This study was made to clarify the usefulness of POSSUM Score as the risk assessment of gastrointestinal surgeries in the elderly. A series of 251 elderly patients over 80 years operated on under general anesthesia in the hospital from 1996 to 2003 were enrolled. They were divided into two groups with (n=88) or without (n=163) postoperative complications, and comparatively studied for preoperative factors, hematological data, surgical factors, and POSSUM. As a result, there were statisticall significant differences (<0.001) in the following seven items; white blood cell count, emergency operation, peritonitis, and four POSSUM items involving physiological score (PS), operative severity score (OS), predicted mortality rate, and predicted morbidity rate. When ‘high risk’ was designated as PS 25 or more, the incidence rate of postoperative complications was 70% (45/64) in the high risk group, which was significantly higher than that in the low risk group (23%; 43/187).
It is concluded that the POSSUM score is useful as an indicator for the risk assessment of gastrointestinal surgeries in elderly patients. High risk group in terms of the incidence rate of postoperative complications can be assessed based on preoperative PS.

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In patients with mental disorders, psychic symptoms as well as effects of antipsychotic drugs may mask the symptoms and signs of physical disorders which they have and impede the early diagnosis. As for acute appendicitis, not a few patients with mental disorders visit a surgeon, when the symptoms of the disease are greatly modified due to delayed diagnoses. Clinical and pathological findings were studied in eighty patients with mental disorders who underwent operations for acute appendicitis in Tokyo Metropolitan Matsuzawa Hospital (the mental group). Ninety-five patients without mental disorders undergone operations for acute appendicitis in Yuai Hospital were served as control (the control group). Although right-lower abdominal pain was the most predominant symptom in both groups, patients of the mental group showed more variegated symptoms than the control. The ailing period between the onset of appendicitis and operation was longer in the former group than in the latter. General anesthesia was used for the operation more frequently in the mental group. The median or paramedian incision was selected for laparotomy more often in this group. The incidences of the postoperative complications were also higher in the mental group probably due to the delayed diagnosis. A careful and constant observation would be necessary for the early detection of the physical disorders in patients with mental disorders who can not tell others their abnormalities.

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We microscopically investigated tissues extracted from external through internal orifice of anal fistulae, categorized with 7 tracts with extended abscess cavity, 36 fistulous tracts with abscess, 25 fistulous tracts without abscess and 21 cicatrized fistulae. Anal glands were detected in 60% in these resected fistulous tissues and were compared with anal glands from 19 operated hemorrhoids as a control. The subjected anal glands were constructed with columnar epitherium and/or squamous epitherial metaplasia. In the tracts with extended abscess cavity, and fistulae with or without abscess, size of columnar cells and outside and inside diameters of columnar epitherial ducts were significantly greater than those of the control. In the squamous metaplastic anal glands, outside diameter of the ducts was significantly larger in the tracts of extended abscess cavity and fistulae with abscess than those of the control. Proportion of squamous epitherial glands was increased in the cicatrized anal fistulae. It is speculated that, in cryptglandular origin, anal fistulae are formed by repeated infection causing fecal contents trespassing through the enlarged columnar epitherial anal glands. Anal ducts are closed by metaplastic squamous epithelium, and subsequently, inflammation is ceased by preventing the invasion of faeces. Conversely, abscess expands into the surrounding adipose tissue by affecting inflammation.

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A retrospective study on the diagnosis and treatment for pancreatic trauma was carried out. From 1994 to 2001, a total of 13 cases of pancreatic trauma were treated that represented 5.9% of all cases of abdominal trauma in the hospital. Twelve cases of them were of blunt injury, and nine (69.2%) of them were of traffic accident. Eleven cases (84.6%) of them had other organ injuries, and the liver (seven cases; 53.8%) was the most frequently injured organ. Diagnosis was mede by present illness, abdominal physical findings, the change in serum amylase level and CT findings. Among them, the sequential elevation in serum amylase level was useful for making the diagnosis, and positive rate of abdominal CT findings was 53.8%. Six patients were treated conservatively, the other seven were operated on, and one patient died of hypovolemic shock before converting to operation. Postoperative complications occurred in three (42.9%), but all of them were treated conservatively and we had no postoperative death.
We think that the precise pre-and intra-operative estimation of injured type of pancreas, best selection of operative procedure according to the patient's general condition and local findings, and adequate postoperative management are important for patients with traumatic pancreas injury.

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We report a case of toxic shock like syndrome presented with peritoneal sign.
A 67-year-old woman was seen at the emergency clinic in our hospital because of abdominal pain. There were abdominal tenderness and muscular rigidity in the entire abdomen. Laboratory data showed a significantly elevated CRP level and metabolic acidosis. Emergency laparotomy was performed under a diagnosis of panperitonitis. Since operative findings revealed only turbid ascites without other pathological findings, drainage tubes were placed. She was managed in the intensive care unit because of high fever, respiratory and renal failure in the early postoperative course. Streptococcus was isolated from the blood culture on the third postoperative day. She was diagnosed as having toxic shock like syndrome. Despite administration of antibiotics and immunoglobulin, as well as performance of PMXDHP (hemoperfusion with polymyxin Bimmobilized fiber) and CHDF (continuous hemodiafiltration), she died from multiple organ failure on the 11^th postoperativeday.
It is rare that toxic shock like syndrome presents with acute abdomen and demands laparotomy. So far only four such cases have been reported in Japan and this is the fifth case.

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A 71-year-old woman who underwent extended total resection of the right parotid gland for right parotid gland cancer (adenoid cystic carcinoma) in 1994 was found to have a giant liver tumor, about 10 cm in diameter, by ultrasonography (US) in 1998. No local recurrence or distant metastasis had occurred for these 4 years. Abdominal computed tomograpy (CT) showed the liver tumor, through which the portal branch passed. Doppler US showed spoke-wheel-like blood flow, and we suspected the possibility of focal nodular hyperplasia (FNH). Biopsy yielded a diagnosis of liver metastasis of parotid gland cancer, and she underwent extended right lobectomy of the liver. In 2003 after an uneventful postoperative course, US showed intraperitoneal tumors and a small liver metastatic tumor. Laparotomy revealed severe peritoneal dissemination of parotid gland cancer, and these were unresectable. Considering the characteristic of parotid gland cancer that may metastasize to the distant sites long after resection, we need careful long-term follow-up for these patients.

