Although utility of three-dimensional (3D) helical CT for preoperative examination of breast cancer has been discussed, the accuracy of the helical CT in diagnosing breast cancer has not been fully evaluated. In this study 56 malignant and 28 benign breast tumors were evaluated preoperatively with 3D-helical CT, and their imaging results were compared with pathological findings of surgical specimens. Helical CT identified the presence of malignancy in 54 out of the 56 cancer cases tested and the sensitivity and specificity in distinguishing between malignant and benign tumors were 82% and 57%, respectively. The sensitivity and specificity in diagnosing the presence of metastatic axillary lymph nodes using helical CT were 70% and 80%, respectively. The sensitivity and specificity in diagnosing the presence of EIC using helical CT were 71% and 86%, respectively. Helical CT visualized all of the tumors in multifocal breast cancer cases. In conclusion, 3D-helical CT is a useful modality for preoperative examination of breast cancer, especially for assessing axillary lymph node status, and extensive intraductal component (EIC), and will be helpful for conducting sentinel lymph node biopsy (SNLB) and breast-conserving surgery.

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For doxifluridine (5'-DFUR) to be efficiently converted to 5-FU, it is necessary for thymidine phosphorylase (TP) expression to be induced. We investigated the effects of docetaxel (TXT) and 5'-DFUR on the induction of thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) expression in postoperative cases of advanced gastric cancer. In Study 1 (n=11), the TP and DPD levels in cancer tissue and normal mucosa were measured before and 1 week following a single administration of TXT 20mg. In Study 2 (n=14), the TP and DPD levels in cancer tissue and normal mucosa were measured before and after the administration of 5'-DFUR 1200mg/day for 2 days. Then, in the same patient group, TXT 40mg, and 5days later 5'-DFUR 1200mg/day for 2 days, were administered and the TP and DPD levels in cancer tissue and normal mucosa were measured 1 week after administration of TXT. TP expression was induced in cancer tissue by administration of TXT 40mg (p=0.0052), whereas TP expression in normal mucosa was unchanged. The expression of DPD in cancer tissue was unaffected by TXT administration, but it was decreased following the administration of 40mg TXT in normal mucosa (p=0.0092). The TP/DPD ratio in cancer tissue was increased by TXT administration (p=0.0303). The administration of 5'-DFUR did not affect the TP and DPD levels in cancer tissue and normal mucosa. Concomitant use of TXT and 5'-DFUR can be expected to synergistically potentiate individual anti-tumor effects in cases of gastric cancer.

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In 1996, we established guidelines for the management of liver injury, consisting of transcatheter arterial embolization (TAE), conservative management (CM), or operative management (OM) on the basis of blood pressure, presence of response to fluid therapy, and findings of computed tomography (CT) etc. We have applied these guidelines to type III blunt liver injury (the subject of this study) as well. In this study we retrospectively examined whether these guidelines were suitable together with consideration of whether it was necessary to add two more criteria, injury severity score (ISS) and revised trauma score (RTS), both of which are quantitative indices of the severity of injury. In this study we examined 25 cases that were classified into the above three groups. Eighteen cases (72%) were classified into the non-operative management groups, and all the patients in these groups were safely and effectively treated without changing the initial therapeutic strategy. Systolic blood pressure, ISS, and RTS in the OM group were significantly different from those in the other two groups. In the OM group, blood loss was greater because of the higher severity of multiple injuries, thus leading to hypotension with altered consciousness level and respiratory rate. These findings not only indicate that systolic blood pressure can substitute ISS or RTS, but also verify the usefulness of the current guidelines, suggesting that non-operative management is possibly indicated even in type III blunt liver injury.

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We report surgical outcomes for TS1 pancreatic cancers with the diameter of less than 2cm. A total of nine cases of TS1 pancreatic cancer operated on at the hospital in a recent 17-year period were enrolled in this study. Of these nine patients five patients were symptomatic and the remaining four patients were asymptomatic including three who were detected at mass screening. In diagnosing the disease by imaging methods before surgery, abdominal ultrasonogaphy was useful to visualize the tumor and endoscopic retrograde cholangio-pancreatography was helpful to visualize the irregular pancreatic duct. As for the prognosis, five patients died of cancer, one patient died during hospital stay, and the remaining three patients are living without recurrence for more than 5 years. The cumulative 1-year survival rate was 88.9%, and the three-year and the five-year survival rates were 44.4%. Compared with the 5-year survival rate of 6.8% in all patients with pancreatic cancer resected at the department, the prognosis of the disease appears to be favorable. There were three patients with Stage I cancer and six patients with Stage III cancer. Comparing by stages, five out of the six Stage III patients died of cancer comparatively soon after the operation.
It is thought that we have to cope with TS1 pancreatic cancer of Stage III or more by the same therapeutic strategies for those for pancreatic cancer with the diameter of more than 2 cm.

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In order to clarify the effectiveness and problems of thoracoscopic sympathectomy for palmar hyperhidrosis, a total of 47 patients undergone sequential bilateral thoracoscopic sympathectomy (ETS) at the hospital were enrolled in this questionnaire study. We sent them questionnaires asking about sweating, recurrence, wound pain, compensatory sweating, cosmetic aspect and satisfaction. We recover-ed answers from 31 patients. There were 12 males and 19 females with a mean age of 26±14 years. Though the degree of palmar and plantar hyperhidrosis at the preoperative period was about 5.6±1.6 points (7 points scale), that of palmar hyperhidrosis was significantly improved to 1.6±1.0 (right) and 1.9±1.4 (left) at the postoperative period (p<0.001). There were three recurrence cases of palmar hyperhidrosis (9.7%). Compensatory sweating was occurred in 30 cases, 97%, most of them complained of it on the back, chest, femur, hip and axilla. Wound pain was minimal (2.8±2.6 points, 11 points scale), satisfaction for wound had good points (8.8±1.1 points, 10 points scale). We considered that they were almost satisfied with the ETS procedure (7.8±2.0 points, 10 points scale). It is concluded that ETS was remarkably effective for palmar hyperhidrosis in term of recurrent rate, wound pain, cosmetic aspect and satisfaction. But we must continue to improve this procedure because the compensatory sweating decreased the patient's quality of life.

