Parathyroid carcinoma is a rare entity in parathyroid neoplasms that cause primary hyperthyroidism (PHPT) and is often difficult to diagnose preoperatively. We studyied clinical features of 6 patients with parathyroid carcinoma (2.6%) from among 235 patients with PHPT undergoing surgery in the last 36 years. Compared to cases of parathyroid adenoma, findings in parathyroid carcinoma of palpable neck mass (p<0.0001 vs. adenoma), a larger mass (p<0.0001), bone disorders (p=0.04), and higher levels of calcium (p=0.0002) and parathormone (p=0.0005) were significant for diagnosis. PHPT meeting these clinical features turned out to be malignant and are important in determining surgical procedures.

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Cystic tumors of the mediastinum have been thought to be relatively rare, but those tumors have increasingly been encountered in daily clinical scenes with an improvement of imaging techniques and diagnosis. Although the majority is for the opinion that cystic mediastinal tumors should be followed because of their benign nature, surgical resection is often indicated for thymic cysts. So we made a retrospective clinical study, and enrolled 68 cases of mediastinal cystic tumor-s operated on at the department.
As for initial manifestations, 75.8% of all subjects were asymptomatic. Of mediastinal cystic tumors, the ratio of thymic cysts was highest, accounting for 42.4% of all tumors. The most frequently employed operative procedure was video-assisted thoracoscopic surgery (VATS), accounting for 48.5% of them. Patients groups undergone VATS and median sternotomy or lateral thoracotomy were compared for postoperative hospital stay, with a statistically significant difference.
In earlier years median incision of the sternum had been frequently used even for thymic cysts aiming at complete removal of the cysts. But in recent years, the operative procedures for the disease have been established and the less invasive VATS is primarily employed for cystic tumors of the mediastinum.

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We conducted a questionnaire survey asking patient's and/or family member's wish to be told the true diagnosis when they were first seen at the hospital from July 1999 to May 2001, and we told about the diagnosis to them according to the results of the survey. We told the diagnosis to 60 out of 73 patients with respiratory malignant tumor to be operated on, based on the results of the survey. Nine (12%) of those 60 patients presented postoperative depressive condition, and three (4%) of the nine patients developed depression that required psychiatric therapy. All the three patients with depression were those who desired to be told but whose family members disagreed; the family members knew well that their emotional ability to accept the truth might be doubtful. After June 2001 when we started to consider well the family's intention, a proportion of patients who presented postoperative depressive condition de-creased to 7% (seven out of 103 patients), and no patients developed depression probably due to the truth-telling.
It is clarified that the truth-telling to the patient based on the questionnaire survey conducted when he or she is first seen is a valuable method, and that the family's opinion is very helpful to grasp some patients whose emotional ability to accept the diagnosis may be doubtful.

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To clarify the effect of lymph node removal at the root of the inferior mesenteric artery on curative resection in colorectal cancer, we studied patients with cancer of the rectum and sigmoid colon. Nine of 697 (1.29%) showed lymph node metastasis at the root of the inferior mesenteric artery. Eight of the 9 (n3(+) group) showed recurrence following curative resection. Of 463 patients, 24 (5.18%) showed lymph node metastasis along the superior rectal artery or the sigmoid artery (the intermediate lymph node). Of the 24 (n2(+) group), 14 showed recurrence following curative resection. Cumulative 5-year disease-free survival was 33.3% in the n3(+) group and 45.8% in the n2(+) group. Cumulative 10-year disease-free survival was 0.0% in the n3(+) group and 41.3% in the n2(+) group (p=0.045). In conclusion, the positive effect of lymph node removal at the root of the inferior mesenteric artery is negligible in patients with n3(+) colorectal cancer.

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Trainees in the new board certification curriculum of surgical specialization must be able to manage the initial care of trauma patients, triage polytrauma patients, and determine indications for emergency surgery after completing a 3-month training course at the emergency center. We studied 1, 384 neck-chest-abdominal trauma and polytrauma patients treated mainly by surgeous at our emergency room (ER). These included 270 cardiopulmonary arrest (CPA) patients and 495 patients (225 non-CPA and 270 CPA) undergoing emergency surgery. The planning of training in the board certification of surgical specialization was discussed based on the hourly incidence of trauma patients and their surgery. Trauma patients were mainly transferred during the night shift, with an average of 14.9 non-CPA trauma patients (26.7%) transferred during the day shift and 40.8 during the night shift in 3 months. Surgery was also mainly done during the night shift, i. e., 3. 0 non-CPA patients (26.2%) and 7.0 of all trauma patients (including CPA) underwent surgery during the day shift and 8.3 non-CPA and 17.8 of all trauma patients, during the night shift in 3 months. We concluded that surgeon trainees receive adequate oppotunity for initial trauma patient care and surgery if they work exclusively at the emergency center and are on frequent night duty.

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We report a case of superior mesenteric artery syndrome (SMAS) associated with primary hyperthyr-oidism. A 29-years-old man with voluminous vomiting referred to an orthopedic surgeon for a fracture of right femoral cervix.
He had hyperthyroidism untreated for the last 2 years. His thyroidal function was greatly elevated, and radiological studies demonstrated the interruption of the horizontal portion of the duodenum due to compression by the superior mesenteric artery. Under a diagnosis of SMAS, we started conservative treatment with intravenous hyperalimentation. His condition improved in about 2 weeks to where we could medicate his hyperthyroidism per os.

