We retrospectively studied late results of patch repair for saccular aneurysm of the thoracic aorta. Eight patients underwent this surgery between August 1988 and December 2001 at our institute. All patients had atherosclerotic aneurysm, i.e., 7 in the aortic arch and 1 in the descending aora. Seven patients survived surgery and late results were available on 6 patients. Three patients showed late aneurysm formation at the repair site, 2 having been repaired. Two patients died suddenly during follow-up, 1 confirmed by autopsy to have suffered rupture at the suture site. In conclusion, late aneurysmal formation or rupture seemed inevitable after this type of surgery, so graft replacement of the aorta should be advocated for saccular aortic aneurysm and patch repair should be applied strictly only for high risk cases or non atherosclerotic aneurysms.

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In this study, we evaluated the clinical factors between single loop jejunal interposition (JI) and jejunal pouch interposition (JPI) as a reconstructive procedure after proximal gastrectomy. Proximal gastrectomy was performed in 72 patients with gastric cancer in the upper third of the stomach between 1985 and 2002. As for the operation time, blood loss volume and hospital stay after surgery, there was no difference between the two groups. Postoperative complications were seen in 92.3% in the JI group compared with 42.4% in the JPI group (P=0.0014). Endoscopic observation of the remnant stomach was technically easier after JPI. Recovery of body weight and serum total protein after operation was better in the JPI group. The surgical technique of JPI is comparatively easy although the cost of some of the apparatus is high. In conclusion, the surgical procedure of JPI is better than JI for proximal gastrectomy.

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We performed percutaneous drainage for intraabdominal abscesses due to appendicitis in 7 cases. We compared these 7 cases with 16 cases in whith laparotomy was performed for intraabdominal abscesses due to appendicitis in adults. In the patients who underwent percutaneous abscess drainage, the average age was 51.4 year-old, and there were 4 males and 3 females. In all patients local anesthesia was used, US-guided percutaneous drainage was performed in 6 cases, and in the one remaining case percutaneous drainage was performed via a small incision. The average hospitalization was 31.1 days. In the patients who underwent laparotomy, the average age was 56.9 year-old, and there were 9 males and 7 females. General anesthesia was used in 12 cases and spinal anesthesia in 4 cases. The laparotomy methods consisted of appendectomy with drainage in 13 cases, ileocecal resection in 2 cases, and abscess drainage without appendectomy in one case. The average hospitalization was 28.3 days. In all patients, whatever the method of therapy, an appendiceal fistula was never created. Percutaneous drainage for intraabdominal abscesses due to appendicitis in adults was a simple, safe, and less invasive method, therefore we recommend that this method becomes the main procedure of choice.

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We report 8 cases of hepatectomy for hepatic metastases of breast cancer in the last 7 years. Patients were a mean 48.5±11.6 years old. Mean tumor diameter was 3.6 cm (2.2-6.0cm), with single tumors in 3 and multiple tumors in 5. Resections involved partial resection in 4, left lobectomy in 2, and extended subsegmentectomy and left lobectomy with right partial resection in 1 case each. No hospital deaths occurred. One-year survival was 87.5% and 3-year survival 33.3%. Three-year survival for single tumors was 66.7% and that for multiple tumors 0%. Significantly higher cumulative survival was noted in single-tumor cases (p<0.05). Recurrence in the remnant liver had a digmal prognosis, although recurrence in other organs had a comparatively better proguosis. In conclusion, hepatectomy of liver metastases from breast cancer maybe hopeful in patients with single tumors, but limited in efficacy in patients with multiple tumors.

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It is not easy to detect carcinoma of the pancreas when the tumor size is less than 2 cm, despite the recent progress in abdominal imaging techniques. In the past twelve years, eight cases of small pancreatic carcinoma were treated by resection in our hospital. The initial symptom in five patients was pain in the epigastrium or back, and the other three patients were asymptomatic and were diagnosed by US or close examination of diabetes mellitus. US showed the mass and the dilatation of the main pancreatic duct in all the patients. Though ERCP showed stenosis or obstruction of the main pancreatic duct in every cases, the tumor was insufficiently detected on CT images. Histopathologically detected metastases in the lymph nodes were found in 5 of 8 cases, of which one had liver metastasis and the other involved the portal vein. The five year survival rate after operation is 43%, and is better than that of surgical cases when the tumor size is beyond 2 cm (p<0.01). Our findings suggested that in small pancreatic carcinomas it is sufficient to perform pancreatectomy with dissection of the second group of lymph nodes, together with partial resection of the extrapancreatic nerve plexus, considering the postoperative quality of life of the patient.

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A 72-year-old woman underwent a left hemi-thyroidectomy, modified radical neck dissection and resection of the left recurrent laryngeal nerve (T4, Ex2, N1) due to invasive papillary thyroid carcinoma. Five years later, recurrence of thyroid cancer was diagnosed. Unilateral vocal cord paralysis was observed on bronco-fiber examination. After the resection of the recurrent tumor, reconstruction of the left recurrent laryngeal nerve, which had been resected in the previous operation, was camed out. We could not utilize the left ansa cervicalis because of the previous lymph node dissection. The proximal edge of the recurrent laryngeal nerve was identified by separation of the inferior constrictor. An anastomosis of the right ansa cervicalis to left recurrent laryngeal nerve was performed in front of the trachea. After the operation, the patient's phonation gradually improved and the maximum phonation time recovered. Even in re-operation cases, reconstruction of the recurrent laryngeal nerve is possible and recovery of phonation can be expected.

