We have experienced eight cases of HER2 positive metastatic breast cancer treated with trastuzumab in a recent 2 years 4 months from July 2001 to November 2003. Their mean age was 55.1 years old ranging from 50 to 66. There were six patients with scirrhous carcinoma and two with solid-tubular carcinoma. The hormone receptors were positive in three cases and negative in five cases. Hercep test was performed in all cases, which resulted in 3+ in six cases and 2+ in the remaining two cases (FISH-positive). The numbers of times administered trastuzumab ranged from 26 to 103, with a mean of 59 times. The combined chemotherapies with trastuzumab were conducted in seven cases. Two complete responses (25%), one partial response (12.5%), three no change situations for more than 6 months (37.5%), and two progressive diseases (25%) were obtained, the overall response rate being 37.5%. Leukopenia (grade 3) occurred in three cases, infusion reactions in three cases, and cardiac toxicity in one case, but these patients clinically well tolerated.
This study suggests that the treatment with trastuzumab is effective and safe, and could be the first-line therapy for HER2 positive metastatic breast cancer.

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The purpose of this study was to evaluate the effects of esophageal stents for patients with inoperable esophageal carcinoma. We enrolled 18 patients treated with Ultraflexstent (self-expandable nitinol stent) and divided them into five groups by performance status (PS) of patients before surgery. There were three cases of PS0, seven of PS1, three of PS2, two of PS3, and three of PS4. As a result the success rate of palliation of discomfort symptoms was 77.8% (14/18 cases). No remission was noted in four cases. The amounts of oral ingestion divided by PS were 83±17%, 94±6%, 53±29%, 15±5%, and 37±32% in PS0, PS1, PS2, PS3, and PS4 cases, respectively. Four patients could not eat even after insertion of esophageal stents. Three of these four patients were in poor performance status caused by advanced cancer. Complications accompanying by insertion of the stent included displacement in three cases, bleeding in one and tachycardia in one. A satisfactory result of esophageal stent might not be anticipated in patients in poor performance status due to advanced esophageal cancer.

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August 2001. we introduced early enteral feeding after distal gastrectomy (DG) (135 patients) and total gastrectomy (TG) (58 patients). This study was designed to examine the effectiveness of early enteral feeding after gastrectomy. Before the introduction, total parenteral nutrition (TPN) was standard postoperative nutritional support after gastrectomy. An enteral tube was inserted through the nose into the proximal jejunum intraoperatively. A 200ml of commercially available low residue diet was administrated through an EN tube on POD1. Volume was increased up to 800ml and the feeding was continued until POD7. Enteral feeding was successfully accomplished throughout 5-7 days on 81.5% of DG patients and 69.0% of TG patients. Abdominal distension and dislocation of the tube were main reasons for ceasing the EN feeding. According to period of the EN feeding, patients were divided into two groups: EN completed group (EN was done for 5-7 days) and EN discontinued group (EN was done for less than 5 days). These two groups and TPN group (comprising of 105 cases of DG patients and 66 cases of TG patients who were operated on befors July 2001 and applied TPN after operation) were compared in terms of changes in laboratory data and the patient's clinical course. Serum albumin levels, total lymphocyte counts and CRP were recovered earlier in the EN completed group than in both the EN discontinued group and TPN group. Incidence of postoperative inflammatory complication was lower in the EN completed group. Postoperative early enteral feeding can be carried out safely on gastrectomised patients and has beneficial effects from the nutritional and clinical aspects.

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The purpose of this study was to examine the possibility of early start in oral intake after surgery for colorectal cancer under laparotomy. Subjects were 67 patients with colorectal cancer undergone elective surgery under laparotomy. They were scheduled to be removed a gastric tube on the 1st postoperative day; to start drinking in the evening of the 1st or in the morning of the 2nd postoperative day; to start liquid diet from the evening of the 2^nd postoperative day; to start thin rice gruel (‘sanbugayu’) from the morning of the 3^rd day; and then to thicken rice gruel to ‘gobu-gayu’ and ‘zen-gayu’ from the morning of the 4^th and 5^th postoperative day, respectively. As a result, 39 patients were able to follow the schedule perfectly, 14 patients were able to start oral intake after one-day behind of the removal of gastric tube; and namely, 80% of the patients were able to take usual diet orally one week after operation.
It is conventionally recommended for postoperative patients with colorectal cancer to start oral intake after evacuation and defecation are confirmed and no suture failure is identified. However, we think that early start in oral intake is possible for postoperative patients with colorectal cancer under laparotomy and it may not pose problems from the standpoint of safety including complications.

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Influence on perioperative risks of hepatectomy in the presence or absence of psychiatric disorder was examined in this retrospective study. Subjects were 82 hepatectomy cases of 72 patients performed in our department between April 1996 and July 2003. These cases were divided into two groups; 13 hepatectomy cases of 11 patients with psychiatric disorder were assigned to the coexisted group and 69 hepatectomy cases of 61 without psychiatric disorder to the non-existed group. Perioperative results (operative method, operation time, quantity of hemorrhage, blood transfusion, postoperative complication, and postoperative hospital stay) were compared between both groups. There was no significant difference in background factors such as age, sex, liver function, and operative method between them. Incidences of resistance to medical treatment and physical restriction needed in postoperative course were significantly higher in the coexisted group than in the non-existed group. However, there was no significant difference in the frequency of physical complications and duration of postperative hospital stay. The hepatectomy can be performed with equal safety whether patients have psychiatric disorder or not, and so, coexistence of psychiatric disorder is unlikely to rise risks of hepatectomy.