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Diabetic mastopathy is an unusual benign fibroinflammatory breast lesion that presents in hongstanding diabetes mellitus. Differential diagnosis from breast cancer may be difficult, because imaging studies and clinical findings are similar. We report 5 cases of diabetic mastopathy in women aged 34 to 73 years old. Two had insulin-dependent diabetes mellitus and 3 noninsulin-dependent diabetes mellitus. Three have been receiving insulin therapy. On palpation, all had a firm breast tumors. Mammography showed tumor shadows in 2 cases. Ultrasonography showed hypoechoic lesions with unclear borders. Fine-needle aspiration biopsies were all negative and core needle biopsies or incisional biopsies we required to confirm diagnosis. Pathologic examination showed dense keloidal fibrosis and periductal and perivascular lymphocytic infiltrates in all cases, findings compatible with diabetic mastopathy.

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A 72-year-old woman seen for an irregular tumor 3 cm in diameter at CD of the left breast was found in ultrasonography to have a tumor with a partially unclear border, internally heterogeneous, partially cystic, and hypoechogenic. Mammography was classified as category IV. In mammary MRI, the tumor showed low intensity in T1 enhancement and high intensity in T2 enhancement, had a relatively clear border, and was enhanced from early to late phases, suggesting malignancy. In needle aspriation biopsy, cell clusters showed the loss of a two-cell pattern, high N/C ratio, irregularly shaped nuclei, high chromatin density, and many cytoplasmic inclusion bodies, diagnosed as class V. Left mastectomy was done under a diagnosis of left breast cancer. Histologically, mammary duct epithelium had increased with myoepithelium around it, yielding a diagnosis of adenomyoepithelioma in immunohistochemistry. Adenomyoepithelioma is a rare tumor difficult to diagnose preoperatively with imaging between cancer and adenomyoepithelioma. Immunohistochemical findings are thus required for a definitive diagnosis.

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A 51-year-old woman undergone a left mastectomy for malignant phyllodes tumor of the left breast 3 years earlier developed fever and a cough and noticed a subcutaneous tumor at the parietal region. Chest CT scan revealed tumors in the right thoracic cavity and left upper lobe of the lung. Upper gastrointestinal endoscopy disclosed a lesion with hydrophthalmia finding, type I like finding, and irregular elevation. Biopsies of the intrathoracic and gastric tumors showed similar histologic findings to those of previously resected malignant phyllodes tumor of the breast. Heterochronous metastases were diagnosed. Since the both tissues were c-kit positive, chemotherapy with imatinib mesylate was given. Macroscopically a slight diminishing effect for the subcutaneous metastasis of the parietal region was confirmed, however, the patient's general condition deteriorated and she died.
There are many reports on hematogenic metastases of malignant phyllodes tumor of the breast to the lung, bone, and brain, but no reports on its metastasis to the stomach have been seen. Moreover, no cases in which imatinib mesylate is administered to c-kit positive malignant phyllodes tumor have been reported. From these standpoints, this case is thought valuable and reported here.

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Phyllodes tumors, classified as mixed connective tissue and epithelial tumors, may be benign, borderline, or malignant. Differentiate among benign and malignant tumors is vital to planning adequate treatment.
We report 3 cases of phyllodes tumors, 2 malignant and 1 benign. MMG and US could not determine malignancy. Time-intensity curves of dynamic MRI showed a slow growth pattern in the 2 malignant cases and rapid enhancement pattern in the benign case-the inverse of breast cancer diagnosis. We identified a phyllodes tumor as malignant by using vacuum-assisted core needle biopsy before eradication. Simple mastectomies were done in the 2 malignant cases and wide excision in the benign case. Immunohistochemical staining (IHC) of Ki-67 and p53 showed a high proportion of staining in the 2 malignant cases and a low proportion in the benign case. All cases showed positive staining for CEA in the epithelial region. IHC profiles of Ki-67 and p53 are thus useful in differentiating between benign and malignant cases.
No patient was followed with any adjuvant therapy and had local and distant reccucurences.

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We report a 37-year-old woman who developed adenoma of the nipple, seen for nipple erosion that had continued for 6 months. The swollen right nipple was elastically hard and with palpation showed the tumor to be 1.5 cm in size. Erosion formed around the top of the mamilla. By inspection, palpation, and biopsy, we diagnosed the case as adenoma of the nipple. Since it entailed refractory erosion, total nipplectomy including the tumor and reconstruction of the nipple using one third of the contralateral nipple papilla were conducted. Pathological findings confirmed the diagnosis.
Even though this lesion is benign, clinicians and pathologists should take particular care with the differential diagnosis with special consideration for Paget's disease and papillo-tubular carcinoma.
We would like to remind clinicians to develop an accurate concept of adenoma of the nipple and to notify pathologists of the region where the adenoma exists. These approaches can help both patients and clinicians by achieving a precise diagnosis and saving the patient from having to undergo excessive surgery.

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A 51-year-old woman admitted for a painles right mammary tumor 8×6 cm in diameter palpated in the AC area of right breast. The smooth, hard tumor was not diagnosed by clinical presentation on clinical imaging findings. Incision biopsy led to a pathological diagnosis of angiosarcoma. We conducted right mastectomy with level III lymph node dissection, finding no lymph node metastasis. She underwent interleukin 2 adjuvant therapy and remains alive and recurrence-free 1 year after surgery.
Angiosarcoma of the breast is rare and its prognosis poor. Our case is noteworthy for the patient's survival regardless of the 8-cm tumor.

