To investigate the psychological factors associated with the quality of life of patients with breast cancer, 154 patients who were between 1 and 3 years after surgery were subjected to a HADS questionnaire survey. The HADS which consists of 14 questions is a conventional method to estimate psychological anxiety and depression. In this study, patients whose total score of odd numbers is more than 8 are estimated to feel anxiety, and patients whose total score of even numbers is more than 11 are estimated to feel depression. We obtained answers from 125 out of 154 patients (a recovery rate of 81%). Except two patients who underwent biopsy at another hospital, 123 patients were enrolled in the study and _x2 analysis was made on their answers. Nineteen (15.4%) patients showed anxiety and 11 (8.9%) patients showed depression. A significantly higher HADS anxiety score was noted in premenopausal patients than postmenopausal patients (p=0.015). Patients whose tumor diameter of 2cm or less showed a significantly higher HADS anxiety score (p=0.03). Moreover, HADS anxiety score in patients with noninvasive cancer was significantly higher than that in patients with invasive cancer (P=0.033). In conclusion, the HADS questionnaire is useful for psychological screening of outpatients with breast cancer after surgery.

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Treatment of early breast cancer using breast conservative therapy (BCT) should ensure local control and acceptable cosmetic result. To repair defects caused by partial mastectomy in the upper inner quadrant, some reconstruction should be used. BCT is especially problematic for women who have small breasts to which it may leave remarkably deformed breasts. BCT with immediate reconstruction was performed for 4 patients with early breast cancer in the inner quadrant. Autologous free dermalfat graft was used for the reconstruction, with a good cosmetic effect. This technique has better cosmetic benefits than transposition of residual breast tissue, is more convenient than muscle flap grafting, and safer than implantation of foreign materials.

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In order to establish the therapeutic guidelines for mediastinal cysts, especially for thymic and bronchial cysts, a series of patients operated on at the hospital till April 2003 were subjected to the study.
Ten patients had a thymic cyst, whose ages ranged from 40 to 71 years, with a mean of 65.3. The male-to-female ratio was 3:7. The site was the anterior mediastinum in all cases. Thymectomy under longitudinal incision of the sternum was employed as the operative procedure in all cases. There were no cases associated with myasthenia gravis or autoimmune disease, nor recurrent cases.
Nine patients had a bronchial cyst, whose ages ranged from 16 to 77 years, with a mean of 49.3. The male-to-female ratio was 5:4. The sites of the disease were the right bronchus in seven, and the tracheal bifurcation in two. Operative procedures included thoracoscopy-aided surgery in one, thoracotomy in seven and longitudinal incision of the sternum in one. One patient with intrapulmonary type experienced recurrence on the 7^th year after the operation and underwent surgery again.
Another nine patients had a pericardial cyst, whose ages ranged from 48 to 73 years, with a mean of 56.2. The male-to-female ratio was 1:2. The sites of the disease were the right lateral in eight cases and left lateral in one. Operative procedures included thoracoscopy-aided surgery in four cases, thoracotomy in three, and longitudinal incision of the sternum in two. No recurrent cases have occurred.
Magnetic resonance imaging (MRI) is useful in differentiation of these diseases preoperatively. The keys in performing surgery for bronchial cysts are to be careful for possible recurrence and to resect the cystic wall completely; those for thymic and pericardiac cysts are to employ a minimally invasive operative procedure, because these cysts recurs in a lowest incidence. At present, it is desirable that thymectomy under longitudinal (partial) incision of the sternum is the first choice for thymic cysts and thoracoscopic removal of the cyst for both bronchial and pericardial cysts.

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We investigated the effects of low-frequency electrostimulation on 8 male and 10 female patients with fecal incontinence associated with anal sphinctor dysfunction. Incontinence score was improved in both men and women after an average treatment period of 116±39 days. Electrostimulation provided increased maximal resting pressure, 83% in men and 52% in women (p<0.01) as well as increased maximal squeeze pressure, 63% in men and 21% in women (p<0.01). This treatment was more effective in men than women (p<0.05). Anorectal reflex in fecal incontinence showed the reduced relaxation of the internal anal sphincter which was sensitive by a rise in rectal pressure, and this reflex was ameliorated by this treatment (p<0.05). Furthermore, the electrostimulation enhanced the blood flow, blood volume, and blood velocity of the anal tissue (p<0.05). It is expected that the low-frequency electrostimulation improves fecal incontinence by the mechanism of increasing internal and external anal sphinctor contraction and increasing expansion of the anal cushions by augmented anal circulation.

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A 52-year-old woman was admitted to the hospital because of a mass of her left breast which she had noticed about 2 years earlier. The smooth, hard, and mobile mass was palpable in the upper inner quadrant of the left breast. Mammography showed no clear mass, but ultrasonography showed an approximately 12mm-in-size unequally hypoechoic round mass with a clear border. Magnetic resonance imaging (MRI) scan showed a unequally high intensity lesion with a clear border in T2-weighted images (T2WI). In contrast enhancement images, only the border of the tumor was visualized in the early phase. Immediately many small dot-like lesions were visualized inside the tumor, and then the whole region of the tumor was quickly enhanced. This tumor was diagnosed as adenomyoepithelioma histopathologically and a wide excision of the tumor was performed. There have been few reports on the images of this disease, and we often have great difficulties in preoperative diagnosis. MRI findings with contrast enhancement obtained in this case were very characteristic. We think that these findings on MRI are useful for the diagnosis of this disease.

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An 83-year-old woman was seen at the hospital because of a right breast mass. An elastic firm and well movable tumor 1cm in diameter was palpable in the C' area of the right breast. Ultrasonographic findings revealed a tumor with the diameter of 9.5mm, comparatively clear borders, and heterogeneous internal echos, and the time-intensity curve of magnetic resonance imaging suggested that the tumor might be malignant neoplasm. On the other hand, mammography showed a well-defined and high density mass. Aspiration biopsy cytology of the tumor resulted in class V. Breast cancer was the most likely diagnosis, but a wide excision was performed under regional anesthesia because her general condition was poor. Histologically, the tumor showed a bicellular pattern of proliferating epithelial and myoepithelial cells for HE stains. Immunohistochemically, the tumor showed strong positivity for AE1/AE3 in the epithelial component, while the myoepithelial cells reacted with SMA. The final pathological diagnosis was adenomyoepithelioma.
Adenomyoepithelioma of the breast is a rare entity, and it is considered to be capable of exhibiting a wide range of biological behaviors from benign to malignant features. Therefore, it is important not to make overdiagnosis.