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While intraarterial administration of hepatic chemotherapy via an implantable port is common, life-threatening complications such as port infection have been reported. We report a patient who underwent construction of a bypass between the right external iliac and superficial femoral arteries prior to removal of the infected port. A 60-year-old man with liver metastasis after low anterior resection for rectal cancer underwent insertion of an arterial infusion catheter through the right common femoral artery into the hepatic artery. The port was placed in the right groin. Fifteen months after implantation, the patient was referred for high fever and right groin pain. Clinical inspection showed port infection necessitating emergency surgery. We first created a right external iliac-superficial femoral artery bypass using the left great saphenous vein as a graft. The bypass was placed well away from the infected port. All wounds were closed and covered with film dressing before port removal. The common femoral artery was ligated and the right external iliac artery was ligated distal to the proximal anastomosis. Postoperatively, the patient was found to have hepatic and splenic abscesses and a hepatic artery aneurysm. He nonetheless recovered with conservative therapy and was discharged from the hospital on postoperative day 40.

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Malignant lymphoma of the breast is rare, accounting for 0.04-0.5% of all malignant diseases of the breast, or about 2.1% of all extranodal malignant lymphomas. It is especially rare that the disease occurs in pregnant or lactating women, and most reported cases in such women are of Burkitt's lymphoma pathologically and few cases are of diffuse B-cell lymphoma, which is common in usual cases. We report a case of diffuse B-cell type lymphoma of the breast in a pregnant woman.
A-30-year-old woman at 13 weeks' gestation presented with a mass in the left breast. We diagnosed the mass as primary malignant lymphoma (PML) diffuse B-cell type in stage I E by an excisional biopsy. After therapeutic termination of pregnancy, chemotherapy with CHOP was done.
It is difficult to distinguish PML of the breast from breast carcinoma without using pathological diagnosis. In this case, we could diagnose and treat by fine needle aspiration cytology and lumpectomy with chemotherapy. It is important to avoid unnecessary extended operation and to employ appropriate therapies in such cases.

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We treated a patient surgically for refractory hypercalcemia due to mediastinal metastasis from parathyroid carcinoma. A 55-year-old man suffering from general fatigue, thirst, polyposia, and polyuria had been operated on 3 times for parathyroid tumor. When admitted for duodenal perforation elsewhere, he was found to have hypercalcemia and chest computed tomography showed a mediastinal parathyroid tumor, for which he was admitted for surgery. Serum calcium was abnormally high, and preoperative attempts to normalize it by pharmacotherapy failed. We extirpated the tumor by sternostomy. Postoperatively, his serum calcium returned to normal and he was free of preoperative symptoms. Pathological findings showed mediastinal metastasis from previous parathyroid carcinoma. Hypercalcemia requires emergency treatment, so localization should actively consider ectopic parathyroid tumor in repeated or refractory cases. Any tumor must be completely resected if the prognosis is to be favorable.

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A 69-year-old woman admitted for severe abdominal pain showed no abnormal findings in electrocardiography on admission.
Emergency surgery under general anesthesia revealed a perforation of the anterior wall of the bulbus of the duodenum. The perforation was closed by omentum with drainage. The next day, she complained general fatigue without chest pain and was diagnosed to have congestive heart failure by chest radiography. Electrocardiography showed ST-T elevation and negative T wave in V2-5. Echocardiography showed ventricular hypokinesis and plasma toroponin was elevated. She was treated for suspected acute myocardial infarction and recovered from heart failure by postoperative day 9. On 29 postoperative day cardiac catheterization was performed and it showed no significant coronary artery stenosis and ventricular motion was almost normal. “TAKOTSUBO” cardiomyopathy was suspected which is very similari to acute myocardial infarction but has a better prognosis.
“TAKOTSUBO” cardiomyopathy may occur perioperatively, leading to severe complications such as heart failure and shock in the clinical course.

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A 60-year-old woman who had undergone 2 operations for lumber herniation developed congestive heart failure 16 years after the second operation caused by a left iliac arteriovenous fistula. The patient was successfully operated on by direct closure of the fistula from inside of the left common iliac artery. After surgery, symptoms of congestive heart failure were ameliorated. This woman had no history of abdominal injury or iliac arterial aneurysm, and operation for lumber herniation was suspected to be the cause of the arteriovenous fistula.

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We reported a case of spontaneously ruptured aneurysm of the middle colic artery. A 53-year-old man was brought into the hospital by ambulance because of sudden onset of abdominal pain and consciousness disturbance. On arrival, tha patient was in a shock status and physical examination revealed abdominal distention and severe upper abdominal tenderness. An abdominal CT scan showed intraabdominal hemorrhage and a huge hematoma in the mesenterium of the transverse colon. Emergency angiogram demonstrated an aneurysm of the middle colic artery and extravasation of contrast media from this point. Because the transcatheter arterial embolization (TAE) failed, we converted the hemostatic procedure to emergency laparotomy. At surgery, pulsatile bleeding from the ruptured aneurysm of the middle colic artery was identified. This affected vessel was ligated proximally and distally. The postoperative course was uneventful and the patient was discharged from the hospital on the 18th postoperative day. We should select either TAE or surgery for the ruptured visceral artery aneurysm in accordance with the patient's general condition after consideration of the characteristics of each procedure.

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A 62-year-old man who visited a physician because of a pain covering from the left chest to back was found to have fractured ribs, and referred to the hospital. After admission, multiple tumors involving the ribs in the left chest were identified on chest CT scan, and the patient was operated on. At surgery, the chest wall including four ribs from the left 7^th to 10^th was removed. Since the surgical defect was as large as 15×10 cm in diameter and reconstruction by using Marlex mesh alone might result in deformity in the thorax, we employed a titanium reconstruction plate for the reconstruction. No flail chest wall or inflammation occurred and his postoperative course was uneventful. He has been free from recurrence as of 3 years after the operation. With the use of titanium reconstruction plate, the deformity in the thorax was minimal and his pulmonary function has been kept favorable.