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We report a case of follicular thyroid carcinoma with bone metastases showing TRAb-positive hyperthyroidism after total thyroidectomy. A 58-year-old woman noticing a left scapular tumor was found in pathological studies to have bone metastasis from follicular thyroid carcinoma, necessitating total thyroidectomy in September 2003. Her serum fT3 and fT4 were slightly high (fT3 9.3 pg/ml: normal 2.2-4.1, fT4 1.8 ng/dl: 0.8-1.9) taking levothyroxine at 100 μg/day when discharged. These gradually rose despite total thyroidectomy. Her serum TRAb was positive (26.7%: normal 0-10%) in October, so we considered that she has functional bone metastases with Graves' disease and prescribed thiamazole at 10 mg/day. Her TRAb remained high (31.8%), but thyroid function fell to within normal limits and the scapular metastatic tumor shrank slightly after therapy.

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A 67-year-old man reporting cough and dyspnea and admitted for left tension pneumothorax found in chest radiography. He had undergone esophagogastrectomy for esophageal carcinoma. Abdominal radiography showed severe pneumoperitoneum. He had no apparent abdominal pain. A thoracic catheter was inserted into the left thorax and abdominal paracentesis done, after which he experienced pulmonary edema. Air leakage continued, so bullectomy was done, in which we found a connection between the abdominal and left thoracic cavities. His severe but rare pneumoperitoneum was thus caused by pnemothorax after esophageal carcinoma surgery.

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A 47-year-old woman complaining of cough and left lateral chest pain was admitted to the hospital because she was pointed out to have left lateral pleural effusion at another hospital. Thoracentesis revealed about 200 ml of bloody discharge. Chest plain x-ray film and CT scans visualized a sharp foreign body at the dorsal aspect of the left chest wall which projected into the thoracic cavity. From her previous history of receiving a wound at the same area due to a penetrated piece of glass when she fell down 8 months earlier, which was treated by sutures elsewhere, delayed traumatic hemothorax due to a piece of glass remnant was diagnosed. As for treatment, clots in the thoracic cavity were removed under thoracoscopy and then the identified piece of glass which slightly projected into the thoracic cavity was removed through an approach from the dorsal aspect.
Usually, traumatic hemothorax often occurs immediately after trauma. Delayed onset of the disease has been reported after fracture of the ribs in many cases, but in such cases the duration from receiving trauma to the onset of symptoms is one month at the longest. Since it is uncommon for the disease to occur after a long delay of 8 months like in this case, we present this case together with a review of the literature.

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A 65-year-old man who had undergone adjuvant chemotherapy with gemcitabine after pancreatoduodenectomy for pancreatic carcinoma was given gemcitabine on days 1, 8 and 15, and this was repeated on day 29 at a dose of 1, 000 mg/m². After 3 courses, the total infusion was 8, 500 mg. Eight days after the last infusion, he suffered from fever, dyspnea, dry cough, and general fatigue. He soon went into respiratory failure of WHO grade 4. Arterial blood gas analysis revealed severe hypoxemia (pO₂ 45mmHg, pCO₂ mmHg). Chest radiograph and CT showed interstitial infiltrates of the bilateral lower lung. He was diagnosed with drug-induced interstitial pneumonitis due to gemcitabine. Therapy with 60 mg/d of prednisolone was started. After a week, his symptoms were ameliorated clinically and radiographically. He was discharged after two weeks. Interstitial pneumonitis is rare but may become a serious complication in long-term gemcitabine treatment.

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Multifocal micronodular pneumocyte hyperplasia (MMPH) is a rare lung disease detected in tuberous sclerosis (TS) patients. We report a case of MMPH with lymphangioleiomyomatosis (LAM) in a suspected TS patient.
A 22-year-old woman seen for an abnormal shadow in chest X-ray during a physical examination was found in chest HRCT to have lesions, left S¹⁺² 10 mm ground-glass attenuation, left S⁸ 20 mm infiltration, and multiple minute nodules in both lungs.
To determine the pathological diagnosis, VATS lung biopsy of left S¹⁺² and S⁸ lesions was done. Both lesions had same histological features, hyperplasia of type II alveolar cells, etc. The final pathological diagnosis was MMPH with a minor LAM component.
In ground-glass attenuation and infiltration, we should keep MMPH in mind, despite its rarity.

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This paper deals with a patient with corrosive esophagitis causing stricture formation of the esophagus after ingestion of caustic soda for a suicide attempt, who denied to undergo surgery and whose dilatation method for the esophagus was unsuccessful in long-term improvement. In the patient we aimed at improvement of the stricture with placement of an esophageal stent.
A non covered stent was placed, but granulation from apertures of mesh occurred to cause the stricture formation again. Then placement with covered stent was added, which resulted in favorable clinical course.
Corrosive esophagitis especially caused by ingestion of strong alkali solution may lead to delayed infiltration of inflammation into the deep structure, so that surgical therapy must be employed for the cases of the disease with moderate severity or more. However, in cases in which surgical operation is unavailable and stricture formation of the esophagus has occurred in the chronic phase, the stent placement is thought to be a useful therapy.