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A 43-year-old woman, who was pointed out a tumor in the anterior cervical region at a mass screening, was diagnosed as having a thyroid tumor with calcification and underwent surgery. During surgery, a restiform matter continuing to the inferior horn of thyroid cartilage from the thyroid tumor was found. It was diagnosed as piriform sinus fistula. As much of the restiform matter as possible was separated with ligation from the oral side, and extracted along with the tumor. After surgery, an esophageal transillumination demonstrated no apparent fistula.
Piriform sinus fistula is a disease which usually presents with a cervical abscess during childhood. To the best of our knowledge, this case in which the fistula had been asymptomatic and was detected in adulthood is the first one in Japan. When a restiform matter continuing from a thyroid tumor is uncovered, as was observed in this case, the possibility of this disease should always be considered. It is considered necessary to ensure the closure of the fistula in order to prevent a cervical abscess after surgery.

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Ductal adenoma of the breast is a rare disease and is often mistaken for carcinoma clinically and pathologically. We recently treated a case of ductal adenoma of the breast forming an intracystic papilloma, which was difficult to diagnose. A 66-year-old woman was referred to the hospital because of a right breast tumor 7×5 cm in diameter with nipple retruction. Mammography and ultrasonography showed an intracystic papilloma with linear calcifications. A core needle biopsy revealed a suspicion of apocrine carcinoma (class V), which was confirmed to be HER2 positive by Herceptest showing 2+ staining and Estrogen receptor (ER) positive using the EIA method. After getting informed consent, we performed modified simple mastectomy. Histologically, the tumor was composed of proliferation of tubular adenomatous part surrouded by sclerotic fibrous lesion. Pseudoinvasion and apocrine metaplasia were also found within the tumor. The tubules of the tumor were lined with epithelial cells and surrouding myoepithelial cells. The tumor was definitaly diagnosed as ductal adenoma of the breast. Although the clinical diagnosis of ductal adenoma is very difficult, it is important not to overdiagnose it as carcinoma and to consider this as an initial diagnosis.

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We report here a rare case of osteosarcoma with fibroadenoma of the breast. A 56-year-old woman was admitted to the hospital because of a rapidly growing tumor in her left breast. On physical examination, a hard multilobular tumor measuring 6×6cm with well-circumscribed margin was detected in the inner half of the left breast. Mammography revealed both an irregular heterogeneous tumor with an acoustic shadow and an anechoic area, and a regular homogeneous tumor which was adjacent to the irregular tumor. Fine needle aspiration cytology suggested that the tumor was malignant. Intraoperative frozen section diagnosis was metaplastic carcinoma with cartilaginous differentiation typical of chondroma. Mastectomy with lymph node dissection was carried out. Pathologically, the tumors were diagnosed as osteosarcoma and fibroadenoma. As of one year after the surgery, there have been no recurrence and metastasis.

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We report a case of apocrine ductal carcinoma in situ of the breast, for which we could foresee an extensive intraductal spread by dynamic magnetic resonance imaging (MRI) of the breast.
A 47-year-old woman diagnosed as having apocrine ductal carcinoma in situ of the left breast after excisional biopsy for a 1-cm breast tumor at another hospital was referred to the hospital. On dynamic MRI of the left breast an extensive intraductal spread was suspected, though there were no specific mammographical and ultrasonographical findings. After nipple preserving total glandectomy, the definite histological diagnosis was obtained as apocrine ductal carcinoma in situ with quite extensive intraductal spread in accordance with the enhanced lesions in MRI. So far 16 cases of ductal carcinoma in situ with apocrine metaplasia, including this case, have been reported in the Japanese literature, but the disease has not been defined in the General Rules for Clinical and Pathological Recording of Breast Cancer, the Japanese Breast Cancer Society. Since there is no report describing dynamic MRI findings in diagnosing this disease, this case is supposed to be valuable.

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Impregnated graft is frequently used for operations of the large vessels and the usefulness is known to everybody, however, it entails a risk of causing serious inflammatory reaction after surgery. This inflammatory reaction presents difficulties in differentiation from graft infection and can impede postoperative management by physical effects due to exudates of plasma components and pleural effusion. We report two cases of severe inflammatory reactions caused by an impregnated graft after total aortic arch replacement. Case 1: A 77-year-old woman suffered from left prolonged pleural effusion for four weeks since the 15th postoperative day. Because the pleural effusion seemed to be transudate and caused declines of serum albumin and electrolytes, recruitment of these was needed for improvement of the patient's general condition. Case 2: A 70-year-old man with severe chronic pulmonary emphysema had an uneventful postoperative course, however, on the 9th postoperative day, went into cardiac tamponade in several hours. We performed an emergency operation to save the life of the patient when we found a little effusion in the cardiac sac. It was clarified that the effusion was aseptic and resulted from inflammatory reaction due to an impregnated graft. In a condition that a capacity of the pericardial sac was reduced by chronic pulmonary emphysema, only a little fluid might cause a repid progress of cardiac tamponade.

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Five cases of MALT lymphoma of the lung performed surgical resection were reviewed in special reference to CT findings and prognosis. There were two male and three female patients whose ages ranged from 50 to 77 years. All patients were asymptomatic. On CT images a consolidation with air-bronchogram was seen in four cases, and CT angiogram sign was also recognized in two of the four cases. Homogeneous nodular consolidation with clear margin was seen in the residual one case. All patients underwent complete resection with negative margins, and received no adjuvant chemotherapy. Eightynine months after the resection, one patient died of unrelated cause without recurrence. At the time of last follow-up, three patients were alive and well without any signs of recurrence for 48, 58, and 82 months after the operation, respectively. The remaining one patient had recurrence in the contralateral lung and celiac lymph node at 55 months after the operation. She received chemotherapy, and is alive, as of 67 months after the resection.