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A 46-year-old woman seem for a cough and fever in March 2001 had suffered from repeated pulmonary infections, and chest CT revealed pneumonia of the right lower lung. The aberrant artery was identified with MRI and DSA, which showed pulmonary sequestration classified as Pryce's classification type I. Arteriography of the aberrant pulmonary sequestration and pulmonary arteriography simultaneously undertaken before surgery showed correlation between pulmonary vessels (artery and vein) and the aberrant artery involved in pulmonary sequestration. This information was very useful in planning the radical surgery required.
The aberrant artery was estimated to be 1 cm in diameter and the wall was thick, so we chose open thoracotomy rather than video-assisted thoracic surgery (VATS). The large aberrant artery was identified, ligated, and cut out, and a right lower lobectomy of the aberrant artery undertaken. The postoperative course was uneventful and she left was dischanged on postoperative day 17. She has not returned for pulmonary infection treatment since then.

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Internal herniation through an abnormal defect in the broad ligament and catamenial pneumothorax are very rare. We report internal herniation through an abnormal defect in the broad ligament occurring in a case of catamenial pneumothorax. A 45-year-old woman was diagnosed with catamenial pneumothorax, with a history of 3 episodes of right peumothorax associated with menstruation in August 1999. Gn-RH analog therapy was started and peumothorax did not occur. On January 12, 2000, she reported severe abdominal pain. Abdominal CT showed an abnormal dilated ileum under the uterus and massive ascites. Emergency lapararotomy under a diagnosis of suspected stranglation ileus revealed. Massive ascites due to a necrotic ileum and internal herniation through an abnormal defect in the left broad ligament. The necrotic ileum was removed and the defect sutured closed. The postoperative course was uneventful. Eight months of hormone therapy was stopped at the woman's request in April 2000. She then experienced 3 episodes of pneumothorax. In video-assisted thoracic surgery (VATS) on October 17, 2000, we detected two blueberry-like pin-holes in the diaphragm and resected the abnormally thin part of the diaphragm. Endmetriosis of the diaphragm was not detected pathologically. Postoperative hormone therapy was continued. and pneumothorax occurred 2 and 3 years after surgery, but neither was severe.

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Late-presenting congenital diaphragmatic hernia (CDH) are a diagnostic challenge. This study was undertaken to define patterns of delayed presentation and treatment. Fifteen children with CDH were treated between 1993 and 2002. Of these, 4 (3 boys and a girl) or 26.7% diagnosed after the age of 2 months-2 years (median: 9.5 months) are reported. Clinical presentation included asthmatic attack, bad temper, cyanosis, pyrexia, vomiting, and abdominal distension. All showed intestinal gas within the left thorax, and were diagnosed as CDH. Diaphragmatic defects, all on the left side, were treated through an abdominal approach with primary closure of the defect without using a patch. All diaphragmatic defects were 2.5-5.0 cm in diameter, and lacked its hernia sac. The intrathoracic hernia contents were the small intestine and the colon in 3 patients, the spleen in 3, the stomach in 1, and the greater omentum in 1, respectively. Postoperative course was uneventful in each case, and all left the hospital within 3 weeks after surgery. No recurrence has been reported since then.

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A 72-year-old man referred for cough and back pain was found in CT and MRI to have a tumor 4 cm in diameter in back of the right kidney and protruding into the thoracic cavity. He underwent en block resection of the tumor and part of the diaphragm. The tumor was considered to have arisen from the diaphragm, because it could not be separated from the diaphragm, and was histologically connected there to. The histopathological diagnosis was storiform-pleomorphic malignant fibrous histiocytoma (MFH). Ten months after the operation, he died of local tumor recurrence. MFH is difficult to diagnose preoperatively because of its polymorphologic spectum. MFH occurring in the diaphragm appears to have a worse prognosis due to its deeper location than that in the extremities.

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A 52-year-old man was diagnosed with having esophageal leiomyoma and underwent laparoscopic tumor excision. He was postoperatively complicated with right pyothorax caused by the leakage in the esophagus. Despite of conservative treatments including surgical drainage, refractory esophagocutaneous fistula developed in a month. Fibrin glue with ×20 diluted thrombin was injected repeatedly into the fistula under esophagoscope. The abscess cavity got smaller subsequently, and the fistula was healed after 5 sessions of the treatment.
We employ ×20 diluted thrombin for injection of fibrin glue, because an in vivo experiment shows that it prolongs the coagulation time to more than a minute. This method enables fibrin glue to penetrate the whole periphery of the fistula followed by gradual coagulation, so that it entails a minimal rist of causing dead space. This simple technique with diluted thrombin seems useful, especially for complexed fistulae.

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A 76-year-old man with several episodes of consciousness disturbance was admitted to the hospital and was diagnosed as having gastric cancer. On admission the serum level of glucose was 45 mg/dl, however, the levels of insulin (1 μU/ml) and CPR (21.3 μg/day) were low or within normal limits. Endocrinological examinations revealed low level of IGF-I (36 ng/ml), and high level of IGF-II/IGF-I ratio. Abdominal CT scan showed multiple tumors in both hepatic lobes. No cerebral or adrenal abnormalities were seen. TPN management was started after admission, but consciousness disturbance due to hypoglycemia frequently occurred and the patient died of cancer 10 weeks after making the diagnosis. Histopathological examination showed poorly differentiated adenocarcinoma and immunohistochemcal staining for IGF-II was positive in tumor cells in gastric biopsy. Consequently the case was diagnosed as gastric cancer producing IGF-II, which caused extrapancreatic tumor hypoglycemia. IGF-producing tumors are common in patients with hepatic metastasis and have a poor prognosis. In this case we have great difficulty in treatment due to frequent episodes of hypoglycemia even by TPN management.

