior abdominal wall should be perfomed for these patients, if possible.

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A 30-year-old man was referred to the hospital because of constipation due to a narrowing of the sigmoid colon. Barium enema study disclosed a narrowing over the entire circumference of the rectum Rs to sigmoid colon with the longer diameter of 15 cm. Lower gastrointestinal endoscopy showed prominent edema of the mucosa. A biopsy revealed only inflammatory findings. CT visualized significant thickening of the wall and mild bilateral hydronephrosis. Conservative therapy was unsuccessful and the patient was operated on. During surgery, we diagnosed the case as stricture of the sigmoid colon due to extended inflammation from appendicitis and hydronephrosis. An appendectomy and construction of artificial anus creating two foramina at the sigmoid colon were performed. Five months later when inflammation was confirmed to disappear, the artificial anus was closed.

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A 51-year-old man with an about 2-year history of recurrent right side abdominal pain which had been conservatively treated was seen at the department of internal medicine in our hospital because of intensifying abdominal pain. With close examination after admission, abscess formation due to penetration of diverticulosis was diagnosed and the patient was operated on. Pathologic diagnosis was actinomycosis. A part of wall of the abscess was left, which demanded chemotherapy with PIPC and AMPC for 6 months after the operation. Then the abscess wall became extinct and no recurrence of this disease has been seen over 2 years. In recent years abdominal actinomycosis is a relatively rare entity. It is defined as a chronic granulomatous disease caused by actinomycoces. Preoperative diagnosis is difficult because it has no characteristic findings. So in many cases, surgery was performed for suspected malignancy. We must keep the disease in mind as a differential diagnosis for patients with underlying diseases like diverticulum which can be a trigger of actinomycosis. A long term use of antibiotics is not always necessary, if complete resection is made. But in cases in which residual abscess is probable, we should determine appropriate period of dosing antibiotics on the basis of findings of follow-up CT.

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A 68-year-old man undergone an abdominoperineal excision of rectum and an artificial anus with a diagnosis of rectal cancer in 1980 was seen at the hospital because of redness of the skin around the artificial anus in June 2001. He was administered antibiotics and anti-inflammatory drugs and returned home. In the early morning of the next day the skin redness became worse and dyspnea occurred so that the patient was emergently admitted to the hospital. After admission, the entire abdominal wall turned into dark red in color and the level of consciousness decreased. So his trachea was intubated and artificial respiration was begun. Smears from tissue of the abdominal wall revealed Streptococcus pyogenes of group A. Necrotizing fasciitis caused by fulminant infection due to group A Streptococcus pyogens was diagnosed, and an emergency operation was performed. At surgery, we employed a surgical debridment in which the full thickness of subcutaneous fatty tissue and entire fascia in the necrotizing area were removed. After received dermal grafting several times, the patient was discharged very much improved on the 126^th postoperative day.
Since the disease follows an extremely rapid clinical course and is prone to be fatal, early diagnosis and early surgical treatment would be required.

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We report a case of left hemicolon volvulus with non-fixation of the descending colon 34 years after a sigmoidectomy for sigmoid volvulus. A 65-year-old man was seen at the hospital because of abdominal pain and distension. Under a diagnosis of ileus, the patient was inserted a long ileus tube, but the abdominal pain was intensified. The patient underwent an operation. Upon lapalotomy, we noted that the descending colon was not fixed to the retroperitoneum, and the left hemicolon was twisted counter-clockwise by 180 degrees showing remarkable dilatation with the maximum diameter of 30cm. Since there was no ischemic change in the twisted colon after reduction of the volvulus, we fixed the descending colon to retoroperitoneum. It is thought that sigmoidectomy may be an inadaquate operation for sigmoid volvulus with non-fixation of the descending colon, and that left hemicolectomy or fixation of the descending colon to the retroperitneum after sigmoidectomy is necessary for this type of volvulus.