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We experienced a case of spontaneous rupture of the esophagus associated with advanced gastric cancer.
A 57-year-old man was seen at the emergency clinic in our hospital about 4 hours after the abrupt onset of severe right chest pain and upper abdominal pain following vomiting which developed after a lunch. From chest and abdominal findings, chest plain x-ray, chest and abdominal CT scans, and esophagography, rupture of the lower thoracic esophagus and pyloric stenosis were diagnosed and emergency operation was carried out. One-stage simple sutures, pedicled omentum coverage, mediastinal drainage, gastrojejunal bypass were performed via transesophageal hiatus approach on upper median lapalotomy incision. It was conceivable that bleeding as well as pyloric stenosis due to gastric cancer might cause vomiting, followed by the onset of symptoms.
This case was the 9^th reported case of spontaneous rupture of the esophagus associated with gastric cancer in Japan. Both esophageal rupture and gastric malignancy were diagnosed at the same time in five out of the nine cases. And cases of esophageal rupture associated with advanced gastric cancer numbered four. Esophageal rupture has a high mortality unless early diagnosis and treatment, and we have greater difficulty in making diagnosis if the patient has some underlying disease. It is important to keep the presence of esophageal rupture in mind, and then to explore probable underlying disease as a factor causing vomiting.

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A 71-year-old man with a history of a gastrectomy for the treatment of a gastric ulcer complained of upper abdominal pain and coffee ground-like vomitus. Based on the results of a UGI gastro-graffin enema and computed tomography and gastric fiberscopy studies, he was diagnosed as having a jejunogastric intussusception.
Laparotomy findings showed that a distal gastrectomy had been performed using the antecolic Billroth II method without Braun anastomosis. The efferent jejunal loop had prolapsed in a retrograde manner into the jejunogastric anastomosis.
The color of the reduced jejunum was poor, so an area of about 30 cm was resected. Braun anastomosis and efferent loop fixation were also performed.
This disease was easily diagnosed based on the characteristic findings of preoperative examinations.
In the diagnosis of postgastrectomy complications, the possibility of retrograde jejunogastric intussusception should be kept in mind.

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We report a rare case of signet-ring-cell carcinoma of the ampulla of Vater. A 64-year-old man admitted for upper abdominal pain on September 25, 2000 was found in ultrasonography to have a dilated biliary tract, and laboratory tests showed an obstructive cholangitis pattern. Computed tomography showed a tumor in the lower biliary tract area and fiberscope an ulcerating tumor of the ampulla of Vater. Biopsy specimens showed signet-ring-cell carcinoma, necessitating pylorus-preserving pancreatoduodenectomy an October 11. Although the tumor size was only 10×10×8mm, carcinoma cells had invaded pancreas tissue and lymph node metastasis was found. Adjuvant chemotherapy was continued after discharge but CEA was elevated 23 months after surgery and bone scintigraphy showed multiple bone metastasis. The man died 31 months after surgery due to disseminated intravascular coagulation.

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We report two cases of dietetic ileus caused by Japanese rice cake intake and review 28 cases in the Japanese literature from 1982 to 2003. Case 1: A 68-year-old man presenting at the emergency room with vomiting and severe upper abdominal pain was found in abdominal CT to have expanded small intestines with an ileus shadow and a high-density lesion, suggesting strangulated obstruction of the small intestines necessitating emergency surgery. The offending rice cake was found and removed. Case 2: A 65-year -old woman with the same complaint as in case 1 was diagnosed by CT. The intestine was incised and the rice cakes removed. Dietetic ileus caused by rice cake ingestion is easily diagnosed by CT by physicians experiencing the need for treating it. The choice of emergency surgery should be dictated by the severity of abdominal pain, with the timing of the decision to operate of paramount importance.

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Only 41 cases with true enteroliths have been reported in Japan. A case with a true enterolith accompanied by multiple stenosis of the small intestine is presented. A 55-year-old man was admitted to our hospital with a diagnosis of cholecystolithiasis. He had a history of repetitive abdominal pain and unstable bowl habits for ten years. Abdominal CT scans revealed two enteroliths. Abdominal CT just before the operation confirmed one enterolith in the terminal ileum. Laparoscopically-assisted surgery for the enterolith and a cholecystolithiasis revealed multiple stenosis of the ileum and an enterolith at 160 cm from the terminal ileum, No entero-bilary fistula was identified. Cholecystectomy and removal of an enterolith were performed. The analysis of the enterolith, 4 cm maxcimum diameter and 10 g in weight, revealed that it mainly consisted of bile acid. Most of the reported cases with true enteroliths were accompanied by diverticulas, stenosis or blind loops which obstruced intestinal emptying. The existence of multiple stenosis of the small intestine was considerd to be one of the most causative factors for the formation of the true enterolith in the present case.

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A 70-year-old man was brought into the hospital by ambulance because of fever, vomiting, and epigastralgia. When he arrived, there was tenderness in the epigastrim and the abdomen slightly distended. On hematological examinations, BUN was 41.2 mg/dl and Cr was 2.7 mg/dl which indicated impaired renal function and dehydration; and metabolic acidosis was apparent from CPK of 9418 IU/l and BE of -1.2. Intestinal ischemia was thus suspected. Abdominal plain CT scans showed intrahepatic portal venous gas in the left hepatic lobe. From these findings, we diagnosed the case as thrombosis of the superior mesenteric artery. Angiography of the superior mesenteric artery revealed poor visualization of peripheral arteries and alternate manifestations of narrowing and dilatation of arteries that indicated non-occlusive ischemia of the small intestine. Intraarterial infusion of a vasodilator was ineffective so that an emergency operation was carried out. At surgery we saw the discontinuously and extensively necrotized jejunum, and performed a partial resection of the jejunum by 125 cm in length under guidance of intraoperative small intestinal endoscopy to confirm the extent of surgical resection. After an episode of postoperative hepatic failure, the patient was discharged from the hospital one month after the operation.
We report this case of non-occlusive ischemia of the small intestine with intestinal necrosis. Intraoperative small intestinal endoscopy is of value to decide the extent of surgical resection.

