Introduction and aim: Chemotherapy for colorectal cancer is presently, practiced by surgeons, who have many things to do, in 88% of cases that exerts significant influences on their surgical activities and safety management. Given this factor, we studied the possibility and efficacy of cooperation between our clinic and a general hospital in chemotherapy practice.
Methods: A total of 125 patients with colorectal cancer received chemotherapy under cooperation between our clinic and a general hospital during three years from 2001 to 2003. Intravenous injections were given 2203 times in total. Clear guidelines for dosage and administration as well as approaches for adverse events were defined. A questionnaire survey about the chemotherapy was conducted to these patients as well.
Results: As for adverse side effects, except two patients who had severe diarrhea required hospitalization, others successfully received chemotherapy as outpatients under the management by two facilities without major troubles. The response rate for questionnaires was 68%, and 91% of those responders answered “good” or “acceptable” after the therapy. Reduced waiting time in the cooperated hospital was valued high, whereas comfort level was rated higher in our clinic than the other. A further more intense cooperation was approved by about 70% of the responders.
Conclusion: Our study shows that chemotherapy for colorectal cancers under cooperation between the clinics and general hospitals can be safely practiced, and is rated high by the paients. Further enlargement of such cooperation is expected.

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We conducted a prospective study to determine whether esophagectomy with muscle-preserving thoracotomy and hand-assisted laparoscopic surgery (HALS) for thoracic esophageal cancer would help to reduce surgical invasiveness compared to conventional thoracotomy and laparotomy. Subject were 23 patients with thoracic esophageal cancer operated on at the hospital from April 2000 to October 2001. They had not serious complications. Several surgical stress markers and clinical results were compared between esophagectomy through conventional thoracotomy and laparotomy (open TA group: n=12) and esophagectomy through muscle-preserving thoracotomy and HALS (MPT+HALS group, n=11) No significant differences were seen in surgical duration, blood loss; and the number of dissected lymph nodes between the two groups. Postoperative changes in WBC and CRP tended to be lower after MPT+HALS than the other, though there was no statistically significant difference. Postoperative serum IL-6 on POD 1 was significantly lower in the MPT+HALS group than in the open TA group (p=0.044). Although no difference was seen in the duration of mechanical ventilation between the two groups, the duration of SIRS was significantly shorter in the MPT+HALS group (p=0.014). Vital capacity 1 month after the operation in the MPT+HALS group was significantly less adversely affected. Esophagectomy with muscle-preserving thoracotomy and HALS provided clinical advantages such as less surgical invasiveness and early recovery from impaired respiratory function after surgery, compared to conventional open thoracotomy and laparotomy.

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To evaluate the significance of omento-bursectomy for T2 and T3 gastric cancers, a retrospective study was carried out. A series of 787 patients with gastric cancer who underwent gastrectomy in our hospital from 1991 to 2001 were enrolled in the study and divided into two groups; omentum and bursa preserving gastrectomy group (Preserving group: PG) and gastrectomy with resection of the omentum and brusa (Resection group: RG). Several clinical factors, such as survival rate, operation time, blood loss volume, postoperative hospital stay, postoperative complications and recurrence mode, were compared between PG and RG. The 5-year survival rates in T2PG and T2RG were 85.4% and 74.6% (p=0.003), and those in T3PG and T3RG were 60.2% and 50.5% (p=0.24), respectively. Rates of peritoneal recurrence in T2PG and T2RG were 2.4% and 5.0% (p=0.22), and those in T3PG and T3RG were 10.0% and 23.2% (p=0.15), respectively. No survival benefit of omento-bursectomy was observed, and prophylactic effect of the procedure for peritoneal recurrence could not be expected. But significantly less operation time, blood loss volume, postoperative hospital stay were noted in PG than RG. The incidence of postoperative complications including postoperative pancreatitis and ileus was also less in PG. In conclusion, omentum and bursa preserving gastrectomy is a reasonable procedure for T2 or T3 gastric cancer patients.

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Background: Tension-free repair of adult inguinal hernia is now common in Japan, using such techniques as mesh plug repair and PHS, which have been shown to produce better results than conventional repairs in several studies. We evaluated tension-free repair, mainly mesh plug repair, for recurrent inguinal hernia. Methods: From January 1995 to December 2002, 110 patients who underwent tensionfree repair were reviewed. We chose mesh plug repair or PHS. We surveyed all patients by telephone. We evaluated their recurrence of hernia, complications, and the comparison with their first hernioplasty. Results: We conducted mesh plug repair for 96 patients and PHS for 5. We followed up 87. The mean postoperative term was 46.7 months (9-109 months). Five patients had recurrence after placement of a mesh plug. Only 3 patients reported long wound pain after surgery. Some 80 (91.3%) felt that our surgery was more comfortable. Conclusion: Mesh plug repair shows advantages in the treatment of recurrent inguinal hernia. This technique is easier to conduct for physicians and more comfortable for patients than conventional repair.

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This study was designed to evaluate the usefulness of measurement of serum iron level in screening tests for gastrointestinal cancer. Of a series of 5, 623 subjects who received immunological stool guaiac test in the outpatient clinic, 341 patients whose tests were positive were enrolled in this study. After close examinations, these patients who were found to have some disease were divided into two groups: anemia and normal groups bounded by a serum hemoglobin level of 12g/dl measured when they were first seen. The calculated mean serum iron level (μg/dl) by diseases in the anemia and normal groups were 30.4±7.7 and 52.6±23.0 in colorectal cancer; 43.8±11.3 and 52.0±31.1 in gastric cancer; 55.5±20.2 and 116.9±38.8 in colorectal diverticulum; 114.0±29.2 (normal group only) in colorectal polyp; and 56.0±26.2 and 109.9±64.3 in gastroduodenal ulcer, respectively. In the normal group, there were significant differences between malignant and benign diseases; namely, between colorectal cancer and colorectal polyp; colorectal cancer and gastroduodenal ulcer; colorectal cancer and colorectal diverticulum; gastric cancer and gastroduodenal ulcer; and gastric cancer and colorectal diverticulum (p<0.01).
From these findings, it is thought that the measurement of serum iron level might contribute to improve detection rate of malignant diseases in mass screening for gastrointestinal malignancy.

