Recently, the incidence of postoperative pneumatic thromboembolism (PPT) has been rapidly increased in Japan, and it is essentially important to prevent PPT. During a period between May 1998 and May 2000, we had eight patients (0.17%) who developed PPT among 4, 780 consecutive patients operated on under general anesthesia, and two of them thereby died. Although the background factors were compared between the eight patients with PPT and another 16 age-, gender- and disease-matched patients without PPT (matched control group), no specific factors predicting high risk group could be identified. Since June 2000, accordingly, we have routinely applied an intermittent sequential pneumatic compression of the legs (IP) for a postoperative one day after intubation over thromboembolism-deterrent stockings (ES) which are put on before entering the operating room until starting to walk, for all patients who undergo surgery under general anesthesia. As a result, none (0%) of consecutive 5, 645 patients after June 2000 developed PPT, to date. The incidence of 0% is significantly low compared with 0.17% in patients before June 2000. This combined use of ES with IP is helpful to prevent PPT especially for non-pediatric patients in the cancer center.

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To evaluate the rationale lymph node dissection for submucosal gastric cancer, consecutive 258 patients with solitary submucosal gastric cancer located in the middle and lower third of the stomach were analyzed in terms of lymph node metastasis and type of recurrence. Positive pathological N1, N2, and N3 nodes were found in 42 (16.3%), eight (3.1%) and two (0.8%), respectively. Metastasis to the lymph node (LN) along the proximal part of the splenic artery (No.11p), LN in the hepatoduodenal ligament (along the hepatic artery) (No.12a) and LN along the superior mesenteric vein (No.14v) were not found in pathological N2 cases. Lymph node metastasis and venous invasion were selected by a multivariate analysis as the significant prognostic factors affecting submucosal gastric cancer, but lymph node dissection was not selected. Hematogenous recurrence was most common type of recurrence. Each three cases from pathological N0 and N1 cases were of recurrent. However, lymph node recurrence was not found in those cases. No lymph node recurrence was recognized in surgical N0 and N1 cases. On the basis of the results in this study, D2 lymph node dissection in patients with N1 positive submucosal gastric cancer had little survival benefit.

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To elucidate the role of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in the malignant potential of AFP producing gastric cancer, we examined the immunohistochemical expression of MMPs (MMP-2, MMP-7 and MMP-9) and TIMPs (TIMP-1 and TIMP-2) in five cases of AFP producing gastric cancer (AFP-GC) and 48 cases of non AFP producing gastric cancer (Non AFP-GC), and compared them for pathological findings. In the Non AFP-GC cases, MMP-2 immunoreaction significantly correlated with vascular invasion. Moreover, MMP-7 immunoreaction significantly correlated with the depth of tumor invasion and lymph nodes metastasis. Between AFP-GC and Non AFP-GC cases, no significant differences were found in immunoreactions for these MMPs and TIMPs. These data suggest that MMP-2 and MMP-7 are important factors implicated in invasion and metastasis of gastric cancer. But we were not able to suggest any relations between the pathological malignant potential and expression of MMP-2, MMP-7, MMP-9, TIMP-1 and TIMP-2 in AFP producing gastric cancer.

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The purpose of this study was to establish a primary lesion opening surgery for anal fistula, an operative procedure which can be indicated for almost all anal fistulae and is a simple procedure causing minimal impairment to the postoperative anal function.
A total of 27 patients with (high) anal fistula treated at the hospital from August 1999 to December 2001 were enrolled in this study. These patients underwent an operative procedure in which the internal opening, primary fistula, and primary lesion were removed together with subcutaneous external sphincter muscle of anus to create an open wound with good drainage, and the secondary fistula and the secondary opening were left intact.
Observation time ranged from 12 to 40 months, with the mean of 29 months. No recurrence has occurred. The mean hospital stay was 13 days. Durations until cure of the surgical wound after the operation ranged from 7 to 17 weeks, with the mean of 10 weeks. All remnant secondary fistulae and openings became scars. A questionnaire survey was conducted in 26 out of the 27 patients. Four (15%) patients complained of frequent passing of gas, but no patients answered to have incontinence of feces. We could obtain overall favorable outcomes as 19 patients (73%) answered to have almost no problems.
In conclusion, this study has clarified that this primary lesion opening procedure (localized laying open procedure) that we have developed can be used in place of the conventional laying open procedure for anal fistula hereafter.

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Surgical procedures for elderly patients were retrospectively analyzed to evaluate the adequacy of the surgical indication and procedure. Contributing factors for 30 days mortality, hospital death, and postoperative survival were studied in a total of 136 patients 80 years of age and older operated under general anesthesia. Operative mortality rate was 2.2% (3/136). Hospital death occurred in 6.6% (9/136) of the cases. Non-curative operation, preoperative long stay in the hospital, emergency operation, and postoperative complication were defined as significant risk factors for hospital death by a univalent analysis. Stepwise logistic regression analysis demonstrated that preoperative long stay in the hospital and emergency operation were risk factors associated with hospital death. Only postoperative complication was identified as a risk factor for 30 days mortality. One-year and 3-year overall survival rates were 80% and 69%, respectively. There was no significant difference between patients aged 80-84, 85-89, and 90 and older. One-year survivor was not seen in the patients who underwent non-curative operation for cancer. By Cox's proportional hazard model, curative operation was defined as a positive factor for postoperative survival and emergency operation was defined as a negative factor for postoperative survival. These results suggest that adequate and optimal surgical procedures considering physical and psychological status enable a reduced surgical mortality, and may contribute to the quality of life of the elderly patients.