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This paper deals with a 40-year-old woman who experienced metastasis to the contralateral breast about 3 years after surgery for angiosarcoma of the right breast. The patent had not been exposed to radiation through the entire clinical course. After undergoing simple mastectomy for angiosarcoma of the right breast about 3 years earlier, she had been followed in the clinic. In April 2003, she was seen at the hospital because she felt a tumor about 3 cm in diameter in the C area of the left breast. On July 17, the tumor was removed, when the surgical stump was found to be positive. Then left simple mastectomy was carried out on August 5. Histopathologically the tumor was diagnosed as invasively growing angiosarcoma, intermediate grade. On pre-and post-operative imaging methods, no metastasis to the other organs was revealed.
We have great difficulties in differentiation of breast angiosarcoma from benign angiomas and in the assessment of the degree of malignancy, and almost all therapies are ineffective except for surgery. The disease is accordingly thought to have poor prognosis. Future increase of the disease is predicted with further increase in radiation therapy along with the spread of breast-conservative therapy.

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We report a case of male breast cancer in a 64-year-old man with chronic renal failure who had undergone hemodialysis for chronic renal failure for about 2 years. He had noticed a gradually growing painful tumor right under the left nipple in September 2001, but let it alone until December 19 when he was first seen at the hospital. On physical examination, a 2×3cm hard tumor with uneven and irregular surface was palpated right under the left nipple. Ultrasonography showed partly irregular margine, heterogeneous center, and enhanced posterior echo. Mammography visualized a 3.0×3.5cm well-defined circular tumor right under the left aeolar mammae, but showed no calcification. Fine needle aspiration cytology provided obscure result. Incisional biopsy was conducted, and the histological diagnosis was invasive ductal carcinoma, solid tubular type. A pectoral muscle-conserving mastectomy (Bt+Ax) was carried out under general anesthesia. No axillary lymph nodes were involved. On hormone receptor assay, both ER and PgR were positive and then postoperative hormone therapy was added. The patient is followed in the outpatient clinic, as of 26 months after the operation.

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We report a rare case in which a migrated Kirschner wire (K-wire) penetrated the common carotid artery. The K-wire had been used to treat a fractured right clavicle in a 71-year-old-man. Five months later, the chest X-ray showed one of the wires migrating into the mediastinum. A computed tomogram of the chest showed no vascular involvement, and the patient was asymptomatic. A median sternotomy was performed to remove the wire. Unexpected massive bleeding from the wire fistula was noted, and the wire was found to have penetrated the left common carotid artery. The injured portion of the artery was resected, and the cut ends were anastomosed end-to-end.
K-wire migration is an occasional complication of orthopedic surgery, although arterial penetration has never been reported in Japan. It should be stressed that foreign bodies in the mediastinum may cause fatal complications and that caution is necessary to prevent them.

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We report a case of an intrapulmonary aberrant needle removed using video-assisted thoracoscopic surgery (VATS) and briefly review the literature. A 37-year-old woman referred to check a cough and bloody sputum was found in chest X-ray and CT to have an intrapulmonary aberrant needle located at left S9b. Bronchoscopic extraction failed, so we conducted VATS. The needle was palpated directly beneath the pleura at left S9b and removed. The postoperative course was uneventful and the woman was discharged on postoperative day 10.

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A 25-year-old man attempting suicide by swallowing a chemical substance was saved by previous intervention but esophageal stricture occurred after corrosive injury.
He could not swallow due to severe esophageal stricture and was referred for further treatment. Esophagography showed wide-ranging esophageal stricture except for part of the upper esophagus.
Endoscope balloon dilation caused esophageal perforation, so we attempted subtotal esophagectomy, but did not excise the stenotic upper esophageal lesion, planning to attempt endoscopic balloon dilation for the remnant stenosis after surgery.
After endoscopic balloon dilation, the esophageal stricture improved and the man could be fed orally.
Swallowing a corrosive agent in attempted suicide often causes esophageal stricture, which is very difficult to treat. Treatment strategies must be decided based on stenosis findings and the patient's psychological condition.

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A 70-year-old woman complaining of shortness on body movements was referred to the hospital because severe anemia was noted on blood biochemical studies at another hospital. Gastrointestinal endoscopy revealed that several folds from the upper body of stomach converged to enter the p-ring and the antrum was compressed extramurally. Abdominal CT scan visualized a tumor 8 cm in longer diameter in the duodenal bulb, which was well-defined but had heterogeneous internal structure. We thought that the submucosal tumor of the stomach was incarcerated in the duodenal bulb to cause bleeding, and performed surgery. At laparotomy a tumor with the size of a duck egg was identified in the duodenal bulb. We reduced the tumor into the stomach by hands, and performed a partial gastrectomy including the tumor. The removed tumor was 8.5×6×5cm in dimension, showed histological growth of fibrous cells, and was positive for c-kit and CD34 and negative for S-100 protein and smooth muscle actin on immunostainings. Gastrointestinal stromal tumor (GIST) of the stomach was definitely diagnosed.