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Pneumatodes cystoides intestinalis is a disease that can be treated conservatively, if the correct diagnosis is made as far as serious clinical manifestations are absent. We report a case of pneumatosis cystoides intestinalis performed laparotomy with a diagnosis of intestinal perforation.
An 80-year-old woman was seen at the department of internal medicine in our hospital because of right lower abdominal pain. No abnormalities were shown on chest and abdominal x-ray films. Abdominal CT and ultrasonography revealed intraabdominal free air on the surface of the liver and thickening of the wall of the gut covering from the cecum to ascending colon. From these findings, peritonitis due to perforation of either colonic diverticulum or the appendix was suspected, and an emergency laparotomy was performed at the department. No recognizable perforation was seen in the gut, but numerous emphysematous changes and scattered elastic-hard indurations like submucosal tumors were palpated in the subserosal structure and mesentery of the ileum about 90cm proximal to the terminal ileum. At surgery, the ileum by about 25cm was resected. Histopathologically these cystic lesions were identified to be submucosal, and pneumatosis cystoides intestinalis was diagnosed. The patient's postoperative course was uneventful. There have been no signs of recurrence as of 8 months after the operation.

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Perforation of intestinal tuberculosis is rare. We report here a case of perforative peritonitis caused by intestinal tuberculosis. A 65-year-old woman was admitted to a local clinic complaining of a fever and abdominal pain. On the third hospital day, the abdominal pain increased and she developed signs of muscular defense. She was transferred to our hospital. A chest X-ray revealed an infiltrative shadow on the right upper lung field and free air in the subphrenic space. An abdominal computed tomography revealed free air and ascites. We performed an emergency operation based on a diagnosis of perforative peritonitis. The operative findings revealed a circular ulcer located 20 cm on the oral-side from the end of the ileum. Diffuse lymph node swelling was observed, and a whitish node was observed on the intestinal serosa. We excised the perforated intestine, and performed an end-to-end anastomosis. The histological findings revealed tuberculous nodules comprised of Langhans giant cells, epitheloid granulomas, and lymphocytes. Immediately after the operation, the patient developed disseminated intravascular coagulation and died of multiple organ failme on postoperative day 12.

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We describe a case of heterotopic pancreas of the ileum causing intussusception. An 81-year-old woman was referred to our department for abdominal pain and vomiting. Ultrasonography (US) and computed tomography (CT) examinations of the abdomen showed a Target sign and obstruction of the small bowel. Surgical exploration was performed under a diagnosis of small intestinal intussusception. The partially resected ileum contained a mass with invagination, about 28 cm in length, located in the ileum about 60 cm proximal to the ileocecal valve. A 2.5×2×1-cm submucosal tumor was found in the resected ileum. Histopathological examination showed heterotopic Heinrich type II pancreatic tissue. Heterotopic pancreas occurs near the pancreas in organs such as the stomach and duodenum but rarely arises in the ileum. Heterotopic pancreas of the ileum is rarely found until it has caused complications, such as intussusception and ileus, and is difficult to diagnose.

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We report a case of intussusception at Braun's anastomosis occurring 15 years after gastrectomy. An 80-year-old woman with a history of gastrectomy seen for sudden-onset abdominal pain and vomiting was found in abdominal ultrasonography to have the target sign and in abdominal computed tomography to have a multiple concentric ring sign. Based on a diagnosis of intussusception, we conducted emergency laparotomy.
Laparotomy showed a moderate volume of bloody ascites. Antecolic Billroth II method with Braun's anastomosis had been done, and the efferent jejunal loop was found to be intussuscepted retrogradedly through the Braun's anastomosis 20 cm from the anal side. After manual reduction, part of the gangrenous and perforative jejunal intussusceptum was resected. The postoperative course was uneventful, and she has remained well in the three years since surgery.
Intussusception followry gastrectomy is rare, but should be considered in the differential diagnosis of upper abdominal obstruction.

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We report two cases of intussusception that were probably induced by the removal of long intestinal tubes after operations for the treatment of ileus. A 72-year-old man and a 75-year-old man received ileus tubes for the treatment of adhesional ileus, but remission was not noted and operations were performed (freeing of the adhesion in case 1 and a small intestine bypass in case 2). The ileus tubes were left in the terminal ileum. After the removal of the ileus tube, the patients complained of nausea and abdominal pain. CT scans and enterography studies indicated small intestinal intussusception and second surgeries were performed in both cases. In case 1, an antegrade jejunojejunal intussusception was noted and the intestine was excised. In case 2, retrograde intussusception of the ileum was noted and the adhesion was freed. Ileus tubes that remain in position during ileus operations should be removed as early as possible and the possibility of intussusception should be considered before and after tube withdrawal.

