Thirty-seven operative cases of breast (n=26) and thyroid disease (n=11) were randomly allocated to two groups. One group was administrated 500mg/day of azithromycin (AZM) for 3 days from 2 days before operation to the day of operation, and the other group was administrated 3g/day of sulbactam/ ampicillin (SBT/ABPC) for 3 days from the operative day. Two groups were evaluated for the incidences of postoperative wound infection and remote infection prospectively. There was one surgical site infection (SSI) in SBT/ABPC group (1/17:5.9%), and one case of remote infection (RI) in AZM group (1/20:5.0%).
The remaining 35 cases had no clinical infectious signs, and were in normal rangs as to CRP, WBC, and body temperature for a 7-day observation period after the operation. There were no significant differences between two groups in those factors.
The oral administration of AZM appears to have the same effect to prevent postoperative infection as intravenous administration of SBT/ABPC has.

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This study enrolled 25 lesions of 23 cases of juvenile polyp removed surgically or endoscopically at the department in a 30-year period from 1975 to 2004. Their ages ranged from 11 months to 12 years. The male-to-female ratio was 15:8. Twenty patients presented with bloody stool; seven patients, with prolapse of a polyp through the anus; two patients, with intussusception caused by a polyp; and the remaining patient, with anemia. As for treatment, we performed transanal polypectomy for 12 polyps of 11 cases; endoscopic polypectomy for 10 cases; laparotomic removal for one case; and hemostatic procedure after manual removal by the patient's mother for one case. The most common site of the disease was the rectum (15 polyps), followed by the sigmoid colon (5). There were two metachronous cases and one synchronous case.
Since juvenile polyp can cause intussusception or anemia and cancer change of the lesion has been reported in some cases, surgical resection is required as early as possible after making the diagnosis.

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Thyroid crisis is a critical condition that presents with a sudden and life-threatening exacerbation of symptoms of hyperthroidism. It can be induced by physical stress such as traffic accident or infection. We report a 41-year-old woman with thyroid crisis induced by a traffic accident. When she was transferred to the hospital after the traffic accident, she was in thyroid crisis revealing sinus thachycardia, high fever, sweating, diffuse swelling of the thyroid. Laboratory data showed remarkably high free T3 and T4 levels and low TSH level. She was treated with Lugol's solution, propranolol hydrochloride, and propylthiouracil. Although the laboratory data were improved quickly with the treatment, myopathy consisting paralysis of muscle persisted. When we see the patient with severe multi trauma, the time for making diagnosis is limited in emergency condition, and we can not interview the patient sufficiently. Further we are apt to pay attention only to serious traumas which demand emergency treatment. It is important to evaluate changes in physiological signs precisely not to overlook some unexpected underlying condition.

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It is rare that a fibroadenoma is associated with breast cancer. Fibroadenomas are often followed after diagnosed as benign with mammography, echography, and needle aspiration biopsy cytology. We report a case of fibroadenoma associated with ductal carcinoma in situ (DCIS).
A 47-year-old woman diagnosed as having a fibroadenoma 20 years earlier presented with bloody nipple discharge and a 4.5×4.0cm breast lump. The clinical diagnosis based on palpation, mammography, and ultrasound was ‘suspected breast cancer’. In addition, the pathological diagnosis of core niddle biopsy was atypical ductal hyperplasia and a cytology of aspirated nipple fluid was Class IV. To obtain the definitive pathological diagnosis, surgical biopsy was carried out. DCIS covered with fibroadenoma was identified histologically. In conclusion, it is preferable to perform open-biopsy when a breast tumor is suspected of cancer.

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A rare case of breast carcinoma with osteoclast-like giant cells is described.
A 49-year-old woman presented with a lump in her right breast. Physical examination revealed a firm mass measuring 2.0×1.8cm in the right upper outer quadrant. Ultrasonography and mammography findings suggested breast cancer. A fine needle aspiration biopsy cytology revealed numerous multinucleated giant cells and small clusters of atypical epithelial cells. Excisional biopsy was performed to differentiate from other benign tumors with giant cells. Since immunohistochemical staining for CD68 revealed strong positivity in multinucleated giant cells, the tumor was diagnosed as invasive ductal carcinoma with osteoclast-like giant cells. She underwent a breast conservative surgery with axillary dissection, and has been well without signs of recurrence during an 8-month follow up period.
Because breast tumors with giant cells are multifarious, histopathological study including core biopsy or excisional biopsy is necessary when the diagnosis can not be made by cytological examination.

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This paper presents a case of breast cancer with meningeal dissemination which is comparatively rare.
A 49-year-old woman with far-advanced inflammatory carcinoma of the right breast was admitted to our department of surgery. Neoadjuvant chemotherapy to diminish the tumor size, operative procedure (rBt+Ax+Mn) and adjuvant chemotherapy were successively conducted for this patient. However, local recurrence in the skin of the operative site and metastasis to the left breast appeared immediately after these treatments. The local recurrence was controlled by radiation therapy. Moreover, abdominal CT and bone schintigram revealed multiple liver and bone metastases. Then weekly paclitaxel infusion therapy was started. The liver metastases grew rapidly despite this chemotherapy. In order to suppress the proliferation of the liver tumors, hepatic arterial infusion of anti-cancer drugs (5-FU, ADM) was performed, but in vain. During these procedures, she complained of headache, nausea, vomiting and loss of appetite. Gadolinium (Gd) enhanced magnetic resonance imaging (MRI) scan revealed metastases to the left cerebellum and meningeal dissemination. Radiation therapy was scheduled, but she died of liver failure. The total course of her disease was 13 months.