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An 18-year-old woman reporting epigastric pain was found in gastric X-ray and endoscopy to have a depressed lesion on the lesser curvature of the lower body of the stomach. She underwent distal gastrectomy and D₂ lymph node dissection on September 18, 1998. Histological findings showed signet ring cell carcinoma localized in the mucosal layer and no lymph nodes metastasis. Early gastric cancer in patients under 20 years of age is very rare. We reviewed 30 such cases, finding that early detection of gastric cancer and early surgery provides satisfactory results. This study suggests that young patients with abdominal symptom should undergo X-ray and endoscopic examination.

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We report a case of small cell carcinoma of the Vater's papilla. A 62-year-old man found to have liver disfunction in a medical examination was found in biochemical studies to have normal bilirubin but excess transaminase, alkalinephosphatase, and γGTP. Tumor markers such as CEA, CA19-9, NSE, and ProGRP were within normal levels. Endoscopy detected 16 mm swelling of the papilla and biopsy results showed small tumor cells with naked round hyperchromatin nuclei in nests on the proper lamina. In pyrolus-preserving pancreatoduodenectomy, we found a 20×16 mm tumor on the papilla of duodenum whose surface was smooth, partially ulcerated, and had a clear borderline with normal mucosa. The tumor did not stain for chromogranin A, synaptophysin, or grimelius, but stained for NSE, and diagnosed as small cell carcinoma. After supplementary chemotherapy with low-dose FP and OK-432, the man remains alive 19 months after surgery.

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A 77-year-old man with a history of angina pectoris who was being treated for a cerebral infarction suffered from ileus. Conservative therapy with an ileus tube was not successful. During a laparotomy, a dilated and stenotic jejunum, 45 cm in length, was found 20 cm on the anal side of Treitz's ligament; no other abnormal findings were found. The resected jejunum was narrow with ulcerations. Histological examination revealed chronic ulceration of the jejunum caused by cholesterol crystal embolization (CCE). CCE is usually an iatrogenic complication of invasive aortic procedures. The present case shows that CCE may spontaneously occur in the jejunum and can be successfully treated by a partial jejunostomy.

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A 61-year-old man with diabetic mellitus admitted for nausea and vomiting was found to have a fuze bezoar, but lithotomy by fluoroscopy failed. During several days in the hospital, he suffered from ileus due to the intestinal bezoar, diagnosed in intestionalography using a long tube, computed tomography, and echography. Both partial resection of the ileum and gastrotomy were necessary to remove the bezoar.

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A 75-year-old woman was admitted because of pain in the right lower quadrant of the abdomen. An emergency operation disclosed a small intestinal diverticulum and abscess on the mesenteric side 50 cm proximal to the ileocecal valve. The diverticulum and abscess adjacent ileum were resected, and histopathological examination revealed that the intraluminal surface of the diverticulum was covered with intestinal mucosa and that its wall consisted of muscularis mucosae, the submucosa, and a smooth muscle layer, and a diagnosis of true diverticulum was made. Most small congenital true intestinal diverticula are Meckel's diverticula. However, the lesion in our case seems to have been an ileal duplication small intestine because of the mesenteric location of the diverticulum and the presence of the smooth muscle wall between the ileum and diverticulum.

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An 86-year-old woman was seen at the hospital because of a gradually progressive downhill course of intestinal obstruction after repeated temporary remissions for a long time. An ileal tumor was diagnosed after close exploration, and ileectomy was carried out. The removed ileum showed atrophy of the entire mucosa, two narrowing portions caused by chronic inflammatory change, and a mass like tumor, 2.5×4.0cm in diameter. Clinical stage was rated as ss, v1, lyx, n(-), P0, H0, M(-) and in Stage II. Pathological diagnosis was primary ileal mucinous carcinoma. The patient's postoperative course was uneventful. There have been no signs of recurrence, as of 13 months after the operation.
Ileal cancer is relatively rare, especially mucinous carcinoma of the ileum. Domestic cases of mucinous carcinoma of the small intestine from 1991 to December 2003 amounted to only seven including our case. Early detection of small bowel cancer is difficult, and the prognosis is commonly poor. In the meantime, patients whose operation resulted in curative resection have comparatively good prognosis, and hence early detection by making most use of small bowel fluoroscopic study might result in improved prognosis.

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A 73-year-old man reporting abdominal pain was found in abdominal computed tomography (CT) to have a tumorous lesion of the terminal ileum and in barium enema to have a small tumor about 2 cm in diameter of the cecum. His symptoms worsened and he was admitted for ileus. The radiological enteroclysis showed severe stenosis of the terminal ileum, suggesting ileal cancer. Ileocecal resection was done without regional lymph node dissection because of peritoneal dissemination. The histological diagnosis was moderately differentiated adenocarcinoma of the ileum and well-differentiated adenocarcinoma of the colon, presumably synchronous. He is currently undergoing TS-1 treatment and has survived 1 year since surgery.

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A 52-year-old man was seen at the hospital because of right lower abdominal pain. Abdominal CT scans offered a diagnosis of appendicitis and intussusception. Emergency operation was thus performed on the same day. During surgery inflammatory swelling of the appendix was seen and an about 4-cm sized elastic hard tumor in the cecum was felt on palpation. The ileocecal resection was performed. On the excised material, diverticula were idendified in the cecum and appendix, and a 1.5×5.0 cm protruded lesion which had smooth surface was present in the cecum. Histopathological study of the protruded lesion disclosed the absence of proper muscle layer, and then the inverted diverticulum of the cecum was diagnosed.