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A 72-year-old man was admitted to the hospital because of a palpable breast mass.
On physical examination, a mass 2.5cm in diameter was palpated in the right breast and an enlarged lymph node 1cm in diameter in the right axilla. The right chest wall was studded with erythema. Ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI) revealed an illdefined mass 2cm in diameter in the right breast and an enlarged lymph node 1cm in diameter in the right axilla. Aspiration biopsy cytology of the breast mass confirmed adenocarcinoma. Following simple mastectomy, chemotherapy (paclitaxel, 120mg/week) and radiotherapy (a total of 60Gy to the supraclavicular lymph nodes, a total of 50Gy to the parasternal lymph nodes, and a total of 47Gy to the right chest wall) were performed. As of 15 months after the operation, the patient is still alive without recurrence. Although male inflammatory breast cancer (IBC) is an extremely rare entity, we should consider the possibility of breast cancer when a man presents with persistent breast eczema. Multimodality therapy is recommended for the management of male IBC, just like female IBC.

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Patient 1, a 68-year-old woman admitted to the hospital because of intestinal obstruction due to proctostenosis, also had invasive cancer of 4.3×4.7cm in diameter in the upper outer quadrant of the left breast. As Schnitzler's metastasis from the left breast cancer was suspected, a left breast tumorectomy and an exploratory laparotomy were performed under general anesthesia. In addition to disseminated diseases in the mesentery, small bowel involvement was also seen. Partial resection of the small bowel, a bypass, and a sigmoid colostomy were carried out. Microscopically invasive lobular and ductal carcinomas coexisted in the breast tumor, but only invasive lobular carcinoma was seen in the abdominal dissemination. Patient 2, a 66-year-old woman, underwent a modified radical mastectomy for left breast cancer. Pathological diagnosis was invasive lobular carcinoma (signet ring cell carcinoma). Close exploration for postoperatively increased tumor markers demonstrated no prominent metastasis. Five years later, barium enema revealed rectal stenosis and a rectal biopsy showed infiltration of signet ring cell carcinoma. Because there were disseminated diseases in the entire abdominal cavity under exploratory laparotomy, a biopsy and a transverse colostomy were done. Microscopically, the disseminated disease had the same histological findings as the primary tumor and rectal biopsy showed.

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A 41-year-old man was admitted to the hospital for surgical resection of a locally recurrent ameloblastoma in the left maxilla. Previous history included a maxillary tumor resected first at the ago of 18, with pathology of ameloblastoma. The patient had since been operated on eleven times for repeated local recurrence of the maxillary ameloblastoma. Before plastic surgry to the primary site, a large mass shadow 7cm in diameter was pointed out in the right lower lung field on a chest x-ray film. With the diagnosis of pulmonary metastasis from the maxillary ameloblastoma, a right lower lobectomy was carried out following resection of the locally recurrent tumor. Histologically, the pulmonary mass showed benign features including proliferating odontogenic tall cells and columnar epithelia supported by fibrous stroma. No invasion or dyskaryosis was seen. Comparing these features with those of the primary site, this lesion was believed to be pulmonary metastasis from the benign maxillary ameloblastoma, though there is a category of malignant ameloblastoma in the WHO classification which behaves as malignant neoplasm. Generally metastasis of benign ameloblastoma to other organs very rarely happens, in the frequency of less than 1% of all cases. We report this case along with some discussion.

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A 79-year-old man complaining of abrupt onset of dyspnea was admitted to another hospital on January 15 2004 with a suspicion of left diaphragmatic hernia because elevation of the left diaphragm was demonstrated by a chest X-ray film. After admission his dyspnea was gradually aggravated up to degree V in the Hugh Jones classification, requiring oxygen inhalation. His dyspnea was intensified in a supine position and alleviated in a sitting position. He was referred to the hospital on January 17. From chest CT findings, hernia of the celiac organs from behind the left diaphragm into the left thoracic cavity was considered. Surgery was performed on January 23. At surgery, we saw that the diaphragm was pushed up toward the thoracic cavity by the celiac organs and thinned remarkably, but there was no hernia opening. The diaphragm was incised and, while confirming the abdominal cavity, we performed plication. Chest X-rays after the operation showed that the left diaphragm was fixed in the normal location. Further foollow-up would be required for possible recurrence in this patient.

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A 53-year-old woman in whom a right phrenic tumor had been found 7 years earlier at laparoscopic cholecystectomy for cholecystolithiasis was admitted to the hospital for close exploration and treatment of the tumor. She had other previous histories of undergoing appendectomy for appendicitis, cesarean section, and hysteromyomectomy. Computed tomography showed a low density area in the right diaphragm and enhancement around it. Magnetic resonance imaging scan showed a tumor in the same location of low signal intensity on T1W1 images and high signal intensity on T2W1 images. Phrenic tumor was diagnosed. Under thoracotomy, a partial resection of the diaphragm was performed when we saw adhesions of the tumor to the liver. It was thought to be hepatic invasion, and a partial excision of the liver was also performed. The pathological diagnosis was phrenic abscess. No abscess formation was identified in the hepatic parenchyma, and E. coli was isolated in culture. Although the origin of the phrenic abscess was unknown, it was thought to have originated from penetration of liver abscess related to the acute appendicitis. Such a case is extremely rare.

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A 58-year-old man was admitted to the hospital because of epigastralgia and chest pain 4 days after he had eaten a fish (cooked sea bream). Endoscopic examination showed a fish bone stuck into the esophageal wall, so we removed it endoscopically. Chest CT scan after endoscopy revealed mediastinal and subcutaneous emphysema, mediastinal effusion, and pneumonia. The patient was intubated to control respiration because he suddenly developed severe dyspnea. On the hospital day 9 chest CT scan relieved mediastinal abscess formation and serious pneumonia and esophagogram showed leakage of contrast medium. Chest CT scan performed on the hospital day 20 demonstrated reduction of the mediastinal abscess, improvement of preumonia of the right lung field, and development of pneumonia in the left lung field. Thereafter pneumonia persisted, but his respiratory condition became stable. On the hospital day 57 esophagogram revealed no leakage and chest CT scan did not visualize mediastinal abscess and pneumonia. On the hospital day 87 endoscopic findings showed no perforation of the esophagus.