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We report a case of adenoma of the nipple. A 68-year-old woman referred for induration under the left areola was found by palpation to have a goose-egg tumor with a smooth surface, elastic hard consistency, and good mobility. Neither nipple erosion nor discharge were seen. Mammography showed a 15×25mm tumor shadow. Ultrasonography showed fluid-fluid level formation in a cystic lesion, suspected of malignancy. Fine-needle aspiration cytology showed a papillary cell cluster with apocrine metaplasia, suspected of being papilloma. The left mammary gland partially resected. The resected frozen section examined during surgery was diagnosed as adenoma of the nipple. The tumor was a 10×9×10mm intracystic type. Pathological examination showed growing papillary tumor cells with so-called pseudoinvasion and apocrine metaplasia. Myoepithelium was observed. The patient was dischar-ged without complication and no recurrence was seen. The present case was very difficult to diagnose definitively.

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Adenomyoepithelioma (AME) of the breast is a very rare entity in which glandular epitherial and myoepithelial cells proliferate. We experienced a case of AME coexisted with intracystic carcinoma in the ipsilateral breast in an old woman.
A 91-year-old woman was seen at the hospital because of cystic and solid tumors of the left breast which had enlarged during one year, namely from 31mm to 80mm in diameter for the cystic tumor and from 11mm to 15mm for the solid tumor on ultrasonography. Under a diagnosis of double breast cancer, a simple mastectomy was performed. Histologically, the cystic tumor was non-invasive ductal carcinoma. And the solid tumor showed bicellular proliferation of both epithelial cells forming ducts and myoepithelial cells. The glandular epithelial cells were strongly positive for cytokeratin. The myoepithelial cells were strongly positive for S-100 and vimentin. AME of the breast was diagnosed. There have been 32 cases in the Japanese literature, and almost of them were treated with a suspicion of malignancy without definite preoperative diagnosis. The disease is relatively common in people of middle and advanced age. She is the oldest case reported in Japan.

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Hypereosinophilic syndrome (HES) is an idiopathic systemic disorder characterized by peripheral blood eosinophilia and tissue infiltration by eosinophils. Eosinophilic infiltration into the breast, however, is apparently uncommon. A 45-year-old woman was seen at the hospital because of swelling and mastalgia of the left breast. Clinical diagnosis was a type of acute mastitis. To make the definite diagnosis, an incisional biopsy was carried out. The histopathologic diagnosis was eosinophilic mastitis. Her eosinophil count was first noted to be 1, 920/μl at the time of the operation. She had no allergic and parasitogenic diseases. A sternal bone marrow biopsy and computed tomography showed no neoplasms. Although no cases of peripheral blood eosinophilia lasting for more than 6 months have been reported to the best of our knowledge, the case is thought to be of hypereosinophilic syndrome with eosinophilic mastitis.

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Phyllodes tumor of the breast is a relatively rare disease and cases associated with breast cancer are very rare. We experienced two patients with both a benign phyllodes tumor and non-invasive ductal carcinoma in the ipsilateral breast at the same time. Patient 1, a 28-year-old woman, underwent tumor resection with a diagnosis of a benign phyllodes tumor. A histopathological examination revealed the presence of non-invasive ductal carcinoma within the tumor. Patient 2, a 63-year-old woman, was diagnosed as having a phyllodes tumor that had suddenly become large. When the tumor was resected together with the surrounding tissue, non-invasive ductal carcinoma was present within the adjacent mammary gland in a histopathological examination. Both patients required no additional resection, have been free from signs of recurrence. In cases of a phyllodes tumor, the possibility of both homochronous and heterochronous cancer as a complication should be taken into consideration and careful histological examination is important. Since local reccurence often occurs, strict follow-up is necessary.

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A 34-year-old woman was seen at the hospital because of exertional dyspnea. Before entry, radical mastectomy for left breast cancer was performed in June 1998, and resection and reconstruction of the chest wall for recurrence of left breast cancer were performed in April 2001. She was admitted because of exertional dyspnea with right pleural effusion in October 2002. About 5002000ml/day of pleural effusion was discharged by continuous thoracic drainage. Cytology resulted in class II, and the culture of bacteria and tubercle bacillus yielded negative result. No findings of cardiac failure were revealed. Being under the treatment of cryptogenic intractable pleural effusion, she was found to have a huge pelvic tumor with abdominal full sensation. Primary organ was unknown. She was operated on and bilateral ovarian tumors were removed in November 2002. After the operation, right pleural effusion was vanished and she was diagnosed as having pseudo-Meigs' syndrome with bilateral ovarian metastasis of breast cancer. There has been no report on pseudo-Meigs' syndrome with bilateral ovarian metastasis of breast cancer, and our case is the first report.

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A 50-year-old woman with a palpable bean shaped mass in the upper outer quadrant of the left breast since May 2001 underwent excisinal biopsy, and solid-tubular carcinoma with scirrosum pattern was histopathologically diagnosed. The patient underwent quadrantectomy with axillary lymph node dissection 2 weeks after the biopsy. This case was in stage I (T1N0M0). She was given 5'DFUR (600mg, po) and local radiotherapy (30Gray) to the residual left breast, though no remnant cancer cell or lymph node metastasis was present. In January 2002, the patient with a 12-year history of bronchial asthma had attacks of athma, and was admitted to the hospital for evaluation of mononeuritis multiplex with paralysis of the lower extremities in April 2002. The patient was diagnosed as having Churg-Strauss Syndrome (CSS) because she had hypereosinophilia, hyper γ-globulinemia, and positive responses to rheumatoid factor and anti-nuclear antibodies. Steroid therapy for about one year led to dramatic improvement in the symptoms and laboratory findings, but in April, 2003 she was found to have recurrence with multiple liver matastases. She has been treated with chemotherapy. No report on CSS with liver matastases of breast cancer has been seen in the literature. Since CSS occurred after surgery for breast cancer followed by liver matastases after improvement of CSS with steroid therapy for a short time in this case, it was etiologically considered that immunological abnormality in autoimmune disease might be related to carcinogenesis.