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Esophageal cancer rarely metastasizes to the small intestine. We present a case of squamous cell carcinoma of the esophagus causing intestinal obstruction due to small intestinal metastasis, in which stricture of the cervical esophagus was treated by insertion of a stainless stent.
A 62-year-old man presented with difficulty in swallowing, and was found to have esophageal cancer type 3 in the intrathoracic upper third of the esophagus (Ut). Multiple pulmonary and mediastinal lymph node metastases were identified. We diagnosed the case as esophageal cancer in stage IVb and conducted chemotherapy. Four months later he was seen at the outpatient clinic because of repeated bouts of vomiting and was emergently admitted to the hospital with a diagnosis of intestinal obstruction. Because of his previous history of undergoing appendectomy, he was diagnosed as having intestinal obstruction due to adhesions and placed an ileus tube. Laparoscopic adhesiotomy disclosed a tumorous lesion in the small intestine, so that small bowel resection under laparotomy was performed and small bowel metastasis of esophageal cancer was diagnosed. Thereafter a stainless stent was inserted into the stricture of the cervical esophagus. This paper deals with the case with a review of the literature.

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We report a case of gastrointestinal stromal tumor (GIST) of the stomach with an adenoma of the parathyroid. A 68-year-old man was admitted to the hospital because of low grade anemia. A submucosal tumor of about 4 cm in diameter situated in the gastric fornix was discovered by upper gastrointestinal endoscopy. Since he also had hypercalcemia and hyperparathyroinizum, we searched the origin of the hypercalcemia, and recognized a swelling of the parathyroid. A local excision of the stomach with fundplication was performed, and one month later parathyroidectomy was performed. Histologically, the parathyroid tumor was an adenoma. The gastric tumor was a submucosal tumor with central delle and consisted of proliferation of spindle-shaped neoplastic cells with rather in frequent mitotic figures (3 mitoses per 10 high-power fields). Immunohistochemically, the neoplastic cells displayed diffuse positive reactions to antibodies CD34, c-kit, Desmin, α-SMA and S-100. The frequency of positive reaction with antibody ki-67 was less than 5% in the tumor. The gastric tumor was therefore inferred to be GIST of the combined smooth neuroral-muscular type with low grade malignancy. The patient's postoperative course was excellent, and now he is followed in the outpatient clinic at our hospital without recurrence or metastasis of the tumor. There have been no reports on GIST associated with adenoma of the parathyroid. So this case is presented here because it is thought to be valuable, though no etiological relation between the both diseases is obscure.

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A 70-year-old man was admitted to the hospital because of leukocytosis, gastric cancer (wide spread OIIa) at the angular notch and gastric ulcer (H1 stage) at the posterior wall of the upper body of the stomach. The white cell count was 20, 500/μl with 78% lymphocytes and these were identified as B cells. Hematologic analysis led to the diagnosis of B cell type chronic lymphocytic leukemia (CLL). Total gastrectomy was performed. It was early gastric cancer (type OIIa+IIc, sm2, por2+sig) and had no lymph nodes involvement. Moreover, in part of gastric ulcer marked lymphocyte infiltration was noticed from the submucosal to subserosal layers and B cell type CLL was identified.
In Japan CLL occurs in a low frequency, but the frequency of associating with cancer is high. Cases of CLL associated with cancer are so few that only 37 cases have been reported after 1965 in the Japanese literature except our case. Gastric cancer is the predominant second cancer. As for cell type of CLL, B cell is more (19 cases) than T cell (7 cases). Gastrointestinal involement of CLL is rarely encountered and our case is the 9th in the literature.

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A 54-year-old man complaing of epigastralgia and pyrosis since September 2001 was referred to the hospital because upper gastrointestinal endoscopy revealed a huge tumor on the antrum at another hospital. Physical examination revealed gynecomastia, and blood test showed high level of serum HCG, 13, 400. Upper GI series and gastrointestinal endoscopy visualized a huge gastric tumor with ulcer formation located from the posterior wall to the greater curvature of the antrum. Abdominal CT scan demonstrated extra-gastric extension, multiple lymph nodes metastasis and multiple liver metastasis. He was diagnosed as having primary gastric choriocarcinoma and was not a candidate for a curative operation, so chemotherapy with TS-1 was started. But the multiple liver metastasis rapidly grew and the patient died on January 5, 2002. Choriocarcinoma can present gynecomastia because chorionic gonadotrophin is elevated in blood. It is highly malignant and curative resection is often impossible when it is detected. HCG-producing tumor must be kept in mind as a differential diagnosis in treating patients who have gynecomastia of unknown origin.

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An 83-year-old woman was admitted to the hospital because of watery diarrhea and vomiting. Endoscopic study of the stomach revealed a Borrmann type 2 tumor with a deep ulcerative lesion on the greater curvature of gastric antrum. Biopsy of the lesion revealed poorly differentiated adenocarcinoma. Distal gastrectomy with regional lymph nodes dissection was performed. Histopathologic examination disclosed squamous cell carcinoma, and no adenocarcinomatous component was found in all sections. Squamous cell carcinoma of the stomach is very rare and this is an intringuing case in the carcinogenesis.

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We present a case of right paraduodenal hernia diagnosed before surgery. A 32-year-old man was admitted to the hospital because of epigastralgia. Laboratory data showed the white blood cell count of 10, 600/μl. But other blood biochemical data were within the normal ranges including liver, muscle and renal functions. There was distention with tenderness in the upper abdomen, but no peritoneal signs were present. He had experienced the same symptoms at the age of 28 when the symptoms disappeared with hospitalization and treatment for several days. Abdominal plain roentgenogram demonstrated the right-side colon pushed out to the lower wall of liver. Enhanced computed tomography (CT) of the abdomen showed a 12-cm mass of the small intestine at medial side of the ascending colon and dorsal aspect of the transverse colon. It was thought that this mass was formed because the small intestine had penetrated through the dorsal aspect of superior mesenteric artery into the right retroperitneal space. So we diagnosed the case as right paraduodenal hernia and an emergency operation was performed. A 150-cm portion of the proximal jejunum penetrated into the right retroperitneal space through the caudal side of the ascending portion of the duodenum. Because this jejunum had no ischemic change after manual reduction, we only sutured the hernial orifice. He improved despite paresis of intestine and was discharged from the hospital on the 48th day after the operation.
Generally, paraduodenal hernia is difficult to diagnose before operation. In our case, we could diagnose before the operation based on subjective, and objective symptoms, X-ray and CT findings typical of this disease.