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A 65-year-old man was diagnosed as having esophagogastric varices and 0-IIa+IIc gastric cancer at the angular notch during treatment for primary biliary cirrhosis at another hospital. Endoscopic variceal ligation (EVL) was performed for esophageal varix and endoscopic mucosal resection (EMR) for gastric cancer. Thereafter the patient was referred to the department for operation because the gastric varix was left without treatment and the depth of tumor invasion of gastric cancer was sm. The patient was scheduled to undergo elective surgery, however, bleeding from the esophageal varix occurred again and it was managed with emergency EVL. Operative procedures included total gastrectomy and associated splenectomy. After the operation, a narrowing at the anastomosis developed which demanded endoscopic dilatation, but the esophageal varix completely disappeared.
We performed total gastrectomy with splenectomy for the patient with biliary cirrhosis with esopagogastric varices and gastric cancer, resulting in the patient's uneventful postoperative course.

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A case of ampullary cancer with splenic artery aneurysms (SAA) performed pylorus preserving pancreaticoduodenectomy (PPPD) is reported.
A 62-year-old woman seen at the hospital because of jaundice and vomiting was diagnosed as having ampullary cancer. After admission she was detected to have SAAs on preoperative CT. Abdominal angiography revealed two aneurysms with the diameter of 1.2 cm and calcification; one at the distal site of the splenic artery, and another one in the hilus of the spleen. In order to preserve the patient's immunoresistance and to insure the blood supply to the remnant pancreas and stomach after pylorus preserving PPPD, splenectomy had to be avoided.
We thus performed resection of the aneurysms, preserving the spleen, and PPPD with lymph nodes dissection. The patient's postoperative course was uneventful and the perfusion from the short gastric artery to the spleen was of excellent quality on MR angiography. Splenectomy can be avoided by determining the blood supply with the use of intraoperative ultrasonography, even if the aneurysms are at the distal site.

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A 39-year-old woman was referred to the hospital because of abdominal pain and vomiting. An abdominal CT scan demonstrated ileal obstruction and showed an irregular high density lesion near the dilated intestine. A long intestinal tube was inserted, but no symptomatic remission was gained. Furthermore, the CRP value rose rapidly. As strangulated ileus was suspected, emergency laparotomy was performed. A calcified nodule measuring 8 mm in diameter was found on the mesentery of the small intestine. An inflammatory cord that originated from the nodule had strangulated and necrotised the intestine. On histological study, the nodule was granuloma with polymorphocytic infiltration and a necrosed parasite was found within the nodule. The parasite was morphologically identified as an Anisakis simplex IV stage larva. It was concluded that old extra-gastrointestinal anisakiasis had caused strangulated ileus. Although the mechanism of strangulated ileus like in this case is quite rare, participation of extra-gastrointestinal anisakiasis should be considered as a probable cause if there is no other basis for strangulation, such as a history of laparotomy.

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An 83-year-old man was seen at the hospital because of attacks of asthma and abdominal pain. The abdomen remarkably distended and peritoneal signs were noted. Abdominal plain x-ray film showed intraabdominal free air. Then the patient was operated on with a diagnosis of peritonitis due to intestinal perforation. At surgery, air-filled cystic change extended over the diaphragm and small intestinal wall, and a partial excision of the small intestine including a portion where was suggestive of perforation was carried out. Pathologically there were cysts in the submucosal to muscular layers and sabserosal cysts, and fibrous hypertrophy and granulomatous change were observed in the vicinity of the cysts. From these findings, pneumatosis cystoids intestinalis was diagnosed.
Conservative therapy including hyperbaric oxygenation is the mainstay of treatment for the disease. But it would be important to differentiate from gastrointestinal perforation if the patient has peritoneal signs.

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A 74-year-old woman was admitted to the hospital because of abdominal distension and vomiting. A plain abdominal X-ray film showed air fluid level. The WBC number and CRP level were increased. Abdominal CT scan and ultrasonography (US) showed hepatic portal venous gas, but rebound tenderness and metabolic acidosis were not found on the first day of the admission. We treated conservatively under a diagnosis of intestinal obstruction. Eighteen hours later, however, CRP, LDH, CPK increased and peritoneal stimulating signs appeared. Emergency operation was performed with a suspicion of intestinal necrosis. At the time of laparotomy, entire the small intestine seemed necrotic or cyanotic. But after reducing the fluid in the dilated intestine, we could find only 180cm of necrotic ileum. No mechanical obstruction of the intestine was present and pulsations of the superior mesenteric artery was preserved. Her general condition was poor, so we resected the necrotic intestine and made jejunostomy and ileostomy. On 52nd day after the operation, we closed them by making end to side jejunocecostomy. She was discharged 55 days after the operation. Abdominal CT scan and US were useful for the diagnosis of necrosis of the intestine by showing clear hepatic portal venous gas prior to gaining physical and hematological results.

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We report a rare case of jejunal diverticula associated with massive melena and hemorrhagic shock. A 75-year-old woman with massive melena in hemorrhagic shock on June 1, 2002, was brought into remission by conservative treatment. Upper gastrointestinal endoscopic examination and colonoscopy revealed no bleeding site, but subsequent small-bowel barium ingestion showed multiple diverticula in the proximal jejunum. Under a diagnosis of massive bleeding from jejunal diverticula, we conducted a laparotomy on July 3. Multiple jejunal diverticula, distributed from 28 to 103 cm distal to the ligament of Treitz were resected. The 2 diverticula contained a blood clot. On histopathological examination, an exposed vessel suggestive of the source of bleeding was seen in resected jejunul diverticula. Although the diagnosis and treatment of limited intestinal bleeding is generally difficult, jejunal diverticula can be a cause of massive bleeding.