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We have experienced a patient with Darling Ia type of total anomalous pulmonary venous connection (TAPVC) without marifesting symptoms until 64 years old. It is very rare for a patient with this anomaly to survive to reach at this age without surgical correction. A 64-year-old woman with an abnormal shadow on chest X-ray was diagnosed as having TAPVC. Cardiac catheterization and angiogram demonstrated TAPVC (Darling type Ia) with a pulmonary artery pressure of 60/16mmHg, Qp/Qs of 2.48, Pp/Ps of 0.44, and Rp/Rs of 0.10; the total pulmonary resistant index was only 3.14 unit. Operative procedures included large anastomosis between the left atrium and common pulmonary vein using superior approach, closure of the atrial septal defect, and ligation of the vertical vein. We consider that the greatest determinant factor affecting the long-term survival is normal pulmonary vascular resistance, and that the superior approach is useful for repair of supracardiac type TAPVC, because it offers an excellent operative field and the risk of postoperative atrial arrhythmia may be minimal. We also reviewed reports of domestic cases of TAPVC for over 40 years.

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A rare case of adenoid cystic carcinoma originated in the peripheral lung is reported, together with a review of the Japanese literature.
A 68-year-old woman, who was a retired internist and had been hospitalized for the treatment of manic-depressive psychosis, was accidentally pointed out an abnormal shadow in the right lower lung field in a chest x-ray film. Although no definite diagnosis was made before surgery, lung cancer was suspected because the tumor tended to enlarge. We performed right lower lobectomy and ND2a for the coin lesion in the right lower lung. The pathological examination showed adenoid cystic carcinoma arisen from periphery of the bronchus B9. She has had no recurrence for over 4 years.

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Esophageal diverticulum is usually asymptomatic and few cases are indicated surgical therapy. This paper presents a surgical case of a huge epiphrenic diverticulum which was detected at a medical checkup and showed an increasing tendency during clinical course, together with some bibliographical comments.
A 45-year-old woman, who had been followed for asymptomatic epiphrenic diverticulum detected on an upper gastrointestinal series at a medical checkup, was admitted to the hospital because of an increasing tendency of the diverticulum. Esophagography revealed a 7.5-cm cystic diverticulum on the left wall of the thoracic lower esophagus, when the exudation of contrast material was poor. Upper gastrointestinal endoscopy showed an opening of the diverticulum on the left wall of the lower esophagus, and retention of saburra in the lumen of the diverticulum. Epiphrenic diverticulum was resultantly diagnosed. Because the patient's diverticulum was of pulsion diverticulum with the increasing tendency and poor exudation of its contents, an operation was indicated. Considering the etiolosic mechanisums of pulsion diverticulum, we performed a transabdominal removal of the diverticulum, an extra mucosal excision of tunica muscularis with the diameter of 5cm around the esophagogastric junction, and sutures of the gastric fundus, resulting in uneventful postoperative course.

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A 48-year-old man was seen at the our hospital because of general fatigue and edema. Laboratory studies showed anemia and hypoproteinemia. Endoscopic examination of the stomach revealed numerous small polyps which formed giant folds. Pathological diagnosis was juvenile polyposis with infection with H. Pylori. This case was judged to be one type of protein losing hypertrophic gastropathy, which is so called Menetrier's disease. We tried medication and eradication of H. Pylori however, endoscopic findings disclosed progress of the disease and no symptomatic remission was attaind. Total gastrectomy was finally performed. In the case of juvenile gastrointestinal polyposis which progresses or has no response to the medicine, surgical therapy should be considered.

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An 86-year-old man complaining of epigastralgia was administrated H₂ blocker for 4 months for gastric ulcer, but his epigastralgia got worse and vomiting and anemia appeared. Barium meal and endoscopic examination of the upper digestive tract revealed a huge ulcerative lesion with crater and a clear border in the lower stomach and pyloric stenosis. Histological examination of biopsy samples did not reveal malignant cells. The patient underwent distal gastrectomy with a diagnosis of gastric ulcer with pyloric stenosis. Histological examination of the resected stomach revealed Candida from submucosal layer to mascularis of the ulcer lesion. These observations suggested Candida-infected gastric ulcer. Gastric candidiasis is recognized as opportunistic infection, and it is known that taking H₂ blocker for a long time may cause Candida-infected gastric ulcer. Gastric candidiasis should be considered in the case of intractable gastic ulcer that can not be controlled by H₂ blocker.

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We present a case of huge gastrointestinal stromal tumor (GIST) of the stomach which was initially diagnosed as unresectable but successfully resected after administration of imatinib mesylate, together with a review of the literature.
A 66-year-old man was found to have a huge tumor occupying the entire abdominal cavity and multiple hepatic lesions suggestive of metastasis in close exploration for anemia. GIST of the stomach was diagnosed based on biopsy, and was thought to be unresectable. Administration of imatinib mesylate at a dose of 400mg/day was started. After administration the tumor dramatically diminished, and then a total gastrectomy, a left lobectomy of the liver, and a partial hepatic excision (S6) were performed. Surgical material revealed that all lesions had gone into liquefied state, namely they had transparent and serous inner parts. Histopathologic studies demonstrated no viable tumor cells. Gene analysis after surgery disclosed variation in c-kit gene Exon 11.

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A 78-year-old man pointed out progressive anemia was diagnosed the as having advanced gastric cancer with multiple liver metastases and peritonitis carcinomatosa. Anti-cancer drug (TS-1) was orally administered at a dose of 100mg/body/day. After four weeks of the treatment, the primary tumor was reduced in size and liver metastases and ascites disappeared. Two weeks after this TS-1 regimen, primary gastric choriocarcinoma was detected in progress observation by gastric endoscopy. After the drug withdrawal period of 2 weeks, a partial excision of the stomach and sampling of peritoneal dissemination and lymph node were perfomed. Histologically, poorly differentiated adenocarcinoma and choriocarcinoma were identified in the surgical specimen, however no survived cancer cells were detected at all. Therefore this chemotherapy was considered to result in complete remission.