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A 59-year-old woman admitted for abdominal pain on July 26, 1996, was found in abdominal X-ray to have mild gaseous dilation of small bowel loops and air-fluid levels. Laboratory results were unremarkable but the white blood cell (WBC) count was 10.1×10³/mm³. Physical examination showed rebound tenderness and muscular defence in the abdomen. An emergency laparotomy on July 27. Showed bloody ascites in the abdominal cavity. The unfixed ileocecal region was twisted 270° clockwise and small bleeding spots were visible on the small bowel mesentery. A submucosal tumor was found in the jejunum 80 cm from the ligament of Treitz. After detorsion, we segmental by resectied the jejunum and conducted reanastomosis. Macroscopically, the submucosal tumor was 2.0 cm in size. Submucosal adenomyoma consistied of irregularly arranged glands lined by columnar epithelium and intervening bundles of smooth muscle. The definitive diagnosis was adenomyoma of the jejunum. No mitotic figures or cellular atypia were found in ductal or glandular elements. Her postoperative recovery was uneventful.

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The majority of Meckel's diverticulum cases are silent on the clinical course. Among complications of Meckel's diverticulum, perforation due to a foreign body is uncommon. We report a case of Meckel's diverticulum perforated by a fish bone. A 68-year-old man admitted for sudden onset of right lower abdominal pain had undergone appendectomy previously. We undertook emergency surgery for suspected peritonitis possibly caused by intestinal perforation. At laparotomy, Meckel's diverticulum with a perforation caused by a fish bone 2.5 cm long was found and the Meckel's diverticulum excised. Retrospectively, we reviewed preoperative CT scans and confirmed a liner calcified foreign body as a fish bone in the small intestine.
It is rare that a fish bone perforates Meckel's diverticulum and this has been reported only 11 times in the Japanese literature. Most reported cases involved acute onset peritonitis due even to a fish bone and simulated acute appendicitis. Surgery was usually done based on a preoperative diagnosis of perforated appendicitis. No case radiographically demonstrated a fish bone before surgery.

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A 67-year-old man was found to have a small intestinal tumor based on an abdominal CT scan and a fluoroscopic study using a long tube for ileus. A tumor measuring about 4 cm in diameter was recognized in the jejunal wall, and a partial resection of the jejunum was performed. The pathological findings revealed a gastrointestinal stromal tumor (GIST) and mesenteric lymph node metastasis. An immunohistochemical study revealed c-kit and S-100 protein positivity and negative results for CD-34, α-SMA and desmin. These results suggested a neural-type GIST with mesenteric lymph node metastasis. Liver metastases were recognized six and twenty months after the first operation and were resected during a partial hepatectomy. Abdominal dissemination was recognized forty-four months after the first operation, and these tumors were also resected. After the final operation, the oral administration of imatinib mesylate was initiated.

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We report a case of perforation of the appendix by a fish bone. A 43-year-old man admitted for lower abdominal pain was operated on based on abdonimal findings and abdominal CT examination yielding a diagnosis of acute appendicitis involving a fecalith. We found a fish-bone-like foreign body penetrating the central appendix, necessitating normograde appendectomy. The foreign body was definitively found to be a fish bone. Histological findings demonstrated perforation of the appendix by the fish bone, but not perforating appendicitis. Such perforation is rare, and our case is interesting because we could confirm perforation of the appendix histologically.

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We experienced two cases of sigmoidovesical fistulas caused by diverticulitis and reviewed the complaints and indications for operation. Case 1: A 69-year-old man had experienced pneumaturia, fecaluria, and diarrhea for 10 years. He was admitted to our hospital because of the aggravation of fecaluria and the appearance of urodynia. The patient was diagnosed with a sigmoidovesical fistula based on a preoperative examination, and a partial removal of the sigmoid colon and bladder and a compute removal of the fistula was performed. The pathological findings revealed a sigmoidovesical fistula. Case 2: A 70-year-man complained of abdominal pain. Afterwards, he showed colonic stricture symptoms and fecaluria. The patient was diagnosed with a colovesical fistula and colonic stricture caused by sigmoid colon diverticulitis, and a partial removal of the rectum and sigmoid colon was performed 21 days after the appearance of symptoms. The surgical and pathological findings did not confirm the presence of a fistula. Neither patient experienced a recurrence after operation, and the patients are presently being followed as outpatients. Case 1 suffered his symptoms for a long period of 10 years, while case 2 suffered for a short period of 21 days, suggesting that the fistula in case 2 closed spontaneously.

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A 59-year-old woman admitted for melena was found in digital rectal examination, MRI, and colonoscopy to have a large submucosal tumor in the lower rectum. Transrectal needle biopsy per anus confirmed the diagnosis. Irregular fascicular proliferation of spindle cells was seen in HE staining. These cells were strongly positive for both c-kit and CD34, So the tumor was diagnosed as rectal gastrointestinal stromal tumor (GIST). Tumor resection included partial resection of the rectum. The tumor was 8×6×5 cm. There have been no signs of recurrence to date. Biopsy specimen staining for c-kit and CD34 was helpful in preoperative diagnosis. Preoperative diagnosis of GIST may minimize surgical resection, resulting in fewer postoperative complications. We suggest that immunohistochemical examination of biopsy specimens be done when rectal GIST is suspected.

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A 26-year-old woman admitted elsewhere for constipation, abdominal pain, and fever was found in a barium enema examination to have a marked stricture and fistula of the sigmoid colon, so she was referred to us for treatment with a tentative diagnoses of Crohn's disease. Colonoscopy showed an annular stricture from which moderatly differentiated adenocarcinoma was diagnosed. Accordingly, the tumor was recognized as diffuse infiltrating sigmoid colon cancer. Sigmoidectomy with D3 lymph node dissection was done. The resected specimen showed stenosis with thickening of the colonic wall, giving an impression of submucosal scirrhous infiltration of carcinoma, and a protruding tumor 2 cm in diameter was located at the center of the stenotic segment. Histologically, the protruding tumor was shown to be moderatly differentiated adenocarcinoma with invasion into the muscular layer, and stenosis around the tumor showed inflammatory change without malignant cells. The pathological diagnosis was type 1, 2×2 cm, mp, n1 (+), stage IIIa, with nonspecific colitis. The patient has remained disease-free in the 23 months since surgery. Colon carcinoma with diffuse inflammation is rare, with only 8 cases, including ours, reported in the Japanese literature.