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An 85-year-old woman admitted for showed tenderness in the left lateral region with a palpable mass, and was diagnosed as having intussusception caused by a tumor of the tranverse colon based on the results of abdominal computed tomography, gastrogaphin enema, and digital examination. An emergency laparotomy showed intussusception with bowel necrosis. We conducted left semicolectomy and transverse colostomy. As histological findings revealed the tumor at the head of intussusception was adenoma, this case is comparatively rare in adult intussusception.

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A 53-year-old woman complaining of anal bleeding at defication pointed out having a hard tumor by a digital examination at elsewhere was referred to the hospital with a suspicion of rectal cancer. When she was first seen at the hospital, no tumor was palpable by a digital examination, but a hard mass was palpable at admission, indicating that the tumor changed its location. Pelvic CT scan disclosed the edematous rectum presenting polyptychial structure and identified the tumor in its lumen. Colonofiberscopy visualized the tumor 6 cm from the anal verge. The patient was operated on with a diagnosis of advanced rectal carcinoma with intussusception. At laparotomy, we saw a sigmoid colon-rectum intussusception caused by cancer of the sigmoid colon. After the intussusception was reduced, the sigmoid colon was excised.
In this country only 55 adult cases of intussusception caused by colorectal cancer have been reported since 1987. We also report an analysis of these cases to clarify the clinical features.

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A 14-year-old boy diagnosed as having ileus with appendicitis and medicated antibiotics at elsewhere was referred to the hospital. There was tenderness on the right lower quadrant of abdomen. Abdominal CTscan did not show swelling of the appendix, but we thougt it was caused by preceded care, and performed an appendectomy. During operation, we could not find obstructive portion. After the operation we reviewed CT and confirmed the wall thickning of the splenic flexure of transverse colon. Barium enema studies and colonic fiberscopy demonstrated obstructed colon and a tumor with irregular surface. A biopsy reported that the tumor was poorly differentiated adenocarcinoma. At the second operation, a whole-circumferential tumor was present at the splenic flexure and peritoneal dissemination was observed. A left-sided colectomy and intraabdominal administration of 100 mg CDDP were conducted. Pathologic stage was stage IV (ss, n1(+), H0, P3, M(-), por, sci, ly2, v1, infγ). 3rd operation was performed 62days after the 2nd operation, because of multiple small intestinal obstrucion due to dissemination. We consider that colon cancer should not be excluded in children only on the basis of age.

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A 76-year-old woman, who had been pointed out primary biliary cirrhosis since 1995, was seen at the hospital because of melena on August 5, 1999. A colonoscopy revealed a protruded lesion of the sigmoid colon, 4cm in diameter. A biopsy of the lesion revealed tubulovillous adenoma, Group 3. A sigmoidecyomy with lymph node dissection was performed on September 30. The pathological diagnosis was well differentiated adenocarcinoma, mp, INFβ, ly1, v0, n(-) and stage I. An easily hemorrhagic tumor, 2cm in diameter, was pointed out in the perineal lesion in January 2000. A biopsy of the tumor offered a suspicion of adenocarcinoma and the tumor with a surgical margin of 5mm was excised on March 6. The tumor did not invade the internal and external anal sphincter. Histopathologically the tumor was diagnosed as metastasis of the sigmoid colon cancer. Skin metastasis of visceral cancers is relatively rare and common primary malignancies are gastric, breast and lung cancer. We report this rare case of perineal skin metastasis of sigmoid colon mp cancer, together with some bibliographical consideration.