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A 68-year-old man with a 4-day history of epigastralgia was admitted to the hospital because of intra-abdominal free air on a chest X-ray film. Upper GI endoscopic study following 7-day conservative management for gastric perforation revealed multiple (six) depressed lesions of the stomach. Biopsy proved group V cells in all the six lesions. Total gastrectomy with Roux-en-Y reconstruction and D2 lymph node dissection was performed. Postoperative pathological evaluation disclosed 22 lesions, including one IIc like advanced carcinoma, five 0-IIc type early carcinomas, and sixteen 0-IIb type early carcinomas. Of these 22 lesions five were well-differentiated tubular adenocarcinoma, 11 were moderately differentiated tubular adenocarcinoma, one was non-solid poorly differentiated adenocarcinoma, and the other five were signet-ring cell carcinama.
Recently, synchronous multiple gastric carcinomas have been increasingly reported. However, most of them occur in two or three lesions. The synchronous gastric carcinoma in 22 lesions showing various histologies as in this case seems to be extremely rare.

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An 88-year-old man who had been aware of an abdominal tumor since May 2001 was seen at the hospital. Abdominal echography and abdominal CT scan revealed a 6-cm sized tumor with heterogeneous internal structure and plenty with vessels, locating near the greater curvature of the stomach, on the left side of the duodenum, and in contact with the pancreas body. Abdominal magnetic resonance imaging scan demonstrated that a branch of the gastroduodenal artery fed the tumor. Since the tumor was well movable, the tumor arising from the greater omentum or stomach seemed likely. A possibility of malignancy could not be ruled out, and so laparotomy was performed. During surgery, we saw the tumor arising from the transverse part of the duodenum and partially invading the pancreas capsule. A partial resection of the duodenum and a partial pancreatectomy were carried out. Histopathologically the tumor arose from the proper muscle of the duodenum, and was positive for c-kit, CD34 and S100 protein and negative for SMA on immunostainings. The tumor was diagnosed as gastrointestinal stromal tumor (GIST) with a low grade of malignancy showing differentiation to the nervous system.

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We report a rare case of a carcinoid tumor of the ampulla of Vater and discuss the treatment.
A 73-year-old woman, pointed out abnomalities on upper gastrointestinal investigation (UGI), was seen at the hospital. The UGI showed a smooth defect in the antral region, and a swelling with a partial depressive lesion in the ampulla of Vater accidentally. There was a 1.8×1.3cm low echoic area in the submucosal layer on an endoscopic echogram. Biopsy specimen revealed a carcinoid tumor histopathologically.
A pylorus-reserved pancreaticoduodenectomy with dissection of the regional lymph nodes was performed. During the operation, we found two thumb-sized lymph nodes in the first branch of the jejunal artery. On the frozen section, the metastasis of the carcinoid tumor was diagnosed.
The invation of the tumor to the duodenal mucosa and lymph vessels was observed microscopically, and tumor cells showed positive immunohistochemical staining for somatostatin. Surgical stage was III.
She has been alive without recurrence for 1 year after the operation.
Concerning the therapy of the carcinoid tumor, it is important to evaluate the lymph node metastasis as well as the tumor size preoperatively, and the radical resection combined lymph nodes dessection is necessary.

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We report a case of intussusception presenting with intestinal perforation in an infant together with a literature review. A female infant delivered by caesarean section with the birth weight of 2160g, was diagnosed as having intestinal perforation by leakage of contrast medium from the intestine on abdominal X-ray. She underwent emergency operation on the 1st day after birth. At laparotomy, there were an intestinal stenosis at 20cm proximally from the ileocecal valve, ileal perforation and a polypoid tumor communicated with the intestine in the lumen. Macro-and microscopic findings of the resected intestine and gestational history of fetal ascites suggested that intestinal ischemic damage evoked by intrauterine intussusception might have caused intestinal stenosis with perforation.
Thirty-eight cases of neonatal intussusception from the Japanese literature were reviewed and the characteristics of the entity were discussed. It was etiologically thought that intussusception in most infants might be caused by intestinal ischemia due to perinatal hypoxia, but that, in eight cases of mature infants, the existence of some intestinal disease such as intestinal duplication might evoke the condition. As for 18 cases (12 cases: mature infants, 6 cases: infants with low birth weight), the cause was considered as intrauterine intussusception, because of its early onset of the disease within 24 hours after birth. It was thought that the disease might be caused by intestinal ischemia or some associated organic disorder in mature infants, and by intestinal ischemia in other infants with low birth weight. And intestinal perforation or death cases were often noted in the infants with low birth weight.

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Hamartomas of the intestine are usually seen in patients with Peutz-Jegher's syndrome, but may occur very rarely as a solitary lesion in patients who are free of associated anomalies. A case of intussusception caused by a hamartoma of the small intestine in an adult is reported. A 26-year-old woman was admitted to the hospital because of right lower abdominal pain. Ultrasonography and computed tomography of the abdomen demonstrated target-shaped thickening of the small intestine suggesting intussusception. Emergency laparotomy disclosed ileo-colic intussusception with a thumb tipsized mass at its apex. Ileocecal resection was performed. Histopathological diagnosis of the mass was hamartoma. Because making preoperative diagnosis of hamartoma of the intestine is difficult, complications such as intussusception, ileus and gastrointestinal hemorrhage often lead to surgical resection.

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We report here a case of postoperative intussusception caused by a long intestinal tube which inserted for the decompression and stent of the small intestine. A 61-year-old woman who had undergone laparotomy three times was admitted to the hospital for bowel obstruction. Conservative therapy using a long intestinal tube was unsuccessful and so operation of freeing adhesion was performed. A long intestinal tube was passed in to the terminal ileum during the operation and kept placing after the operation. The drainage volume from the tube abruptly increased and vomiting occurred on the 5th postoperative day. Conservative treatment under a diagnosis of intestinal edema was ineffective. Roentgenography of the small intestine and abdominal CT scan revealed intussusception of the small intestine. Reoperation was carried out on the 15th postoperative day, when an anterograde intussuscpetion was found at the 10cm distal jejunum from the Treitz' ligament. A partial jejunectomy was performed. The early diagnosis and therapy are required considering the possibility of intussusception, when the drained fluid increases and vomiting occurs in usinig a long intestinal tube.