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We removed an elastofibroma dorsi by using the applied wound retractor (Alexis) in a 76-year-old woman. The patient was seen at the hospital because of a right dorsal tumor. A tumor was palpated inferiorly to the right scapula on abduction of the right shoulder joint, but was not palpated on the intermediate position. The tumor was elastic-hard and immovable, and had a smooth surface. There was no tenderness. CT scan revealed an about 5-cm tumor in the inner side of inferior angle of the scapula. Percutaneous needle biopsy gave the most likely diagnosis of elastofibroma. A skin incision about 6cm in length was made on her right side under general anesthesia. The latissimus dorsi muscle was separated off and oppressed forward by using Alexis. Separating off the lower layer of the greater rhomboid and anterior serratus muscles, the Alexis was placed under the lower layer and the operative field was developed. All the latissmus dorsi, greater rhomboid, and anterior serratus muscles were preserved, and the tumor was removed. There was no invasion into the surrounding organs, but we had great difficulties in separation from a part of periosteum of the 6t5 rib. The removed tumor was 56×45×15mm in dimension, grayish white in color, and solid. The histological diagnosis was elastofibroma. The patient's postoperative course was uneventful without any complications. In operation the Alexis was very helpful in protecting the wound edge and developing the surgical field.

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A 54-year-old woman seen at the hospital because of right flank pain was found to have tenderness in the same point. Abdominal ultrasonography, CT, and magnetic resonance imaging scans showed a mass compressing the lumen of the inferior vena cava at the juction of renal veins. At laparotomy the tumor was fixed to the anterior wall of the inferior vena cava at the junction of the renal vein, and it was removed with a part of the wall of the vena cava. Pathological diagnosis was leiomyosarcoma. About 5% of the tumor cells were positive for estrogen receptor. The patient has been well without reccurence as of 3 years and 3 months after the surgery.

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Morgagni foramen hernia is a rare diaphragmatic hernia, especially the disease associated with esophageal hiatal hernia is very rare, and only 13 cases have been reported in Japan. We report a case of Morgagni foramen hernia associated with an esophageal hiatal hernia.
A 75-year-old woman, complained of right chest-abdominal pain and dyspnea, was referred to the hospital for evaluation of an abnormal shadow in the right lower lung field on chest X-ray films. Computed tomographic scans demonstrated a hernia of the transverse colon and omentum protruding into the right thoracic cavity through the foramen of Morgagni, and gastrointestinal endoscopy revealed reflux esophagitis with a sliding esophageal hiatal hernia. An upper abdominal median laparotomy was employed for the surgical approach. During surgery a hernia was found at the foramen of Morgagni with a sac containing the greater omentum alone. After reducing the omentum, the sac was inverted and removed. The hernia opening, which was 3cm in diameter, was closed with direct sutures. For the esophageal hiatal hernia, modified Nissen type fundoplication and repair of the esophageal hiatus were performed. The postoperative course was uneventful, and she was discharged from the hospital 14 days after surgery.

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Congenital bronchial atresia is a rare disorder. We treated two cases of this disease.
The first patient, a 33-year-old woman, always needed time to recover from her cough when she took a common cold. The second patient, a 22-year-old woman, complained of exertional dyspnea, whose chest x-ray examination showed mediastinal shift to the normal side. These two patients underwent operation, and got symptomatic remission. Congenital bronchial atresia does not require any treatment if it is silent. But we must consider surgical treatment for some cases, in which ill effects due to infection or over inflation of the lung occur like these two cases.

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A 56-year-old man was admitted to the hospital because of dyspnea. Chest X-ray and CT revealed emphysematous giant bulla in the right lung with mediastinal deviation to the left. Under oxygen inhalation, blood gas values were PaO₂: 71.1mmHg, PaCO₂: 58.6mmHg, and the forced vital capacity (VC): 1.751 (%VC: 47.0%) with FEV_1.0: 0.681 (FEV_1.0%: 38.8%). Intracavity suction of the giant bulla resulted in the patient's release from dyspnea, when evaluation of the residual lung function became possible. Video-assisted bullectomy was subsequently done. The residual lung reexpanded well after the operation. Blood gas analysis turned out to be PaO₂: 76.4mmHg and PaCO₂: 45.9mmHg without O₂ inhalation, VC: 3.021 (%VC: 81.2) and FEV_1.0: 2.431 (FEV_1.0%: 85.3%).
Intracavitary suction of the giant bulla is useful to assess the residual lung function, and to prevent reexpansion pulmonary edema after bullectomy for patients with dyspnea due to emphysematous giant bulla. Video-assisted surgery is advantageous to preserve the lung function.

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An asymptomatic 80-year-old man, who was under treatment for hypertension and diabetes, was admitted to the hospital because of a mobile coin lesion on a chest X-ray film. CT and magnetic resonance imaging scans demonstrated a round mass lesion, about 2.0cm in diameter, between S² and S⁶ segments of the right lung. Video-assisted thoracic surgery (VATS) was performed to remove the mass located in the oblique fissure. The easily removed mass was 2.2×2.0×1.8cm in dimension, eggshaped and elastic-hard, and had smooth surface. Histologically this mass had an eggshell like structure composed from coagulation necrosis of fat cells surrounded by collagen fibrous tissue, which was identical to that of the intraperitoneal loose body. The definite diagnosis was thoracolithiasis, which is known to encounter very rarely.