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A 60-year-old man referred on September 1, 2002, for a 1-month history of nonresponsive dyspnea had undergone radiotherapy for laryngeal cancer at age 44 and surgery for esophageal cancer followed by chemotherapy with cisplatin 100 mg+5-fluorouracil 5000 mg+leucovarin 150 mg at age 56. Blood examination showed a white blood cell count of 2100/μl, red blood cell count of 1650, 000/μl, hemoglobin of 5.8 g/dl, and platelet count of 46, 000/μl, indicating pancytopenia. Recurrence of esophageal cancer with disseminated intravascular coagulation syndrome was initially suspected and imaging conducted, but no findings of recurrence were found. Bone marrow puncture showed significant morphological abnormality of blood cells and complicated chromosomal aberration. Secondary myelodysplastic syndrome was considered. We diagnosed a secondary tumor with poor prognosis appearing 6-8 years after chemotherapy and radiotherapy. Successfully differentiating this case from recurrent esophageal cancer, however, led to good quality of life for the patient.

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Malignant oncocytoma is an extremely rare entity. We report a 74-year-old man who noted a painless hard right salivary gland tumor. Preoperative examination showed a malignant salivary gland tumor with infiltration into the adjacent gland but without lymph nodal swelling. The tumor resected under general anesthesia was 1.8×1.5 cm, partially capsulated and whitish-gray. It had been located at the superficial lobe of the right salivary gland with no involvment of the facial nerve. Histology showed atypical large cells with eosinophilic cytoplasm and irregular nuclei in hematoxylin-eosin staining. The tumor had 2 different histological patterns, a solid pattern with a slight invasion into the lymphaties and vessels, and a papillary pattern with severe invasion. The tumor was also vascularly associated with lymphatic invasion. PTAH staining of the tumor showed abundant mitochondria, with an eventual diagnosis of malignant oncocytoma. The patient's postoperative course was uneventful and free of symptoms suggesting tumor recurrence. Malignant oncocytoma is rare, with an incidence of 0.05%. We present this case because of its rarity.

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Spontaneous hemorrhage from a parathyroid adenoma is rare. It can cause cervical ecchymosis or massive hematoma with hypercalcemia. We have encountered a case of parathyroid adenoma presented with spontaneous hypocalcemic tetany and massive cervical hemorrhage.
A 58-year-old man was referred to the hospital after the sudden onset of cervical ecchymosis following digital numbness which had been treated with a diagnosis of hypocalcemic tetany at another hospital. There was previous history of urolithiasis. CT and T1^-201, Tc^-99m scintigraphy demonstrated a small tumor behind the left lobe of the thyroid. Although intact-PTH was normal at presentation, it increased when he was admitted to the hospital 4 days later. The tumor was surgically removed and a parathyroid adenoma with hemosiderin deposition was histologically diagnosed. The intact-PTH level was normalized after the operation.

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We report papillary thyroid carcinoma (PTC), which developed in both of the identical twins at the same time. Patient 1 was a 34-year-old woman who was accidentally found to have a nodule in the left lower thyroid by ultrasound. PTC was diagnosed from an aspiration biopsy cytology (ABC). In detailed ultrasonogram another nodule in the right middle thyroid and multiple lymph node metastasis were detected. Total thyroidectomy with bilateral neck lymph node dissection was performed. Histological diagnosis was bilateral well differentiated papillary carcinoma, pT4b, pEx1, and pN1b. Patient 2 was a 35-year-old woman, who is older sister of patient 1. Because she was the other one of the identical twins, she became anxious and hoped to be checked her thyroid by ultrasonography. A nodule in the left lower thyroid, for which PTC was highly suspected by ABC, was found. Left subthyroidectomy with neck lymph node dissection was performed. Histologically, the tumor was well differentiated PTC with lymph node metastasis, and intragrandular metastasis. Both patients have been well for 2 years to date without any signs of recurrence.

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We present a case of multiple parathyroid carcinoma and discuss a possibility of preoperative diagnosis. So far no reports on multiple occurrence of the disease have been seen in the literature and the case might be the first report. In this case, the patient had two tumors, a right and left tumor with the diameter of 21mm and 16mm respectively, which had no infiltration into the surrounding tissue and lymph nodes involvement. So we did not diagnose the tumor as cancer. In terms of the size of these tumors, though, we could guess that the tumor would be cancer. Pathologically, the character of parathyroid carcinoma is that of structural disorder rather than that of cytological one. The right tumor involved the normal thyroid, and partial hemorrhage and coagulation necrosis were found microscopically. We diagnosed the right tumor as cancer. Because of similarities between the two tumors, the left tumor was diagnosed as cancer too. It was unlikely that one tumor metastasized to other tumor. Intraoperatively, we should be careful not to injure the capsule of the tumors. When a tumor is first diagnosed as parathyroid cancer on the histologic study of a permanent preparation after an operation, we are required either to perform operation again or to watch the clinical course strictly. Laparoscopic surgery must be carefully indicated.

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A 50-year-old woman was reffered to our hospital because of a 7cm mass in the right breast. She had left pectral muscle conserving mastectomy for scirrhous carcinoma nine years earlier. On magnetic resonance imaging, the peripheral zone of the mass was emphasized by using contrast enhancement on Gd-GPTA. Right breast cancer was suspected by an aspiration cytology. She underwent a pectral muscle conserving mastectomy and reconstruction by inserting a tissue expander. The histo-pathological examination showed proliferation of small tumor cells forming trabecular, solid nests with massive necrosis and abundant fibrous stroma. Cellular atypia and nuclear division were also seen and the nuclear grade was rated as 3. Immunohistologically, the tumor cells were positive for Vimentin, S-100 protein and AE1/AE3. From these findings, the tumor was diagnosed as matrix-producing carcinoma.

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A 72-year-old woman was admitted to the hospital because of a growing left breast mass. On physical examination, a sharply demarcated, elastic-hard mass with the diameter of about 30 mm was felt in the left breast. There was no nipple discharge. Mammography revealed a round-shaped mass without any signs of malignancy such as spiculation and microcalcification. Ultrasonography showed a papillary lesion inside a cyst 24 mm in diameter. Result of a cytological study of serous fluid in the mass was class 3, which did not indicate malignancy. A lumpectomy was performed under general anesthesia, and intraoperative frozen section pathological findings revealed malignant component within intraductal papilloma. Because the patient preferred to undergo mastectomy in case of malignancy before operation, a mastectomy was performed. It has been reported that about 0 to 4% of cases of solitary intraductal papilloma involve invasive breast cancer in recent years. Careful follow-up is needed for patients with solitary intraductal papilloma.