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A 45-year-old woman admitted for a 1-month history of productive cough was found in chest radiography to have bilateral pulmonary tuberculosis and her sputum was positive for Mycobacterium tuberculosis. She was started on medication for pulmonary tuberculosis. Nine days later, she had acute right lower quadrant pain and abdominal fullness with peritoneal irritation. Computed tomography of the abdomen showed wall thickening from the ileum to the ascending colon, multiple stenosis of the ileum, and ascites. The possibility of strangulation ileus could not be ruled out, necessitating emergency laparotomy.
Operative findings were 8 encircling stenotic lesions from the ileum to the ascending colon, one of which was the focus of ileus, which was obstructed by the content. We conducted partial ileectomy for 3 main lesions and peritoneal drainage. Macroscopic study revealed a ring ulcer and, histopathologically, multiple epithelioid granuloma with Langhans' giant cells and caseous necrosis. Intestinal tuberculosis was definitively diagnosed based on Mycobacterium tuberculosis positive in a caseous necrosis. Even if treatment for pulmonary tuberculosis is started, the presence of intestinal tuberculosis must therefore be kept in mind.

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A 30-year-old man was seen at the hospital because of abdominal pain and vomiting. He had a history of undergoing laparotomy for intussusception and was diagnosed as having Peutz-Jeghers syndrome (PJS) at the age of 12. Computed tomography (CT) of the abdomen showed two intestinal intussusceptions; one in the jejunum and the other in the ileocecal portion. We diagnosed the case as intussusception caused by an intestinal tumor and performed laparotomy. Only ileocecal intussusception was confirmed and reduced manually, then ileal resection was performed.
Five days later, intussusception occurred again, so the second operation was arranged at the postoperative 12^th day. On laparotomy, an intussusception was found in the jejunum and reduced manually. We then applied enteroscopy through an enterotomy incision in the jejunum to remove 10 polyps endoscopically for the prevention of intussusception. The patient was discharged from the hospital without recurrence after the second operation. Thereafter he has been free from complaints for 14 months.
Patient with PJS often have to undergo multiple laparotomies for repeated intussusception of the small intestine and/or gastrointestinal bleeding. Intraoperative polypectomy for multiple intestinal polyps can be expected to prolong symptom-free interval.

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A 65-year-old woman was admitted to the hospital because of right upper abdominal pain and for evaluation of multiple liver tumors. After abdominal ultrasonography CT and angiography, the tumors were diagnosed as cholangiocellular carcinoma with intrahepatic metastases. After embolization of the right branch of the portal vein, right trisegmentectomy of the liver was done. On immunohistologic evaluation, the resected material was positive for vimentin and SMA and negative for S-100, c-kit, CD34 and cytokeratin AE1/AE3. The histologic diagnosis was leiomyosarcoma. After the operation, lower abdominal CT showed another tumor in the ventrad inferior vena cava, which was 25×19mm in size. A primary tumor was suspected, and laparotomy and resection of the tumor were done. The tumor was located in the small bowel mesenterium, and the pathological diagnosis was leiomyosarcoma which had caused metastasis to the liver. The patient has been doing well without evidence of recurrence 7 months after the operation.

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A 75-year-old woman admitted for nausea and abdominal distension and no history of laparotomy was treated conservative using a long tube under a diagnosis of bowel obstruction. Radiological intestinal contrast study through the tube showed a loop together with stenotic lesions of the small intestine in the right lower abdominal space. Internal hernia was suspected, and laparoscopic surgery was conducted to find the cause. Laparoscopic observation showed a retorocecal hernia. We reduced the incarcerated ileum and incised the hernial sac under laparoscopy. Intestinal resection was not required. To our knowledge, no case reports of retrocecal hernia treated with laparoscopic techniques have been made, so our case points up the usefulness of this treatment.

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A 40-year-old woman admitted with lower abdominal pain and nausea but no history of abdominal surgery and or other relevant history was diagnosed with small bowel obstruction and a long tube was emplaced to decompress the bowel. Radiographic study of the small bowel showed a loop-shaped small bowel and stenosis on the oral and anal sides of the small bowel, suggesting an internal hernia. Abdominal computed tomography showed that the small bowel wall was partially thickened, leading us to suspect incarcerated small bowel. The expanded small bowel continued in that incarcerated small bowel might go around the left mesosigmoid colon. Since no tumor was seen, we made a diagnosis of intramesosigmoid hernia. During laparoscopy, we found a 2cm hole in the mesosigmoid. The loop-shaped small bowl was reduced and appeared viable, and so we closed hole using a hernia stapler. Recovery went smoothly, and the woman was discharged on 8 post operative day. We reported this case because preoperative diagnosis is rare, as is reduction in laparoscopy.

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A 55-year-old man with histories of chronic renal failure, sequela of cerebral infarction, and ataxia complained of abdominal pain on August 27 2003, while he was hospitalized to the department of psychiatry in our hospital for receiving hemodialysis. Because both subjective and objective symptoms were mild, the patient was followed. On August 29, the patient went into shock and muscle guarding appeared in the entire abdomen, so that he was referred to the department of surgery and underwent an emergency operation. During surgery, the pulsating superior mesentric artery was identified, but patchy and segmental necrosis was present in the small intestine, nonocclusive mesenteric ischemia (NOMI) being thus diagnosed. Large quantities of the small bowel including the cecum and a part of ascending colon were resected and primarily anastomosed. After the operation, the blood pressure was stabilized due to endotoxin absorption therapy, no suture failure or short bowel syndrome occurred, and the life of the patient was saved.
Since NOMI is a disorder which will increase with the further aging of the Japanese population, we present this case together with a review of the literature.