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We report a case of transanal intrarectal foreign body extraction using special forceps in an ingenious position. A 56-year-old man who had inserted a bottle while masturbating but then could not remove it was admitted for assistance. Unable to remove it manually, by colposcopy, or by rectoscopy, we conducted pelvic radiography to definitively locate the 4 cm×15 cm bottle in rectum. To remove it, we choose a transanal approach under lumbar anesthesia. We first tried using conventional forceps in a lithotomy position. Failing this, we lifted the man's legs, bent his hips, pressed the abdomen gently, and spread the anus by spatulas, exposing the entire bottom of the bottle. Grasping the bottle using HASSOU bone forceps, we removed it. The postoperative course was uneventful. It conventional forceps in a normal lithotomy position fail to remove objects such as bottles from the rectum, we suggest the above alternative as a feasible choice.

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A 75-year-old man treated for ulcerative colitis (UC) since March 2000 admitted for painful micturition and fecaluria. He was found in pelvic 3-dimension computed tomography (3D-CT) followed meglumine sodium amidotrizoate (Gastrografin^®) enema to have multiple diverticula and colovesical fistula at the sigmoid colon. Endoscopic findings suggested that the cause of fistula is diverticutitis rather than U. C. We conducted sigmoidectomy and direct closure of the fistula.
Inflammatory bowel disease (IBD) and diverticular disease are both common and occasionally coexist. UC-like mucosal inflammation associated with diverticular disease has also been described, and it may be difficult to differentiate diverticular disease from IBD based on features of the biopsy specimens. Further study is thus needed to choose the surgical procedure for colovesical fistula coexisting with other IBD, especially ulcerative colitis.

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A 45-year-old man admitted for positive fecal occult blood in screening was found in colonoscopy to have a submucosal tumor in the transverse colon, necessitating laparoscopy-assisted wedge resection of the colon. Histopathological findings showed the fascicular growth of spindle cells. Immunohisto-chemical studies showed tumor cells to be positive for c-kit, vimentin, S-100, and neuron-specific enorase (NSE) but negative for CD34, desmin, α smooth muscle actin (SMA), and neurofilament (NF). The tumor was diagnosed as gastrointestinal stromal tumor (GIST). The patient is doing well without recurrence 10 months after surgery.

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Following a positive fecal occult blood test, an asymptomatic 59-year-old man was found in colonoscopy to have a 2-cm Ip type tumor in the sigmoid colon that proved in histological biopsy to be carcinoma. CT showed 6.5-cm liver metastasis at S6-7, necessitating sigmoid colon resection, hepatic posterior segmentectomy, and cholecystectomy. Surgical specimens showed well-differenciated adenocarcinoma of depth sm2 with moderately to poorly differenciated adenocarcinoma and budding at the invasive front. There were lymphovascular invasion and lymphnode metastasis. P53 was negative and Ki-67 was positive in immunohistochemical staining.

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A 58-year-old man was seen at the hospital because of anal bleeding. Barium enema study revealed apple core sign from Ra to Rb. Colonofiberscopy showed ulcerative lesion in the Rb. Biopsy showed well differentiated adenocarcinoma. CT scan visualized a tumor adjacent to the bladder and sacrum extensively, and tumor invasion to the organs was likely. Magnetic resonance imaging scan showed the tumor adjacent to the sacrum in a wide area, from which severe adhesions between them were suspected. Since the tumor was diagnosed as lower rectal cancer with probable invasion into the sacrum, radiochemotherapy was started before surgery. The patient was given external irradiation at 2.2Gy×25 times, with a total dose of 55Gy, and intraarterial infusion of 2000mg of 5 fluorouracil, 25 mg of cisplatin, and 500mg of leucovorin through the superior rectal artery. CT scans conducted after the radiochemotherapy visualized shrinkage of the lesion and abdomino-perineal resection of the rectum was performed. On the removed material type 2 lesion was identified in the Rb of the rectum. Histological study showed no tumor cells or lymph node metastasis. The patient has been free from recurrence as of 2.5 years after the operation.
In cases of rectal cancer in which multi-organ invasion is suspected and surgery may not provide curability A, preoperative radiochemotherapy should be considered.

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A 62-year-old female developed slight hemorrhaging around a percutaneous transhepatic cholangiodrainage (PTCD) tube inserted preoperatively for pancreatoduodenectomy for carcinoma of the pancreatic head. On postoperative day (POD) 22, massive hemorrhaging was observed immediately after the tube was removed. Compression with a thick catheter achieved hemostasis, but slight hemorrhaging persisted that. It was difficult to determine whether it was portal or arterial hemorrhaging. On POD 44, we conducted portography and embolization because pulsating hemorrhaging had been ruled out. On POD 59, additional hemorrhaging, shown by gas analysis revealed to be arterial, occurred. Radiography via catheter confirmed communication between A2, 3, and 4 bifurcation points and the PTCD fistula. Emergency embolization achieved complete hemostasis. Peritonitis related to rupture of a liver abscess necessitated removal of necrotic liver tissue and intraperitoneal drainage on POD 64. After surgery, the patient responded to multidisciplinary treatment and as discharge. On POD 154. Blood gas analysis is thus simple and useful for determining the etiology of biliary tract hemorrhaging after PTCD. The possible development of a liver abscess and peritonitis related to pus leakage should also be considered after embolization.