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A 66-year-old man, who had drunk a bottle of detergent of hydrochloric acid by mistake, underwent gastrojejunostomy for pyloric obstruction and received multiple insertions of expandable metallic stents (EMS) for esophageal stricture caused by corrosive gastritis and esophagitis at another hospital. Thereafter, stricture symptom was not dissolved but pneumonia and mediastinitis developed. Three years after the accident, he was admitted to the hospital and underwent emergency operation of esophagostomy and jejunostomy to improve his general condition and to prevent aspiration pneumonia. A month later, esophageal reconstruction using the right colon and distal gastrestomy were performed. In a postoperative period, the oral side of the reconstructed colon became necrotic, so that esophagostomy was performed again. A month later, an esophago-bronchial fistula due to compression by the EMS developed. Then, total thoracic esophagectomy and closure of the fistula using the latissimus dorsi muscle flap were performed. Finally he resumed oral intake after esophageal reconstruction with free jejunal interposition 4 months later.
We present this case of corrosive esophagitis with mediastinitis and esophago-bronchial fistula caused by insertion of EMS. Considering life threatening complications of inserting EMS, we should not apply EMS for the treatment of benign esophageal stricture due to corrosive esophagitis.

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The patient was a 71-year-old man undergoing a total gastrectomy with associated resection of the pancreas body and tail and splenectomy for advanced carcinoma of the posterior wall of the upper body of the stomach on January 8, 2003. He developed perforation of the jejunum which had been elevated for oppressed necrosis due to a drain indwelt into the Wislow's foramen after the operation, but was discharged from the hospital after getting a cure of the perforation with conservative treatment. On June 30, 2003, the patient was admitted to the hospital for abdominal wall abscess of the right loin and received incision drainage. Upper gastrointestinal series disclosed leakage of contrast material from the perforated portion occurred after the former operation at the elevated jejunum. We accordingly thought that the portion became an intractable fistula which persisted for a long time leading to abscess formation on the abdominal wall. Without closing the fistula, we infused histoacryl into the fistula via an endoscope, when the fistula was immediately closed and the patient became to be able to eat.
We often have great difficulties in treating intractable fistula formed in the gastrointestinal tract. There has been only another case of intractable GI fistula successfully treated by histoacryl infusion as far as we could review. This very simple and easy method might be one of therapies that should be attempted.

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We present a case of clear cell carcinoma arisen in the gastric serosa after surgery for carcinoma of uterine body, together with some bibliographical comments.
The patient was a 50-year-old woman who underwent total hysterectomy+bilateral adnexectomies for carcinoma of uterine body at the department of gynecology in our hospital in October 2002, and then was followed after postoperative chemotherapy. Abdominal CT scan conducted in May 2003 visualized a tumor shadow at the surroundings of the hilum of spleen. Thereafter the tumor became enlarged and the patient was referred to our department of surgery. As a result of close exploration, the tumor was diagnosed as primary submucosal tumor of the stomach, and a laparoscopic operation was carried out. The histopathological diagnosis was clear cell carcinoma arisen in the gastric serosa. Further 4 months later a recurrent lesion was confirmed near the primary site, and laparoscopic removal of the recurrent tumor was carried out in May 2004. Histopathological diagnosis was also clear cell carcinoma. There has been no appreciable recurrence as of 6 months after the operation. Further strict follow-up of her clinical course would be mandatory because of scarce accumulation of clinical cases of the disease.

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A 54-year-old man pointed out gastric abnormalities by mass examination was diagnosed as having type 3 gastric cancer by endoscopic study. Successive multiple tumors like octopas sucker at the right colon was revealed by barium enema and endoscopic studies. Cytology of these colonic tumors revealed the same findings as gastric cancer showed. We diagnosed the case as gastric cancer and its metastasis to the colon. Operative findings included no peritoneal dissemination, no malignancy of asites cytology, and metastasis to the lymph nodes surrounding the left gastric artery and abdominal aorta. Distal gastrectomy and right colectomy were palliatively performed for gastric cancer and metastatic colon cancer because nephrotic syndrome due to malignant tumor was also associated. Histological study showed that the colonic tumor (tub2) had the same findings as the gastric tumor had and the marked lymphatic invasion (ly3) was revealed. Metastatic colonic tumor from gastric cancer was diagnosed by immunological atain of the colonic tumor. Supraclavicular lymph node metastasis was recognized 5 months, and anastomotic recurrence 9 months after the operation. It was thought that lymphogenous metastasis had occurred. Chemotherapy was ineffective, and the patient died of lymphatic recurrence 317 days after the operation.

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An 81-year-old woman who had been laid up with appetite loss for almost these 2 days was seen at the hospital because of nausea and vomiting on March 22, 2004. Following failure to alleviate intestinal obstruction with a long nasointestinal tube with deterioration of the general condition, we perfomed an emergency operation. Upon laparotomy, we noted the presence of bloody ascites and necrotic intestine. The necrotic ileum was rotated clockwise and strangulated by an obturator hernia. Resection of the necrotic intestine by about 150cm was performed, and the obturator hernia was closed.
Strangulated ileus caused by obturator hernia is very rare and no other cases have been reported as far as we could review.

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A case of nonspecific multiple diaphragm-like strictures in the small intestine is reported. A 72-year-old woman with a 24-year history of receiving oral form and suppository of NSAID for disk herniation presented with repeated vomiting and appetite loss. Laboratory data showed severe anemia and hypoproteinemia. Abdominal X-P showed niveau formation in the small intestine. We inserted a long tube and made small intestinal contrast study. The study revealed segmentary stricture and ballooning of the ileum. Examination of small intestinal juice for occult blood was positive. We performed a partial resection of the small intestine by 2m in langth with the diagnosis of small intestinal obstruction and bleeding. Macroscopic appearance of the small intestine showed multiple “diaphragmlike” strictures with shallow ulcers where the strictures were of minor degree. Histological examination of the specimen revealed submucosal fibrosis. We diagnosed the case as NSAID-induced “diaphragmlike disease” stricture of the small intestine.