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A 53-year-old man was referred to the hospital with a suspicion of ileus with the chief complaints of abdominal pain and vomiting after infusion of dinoprost and enema of glycerin. An abdominal ultrasonography revealed dilated small bowels and portal venous gas, and an abdominal computed tomography also showed the same findings. Physical and laboratory examinations indicated not so severe conditions, and the patient was treated conservatively. But peritoneal signs gradually appeared and acidosis progressed, so a laparotomy was performed 18 hours after the onset of symptoms. Operative findings revealed segmental necrosis of the jejunum for about one meter just distal to the ligament of Treitz, and the lesion was resected and anastomosed. Histopathological findings of the specimen revealed hemorrhagic necrosis of the jejunum without specific findings like as thrombosis or angitis in the mesenteric vessels. Based on these findings, we diagnosed the case as nonocclusive mesenteric ischemia. Portal venous gas caused by bowel necrosis is reported to suggest poor prognosis with a mortality rate of 52%. Laparotomy following administration of vasodilators may result in a favorable outcome, if patients have no severe associated conditions and need minimal intestinal resection.

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A 65-year-old man was seen at the hospital because of a tumor prolapsed from the anus. He had noticed stools containing blood and a decrease in the body weight since around the summer of 1997, but had not consulted with any physician. Since January 1998, he started to use diapers because stools with mucus and blood persisted. Thereafter a tumor became prolapsed from the anus at defecations, and he was admitted to the hospital with the referral from a physician on February 18, 1998. The prolapsed tumor at defecation was 12cm in size, like cauliflower in shape and soft, from the surface of which exudation of mucus being identified. However, no depletion syndrome including abnormalities in electrodes and dehydration was revealed. And the prolapsed tumor was able to be reduced. With close exploration, villous tumor with possible association of malignancy was diagnosed, and transanal resection was carried out. Histopathological diagnosis was carcinoma in tubulovillous adenoma, with the invasion depth of tumor of m. As of 5 years after operation, no findings of stricture or recurrence have been seen, and the patient is doing well.

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A 63-year-old woman presented with right lower abdominal pain had a palpable tumor with the size of a tip of the thumb at the same area. Her symptom was once subsided but recurred 19 days later. Although abdominal CT scan visualized abscess at the ileocecal region, colonofiberscopy was carried out for a possibility of colorectal cancer because her general condition was comparatively stable. As a result, a tumor was found at the opening of the appendix, and a pathologist reported that a biopsy resulted in adenocarcinoma. The patient was operated on with a diagnosis of cecal cancer with appendicitis. At laparotomy the appendix with severe inflammation perforated and formed abscess around the organ. The abscess cavity was resected as possible as we could and dissection of group 3lymph nodes was carried out. The resected tumor was 22mm in diameter and type 2, and the opening of the appendix was present at the base of ulcer. Histopathological findings included well, a2, ly1, v2, and n0; the tumor was in stage II and the operation resulted in curability A. The patient developed ileus due to peritoneal dissemination 9 months after surgery, and jejunotransversostomy was performed. Despite chemotherapy, the patient died of cancer 22 months after the initial operation.
Possible association of colorectal cancer must be kept in mind in the case of appendicitis in the middle and elderly people.

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We experienced a case of solitary bacterial liver abscess presumably caused by rectum cancer. A 53-year-old man with a long standing history of anal bleeding was admitted to the hospital because of a fever and general fatigue. Abdominal ultrasonography and CT scan revealed a 2.0×1.5cm liver abscess. Percutaneous transhepatic drainage of the abscess as the initial treatment was performed. In order to determine the source of the liver abscess, barium enema and colonoscopy were carried out. These studies disclosed type II rectum cancer. A biopsy revealed that the cancer was moderately differentiated adenocarcinoma. Percutaneous transhepatic abscess drainage was carried out, and Klebsiella pneumoniae was isolated. On cytological study, no cancer cells were identified. After the drainage the fever subsided and the abscess disappeared on imaging, so that low anterior resection was performed under general anesthesia. The resected specimen revealed SS, N₁(+), P₀, H₀, M(-) in Stage IIIa and ss, n₂, ly₁, v₀ microscopically. The patient has been free from recurrence of rectal cancer or liver abscess 24 months after the operation.

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We report a case of cancer of the sigmoid colon with intussusception prolapsed from the anus. An 87-year-old woman with senile dementia and chronic pulmonary insufficiency was seen at the hospital because of anal bleeding. A tumor was palpable in the rectum on digital examination. The intestine with the tumor frequently prolapsed from the anus and the tumor was diagnosed as well-differentiated adenocarcinoma on a biopsy. A pelvic CT scan presented target like in the rectum and the sigmoid colon was invaginated in the rectum (RS). Cancer of the sigmoid colon which caused intussusception with colorectal prolapse was diagnosed. The intussusception and prolapse could not be reduced, and a sigmoidectomy by Hartmann's method was performed because of her poor general condition. The ischemic change was recognized in the returning wall of the intussucuption in the resected sigmoid colon, and the leading part of the intussucuption was colon cancer of Borrmann type 2, 2×2cm in diameter, mp, ly1, v1, n0, and moderately differentiated adenocarcinoma. Removal of adhesion was performed due to postoperative ileus. She died of sepsis and DIC resulting from MRSA pneumonia in the hospital on January 8 2003.

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A 78-year-old man was seen at the hospital because of general fatigue, appetite loss and anal bleeding. Colonoscopic examination showed a type 1 tumor in the lower rectum and the histological diagnosis from a biopsy specimen was poorly or undifferentiated adenocarcinoma. Multiple liver metastases were discovered by abdominal computed tomography (CT). Abdomino-perineal amputation of the rectum and reservoir implantation were performed. Immunohistochemically the resected specimen was positive for chromograine A and NSE stain. The definite diagnosis was endocrine cell carcinoma. Chemotherapy was started but the patient died 6 months after the surgery.
Endocrine cell carcinoma has malignant potential and discrimination from poorly or undifferentiated adenocarcinoma is difficult. In a review of the Japanese literature 37 cases of neuroendorine tumors of the rectum have been reported. Of the 37 cases, liver metastasis was confirmed in 22 cases before surgery. Five cases were early carcinoma but the prognosis of them was poor. It is thought that the prognosis is not related to infiltration depth. Endocrine cell carcinoma has a very poor prognosis and effective multimodal therapy including operation and chemoradiotherapy should be established.