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We report a case of liver hemangioma showing extrahepatic growth. A 50-year-old woman was admitted to the hospital because an elevated lesion in the fornix of her stomach was detected during a routine medical check-up. An abdominal CT scan revealed a mass which was partially enhanced near the stomach. An abdominal angiograpy revealed a tumor that had a cotton wool like stain, which was fed by the left lateral hepatic artery. Diagnosed with liver hemangioma showing extrahepatic growth, a laparoscopic hepatectomy was performed. The excised specimen was a tumor 3.0×2.0 cm in dimension and 5 grams in weight. Histopathologically, it was diagnosed as cavernous hemangioma.
Liver hemangiomas with extrahepatic growth are rare. In Japan, only 43 cases of liver hemangioma with extrahepatic growth have been reported (including our case). These cases were in 14 men, 28 women, and one unknown individual. The age range was 35-81 years old with an average of 55.9. Twenty-nine tumors were situated in the left lobe, eight in the right lobe, and six in the caudate lobe. The tumor sizes were 3-18 cm in maximum diameter with an average of 7.9 cm. Of these 43 cases, there were three ruptured cases and another three cases in which laparoscopic surgery was performed.
Liver hemangioma with extrahepatic growth which has a risk of rupture would be a good candidate for laparoscopic surgery, because it is gentle on the body and allows a proper diagnosis to make.

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This paper presents a rare case of communicating accessory bile duct associated with intrahepatic stones of the caudate lobe. A 66-year-old woman was admitted to the hospital because of abdominal pain and fever. Abdominal ultrasonography and abdominal CT showed multiple stones in the left caudate lobe. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) demonstrated an anomaly of the extrahepatic bile duct. Under a diagnosis of aberrant bile duct associated with intrahepatic stones of the caudate lobe, the patient was operated on. Intraoperative balloon-occluded cholangiography visualized a communicating accessory bile duct between the common bile duct and left hepatic duct. An extended left hepatectomy including the left caudate lobe was carried out. Post operative course was unevenful. Intraoperative balloon-occluded cholangiography was most helpful in the diagnosis of this abnormality.

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A 72-year-old man, who had undergone a pancraticoduodenectomy for duodenal carcinoma at the age of 55, had recurring attacks of cholangitis after the operation. When he consulted his doctor for high fever in November 2001, he was pointed out a low density area in S5 of the liver on CT, about 2cm in diameter, then he was introduced to the hospital. A dynamic CT study revealed that the tumor was not enhanced at early phase, but an enhancement of peripheral area appeared at delayed phase and this effect was prolonged until super-delayed phase. The air density in the tumor, dilatation of the intrahepatic bile duct, and air cholangiogram were detected. On a magnetic resonance imaging scan, the tumor showed low-intensity on T1-weighted images and irregularly high intensity on T2-weighted images. CTHA revealed maginally enhancement of the tumor from early phase to delayed phase. A cholangiography at PTBD revealed the stricture of hepatodochojejunostomy and a fillig defect, about 2cm in diameter, just above the anastomosis. However, 2 weeks after PTBD, this defect disappeared and we diagnosed that a stone was fallen. Choledochofiber and biopsy showed only inflammatory change of the bile duct. We performed operation with diagnoses of hepatodocholithiasis and IPT of the liver accompanied by the stricture of hepatodochojejunostomy and recurrent cholangitis. The common hepatic duct was removed including a part of the jejunum, then the jejunum wall was closed and a hepatodochojejunostomy was made at the hilum. Histopathologically, the anastmoses had pyroric metaplasia and the liver tumor had scared fibrosis. We definetely diagnosed the case as benign stricture of the anastomosis and scared abscess after the pancreaticoduodenectomy.

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A 65-year-old man, complaining of constipation, was admitted to the hospital because a hard and unmovable mass was palpated in the lower rectum on a digital examination. Barium enema and a colonoscopy revealed an elevated lesion about 3 cm in diameter in the rectum and a biopsy under colonoscopy offered a suspicion of carcinoid tumor. For the rectal tumor which invaded the sacral bone, an abdominoperineal resection was performed. Radiation therapy to the sacrum was added after the operation. Eighteen months later hepatic metastases occurred and transarterial embolization (TAE) was performed. Though the metastatic foci temporalily diminished with the TAE, recurrence was repeated and therafter a total of three times of TAE were conducted. Eight years after the operation multiple lung and bone metastases occurred, and 6 months later the patient died of respiratory failuse due to ling metastasis. It is thought that aggressive multidisciplinary therapy is useful for advanced rectal carcinoid tumor like in this case.