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We report an unusual case of intra-thyroidal lymphoepithelial cysts. A 59-year-old woman was admitted to our hospital for the investigation of a thyroid mass. Her thyroid function was normal, but 5-mm masses were found in bilateral lower lobes of the thyroid gland. A partial resection of the left lower lobe was performed for diagnosis and treatment. A cystic lesion, containing a thick whitish-yellow substance, was identified. Microscopically, the cyst had a squamous epithelial lining with abundant underlying lymphoid tissue, including lymphoid germinal centers. Lymphoepithelial cysts, which may originate from the branchial pouch, are typically found in the lateral part of the neck, anterior to the sternocleidomastoid muscle. To the best of our knowledge, only 18 other cases of intra-thyroidal lymphoepithelial cysts have been reported.

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A 20-year-old male was seen at our institute for the investigation of a 3-cm mass in the midline of his anterior neck. A computed tomography scan and ultrasonography study revealed the presence of a cystic lesion with a calcified papillary mass. A papillary carcinoma arising from a thyroglossal duct cyst was suspected. A Sistrunk procedure was performed for diagnosis and curative treatment. The pathological findings showed a papillary carcinoma arising from a thyroglossal duct cyst with no invasion to the surrounding tissues. Thyroglossal duct cyst is a benign disease that is often recognized as a mass in the anterior neck during daily examination. The condition represents a common developmental abnormality of the thyroglossal remnant and rarely involves a malignant disease. We report the case of a papillary carcinoma arising from a thyroglossal duct cyst.

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Human sparganosis mansoni is an infection caused by a plerocercoid larva (sparganum) of Diphyllobothrium mansoni. This sparganum usually migrates in subcutaneous tissue. Sparganosis of the breast forming a mass, however, is rare worldwide.
A 78-year-old woman noticed a painful mass in the left breast a day before her visit. She had no history of consuming uncooked frog, snake, catfish or impure water. On physical examination, the breast mass was 20×16 mm in diameter, round and elastic firm with an indistinct border, and the left axillary lymph nodes were swollen. Ultrasonography revealed a heterogeneous, indistinct and hyper echoic mass. Mammography showed a snowman like appearance, elliptical, indistinct and high-density mass without calcification. Although these findings suggested panniculitis or breast cancer, aspiration biopsy cytology (ABC) revealed a sparganum larva in a histological examination. The extirpated mass consisted of an abscess and granulation, in which a white tapeworm was found. It was identified as sparganum histologically. The breast mass caused by sparganum is difficult to be distinguished from cancer or other diseases preoperatively. The mobile and migrating mass is characteristic of Sparganosis mansoni and preoperative ABC is a valuable diagnostic method if sparganum is obtained in cytological specimen.

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A 42-year-old woman was seen at the hospital because of increasing tendency of erosion surrounding the right nipple in July 2001 which had been left since 1997 or thereabout. There was a previous history of undergoing a breast-conserving surgery (Bq+Ax) at another hospital on July 20, 1993, which was histologically diagnosed as breast cancer and n0, but other data were unavailable. When she was first seen at the hospital, erosion 4.8×6.8 cm in diameter surrounding the right nipple as the center was noted, but no tumor mass was palpable. No tumors were visualized by ultrasonography, and no distant metastases were shown by chest and abdominal CT scans and bone scintigraphy. Paget's disease of the right breast was suspected, and a biopsy of the erosion was conducted on August, 16, 2001. Paget's disease was diagnosed with intraoperative frozen section diagnosis and mastectomy of the right breast remnant was carried out. There have been no signs of recurrence as of 2 years after the operation. Histologic diagnosis was Paget's disease.
Since reports on Paget's disease of the breast after breast-conserving surgery are uncommon, this case is presented here, together with a review of the literature.

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Of invasive ductal carcinomas of the breast, invasive micropapillary carcinoma (IMP) of the breast that metastasizes to lymph nodes and invades lymphatic vessels with high frequencies is thought to be a histological type with poor prognosis. Recently we experienced two cases of IMP of the breast.
Patient 1 with stage I IMP of the breast (T1N0M0) underwent pectoral muscle preserving mastectomy. Histological type was IMP and three out of seven lymph nodes were positive. Since the tumor was positive for both ER and PgR, the patient has been treated with endocrine therapy.
Patient 2 was admitted to the hospital after being diagnosed as having IMP with an incision biopsy at another hospital. The tumor was rated as T1N0M0 in stage I. Breast-conserving surgery was performed. Histologically it was diagnosed as IMP, and one out of 20 lymph nodes was involved. Since it was negative for both ER and PgR, the patient underwent 6 courses of chemotherapy with FED and then radiation therapy.
Both two patients had a tumor with the diameter of less than 2 cm, but serious lymphatic invasion was noted. IMP is a histological type which has not been described in ‘the General Rule for Clinical and Pathological Record of Mammary Cancer’ as yet. We think that IMP must be classified into a special type of breast cancer from the standpoint of characteristic histological findings and strong malignant potential.

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A 54-year-old woman who had been administered psychotropic drugs for asyndesis since 1977 was seen at the hospital because of a left breast tumor on January 17,2004. On palpation an elastic-hard, demarcated, and well-movable tumor with a smooth surface was present in the CA area of the left breast. Benign phyllodes tumor was diagnosed by fine needle biopsy cytology, and a total mastectomy was performed on March 8. Histopathologically the main part of the tumor was borderline phyllodes tumor, and in its deep part a scirrhous carcinoma was present with intraductally invading foci close to the tumor.
It is extremely rare that a phyllodes tumor and breast cancer synchronously occur in the ipsila t eral breast, so that this case is presented here, together with a review of the literature.

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A 76-year-old woman was seen at the hospital because of an elastically hard mass in the left nipple. On palpation there was a 1.0-cm mass in the nipple but no mass at the subareolar area. The pathological diagnosis was made as invasive ductal carcinoma by a biopsy. A breast concerving surgery was carried out. The macroscopic excision specimen revealed cancer nest localized at the nipple and just below the nipple. The final histological diagnosis was invasive ductal carcinoma (scirrhous), and there was no invasion into lymphatic duct and blood vessels.