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A 57-year-old man who had had dysphagia from the beginning of April 2003 was seen at the hospital in May, and was diagnosed as having type 3 advanced esophageal cancer in the LtAe area, T4N2 in stage III. Chemoradiotherapy using 5FU and CDDP which preceded surgery resulted in a PR after completion of irradiation at a total dose of 40Gy, but the therapy failed to achieve the down staging. Additional irradiation of 20Gy resulted in the down staging and we judged the case as operable. Total excision of the thoracic esophagus with three field lymph node dissection and anastomosis between the stomach tube and cervical esophagus through posterior mediastinal route were carried out in August. Histopathological findings revealed degenerated squamous cell carcinoma, pT3NO in stage II, ly2v1, without prominent viable cells. The effect of the chemoradiotherapy was rated as grade 3. No regional lymph node involvement was identified, but sarcoid reaction was remarkable. Since no findings suggestive of systemic sarcoidosis were seen, the sarcoid reaction might be of regional lymph nodes of the esophageal cancer.
There have been few reports on sarcoid reaction of regional lymph nedes of esophageal cancer, and this condition in this case is thought to be rare.

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A 63-year-old man underwent distal gastrectomy with Billroth I reconstruction for type 3 gastric carcinoma localized at the body of the stomach. A nasogastric tube was inserted into the residual stomach. He developed a fever since the 2nd postoperative day, and laboratory data were compatible with inflammatory disorders. Abdominal CT scans showed a small quantity of fluid which was considered to be caused by operative procedures. On the 5th postoperative day, purulent discharge through the intraabdominal drainage tube was recognized. Fluoroscopic examination using contrast media revealed penetration of the nasogastric tube through gastric wall and the extragastric discharge of the media at the greater curvature. Conservative treatment including total parenteral nutrition and antibiotics was performed because the intraabdominal drainage was assured by the drainage tube. Oral intake was started on the 34th postoperative day. The patient was discharged without other complications on the 44th postoperative day.

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G-CSF producing gastric cancer is a rare entity and a total of 26 cases including ours have been reported in Japan. We report a case of gastric cancer which showed a high level of serum granulocyte-colony stimulating factor (G-CSF) preoperatively and was immunohistologically diagnosed as G-CSF producing gastric cancer in the metastatic lymph nodes biopsied during surgery. A 75-year-old man admitted to the hospital because of epigastralgia was found to have type 4 gastric cancer almost encircling the upper gastric body by gastrointestinal endoscopy, of which biopsy revealed poorly differentiated adenocarcinoma. The preooperative laboratory data included leukocytosis (22, 500/μl) and a high level of serum G-CSF (25pg/ml). Abdominal computed tomography showed wall thickening of the stomach with enlargement of adjacent lymph nodes and ring enhancement areas indicating the multiple liver metastasis. At surgery, the tumor had invaded the adjacent organs, and a biopsy of the metastatic lymph node was performed. After the operation, the patient received chemotherapy and leukocytosis gradually improved to be the lowest level of 9, 700/μl at the completion of one cource, but the serum G-CSF level increased up to 29pg/ml. Thereafter the hepatic metastasis rapidly progressed and the patient died on the postoperative day 120. Immunohistochemical examination with anti-G-CSF antibody of the resected lymph node revealed positive reaction in the tumor cells. The definite diagnosis of G-CSF producing gastric cancer was thus made.

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The patient was an 84-year-old man undergone distal gastrectomy with Billoth-I procedure for gastric cancer in August 2000, of which pathological findings included mod, se, ly3, v2, n2, aw(-), ow(-), and stage IIIb. The patient experienced recurrence in the remnant stomach in March 2002, when severe stenosis was observed at the anastomosed site, but no lymph node involvement, metastasis to other organs including the liver, nor peritoneal dissemination was present. Although re-operation was considered to be possible, an expandable metallic stent (EMS) was placed and chemotherapy with TS-1 was started due to his advanced age. No diminishing in size of the tumor was identified, but NC was kept and the patient was able to visit our outpatient clinic for more than 2 years.
Therapeutic outcomes of recurrent gastric cancer are poor and surgical resection of the foci is often difficult. Chemotherapy after placement of EMS for severe stenosis is thought to be a very useful intensive therapy for patients at high risks such as advanced age, because this therapy is less invasive and maintains good QOL.

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Four cases of food-induced small bowel obstruction treated in the hospital are studied. Case 1: An 80-year-old woman who had a history of abdominoperineal resection of the rectum for rectal cancer was referred to the hospital because of small bowel obstruction. Massive indigested kombu impacted in the ileum was confirmed at surgery. Case 2: An 82-year-old woman who had a history of hysterectomy for uterine cancer developed small bowel obstruction. Abdominal CT scan showed dilated intestinal loops and a foreign body in the small bowel. Exploratory laparotomy revealed a plum impacted in the ileum 60cm proximal to the ileum end. Case 3: A 56-year-old man without any history of laparotomy developed small bowel obstruction caused by a chunk of meat impacted in the ileum 100cm proximal to the ileum end. Case 4: A 61-year-old woman without any history of laparotomy developed small bowel obstruction. CT findings were suggestive of the presence of a foreign body in the dilated small bowel. Exploration revealed an indigested shiitake impacted in the jejunum. All four patients had no past history of gastrectomy, but were almost toothless. Food-induced small bowel obstruction must always be kept in mind when we encounter patients presented with ileus, and the keys to successful preoperative dignosis are to verify the patient's habit of diet as well as recent dietary contents, to observe the condition of teeth, and to detect the foreign body on imaging methods including CT.

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A 38-year-old man who had multiple hemangiomas and dyschondroplasia in the limbs since infancy which was diagnosed as Maffucci's syndrome, was admitted to the hospital because of melena. Computed tomography and angiography demonstrated hemangiomas in the small intestine. Bleeding from the hemangiomas was diagnosed, and conservative therapy was started but was unsuccessful. So emergency laparotomy was performed. We saw multiple hemangiomas in the small intestine from about 10cm to about 60cm to the Treitz's ligament and a partial excision of the small intestine was performed.
Maffucci's syndrome is congenital, non-hereditary mesodermal dysplasia associated with multiple enchondromas and subcutaneous hemangiomas. It is a rare disease and few cases have been reported. We report an extremely rare case of Maffucci's syndrome with intestinal bleeding from hemangiomas treated by surgical resection.