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An 86-year-old woman admitted to the hospital because of cholecystolitiasis was diagnosed as having cancer of the transverse colon with cholecystolitiasis on close exploration. She underwent operation, when a round shaped whitish focal lesion which was clearly demarcated, 5mm in diameter, on S6 of the liver, was accidentally found. The lesion was resected with a diagnosis of metastatic liver cancer. Histopathologic studies showed adenomatous bile duct among dense fibrous tissues. Immunohis-tochemically, the surgical material gave positive responses to cytokeratin No.7, 18 and 19, suggesting that might be derived from bile duct cells. Intrahepatic bile duct adenoma was definitely diagnosed.

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We reported a case of primary so-called carcinosarcoma of the gallbladder in a 73-year-old woman. Carcinosarcoma shows the presence of malignant epithelial and mesenchymal elements. Humphrey et al defined typical carcinosarcoma as including specific elements of mesenchyma of bone, cartilage, or muscle tissue. They distinguished it from undifferentiated spindle cell carcinoma, so-called carcinosarcoma, which only shows sarcomatous change. Undifferentiated spindle cell carcinoma frequently occurrs in tissue from squamous epithelium, so a primary case of the gallbladder is rare. This histological appearance which carcinoma shows sarcomatoid change is indeed interesting in terms of carcinogenesis.

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A 66-year-old woman seen at a physician because of epigastralgia was referred to the hospital because acute cholecystitis was suspeted based on ultrasonographic (US) findings and leukocytosis. There were no noticeable habits or previous histories. Although right hypochondralgia, lukocytosis, rises of CRP, ALP and γ-GTP were noted, tumor markers including CEA, CA19-9, DUPAN-2 were not elevated.
US and computed tomography of the abdomen revealed a heterogeneous mass lesion in the gallbladder and markedly swollen lymph node in the hepatoduodenal ligament and endoscopic retrograde cholangiopancreatography demonstrated anomalous arrangement of the pancreaticobiliary duct with dilatation of the biliary duct. Under a clinical diagnosis of gallbladder carcinoma with metastasis of lymph nodes, a cholecystectomy with a liver bed resection and a pancreaticoduodenectomy was performed (TNM stage III).
Histologically, undifferentiated carcinoma of large cell type was diagnosed.

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Cystic duct cancer, which is relatively rare, has been difficult to correctly diagnose preoperatively. We report a cystic duct cancer case detected incidentally in a preoperative histopathologic examination and discuss findings from the literature. An 83-year-old man with abdominal pain was hospitalized with suspected cholecystitis. Under a diagnosis of cholelithiasis and gangrenous cholecystitis determined by a series of examinations, he underwent emergency surgery. Intraoperative findings showed necrosis from the body to the fundus of the gallbladder wall. Since no intraoperative finding suggested malignancy, we conducted standard cholecystectomy following intraoperative cholangiography. Postoperative histopathologic examinations showed an epidermal growth with a papillary structure localized in the cystic duct, so the case diagnosis was papillary adenocarcinoma. We advised the patient to undergo additional surgery, but he refused by reason of age, so we decided to follow up on his condition. In the ten months since surgery, he remains alive and has shown no signs of recurrence.

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A 49-year-old man who had been asymptomatic was found to have a pancreatic mass at a medical checkup. A multilocular cyst, about 4cm in diameter, protruding from the surface of the head of the pancreas was identified on abdominal computed tomography. Endoscopic ultrasonography showed debris components within the cystic lesion. Laboratory data revealed elevations of CA19-9, CEA and Span-1 in the serum. We could not rule out a suspicion of malignant tumor, laparotomy was performed. We enuclated the tumor from the pancreas easily. Macroscopically, the cyst was filled with yellowish viscous fluid and atheromatous material. On microscopic findings, the cyst wall was composed of stratified squamous epithelium, surrounded by abundant lymphoid tissues. Based on these pathological findings, the tumor was diagnosed as lymphoepithelial cyst of the pancreas (LECP). This is a relatively rare condition and about 66 cases have been reported in Japan. We report this patient with LECP together with a review of the literature.

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A 41-year-old man complained of right lower abdominal pain and fever up was diagnosed as having diverticulitis of the colon, and admitted to the hospital. Accidentally a tumor of the pancreas tail was pointed out by enhanced CT scan of the abdomen. CT showed no cystic lesion, calcification, or enhancement in the tumor. Angiography showed a hypovascular tumor compressed the splenic vein, but no tumor stain. We performed distal pancreatectomy and splenectomy under a diagnosis of a solid-pseudopapillary tumor. Histopathologically the tumor was similar in structure to islet cell, and immunologically the tumor cells were positive for chromogranin A. We finally diagnosed this case as asymptomatic islet cell tumor.
Since some non-functioning endocrine tumors of the pancreas can show untypical images such as hypovascular one, islet cell tumor must be kept in mind in diagnosing pancreatic tumors.

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We report herein a rare case of hemosuccus pancreaticus related to the remnant malignant lymphoma after surgery. A 65-year-old man underwent surgery for perforated malignant lymphoma of the small intestine. We suspected there was remnant tumor in the retroperitoneal tissue, but we were unable to perform adjuvant chemotherapy because the patient had multiple organ failure after the surgery. Bleeding from the nasogastric tube and melena were observed on the 25th postoperative day. Endoscopic findings showed bleeding from the papilla vater to the duodenum and angiography revealed extravasation from the periphery of the superior pancreatoduodenal artery. We diagnosed hemosuccus pancreaticus and performed embolization of the gastroduodenal artery. Although the embolization was successful temporarily, rebleeding occurred and the patient died from multiple organ failure.

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A 43-year-old woman visited a hospital because of abdominal pain was transferred to our hospital for a low echoic mass of the panceas head visualized on abdominal ultrasonography (US). The image (abdominal CT and US) findings showed that a solid tumor mass, 15mm in diameter, developed in the pancreas head and was enhanced. Endoscopic retrograde cholangio-pancreatography showed an obstruction of the pancreatic duct in the body and deficit of the Santorini duct. A non-functioning islet cell tumor with agenesis of dorsal pancreas was diagnosied and pyrolus preserving pancreatoduodenectomy was performed. An the tesected material an 18×18mm firm tumor with smooth surface was present. The biopsy specimen taken from a part of the pancreatic tail-like tissue was yellow fat, involving no pancreatic tissue. Pathological and immunohistochemical studies indicated low-grade malignant islet cell tumor, non-functioning well-differentiated tumor. This rare case of non-functioning islet cell tumor with agenesis of dorsal pancreas is presented together with a review of the literature.