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A 58-year-old woman underwent total thoracic esophagectomy and partial hepatectomy and cholecystectomy for esophageal squamous cell carcinoma with liver metastasis. She was treated with nedaplatin and fluorouracil chemotherapy, but experienced anaphylacic shock with whole-body itching as soon as nedaplatin was infused. She was discharged without adjuvant chemotherapy. Six months later, 5 cm solitary liver metastasis found by computed tomography (CT) was treated with radiation therapy. The treated volume was encompassed by the anteroposterior and right lateral opposing fields, shaped by a multileaf collimator. The daily fraction size was 1.8 Gy, 5 days per week, for a total dose of 54 Gy. During the course of treatment, she experienced no complication. After radiotherapy, abdominal CT showed that the enhanced solid tumor had changed to a very low density mass lesion with a clear margin, and it gradually shrank within 12 months. Radiotherapy may thus be the treatment of choice in patients with liver metastasis from esophageal squamous cell carcinoma.

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A resectable case of liver metastasis from gastric cancer is rare and has a poor prognosis. We treated a patient with liver metastasis from early gastric cancer in a 65-year-old man who have a 5-year survival. The patient who had undergone a distal partial gastrectomy for early gastric cancer at another hospital 4 years earlier was found to have a metastatic tumor invaded the remnant stomach and pancreas body with high CA19-9 value (2, 490U/ml). Left lateral segment of the liver, remnant stomach, distal pancreas and spleen were resected en block. Over 5 years passed since the operation, and no signs of recurrence have occurred with normal CA19-9 level.
In our institute, the incidence of liver metastasis from early gastric cancer was 1.17% of a total of 426 cases operated on for early gastric cancer from 1980 to 1992. Although a recurrence case of gastric cancer with high CA19-9 is believed to have poor prognosis, a long-term survival might be expected, if surgery successfully normalizes the high CA19-9 level like in this case.

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Portal venous gas (PVG) is rarely detected even in patients with necrotic bowel and known to be a sign of a poor prognosis. We report a case of postoperative simple ileus with PVG in an adult.
A 59-year-old man was admitted to the hospital because of vomiting and abdominal pain. He was diagnosed as having ileus on plain abdominal X-ray examination. PVG was detected on abdominal computed tomogragraphy, but he was conservatively treated with a diagnosis of postoperative simple ileus and had uneventful course. He was discharged from the hospital on the 13th hospital day.
Only four cases of simple ileus with PVG including this case have been reported in the Japanese literature. When PVG is seen in patients with ileus, we must first consider a possibility of strangulated ileus with intestinal necrosis which demands emergency operation. There are, however, some patients who have PVG caused by simple ileus. Patients with ileus associated with PVG require serious consideration of determining a best treatment including conservative therapy.

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A 56-year-old man with disseminated intraperitoneal metastases caused by the ruputure of hepatocellular carcinoma (HCC) admitted for acute abdomen was found in ultrasonography (US) and computed tomography (CT) to have a liver tumor and a large amount of ascites. Partial hepatectomy (S2) was conducted on February 2, 1994.
He was readmitted 25 months later for abdominal tumors. CT and US showed extrahepatic abdominal tumors and a liver tumor. Abdominal angiography showed 4 intraperitoneal tumors and a liver tumor. At surgery, we found and resected 6 intraperitoneal tumors. Microscopically, all were confirmed to be HCC, of which he died 12 months after resection of intraperitoneal metastases and 39 months after spontaneous HCC ruputure.
We concluded that surgical resection of intraperitoneal metastases from HCC may be life-prolonging.