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We report a rare case of recurrence of a mixed hepatocellular and cholangiocellular carcinoma in the abdominal para-aortic lymph nodes and gingiva.
A 59-year-old man with HCV-positive hepatitis underwent partial hepatectomy on February 6, 2003 for a preoperative diagnosis of a 5 cm solitary hepatoma of the liver (S5-6). The pathological diagnosis was mixed hepatocellular and cholangiocellular carcinoma, eg, fc(-), sf(+), s0, vp0, vv0, va0, b0, stage II. Three months after the operation, swelling, aching and bleeding developed with calyx in the molar portion of the gingiva on the left side. It was then diagnosed by biopsy as a metastatic tumor from the primary liver cancer. After preoperative radiation chemotherapy, the metastatic gingival tumor was resected on September 24. Computed tomography and ultrasonography images revealed a metastatic lymph node in the para-aortic space measuring 5×3×2.5 cm, and it was resected on October 28. The pathological diagnosis of both the gingival and lymph node tumors was metastatic mixed hepatocellular and cholangiocellular carcinoma from the primary liver cancer.

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A 39-year-old woman who had been diagnosed as having systemic lupus erythematosus (SLE) at the age of 23 and had a one-month history of increased activity of SLE with increased PSL was seen at the emergency clinic because of intensifying epigastric pain which started 6 days earlier. On physical examination, there were localized tenderness and rebound soreness in the right upper quadrant of the abdomen. The WBC was 10, 800 and CRP was 2.2, showing mild inflammatory reaction. Abdominal CT scans revealed the contents of the gallbladder was composed of high and low density areas concomitantly. Ultrasonic study showed the gallbladder tightly filled with debris. After admission to the hospital the pain was aggravated and muscle guarding over the entire abdomen appeared. Generalized peritonitis was considered and an emergency surgery was carried out on the same day. During surgery, massive clots and bloody ascites in the abdomen and clots filled gallbladder were identified. Cholecystectomy and irrigation drainage were carried out. On pathological examination, bleeding from the full thickness of gallbladder wall, infiltration of inflammatory cells to small arteries under the muscular layer, and destroyed internal elastic lamella on EVG staining were noted. Gallbladder bleeding associated with aggravation of angitis due to SLE was considered.
Since gallbladder bleeding caused by angitis associated with collagen diseases rarely occurs, this case is reported together with some bibliographical review.

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A 43-year-old man admitted for hematemesis and melena was found in emergency endoscopy to have arterial bleeding from a duodenal submucosal tumor 1.5 cm in diameter and about 2.0 cm orally from the major duodenal papilla. Endoscopic and interventional radiological hemostasis failed, neceseitating surgical resection of the tumor on day 4 after admission. Histopathologically, the tumor was diagnosed as an ectopic pancreas. The patient was also diagnosed postoperatively with hemophilia B perhaps due to the difficulty in controlling duodenal bleeding. When bleeding from the duodenal submucosal tumor is found, ectopic pancreas should be considered and appropriate surgical treatment selected if conservative therapy fails to bring about hemostasis.

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A 46-year-old man with exacerbated chronic alcoholic pancreatits requiring hospital admission May 10 was found in repeated computed tomography (CT) to have an enlarged cystic lesion in the pancreatic tail. Colonoscopy, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde pancreatography (ERP), hemorrhage photosyntigraphy, barium enema, and angiography were conducted after initial melena. Subrequent serious melena sending him into shock on June 24 necessitated emergency surgery on July 31, leading to discovery of a cystic lesion about 6 cm in diameter in the tail of the pancreas and distal pancreatectomy with splenectomy and transverse colonectomy. Histopathological examination showed the absence of epithelial lining and penetration into the transverse colon of the pancreatic pseudocyst. The patient was discharged uneventfully on postoperative day (POD) 25.

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Traumatic rupture in renal angiomyolipoma is rare, although spontaneous cases are not infrequent. A 78-year-old woman with sigmoid cancer developed a rupture of right renal angiomyolipoma by trauma on the previous day prior to scheduled surgery. Hemorrhage from the tumor was controlled by arterial embolization. At laparotomy on the following day, right nephrectomy with simultaneous sigmoidectomy was necessitated because of enlarged hematoma and a tumor over 4 cm in diameter.
The case is the second case report of traumatic rupture in renal angiomyolipoma. Treatment of renal angiomyolipoma differs with symptoms and tumor size. Positive surgical treatment by endovascular surgery or extirpation is preferable in cases where the tumor is larger, even if asymptomatic.

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A 78-year-old man was admitted to our hospital because of a qurulent umbilical discharge with no fever or pain. Urine cultures were negative, but cultures of the umbilical fluid grew Escherichia coli. Abdominal computed-tomography showed a cystic mass about 5 cm in diameter lying near the peritoneum in the middle of the lower abdomen and extending from the umbilicus to the urinary bladder.
The boundary between the mass and adjacent sigmoid colon with diverticulosis was indistinct. A urachal abscess perforation secondary to of a sigmoid diverticulum was suspected, and surgery was performed. Intraoperatively, a 7 cm-diameter peritonealized abscess filled with purulent matter was found extending from the umbilicus to the bladder and was assumed to be the urachus. Two fistulas extended from the abscess, one to the umbilicus, and the other to sigmoid colon with the diverticulosis. Total resection of the abscess with partial sigmoidectomy and partial cystectomy was performed. Based on these findings, we made a diagnosis of urachal-sigmoid fistula and urachal-umbilical fistula secondary to perforation of a sigmoid diverticulum. Urachal abscess presenting with umbilical discharg is rare, and this was the first case in Japan caused by perforation of a colonic diverticulum.