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A 33-year-old woman consulted our hospital because of a mass in her left breast. The diameter of the palpable mass was 17 mm at the time of the first visit and decreased to 13 mm after 2 months. The mass then increased in size to 21 mm and the patient experienced a sharp pain 4 months later. The cytological fine needle aspiration biopsy findings showed a class V carcinoma. Though the size of the mass diminished to 15 mm one month later, the tumor was excised. The tumor was yellow and exhibited a clear boundary. Intraoperative frozen section diagnosis revealed a small cancer nest around the necrotic tumor. Based on the findings for the permanent pathological specimen, the tumor was diagnosed as a medullary carcinoma with necrosis. The change in the size of the tumor was thought to result from the necrosis.

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Primary chondrosarcoma of the rib is of a rare entity. We have recently operated on a patient with a chondrosarcoma recurring in the right fifth rib 16 years after the initial surgery for its primary lesion.
A 56-year-old woman was seen at the hospital because of right chest pain. On physical examination, an 11×9 cm hard tumor was palpated just lateral to the right breast. With a CT-guided needle aspiration biopsy, well differentiated chondrosarcoma was diagnosed. At surgery, an extended excision of the tumor was performed. The chest wall defect was filled with double Marlex mesh and implantation of pedunculated latissimus dorsi muscle and skin flap.
A chondrosarcoma showed be treated by an extended excision of a tumor with a safety margin as wide as we possible.

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A 68-year-old man underwent a partial hepatectomy for hepatocellular carcinoma of S8 in August 2000. One year later an intrahepatic recurrence took place and was treated by 4 courses of intrahepatic arterial infusion therapy and 3 times of TAE. The patient returned to the hospital because of the abrupt onset chest pain in December 2001. A chest X-ray disclosed hemothorax, when a tube thoracostomy was done. Further examination led to a diagnosis of a mediastinal lymph node metastasis with repture. Since hemorrhage persisted after tube thoracostomy, TAE was conducted to the left subphrenic artery. AFP level however elevated thereafter and a rapid enlargement of the tumor became apparent in 2 weeks following TAE. The tumor was removed surgically because of a high risk of rerupturing in February 2002. The tumor was seen adherent to the inferior vena cava without directly invasion. Histological pictures of the tumor were same as the original tumor. On the 14^th postoperative day, chemotherapy with CDDP/MMC (intrapleural), CPT-11 (systemic), and UFT (oral) was started. Thereafter the AFP level gradually decreased and the patient was discharged from the hospital 60 days after the operation. After discharge the chemotherapy was maintained. The patient is well without signs of recurrence as seen in the outpatient clinic 12 months after the operation.

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An 81-year-old man was admitted to the hospital for surgical treatment of cancer of the transverse colon. Partial resection of the transverse colon was performed. On the first postoperative day, he had chest symptom. Electrocardiogram revealed abnormal Q and comprehensive negative T wave. Echocardiography showed hypokinesis of the left ventricle at the anterior wall septum to apex cordis. Because ischemic heart disease was suspected, we informed the necessity of examinations, including cardioangiography to the patient and his family, but they didnot agree. We treated conservatively, but his symptom and changes in electrocardiogram persisted. On the 23rd postoperative day, cardioangiography was conducted. No significant stenosis of the coronary artery was revealed, but a left ventriculography showed hypokinesis at the anterior wall septum to apex cordis. We found a defect at the hypokinesis area in ¹²³I-MIBG scintigram to study the myocardial blood flow, but no defect was seen in ²⁰¹T1 scintigram to study the function of sympathetic nervous system in the heart. Therefore, we diagnosed the case as transient left ventricular apical ballooning without coronary artery stenosis, so called “Takotsubo” myopathy. In this case, we supposed that perioperative stress might cause the disease. It is important to differentiated between “Takotsubo” myopathy and ischemic heart disease, when an electrocardiogram reveals changes suggestive of ischemic heart disease perioperatively.

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Radical surgery has been considered to be the only chance for long-term survival from pancreatic cancer, however, the patient's prognosis has remained poor. Here we report a radically resected case of metastatic lung cancer in the bilateral lobes. The patient had undergone total pancreatectomy for advanced pancreatic cancer nine years before the bilateral lung segmentectomies. The resected tissue specimen of the lung tumor pathologically quite resembled to the tumor of pancreatic cancer; both the lung and pancreatic tumors histologically consisted of papillary adenocarcinoma with mucin production; and was considered as metastasis from the pancreatic cancer. This is an extremely rare long-term survival case of pancreatic cancer of which lung metastases were able to be surgically resected.

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A 61-year-old woman was seen at the hospital because of abdominal pain on March 29, 2001. Two days before entry, she had tried to remove a fish bone stuck in her pharynx during a dinner by herself using a butter knife and had swallowed the knife by accident. On the next day, she developed abdominal pain. When she was seen, an increase in inflammatory reactions was noted. Abdominal x-ray film confirmed the knife. There were no peritoneal signs. Endoscopic findings revealed that the end of knife was stopped out at the pyloric antrum of the stomach and the grip caused perforation at the greater curvature of the lower gastric body. We could not remove the butter knife endscopically and performed an emergency laparotomy. Upon laparotomy, the butter knife grip had penetrated the greater curvature of the gastric lower body forming abscess surrounding the perforation which was covered with the omentum. After we removed the knife and closed the gastric wall by sutures, intraabdominal cleansing with drainage was conducted. The postoperative course was uneventful. The patient was discharged from the hospital on 12^th day after the operation.