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A 54-year-old woman referred to the hospital because of a left axillary mass 3 cm in diameter was diagnosed as having metastatic lymph node from adenocarcinoma by fine needle aspiration cytology. Since no primary lesion was detected, lymph node dissection was performed. Left breast cancer was most likely because hormone receptor of lymph node was positive. Mastectomy was performed after informed consent was obtained and a tiny lesion 3 mm in diameter was detected by histologically. It was invasive ductal carcinoma scirrhous type. The patient received chemoradiation therapy postoperatively because level III lymph node was positive.
Most cases of occult cancer with axillary lymph node metastasis are of breast cancer, in that we must make efforts to detect the primary lesion and treat according to the typical therapies for breast cancer in stage II or more. In cases in which the primary lesion can not be identified, however, dissection of level I and II lymph nodes might be required to carry out hormone receptor assay of the lymph nodes. And no consensus on the propriety of indicating mastectomy for the breast without any mass has established as yet, and the standardization of therapies for the disease is expected in future.

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A 58-year-old woman underwent a modified radical mastectomy and immediate transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction after receiving neo-adjvant chemotherapy for the treatment of a T4N2M0 breast cancer in 2001.
In 2003, the patient developed a local recurrence and carcinomatous pleurisy. After undergoing trastuzumab-docetaxel treatment and radiation therapy, a complete response (CR) was obtained for 10 months. In February 2004, however, the patient began to complain of headaches. CT and MRI studies revealed a brain metastasis with a diameter of 3 cm in her left thalamaus. The neoplasm was reduced using a gamma knife. Trastuzumab has not been reported to have a direct effect on the promotion of brain metastasis. However, since trastuzumab does not pass the blood-brain barrier, brain metastasis may appear and progress, even if a CR has been obtained in organs outside the brain. Examinations for brain metastasis are thus believed to be important after trastuzumab therapy.

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A 55-year-old male was found to have an abnormal shadow on a chest X-ray in 1997. A chest computed tomography (CT) showed a cystic tumor with a thick wall in the anterior mediastinum, suggesting a benign cystic tumor. Since the patient was receiving home oxygen therapy for the treatment of severe chronic pulmonary emphysema, he was observed for 2 years without surgical extirpation. He suddenly suffered chest pain, dyspnea and bloody sputum in January 1999. A chest X-ray showed an intrapulmonary perforation of the tumor. After a remission of the pneumonitis for 2 months, the tumor was resected along with the patient's thymus and part of the right upper lobe of the lung. Histologically, the tumor was diagnosed as a mature cystic teratoma.
Conclusion: Mature teratomas should be immediately resected. However, in cases with intrapul-monary perforations that occur during the follow-up period for some other condition, an alternative treatment strategy in which the remission of pneumonitis is awaited prior to proceeding with surgery may be considered.

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We report a case of long-term survival in a patient with primary hepatocellular carcinoma (HCC) following repeated pulmonary metastatectomy.
A 53-year-old man diagnosed with chronic viral hepatitis type B underwent right hepatic lobectomy for solitary HCC in the anterior segment 9 years ago. Under surveillance of by chest CT, pulmonary metastases were found as multiple bilateral nodules or masses at 29 months, 46 months, 59 months, and 71 months after initial surgery. Repeated resection localized pulmonary metastasis can improve survival in at least some patients with HCC provided intrahepatic metastasis is completely controlled.

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A 14-year-old boy seen for abdominal blunt trauma was found in chest X-ray and CT to have abdominal content entering the pleural cavity, necessitating emergency surgery. We confirmed that abdominal contents were the transverse colon and a defect 3×2 cm in diameter was found in the posterolateral left diaphragm. The edge of the diaphragmatic defect was smooth, so we diagnosed this as Bochdalek hernia. After the organ was restored, the defect was directly closed.

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It is reported that ectopic gastric mucosa occurs in 310% of Japanese adults, and is sometimes mentioned as the origin of adenocarcinoma in the upper esophagus. However, the number of cases of esophageal adenocarcinoma arising from ectopic gastric mucosa reported in Japan is only nine. We describe a surgical case of primary esophageal adenocarcinoma arising from ectopic gastric mucosa in the cervico-thoracic esophagus.
A 51-year-old man was admitted to the hospital because of hoarseness. X-ray examinations and upper gastrointestinal series showed a tumorous lesion on the left wall of the cervico-thoracic esophagus. Esophagoscopy revealed an elevated tumor. A biopsy specimen of this tumor showed that it was moderately differentiated adenocarcinoma arising from ectopic gastric mucosa. A subtotal esophagectomy was perfomed. The macroscopic view of the resected specimen showed a tumor of 3.0×2.0 cm in diameter. Pathological diagnosis was moderately differentiated adenocarcinoma arising from ectopic gastric mucosa. No postoperative adjuvant therapies were added to the patient because he had asyndesis. He died of recurrence 11 months after the operation.
We report this quite rare case of adenocarcinoma arising ectopic gastric mucosa in the cervicothoracic esophagus.

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A 62-year-old woman was admitted to the hospital because of a gastric submucosal tumor. Gastroscopy revealed an elevated lesion about 2 cm in diameter covered with normal mucosa near the gastric cardia. Endoscopic ultrasonography revealed the lesion occupied the proper muscular layer and showed a uniformly low echoic lesion. CT scan revealed no lymph nodes, liver metastasis, nor invasion to the neighbor organs. We diagnosed the tumor as gastric submucosal tumor with benign or borderline malignancy, and performed a new endoscopic treatment, so called endoscopic resection, for this tumor. Using the IT knife, the surface epithelium and submucosal thick fibrous tissue were cut and dissected around the tumor. Finally the tumor was removed with the help of snarring for prevention of massive bleeding or perforation. The resected specimen was 12×24×7 mm in dimension. The histological diagnosis was gastrointestinal stromal tumor, borderline malignancy.
Although gastric submucosal tumors are generally treated by open surgery or laparoscopic surgery, we employed the endoscopic resection technique for the treatment of the tumor with successful outcome. This simple and safe technique will be useful for the diagnosis and treatment of gastric submucosal tumors with possible malignancy. Our therapeutic guidelines for the tumors are also presented here.