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A 69-year-old man was seen at the hospital because of right lower quadrant pain which started early in January and was intensified late in February. When he was first seen, there was tenderness in the right lower quadrant of the abdomen and a poorly movable and hard tumor about 7 cm in diameter was present at the same area. The white blood cell count was 10, 800/ul and CRP was 12.9mg/dl. Abdominal CT scan visualized a 5-cm tumor with slightly unclear border in the right lower quadrant. And a linear high density part with the length of about 3 cm was identified in the center of the tumor. Based on these CT findings and clinical history, perforation of the appendix due to a fish bone was diagnosed and surgery was carried out. At the time of surgery, a fish bone 2.5 cm in length perforated into the center of the appendix was seen, and a mass-formed ileocecal region was removed. The postoperative course was uneventful, and the patient was discharged from the hospital on the 17^th postoperative day.
Perforation of the appendix caused by a fish bone is often diagnosed during surgery, however, there have been some reports describing that preoperative diagnosis of the disease could be made from careful hearing of clinical histories and imaging findings including those of CT. It would be important to keep the disease in mind.

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An 86-year-old woman seen at the hospital because of abdominal pain and vomiting was diagnosed as having ileus based on an abdominal plain x-ray film. A gastric tube was inserted and conservative therapy was started, but sufficient depression could not be obtained. Abdominal echography showed prominent dilatation covering from the stomach to small intestine, and strong echo continued to the dilated small intestine at the posterior aspect of the cecum, where might be the site of obstruction. Abdominal CT scan also visualized significant dilatation of the small intestine and the dilated small intestine locating in the dorsal aspects of the cecum and ascending colon; the ascending colon was deviated ventrad. From these findings, occlusive ileus due to internal hernia in the vicinity of the ileocecal region was suspected, and surgery was performed. At surgery, the ileum by about 20 cm in length was incarcerated in the retrocecal pouch at a point about 30 cm proximal to the Bauhin's valve. So a partial resection of the small intestine was carried out.
Of all internal hernias, pericecal hernia is very rare, accounting for about 6%. Although the age of clinical manifestation and modes of the onset of the disease are variable, the disease must always be kept in mind when we encounter internal hernia.

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An 80-year-old woman complaining of right lower quadrant pain was referred to the hospital for close exploration. Abdominal CT scan visualized a cystic lesion 6 cm in diameter with a part of calcification on the intestinal wall, where was identical with the intestine from the ileocecal region to ascending colon. On coronal image, the impacted mesentery was seen at the caudal side of the cystic lesion, and the cystic lesion caused invagination within the ascending colon as the lead point. Colonofiberscopy revealed a ridge like a submucosal tumor toward the lumen of the ascending colon from the fundus of the cecum; its copular part which was associated with erosion seemed to be opening of the appendix. A biopsy resulted in group II. A fiberscope passed through the ileocecal valve. From these findings, intussusception due to mucinous cystadenoma of the appendix was diagnosed and ileocecal resection was carried out. The histopathological diagnosis was mucinous cystadenoma of the appendix.
This is a rare case of mucinous cystadenoma of the appendix causing intussuception, in which coronal reconstruction CT was helpful in diagnosis. Intraoperative frozen section diagnosis of regional lymph nodes demonstrated no malignant cells, and then we employed ileocecal resection.

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A 52-year-old man, who let abnormal bowel movements alone since early in August, consulted a physician because of abdominal pain and abdominal distention started in August 13. He was referred to the hospital with a diagnosis of ileus. Colonofiberscopy visualized a tumor causing complete obstruction at the descending colon. A gastric tube was placed and decompression was attempted, but in vain. Emergency operation was carried out on August 15. Upon laparotomy, a tumor completely encircling the descending colon was identified, the colon proximal from the tumor dilated, and a change in color to dark red extending until the middle of the transverse colon was observed. Obstructive colitis associated with cancer of the descending colon was thus diagnosed, and a left hemicolectomy was carried out.
Complete resection of the ulcerated and necrotic area including the primary lesion is the principle of therapy for the disease, but it results in massive removal of the intestine. And it is a fact that the muscular layer at the ulcerated area is kept intact. From the standpoint of these facts, it may be an option to perform anastomosis at the ulcerated area like in this case.

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An internal malignancy metastasized to the umbilicus is known as Sister Mary Joseph's nodule. which is comparatively rare. We report herein on a resected case with a synchronous umbilical metastasis of colon carcinoma. An 89-year-old female had visited an internal medicine clinic near-by with pain and a tumor on her umbilicus. Physical examination showed a nodular tumor about 2 cm in diameter on her umbilicus and a palpable mass in the right lower abdominal region. An endoscopic examination revealed a cecal cancer. We performed a right hemicolectomy and resection of the umbilical tumor on March 12, 2003. There were no metastases to liver or peritoneal dissemination. The continuation with the cecal cancer and the umbilical tumor was not recognized. Histopathological examination revealed a cecal cancer and an umbilical metastasis of a moderately differentiated adenocarcinoma. The patient had an uneventful postoperative course, and was discharged from our hospital.
Our first appreciation of the ominous prognostic significance of the primary malignant lesions might well have been due to the presence of the umbilical metastasis.

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A 72-year-old woman was referred to the hospital because of anemia found at another hospital. With digital examination, rectal carcinoma was diagnosed. She had history of situs inversus, however, she had no associated malformation on CT scan. With a preoperative diagnosis of rectal carcinoma with situs inversus tatalis, we performed abdominopenineal excision. At the time of surgery, the liver was on the left side and the stomach on the right side, showing situs inversus tatalis. No malrotation or vascular anomaly was found, so that we had no serious problems during surgery. This is, to our knowledge, the third case of rectal carcinoma with situs inversus tatalis in Japan. We report this case, together with some bibliographical comments.

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A 75-year-old man with a 6-year history of recurrent anal pain, swelling and pus discharge was seen at the hospital because of intensifying anal pain started in May 2001. A 5×3 cm tumor was preset in the direction of two o'clock of the anus. And second openings were identified at one, three and five o'clock, at where mucin like secretions were identified. A biopsy of the tumor resulted in malignancy. Preoperative barium enema study revealed the depressed anal canal, but visualized no lesion. CT scan showed a low density lesion with irregular enhancement in the left side of the ischiorectal fossa, but it was obscure. Magnetic resonance imaging (MRI) scan, meanwhile, visualized the tumor clearly as a lesion with high intensity on T2-weighted image.
Since cancer arisen in an anal fistula often shows extramural growth, we have great difficulties in specifying the area involved by endoscopy and barium enema. In this case T2-weighted image of MRI was very helpful to make diagnosis of the extent of the cancer.