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A 69-year-old man underwent an appendectomy under a diagnosis of perforated acute appendicitis on August 2001. The appendix was swollen and perforated, and no metastatic carcinoma lesions were observed macroscopically in either the appendix or the peritoneal cavity. Postoperative histological examination revealed a small nest of atypical cells in the serosa of the appendix that proved to be an adenocarcinoma metastasis. Type-2 advanced gastric carcinoma with multiple hepatic metastasis was subsequently discovered postoperatively. In spite of hepatic arterial infusion therapy following the oral administration of TS-1, the hepatic metastasis increased gradually. The patient died 12 months after their first visit. No obstruction or stenosis caused by cancer infiltration was observed in the lumen of the appendix, so the definite etiology of the appendicitis was unknown. Appendiceal metastasis of gastric cancer is rare and is usually found during surgery for gastric cancer, whereas the gastric cancer was found after the appendiceal metastasis was identified in the present case. To avoid overlooking appendiceal metastasis, careful intraoperative observation and postoperative pathological examination are very important.

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We report a case of squamous cell carcinoma of the Papilla Vater. A 62-year-old man was admitted to the hospital because of upper abdominal pain and tarry stool. Upper gastrointestinal endoscopy revealed a tumor in the second portion of the duodenum. Imaging studies and operative findings disclosed that the tumor had invaded the head of the pancreas. A pancreatoduodenectomy was performed and the tumor was rated as T3, N0, H0, P0, M(-), and Stage III. A pathological study revealed pure squamous cell carcinoma originating from the Papilla Vater. The patient has been well without any evidence of recurrence for 20 months after the surgery.
Only seven cases of squamous cell carcinoma of the Papilla Vater have been reported. Four patients of them including this patient were operated on and three out of these four patients survived for more than one year as far as we could review. Previously published articles have inferred that cancer change occurs subsequent to squamous metaplasia or metaplastic change of adenocarcinoma as the origin. However, the etiology of this rare tumor has not been elucidated as yet. Further investigations are essential for understanding of the tumor.

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We report here a case of small intestinal bleeding, in which intraarterial indwelling microcoil as an indicator was useful for intraoperative localization of the responsible lesion. A 38-year-old man was brought into the hospital by ambulance, because of massive bloody stool and anemia. The patient had undergone intestinal resection two times for Crohn's disease. As routine gastrointestinal examinations and radionuclide blood scintigraphy failed to show the accurate bleeding site, angiography was performed for further exploration. A selective mesenteric angiogram revealed the presence of bleeding site in the terminal ileum. Considering the difficulty of identifying hemorrhagic site at laparotomy, a microcoil was detained for hemostasis and marking prior to surgery. Upon laparotomy, no leakage of blood to the abdominal cavity and serosa side were recognized. Therefore we identified the affected segment by using the microcoil in X-ray, and resected the localized segment of ileum. The postoperative course was uneventful, and no hemorrhage from the digestive tract is recognized at present. Intraoperative identification of intestinal hemorrhagic site using an intraarterial indwelling microcoil as an indicator is extremely useful for the decision making of a site and a range to be excised.

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An 83-year-old woman was admitted to the hospital because of anemia with tarry stool and palpitation. Gastrointestinal fiberscopy and a colonoscopy failed to confirm bleeding site. Abdominal angiography was performed. Superior mesenteric arteriogram demonstrated an abnormal capillary staining in the peripheral area feeded by the fifth jejunal artery, and draining veins from early arterial phase to late venous phase, leading to the diagnosis of arteriovenous malformation (AVM) of the jejunum. A microcoil was placed within the feeding artery near the AVM by selective angiographic technique, to identify the small lesion during the operation. On gross observation we could not find the AVM, but a partial resection of the jejunum, 10cm in length, was successfully performed under the identification of the coil as a marker by an intraoperative fluoroscope. We conclude that the technique of placing a microcoil as a marker during surgery is an useful strategy for localizing small intestinal AVMs.

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A 75-year-old woman was seen at the hospital because of abrupt onset of abdominal pain and nausea. There was a previous history of undergoing a total gastrectomy {loop-esophagojejunostomy (Graham method)+Braun anastomosis} for plasmacytoma of the stomach. On admission a tumor with tenderness was present in the vicinity of the navel. With an abdominal ultrasonography and an abdominal CT scan, intussusception was diagnosed and an emergency operation was performed. Upon laparotomy, the efferent loop jejunum which had gone beyond the Braun anastomosis invaginated into the afferent loop jejunum. We attempted to reduce the invagination by hands but the intestine presented circulatory impairment so that we performed a partial jejunectomy. There was no organic lesion at the head of the prolapsed portion.
Intussusception following gastrectomy is rare, especially that provoked with the same mode of intussusception as this case showed. Only eight cases including our case have been reported in Japan. In the diagnosis and treatment of postoperative complications, this entity must also be kept in mind.

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We encountered a rare case of multiple ileal adenocarcinoma associated with von Recklinghausen's disease. The patient was a 40-year-old man with the chief complaint of left lower abdominal pain, and was found to be anemic. When in elementary school, he had presented with torous eruptions and left lateral dermal tumor, and von Recklinghausen's disease was diagnosed. Pelvic CT revealed a tumor extending from the intestinal tract to the pelvis. Surgical findings showed that the tumor was located in the ileum, 200 cm distal to the ligament of Treitz, and enlargement of the mesenteric lymph nodes was also noted. Subtotal resection of the ileum and ileo-jejunal end-to-end anastomosis were performed. Multicentric adenocarcinoma was diagnosed on histopathological examination.