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Toxic shock syndrome (TSS) is an acute, toxin-mediated febrile disease characterized by rapid onset of high fever, hypotension, skin eruption and variety of other signs and symptoms. It rapidly leads to multiple organ failure with serious morbidity and mortality. There are few reports on definite TSS after gastrectomy in Japan. We report a case of TSS occurred after operation for gastric cancer. A 48-year-old woman with early gastric cancer underwent a proximal gastrectomy on December 26, 2003. Two days after the operation, she had a spiking fever up to 40°C followed by hypotension and oliguria. Generalized erythematous macular rash, hepatic dysfunction and diarrhea also appeared. On the 5th postoperative day, she developed ARDS and DIC. Bacterial culture of the stool and pus from surgical wound yielded Methicillin resistant staphylococcus aureus producing toxic shock syndrome toxin-1. She fulfilled the criteria for the case definition of TSS within the CDC guidelines. Surgical drainage was performed and intraveous antibiotic therapy with VCM was initiated immediately. As a result of appropriate intensive care for multiple organ failure, she recovered from TSS.

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We report here the clinicopathological details of a case of primary gstric small cell carcinoma that was diagnosed as poorly differentiated adenocarcinoma based on the results of preoperative examinations. A 34-year-old woman was referred to our hospital for further examination of a gastric tumor. Physical and laboratory examinations revealed no abnormalities. Radiological, endoscopic, and imaging examinations demonstrated a gastric protruding and ulcerated lesion. The preoperative histological diagnosis of a biopsy specimen was poorly differentiated adenocarcinoma, and a gastrectomy was performed. Macroscopically, the surgical specimen showed a fungating and ulcerated gastric tumor. A microscopical study revealed the proliferation of small to intermediate-sized carcinoma cells with a high N/C ratio in the ulcer bed, extending to the subserosa. At the edges of the ulcer, the tumor was covered with non-neoplastic epithelium. Based on these observations, the tumor was diagnosed as a small cell carcinoma (SmCC). Immunohistochemically, the carcinoma cells showed a strong and diffuse positivity for cytokeratin CAM5.2, neural cell adhesion molecule (NCAM: CD56), chromogranin A, and thyroid transcription factor-1 (TTF-1) as well as focal positivity for neuron-specific enolase (NSE), N-cadherin and E-cadherin. Argyrophilic granules were also observed using a Grimelius stain. Our study suggests that primary gastric SmCC is very similar to SmCC of the lung or other sites, both clinically and histopathologically.

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It is very rare that essential thrombocythemia (ET) is associated with gastric cancer. We report two operated cases of ET with gastric cancer in terms of perioperative management of platelet count.
Patient 1, a 65-year-old man, complaining of appetite loss was referred to the hospital because he was found to have gastric cancer (Borrmann type II) at another hospital. On admission his platelet count was 85.5×10⁴/μl. The platelet count was controlled by increasing the dose of hydroxyurea, and a distal gastrectomy was performed when the count was reduced to 56.8×10⁴/μl. Medication with hydroxyurea was resumed on the 4^th postoperative day. The postoperative course was uneventful.
Patient 2, a 71-year-old man, was diagnosed as having stump cancer after a distal gastrectomy and scheduled for total gastrectomy. On admission his blood platelet count was 104×10⁴/μl and he was diagnosed as having ET. His disease was also controlled with hydroxyurea regimen. When the blood platelet count decreased to 52×10⁴/μl 14 weeks after starting the regimen, a total gastrectomy was performed. The hydroxyurea regimen was resumed 7 days later than patient 1, so we also used heparin to prevent complications such as cerebral thrombosis. Adequate control of platelet count through the entire perioperative period and anticoagulant therapy are important for surgical patients with ET.

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Chilaiditi syndrome is a general term designating a condition that part of the gastrointestinal tract is trapped between the right diaphragm and liver. We report a case of Chilaiditi syndrome in which part of the small intestine was trapped (small intestine type Chilaiditi syndrome), that is relatively rare and only 31 cases have been reported in Japan. An 82-year-old man was seen at the department because of abdominal pain and vomiting. Based on abdominal X-ray examination, CT, and three-dimensional computed tomography (3DCT), the patient was diagnosed as having small intestine type Chilaiditi syndrome associated with strangulated ileus, and was operated on. This case is relatively rare in which small intestine type Chilaiditi syndrome was associated with strangulation ileus caused by internal hernia of the small intestine in the vicinity of the Treitz' ligament.
Care must be exercised that Chilaiditi syndrome involving the small intestine is prone to cause strangulation ileus. The identification of the involved organ is of importance in the treatment, in that 3DCT is very helpful.

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Ischemic enteritis of the small intestine is relatively rare. A case of ileus resulting from idiopathic ischemic enteritis that we experienced is described in this report with some review of the literature. An 84-year-old woman who had been treated for epigastralgia at a local clinic for 2 weeks, was suspected to have esophageal hiatus hernia because chest X-ray indicated a niveau sign in the mediastinum. The patient was referred to us for further examination. Her back was strongly bent forward and there was tenderness throughout the abdomen. Multiple deposits of small intestinal gas were present on abdominal X-P. Esophageal hiatus hernia was demonstrated by upper gastrointestinal endoscopy. The fiberscope could not be passed into the anal side of the stomach, because the stomach was strongly deformed and the lower part became narrower as the stomach wall compressed it. Abdominal CT scan revealed accumulated intestinal fluid and that the stomach was displaced in the mediastinum. Severe tenderness prevented manual reduction, and surgical treatment was selected. A 3×2cm necrotic lesion was present about 15cm proximal to the distal ileum on the controlateral side of the mesentery. The entire stomach with esophageal hiatus hernia was prolapsed into the mediastinum due to increased intra-abdominal pressure. The stomach was reduced to its normal position. Ischemic necrosis of the small intestine was definitely diagnosed by histopathological examination of the surgical specimen.