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A 50-year-old woman with epigastric pain was admitted to the hospital because a cystic tumor on the pancreatic tail was detected by ultrasonography. Computed tomography of the abdomen showed an 8.0cm-sized simple cystic tumor without solid component. We diagnosed the tumor as pseudocyst of the pancreas and performed endoscopic percutaneous transgastric drainage for the cyst. The cyst contained mucinous liquid and the cytopathological diagnosis was squamous cell carcinoma. With the preoperative diagnosis of squamous cell carcinoma of the pancreas with cystic degeneration, we performed distal pancreatectomy. The resected specimen showed a solid pseudo papillary tumor of the pancreas tail. Histopathological findings showed the cystic wall covered with either squamous atypical cell or squamous cell carcinoma and tumor cells infiltrated into the connective tissue. No adenocarcinoma component was found. Squamous cell carcinoma of the pancreas is a rare malignancy and has a dismal prognosis. The patient has been free from recurrence two years 11 months after the operation. We report this very rare case of primary pancreatic squamous cell carcinoma, together with some bibliographical comments.

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Internal supravesical hernia is an uncommon disease, and there has been no report of accurate preoperative diagnosis of this disease. This paper presents a case of internal supravesical hernia and our consideration of preoperative diagnosis based on a retrospective study of CT findings taken preoperatively in this case, which had revealed characteristic findings suggestive of the disease.
A 78-year-old man complaining of abdominal pain, distension, and nausea. Patient was referred to the hospital with a diagnosis of ileus. The patient had no history of undergoing laparotomy. At first, we diagnosed the case as incarceration of the inguinal hernia from CT findings. Conservative treatment for incarceration was performed. However, on the next day, abdominal CT scan revealed similar findings, namely ileus and abnormal positioning of the small intestine near the urinary bladder. Emergency operation was done. Upon laparotomy, the ileum which was 70cm from the terminal ileum incarcerated into the internal supravesical hernia. Partial resection of the ileum was performed because of strangulation. Hiatus of the hernia was repaired. Postoperative course was uneventful and the patient discharged on the 11^th postoperative day. In treating a patient presented with ileus of unknown origin, we must carry out abdominal CT scan by keeping a possibility of the disease in mind, and we are able to make correct diagnosis before surgery, if characteristic CT findings shown in this case are visualized.

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Omental torsion is a rare disease, and preoperative diagnosis is very difficult. Only 10 cases were diagnosed preoperatively in Japan. We report a case of omental torsion secondary to a right inguinal hernia. A 66-year-old woman was admitted to our hospital because of pain in the right lower abdomen. Blood studies revealed an elevated leukocyte count, CRP level and serum total birirubin level. Ultrasonography (US) showed a hyperechoic mass with low echoic center. Computed tomography (CT) of abdomen demonstrated a right inguinal hernia and a large mass with concentric folds or an allow pattern, and omental torsion was suspected.
Surgery was performed after 2 weeks of conservative therapy. The omentum is resected at its normal site. The postoperative course was uneventful, and the patient was discharged on postoperative day 13. CT was useful in making the preoperative diagnosis.

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Primary torsion of the greater omentum which presents with acute abdomen is a relatively rare entity. A 48-year-old man was referred to the hospital with a suspicion of acute appendicitis for right lower abdominal pain. He had tenderness with Blumberg sign in the right lower abdomen. Computed tomography (CT) showed a large fat density mass with concentric linear strands in the anterior transverse colon. At emergency laparotomy a fistic size of dark red, omentum mass was found associated with a small quantity of bloody ascites. It was a part of the greater omentum, which twisted counterclockwise by five turns. The greater omentum below the torsion was resected including normal portion. Primary torsion of the greater omentum is not common. When we encounter a patient manifesting a similar symptoms to those of acute appendicitis without gastrointestinal symptoms, abdominal radiographic CT is extremely useful for differentiating them.

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We report a rare case of primary omental torsion after parturition. Ten days after normal delivery, a 26-year-old woman felt colicky pain in the right lower abdomen. She was transferred to our hospital with the suspition of a malignant tumor in following initial surgery under a diagnosis of ovarian torsion. Physical examination palpated a hard mass with tenderness and muscular defense in the umbilicus. Blood analysis showed the white blood cell count in the normal range, but CRP was slightly increased. Abdominal computed tomography (CT) showed a fat density mass with concentric linear strands and a right ovarian cyst. In laparotomy under a diagnosis of omental torsion, we found a 8.0×2.0cm mass, built up of concentrated omentum under the umbilicus. This mass and a right ovary were resected. Primary omental torsion was definitively diagnosed due to the lack of other findings in the abdominal cavity. If acute abdomen shows no gastrointestinal symptom and mild inflammatory findings compared to a severe stimulant peritoneal sign, abdominal CT, which shows characteristic findings of omental torsion, is highly useful in the differential diagnosis of this disease.

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A case of an omental tumor suggestive of peritoneal metastasis of advanced colon cancer is reported. An 83-year-old man was admitted to the hospital because of abdominal pain. Barium enema and colonoscopy showed ascending colon cancer. Right colectomy was performed for ascending colon cancer, when an omental tumor was found out. So partial resection of the small intestine with the omental tumor was performed because a possibility of peritoneal metastasis could not be ruled out. Histopathologically, the colon tumor was well differentiated adenocarcinoma, ss, ly0, v0, n (-), and the omental tumor was an inflammatory granuloma caused by a fish bone.
Perforation due to a fishbone is often identified in emergency cases accidentally and is often diagnosed as an omental tumor of unknown origin in chronic cases. In this case the intraabdominal tumor could not be diagnosed before surgery. A retrospective review of CT findings disclosed that we had to be able to recognize a linear calcified lesion which coincided with the omental tumor. In order to avoid excessive treatments for an intraabdominal tumor, minute exploration of imaging findings is required by keeping the possibility of the disease in mind.

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