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We present a case of anorectal primary amelanotic malignant melanoma, together with a review of the Japanese literatures. A 72-year-old man with fresh anal bleeding was found to have a slightly dark reddish polyp above the dentate line. Histological studies of the biopsy specimen showed poorly differentiated adenocarcinoma. After local excision, histological examination of the resected specimen showed pleomorphic tumor cells with large vesicular nuclei. Tumor cells stained positive for S-100 protein and HMB-45 antibody even though almost no melanin granules detected. Four months after surgery, local recurrence in the anorectum necessitated local excision again. Two years after the first operation, no recurrence has been observed. We cannot overemphasize the need for early detection of the disease and careful observation to improve the prognosis.

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A 66-year-old man who had been followed for chronic hepatitis C virus infection was found to have a 4.8×4.6 cm hepatoma in the posterior segment of liver and paratroop lymph node metastasis in the dorsal aspect of the pancreqs head by ultrasonogrphy in August 2000. Alpha-fetoprotein (AFP) level was high, 9820. 7 ng/ml. In November 2000, AFP decreased to 2741. 8 ng/ml and the hepatoma also decreased to about 2 cm in diameter without therapeutic intervention. Paraaortic lymph node swelling increased in size despite spontaneous regression of the hepatoma. AFP showed a constant increase upto 21164. 9 ng/ml in Februaly 2002. Lymph node dissection was performed in April 2002. No hepatoma could be detected intraoperative ultrasonography. Four months after the surgery, AFP increased again after transient decrease and a 3-cm sized new lymph node swelling appeared in the ventral aspect of the pancreas head. The hepatoma did not show enlargement. Although no treatment was given, the hepatoma, lymph node metastasis and AFP were stable a year after surgery.
Spontaneous regression of hepatocellular carcinoma like in this case rarely occurs, and it is very interesting that the primary and metastatic lesions exhibited contrary behavior each other.

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Patient 1 was a 69-year-old woman who underwent cadaveric renal transplantation with immunosuppressive therapy in 1988. In 1995, she was found to have hepatocellular carcinoma 6 cm in diameter in S8 of the liver by abdominal ultrasonography. Because she had HBV hepatic cirrhosis and her ICG15 value was 32%, transcatherter arterial embolization (TAE) was performed. In 1996, multiple recurrence of carcinoma was observed in the bilateral lobes. Although TAE and PEIT were performed again, the patient died of cancer. Patient 2 was a 72-year-old man who underwent cadaveric renal transplantation with immunosuppressive therapy in 1990. In 2001, he was found having hepatocellular carcinoma in the S4 by abdominal ultrasonography. The patient was HBV positive and had an ICG15 value of 10% and solitary hepatocellular carcinoma (T2, N0, M0), so that he underwent left hepatic lobectomy. Postoperative acute rejection reaction associated with surgical invasion occurred, and intravenous tacrolimus at a dose of 0.01 mg/kg/hr was administered continuously to maintain the blood concentration of at least 20 ng/ml. The patient was discharged from the hospital without serious complications on the 20^th hospital day. He is alive with normal renal function and has been free from recurrence of carcinoma 24 months after surgery.

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We report 2 cases of acute emphysematous cholecystitis with intrahepatic gas. Case 1: A 65-year-old man with a history of diabetes admitted for abdominal pain and fever about 6 weeks after undergoing total esophagectomy for esophageal cancer was found in computed tomographic (CT) to have gas in the gall bladder and pneumobilia. He underwent cholecystectomy and choledocholithotomy. Case 2: A 68-year-old man admitted for syncope was found in initial CT to have gas in the gall bladder and intrahepatic portal vein. On the day after the admission, he had severe abdominal pain and CT showed perforation of the gall bladder. He underwent emergency cholecystectomy and lavage. It is Emphysematous cholecystitis is rarely accompanied by pneumobilia or by portal venous gas. The disease tends to deteriorate rapidly, making early diagnosis and appropriate management important.

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Traumatic neuroma in the biliary system is a nonneoplastic overgrowth of nerve fibers including Schwann cells around the bile duct to form a node covered with nerve fibers. It is often caused by injuries of nerve fibers around the bile duct due to surgical operations. Recently we experienced a case of traumatic neuroma in a patient who developed complete occlusion of the common bile duct after having undergone biliobiliary anastomosis, which was diagnosed by pathological examination.
A 70-year-old woman was seen at the hospital because of general fatigue and jaundice, and was admitted with a diagnosis of acute pancreatitis and cholecystitis. Laparoscopic cholecystectomy was carried out after inflammation subsided, however, the common bile duct was injured and biliobiliary anastomosis of the common bile duct was performed. On the 7^th, month after the operation, the patient was readmitted to the hospital because of cholestatic jaundice. With imaging methods complete occlusion of the common bile duct was identified. Abdominal CT scan visualized tumor shadow. A possibility of malignant disease could not be ruled out, and the patient was operated on again. Traumatic neuroma of the bile duct was definitely diagnosed with postoperative histopathological exploration.

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We report two cases of laparoscopic cholecystectomy (LC) for Mirizzi syndrome with liver cirrhosis. Patient 1, a 49-year-old man, admitted to another hospital because of local pain in the right upper quadrant, was referred to our hospital with a diagnosis of Mirizzi syndrome with liver cirrhosis. He underwent LC. Patient 2, a 71-year-old man, who had been treated liver cirrhosis in another hospital on an ambulant basis was referred to our hospital with a diagnosis of cholecystitis. He was diagnosed as having Mirizzi syndrome with liver cirrhosis and was performed LC. Postoperative complications occurred in both cases; postoperative bleeding in patient 1 and 2 and postoperative ascites in patient 1. In the case of requiring a long time for difficult dissection or hemostasis in LC, postoperative complications might occur. So it is considered that the shift to subtotal cholecystectomy and laparotomy should always be set in mind about LC for Mirizzi syndrome with liver cirrhosis.