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A 78-year-old woman was seen at the hospital because of lower abdominal pain and anal bleeding. On digital examination, reversed rectal mucosa was palpable about 4 cm to the anal verge and, in its head, a hard tumor was present. Added findings on abdominal CT scan to those findings, we diagnosed the case as ileus due to intussuscepted sigmoid colon cancer within the lower rectum. Transanal decompression could not reduce the intussusception, so that the patient was operated on. During surgery, the sigmoid colon had invaginated within the Rs area of the rectum, and its leading point was present hear the anal canal. While pushing back the invaginated colon into the abdominal cavity by fingers through the anus, we reduced the intussusception by means of Hutchinson technique, but found a transmural lacerated wound in the sigmoid colon, and then performed Hartmann operation. The muscle layer of the lacerated wound became thin, suggesting ischemic change.
Intussusception is relatively rare in adults. In this paper we present this relatively rare case, together with a review of the literature in terms of intraoperative reduction of intussusception.

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A 33-year-old man was admitted to the hospital because of high fever and right hypochondralgia. Abdominal CT scan revealed a liver abscess, 12cm in diameter, in the medial segment. To investigate causative micro-organisms and treat the liver abscess, percutaneous transhepatic abscess drainage (PTAD) was performed. Some little dirty brown purulent fluid was aspirated from the abscess cavity. Incubation of the fluid and microscopical examination for amoeber was carried out several times, but any bacteria were not isolated nor amoeber could not be found. Intravenous injection of antibiotics was started, but the fever persisted. The rupture of the abscess into the duodenum broke out and he went into shock due to bleeding from the lesion 20 days after admission. Hemostasis and drainage of the abscess were performed in an emergency operation. Trophozoites of Entamoeba histlytica were detected in the necrotizing tissue within the abscess cavity microscopically.
The abscess cavity diminished and he was recovered consequently after administration of dehydroemetine followed by metronidazole. This rare case of amebic liver abscess causing rupture into the duodenum is presented with a review of the literature.

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A 73-year-old woman was admitted to the hospital because of abdominal pain, fever, and appetite loss lasting from September 2002. There was a previous history of undergoing pylorus preserving pancreatoduodenectomy for cancer of the duodenal papilla in January 1999. After admission close exploration offered a suspicion of intrahepatic bile duct cancer, and a left lobectomy of the liver was carried out. On the removed material, a white and solid tumor was identified. Pthological diagnosis was inflammatory pseudotumor of the liver. It was etiologically thought that this inflammatory pseudotumor of the liver might be caused by cholangitis after pancreatoduodenectomy.
In a review of the literature, three cases of inflammatory pseudotumor of the liver after pancreatoduodenectomy, including this case, have been reported in Japan, and hepatectomy was performed in all the three cases. In order to avoid excessive surgical stress, it is important to make correct diagnosis after full consideration of symptoms, hematological tests, imaging and pathological findings, keeping a probable diagnosis of inflammatory pseudotumor of the liver in mind.

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A 70-year-old man was admitted to hospital because the stool guaiac test was positive. Lower gastrointestinal endoscopy revealed advance sigmoid colon cancer. In abdominal computed tomography, magnetic resonance imaging and angiography, multiple small lesions suspected as cysts were recognized in the liver. Ultrasonography showed those lesions as nodules with various echo levels. It was difficult to make a diagnosis of metasatatic lesions or liver cysts. Sigmoidectomy was perfomed, and we found a large number of grayish white or dark green small nodules scattered throughout the liver. Histopathological examination of the resected liver specimen showed von Meyenburg complex without any malignant cells. In cases of von Meyenburg complex coexisting with malignant disease, careful followups are necessary because the early detection of metastatic liver tumor is very difficult to achieve.

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A 55-year-old woman underwent cholecystectomy combined with partial (S4/5) hepatectomy and lymphadenectomy for small cell carcinoma of the gallbladder. Since positive nodes were observed in resected specimens, she underwent 5-fluorouracil (250mg/day) infusion via the hepatic artery for two postoperative weeks and an oral administration of UFT (Tegaful-Uracil) (300mg/day) for 32 months as prophylactic treatment. Immediately after the interruption of chemotherapy (4 months), cancer recurrence became obvious in the paraaortic region, causing lumbago. Although UFT, Cisplatin, or Etoposide were given again, none was effective. She died 4 months after disease recurrence. We concluded that long-term adjuvant chemotherapy should be scheduled even for small resectable small cell carcinoma of the gallbladder.