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Abdominal aortic aneurysm (AAA) occurs most frequently in the infrarenal aortic segment that lies in close association with the duodenum. Nonetheless, duodenal obstruction caused by AAA is rare.
We report two cases of AAA presented with ileus symptoms due to duodenal obstruction.
Patient 1, a 77-year-old man found to have an infrarenal AAA 80 mm in diameter during hospitalization elsewhere for hypertension (200/100mmHg), was emergently admitted to the hospital because of frequent bouts of vomiting. Patient 2, a 77-year-old man found tohave an AAA 80 mm in diameter during hospitalization elsewhere for ileus symptoms, was transferred to the hospital for the purpose of operation.
After their general conditions were improved with nasogastric suction and total parenteral nutrition prosthetic graft replacement of the abdominal aorta was performed. Their postoperative courses were uneventful.
In the treatment of ileus, a huge AAA which can compress the 3rd and 4th portions of the duodenum should be considered as one of probable causes.

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A case of hemorrhagic cytomegalovirus (CMV) enteritis in a hemodialysis patient is reported.
A 68-year-old woman received steroid pulse therapy for purpura in the extremities occurred during hemodialysis developed poor respiratory condition elsewhere, and was admitted to the department of internal medicine in our hospital in June 2002. The patient had massive anal bleeding in July and was found having ulcerative lesions at the terminal ileum on an endoscopic study. Thereafter anal bleeding occurred intermittently, and so she was transferred to the department of surgery to undergo emergency operation. Intraoperative endoscopy showed pseudopolyps and shallow ulcers at the terminal ileum, and ileocecal resection was carried out. Histopathological studies showed that CMV inclusion body was identified in all ulcers, the CMV antibody titer was 64 times and CMV antigen was positive. Hemorrhage from small intestinal ulcers due to CMV enteritis was thus diagnosed. The patient's postoperative course was uneventful and administration of antiviral agent resulted in negative conversion for CMV antigen.
Early diagnosis and early treatment are important for CMV infection before it is aggravated. The risk of the disease must always be kept in mind in treating patients who are prone to be immunocompromized like this case.

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We report a rare case of perforation of the ileum end due to the accidentally swallowed press through package (PTP). A 68-year-old man was seen at the hospital at night because of lower abdominal pain. Inspite of marked tenderness in the lower abdomen and fever, the white blood cell count was 8550/mm³ which was within normal limits. So we chose conservative treatment using antibiotics. On the next day, the white blood cell count was slightly elevated to 9520/mm³, tenderness was intensified, and the Blumberg's sign was noted. Abdominal CT scan revealed free air around the ileum end and mesentry, so we performed an emergency operation. Inflammatory changes around the ileum and cecum were slight and ileo-ceacal resection was carried out. We found PTP in the oral stump of the ileum end. After the operation we detected the perforation due to PTP in the resected ileum end.
We think that some devices in package of drugs would be necessary, because clinical cases of various diseases caused by ingested PTP are increasing year by year.

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A 72-year-old man was admitted to the hospital because of right lower abdominal pain on December 3, 2002. Plain abdominal X-ray film showed dilatation of the intestine and niveau, and abdominal CT scan on admission revealed the wall thickening and a foreign body of the ileum. At that time, we could not diagnose the ingested foreign body. On the 4th hospital day, follow-up CT scan showed that the foreign body had a small round nodule in the center and a high density area in the neighborhood. So we diagnosed the case as ileus due to ingested PTP, and performed emergency laparotomy on December 6. Intraoperative findings revealed inflammatory adhesions in the ileum 30 cm adoral to the end of the ileum, and partial resection of the small bowel was performed. The resected specimen contained Meckel's diverticulum covered by PTP. It was etiologically thought that the ingested PTP penetrated the opening of the Meckel's diverticulum causing inflammatory adhesions and evertual ileus. Preoperative diagnosis of accidentally swallowed PTP is often difficult, but abdominal CT scan is useful for diagnosis.

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A relatively rare case of intestinal obstruction due to persimmon bezoars is reported. Fifty-one cases are reported during these fifty years. A 77-year-old woman presented primarily with abdominal fullness and vomiting. Abdominal plain radiograph showed gas in the small intestine and air-fluid levels. Computed tomography showed dilation of the small intestine. Although she was diagnosed as having intestinal obstruction and treated conservatively, her symptoms persisted. Small bowel series by an ileus tube showed multiple filling defects in the small intestine. She was operated on with the diagnosis of obstruction of the ileum due to multiple foreign bodies or tumor. At laparotomy, a total of 19 foreign bodies 3 cm in maximum diameter were palpated in the ileum. Partial resection of the small intestine including the foreign bodies were performed. Foreign bodies contained over 98% tannic acid and were clarified to be persimmon bezoars. When we reviewed CT findings retrospectively, persimmon bezoars were visualized as sponge-like masses in the small intestine.

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A 49-year-old man was admitted to our clinic for management of hyperlipemia, gout, diabetes, and obesity.
A circumferentially growing asymptomatic tumor was found in the ileum at just oral side of the ileocecal valve on a screening colonoscopy. The tumor was located in the ileum end on barium enhanced colonography. No lymph node enlargement or metastasis lesion was detected on an abdominal CT scan. We judged that surgery might result in radical treatment and laparoscopic and video-assisted resection of the tumor was performed. Pathologically, monoclonal lymphocyte with mild atypia increased and permeated in germ center of the tumor on H & E staining. Immunohistochemical staining of the tumor celles by monoclonal antibody of L26, Bcl-2, and CD10 was positive. The tumor was diagnosed as mucosa-associated lymphoid tissue lymphoma (MALToma). Post-operative course of the patient was uneventful. The patient was discharged from the hospital on 13^th day after the surgery.

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We report two adult cases inflammatory fibroid polyp (IFP) of the small intestine presented with intussusception. A 65-year-old woman was admitted to the hospital because of epigastric pain and vomiting.
A 71-year-old woman was admitted because of a 3-month history of abdominal pain and constipation. In both patients, abdominal CT scan indicated intussusception caused by a tumor of the small intestine. On emergency laparotomy, the intussusception caused by the tumor of the small intestine was identified and partial resection of the small intestine including the tumor was performed. The histopathological diagnosis of the tumor was IFP.
IFP of the small intestine is relatively rare and frequently presents with intussusception. Therefore, IFP must be kept in mind as a propable cause of intussusception in adults.
To make the diagnosis of intussuception is not so difficult if characteristic findings are shown by preoperative abdominal CT scan, but to make the qualitative diagnosis of the leading point of the intussusception is still difficult pre- and intra-operatively that might be a further problem awaiting solution.