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A 29-year-old man was brought into the hospital by ambulance because of abdominal pain covering entire the abdomen. On palpation, muscle defence was present mainly in the lower abdomen. The white blood cell count increased to 9560/μl, and an increase in serum creatine phosphokinase level to 433IU/l was noted. Abdominal CT scan revealed the dilated small intestine and niveau. He had no past history of undergoing open laparotomy. Although no causes could be identified, an emergency operation was performed with a diagnosis of strangulation ileus. At laparotomy, a Meckel's diverticulum was present at the ileum 60 cm proximal to the distal ileum, and adhesive changes probably caused by old inflammation were seen between the apex of the diverticulum and mesenterium. The ileum was incarcerated into the loop causing strangulation ileus. The Meckel's diverticulum was extremely distended and changed to dark red in color. Congestion was noted in the ileum, but reduction of the ileus by adhesiotomy resulted in improvement in color. So only Meckel's diverticulum was resected. Strangulation ileus caused by inflammatory adhesion of the Meckel's diverticulum is comparatively uncommon and accounts for 16% of all intestinal obstructions caused by Meckel's diverticulum. We must take this disease into consideration when we encounter a patient presented with the symptoms of ileus without history of undergoing laparotomy.

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A 35-year-old man was seen at the hospital because of upper abdominal pain and anal bleeding. Abdominal plain x-ray film showed niveau formation. Abdominal ultrasonography visualized target sign with a lipoma in its center and intussusception of the ileum was suspected. Magnetic resonance imaging scan showed ileal intussusception led by a 2.5-cm lipoma. Peristalsis of the intussuscepted segment was confirmed and no ischemic findings of the intestine were seen. No improvement in intestinal obstruction was attained, and then laparoscopic aided laparotomy was performed when ileo-ileal intussusception was identified about 120cm proximal to the distal ileum. A partial excision of the ileum was carried out. A lipoma like polyp of 2.5 cm in diameter and 10 cm in length sumed to be the leading point of intussusception. Histological study revealed that the leading point was true diverticulum, which was definitely diagnosed as inverted Meckel's diverticulum because ectopic gastric mucosa was proved at the head of the leading point. The tumor which was thought to be lipoma was fatty tissue communicated with inverted subserosal structure.
It is relatively rare that intussusception caused by inversion of Meckel's diverticulum occurs in adults and hence preoperative diagnosis of the disease is difficult. This case is presented with some bibliographical comments.

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We report a case of non-specific multiple ulcer of the small intestine, a rare entity, in an elderly patient who was operated on with resultant symptomatic remission.
A 67-year-old man had frequent gouts of intestinal obstruction after receiving laparotomic cholecystectomy which had been relieved by conservative treatments. In June 2003, he was admitted to the hospital because of intestinal obstruction. Small intestinal fluoroscopic study revealed multiple strictures from the middle to lower portions of the small intestine. We determined that these strictures might cause intestinal obstruction, and then a partial resection of the small intestine including the narrowing portions was carried out. In determining the extent of surgical resection of the narrowing portions, intraoperative endoscopy was very helpful. From overall interpretation of macroscopic findings, clinical symptoms and histopathological findings, non-specific multiple ulcer of the small intestine was diagnosed. The patient's postoperative course was uneventful and there have been no episodes of intestinal obstruction for approximately one year after surgery. However, further careful observation of his clinical course would be required to rule out another probable diagnosis of intestinal tuberculosis or Crohn's disease and then to establish the definite diagnosis of the disease.

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A 66-year-old man complaining of dyspnea and anal bleeding was referred to the department of internal medicine in our hospital with a suspicion of lung cancer. The patient was diagnosed as having lung cancer by transbronchial lung biopsy and was scheduled to be operated on. However, his anemia progressed and small intestinal fluoroscopic study offered a suspicion of a tumor of the small intestine. The patient was thus transferred to the department of surgery, and underwent laparotomy with a suspicion of metastatic tumor of the small intestine from lung cancer of primary small intestinal tumor. Upon laparotomy, the tumor was present in the jejunum and partial excision of the small intestine was carried out. The histopathological diagnosis was Ki-1 lymphoma. This was a rare case of lung cancer associated with lymphoma, especially a special histological type of Ki-1 lymphoma. Therapeutic methods for the disease have not been established as yet so that further close observation of his clinical course would be mandatory.

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A case of carcinoma of the ileum with intussusception is very rare.
A 64-year-old man admitted for right lower abdominal pain and vomiting was diagnosed with a tumor of the ileum with intussusception by colonoscopy, abdominal ultrasonography, and barium enema. Surgery showed a type I elevated tumor 20 cm from Bauhin's valve associated with intussesception into the ascending colon. We conducted ileocecal resection with lymph node dlssection. The tumor was histologically diagnosed as well differentiated adenocarcinoma. No problem has been observed in the 36 months since surgery.

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A 78-year-old man was found having a solid tumor 6 cm in diameter in the left lower abdomen by abdominal CT scan. Gastrointestinal fluoroscopic study revealed displacement of the small intestine, but no passage disturbance was present. Angiography showed accumulation of contrast material fed by jejunal branch of the superior mesenteric artery. With a probable diagnosis of a submucosal tumor of the small intestine or a mesenteric tumor, laparotomy was performed. At laparotomy, a tumor was present in the jejunal mesentery, about 100 cm distal from the Treitz' ligament, and a partial jejunectomy was carried out because the tumor involved a part of the jejunum. The removed tumor was 8×7×4 cm in dimension and no abnormal findings were seen on the mucosa of the jejunum. Histopathologic studies revealed that the tumor had grown as it had been adjacent to the proper muscle of the jejunum, its margin was encapsulated with subserous structure and serosa of the jejunum, and the tumor was originated from inside of the jejunal wall. HE staining showed proliferation of eosinophilic spindle-shaped cells which arranged in short curving fascicles with intarlacing pattern. On immunostainings, the tumor was strongly positive for c-kit protein, weakly positive for CD34, positive for S100 protein, and negative for α-SMA. From these findings, the case was diagnosed as extratubally growing gastrointestinal stromal tumor (GIST) of neural type of the jejunum.