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Primary adenosquamous cell carcinoma of the bile duct is an extremely rare entity. We report a case of adenosquamous cell carcinoma arising from the lower bile duct.
A 55-year-old man was referred to the hospital for close exploration and treatment because abnormalities in hepatic function and obstructive jaundice were pointed out at another hospital. On admission, the serum-bilirubin level was high, 12.19 mg/dl, and abdominal ultrasonography and abdominal CT scan revealed dilatation of the common bile duct. Percutaneous transhepatic biliary drainage (PTBD) was thus immediately conducted. PTBD and ultrasonic endoscopic examination showed narrowing at distal end of the bile duct. Carcinoma of the lower bile duct was diagnosed and pancreatoduodenectomy was carried out. On histopathological findings, cancer foci involving from mucosal layer to muscular tunics presented findings of well to moderately differentiated adenocarcinoma, and those involving from the proper muscle layer to pancreas parenchyma involved many portions forming nest of squamous cells in which obvious cornification and desmosome was identified. Adenosquamous cell carcinoma was definitely diagnosed. There have been no signs of recurrence, as of 8 months after the operation.

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We report a rare case of squamous cell carcinoma of the gallbladder producing granulocyte-colony stimulating factor (G-CSF). A 78-year-old woman admitted for right upper abdominal pain had no palpable mass in the abdomen but was found in ultrasonography and computed tomography to have a mass lesion of the gallbladder invading the liver. Blood examination showed marked leukocytosis without inflammatory changes. A diagnosis of gallbladder cancer was made, and cholecystectomy with partial resection of the liver was done. Pathological findings indicated squamous cell carcinoma of the gallbladder invading the liver. The patient had an uneventful postoperative course and the white blood cell count normalized postoperatively.
Nine months later, the white blood cell count increased again and CT detected multiple liver metastases. A diagnosis of G-CSF producing gallbladder cancer was confirmed by high serum G-CFS and positive immunohistochemical findings of the primary tumor. Although chemotherapy was initiated, the patient died 1 year after initial surgery.

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A 63-year-old woman undergoing left hemicolectomy for descending colon cancer in May 1997 and right superior lobectomy for right lobe metastasis in July 2000 was found in January 2003 to have elevated plasma CEA and a pancreatic tumor. Abdominal computed tomography (CT) showed a mass in the pancreatic tail. Endoscopic retrograde pancreatography showed main pancreatic duct obstruction. We diagnosed the mass as pancreatic metastasis because CA19-9 and DUPAN-II levels were within normal limit.
We resected the pancreas body, tail, and spleen en bloc and histological by identified the resected tumor as matastatic colon cancer. We thought that there was an indication for pancreas resection and anticipate a good prognosis.

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Splenic hemangioma is the most common benign tumor of the spleen. However, splenic sclerosing hemangioma (SSH) is an unusual tumor that features secondary changes such as fibrosis or calcinosis. We report on a patient with this rare clinical entity. A 45-year-old male visited our department with a splenic tumor found incidentally at a regular check up. On ultrasonography, the tumor was revealed to be moderately vascular and enhanced CT showed delayed clearing of the contrast medium. We performed splenectomy as a diagnostic treatment, and the pathology findings were compatible with SSH. For most splenic tumors, diagnosis is often made after excision of the tumor.

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A 45-year-old man who had hypertension and central obesity was diagnosed as having Cushing syndrome from examinations including hematologic study. And a tumor about 8cm in diameter was found in the right adrenal gland on CT scan, which was thought to be primary adrenal cancer. Although the tumor was encapsulated, it was adjacent to the kidney, liver, and inferior vena cava, and the tumor was in the height of its proliferation. Considered these findings, we decided that complete removal of the tumor by surgery was difficult and started preoperative chemotherapy with continuous administration of mitotane and 4 courses of etoposide. When a mild diminishing of the tumor and center necrosis of the tumor were identified by imaging methods, adrenectomy, associated resection of the right kidney, and partial hepatectomy were performed. Histopathological findings disclosed no invasion into the kidney and liver, so that the tumor was able to be removed completely.
No definite protocols for the kinds of chemotherapeutic drugs and duration of administration have been established as preoperative chemotherapy as yet. In this case we carried out surgery at the time when some changes in the tumor were identified on CT, however, some protocol should be established hereafter.

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A 43-year-old man was admitted to hospital complaining of abdominal pain in the right lower quadrant and mild fever. A firm mass with tenderness was palpable on the right side of the umbilicus. Abdominal computed tomography and ultrasonography examinations demonstrated a soft tissue mass in the mesentery of the ileum. The tumor was resected along with a 55-cm segment of the ileum, and a histological examination revealed an inflammatory pseudotumor of the mesentery. The patient's symptoms disappeared, and his postoperative course has been good for the past 11 months.

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A 22-year-old man operated on twice for abdominal bleeding of unknown origin in February and August 1999 and pneumothorax in June 2002, and seen in September 2002 for severe abdominal pain was found in enhanced CT to have massive bleeding in the abdomen. Superior mesenteric arteriography showed extravasation in the perfusion area of the middle colic artery, necessitating emergency surgery. Massive peritoneal bleeding and a large mesenteric hematoma were found at the medial side of the descending colon. Bleeding was apparently due to the rupture of marginal arteries of the middle colic artery. A portion of the descending colon was necrotic, requiring resection. During surgery, because intestinal walls were too friable for anastomosis, both a transverse colostomy and a sigmoid colostomy were made in different places. The postoperative course was uneventful, witiout bleeding. The patient's elder sister underwent coronary artery bypass grafting for a coronary aneurysm when she was 24 year old. Both his clinical course and family history suggest that he had Ehlers-Danlos syndrome type IV, which may have induced repeated retroperitoneal hemorrhage.