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An 87-year-old woman with a history of cholelithiasis and senile dementia suffering swelling with fever and redness in the right lower quadrant (RLQ) was found in abdominal US and CT to have a possible subcutaneous abscess in the RLQ and an intraperitoneal cystic lesion with calcified stones connected to the subcutaneous lesion. In emergency surgery, the intraperitoneal lesion proved to a chronic inflamed floating gall bladder and the subcutaneous lesion was a spontaneous cholecystocutaneous abscess. Similar to spontaneous cholecystocutaneous fistulas, spontaneous cholecystocutaneous abscess is rare. We report the first case, to our knowledge, of floating gall bladder complicated with spontaneous cholecystocutaneous abscess.

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We report a case of adeno-endocrine cell carcinoma of the gallbladder with a giant lymph node metastasis. A 71-year-old woman referred to the hospital for right dorsalgia with a diagnosis of gallbladder cancer was found to have a solid tumor 4 cm in diameter at the gallbladder and a lymph node 5 cm in diameter at the back of the pancreas on computed tomography (CT). Magnetic resonance cholangio-pancreatography (MRCP) showed a defected image due to the solid tumor. Pancreaticoduodenectomy and extended cholecystectomy (+D3+18) were conducted. Microscopically, the gallbladder tumor consisted of poorly differentiated adenocarcinoma and ednocrine cell carcinoma (ecc) cells for the most part and poorly differentiated adenocarcinoma only on the surface. On immuno stainings were positive for NSE and negative for chromogranin and grinelius. Lymph node metastasis was seen only at the back of the pancreas head, which was composed of ecc cells. The endocrine cell carcinoma is reported to have a high malignant potential. Frequent lymph node metastasis, hepatic involvement, and vascular invasion occur, in the early state. Our case showed extraordinal occurrence, as solitary huge lymph node metastasis of ecc. The patient is followed carefully and has been asymptomatic for seven months after the operation.

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A 70-year-old man, treated with radiotherapy to inguinal lymph node metastasis after cystectomy for bladder cancer, underwent percutaneous transhepatic cholangiodrainage (PTCD) becaused obstructive jaundice developed five months after the radiotherapy. Abdominal ultrasonography and computed tomography. PTCD tube-cholangiography showed no abnormalities except stenosis of the lower common bile duct and swelling of the pancreatic head. Endoscopic retrograde cholangiopancreatography revealed smooth stenosis encirculing the lower common bile duct in the head, magnetic resonance imaging scan showed tapering narrowing of the main pancreatic duct in the head without showing no dilatation of the pancreatic body and tail. He underwent laparotomy because cancer of the pancreatic head could not to be ruled out completely. Cholangiojejunostomy was performed because intraoperative rapid biopsy of the diffuse hard pancreas gave the histopathological diagnosis of chronic pancreatitis. The excised pancreas and bile duct revealed severe fibrosis at the pancreatic parenchyma and infiltration of inflammatory cells including lymphocytes and plasma cells. Postoperative immunochemical study suggested autoimmune pancreatitis; eosinophilia, hyper γ-globulinemia, elevated IgG and positive responses to autoantibodies. The inguinal lymph node matastasis recurred seven months after the operation and the patient died of bone metastasis of bladder cancer. It is considered that autoimmune pancreatitis is very important as differential diagnosis of obstructive jaundice with stenosis of the lower common bile duct.

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We report a rare case of intrapancreatic accessory spleen mimicking non-functional islet cell tumor. A 35-year-old man complaining of watery diarrhea and epigastralgia was admitted to the hospital because urtrasonography showed a hypoechoic mass measuring 1 cm in diameter in the tail of pancreas. The pancreatic mass was confirmed in the early phase of enhanced computed tomograph and T1-and T2-weighted magnetic resonance imaging (MRI) scan revealed a low intensity mass. Abdominal angiography demonstrated a hypervascular mass. Serum level of each pancreatic hormone was within a normal limit. Both the pancreatic tail and spleen were resected with a diagnosis of non-functional islet cell tumor or accessory spleen. Histological examination revealed normal splenic tissue and confirmed an accessory spleen within the pancreatic tail. We have often difficulty in differentiating islet cell tumor from accessory spleen within the pancreas tail clinically and based on imaging methods except T2-weighted MRI which may contribute to differentiation between them. We should consider Tc-99m phytate scintigraph or superparamagnetic iron oxide MRI if we encounter a hypervascular mass in the pancreatic tail.

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We report a case of lymphoepithelial cyst of the pancreas. A 70-year-old man with left flank pain found in abdominal ultrasonography to have a mass in the pancreatic tail was admitted for detailed examination. Enhanced computed tomography showed a 4 cm multilocular cystic lesion in the tail of the pancreas. Endoscopic retrograde pancreatography showed a normal duct system. Since we could not exclude possibility of a malignant tumor because elevated serum CA19-9 and CEA, we conducted laparotomy. The mass resected in combination with distal pancreatectomy and splenectomy was diagnosed histopathologically as a lymphoepithelial cyst of the pancreas. The postoperative course was satisfactory. Elevated serum CA19-9 and CEA decreased to within normal range after surgery. Preoperative diagnosis of lymphoepithelial cysts of the pancreas is still difficult because it resembles other cystic neoplasms of the pancreas in imaging and elevated serum tumor markers such as CA19-9 are often detected.