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Mixed gonadal dysgenesis has a chromosomal aberration mainly due to 45X/46XY chromosomal mosaic, so the lateral gonad may be a testis and the contralateral a linear gonad with Müllerian duct rests including an undifferentiated vagina, uterus, and oviduct. Mixed gonadal dysgenesis is also associated with certain physical features. Although it is principally treated by pediatric physicians and surgeons, we found it accidently in a 45-year-old patient being treated for inguinal hernia. After getting sufficiently informed consent, we successfully removed the linear gonad and Müllerian duct.

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A 30-year-old man with advanced embryonal carcinoma and late retroperitoneal recurrence 15 years after orchiectomy was addmitted for an abdominal mass (50 mm diameter) in December 1996. He had undergone orchiectomy for embryonal carcinoma of the right testis. He had retroperitoneal tumor with inferior vena cava obstruction. Serum α-fetoprotein was elevated to 7200 ng/dl. He underwent multidisciplinary treatment consisting of systemic chemotherapy, radiation, and surgical tumor excision with partial inferior vena cava resection. The efficacy of combined treatment normalized tumor markers within 2 months and maintained complete serological remission 7 year after combination therapy.

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Intestinal herniation through a defect in the broad ligament of the uterus is an uncommon form of internal herniation. We report the case of a 43-year-old woman who was admitted with upper abdominal pain. Symptoms of ileus developed the next day, but since they were not severe we instituted conservative therapy. However, 4 days after insertion of a decompression tube, the flow had not decreased. Repeat radiologic diagnosis suggested internal herniation through a defect in the broad ligament, and we performed emergency surgery. Since intestinal necrosis had not developed, we extricated the intestine and sutured the defect closed without resecting the intestine. Internal herniation through a defect in the broad ligament is rare, but the diagnosis should be considered in ileus patients without a history of surgery so as not to miss the chance to operate before necrosis develops.

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A 77-year-old woman on hemodialysis for chronic renal failure suffering sudden severe abdominal pain onset had abdominal distension and muscular defense. Abdominal computed tomography showed intraperitoneal free gas, ascites, SMA calcification, and small SMV. Suspecting panperitonitis due to perforation of the intestine, we undertook laparotomy. The small and large intestines fed by the superior and inferior mesenteric arteries were gangrenous and the sigmoid colon perforated. We resected necrotic intestines and conducted jejunotransversostomy and transeverse colostomy, closing the rectal stump. The next day, the transverse colon became gangrenous, so we resected the necrotic intestine and conducted jejunostomy. She died postoperatively of progressive multiple organ failure 2 days after the first surgery. In chronic hemodialysis, acute superior and inferior mesenteric artery occlusion must be promptly diagnosed, even by laparotomy, with postoperative intensive care.

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Superior mesenteric vein thrombosis (SMVT) is rare even among emergencies causing acute abdomen. SMVT commonly lacks typical clinical manifestations and is rarely diagnosed early. We report 2 cases with different selected therapies. Case 1: A 55-year-old woman with dyspnea and pain in the left abdomen and chest was found in abdominal angiography and angio-CT to have superior mesenteric vein thrombosis (SMVT). We undertook conservative treatment by continuous urokinase infusion via a catheter in the superior mesenteric artery and systemic heparinization. Her clinical manifestations improved. Case 2: A 75-year-old man with vomiting, hematochezia, and abdominal pain was found in abdominal enhanced CT to have a central filling defect in the lumen of the superior mesenteric vein. We diagnosed this case as SMVT and conducted emergency laparotomy, identifying necrotic changes and conducting resection and anastomosis of a 170-cm segment of the small intestine. The postoperative course was uneventful.

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A 71-year-old woman who had been on hemodialysis for chronic renal failure since 1998 visited another hospital because of mild left lower abdominal pain on January 8, 2003. She was followed with a suspicion of acute enteritis until January 10, when the abdominal pain was aggravated and then she went into shock. On enhanced abdominal CT scan conducted at the hospital visualized superior mesenteric vein but enhancement effect for the inferior mesenteric artery was obscure. She was admitted to the hospital with a suspicion of obstruction of the inferior mesenteric artery, and underwent surgery on the same day. At laparotomy no prominent intestinal perforation was present on the left colon covering from the center of the transverse colon to the sigmoid colon, but severe necrotic change was noted. On palpation, pulsation of the inferior mesenteric artery disappeared. Left hemicolectomy was performed, interposition of the rectum was carried out, and a stoma was constructed on the transverse colon. After the operation the patient's general condition became stable, however, she developed cerebral infarction on the sixth and acute myocardial infarction on the 14^th postoperative day, and died on January 25.