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We report a case of small intestinal cancer arisen in the elevated intestine after total gastrectomy.
An 81-year-old man, who had have uneventful course after total gastrectomy for gastric cancer on May 10, 2002, was found to have a tumorous lesion in the elevated intestine for reconstruction by an endoscopic study on May 27, 2003. Biopsy resulted in group V. Determined that he had no other metastases than the lesion based on abdominal CT and ultrasonic findings, we performed operation. No findings suggestive of metastasis were seen in the abdomen, and so the elevated intestine was dissected and transected as much as possible and reconstructed by Roux-Y anastomosis again. Histopathologically it was moderately differentiated adenocarcinoma.
We think that the tumor is primary small intestinal cancer from the following etiological reasons; 1) histological type of the gastric cancer was poorly differentiated adenocarcinoma; 2) it is too distant to consider it as scattered cancer cells at the initial operation; 3) and the location of this small intestinal cancer was in the jejunum within 50 cm from the Treitz' ligament before it was elevated, where is the common site for cancer of the small intestine.

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A 57-year-old man was seen at the emergency department in our hospital because of right lower abdominal pain. Tenderness and abdominal guarding were recognized in the right lower quadrant. Abdominal CT scan showed a mass measuring 4cm in diameter with a high density spot in the center of the mass. Acute appendicitis caused by a coprolith was suspected and appendectomy was performed. A fish bone 1cm in length stuck in the appendiceal wall was seen in the resected specimen. The appendix sitnated distal to the fish bone showed a marked swelling. Microscopic examination revealed a cut on the appendiceal wall from where the fish bone might have stuck, severe inflammatory changes around the cut, acute appendicitis, and multiple diverticula lacking the muscularis propria. Thus, inflammatory obstruction of the appendix caused by the ingested fish bone was thought to contribute the pathogenesis of both acute appendicitis and diverticula of the appendix in the present case.

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A 62-year-old woman was referred to the hospital for close examination for anemia from her home doctor in August 2000. Laboratory data revealed anemia, thrombocytopenia and a rise in serum CEA. She was diagnosed as having sigmoid colon cancer with idiopathic thrombocytopenic purpura. She was treated with γ-globulin and platelet concentrate pre-operatively, and underwent sigmoidectomy and splenectomy on August 23 2000. The platelet count increased after operation, however, the response was temporary. In June 2001 and May 2002, she was treated with the pulse therapy of prednisolone which resulted in temporary remission. She was given low dose of prednisolone to maintain the platelet count. In November 2001, she was treated with eradication of Helicobacter pylori. The platelet count was increased and platelet-associated IgG (PAIgG) was decreased to normal range. This case suggests that the eradication of Helicobacter pylori may be useful for patients with ITP associated with cancer of the digestive organ.

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A 33-year-old man was admitted to the hospital because of right lower abdominal pain. An abdominal CT scan revealed an abscess, 8 cm in diameter, at the right iliac fossa. Under a diagnosis of acute gangrenous appendicitis, appendectomy with drainage of the abdominal abscess was performed. His general condition was improved temporarily, but on the 19th postoperative day, cecal perforation was detected. Iliocecal resection with ileostomy and ascending colostomy was carried out, however, 3 days later, toxic megacolon with necrosis of the remnant colon occurred. Consequently, total colectomy was performed. The cause of his disease was pathologically proven to be fulminant amebic colitis by the detection of Entameoba histlytica in the cecal specimen. By means of antiamebic drugs, he got well gradually. In Japan, amebic colitis has been recently increasing as an overseas infection and a sexually transmitted disease among homosexual men. Especially, the fulminant type like this case suddenly takes a turn for the worse and can be fatal in many cases. Amebic colitis should be kept in mind in diagnosing colitis which progresses rapidly despite surgical treatments.

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A 16-year-old man was transferred to the hospital from a physician because of deteriorated diarrhea, melena, and difficult defecation lasting from his childhood. Endoscopy and barium enema showed a 5×3 cm polypoid lesion in the lower rectum. Features of biopsy specimens were compatible with mucosal prolapse syndrome of the rectum (MPS). Defecography showed abnormal perineal descent and rectal intussusception. Anorectal manometry showed a decrease in maximal capacity. We thought that the polypoid lesions of MPS had caused disordedred defecation, and performed transanal resection of the lesions. After the operation, discomfort after defecation disappeared and the disordered defecation was improved. Transanal resection is an effective option for the treatment of polypoid MPS in instances in which the presence of the lesion itself causes discomfort after defecation.

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An 84-year-old woman, who underwent a right hemicolectomy with lymph node dissection for cancer of the descending colon in April, 2003 which was mucinous adenocarcinoma, ss, n2(+), ly2, v0, P0, H0, M(-) and in stage IIIb, was admitted to the hospital because of a painless and elastic hard nodule, 3cm in diameter, in the perineal lesion in August, 2003. Except mild anemia, no abnormalities including tumor markers were noted on blood examination. Abdominal (pelvic) computed tomography revealed an enhanced tumor in the perineal subcutaneous lesion, 3cm in diameter. Extirpation of the tumor was performed. The tumor had capsule, and was diagnosed as metastasis of the ascending colon cancer histopathologically. There is no evidence of recurrence for a year, as of the time of writing. Although subcutaneous metastasis of colon cancer is rare, we should consider aggressive resection of metastatic tumors which may result in long-term survival in some cases.

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A 68-year-old man was seen at the hospital because of perineal pain lasting from June 2002. There were previous histories of undergoing a low anterior resection of the rectum for rectal cancer at the age of 52, and undergoing an abdominoperineal excision of the rectum for recurrence of the rectal cancer at the anastomosis at the age of 54. This time, abdominal and pelvic CT scans visualized a tumor 5cm in diameter on the left side of the pelvis and the left ureter which was involved by the tumor, presenting left hydronephrosis. Local recurrence of the rectal cancer with invasion into the bladder and ureter was diagnosed. Removal of the tumor with associated resection of the bladder, prostate, and ureter was carried out. And an ileal conduit was made. Pathological findings were compatible with those of recurrence of the rectal cancer. Local recurrence of rectal cancer 16 years after surgery for the primary lesion was definitely diagnosed.