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A 50-year-old man seen at another hospital because of abdominal pain and pointed out having an abdominal tumor with calcification on CT was referred to the hospital for close examination and treatment. The patient was operated on with a suspicion of a tumor of the small intestine. Upon laparotomy, there was a Meckel's diverticulum with an enterolith about 20 cm distal to the ileocecal region. Since the surroundings of the diverticulum became inflammatory and were adhesive, the ileum and the ileocecal region were excised. The mucosa of the diverticulum was ectopic pancreatic tissue. The enterolith was 2.5×2.5×1.5 cm in dimension.
Meckel's diverticulum with an enterolith is a very rare entity. This rare case is reported, together with some bibliographical comments.

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A 72-year-old woman was admitted to the department of internal medicine in our hospital because of lower abdominal discomfort. On admission there was only a slight tenderness in the lower abdomen, but on the 4^th hospital day the white blood cell count and CRP increased and fever and rebound tenderness in the lower abdomen appeared. Abdominal CT scan revealed abnormal shadow with form outside the intestine in the pelvic cavity. Retrograde colonography using water soluble contrast material showed leakage of the material to the outside of the intestine. Perforation of the sigmoid colon with peritonitis was diagnosed and an emergency operation was performed at the department of surgery. Upon laparotomy, a small quantity of ascites was present and an abscess was formed in the sigmoidal mesentery. Perforation of the sigmoid colon on the mesentery side was diagnosed and a sigmoidectomy including contaminated mesentery and a Hartmann operation were performed. On the excised material, the perforation was 2 cm in diameter and the surrounding mucosa was normal. Pathologically sharp rupture and acute inflammation of the marginal mucosa at the perforated site were observed. Based on macroscopic and pathological findings, spontaneous perforation of the sigmoid colon was diagnosed. The patient went into septic shock for a while, but recovered and was discharged from the hospital on the 62^nd day after the operation. An artificial anus was closed 9 months after the operation.

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A case of intussusception of the descending colon caused by a lipoma in a 44-year-old man is reported. He was seen at the hospital because of melena. Colonoscopy revealed a tumor of the descending colon. Computed tomography and ultrasonography of the abdomen revealed intussusception in the descending colon and fat density tumor at the distal end of the intussusception. After reduction of intussusception, a laparotomy was performed. The descending colon was fixed loosely to the retroperitoneum. The descending colon was partially resected and the histopathological diagnosis was lipoma of the submucosal layer of the colon. The postoperative course was uneventful. The patient was discharged from the hospital 14 days after the operation.

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We report a case of multiple colonic ulcers associated with cancer of the ascending colon, with difficulty in making the differential diagnosis. An 87-year-old woman was admitted to the hospital with a diagnosis of acute appendicitis and underwent an appendectomy. Since CEA and CA19-9 levels were found to be high at examination of blood on admission, close explorations of the patient's whole body were conducted few days after surgery and type 2 cancer of the ascending colon and multiple colonic ulcers were detected by a colonoscopy. So the patient was operated on again. Intraoperative examination revealed multiple ulcerated lesions in the right hemicolon as well as cancer of the ascending colon. Because we could not clearly rule out malignancy, intraoperative colonoscopy was performed to assess the remaining colonic ulcers. Finally, we decided to perform a wide right hemicolectomy. On histopathological examination, the type 2 lesion of the ascending colon was diagnosed as moderately differentiated adenocarcinoma. A total of 5 punched-out, deep, semicircular ulcers were observed on the anal side of the tumor, but were found to show no malignancy. The patient had no symptoms suggestive of Behçet's disease and the features of her multiple ulcers were compatible with a diagnosis of idiopathic colonic ulcer.

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We report a case of cecal cancer associated with acute appendicitis. A 74-year-old man admitted with right lower abdominal pain underwent emergency surgery for acute appendicitis. He was treated with anticoagulant drugs, so general anesthesia was selected. An elastic hard mass was palpable in the lower right abdomen. Suspecting a tumor of the ileocecum region, laparotomy was done with a pararectal incision. The appendix was swollen, and a 4 cm diameter tumor was found in the cecum, necessitating ileocecal resection. The histopathological diagnosis was appendicitis catarrhalis with 3.8×4.2 cm cecal cancer, Borr1, well-differentiated adenocarcinoma (ss, ly₁, v₀, n₀, H₀, P₀, stage II). Cecal cancer caused by acute appendicitis is rare. To avoid overlooking cecal cancer, it is important to consider intraoperative exploration.

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It is known that acute appendicitis is induced by some obstructive mechanisms to the appendix vermiformis, but cancer is rarely involved in the mechanisms so that preoperative diagnosis is difficult to make. A 68-year-old man presented with acute appendicitis like signs. His WBC was 14400/mm 3. A diagnosis of acute appendicitis was made. Because he had anemia, further examination was conducted. Computed tomography showed a mass lesion in the ileocecal region. Contrast enema and a colonoscopy showed a tumor of the cecum. And a biopsy of the tumor revealed well differentiated adenocarcinoma. He underwent a right hemicolectomy. Pathological findings indicated advanced cecal cancer. It is rare that cecal cancer is associated with signs like acute appendicitis, so that we have difficulty in making diagnosis preoperatively. Cecal cancer associated with appendicitis is often in an advanced stage. In the treatment of people of middle and advanced age manifesting symptoms like appendicitis, a possible existence of cecal cancer must be kept in mind and pre- and intra-operative explorations are required.

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A 30-year-old man complaining of abdominal pain and diarrhea underwent a laparotomy for rectal cancer at another hospital which had already invaded the bladder, ileum and pelvis and were thought to be unresectable. Only a sigmoidostomy was made and thereafter the patient was referred to the hospital. After admission adjuvant radiotherapy at a total dose of 50Gy (2Gy×25times) was attempted. As a result, the tumor significantly decreased and invasive signs disappeared. We decided to carry out a curable operation at this point. Laparotomy revealed that the tumor was localized in the Rs and did not invade other organs, therefore the entire tumor was successfully removed without any damage to other organs. Histological examination of the removed specimen revealed no viable tumor cells.
We retrospectively examined the biopsy tissue and found it stained with P53(-) and P21(+) antigen expression. This means a fact that rectal cancer of P53(-) and P21(+) expression is sensitive to radiation and even far advanced rectal cancer can be cured by using adjuvant radiotherapy.