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We present a case of Crohn's disease with an intramesenteric abscess without fistula. The patient was a 41-year-old man who had been performed a partial resection of the small intestine 9 years earlier for bowel obstruction caused by Crohn's disease. He had a 4-day history of low grade fever and abdominal pain, and was admitted to the hospital. Abdominal CT scan demonstrated an intraabdominal abscess. Although conservative therapy with antibiotics was started, high fever persisted. An emergency operation was performed. At laparotomy, an intramesenteric abscess was present, but no fistula was observed. Simple drainage for the abscess was carried out. The patient's postoperative course was uneventful, and he was discharged from the hospital on the 29th postoperative day. Abdominal abscess as a complication of Crohn's disease represents about 1020 percent of all complications of the disease in the Japanese literature. Intramesenteric abscess, this is so rare that only a cases have been reported during recent 20 years, usually occurs due to perforation of ulcer of the small intestine. We report this case here because intramesenteric abscess associated with Crohn's disease without fistula is uncommon.

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A 70-year-old man admitted to the hospital because of abdominal pain received anticoagulant therapy for aortic valve replacement. Abdominal ultrasonography and computed tomography showed a solid mass and hemoperitoneum. We considered that hemoperitoneum and mesenteric hematoma might be caused by anticoagulant therapy. Hemoperitoneum was reduced by blood transfusion and administration of hemostyptic and he was discharged from the hospital. But he was admitted to the hospital again because of anal bleeding. Superior mesenteric arteriography showed hypervascular tumor stains in the jejunal branch. A mesenteric tumor was diagnosed. Laparotomy revealed an 11×7cm elastic hard tumor of the jejunum and peritoneal dissemination. Partial resection of the jejunum was performed. Pathological examination showed spindle shaped cell, nuclear palisading, nuclear atypia, high cellularity and mitosis of 5-7/10 HPF.
Immunohistochemical stainings showed positive responses to c-kit, α-SMA, desmin, vimentin, NSE, and S-100. We made the definite diagnosis of malignant gastrointestinal stromal tumor (GIST) of the small intestine.

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We report a case of primary adenocarcinoma of the small intestine after resection of rectal cancer with a review of the literature.
A 54-year-old man underwent a low anterior resection for rectal cancer in November 1998, of which pathological diagnosis was moderately differentiated adenocarcinoma, sm, ly0, v0, n0, stage I. Four years and two months later, follow up abdominal CT scan revealed wall thickening of the jejunum. Small bowel endoscopy showed circular stenosis of the jejunum. Endoscopic biopsy allowed a histological diagnosis of poorly differentiated adenocarcinoma. The patient was operated on under a diagnosis of carcinoma of the small intestine. Partial resections of the small intestine and transverse colon with pancreaticosplenectomy were done. On the resected material a 4×6cm type 2 tumor was identified which invaded the colonic mucosa. Pathological findings included poorly differentiated adenocarcinoma, si, n0. It is important to pay attention to associated carcinomas of other organs including the small intestine in postoperative surveillance of colorectal carcinoma.

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A 75-year-old man was referred to the clinic because of left upper abdominal pain which persisted for a few months and resisted the symptomatic treatment at another hospital; no abnormal findings were revealed on ultrasonography and barium enema examinations. Abdominal ultrasonography and CT scan performed at the clinic showed a tumor 2.5cm in diameter oppressing the pancreas tail, but endoscopic retrograde cholangio-pancreatography could not reveal the tumor. Colonoscopy and barium enema study showed a stenosis of the left transverse colon, about 40cm from the anus. Biopsy of the stenosis lesion showed no malignant findings. Abdominal angiography showed a tumor like stain not in the pancreas tail but in the stenosis of the transverse colon. The splenic vein was interrupted near the pancreas tail by the tumor. With chemotherapy for a few months, neither tumor lesion nor the colonic stenosis was improved. Resection of the pancreas tail, partial resection of the colon and splenectomy were performed. Operative findings showed a hard mass on the pancreas tail and extensive inflammation from the pancreas tail to retroperitoneum near the left kidney. Histological examination showed actinomycosis granules in the colon wall and no malignancy in the colon and pancreas tail. Finally, we diagnosed this disease as actinomycosis of the transverse colon with inflammation extended to the pancreas tail.

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A 72-year-old man was admitted to the hospital because of pyrexia, right inguial pain and psoasstellung. Abdominal computed tomography showed a right psoas abscess. Drainage for the abscess with retroperitoneal approach resulted in well control of systemic inflammation.
Five days later, a large quantity of fecal liquid discharge was drained from the drain, of which culture yielded E. coli. Cecal cancer diagnosted with close exploration. On the 17^th day after the drainage, a right hemicolectomy was performed. The tumor was 10cm in diameter and had invaded the retroperitoneum, but no direct invasion into the iliopsoas muscle was confirmed. The patient's postoperative course was uneventful. About 2 months after the operation, however, he developed necrosis of femoral neck due to recurred right psoas abscess and was transferred to an orthopedics hospital.
Colorectal cancer associated with a psoas abscess is rare. The disease is common in the elderly people whose general conditions are often poor. Precise surgical therapy and strict and long-term observation of the clinical would be mandatory.

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The patient was a 61-year-old man undergoing an ileocecal resection for cecal cancer at another hospital on February 19, 1994 when the pathological findings were mucinous carcinoma, si (abdominal wall), ly₂, v₀, n₀, and stage III_b. He felt a right lower quadrant tumor in March 1995, and was seen at the hospital by referral. Abdominal CT scan visualized a tumor 40mm in size in the right lower abdomen, and the patient was operated on June 14. The tumor had invaded the abdominal wall and ileum, and solitary metastasis to iliac lymph node and regional peritoneum was seen. Excision of the tumor with abdominal wall and a partial ileectomy were carried out. Metastasis of cecal cancer was pathologically diagnosed. The patient had a right lower abdominal tumor again in June 2000 and was operated on July 16. The tumor had penetrated to the ileum and mesenteric lymph node metastasis was also identified. Removal of the tumor and extensive resection of the intestine were performed. Pathological findings suggested metastasis. Thereafter no signs of recurrence have been seen until his death duo to lung cancer and pneumonia on November 14, 2003.
In the treatment of mucinous carcinoma of the large intestine, frequent excisions of the metastatic foci might contribute to long-term survival of the patient in some cases, if the foci are localized.