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Intussusception is a highly frequent disease in children. It is idiopathic in many cases. Intussusceptions caused by heterotopic pancreas are rare. We experienced such a case of intussusception caused by an ileal heterotopic pancreas.
A 6-year-old boy visited another hospital because of abdominal pain and distension. On enema bloody stool was observed. Because abdominal distension persisted and vomiting also appeared, he was seen at our department. Ileum gas was apparent on a plain X-ray film and abdominal ultrasonography revealed pseudokidney sign. We diagnosed the case as ileus caused by intussusception. More than 24 hours had elapsed since the onset of the disease, and an emergency operation was performed. At laparotomy, we found an ileo-ileo-colic intussusception. When it was reduced, a mass measuring 2cm in diameter was palpable at the terminal ileum and a partial ileal resection including the mass was performed. Histologically it was diagnosed as heterotopic pancreas (Heinrich I type). The patient's postoperative course was uneventful. No recurrence has occurred.

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A 50-year-old man was admitted to the hospital because of right lower abdominal pain lasting for 10 days. Abdominal ultrasonography (US) revealed an extraluminal low echoic mass and abdominal CT scan showed a low density mass in the ileocecal region. Colonoscopy revealed deformity of the orifice of the appendix and reddish mucosa around the diverticula in the cecum. Although conservative treatment led to a shrinkage of the abscess cavity and reduced levels of inflammatory markers, the abdominal pain persisted. Appendectomy with abscess drainage was performed 3 days after admission. The mesoappendix was swollen with the abscess cavity and adhesion to the thickening wall of the cecum was severe. The appendix including the abscess in the mesoappendix was removed. Microscopic examination of the appendiceal wall showed severe inflammation with aggregation of neutrophil and lymphoid cells around the abscess cavity. Mucosa of the appendix showed mild inflammation. Pathological diagnosis was penetration of the cecal diverticulitis to the mesoappendix with abscess formation. The postoperative course was uneventful. The patient has been symptom-free for 15 months after the operation. Appendicular involvement with colonic diverticulitis is very rare, and only 2 cases have been reported.

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We report a case of cecal cancer presented with intussusception in a young woman.
A 33-year-old woman was admitted to the hospital because of persisting right lower abdominal pain. She had anemia and inflammation in laboratory examinations. Ileocecal inflammation or tumor was suspected and an emergency operation was performed. At laparotomy we saw that a portion from the appendix to cecum prolapsed into the lumen of the ascending colon which was led by a 50×40mm 0-Ip type tumor. Intussusception caused by the tumor was diagnosed and an ileocecal resection was carried out. Pathologically, the cecal tumor consisted of well differentiated adenocarcinoma invaded within mucosa. The tumor arose from the cecum with thick muscular layer and caused intussusception.
Intussusception caused by colon cancer occurs almost in far aged people whose connective tissues surrounding the large intestine become fragile and rarely in young people. Only five young cases have been reported in the Japanese literature during the last ten years.

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A 78-year-old woman was admitted to the hospital because of lower abdominal pain and fecaluria. A diagnosis of colovesical fistula was made by barium enema radiography, which showed the presence of barium in the bladder and multiple diverticula in the sigmoid colon. After 1-month conservative therapy aimed at improving the patient's general condition and reducing local inflammation, a primary resection of a part of the descending colon, the sigmoid colon, and a part of the bladder was performed. The patient's postoperative course was uneventful. We recommend a one-stage operation for colovesical fistula.

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A 51-year-old man visited our hospital because of dysuria and melena was found to have an elastically soft mass at the anterior wall of the rectum by digital examination. Magnetic resonance imaging scan showed a 5×4cm mass with an irreqular margin adjacent to the rectum and air within it. Biopsy specimens collected during CT scanning showed schwannoma, no malignancy. Colonoscopy showed a submucosal tumor with a central groove, 5cm oral from the anal verge. Partial resection of the rectum was conducted transsacrally with the diagnosis of schwannoma of the rectum. Histologically, the tumor was composed of spindle shaped cells with an interweaving bundle pattern. Immunohistochemical tests were positive for CD34, c-kit and vimentin and was negative for SMA and S-100, compatible with gastrointestinal stromal tumor (GIST, umcommitted type). Because this case showed no malignancy, we selected a transsacral method. We think this method is useful for GIST without malignant findings to preserve the anal function.

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A 79-year-old man undergoing a right hemicolectomy for ascending colon cancer in August 1992, of which histopathological diagnosis was mucinous carcinoma, had been followed in the clinic after oneyear oral administration of anti-cancer drugs.
He had been recurrence free for ten years, until he developed diarrhea and body weight loss in November 2002. The level of serum CEA was elevated markedly. Upper gastrointestinal endoscopy and total colonoscopic findings showed no recurrence or other primary lesions. Chest and abdominal CT scans showed lymph nodes swelling at the para-aorta and mediastinal space. Fine needle aspiration biopsy (FNAB) of the supraclaviclar lymph node swelling showed class V. Because ductal formation and mucinous component were found out in the biopsied specimen, recurrence of the colon carcinoma was diagnosed.
Systemic chemotherapy was started in December 2002, but it was not effective. The patient died of cachexia in May 2003.
It is rare that for advanced colon cancer recurs after a long cancer-free period following an absolute curative surgery, and such a case has not been reported in the literature. This paper presents the case with bibliographical comments.