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A case of carcinoma of the ascending colon with metachronous metastasis to the uterus is presented. A 77-year-old woman who had been operated on for ascending colon carcinoma 3 years earlier was referred to the hospital because of a fracture of the iliac bone. Chemical analysis of the blood made for persisting fever and appetite loss revealed elevations of tumor markers (CEA 85.5ng/ml and CA72-4 330u/ml). On magnetic resonance imaging scan of the pelvis, a metastatic tumor in the uterus was suspected. A Hartmann's procedure, a hysterectomy and bilateral oophorectomy were performed. Hystological diagnosis was moderately differentiated adenocarcinoma of the uterus. We conducted CEA staining in both primary and metastatic specimens and gained positive response from them that might be the first attempt in Japan and contribute to prove the relation between the primary and metastatic foci.
The colon carcinoma with metastasis to the uterus is an extremely rare and only six cases including our case, have been reported in the Japanese literature during the past 20 years.

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A 61-year-old man with a 5-year history of anal fistula visited another hospital because of a swelling and a pain at the left side of the anus. The examination of the perianal region revealed a 5-cm diameter mass at 2 o'clock to the anus. The histological diagnosis of the lesion was well to moderately differentiated adenocarcinoma. A total colonoscopy confirmed the presence of a circular, ulcerated mass at the rectosigmoid junction, 20cm from the anal margin. A biopsy of the tumor showed a moderately differentiated adenocarcinoma. He was admitted to the hospital and underwent an abdominoperineal resection with a wide excision of the left perianal lesion. It is difficult to certify histologically that the carcinoma supervenes on anal fistula. In this case, the perineal tumor showed the same histological appearance as the rectal cancer and there was no mucoid discharge common in carcinoma of the anal gland origin. We considered that free tumor cells from the rectal cancer might have been implanted in the anal fistula.

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This paper presents a rare case of hepatic actinomycosis associated with alcoholic chronic pancreatitis. A 57-year-old man, who had been treated for diabetes mellitus and alcoholic chronic pancreatitis, was admitted to the hospital because of vomiting and fever. Abdominal ultrasonography and computed tomography showed a solid tumor, 5cm in diameter, in the lateral segment of the liver. On a plain CT, the hepatic tumor was visualized as an ill-defined low density area. On an enhanced CT, it was visualized as deep stained tumor on the early phase and a low density area on the late phase. And the pancreatic head showed tumor formation. Upper gastrointestinal series revealed a narrowing segment of the duodenum. Magnetic resonance cholangiopancreatography demonstrated the stenosis of the common bile duct in the head of the pancreas. Aspiration biopsy specimen was diagnosed as a chronic liver abscess. A pancreatoduodenectomy and a partial hepatectomy were performed. Microscopic findings of the resected specimen disclosed sulfur granules and the tumor was diagnosed as primary hepatic actinomycosis.

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We herein report two cases of torsion of the gallbladder. Case 1:A 78-year-old woman was admitted to the hospital because of hypochondralgia, nausea and vomiting. A mass measuring 5 cm in diameter was palpable in the right lateral region of the abdomen. Computed Tomography (CT) and ultrasonogaphy (US) were performed and she was diagnosed as to have torsion of the gallbladder. An open cholecystectomy was performed. The gallbladder was free-floating and rotated clockwise. Case 2:A 90-year-old woman was admitted to the hospital because of hypochondralgia. A mass measuring 5 cm in diameter was palpable in the right lateral region of the abdomen. CT and US were performed and she was diagnosed as to have torsion of the gallbladder. An open cholecystectomy was performed. The gallbladder was free-floating and rotated counterclockwise. Both CT and US are useful in making preoperative diagnosis of torsion of the gallbladder. Once the accurate diagnosis is made, early cholecystectomy is necessary to obtain a successful outcome because it is associated with necrosis of the gallbladder.

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We report a difficult-to-diagnose torsion of the gallbladder with acute emphysematous cholecystitis. An 87-year-old woman was admitted to the hospital because of fever, appetite loss, nausea, and vomiting. The temperature was 37.8°C. On physical examination no jaundice was noted. The abdomen was flat, but there were tenderness and muscular gurding in the right hypochondriac region. Abdominal CT scan and abdominal ultrasonography revealed gas formation in the swollen gallbladder. Based on these findings, a diagnosis of acute emphysematous cholecystitis was made, and an operation was performed. At laparotomy, there was bloody ascites with bad smell below the right diaphragma, around the gallbladder, and the gallbladder was swollen, dark-red in color and twisted counter-clockwise by 270 degree. Then a cholecystectomy and drainage were performed. These findings suggest that circulatory dysfunction due to the torsion of the gallbladder caused acute emphysematous cholecystitis.

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A 65-year-old man with a history of chronic pancreatitis was admitted to the hospital because of anemia and tarry stool. Whenever he got melena he had no abdominal pain and no high serum amylase levels, and by upper and lower endoscopies no bleeding point was shown without pooling of the fresh blood and diverticula in the colon. Abdominal computed tomography revealed an 1.5cm pancreatic pseudocyst in the tail of the pancreas. This cyst had not changed in the size and characters throughout the course. Though we performed a partial resection of the colon two times for his diverticula, he still suffered from tarry stool. After that we finally found hemorrhage from the pancreatic duct under gastroscopy, a diagnosis of hemosuccus pancreaticus was made. The patient underwent a distal pancreatectomy and a splenectomy. Communications between the pancreatic pseudocyst and main pancreatic duct, and failure of the splenic artery were recognized by histopathologic studies. No gastrointestinal bleeding has occurred thereafter.