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A 43-year-old man was seen at the hospital because of right lower abdominal pain. Abdominal CT scan showed mild swelling of the appendix and air in the vicinity of the appendix. With the most likely diagnosis of penetration of acute appendicitis into appendiceal mesentery or diverticulitis of the appendix, surgery was performed on the same day. During surgery, purulent ascites around the appendix and the slightly swollen appendix were noted. And redness and hypertrophy of the appendiceal mesentery were seen. Appendectomy was carried out. On the resected material, fecalith was identified near the root of appendix, and deverticulum was present on the mesentery side of the appendix. Histopathologically the appendiceal diverticulum was true diverticulum in which the proper muscular layer was kept intact. Perforation was identified in a part of the diverticulum, with abscess formation around it, so that diverticulitis of the appendix was definitely diagnosed.
Diverticulosis of the appendix is a relatively uncommon entity. Clinically it can perforate in a high frequency, and it poses the problem of indicating surgery if the disease is detected in asymptomatic subjects. If perforation once occurs to develop inflammation, serious complications are often associated. Strict care must be exercised for asymptomatic patients as well as those who are suspected to have inflammation.

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A 53-year-old man, who had lived in the institute for intellectually handicapped people for infantile psychosomatic disorder, was seen at the emergency clinic in our hospital because of appetite loss, vomiting and abdominal pain lasting for two days. His abdomen was markedly distended with tenderness and he seemed to be suffering from abdominal pain. Abdominal plain X-ray film showed coffee beans sign and abdominal CT scan revealed findings of Chilaiditi syndrome. He was diagnosed as having volvulus of the sigmoid colon. Non-operative treatment using colonoscopy was successful to releave the volvulus. However, the strangulated sigmoid colon had already necrotized, and a Haltmann's operation was urgently performed. On the 75th day after the first operation, the anastomosis of the descending colon with the rectum was performed, and the patient returned to the institution. Volvulus of the sigmoid colon is reported to occur commonly in people with infantile psychosomatic disorder. In making the diagnosis and selecting the therapeutic plan and operative procedures for them, the extent of intellectual handicaps which differ at every patient must be considered.

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We report a case of fulminant amebic colitis with colon perforation. A 72-year-old man was admitted for bloody mucous diarrhea and of suspected ulcerative colitis experienced progressive abdominal pain and bloody diarrhea on hospital day 6. He was diagnosed with peritonitis from perforation based on abdominal CT. As amoebic cells were found from biopsy of the colon, we diagnosed perforation of amebic colitis, and conducted emergency surgery. The sigmoid colon and rectum were necrotic in a broad spectrum, So we resected the necrotic colon and conducted a colostomy. Metronidazole was administered on postoperative day (POD) 3. He attained remission without recurrence of amebic colitis. Amebic colitis is increasing and is difficult to diagnose. The mortality for fulminant amebic colitis is high and minimally invasive surgery should be done and antiamebic drugs administered as soon as possible.

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A 66-year-old woman was seen at the emergency department in our hospital because of nausea and left lower abdominal pain. An abdominal plain X-ray film showed the distended transverse colon, gas accumulation in the small intestine, and a calcified shadow of pproximately 5cm in diameter corresponding to the site of the pain. Abdominal CT scan demonstrated a calcified, laminated intestinal stone of approximately 5cm in diameter in the descending colon. On gastrografin enema examination, gastrografin failed to flow in the intestine proximal to the stone in the descending colon, and the abdominal pain persisted. Colonic obstruction from intestinal calculus was thus diagnosed, and emergency surgery was performed. Laparotomy revealed a hard, palpable intestinal stone. The intestine proximal to the stone was distended. We incised the descending colon, and removed the stone. It measured 6×6×5cm, was spherical and hard, and had a dark-brown, rough surface. On sectioning, the stone contained many grayish-white stones of approximately 5mm in diameter in the laminated structure. Chemical analysis showed that the stone was composed of 88% fatty acid calcium and 12% calcium phosphate. We speculate that chronic constipation and a long history of ingestion of calcium carbonate might contribute to formation of the intestinal stone.

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A 73-year-old woman was admitted to the hospital because of discomfort after defecation and stools with slime and blood-streaking. Rectal cancer was the most likely diagnosis clinically, but no definite diagnosis of rectal cancer could be achieved even by four times of biopsies. To improve the patient's quality of life, only stoma was created. Thereafter the patient's disease progressed to its termination, and extramurally growing rectal cancer was definitely diagnosed at autopsy.
Colorectal cancer which exhibits the progressive pattern of forming a tumor extramurally has been reported in 25 cases in Japan. Of these 25 cases, only three cases were of rectal cancer, but the presence of such cases showing the special growing pattern like in this case must be kept in mind and deal with.

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A 71-year-old man undergone a right upper lobectomy for lung cancer one year earlier was found to have a tumor on the surface of the liver (S6) with abdominal echography and CT scan which were conducted for the purpose of postoperative systemic exploration. Primary or metastatic hepatic tumor was suspected. Since the tumor was present close to the surface of the liver, laparoscopic surgery was carried out. When the hepatocolic ligament was dissected and the liver was elevated cranially, a white tumor was identified on the dorsal aspect of the liver. The tumor was fixed to the surrounding tissues with rough connective tissue, but the tumor was easily removed by cutting these tissues. The removed tumor was 30 mm × 25 mm × 16 mm in dimension, 10 g in weight, and milky white in color and had a smooth surface. Histologically its center was composed of necrotic tissue with small chambers, which was inferred to be fatty tissue, and was surrounded by hyalinized fibrous tissue.

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An 86-year-old woman was admitted to the hospital because of periumbilical pain and abdominal distension, and, on the same day of admission, she was operated on with a suspicion of peritonitis and strangulated ileus. At surgery, retention of small quantities of purulent fluid was noted in the abdominal cavity, but no abnormalities were seen in the gastrointestinal tract. A hepatic cyst with fur was found in the S4 of the liver, and purulent fluid was aspirated by puncture of the cyst. From these findings, we diagnosed the case as paralytic ileus due to peritonitis associated with the infectious hepatic cyst, and performed drainage of the hepatic cyst and abdomen. Culture of the cystic fluid and ascites yielded only Klebsiella oxytoca. Fluoroscopic study of the cyst performed after surgery showed communication with the bile duct. The cyst became small and bacterial test gave negative result with infusion therapy with minocycline hydrochloride and intracystic drainage and irrigation. The patient was discharged from the hospital on the 73^rd hospital day. There have been no signs of increasing tendency in the cystic diameter up to now and the patient is followed in the outpatient's clinic.