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A 65-year-old woman whose incision for perirectal abscess resulted in persisting pus discherge elsewhere 2 months earlier was referred to the hospital with a diagnosis of squamopus cell carcinoma, which was made based on a biopsy of the abscess at another hospital. When she was first seen, an incision wound at where we saw pus discharge was identified at the direction of 7 o'clock apart from the anus. We performed an abdominoperineal excision of rectum with dissection up to group 2 lymph nodes including inferior mesenteric lymph nodes. On gross findings of the resected material, a 55×50×45mm tumor was noted on the right posterior wall of the rectum. Histologically an apparent tumor was confirmed under squamous epithelium, in the center of which we saw invasively growing, well to moderately differentiated squamous cell carcinoma with prominent keratinization. However, no continuity between squamous cell carcinoma and superficial epithelium was identified, and the continuity between epithelium of the anal fistula composed from squamous epithelium around the tumor and the lesion was confirmed. Accordingly cancer canceration of squamous epitherium of the anal fistula was thought to occur.

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Primary liver actinomycosis is a relatively rare disease, but it must be kept in mind as a differential diagnosis of a liver mass. We present a case of hepatic actiomycosis which was difficult to distinguish from hepatocellular carcinoma. The patient was a 69-year-old man undergoing total gastrectomy for gastric cancer about 20 years and cholecystectomy about 8 years earlier. In the later operation, the bile duct was damaged due to severe inflammation, which demanded hepaticoduodenostomy. The patient be came to have right epigastralgia in July 2003, and was referred to the hospital because a giant tumor of the right hepatic lobe was found by his family physician. CT and angiography showed a giant tumor with vascular neogenesis in S5/6. Since a possibility of hepatocellular carcinoma could not be ruled out, a right lower lobectomy of the liver was carried out. On macroscopic examination, the liver tumor seemed to be generated from the remaining mucosa of the gallbladder. However, histological examination revealed liver actinomycosis.

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A 69-year-old woman was admitted to the hospital because of obstructive jaundice and impaired liver function. Obstructive jaundice due to bile duct cancer was diagnosed with close exploration, and a pancreatoduodenectomy was performed after biliary drainage. She developed intraabdominal bleeding and went into shock on the 34th postoperative day because of pancreatico-jejunal anastomotic leakage. Emergency angiography of the celiacartery demonstrated rupture of a pseudoaneurysm of the common hepatic artery which resulted in hemorrhagic shock. We performed an angioplasty for the ruptured pseudoaneurysm using auto perfusion balloon catheter (APBC), and transcatheter arterial embolization (TAE) after her general condition became stable. She was discharged from the hospital on the 49th postoperative day. This procedure using APBC is useful for the treatment of the ruptured pseudoaneurysm of the hepatic artery that efficiently prevents liver failure.

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This paper deals with a case of recurrent hepatocellular carcinoma causing needle-tract seeding on the thoracic wall after percutaneous radiofrequency ablation (PRA). The patient was an 83-year-old man who underwent PEI for recurrence in the liver S8 in July 2001 after a posterior segmentectomy of the liver for hepatocellular carcinoma (S6-7) in November 1999. A metastatic lesion 12mm in diameter was detected in the liver S8 in July 2003, and RFA using a cool-tip type electrode was conducted. The PIVKA-II level started to increase and a painless tumor at the punctured site for RFA became apparent in around December 2003, which gradually enlarged. Fluoroscopic ultrasonography visualized tumor vessels and deep stained tumor shadow in the arterial phase, and further stained shadow up to later vascular phase. Needdle-tract seeding on the thoracic wall was thus diagnosed. On April 2, 2004, a removal of the tumor with reconstruction of chest wall was carried out. The histopathological diagnosis was moderately differentiated hepatocellular carcinoma. This paper also presents bibliographical comments on needle-tract seeding after RFA.

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A 62-year-old man complaining of upper abdominal pain was referred to the hospital after pancreatic head cancer was suspected by abdominal computed tomography (CT) and magnetic resonance imaging (MRI) at another hospital, which showed a 4cm tumor and regional lymph nodes swelling. After admission endoscopic retrograde cholangiopancreatography (ERCP) showed a short smooth stenosis of the main pancreatic duct at the pancreatic head, but did not show dilation of the main pancreatic duct at the pancreatic body and tail. Arteriography of the celiac artery and SMA showed no abnormalities. Positron emission tomography (PET) showed diffuse uptake of 18F-fluorodeoxyglucose (FDG) in the entire pancreas, but no malignant findings were revealed. Conservative treatment was started with a suspicion of benign disease such as tumor forming pancreatitis or autoimmune pancreatitis. Theree months later abdominal CT scan showed no swelling of the pancreas head or lymph nodes swelling. PET did not show abnormal uptake of FDG to the pancreas. He was diagnosed as having alcoholic pancreatitis causing temorary swelling of the pancreatic head. FDG-PET is useful for differentiation between malignant and benign lesions.

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We report a case of chronic active pancreatitis differentiated from pancreatic cancer with difficulties, because, in F-18-fluorodeoxyglucose positron emittion tomography (FDG-PET) imaging, FDG accumulation patterns of this pancreatic lesion revealed high level and retention.
A 76-year-old man was seen at the hospital because of anorexia and body weight loss and followed with a diagnosis of chronic active pancreatitis. Abdominal ultrasonography, CT and magnetic resonance imaging scans detected a mass in the pancreatic body. FDG-PET was performed for differentiation of inflammation from malignancy. Standardized uptake value (SUV) of this lesion was 5.1 and was retentive in the delayed phase (SUV=5.4). Distal pancreatectomy with splenectomy was performed, because a possibility of pancreatic cancer could not be ruled out. Pathological findings showed acute and chronic pancreatitis and the regeneration of the pancreatic epithelial duct with hyperplastic change. No malignant findings were revealed. Though FDG-PET is helpful for differentiation between malignant and benign lesions of the pancreas, both false-positive and false-negative results can occur for the diagnosis. Further accumulation of clinical cases and new devices are required.