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We report a case of asymptomatic pancreatic endocrine tumor with some bibliographical comments. A 65-year-old woman was seen at the our institute because she was pointed out occult bloody stool on a regular medical check up. Plain abdominal CT revealed a low density mass of the pancreatic head and the tumor was enhanced. On abdominal magnetic resonance imaging scan, T1-weighted image revealed a low density mass, and T2-weighted image revealed the high density mass. On ERP examination, the main pancreatic duct was compressed by the tumor. Angiography showed a hypervascular tumor. We suspected that the tumor was pancreatic endocrine tumor, and serum hormone levels were measured. Only a slight increase of serum somatostatin level was noted. She was preoperatively diagnosed as having asymptomatic pancreatic endocrine tumor and a pylorus preserving pancreatoduodenectomy was performed. The well-defined solid tumor with the diameter of 27mm was situated at the pancreatic head. In immunohistochemical stainings, the tumor cells were positive for chromogranin and somotostatin.

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Splenic sarcoidosis which lacks both subjective and objective symptoms is a relatively rare disease and there have been a few reported cases in Japan. We recently treated a patient with solitaly splenic sarcoidosis by a laparoscopic splenectomy.
A 52-year-old woman was found to have a splenic tumor at a physical checkup and was admitted to the hospital for close exploration. Abdominal ultrasonography and computed tomography showed a hypoechoic and low dencity solid mass in the spleen. Magnetic resonance image showed a low intensity mass on T2-weighted images. Splenic angiograms showed a hypovascular tumor 3cm in diameter. Because it was difficult to make the definite diagnosis and to rule out a possibility of malignant tumor of the spleen, we performed a laparoscopic splenectomy. The histological diagnosis was splenic sarcoidosis. Splenic sarcoidosis presents difficulty in preoperative diagnosis because it has diverse histologic types with resultant diverse imaging findings. However, we must consider conservative therapy for the disease that is naturally benign, if the definite diagnosis can be made before operation. So we selected laparoscopic splenectomy for the patient to minimize the surgical stress.

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A 76-year-old man with no history of trauma admitted in an emergency due to pain in the whole abdomen with hypovolenic shock was diagnosed with hemoperitoneum by spontaneous splenic rupture and discharged without operation 9 months earlier. Laboratory findings at admission showed marked pancytopenia. Enhanced abdominal computed tomography (CT) scan showed massive hemoperitoneum and splenic rupture. One day later, an emergency laparotomy was conducted due to progressive anemia and the man's poor general condition. Operative findings included extensive coagulation, dark reddened giant splenomegaly, and active bleeding by splenic rupture from the serosa to parenchyma. Splenectomy was done but no lymph node swelling or liver findings were seen. The resected spleen was 32.5×21.0 cm, weighted 3, 050 g, and was infiltrated by malignant diffused large-cell lymphoma. Postoperative chemotherapy with 6 cycles of modified CHOP (CPA, THP, VCR, Pred) has kept the patient in complete regression.
Leukemic change is an important factor in spontaneous rupture in malignant lymphoma.

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We report a case of asymptomatic extra-adrenal pheochromocytoma associated with prostatic cancer, together with some considerations on possible etiology.
A 77-year-old man was seen at the emergency clinic in the hospital because of anuresis during treatment for prostatomegaly in the hospital. With an abdominal CT scan, a retroperitoneal tumor was accidentally detected and the tumor was surgically excised. Pathological diagnosis was pheochromocytoma. No changes in blood pressure were recorded during and after the surgery. Furthermore, adenocarcinoma was diagnosed by a needle biopsy of the prostate after the surgery. A total prostatectomy was added. On immunostainings, over expression of P53 was observed in the both tumors. It was suggested that some genetic abnormality might etiologically participate in this case. There have been no signs of recurrence at present.

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We report 2 cases of idiopathic omental hemorrhage. Case 1: A 30-year-old man repoting abdominal pain, was diagnosed with intraabdominal hemorrhage and hematoma in the omentum based on abdominal ultrasonography, paracenteses, and computed tomography (CT). Bleeding from the omental branch of the left gastroepiploic artery was diagnosed by abdominal angiography. This bleeding of the left gastroepiploic artery was noted intraoperatively. He then underwent partial omentectomy. Postoperative histopathological examination of the resected omentum showed numerous capillary vessels. Case 2: A 40-year-old man reporting abdominal pain was diagnosed with omental hematoma or left subphrenic abscess by an abdominal CT. A hematoma was noted intraoperatively in the omentum. He then underwent partial omentectomy. Postoperative histopathological examination of the resected mass showed a hematoma and necrotic fat tissue.

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A 70-year-old woman was admitted to the hospital because of nausea and vomiting. Ultrasound revealed a hyper echoic mass 10cm in diameter in the lower abdomen. Computed tomographic and magnetic resonance imaging scans showed same density and intensity mass as fatty tissue, which had a septum. The preoperative diagnosis was lipoma in the abdomen. At laparotomy, a large tumor 10cm in diameter was found growing subpediculately from the small bowel mesentery. The tumor was resected with a partial resection of the ileum. The resected material disclosed a yellow and elastic soft tumor with the dimension of 14×12×5cm and the weight of 450g. Neither hemorrhage nor necrosis was detected. The histological diagnosis was lipoma arising from the small bowel mesentery. Mesenteric lipomas are rare among tumors arising from the mesentery, especially the lipomas growing with pedicle. So far a few cases of subpediculate mesenteric lipoma have been reported.