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A 48-year-old man who showed HBs antigen positive and high level of AFP was found to have a 3cm sized tumor in the left hepatic duct and dilatation of the left intrahepatic bile duct. On close exploration, either of hepatocellular carcinoma grown in the bile duct and bile duct cancer was likely. Surgical operation was scheduled, but the patient developed acute abdomen. Percutaneous transhepatic gallbladder drainage (PTGBD) disclosed bloody bile juice, and we thought that bleeding from the tumor in the bile duct might occur. Later, left lobectomy of the liver and choledochectomy were performed, when a tumor 2 cm in diameter was present in the S2, from which cancer cells invaded inside the bile duct to form a papillary growth 5 cm in diameter which obstructed the left hepatic duct. Histological diagnosis was hepatocellular carcinoma. It was etiologically thought that the hepatocellular carcinoma had invaded the bile duct to grow in it and the resultant tumor necrosis caused biliary bleeding.
Since invasion and growth of hepatocellular carcinoma in the bile duct and the resultant biliary bleeding are comparatively rare, this case is presented together with a review of the literature.

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Hepatic resection is thought to be the most curative treatment for hepatocellular carcinoma (HCC), but some HCC patients are not candidates for resection due to the limited hepatic reserve secondary to cirrhosis. For such unresctable patients we started to conduct laparoscopic and thoracoscopic guidance microwave coagulo-necrotic therapy (MCT) since 1991, and employed radiofrequency ablation therapy (RFA) which provides wider therapeutic area, in 1998. Usually, MCT and RFA are considered reasonable alternative for patients with 3 or fewer tumors that are less than 3cm in diameter. On the other hand, separate lesions which consist of early HCC of the well-differentiated type, or which imply tumors of moderately and/or poorly differentiated HCC that have a margin of well-differentiated HCC, can each be considered to have originated in separate sites (multicentric occurrence). We report a case of multicentric occurrence of HCC of the bilateral lobes treated successfully with RFA combined with laparoscopic and small incisional approach using 2 types of ultrasound devices to preserve less invasive surgery.

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We experienced a surgical case of cancer of the lower bile duct with stricture of the intrahepatic bile duct which was difficult to distinguish between benign and malignant stricture preoperatively.
A 70-year-old man who visited another hospital because of fever showed elevated serum total bilirubin, alkaline phosphatase, γ-glutamyltranspeptidase, and serum amylase concentrations. Cholan-giograms showed severe narrowings at the lower bile duct and left intrahepatic bile duct. The cytology of the bile resulted in class IV, and the most likely diagnosis was adenocarcinoma. With a diagnosis of lower bile duct cancer and suspicion of left intrahepatic cholangiocarcinoma, pancreaticoduodenectomy and left hepatectomy with lymph node dissection were performed en bloc. The resected specimen grossly showed a tumor of the lower bile duct. The mucosa of the intrahepatic bile duct was smooth and showed no evidence of neoplastic change. Neither gallstone nor biliary sludge was seen. Microscopically, moderately differentiated adenocarcinoma was seen in the lower bile duct, and fibrosis and inflammation without neoplastic change were localized in the intrahepatic bile duct. When more than two narrowed areas are present in the bile duct, e. g., in the lower and intrahepatic bile duct, the diagnosis and treatment should be considered on a case-by-case basis.

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A 75-year-old man was admitted for the treatment of obstructive jaundice in July 1996 and was subsequently diagnosed as having a bile duct carcinoma. The patient underwent a radical bile duct resection with portal resection in August 1996. Pathological diagnosis revealed a moderately differentiated tubular adenocarcinoma, stage III. The left cervical lymph nodes gradually became swollen, and a tumorectomy was performed 10 months later. Pathological examination revealed a metastases of the bile duct carcinoma. The patient underwent two subsequent tumorectomies for left axillary lymph node swelling, 24 and 32 months later. The surgical specimens were identified as pathologically identical metastases of the bile duct carcinoma. The patient remains disease-free 7 years after undergoing the initial bile duct resection. The prognosis of patients with advanced bile duct carcinoma, especially those with lymph node metastases, is considered to be poor. Herein, we report the rare case of a 7-year longterm survivor who received 3 tumorectomies for distant lymph node metastases after an initial operation for advanced middle bile duct carcinoma.

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A 45-year-old man complaining of upper abdominal pain was referred to the hospital because of ileus and pleural effusion occurred during hospitalization for the treatment of acute aggravation of chronic pancreatitis elsewhere. From physical examination and various laboratory data, pancreatic pleural effusion with strangulated ileus was diagnosed, and an emergency operation was carried out. At surgery a partial excision of the jejunum strangulated and excision of the pancreas tail and splenectomy were performed on the one-step approach. The patient's postoperative course was uneventful, and the patient was discharged from the hospital on the 27^th postoperative day. No recurrence of pleural effusion has occurred, as of one year after the operation.
In this case we simultaneously performed the surgery for pancreatic pleural effusion, which can surely offer radical therapy in a short time, along with surgery for ileus, because the patient's general condition was stable and local findings were favorable.

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A 34-year-old man complaining of abdominal pain, who had been a hard drinker, was diagnosed as having chronic pancreatitis elsewhere in 1995, and thereafter he had bouts of abdominal pain. In November 2002, he was admitted to the department of internal medicine in our hospital because of acute relapsing pancreatitis. Abdominal CT scan revealed localized calcification on the ventrum of the pancreas head, and pancreas divisum was diagnosed by ERP. From these findings, chronic ventral pancreatitis due to pancreas divisum was suspected, and pylorus preserving pancreaticoduodenectomy was performed in the department of surgery. Pancreatogram of the resected specimen confirmed the diagnosis of complete pancreas divisum. Histologically, the ventral pancreas had pancreatolithiasis and chronic pancreatitis, but they dorsal pancreas was normal. After surgery, the patient has been free from abdominal pain and recurrent pancreatitis. Pancreas divisum usually causes dorsal pancreatitis. Ventral pancreatitis is very rare and our case is interesting from the etiological standpoint.