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A 62-year-old man was seen at the hospital because of abdominal pain and poor appetite. Computed tomography revealed tumors in the pancreas and liver. On admission, peripheral leukocyte count was 14, 760/mm³ and serum CA19-9 level was elevated to 73U/ml. Liver abscess was suspected for persistent fever but puncture and drainage of the liver did not demonstrate the presence of pathogens or tumor cells. Because serum concentration of granulocyte-colony stimulating factor was elevated to 160pg/ml, the patient was operated on with a diagnosis of G-CSF producing pancreatic cancer. But only biopsies were done because multiple liver metastases were identified. Histopathologic diagnosis of the tumor was poorly differentiated adenosquamous carcinoma of the pancreas. Immunohistochemical staining showed that pancreatic cancer cells were positive for G-CSF mainly in the squamous portion. Despite postoperative chemotherapy with general administration of gemsitabin hydrochloride and intrahepatic arterial infusion of 5Fu, the patient died 6 months after the tumors were detected.

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A 54-year-old woman, who had received chemo-radiation therapy for unresectable uterine cervical cancer with a complete response 8 months earlier was found to have a tumor 6cm in diameter in the spleen by an abdominal ultrasonography (US). Abdominal CT scan revealed a low density mass with a relatively homogeneous center. Magnetic resonance imaging scan showed a low intensity mass on both TI and T2 weighted images. Enhanced US revealed a splenic tumor with peripheral enhancement. Positoron emission tomography (PET) with 2-deoxy-2 [₁₈F] fluoro-D-glucose (FDG) revealed a focal area of increased uptake of radioactivity in the splenic area, but there were no other abnormal areas of increased uptake in the whole body. We diagnosed this tumor as a solitary metastatic splenic tumor, and performed a splenectomy. The histopathologic findings indicated squamous cell carcinoma, which was compatible with splenic metastasis. Only 7 operated cases of solitary splenic metastasis from uterine cervical cancer have been reported.

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We report a case of rectal involvement secondary to prostatic cancer which needed to distinguish from rectal cancer.
A 72-year-old man was admitted to the hospital because of dyschezia. Barium enema and endoscopic studies suggested diffuse infiltrating carcinoma of the rectum. Biopsy specimens showed poorly differentiated adenocarcinoma. T2-weighted pelvic MRI visualized a low signal intensity area predominantly in the left peripheral zone of the prostate. The level of PSA in serum was significantly higher than the normal range. Cancer cells present in the biopsy specimens of the rectum were positive for PSA immunohistochemical staining. Final diagnosis was established as carcinoma of the prostate invading the rectum. The patient was referred to the department of urology to receive hormonal treatment.
We must keep in mind that carcinoma of the prostate can cause narrowing of the rectum, though it is comparatively rare.

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A 79-year-old woman was admitted on emergency to the institution because of headache and loss of consciousness in July 2004. On arrival she was in shock and her blood pressure was 69/38mmHg. From physical examination, there was a necrotic lesion on her right pubic region and subcutaneous emphysema was observed on her right lower abdomen. Computed tomography disclosed the spread of bubbles in the soft tissue from the right pubic region to right lower abdominal wall. Immediately after we diagnosed her as having Fournier's gangrene with septic shock, we performed debridements of the necrotic tissue around the right pubic region and lower abdomen. Postoperative course was uneventful and we sutured the operative scar 42 days after the operation. It is important to keep Fournier's gangrene in mind as one of the differential diagnoses of such patient with septic shock. This disease is male dominant and only 13 female cases have been reported in Japan. We here report our female case with some bibliographical discussion.

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We report a case of giant peritoneal loose body with situs inversus totalis, together with a review of the literature.
A 75-year-old man with known situs inversus totalis complainted of pollakiuria during hospitalization for treatment of hepatocellular carcinoma in the liver segment S5 with the radio-frequency ablation method. A retroperitoneal tumor compressing the urinary bladder was diagnosed after close exploration, and an operation to remove the tumor was performed. The pathological examination revealed peritoneal loose body. He progressed satisfactorily and was discharged from the hospital 10 days after the operation. There have been no cases of peritoneal loose body with situs inversus totalis like our case in Japan as far as we could review.

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We report a case of malignant lymphoma of the small intestinal mesenterium showing jejunal hemorrhage. A 68-year-old man was admitted to the hospital because of tarry stool. The source of bleeding was not detected by esophagogastroduodenoscopy and colonoscopy. A 58mm×38mm tumor was present at the left side of the abdominal aorta an abdominal CT scan. The tumor was suspected of malignant lymphoma because serum levels of beta-2 microgloblin and soluble interleukin-2 receptor were elevated. Laparotomy was done, and the soft tumor with smooth surface, 50mm in diameter, was found in the mesojejunum. Furthermore, extended invasion into the mesenterium of the small intestine and numerous lymph node metastases in small size were seen. Intraoperative endoscopy of the small intestine disclosed two ulcerative lesions in the jejunum which were thought to be bleeding points. Partial resections of the jejunum were performed to manage hemorrhage and to make the definite diagnosis. The resected specimens showed microscopically follicular lymphoma (B cell type). After surgery, 6 courses of R-CHOP therapy (rituximab 560mg, doxorubicin 75mg, vincristine 2mg, cyclophosphamide 1140mg, and prednisolone 100mg) were performed. The chemotherapy brought a complete response.
We present this case of mesenteric malignant lymphoma in which unknown bleeding points for jejunal hemorrhage were able to be detected by intraoperative endoscopy, resulting in successful management of the hemorrhage.