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It is uncommon that colorectal cancer grows extramurally. We report a case of sigmoid colon cancer with extramural development.
A 70-year-old man was seen at the hospital because of left lower abdominal pain. A fist-sized, elastic-hard tumor was palpated in the left lower quadrant of abdomen, and close exploration was carried out. Abdominal echography and CT scan showed a tumor with the size of about 5cm which was on the mesentery side of the colon and adjacent to the colon. Barium enema study revealed apple core sign in the sigmoid colon. Endoscopy showed a type 2 tumor, and a biopsy resulted in well differentiated adenocarcinoma. The patient was operated on with the most likely diagnosis of colonic cancer with extramural development. At surgery, a fist-sized tumor extending from the sigmoid colon to mesentery was present. Sigmoidectomy was performed. On the removed specimen, the 6.0×4.5×4.0cm tumor extending from the colon to mesentery was identified and a 3.5×7.0cm tumor of type 2 was present on the surface of mucosa. On section we observed that the colonic tumor had invaded toward the mesentery to form extramurally growing mass. Histopathological dianosis was moderately differentiated adenocarcinoma, with the depth of the tumor invasion of si, ly2, v1, and n1(+).

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A 55-year-old woman was admitted to the hospital because of anal bleeding. She had received an Auchincloss operation for left breast cancer 12 years earlier (T2N0M0 in Stage II). Colonoscopic examination revealed sigmoid colon cancer (Type 1), and a pathological examination of a pre-operative biopsy specimen revealed signet ring cell carcinoma. Sigmoidectomy and lymph node dissection (D2) were performed under the diagnosis of sigmoid colon cancer. Pathological diagnosis was signet ring cell carcinoma, ss, n2, in Stage IIIb. Lumbago and a rapid increase in tumor marker appeared about 2 months after the operation. A bone scintigraphy demonstrated multiple abnormal uptake of isotope, by the sternum and thoracic and lumber vertebrae.
She died of disseminated intravascular coagulation (DIC) associated with systemic bone narrow metastasis on the 86^th or 21^st day after the operation or after DIC, respectively.
We present here the case of colonic cancer showing a rapid development of systemic bone marrow metastasis after surgery, together with a review of the literature.

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A case of colon cancer in a child presented with acute abdomen is reported, together with a review of the relevant literature.
A 15-year-old boy was seen at the hospital because of abdominal pain, vomiting, and fever. Abdominal CT scan demonstrated large quantities of ascites and free air. Emergency operation was performed with a diagnosis of generalized peritonitis caused by intestinal perforation. Based on intraoperative findings, peritonitis carcinomatosa with perforation of rectal cancer was diagnosed, and a Hartmann operation was carried out. Histological findings of this diffuse invasive tumor encircling the Rs included mucinous carcinoma, se, n(+), ly1, v1, H0, P3, M0, stage IV. Chemotherapy with 5FU/leucovorin was started on the 10^th postoperative day. However, peritonitis carcinomatosa progressed and the patient died on the 157^th postoperative day.
Colorectal carcinomas in children have poor prognosis. We must keep a possibility of colorectal malignant disease in mind even for children and make efforts to explore for early detection and curative resection.

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Fitz-Hugh-Curtis syndrome is perihepatitis due to sexually transmitted disease. We report three cases of this syndrome due to Chlamydia trachomatis infection. All were women aged from 25 to 36 years, and complained of right upper quadrant pain. The titers of serum IgA antibody and IgG antibody to Chlamydia trachomatis were elevated in the all cases. On abdominal ultrasonography, a low echoic lesion was detected on the surface of the right liver in two cases, which seemed to be ascites. But it was not found in the Morison pouch. And, tenderness of the abdomen was increased by compressing the surface of the right liver with the ultrasound probe in all cases. On abdominal CT, ascites was detected on the surface of the right liver, but it was not found in the Morison pouch in all cases. Contrast enhancement along the surface of the liver was found in one case. These findings were thought to support the diagnosis of Chlamydia perihepatitis. The all patients were successfully treated by antibiotics. Chlamydia trachomatis infection has recently benn on the increase, and we should consider this syndrome as a possible diagnosis when examining young women with abdominal pain of the right upper quadrant.

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The patient was a 52-year-old woman undergone a total thymectomy and a total right lobectomy of the lung for malignant thymoma on November 22, 1993, followed by irradiation at a total of 60Gy. On June 16, 1999, a liver tumor was discovered by ultrasonic examination. She underwent a subsegmentectomy for subsegment 7 and a partial resection for subsegment 3 of the liver on August 17, and these lesions were diagnosed as metastases from the thymoma on histopathological findings. Abdominal CT scan showed another liver tumor on June 18, 2003, and she underwent a partial resection for subsegment 3 and microwave ablation on July 24. As of June 1, 2004, she has no recurrence except for a coin lesion in the left lower lobe of her lung which might be slow growing metastasis. In this case, liver metastases occurred 67 months after the total thymectomy, and it took 46 months until the new liver metastases appeared aftert the first hepatectomy. Therefore, good prognosis can be expected by resection of liver metastases. To the best of our knowledge there have been only 34 cases of liver metastases from thymoma including our case and only 8 cases in which liver metastasis was successfully removed in Japan.

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An 83-year-old man was admitted to the hospital because of fever, epigastralgia, and jaundice with increased total bilirubin of 7.9mg/dl and serum amylase of 1, 096IU/dl. Abdominal ultrasonography, enhanced CT, and magnetic resonance imaging scans showed the dilated bilateral intrahepatic bile ducts and fluid retention in the surface of the left hepatic lobe. Bile juice collected by percutaneous needle aspiration of the area yield a diagnosis of biloma accompanied by acute pancreatitis and obstructive jaundice. A 2.0/1.0cm stone was found in the cystic duct but not in the common bile duct (CBD) by endoscopic retrograde cholangio-pancreatography. We inferred that the stone impacted in the CBD had elevated intrabiliary pressure and perforation of the intrahepatic bile duct resulted in biloma. The CBD stone may have migrated to the duodenum. Such a case of subcapsular biloma caused by impaction of a stone in the CBD is very rare.