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Endocrine cell carcinoma has an extremely poor prognosis. This paper presents a case of endocrine cell carcinoma of the anal canal with multiple dermal metastases 4 months after surgery for the primary lesion.
An 82-year-old woman seen at the hospital because of discomfort sensation at the anus was found to have a tumor projecting outside the anus. As a result of a biopsy, endocrine cell carcinoma was diagnosed. No distant metastases were detected, and local excision of the anorectal canal and construction of artificial anus were performed. On immunostainings the tumor was positive for CD56, CEA, and chromogranin A. Four months after the operation, multiple dermal metastases were noted, but no metastases to the lung and liver were seen.
Domestic cases of endocrine cell carcinoma of the anal canal amounted to only seven including this case. Despite the use of abdominoperineal resection of the rectum to all cases except this case, their prognoses were very poor. Further development of not only surgical excision but also multimodal therapy is expected. In any case, preoperative histological diagnosis is important, because preoperative differentiation between carcinoid tumor and endocrine cell carcinoma determines its operative procedure and prognosis.

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Primary malignant melanoma of the anorectal region is a rare entity and has a poor prognosis. We report a case of advanced anorectal malignant melanoma with pancreatic metastasis at initial presentation.
A 53-year-old woman presented with bloody stool and anal pain lasting for about 2 months. An elastic soft mass was palpated in the lower rectum, and a biopsy specimen was diagnosed as malignant melanoma histologically and immunohistolgically.
Abdomino-perineal resection of the rectum was performed, but peritoneal dissemination was seen. Histologically the tumor was ranked A2, p1, H0, n2, M1, stage IV. No therapy was added to the patient according to her family's request. After discharge she experienced recurrences in various sites including subcutaneous tissue of the right breast and left inguinal region. A total of six operations under local anesthesia were performed. She had ascites 4 months and she died of carcinomatous peritonitis 6 months after the operation. This case suggests that aggressive operation should be restrained for its advanced cases.

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Liver transplantation (LTx) for liver cirrhosis caused by hepatitis C virus is increasing in recent years. The problem of LTx for cirrhosis due to hepatitis C is the reactivation of hepatitis C virus after transplantation. Approximately 50-60% of patients will develop chronic active hepatitis within one year after transplantation. In addition, 20% of those patients develop liver cirrhosis within five years. Unlike hepatitis B, recurrent hepatitis C is usually mild and is characterized by gradual progress. On the other hand, fibrosing cholestatic hepatitis (FCH), a specific histologic manifestation of hepatitis B virus infection, is characterized by periportal fibrosis, hepatocyte ballooning, cholestasis and relatively scant inflammation. FCH will rapidly progress to liver cirrhosis for a short period of time. In recent years, FCH has been increasingly reported to occur after LTx for hepatitis C cirrhosis. Herein, we report a case of FCH after living-donor LTx for hepatitis C, which led to a rapid graft loss on POD 233.

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In this report, we present a case in which the progress from biliary ascariasis to common bile duct stone was tracked. A 84-year-old woman was transferred from another hospital because of abdominal pain caused by biliary ascariasis. An anthelmintic had been administered in the previous hospital and the worms in the bile duct were dead. The abdominal pain subsided immediately after transfer to the hospital. The patient herself did not agree to undergo a papillary incision and she subsequently left the hospital. However, one year and ten months later, she was admitted to the hospital again because of a common bile duct stone. After an endoscopic sphincterotomy, two stones were removed from the bile duct. Histopathological examination of the stones, showed worms in the center of the stones.
In recent years, clinical cases of biliary ascariasis have increased with an increase of the risk of acquiring ascariasis infection by eating chemical-free vegetables, by traveling overseas, and by sending workers abroad. We report the case described here, together with a review of the literature.

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This paper deals with hepatocholangiojejunostomy for a patient with anemnesis of total gas-trectomy, using ρ-loop for reconstruction after extrahepatic bile duct resection for diffuse bile duct carcinoma. Metachronous double cancer involving the stomach and bile duct is rare, especially meta-chronous triple cancer like in this case.
An 80-year-old woman, who had previous histories of undergoing total gastrectomy and splenectomy for gastric cancer followed by reconstruction by ρ double tract method, was seen at the hospital because of chest discomfort and slight fever. Careful examination showed stenosis in the middle bile duct, and cytological examination of bile showed adenocarcinoma. At the operation, a frozen section showed cancer cells diffusely infiltrated a long the bile duct, so we performed resection of the extrahepatic bile duct, caudate lobe of the liver, part of the pancreas head, hepatocholangiojejunostomy, and reconstruction of the pancreatic duct. In the case of re-operation after total gastrectomy, we must consider the reconstruction method used at the previous operation and then select a most appropriate method from among a variety of reconstruction methods.

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Signet ring cell carcinoma of the gallbladder, especially the disease associated with a hematoma in the ligamentum teres hepatis, is rare. This paper deals with a case of signet ring cell carcinoma of the gallbladder in a patient who developed huge hematoma formation in the ligamentum teres hepatis during examination for cholelithiasis and cholecystitis which demanded emergency operation.
A 72-year-old woman brought into the emergency clinic in our hospital by ambulance for acute abdomen was admitted to the department of internal medicine with a diagnosis of cholelithiasis and cholecystitis. Conservative treatment resulted in temporary remission, but she had an attack of severe upper abdominal pain and the levels of WBC and CRP were elevated again. Computed tomography (CT) showed a large low density area at the surface of the left lobe of the liver and moderate amount of ascites. Perforation of the gallbladder was suggested, and so emergency operation was performed on the same day. At laparotomy a hematoma was present in the ligamentum teres hepatis and the gallbladder was firmly applied to the surrounding organs. After dissecting these adhesions, cholecystectomy and drainage of the hematoma were performed. Entire mucosa surface of the gallbladder presented tumorous appearance and invaded the liver. Histopathological diagnosis was signet ring cell carcinoma of the gallbladder.