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We encountered a patient who underwent emergency surgery with a diagnosis of strangulated ileus due to internal hernia and was finally diagnosed as having Winslow foramen hernia.
A 45-year-old woman was admitted to the hospital because of abdominal pain and vomiting. There were abdominal distention and epigastralgia, but no abdominal defense was present. Simple abdominal X-ray examination revealed distended bowel gas at the hight of 12th thoracic vertebra of inside portion of the lesser curvature of the stomach. On abdominal CT scan, the dilated intestine was situated in a portion surrounded by dorsal aspect of the left lobe, lesser curvature of the stomach and ligament hepatoduodenale. She was kept under close medical observation. On the next day, abdominal defense became apparent and an emergency operation was carried out with the diagnosis of strangulated ileus. Upon laparotomy the ileum by about 50cm was incarcerated into the omental bursa from the Winslow foramen and strangulated at 30cm distant from the terminal ileum. Since the herniated bowel was viable, manual reduction was performed without performing intestinal resection.
Winslow foramen hernia often shows comparatively characteristic findings on simple abdominal CT scan, so that we must interpret the imaging findings by taking this disesase into consideration in diagnosing ileus of unknown origin.

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An 87-year-old woman who had undergone a histrectomy 57 years earlier was admitted to our emergency room because of abdominal distension and severe abdominal pain. As abdominal computed tomography revealed pneumoperitoneum, we suspected perforation of the gastrointestinal tract and performed an emergency operation. At laparotomy, no perforation was present in the alimentary tract, whereas ruptured abscess of the vaginal stump after the hysterectomy and purulent discharge from the vagina were observed. General peritonitis due to ruptured vaginal stump abscess was diagnosed. Drainage of the abscess was performed and the vaginal stump was covered with omentum patch. The patient was getting well without any complications and discharged on the 27th postoperative day.
The most common cause of pneumoperitoneum is perforation of the alimentary tract. But we should keep perforated pyometra in mind if the patient is an old woman. It is etiologically thought that abscess was formed at the vaginal stump after the hysterectomy which was performed 57 years earlier, and perforated into the abdomen causing peritonitis. We present this very rare case, together with a review of the literature.

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We experienced a case of laparoscopic resection of retroperitoneal serous cyst which is a comparatively rare entity.
A 60-year-old woman was seen at the hospital because of pain covering from the left lateral abdomen to left lumber region. Abdominal ultrasonography, abdominal CT and magnetic resonance imaging scans showed a 50×30×20mm monolocular cystic tumor with the homogeneous inner part in the left retroperitoneal cavity. Laparoscopic surgery was carried out with a preoperative diagnosis of a retroperitoneal cyst. The cyst was not adherent to the surroundings and was easily dissected and removed under laparoscopy. The removed specimen was 40g in weight and the content was serous liquid with light yellow in color. Histopathologically the epithelium of inner surface of the cystic wall was composed of monolayer of mesothelial cells and monolayer of columnar cells that looked like to be continued. Consequently it was inferred that a portion of the mesothelial cells might differentiate into columnar cells. There have been no signs of recurrence as of 13 months after the operation. The patient's postoperative course has been uneventful.

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A 68-year-old woman was admitted to the hospital because of abdominal fullness. Abdominal CT and magnetic resonance imaging scans revealed two large retroperitoneal tumors covering from the left subphrenic space to pelvis which had different internal structures. We performed laparotomy with a diagnosis of retroperitoneal liposarcomas. There were two tumors in the retroperitoneal space with capsule respectively, and these tumors were separated by the left kidney into the cranial part and caudal part. These cranial and caudal tumors had not invaded the surrounding organs and were relatively easily dissected. The cranial tumor was 2390g in weight, elastic-hard and segmented and the caudal one was 3730g in weight, elastic-soft and like a lipoma. Histological findings showed liposarcoma, well differentiated sclerosing type and well differentiated lipoma like form, respectively. Multicentric retroperitoneal liposarcoma is so rare that only three cases have been reported in the Japanese literature.

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Malignant fibrous histiocytoma (MFH) in the abdominal wall is extremely rare. The authors present here such a case.
An 84-year-old woman was admitted to the institution because of a right upper abdominal mass. After admission she underwent ultrasound scan, CT scan, Ga scintigraphy and barium enema. CT and ultrasound scans showed a mass sized about 15cm in the right upper abdominal wall. Barium enema showed that the ascending colon was compressed by the mass. Ga scintigraphy revealed accumulation of isotope where was correspondent with the tumor location. We suspected that this mass was a myogenic or neurogenic tumor and performed operation under general anesthesia. The tumor was arisen from the abdominal wall with central necrosis and resected with enough surgical margin of normal tissue. It was diagnosed as MFH with HE and immunological stainings. As of 10 months after the operation, no reccurence or metastasis has accurred.
MFH is the most frequent malignant tumor of the soft tissue and often recurs and metastasizes. It is common in the retroperitoneum and extremities but is extremely rare in the abdominal wall. Further strict observation would be required. This rare case of MFH of the abdominal wall which has a high malignant potential and presents difficulty in diagnosis is reparted, together with a review of the literature.