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We report a case of primary carcinosarcoma of the liver which was associated with HCV positive liver cirrhosis and was diagnosed as the disease after hepatic resection in a 70-year-old woman. The patient had been pointed out to have liver dysfunction elsewhere since 1993, which was attributed to HCV positive chronic hepatitis. In 1996, her hepatitis progressed to liver cirrhosis. In the following year hepatocellular carcinoma (HCC) 1.6cm in diameter was detected in the S7 of the liver by abdominal ultrasonography and percutaneous ethanol injection therapy (PEIT) was carried out. Endoscopic variceal ligation (EVL) was performed for esophageal varices in 1999. In April 2000, transcatheter arterial embolization (TAE) was performed to treat recurrent HCCs (1.8cm in diameter in S₂ and 2.0cm in S₇). In July 2000, repeated increases in the serum AFP and PIVKA-II led to the detection of a new HCC (4.5cm in diameter) in S₇ of the liver. In November 2000, she was transferred to the hospital and underwent posterior segmentectomy of the liver. Histopathological findings of the excised specimen revealed primary carcinosarcoma of the liver. Clinically, carcinosarcoma is a rare entity, especially carcinosarcoma originating from the liver parenchyma. Including the present case, only 11 cases have met the WHO criteria for carcinosarcoma of the liver in the English literature during the last 20 years.

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A 72-year-old woman was admitted to the hospital because of sudden onset of recurrent vomiting. Abdominal CT scan showed a 2-cm gallstone and pneumobilia in the wall-thickened gallbladder. The gallbladder and duodenal bulb could not be separated as distinct structure suggesting the cholecystoduodenal fistula. Gastroduodenal endoscopy revealed the impacted gallstone in the duodenal bulb. Upper gastrointestinal series demonstrated radiolucent gallstone in the duodenal bulb with visualization of the common bile duct. Laparotomy was performed under a diagnosis of gastric outlet obstruction due to the impacted gallstone in the duodenal bulb caused by cholecystoduodenal fistula, namely Bouveret's syndrome. After cholecystectomy, the impacted gallstone was extracted from the dilated fistula of the duodenal bulb. The duodenum was closed transversely and covered with omentum.
Duodenal bulb obstruction by a gallstone is a rare cause of gallstone ileus. Gastrectomy is sometimes necessary not only for the treatment of the cholecystoduodenal fistula but also for the extraction of the impacted gallstone because of the severe inflammation around the bulb. Approach of the treatment must be decided carefully according to the general condition of the patient and based on the correct preoperative diagnosis. Herein we report the case of Bouveret's syndrome with a review of 15 cases in the Japanese literature.

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A 75-year-old woman underwent a pancreatoduodenectomy with reconstruction by means of Child method (retrocolic) for bile duct cancer. The postoperative course was uneventful except an elevation in the volume of retrograde trans-hepatic bile duct drainage (RTBD). However, removal of a tube placed in the remnant pancreatic duct produced further elevation of RTBD volume. RTBD was removed on the 35^th postoperative day, when the patient developed abdominal pain, vomiting, high grade of fever, and decreased blood pressure. Increases in the white blood cell count, biliary enzymes, and serum amylase were also noted. Dilation of the afferent loop was detected with ultrasonography and computed tomography and acute afferent loop obstruction was diagnosed. A long tube was inserted into the dilated afferent loop under upper GI endoscopic guidance. Balloon dilatation was attempted for the obstructed afferent loop, but was unsuccessful. Reoperation was performed on the 63rd POD. Afferent loop obstruction in this patient was caused by severe adhesions at the site of meso-transeverse colon. The side to side anastomosis between the afferent loop and efferent loop was performed. The post operative course was uneventful. Gastrointestinal reconstruction by Billroth II anastomosis should be performed via the antecolic route to prevent afferent loop obstruction.

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A 28-year-old man, who had been diagnosed as having a gallstone but had let it alone because he was asymptomatic, was detected to have Salmonella from his feces. Repeated administrations of antibiotics were unsuccessful. We thought that additional antibiotics might still be ineffective and the gallstone might be a probable cause. Cholecystectomy was thus carried out. Bacteriological study of the removed gallstone yielded the same Salmonella as that detected from the feces. The postoperative course was uneventful and he was discharged from the hospital on the 12^th hospital day. Culture of a sample of his feces taken 11 months after the operation gave negative result for Salmonella.
It is believed that people who have a gallstone or malformation of the gallbladder are prone to be asymptomatic Salmonella carriers. In treating a long-standing Salmonella carrier who has a gallstone, we must suspect the gallstone as a probable cause and consider surgical removal of it.

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Necrotizing pancreatitis often causes multiple organ failure in the early stage after the onset. In the latter stage, it is accompanied with infection of necrosis lesions in most cases. There is a limit of conservative treatment for infected pancreatic necrosis, and some surgical treatments are required.
We report a case of laparoscopic cholecystectomy 14 months after retroperitoneal approach to necrotizing pancreatitis.
A 48-year-old man complaining of abdominal pain after excessive drinking was referred to the hospital for treatment of acute pancreatitis in July, 2001. Although a temporary remission was achieved by conservative therapy, his symptoms became worse again. He was diagnosed as having necrotizing pancreatitis by abdominal CT scan, symptoms and positive materials in culture of percutaneous catheter drainage. Retroperitoneal necrosectomy and drainage were performed 95 days after the onset of the disease. The patient's postoperative course was uneventful, and he was discharged from the hospital on the 144th postoperative day. Laparoscopic chyolecyctectomy was able to perform about 14 months after the surgery.
We think that retroperitoneal approach is of great value in treating necrotizing pancreatitis, because it is capable of avoiding direct intraperitoneal operations and performing sequential laparoscopic cholecystectomy.

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We report a rare case of mucin-producing cholangiocarcinoma combined with intrahpatic stone in a 72-year-old man with dementia. There was previous history of undergoing percutaneous transhepatic cholangiodrainage and endoscopic papillectomy with the diagnosis of hepatolithiasis with atrophy in the left hepatic lobe, for which he had been suffered from recurrent cholangitis for 2 years. This time he was transferred to the hospital by ambulance because of fever and chill. Sepsis and deteriorated liver function urged hepatectomy with lithotomy, which revealed cholangiocarcinoma with incarcerated intrahepatic stone. Left lobectomy with lymphadenectomy was performed. Histopathological findings showed papillary adenocarcinoma that spread superficially in the duct of segment 2 and produced mucin filling and dilating the peripheral duct, whereas bilirubin calculus incarcerated the duct just proximal to the tumor. The difficulty in diagnosis for the present case might be attributed to that mucin outflow from the Vater's papilla and delineation of filling defect in cholangiography or massive mucinous outflow from the Vater's papilla were laoked because an intrahepatic stone incarcerated in the biliary branch of S2 prevented mucous produced by the cholangiocarcinoma from flowing out to the common bile duct.