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We report a case of resection of repeated pancreatic metastasis of renal cell carcinoma (RCC) in the remnant pancreas 5 years and 6 months after pylorus-preserving pancreatoduodenectomy (PPPD). A 56-year-old man underwent left nephrectomy for RCC in February 1993 and PPPD for pancreatic RCC metastasis in December 1995. In July 2001, he was referred with remnant pancreatic tumors and a right renal tumor seen on abdominal CT. Celiac angiography showed a hypervascular tumor in the remnant pancreas. The remnant pancreas was resected with splenectomy in July 2001 and the right kidney partially resected in September 2001. All tumors were histologically diagnosed as clear cell RCC metastasizing to the remnant pancreas and the right kidney. The postoperative course was uneventful and the man remains well with no evidence of recurrence in the 2 years and 6 months since surgery.

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Splenic artery aneurysms are potentially life threatening because these may rupture and lead to fatal hemorrhage. A 45-year old woman with splenic artery aneurysm was successfully treated by a laparoscopic resection with alternative technique. Using a snake retractor, we hunged-up the splenic hilum, and the splenic artery was ligated doubly, and then the aneurysm and distal hilum were transected. She was discharged from the hospital uneventfully. Laparoscopic splenectomy can be expected to shorten the postoperative hospital stay and to lessen the postoperative pain compared with the conventional open repair, so that the technique should be considered actively for splenic artery aneurysm. With splenic hilum hang-up technique using a snake retractor, we could deal with the splenic hilum safely.

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We report a case of malignant tumor of the spleen which was detected during close inspection for fever of unknown origin. A 60-year-old man with lasting high fver was referred to the hospital with a suspicion of splenic abscess. Abdominal CT scan visualized a splenic tumor 14×12.5×12 cm in dimension. Abdominal ultrasonography, magnetic resonance imaging scan and angiography offered a suspicion of splenic abscess, though a possibility of malignancy could not be ruled out. His high fever dropped by administration of antibiotics. Because the spleen was so huge, a splenectomy was carried out, when 650 ml of dark-red fluid content was aspirated. Histological examination revealed malignant tumor cells of the spleen, but no definite diagnosis was made even by immunohistochemical methods. Finally unknown malignant tumor of the spleen was diagnosed. He died of liver metastasis 4 months after the operation.

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During surgery for giant extraadrenal pheochromocytoma, it is necessary to control blood pressure and anticipate unexpected bleeding. A 51-year-old man who had an episode of hypertension and atrial fibrillation 15 years earlier was found in ultrasonography to have a giant abdominal nodule diagnosed as extraadrenal pheochromocytoma. The tumor was resected with the right kidney. Intraoperative blood loss was 4986 cc and 2100 cc of collected autologous blood transfused intraoperatively. Autotranfusion was begun before tumor removal and continued until the end of the operation. Blood pressure changed sharply before removal but was stable after removal. The resected specimen was 13×7.2×5 cm and benign. Intraoperative collected autologous blood transfusion contains some catecholamine and tends to elevate the blood pressure in pheochromocytoma, but careful monitoring hemodynamic changes and the preoperative rate of dopamine ensures a safe result.

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An 83-year-old woman underwent low anterior resection in July 2002 for rectal carcinoma. A left adrenal tumor was found incidentally during CT prior to the first operation. The tumor was diagnosed as a nonfunctioning adrenal adenoma and was not resected at the first operation. She was readmitted in January 2003 for general examination. The left adrenal tumor had increased in size, and a liver tumor had appeared in CT scan, yielding a diagnosis of solitary liver metastasis and left adrenal metastasis from the rectal carcinoma and necessitating left adrenectomy and right lobectomy of the liver. Subsequent histological examination showed that the liver tumor was actually liver metastasis from a left adrenal cortical carcinoma. The patient died due to multiple liver metastases 8 months after the second operation. Adrenal cortical carcinoma is difficult to diagnose during its early stages, and we recommend that incidental adrenal tumors be carefully followed up.

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We report a case of endometriosis of the intestine with severe narrowing from the rectum to sigmoid colon, with great difficulty in differentiation from colorectal cancer. A 47-year-old woman was seen at the hospital because stool guaiac test was positive at a medical checkup. Barium enema study and colnofiberscopy showed severe narrowing from the rectum to sigmoid colon. Each biopsy repeated two times resulted in group 1, and endometriosis was a probable diagnosis. Through examination was conducted at the department of gynecology, but they thought that endometriosis was unlikely. Since there was a possibility of colorectal cancer, anterior resection was carried out. At the time of surgery, severe adhesions between the posterior wall of the uterine and rectum were present, and intraoperative frozen section diagnosis of the tissue was endometriosis. For this bilateral oophorectomy was added.
We think that intraoperative frozen section pathological diagnosis is useful for diagnosis of intestinal endometriosis which is undiagnosed before surgery.

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A case of thrombotic thrombocytopenic purpura (TTP) presented with iliopsoas abscess is reported. A 67-year-old man was admitted to the hospital because of high fever and lumbago. On admission, abdominal CT scan demonstrated low dense mass in the both side of iliopsoas muscle. The patient was diagnosed as having iliopsoas abscess, and laparotomy with drainage was performed. Laparotomy revealed no spread of inflammation from adjoining organs, and the iliopsoas abscess was thought to occur idiopathically.
The patient also had thrombocytopenia, hemolytic anemia, mental alienations, high fever and renal dysfunction before through after the operation. The case was diagnosed as TTP presented with iliopsoas abscess.

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A 9-year-old boy who had previously undergone abdominal surgery twice and reported right lower abdominal pain, was found to have a palpable solid mass in his abdomen, with a subjunctive diagnosis of either an inflammatory mass or an malignant tumor. Antibiotics administered for 2 weeks did not reduce the tumor size, necessitating surgery. Frozen section biopsy during surgery confirmed its benign nature. The postoperative course was uneventful. The diagnosis of actinomycosis was made based on microscopic findings. ABPC was administered orally for a year, and the residual mass disappeared.

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