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A girl 1 year and 11 months old admitted for vomiting and pyrexia presented 12 months after birth was found in ultrasonography to have a 2-part low echoic cystic mass in the abdomen. Mostly the tumor was surrounded by a thin wall and the remainder protruding from the main tumor was surrounded by thick wall similar to the intestinal wall. Laparotomy under a diagnosis of duplication or mesenteric cyst revealed a dark red tumor, about 5 cm in diameter, in the mesentery attached to the small intestine 40 cm oral distant from the terminal ileum. The attachment shared serosa and muscular layers but had no apparent passage to the intestine. We separated the tumor from the ileum without resecting the intestine. Microscopically, although the wall of the cystic mass consisted only of connective tissue with macrophages, the wall of the protruding part consisted of endothelial tissue and had an aberrant gastric fundic gland. The cystic mass appeared to be a mesenteric pseudocyst caused by the rupture of duplication to the mesenterium.

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We report 2 patients with panperitonitis due to perforation of the pyometra. Case 1: A 90-year-old woman with appetite loss and back pain was found in abdominal X-ray examination and abdominal computed tomography to have free air, diagnosed as panperitonitis and necessitating emergency surgery. At laparotomy, we found putrid pus and an enlarged uterus with a necrotic area 2 cm in diameter. Because this case associated with sigmoid cancer, we conducted sigmoidectomy. Sigmoid colon cancer had not invaded the uterus. Case 2: An 86-year-old woman with sudden severe abdominal pain onset was found in abdominal X-ray to have free air. Abdominal computed tomography visualized a low-density homogeneous mass, suspected to be the uterus, in which an air-fluid level was noted. We diagnosed this as as panperitonitis due to perforation of the pyometra and performed emergency operation. At laparotomy, we found putrid pus and an enlarged uterus with a necrotic area 5 mm in diameter. Since 1977, 74 cases of ruptured pyometra have been reported in Japan, with 86.5% (64/74) diagnosed as panperitonitis due to perforation of the gastrointestinal tract. When elderly women present with acute abdominal pain, ruptured pyometra should be considered.

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A 73-year-old man admitted for abdominal pain was diagnosed with panperitonitis of unknown origin. Computed tomography (CT) of the abdomen showed a 6 cm low-density area at S8 of the liver and ileus of the small intestine but no free air. We conducted emergency laparotomy and peritoneal lavage due to the fenestrated liver abscess. The abscess gradually diminished and the man was discharged on postoperative day 32. Intraperitoneal rupture of a pyogenic liver abcess is rare, and only 10 cases have, to our knowledge, been reported in Japan in the last 5 years.

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We experienced a case of inflammation of appendix epiploica of the sigmoid colon presented with panperitonitis duo to incarceration in an inguinal hernia with necrosis.
An 86-year-old man was seen at the hospital because of abdominal pain. There were spontaneous pain and tenderness in the entire abdomen, and the abdomen was board-like. A swelling with the size of an egg with pain was noted at the left inguinal region. With a diagnosis of panperitonitis due to incarceration of inguinal hernia, the patient was operated on. At laparotomy under general anesthesia, there were moderate amounts of clouded ascites with floating Eiterbelag in the abdomen. Exploring of the entire intestine revealed no perforation, but an appendix epiploica of the sigmoid colon changed brown in color and was necrotic. It was etiologically thought that the epiploica incarcerated and necrotized in the inguinal hernia to cause peritonitis.
Inflammation of appendix epiploica is a rare entity, especially its presentation with peritonitis due to incarceration in inguinal hernia to cause necrosis, as a complication. This case which is very rare is reported, together with some bibliographical comments.

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We report a rare case of suppurative spondylitis as a postoperative complication of low anterior resection for rectal cancer. An 80-year-old man reporting abdominal pain was found in colonoscopy to have rectal cancer, necessitating low anterior resection with lymph node dissection (D2), which yielded a definitive diagnosis of moderately differentiated adenocarcinoma, mp, n0, stage I. A high fever observed from postoperative day (POD) 5 led to removal of the central venous (CV) catheter, but the high fever did not subside and MRSA was detected in cultures from the catheter and blood. The man's condition deteriorated from POD 10, when he reported lumbago and pain in the left leg. An abscess detected at the anterior lumbar portion (L45) by CT and MRI was diagnosed as suppurative spondylitis. The administration of Vancomycin and rest were not effective, so we conducted curettage of the lesion and laminectomy. His condition improved and he was discharged 70 days after the second operation. Suppurative spondylitis must thus be considered a potential postoperative complication in so-called compromised hosts even in gastroenterological surgery.

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An 89-year-old woman with 10-year umbilical swelling that turned reddish and painful 6 days before admission was diagnosed elsewhere with incarcerated umbilical hernia by CT and reffered to our Emergency Center. The umbilical region was bulging, and reddish, accompanied by subcutaneous emphysema extended from the umbilical region to the left addomen. Abdominal X-ray showed an abnormal gas shadow in the GI tract. CT showed abnormal subcutaneous air. Laboratory data of showed WBC to be 14.000/μl and CRP to be 9.5 mg/ml. The patient underwent emergency surgery under a tentative diagnosis of intestinal perforation. Opening the hernia sac discharged, massive pus and intestinal perforation was found. The intestine was resected and an end-to-end anastomosis done. The patient was discharged on postoperative day 19. Although cases of adult umbilical hernia are not rare, association with subcutaneous emphysema has not, to our knowledge, been reported previously in Japan. We found mixed infection caused by four organisms, Klebsiella oxitoca, Enterococcus faecalis, Bacteroides unifoemis, and Clostridium perfrigens in the subcutaneous pus discharge. Subcutaneous emphysema may thus be a sign of intestinal perforation due to incarcerated umbilical hernia.

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