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We have experienced an operative case of tuberculous peritonitis with ileus due to diffuse lesion of the small intestine. A 34-year-old man was admitted to another hospital because of abdominal pain and fever. Crohn's disease was initially suspected by colonoscopic findings, and he was treated with corticosteroids. Three months later, Mycobacterium tuberculosis was detected in a stool, and he was then treated as tuberculosis for 6 months. Following chemotherapy, Mycobacterium tuberculosis disappeared, but obstructive symptom did not improve. The patient was referred to the hospital and underwent a laparotomy. Multiple small nodules were disseminated over the serosal surface of the small intestine and mesenterium. At each nodule, intestinal walls converged, making a lump of the intestine and colon. Sharp dissection of the adhesive lesion was performed. An ileus tube was inserted from the gastric wall and induced up to the terminal ileum to prevent re-ileus. A large number of Mycobacterium tuberculosis were found by Ziehl-Neelsen staining of the nodule. Following the surgical treatment, the ileus significantly improved. The postoperative course was uneventful and the patient was discharged from the hospital 39 days after the operation. Mechanical cleaning of the nodules and inserting an ileus tube to prevent recurrence of ileus were helpful to this case in which intestinal resection was difficult because of the diffuse lesion.

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A 70-year-old woman was seen at the hospital because of abdominal distension, and further evaluation was conducted for an abdominal mass. The imaging findings were suggestive of a fibrotic abdominal mass originated from the mesenterium or colon. Upon laparotomy, the tumor had invaded the jejunal and transverse colonic mesenteries and colonic wall. The tumor was resected together with some parts of the intestines. The tumor was 55×50×54 mm in dimension and was histologically and immuno-histochemically diagnosed as intra-abdominal mesenteric desmoid tumor. Surgical resection should be performed as soon as possible after a mesenteric (desmoid) tumor containing fibrotic component is diagnosed.

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We report a case of mesenteric desmoid tumor infiltrated into the transverse colon. A 59-year-old woman was seen at the department because of a lower abdominal mass. She had neither history of abdominal surgery nor familial adenomatous polyposis (FAP). A contrast enhanced computerized tomographic scan revealed an enhanced tumor about 7cm in diameter in the lower abdominal cavity and it was stained faintly on a superior mesenteric angiogram. She was operated upon with a dignosis of an abdominal tumor. The tumor was originated from the iliac mesenterium involving a part of the transverse colon. We resected the tumor with a part of the ileum and transverse colon. The resected tumor was histologically diagnosed as mesenteric desmoid tumor. Sporadic mesenteric desmoid tumor is relatively uncommon. The cause of the disease remain obscure, and the therapies are controversial. Further investigation of the disease is required.

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A case of perforated anastomotic ulcer, which is rare recently, was successfully treated by omental implantation.
A 40-year-old man, who had undergone a distal partial gastrectomy with Billroth II reconstruction for perforated duodenal ulcer at the age of 18, was seen at the hospital because of tenderness and muscular defense throughout the upper abdomen. The white blood cell count was 13, 190/mm³, CRP was 0.01mg/dl, and gastrin level was low. Chest and abdominal X-ray films revealed free air in the subphrenic space. An abdominal CT scan showed intraperitoneal free air around the remnant stomach and gastrojejunostomy. An emergency laparotomy was performed with a diagnosis of panperitonitis. During surgery, a perforated ulcer at the anastomotic site, which was reconstructed by antecolic Billroth II procedure and Braun anastomosis, was comfirmed and then peritoneal drainage and omental implantation were carried out. A proton pump inhibitor was given to the patient after the operation. The postoperative course was good and he was discharged on the 20th postoperative day. Omental implantation is useful for perforated anastomotic ulcer and is able to become one choice for emergency surgery. But this method is not a radical operation and there is a possibility of recurrence. It is important to follow the patient as long as possible keeping possible reoperation in mind.

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We have experienced a case of intramuscular hemangioma in the psoas muscle. Intramuscular hemangiomas are relatively uncommon, compared to cutaneous or hepatic hemangiomas. Although all muscules can be affected, it is common in muscules of the lower extremities, particularly those of the thigh. It is rare that intramuscular hemangioma occurs in the iliopsoas muscle. A 50-year-old woman was seen at the hospital because of numbness of the right lower extremity. CT scan showed a large mass in the iliopsoas muscle. Magnetic resonance imaging scan showed a high intensity mass both on T1 and T2. We suspected liposarcoma of the psoas muscles, and performed a wide resection including the psoas muscles. The removed tumor was about 6×4 cm in diameter, and it looked like a lipoma. Histopathological appearances included various sizes of vesseles growing invasively into muscles and a lot of fat cells, but no malignant cells were seen in the tumor. Definite diagnosis of intramuscular hemangioma was made.

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An 81-year-old man was referred to the hospital because of intractable ulcer and pain of the right leg, and was admitted ridden on a wheelchair. On admission the ankle joint-to-upper arm blood pressure ratio (ABI) was 0.3 on the right side and 1.0 on the left side. Ulcer 3 cm in diameter with infection was present at the lateral malleolus of the right leg, and intravenous analgesics were required to control pain of the right leg. Angiography showed obliteration of the right external iliac, superficial femoral, and patella arteries, and visualized only the posterior tibial artery in the leg. Under general anesthesia, an iliac-femoral-distal posterior tibial artery bypass was performed. Immediately after the operation, pain of the leg in resting time disappeared, the patient became to be able to walk by himself 2 week after the operation, and the ulcer of the leg cured 6 months postoperatively.

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A 90-year-old woman was seen at the hospital because of swelling and pain of the umbilical region. A black umbilical stone 3 cm in size was confirmed at the umbilical region. There were tenderness and redness around the navel. She had no memory of washing the navel until now and had undergone no surgery. Abdominal plain x-ray examination showed no abnormal findings, but an abdominal CT scan revealed a lamellar stone 3 cm in size in the navel. Our attempts to squeeze the stone from the umbilical foramen were in vain, so that, under local anesthesia to the periumbilical area, the stone was removed from the sufficiently opened foramen. The removed stone was 27×26×13 mm in dimension. Dirt with unpleasant odor was present in the umbilical pouch after the stone was removed and umbilical inflammation was associated.
So far only several cases of umbilical stone have been reported in the Japanese literature. And no huge umbilical stone as we have difficulty in removal like in this case has been reported. This case is thought to be of very rare.

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