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We experienced laparoscopic excision of umbilical urachal sinus using an abdominal wall lifting method. A 24-year-old man was seen at the hospital because of umbilical pain with pus discharge. Umbilical urachal sinus was diagnosed by abdominal CT scan and fistulography (about 4cm length). He was admitted for laparoscopic excision. Three trocars were inserted into the peritoneal cavity; a 5 mm trocar at the middle right abdomen for laparoscope, and two additional 5mm trocars at the right upper and lower abdomen. Two pieces of Kirschner wire were obliquely inserted to lift up the wall to obtain the working space. The caudal side of the urachus was ligated by absorbable suture and was transected. The umbilical urachal sinus and medial umbilical ligament were separated from the peritoneum cephalad to the umbilicus using ultrasonic coagulating shears. The opening of the sinus was cut and the lesion was then taken from the the peritoneal cavity. The operation time was 85 minutes and operative blood loss was minimal. Pathological evaluation confirmed benign urachal remnant. The postoperative course was uneventful and he was discharged on the 7th post-operative day. No recurrence occurred and no deformity of the umbilicus was observed.
Laparoscopic excision for urachal remnant is a useful procedure in terms of its minimal invasiveness and cosmetic benefit.

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A 35-year-old pregnant woman, who had a previous history of operation 2 years earlier, was referred to the hospital for intestinal obstruction at 24th week of gestation. Abdominal exploration revealed that a 40-cm portion of the small intestine which was elevated due to pregnancy, was strangulated by adhesions between the small intestine and fundus of uterus. The ischemic intestine by about 60 cm in length was resected. She recovered from the surgery and was delivered a healthy male baby at 38th week of gestation by cesarean section.

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A 78-year-old man was admitted to the hospital because of pneumonia on December 16, 2002. As pneumonia did not improve, intravenous infusion of PZFX, a new quinolone antimicrobial agent, was started at a dose of 1000mg/day on December 21, 2002. Eight hours after administration of PZFX, general fatigue, dyspnea and oliguria were noted. Urinary output further decreased and the patient developed acute renal failure on the next day. Serum enzymes, including GOT, GPT, LDH, CPK and serum aldolase and urine myoglobin were markedly elevated, and rhabdomyolysis due to PZFX was diagnosed. Hemodialysis was started on the same day and high levels of serum enzymes promptly decreased. Chest X-ray revealed abdominal free air beneath the bilateral diaphragm on January 8, 2003. However, his symptoms and laboratory data did not suggest severe peritonitis. Both gastroduodenoscopy and colonoscopy showed no abnormal findings. The diagnosis of idiopathic pneumoperitoneum was established. Abdominal free air disappeared in chest x-ray on January 15, 2003. This is the 19^th case of adult idiopathic pneumoperitoneum reported in the Japanese literature.

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We experienced a case of pneumatosis cystoides intestinalis with intraperitoneal free air which is the 13th case report in Japan. A 62-year-old man, who had been in palliative care for terminal cancer of the left lung and taken morphine sulfate for the pain control, was brought into the hospital because of severe abdominal pain. Physical examination showed left lateral abdominal pain. Abdominal X-ray film revealed free air. Abdominal CT scan showed pneumatosis in the intestinal wall and mesenterium. A possible occurrence of intestinal perforation could not be denied and laparotomy was performed. A number of small cysts were present in the intestinal wall and mesenterium, however, no perforation of the intestine was identified. The definite diagnosis of pneumatosis cystoides intestinalis was made. After irrigation a drain was placed and the operation was over. The postoperative course was uneventful and the patient was discharged from the hospital on the 16^th postoperative day. It is inferred that the cause of pneumatosis cystoides intestinalis in this case is chronic constipation induced by taking morphine sulfate and an α-glucosidase inhibitor. When free air is found, it is important to keep the possibility of perforation of intestines in mind. If it is difficult to make the difinite diagnosis, exploratory laparotomy should be considered for suspected perforation.

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A 52-year-old man had the abrupt onset of severe abdominal pain and vomiting during hospitalization in our hospital for the treatment of atrial fibrillation. Enhanced CT scan showed a low-enhanced area in the main trunk of the superior mesenteric artery (SMA), and acute mesenteric artery occlusion was diagnosed. Thrombolytic therapy with intra-arterial infusion was employed for the patient, because surgery entailed a great risk due to his underlying disease of uncontrollable congestive heart failure, and about three hours had elapsed from the onset of the symptoms. Angiography visualized incomplete occlusion at 6cm distal to the bifurcation of SMA. Intra-arterial infusion therapy with 960, 000IU of urokinase and 20μg of prostaglandin E₁ was started 4.5 hours after the onset of the symptoms. Most of the thrombus was lysed by the infusion therapy, but the infusion therapy was sustained for further 48 hours because of a partially remnant thrombus and persisting slight abdominal pain. Thereafter these symptoms subsided and the patient was discharged from the hospital on the 7^th day after the infusion therapy.
We present this case of acute SMA occlusion in which conservative thrombolytic therapy was successfully conducted bymaking early diagnosis.

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We report a case of pseudocyst of the duodenal mesentery in an adolescent patient.
A 16-year-old man was admitted to the hospital because of 2-month history of left flank abdominal pain of increasing intensity. The patient had neither medical history nor abdominal injury. Abdominal computed tomography and magnetic resonance imaging revealed a unilocular cyst about 5.5 cm in diameter on the left side of the abdominal aorta. An enteric duplication cyst was diagnased, and a cystectomy by laparotomy was performed. The cyst had originated from the mesentery of the duodenum. The content of the cyst was milky white fluid. Microscopically, the cyst wall was made of fibrous tissue without epithelial lining, suggesting that it was a pseudocyst arising from the duodenal mesentery. Such pseudocysts of the mesentery are extremely rare, and there have been only 17 cases including ours in the Japanese literature.