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A 17-year-old man, who was a HBV career, was referred to the hospital for close examination of a tumorous shadow in the right lobe of the liver. Abdominal ultrasonography revealed a tumor of the liver S7. Posterior segmental hepatectomy was performed with a diagnosis of hepatocelluler carcinoma. Two years six months later, a new lesion appeared in the liver S8 and TAE+PEI was performed. However 4.5 years later the S8 tumor was regrowing and it was removed. Six years after the first operation, metastatic tumors in the liver appeared and TAE+PEI was performed. Thereafter, a right middle segmental resection, a right lower segmental partial resection and a left partial resection of the lung were performed for multiple lung metastases and RFA was also made for metastases of the liver remnant, however, he died of multiple lung metastases 7 years 2 months after the first operation
Juvenile hepatocellular carcinoma is relatively rare, but it is characterized by a rapid progression when once appears. Therefore, close follow up of the HBV careers, even in young patients, is of particular importance for the early detection of HCC.

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A 30-year-old man complained of epigastralgia, and treated with a diagnosis of acute pancreatitis elsewhere was found to have a tumor in the body of the pancreas while following after discharge. He was referred to the hospital. Enhanced CT and enhanced MRI scans showed a hypovascular tumor on early phase, that was slightly enhanced on late phase. MRCP showed stricture of the main pancreatic duct with dilatation. Distal pancreatectomy was performed under a diagnosis of pancreatic ductal cancer. Histopathological diagnosis was islet cell tumor with microscopic invasion of serosa. Immunohistochemically, tumor cells were positive for only Chromogranin A. We finally diagnosed this case as primary, malignant nonfunctioning islet cell carcinoma. In this case, imagings disclosed untypical patterns so that we have great difficulty in preoperative diagnosis.

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We report a patient with diffuse peritonitis caused by chlamydia trachomatis infection treated by laparoscopic abdominal drainage which successfully avoided unnecessary laparotomy. A 20-year-old woman complaining of lower abdominal pain was brought into the hospital by ambulance with a suspicion of acute pelvic inflammatory disease.
She was referred to our department by a gynecologist because of abnormal abdominal findings. There were marked tenderness, muscular guarding and Blumberg's sign in the entire abdomen. The levels of WBC and CRP were abnormally high. She was diagnosed as having diffuse peritonitis but the cause was obscure. Under general anesthesia, a laparoscopy was performed and the gastrointestinal tract showed no abnormal findings. Abdominal lavage and drainage were carried out laparoscopically. Chlamydia trachomatis antigen was detected in the discharge from the endocervical canal, and acute peritonitis caused by chlamydia trachomatis infection was diagnosed. MINO was administered and the patient's postoperative course was uneventful. Chlamydia thrachomatis infection presents with various pathologic conditions ranging from cervicitis to Fitz-Hugh-Curtis syndrome. Laparoscopic intra-abdominal inspection and laparoscopic abdominal lavage and drainage are useful for the diagnosis and treatment of chlamydia trachomatis causing diffuse peritonitis especially in young women.

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A 53-year-old woman was seen at the emergency outpatient clinic because of abdominal pain and abdominal distention. On physical examination abdominal tenderness and distension were noted. Abdominal ultrasonography and CT detected ascites in the abdominal cavity and a phyma consisting of intermingling solid regions and cystic regions over the upper abdominal region to pelvic cavity. Various tumor markers were in normal ranges. Ascites was bloody and the cytodiagnosis of it was class 1. The upper and lower intestinal endoscopy detected no abnormalities. Ovarian tumor was strongly suspected bases on the imaging findings, and surgery was performed. During surgery, a multilocular cystic phyma measuring 15×15 cm containing elastic blood clots was observed in the greater omentum, and the phyma was excised with the greater omentum. Pathological examination and immunohistological staining showed that the phyma was a CD34-, C-kit-, and desmin-positive mesenchymal tumor, and was diagnosed as primary GIST of the greater omentum. Since primary GIST of the greater omentum is very rare, we report it with a review of the literature.