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Pilonidal sinus commonly occurs in the sacral region, and rarely in other regions. We report a case of pilonidal sinus on the umbilicus. A 27-year-old man was seen at the hospital because of umbilical pain, red dness, and pus dis charge from the umbilicus lastins for 2 months. He was obese as 105kg and 180cm height and hairy by hard hair. A 10mm sized mass was palpated on his umbilicus. Abdominal CT scan showed an enhanced high density area corresponded with the umbilical fossa. No fistula suggesting urachal remnants nor vitelline duct remnants was detected. He was treated with a diagnocis of omphalitis in the clinic for about 3 months but had relapsing inflammation. So he was performed resection of the navel. Resected specimen revealed pilonidal sinus. Pilonidal sinus on the umbilicus have been reportd in 5 cases including our case until now in Japan. Heavy hirsute young adults were ill favorite. But relation with obesity was obscure. Abdominal US and CT were useful to differentiate the disease from urachal and vitelline duct remnants, but difficult from omphalitis, so that the ailing time was prone to be prolonged. We should consider the disease and operate on, if the symptoms persist over 4 weeks or the patint has frequent recurrences over 3 months against conservative therapy.

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A 49-year-old woman was admitted to the hospital because of constipation. Barium enema study showed a whole-circumferential stenosis of the rectum. Colonoscopy showed the narrowed lumen of the rectum but the mucosa was almost intact except edematous surface and slight redness. The biopsy specimen revealed no evidence of malignancy. Hartmann operation combined with hysterectomy and bilateral salpingo-oophorectomy was performed with a diagnosis of a malignant tumor. Histologically, this tumor was diagnosed as pelvic actinomycosis. We treated the patient with penicillin G for 6 months.

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A 33-year-old woman was referred to the department because of a painful induration in her right inguinal region developed after treatment for pelvic in inflammation at the department of gynecology in our hospital. Examinations revealed the retention of lipiodol in the pelvic cavity as well as inguinal induration which was used for a previous hysterosalpingography 4 months earlier. At operation, marked inflammation of a sac of an inguinal hernia and surrounding tissues was seen and excision of the entire hernia sac and herniorraphy by Marcy's method were carried out. Pathological diagnosis was xanthogranulomatous inflammation of the sac.
We concluded that the hernia sac with a xanthogranulomatous change by lipiodol developed symptomatic inflammation due to the spread of pelvic inflammation. This disease must be kept in mind as a probable complication of oleaginous contrast materials such as lipiodol, though it is uncommon.

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A 59-year-old man was admitted to the hospital by referral because of a 4-day history of lower abdominal pain and vomiting. He had experienced neither surgery nor peritonitis, but he had suffered a severe blow to his abdomen at a ‘karate’ practice 35 years before admission. An abdominal X-ray examination showed multiple niveaus of the small bowel. An abdominal CT scan revealed the dilated small bowel, but a part of the small and large bowel were not dilated. Symptomatic remission was achieved with conservative therapy using a transoral long tube. A small intestinal contrast study from the long tube showed a stenotic portion of the ileum without evidence of neoplasm. An operation was carried out with a suspicion of internal hernia. There was incarceration of the ileum 1m proximal to the ileocecal region into a mesenteric defect of the left peritoneal surface of the sigmoid mesentery. We were able to repair the ileum without resection. The postoperative course was uneventful and the patient was discharged from the hospital on the 10^th day after the surgery. The incidence of the intramesosigmoid hernia is very low. Additionally, few case reports showing the left leaf defect of mesosigmoid have been reported so far in Japan. This rare case is presented, together with some bibliographical comments.

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We report a case of incisional hernia after parasacral resection of the rectum. The patient was a 57year-old man complaining of a subcutaneous buttock tumor who had a previous history of undergoing a parasacral rectum excision for rectal cancer. Eight months after the operation, he became aware of the subcutaneous tumor at the incision site on the right side of the sacrum. The tumor enlarged to 8cm×6cm in diameter in October 2004. Pelvic CT scan showed that the intestinal tract had entered into the subcutaneous space on the right side of lower part of the sacrum and surgery was performed with a diagnosis of incisional hernia. The hernia orifice was present near the coccyx excision part of the lower edge of sacrum, the hernia sac was the peritoneum, and the contents of the hernia were the small intestines. We turned over the hernia sac to the pelvic side and repaired the hernia orifice by mesh plug. Furthermore we created a gluteus maximus muscle lotation flap and the flap was used to cover the mesh part. Although no instructions as for repairing methods for incisional hernia after parasacral excision of the rectum have been reported in the literature, it was our impression that the best procedure might be to add a gluteus maximus muscle flap to the hernia orifice closing method of tension free using the mesh.

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Obturator hernia is extremely uncommon in men. This paper deals with two male cases of obturator hernia.
Patient 1, a 79-year-old man, seen at the hospital because of abdominal pain and vomiting was indwelt a long tube with a diagnosis of intestinal obstruction of unknown origin. No symptomatic remission of ileus was attained, and he was operated on after the diagnosis of intestinal obstruction due to obturator hernia was made by abdominal CT scans 4 days after admission.
Patient 2, an 82-year-old man, seen at the hospital because of a several-day history of femoral pain and vomiting was diagnosed as having intestinal obstruction due to obturator hernia by abdominal CT scans. An emergency operation was carried out on the same day.
In a review of male cases of obturator hernia including ours, no cases in which their hernias were spontaneously relieved have been reported, and, from that standpoint, early diagnosis by means of pelvic CT scanning and operation are especially important for male cases. These two cases are presented here, together with some discussion on clinicopathological characteristics of male obturator hernia.

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