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A 55-year-old man seen at the hospital because of an abdominal tumor was found to have a solid and cystic tumor occupying the whole abdomen by abdominal CT scan. In abdominal magnetic resonance imaging scan, T1 emphasis image showed the low signal intensity, and T2 emphasis image showed the high signal intensity. Abdominal angiographic findings indicated that the left and right gastroepiploic arteries fed the tumor. Operation was performed with a diagnosis of primary malignant tomor arisen in the greater omentum. The excised specimen consisted of two tumors, a tumor 23×21×16 cm and the other 15×9×6 cm in dimention, and was 2730g in gross weight. Histopathologically, the tumor consisted of oval-shaped cells or polygonal cells and immunohistochemical stainings showed negative for c-kit and CD34, while positive for α smooth muscle actin. The histopathological diagnosis was epithelioid leiomyosarcoma. Furthermore, the tumor presented positive response in CA125 staining and was cossidered to be a very rare CA125-producing tumor in the male. No signs of recurrence have been found as of 1.5years after the operation.

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We report two cases of giant gastrointestinal stromal tumor (GIST) of the omentum. Case 1: A 63-year-old man developed intraperitoneal hemorrhage during hospitalization for an abdominal tumor was treated by emergency resection of the tumor. The tumor arised from the omentum and was not adherent to the surrounding tissues. And perforation was identified in the right side of the tumor. Case 2: A 79-year-old woman complaining of abdominal pain was detected to have an abdominal tumor in the right lower quadrant of the abdomen. At laparotomy, we found a huge and a small tumors continued to the omentum, and resected these tumors. Immunohistopathological examinations revealed that these tumors stained positively for c-kit, and were diagnosed as GIST. All tumors showed positive response in immunostaining for Ki-67, suggesting a potent proliferating ability of them. Actually intraabdominal metastasis was confirmed at the time of laparotomy in the both cases.
Recently imatinib mesylate has been administered for the treatment of GIST, however, from the standpoints of adverse side effects and long-term use, the safety of the regimen has not been established as yet. Granted that GISTs become huge, those tumors tend to be less invasive to surrounding organs, so that surgical excision would be desirable if it is possible.

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A 76-year-old man who had been hospitalized for medical treatment of a liver abscess and sepsis since June 15, 2002 vomited out a large quantity of blood on June 25, but, he had neither abdominal pain nor abdominal manifestations. Abdominal CT scan showed a diffuse retroperitoneal abscess with emphysema extending from the anterior part of the right kidney to the 2nd portion of the duodenum. Retroperitoneal perforation of the duodenum was diagnosed, and an emergency laparotomy was performed. We suspected the presence of a duodenal diverticulum, but we found a huge abscess cavity in the retroperitoneum, instead of diverticulum, which extended from the anterior surface of the right kidney to the 2nd portion of the duodenum. There were remarkable inflammatory changes in the abscess cavity. After opening the cavity and Kocher mobilization, a perforation, 2±1.5cm in size, was found in the 2nd portion of the duodenum. Because the perforating defect was large with severely inflammatory change, the simple closure of the defect was thought to be difficult and dangerous. For this reason, an omentoplasty for the duodenal defect was employed. Furthermore, a gastro-jejunostomy was added in consideration of postoperative duodenal stenosis. The postoperative course was uneventful, though the patient was in poor condition due to severe diabetes mellitus.

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A 72-year-old man who underwent lymph node dissection for paraaortic lymph node metastasis after operation for left renal cancer on June 17 2002 had abdominal pain on the 13^th hospital day and was diagnosed as having intesinal obstruction by abdominal x-ray examination. Since niveau formation of the large intestine was noted, colonofiberscopy was conducted which showed a narrowing portion at the descending colon. No abnormalities were identified on the mucosa. Abdominal CT scan revealed fluffing of fatty tissue in the vicinity of the descending colon, but no tumor was identified. Laparotomy was performed on July 18. Upon laparotomy we saw the hypertrophied and indurated omentum and mesentery in the vicinity of the descening colon, at where the descending colon narrowed. Pimelitis of the mesentery, omentum and retroperitoneum surrounding the intestine was diagnosed. A part of the greater omentum was excised and side-to-side anastomosis between the transverse and descending colon was made. Histopathological study showed findings of pimelitis. The patient's postoperative course was uneventful.
We present this case of pimelitis with intestinal obstruction after abdominal operation, together with a review of the literature.

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This is a report of a case of lower-abdominal linea alba hernia in a 65-year-old woman. The patient was 152cm in height and 125kg in weight with the body mass index (BMI) of 54, showing serious obesity. She had noticed abdominal distention since 5 years earlier, but let it alone because she was asymptomatic. She was seen at the hospital because a hernia around the umbilicus was pointed out at a medical checkup. A computed tomography showed a hernia that derived from a defect in the abdominal wall. A portion of the intestine protruded from the defect and was incarcerated in the subcutaneous lesion. An operation revealed a defect in the abdominal wall on the lower median part of the abdomen, and the contents of the hernia were the transverse colon and the omentum. Lower abdominal linea alba hernia was diagnosed, and the hilus of the hernia was closed. Linea alba hernia is a rare condition, and 68 cases have been reported in Japan. Furthermore, a hernia in the lower abdomen is extremely rare, and only nine cases, including this one, have been reported in Japan. All of the patients were female. We considered that weakness of the linea alba due to abdominal high pressure by obesity and/or a history of the maternity might be the main cause of lower abdominal linea alba hernia.

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An 84-year-old woman was seen at the hospital because of vomiting, back pain, and pain of the left lower extremity. From her positive Howship-Romberg sign and pelvic CT findings, left obturator hernia was diagnosed and an emergency operation was performed. At laparotomy, the entire loop of the small intestine at about 130 cm to the ileum end was incarcerated into the left obturator and became necrotic, and then the portion was resected. We judged that closure with sutures might be impossible due to the large diameter of the left obturator, about 10 mm, and a mesh was placed on the preperitoneal cavity to repair after careful intra-abdominal lavage. No mesh infection occurred after the operation, and the patient's postoperative course was uneventful.
Recently case reports describing mesh repair for obturator hernia have been seen here and there. The method has many benefits such as tension free, easiness, and wide coverage over the obturator without injuring the obturator nerves as well as arteries and veins, but it entails a risk of mesh infection in cases in which intestinal resection is required. We think that the placement of mesh to the preperitoneal cavity after careful lavage like in this case may result in complete repaire of obturator hernia by means of the mesh method.

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