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A 58-year-old man, who had been operated on for left inguinal hernia 3 years earlier at elsewhere was seen at the hospital because of recurrence of left inguinal hernia 6 months after the operation. On the second operation after admission, we found that the former repair was made by McVay method, and that his hernia recurred from outside of the widened inner ring. Repair was made by inserting a Prolene Hernia System around the cord into outside of the inner ring. Thirteen days after the operation, infection was suspected and the surgical wound was opened with purulent discharge. A culture of the wound revealed MRSA infection. He was admitted to the hospital again to receive combination chemotherapy with FOM and VCM. His wound healed by frequent irrigation within 10 days after admission. There have been no signs of recurrence as of 6 months after the second operation. As PHS is made of polypropylene and tolerates well early infection, anti-infection measures should be taken before attempting removal of the prosthesis. In case of late or refractory infection, the prosthesis might have to be removed.

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A 60-year-old woman was seen at the hospital because of epigastric pain and dullness of the left lower extremity. Abdominal ultrasonography showed a tumor with a cyst in its inner part in the inside of the left kidney. Abdominal CT scan visualized a well-defined tumor with heterogeneous inner part in the left iliopsoas muscle. Magnetic resonance imaging scan revealed high signal intensity on T2-weighted images. Blood level of NSE was high. Accordingly, we considered a neurogenic tumor, especially a schwannoma, and removed the tumor. The excised tumor was 7×5×5 cm in dimension and elastic-soft, with a yellowish white surface. Histopathological diagnosis was benign schwannoma arising in the left iliopsoas muscle. The postoperative course was uneventful. No signs of recurrence and complications such as parethesia of the lower extremity have been seen as of one year after the operation.
Schwannoma originated in the iliopsoas muscle is a rare entity and this is the 11^th case in Japan as far as we could review.

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We experienced a case of sparganosis mansoni followed for 11 years under a diagnosis of varices of the left lower extremity in a 49-year-old woman. In 1991 when she was 38 years old, she was seen at the hospital because of a tumor 1 cm in diameter with partial redness of the left thigh. She was diagnosed as having varices of the left lower extremity and followed for 11 years as an outpatient. In 2001, the patient began to complain of itching and occasiaonal pain of the site and then she underwent an excisional biopsy under infiltration anesthesia. A tapelike body, which seemed to be a parasite, was found in the granulation tissue. On histopathological and immunological analyses, sparganosis mansoni was diagnosed from the existence of calcified corpuscles in the worm body and the serum titer against plerocercoid measured by ELISA. So far more than 300 cases of the disease have been reported in Japan, but no cases of sparganosis mansoni have been reported further north than Aomori Prefecture.

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This paper deals with a 69-year-old male patient with metachronous multiple cancers involving the stomach, colon and lung, all of which have been successfully resected.
In 1998, he had undergone a distal gastrectomy with D2 lymph node dissection for gastric cancer with curability A, which was f Type0 IIc, T1 (SM), tub1, N0, H0, and stage IA. In 1994, he had undergone a sigmoidectomy with D3 lymph node dissection for cancer of the sigmoid colon with curability A, which was type 2, well differentiated adenocarcinoma, sm, n1, H0, P0, M(-), and stage IIIA. In 1998, he had undergone a right upper lobectomy of lung, a wedge bronchoplasty, and ND2a lymph node dissection for squamous cell carcinoma of the right lung, which was moderately differentiated squamous cell carcinoma, p-T3N1M0, p0, pm0, ly0, v0 and stage IIIA. In 2001, he underwent a S6 segmentectomy of the left lower lobe of the lung with ND1 lymph node dessection for adenocarcinoma, p-T1N0M0, p0, pm0, ly0, v0 and stage IA. For these 17 months following the forth operation, no signs of recurrence of any cancer have been obseved.
We have thus successfully resected all four cancers which metachronously occurred during 14 years in this case.

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