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We report a case of traumatic pseudocyst of the pancreas with a unique clinical course.
A 4-year-old girl underwent an emergency laparotomy for intraabdominal bleeding on October 5, 2002, which was diagnosed as rupture of pancreatic pseudocysts due to bruising on the abdomen. One month later, she complained of abdominal pain. Abdominal CT scan revealed a recurred pancreatic pseudocyst. The cyst disappeared with conservative treatment. Thereafter we observed that she had frequently got bruises on the abdomen, but no recurrence had occurred. Nine months after the operation, she readmitted to the hospital because of persisting abdominal pain and vomiting. The laboratory data showed inflammation, but her serum AMY level was within normal limits (84IU/l). A plain abdominal X-ray film showed a deformity in the greater curvature of the stomach. Abdominal CT scan and ultrasonic findings revealed two demarcated cysts (5×5×7cm and 4×3×4cm in dimension) behind the stomach. These cysts were diagnosed as recurred pancreatic pseudocysts. Despite conservative therapy for 4 weeks, the cysts did not change in size. Therefore, a cystjejunostomy using the Roux-en-Y method was performed. The postoperative course was uneventful. On the 8th day after the operation, disappearance of the cysts was confirmed on abdominal CT scan. There have been no signs of recurrence as of 11 months after the second operation.

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Major pancreatectomy was performed in three patients with branched type intraductal papillary mucinous tumor (IPMT) of the pancreas for preoperatively diagnosed parenchymal invasion. Patient 1, 2, and 3 had been followed every 6 months after diagnosed as having branch duct type IPMT until recent detection of parenchymal invasion, when about 4 years, 1.5 years, and 15 years had elapsed in patient 1, 2, and 3, respectively. A tumor invading the common bile duct was found in patient 1 and 2, and a tumor invading the pancreas body was found in patient 3. Pancreatoduodenectomy and total pancreatectomy were performed in patient 1 and 2 respectively. Total pancreatectomy accompanied with total resection of the gastric remnant was done in patient 3. Histologically all of three tumors were diagnosed as invasive carcinoma derived from IPMT. There are some cases of IPMT invading the parenchyma during the follow-up period like in this case. In following cases of benign IPMT after diagnosis, careful observation of not only the entire pancreas but also the neighboring organs would be requied.

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We experienced the case of a solitary splenic metastasis from a sigmoid colon cancer. The patient was a 61-year-old woman who had undergone a laparoscope-assisted sigmoid colon resection for cancer of the sigmoid colon in June 1998. The patient's postoperative course was uneventful, but her serum CEA level increased 54 months after the operation and a splenic metastasis was revealed by CT&MRI studies. A laparoscope-assisted splenectomy was performed, based on a diagnosis of a solitary splenic metastasis, in January 2003. Pathological examination showed the resected tumor to be a moderately differentiated adenocarcinoma. The patient's postoperative course was uneventful, and her serum CEA level normalized. No signs of recurrence have been observed 15 months after the splenectomy. This case is the 28th report of a metachronous solitary splenic metastasis arising from colon cancer to be reported in Japan.

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We have experienced a patient with superior mesenteric venous thrombosis, who had been followed for liver cirrhosis. A 56-year-old man was admitted to the hospital because of acute lower abdominal pain lasting for this morning. An abdominal contrast enhanced CT scan showed superior mesenteric venous thrombosis and massive edema of the mesenterium. Under a diagnosis of superior mesenteric venous thrombosis, an emergency operation was performed 6 hours after the onset of the symptom. At this operation, we admitted hemorrhagic ascites and necrosis of the small intestine, extending about 120cm in length from a point 15cm proximal to the ileocecal region. We removed the thrombus in the mesenteric vein, resected the necrotic segment of the small bowel (total 150cm) including a probably normal part, and performed end-to-end anastmosis. Anticoagulation therapy with heparin was done for 5 days after the operation. On the 7th postoperative day, an abdominal contrast enhanced CT scan showed contraction of the thrombus in the mesenteric vein and expansion of the lumen. No development of thrombus was recognized. The patient recovered and was discharged from the hospital on the 29th postoperative day. There have been no signs of recurrence as of 27 months after the operation. It is important to resect a necrotic segment of the small bowel including a part which seems normal, because thrombus can remain in the veins of the seemingly normal bowel.

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A 52-year-old woman with a history of undergoing an appendectomy for appendicitis was admitted to the hospital because of lower abdominal pain. Four days after a simple hysterectomy for myoma uteri, lower abdominal pain and vomiting developed. Ileus was diagnosed with plain abdominal X-ray examination and initial treatment with conventional medical management was unsuccessful. Surgical operation was performed under the diagnosis of adhesive intestinal obstruction, because severe narrowing in the ileum was discovered by an ileus tube-assisted contrast enema X-ray examination. Since the greater omentum, which had adhered to the ileocecum, formed a tumor involving the ileum in the abdominal cavity the ileocecum including the tumor was excised. Histologically, panniculitis concentrated on the silk threads, and diffused fibrosis with foreign-body giant cells were observed in the tumor of the greater omentum. The patient was discharged from the hospital on the 28th day after the operation. We present the case of ileus caused by an inflammatory tumor of the greater omentum (Braun tumor) which might have originated from ligation threads as the core that was histopathologically verified, together with some bibliographical comments.

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We report a case of spontaneous pneumoperitoneum, which is a relatively rare entity, in an adult.
A 78-year-old woman with a previous history of undergoing surgery for a dissecting aneurysm of the aortic arch in 1996 developed abdominal pain after defecation on October 30, 2002. Then the abdominal pain subsided, but abdominal distention persisted and nausea appeared, so that she was seen at the emergency clinic in our hospital on November 1. When she was first seen, abdominal pain and tenderness were present over the abdomen, but no rebound tenderness and muscle guarding were present. On hematological study, accelerated inflammatory reaction and anemia were noted. Imaging studies revealed intraabdominal free air and retension of ascites. From these findings the patient was operated on with a diagnosis of gastrointestinal perforation and peritonitis. Surgical exploration disclosed no apparent causative findings such as perforated portion. Spontaneous pneumoperitoneum was thus diagnosed, and the operation was terminated after placement of a drain. The patient's postoperative course was uneventful and she was discharged from the hospital on the 29^th postoperative day. Postoperative close exploration showed no abnormalities in the gut other than gastric ulcer.

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