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A 63-year-old woman was seen at the hospital because of epigastralgia and right lower abdominal pain. Abdominal CT scan showed an increase in the content of retroperitoneal adipose tissue from the ileocecal region to the circumference of the pancreas. An exploratory laparotomy was carried out with a suspicion of appendicitis or perforated diverticulitis. At laparotomy, bloody acites was present and an extensive hematoma involving the mesentery and retroperitoneal cavity was seen, but no bleeding point was identified. Several days later, abdominal angiography showed an aneurysm of the pancreaticoduodenal artery, and then trans-catheter embolization was carried out, with an uneventful postoperative course.
Pancreaticoduodenal artery aneurysm is a comparatively rare entity and is usually silent. However, once it ruptures into the abdominal cavity or intestine, the patient can go into shock with a fatal course. Differentiation of the disease from inflammation is reportedly difficult if a hematoma is not localized. Abdominal angiography and trans-catheter embolization are of great value in the diagnosis and treatment of abdominal visceral arterial aneurysms.

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Pancreatojejunal anastomotic insufficiency still frequently occurs after pancreaticoduodenectomy (PD). It is cured by conservative therapy in most cases, but complete external pancreatic fistula is intractable. We report two cases of intractable pancreatic fistula after PD successfully treated by internal drainage under ultrasonographic guidance.
A 78-year-old woman and a 62-year-old man underwent PD for bile duct cancer. Reconstruction was performed by modified Child's method and pancreatojejunal anastomosis was performed by insertion of a stent tube into the main pancreatic duct. In both cases, after removal of the stent tube, pancreatic juice began to leak from the drain. Fistulography showed no communication between the main pancreatic duct and anastomosed jejunum. In order to make the communication between them, puncture was aimed at the elevated jejunum through the sinus tract under ultrasonographic guidance. Internal drainage tube was inserted into the jejunal lumen and placed. About 3 months later, the drainage tube was removed. The fistula was successfully closed in both cases. Internal drainage under ultrasonographic guidance is very useful for treatment of intractable pancreatic fistula.

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A 53-year-old woman complaining of general fatigue, fever, and urine died in yellow was found to have a 4.5×4.0cm tumor at the pancreas head on abdominal CT and echography. Endoscopic retrograde pancreatography (ERP) showed a stricture of the main pancreatic duct, and angiography visualized displacement of the portal vein. However, relatively less invasion of the tumor to the surrounding vessels was observed. Pancreatoduodenectomy was carried out with a suspicion of obstructed jaundice due to a tumor of the pancreas head, especially invasive carcinoma of the pancreatic duct. Intraoperative frozen section diagnosis was undifferentiated carcinoma of the pancreatic duct, but the histological diagnosis based on the permanent preparation was non-Hodgkin's lymphoma, diffuse large cell, B cell type. Two courses of CHOP regimen were conducted as the postoperative adjuvant therapy. There have been no signs of recurrence and the patient is followed in the clinic, as of 2 years after the operation.

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We report a rare case of primary malignant lymphoma of the spleen forming a huge splenoma presented with pancytopenia. A 47-year-old man complaining of general fatigue was referred to the hospital for pancytopenia; the white blood cell count was 400/mm³, the red blood cell count was 136×10⁴/mm³, and the platelet count was 2.2×10⁴/mm³. On close exploration a huge splenoma and a high level of IL-2 receptor were disclosed. The patient underwent a splenectomy with a diagnosis of pancytopenia due to hypersplenism in which a possibility of primary malignant lymphome of the spleen could not be ruled out. The histological diagnosis was malignant lymphoma of the spleen, diffuse small cell, B-cell type. The patients postoperative course was uneventfull, and he was discharged on the 8th postoperative day. One month later he underwent adjuvant chemotherapy with CHOP in the department of hematological medicine. He has been free from recurrence and followed in the clinic as of 31 months after the operation.

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A 48-year-old man was admitted to the hospital for operation with a diagnosis of a giant tumor at the right frank. He had noticed that his pants became tight and ill-fitting since about May 2004. He visited another hospital about the middle of August because of fever, abdominal pain and watery diarrhea, and was pointed out having the tumor. After admission to the hospital, ultrasonography showed a high-echoic huge mass, 20cm in diameter, upward the right kidney in the retroperitoneal space. The tumor had mainly low density on CT scan, high signal on MRI T2 imagings, and was revealed as an avascular area at angiography. The operation was done with a diagnosis of right adrenal myelolipoma. The resected mass was 20×18×16cm in dimension and 2, 400g in weight, and pathologically was composed with fat cells and bone marrow elements with megakaryocyte. Adrenal components were also detected. No malignant findings were seen. The tumor was diagnosed as right adrenal myelolipoma.

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The patient was a 67-year-old man undergone a total gastrectomy for advanced gastric cancer on October 17, 1988, which was poorly differentiated adenocarcinoma, T2 (SS), N0, H0, P0, M0, and in Stage IB. The patient had been given oral 5FU for 3 postoperative years. In November 1998 when about 10 years had elapsed after the operation, an increase in CEA to 27.5ng/ml was noted. Abdominal CT scan revealed a tumor in the left retroperitoneum. On March 4, 1999, tumorectomy with associated excision of the pancreas tail and transverse colon was carried out with a suspicion of a retroperitoneal tumor, considering a possibility of left adrenal metastasis of gastric cancer after the initial operation. The histological diagnosis was adrenal metastasis of gastric cancer.
Most patients with adrenal metastasis of gastric cancer have far advanced gastric cancer and hence are rarely candidates for surgery. There have been only 12 resected cases of adrenal metastasis of gastric cancer including ours in Japan. Long-term survival can be expected for patients with adrenal metastasis of gastric cancer, if no other metastatic foci are present, in that aggressive surgical resection must be considered as an option.

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A 37-year-old woman diagnosed as having left inguinal hernia before 4th pregnancy also had varices at the left labium major during pregnancy. After she was delivered of a baby transvaginally at 40 week 0 day of pregnancy, she developed severe pain and swelling of the left inguinal region, and was referred to our department about 30 hours after the delivery. We diagnosed the case as irreducible inguinal hernia, and manipulated to reduce the herniation, but in vain. Then, emergency operation was perfomed. Operative findings revealed large thrombus in the varices around the round ligament. While a hernia sac of the inguinal hernia was found, no herniation of abdominal organs was seen. It was inferred that the varices developed in the round ligament vein by venous congestion due to pregnancy and rapid formation of the thrombus might cause severe pain.
Round ligament varix is a rare condition and can be caused by venous congestion with pregnancy. When pregnant woman develops inguinal tumor formation, round ligament varices should be considered as a differential diagnosis.