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A 69-year-old man presenting with right thigh pain and high fever with tenderness in the lower quadrant of the abdomen was found in computed tomography of the abdomen to have a retroperitoneal abscess. We conducted interval appendectomy, which involves appendectomy after initial conservative treatment including percutaneous drainage of the abscess. At surgery, the terminal appendix was swollen and adhered to the retroperitoneum. We conducted the appendectomy without complications. Histopathological examination showed a perforated peudodiverticulum of the appendix. Appendiceal diverticulitis is a rare clinical entity presenting clinical features similar to acute appendicitis, but has a higher risk of perforation than acute appendicitis. Retroperitoneal abscess caused by appendiceal diverticulitis is very rare, but interval appendectomy is an effective strategy for a case like ours.

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Patient undergoing continuous ambulatory peritoneal diagnosis (CAPD) are at increased risk for the development of inguinal hernia. We report on 3 CAPD patients with inguinal hernia treated with mesh plug repair. Case 1: An 84-year-old man with chronic renal failure suffered bilateral inguinal hernia after undergoing CAPD for 9 months. Case 2: A 70-year-old man with chronic renal failure developed right inguinal hernia after undergoing CAPD for 7 months. Case 3: A 69-year-old man with chronic renal failure developed right inguinal hernia after undergoing CAPD for 19 months. All 3 patients underwent mesh plug repair and have suffered no hernia recurrence.

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An 83-year-old woman was operated on for right obturator hernia 3 years ago, at which time the hernia orifice was repaired with the right ovary. She was necently admitted to our hospital in March 2003 with abdominal pain. Abdominal computed tomography demonstrated a right recurrent obturator hernia with small bowel obstruction. She underwent an emergency operation, during which it was revealed that both the small intestine and the right ovary were incarcerated in the hernia sac. There was no need to resect the small intestine and we used a teflon patch to repair the hernia orifice. In the Japanese literature, postsurgical recurrences of obturator hernia occurred in cases that were repaired with simple orifice closure or with the ovary and/or the oviduct. Recently, many more cases repaired with a patch have been reported than before. The procedure with a patch should be applied to the repair of obturator hernia to prevent the recurrence after surgery.

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We report 2 cases of strangulated obturator hernia reduced noninvasively. Case 1: An 84-year-old woman reporting right inguinal and femoral pain was diagnosed with strangulated obturator hernia by pelvic CT, but strangulation was spontaneously reduced. We did not operate but followed her up as she requested. Although we reduced her hernia successfully each time it occurred, she had 8 recurrences in 2 years and 11 months. She died of congestive heart failure. Case 2: A 73-year-old woman reporting abdominal and left inguinal pain was found to have a subcutaneous tumor palpable at the left femoral portion and we diagnosed her with strangulated obturator hernia. Noninvasive reduction of strangulation improved her symptoms and then we operated. She recovered uneventfully with no recurrence. Noninvasive reduction of strangulated obturator hernia is useful to abate pain and avoid emergency surgery, but surgical intervention may prevent further hernia in cases of frequent recurrence.

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A 50-year-old woman, whose right gluteal tumor with the size of an egg was diagnosed as an intrapelvic tumor on magnetic resonance imaging scan at the department of dermatology in our hospital, was referred to the department. After admission, colonofiberscopy, barium enema, and CT scan revealed an 8×5×8 cm tumor on the right side of the rectum in the vicinity of the peritoneal reflexion. Either of lipoma, liposarcoma, and leiomyosarcoma was likely as preoperative diagnosis, and laparotomy was performed. The tumor was present inferior from the peritoneal reflexion, and principally on the right side of the rectum, and was comparatively easily removed. The tumor was white in color, and an elastic-hard spherical mass. Histopathologically the tumor was mainly composed of fibroblast and chollagen fibers, and was diagnosed as desmoid tumor.
To the best of our knowledge such a desmoid tumor as that occurs in the vicinity of the rectum with morphology of a submucosal tumor like in this case has not been reported.

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A 73-year-old female was admitted to hospital complaining of a gradually increasing palpable mass in her right palm. The patient had first noticed the mass 8 years earlier but had not received treatment. Ultrasonography and angiography examinations revealed an aneurysm at the orifice of the first finger palmar digital artery. The aneurysm was surgically excised after the ligation of the feeding and draining arteries while the patient was under a local anesthesia. Histopathologically, the mass was found to be a true aneurysm. Aneurysm of the hand is a rare disease. In many cases, blunt trauma or chronic irritation may contribute to the cause of the aneurysm. In the present case, the cause was suspected to be idiopathic because the patient did not have a past history of trauma or irritation.
We recommend resection as the treatment of choice if the collateral circulation is sufficient.

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Trauma, inflammation, habits, convulsions, palsy and paralysis of fibular nerves after orthopedic operation are all known causes of pes equinus. Here, a case of pes equinus of unknown origin is reported. The patient had experienced a pain in his left crus since the age of 14 years, afterwhich he developed pes equinus.
In cases of idiopathic pes equinus, a satisfactory outcome may not be obtained by orthopedic operation alone, and the illness may recur. In the present case, the idiopathic pes equinus was accompanied by marked vasospasm of the foot arteries, and a sympathectomy was performed prior to the orthopedic operation, with favorable outcome.
The cause of the pes equinus in this case was speculated to be due to vasospasm based on angiographic studies. For idiopathic pes equinus with no obvious cause, such as trauma or palsy, the possibility of vascular lesions should be considered. When localized vasospasms are detected by angiography, sympathectomy to alleviate the spasms in combination with an orthopedic operation may be effective.

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