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We report an emergency case of pneumopeirtoneum associated with intraabdominal free air and hepato-portal venous gas from unknown cause.
A 76-year-old woman bedridden due to a sequela after cerebral infarction suddenly vomited serousbloody fluid at night and was transferred to the hospital on December 4, 2003. Her abdomen was markedly distended and hard. Chest and abdominal plain X-rays revealed intra-abdominal free air. Computed tomography showed not only pneumoperitoneum but also intra-hepatic gas images developing a tree-like view in the peripheral portion of the liver. Necrotic perforation of the gastrointestinal tract was suspected, then exprolatory laparotomy was immediately done. An intensive intra-abdominal inspection could detect neither organ rupture nor ischemic changes in the gastrointestinal tract. There were no abnormalities in the genital system and diaphragm. No causes could be identified. Postoperative examination of the digestive system using contrast media or endoscope also revealed no organic abnormality related to the present unusual findings. It is etiologically thought that, since the patient had had remarkable aerophagia, the intraluminal pressure of the small intestine abruptly increased with the increase in intra-bowel gas when she vomited, causing disruption of the mucosal barrier and microperforation.

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We report a case of spontaneous mesenteric hematoma which is relatively rare. A 58-year-old man was admitted to the hospital because of abdominal pain lasting for 4 days. Mild anemia and leukocytosis were noted. Abdominal computed tomography (CT) showed ascites and a hematoma suggesting intraabdominal bleeding. On the next day, emergency operation was performed because the hematoma enlarged and anemia rapidly progressed. On laparotomy, bloody ascites was identified in the peritoneal cavity and a huge hematoma was seen in the right half of mesentery of the transverse colon. Evacutation of the hematoma was performed because bleeding point and intestinal ischemia were not found. Postoperative angiogram showed no definite findings of the middle colic artery which was inferred to have some cause for bleeding. He had no history of abdominal trauma nor bleeding tendency. The case was diagnosed as spontaneous mesenteric hematoma.

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A 30-year-old woman was seen at the hospital because of upper abdominal pain in March 2003 which she first felt in January but let it alone for its prompt remission. No particular abnormal findings were noted on biochemical studies of blood. Abdominal ultrasonography and abdominal CT scan visualized a tumor at the superior margin of the pancreas body. She was admitted to the hospital for close exploration. Endoscopic retrograde cholangio-pancreatography showed no anormalities. Abdominal angiography visualized a 4×3cm tumor with plenty of blood flow fed by the left gastric artery. The tumor was removed on June 26. Histopathological diagnosis was Castleman's tumor (hyaline vascular type). The patient's postoperative course was uneventful, and she was discharged from the hospital on the 8^th postoperative day.
Since Castleman's tumors arising in the lesser omentum are rare, this case of hyaline vascular-type Castleman's tumor is presented together with a review of the literature.

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A 53-year-old woman pointed out having an elevated lesion in the rectum at a medical checkup was referred to the hospital. On close examinations, the lesion was diagnosed as a presacral cystic tumor which measured 4×2.5×4cm in dimension. The patient was followed in the clinic because no malignant findings were revealed. Two years seven months later, magnetic resonance imaging scan showed an enlarging tendency of the tumor, so that a radical operation was planned for probable malignant change of the tumor. Preoperative endoscopic ultrasonography demonstrated that the cystic tumor did not involve the rectal wall, indicating that rectal resection was unnecessary. The cystic tumor was removed through the transsacral approach. The removed tumor was 4×3×4.5cm in dimension. Pathologically the tumor had cystic wall structure lined with squamous cells, no dysplasia was identified in the epithelium, and the cystic wall was composed of fibrous connective tissue. In addition no appendages of the skin was identified, and the tumor was diagnosed as presacral epidermoid cyst. There were no apparent malignant findings.
Presacral epidermoid cysts require radical operations because they have a malignant potential. In this case, however, we were able to select the transsacral approach before surgery, because we knew that no rectal resection was demanded with endoscopic ultrasonography conducted preoperatively.

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We recently experienced an extremely rare case of proximal-type epithelioid sarcoma in a 36-year-old man.
The patient was admitted to the hospital because of a growing superficial nodule in the perineum in October, 2002. Despite various examinations, preoperative definite diagnosis was not made. He received surgical excision of the tumor in November, 2002. Histopathological examinations showed central necrosis with findings compatible with epithelioid sarcoma. In immunohistochemical examination, the cell stained positively for anti-cytokeratin, anti-CD34, anti-vimentin, anti-EMA, and anti-E-cadherin, but not for anti-neurofilament, anti-desmin, and anti-GFAP.
Postoperative course was uneventful, but he died of respiratory failure resulting from multiple lung metastases 1 month after the surgery.

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A 72-year-old woman was admitted to the hospital because of anal bleeding with pain. Colonoscopy and barium enema revealed an ulcerated tumor of the rectum. Laboratory data showed liver dysfunction and positive hepatitis C virus antibody. Abdominal ultrasonography, computed tomography, and angiography showed tumors in the medial and posterior segments of the liver. Radiological examinations indicated that the liver tumors were hepatocellular carcinoma (HCC) associated with liver cirrhosis and not metastases of the rectal cancer. CA19-9 and AFP levels were elevated to 68U/ml and 21.1ng/ml, respectively. Synchronously occurred HCC with liver cirrhosis and rectal cancer were diagnosed. We judged that simultaneous operation was impossible from the patient's hepatic reserve and other abnormalities and performed abdominoperineal excision of the rectum for rectal cancer, followed by transcatheter arterial embolization for HCC with an interval of 30 days. The postoperative course was uneventful. Histological examination of the rectal tumor showed well differentiated adenocarcinoma in stage IIIa (a2, n1). Replication errors in DNA, which may play an important role in development of multiple primary cancers, were not observed in the resected specimens of rectal cancer. Surgical cases of synchronous double cancer consisting of rectal cancer and HCC associated with liver cirrhosis are rare, and this is the third report in Japan.

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