We made a clinical study on rectal tumors undergoing transanal endoscopic microsurgery (TEM) in terms of recurrence and prognosis. A total of 68 cases operated on at the hospital from 1994 to April 2004 were enrolled in this study, whose rectal tumors which were located from 3cm to 18cm distal from the anal verge were excised by using the Buess rectoscope. There were 37 cancers, 16 adenomas, nine carcinoids, and nine other lesions. Local recurrence occurred in three cases, but all three cases were of recurrence of only adenoma component and were radically cured by another TEM or EMR. Three patients died of other disease (associated neoplasm). There were seven patients performed laparotomic radical operation based on the histological diagnosis of excised material with TEM. Of the seven patients, two patients had lymph node involvement, but all the two patients have been alive, as of 4-7 years after the operation.
It is thought that TEM is a useful therapeutic strategy for rectal tumors.

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This analysis was aimed at evaluating predictive factors of the time of relapse and prognostic factors in patients with recurrent stage II of III coloreatal cancer after curative resection. Clinicopathological factors selected in this analysis were lymph node metastasis, pathological stage, venous invasion, lymph vessel invasion and histological type, and the duration between initial operation and relapse was observed. Between January 1991 and December 1996, a series of 470 patients were performed curative resection for colorectal cancer and 96 patients of them experienced recurrence. These 96 patients were subjected to the analysis. Median relapse time was 17.7 months after initial resection. Liver metastasis, local recurrence or lung metastasis within two years was noted in 68.9%, 58.8% or 25.0% of them, respectivly. Univariate analysis showed that initial histological type except for well differentiated adenocarcinoma, lymph node metastasis, relapse within 18 months after initial operation, stage III, and aggressive lymph vessel invasion predicted poor prognosis. Multivariate analysis showed that aggressive lymph vessel invasion only predicted poor prognosis. In conclusion, particular attention must be paid to liver metastasis and local recurrence within 2 years after initial operation, and, if the relapse or metastasis occurs, to evaluate the degree of lymph vessel invasion may predict the prognosis and effects of treatments. Aggressive treatments including surgical operation might result in favorable outcomes for relapsed tumors with less degree of lymphatic invasion.

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We report the operative results of eight patients with positive human immunodeficiency virus and analyzed morbidity and mortality with respect to CD4 cell counts.
Two cases of above normal limitation level of CD4 (CD4 cell counts more than 500/mm³) and one case of lower level of CD4 with relative risk (CD4 cell counts between 200 and 499/mm³) were uneventful after operation. Two of four cases who had CD4 cell counts less than 199 with high risk sufferd from major complications after surgical procedure, especially one case with severely low level of CD4 died without healing the wound. Another two cases were uneventful after operation.
The patients with low level of CD4 have complications frequently, however, two of such 4 cases obtained excellent results in our series. We believe that the operative indications should be determined more flexibly with consider-ation to patient's quality of life.

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A 22-year-old woman visited our hospital because of bloody nipple discharge of the right breast. An ill-defined mass, about 15mm in diameter, was palpable in the B area of the right breast, but ultrasonography and mammography showed no apparent abnormal findings. Ductography showed an obstruction and multiple filling defects of the peripheral ducts. The tumor was suspected to be intraductal papillomatosis and a duct-lobular segmentectomy was performed. Histological examination showed bicellular proliferation of epithelial cells and myoepithelial cells in the ducts. The tumor was diagnosed as adenomyoepithelioma (AME) by immunohistochemical examination, which showed epithelial cells were positive for EMA and myoepithelial cells were positive for α-SMA. Generally AME is considered a benign tumor. However, a few cases with local recurrences or distant metastases have been reported. AME of the breast is an extremely rare tumor and still has many unsolved problems. In this case we could detect multiple tumors in the ducts by ductography because the chief complaint was bloody nipple discharge. This case suggests that in treating we need to consider the intraductal spread of AME even if the tumor is histologically benign.

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We report a very rare case of metastatic tumor to the upper arm from borderline phyllodes tumor of the breast. A 57-year-old woman with 10cm×7cm size right breast tumor underwent mastectomy (Breast + Ax; Auchincloss method) in May 2003 and the resected tumor was pathologically diagnosed as borderline phyllodes tumor. No metastasis in lymph nodes or other organs were found at the time. Ten months after the operation, she noticed a subcutaneous tumor growing at the right upper arm. In June 2004, the tumor reached to the size of 5.5cm×4.5cm and CT and US studies indicated that the tumor was fixed to the muscle. The tumor was resected undes local anaesthesia and pathologically it was found to contain irregular cells similar to the previous mammary tumor, so we diagnosed as metastasis from the breast. We consider the most effective treatment for metastatic tumor of phyllodes is surgical treatment and early detection and resection with ample margins are important.

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We report two patients with huge phyllodes tumor associated with severe anemia. One patient of them had a tumor weighed as heavy as 14kg which was largest among previously reported phyllodes tumors in Japan.
Patient 1, a 58-year-old woman, was admitted to the hospital because of a huge right breast tumor 30cm in diameter and severe anemia, the Hb level of 6.2g/dl, and underwent a mastectomy. The removed tumor weighed 4900g. The pathological diagnosis was benign phyllodes tumor. Anemia was not improved after the operation. Patient 2, a 48-year-old woman, was admitted because of a huge left breast tumor 30cm in diameter. On admission, the laboratory data revealed very low Hb level of 5.8g/dl despite of the lack of tumor bleeding, and chest CT scan showed solitary lung metastasis. She was diagnosed as having a phyllodes tumor by needle biopsy, and underwent a mastectomy and samling of axillary lymph nodes. The removed specimen weighed 14000g and was diagnosed as malignant phyllodes tumor involving the regional lymph nodes on histologic examination. After removal of the tumor, anemia was improved spontaneously. But systemic metastases progressed, and the patient died 6months after the operation. It is reported that huge phyllodes tumors have a propensity to be associated with hypochromic microcytic anemia. In this paper we also present some bibliographical comments with respect to the correlation between huge phyllodes tumor and anemia.

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Invasive micropapillary carcinoma (IMP) is a newly introduced histological entity which has a high incidence of regional lymph node metastasis and a poor clinical outcome.
We have encountered with two IMP patients of 39 and 56 years old. Each had typical pathological features of IMP in histology and complicated with multiple lymph node metastases. Estrogen and progesterone receptors of the tumor were both megative in case 1 and both positive in case 2. Histological grade was 3 in both cases.
In this paper, we presented the case-records of these two cases of IMP and a review of some previous literatures including a collective analysis of 19 cases in Japan.

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We experienced a case of spindle cell carcinoma suspected to show metaplasia from apocrine carcinoma of the breast.
The patient was a 78-year-old female with chief complaint of a mass in her left breast. Preoperative and intraoperative diagnosis was apocrine carcinoma of mammary gland and the patient underwent a modified radical mastectomy (Bt+Ax+Ic). Histological study revealed mixture of sarcomatoid portion with spindle cells and carcinomatous portion with apocrine metaplasia.
In addition, marginal areas of transion from one histological type to the other were observed.
It was suspected spindle cell carcinoma arose from apocrine carcinoma.
There was no lymphnode metastasis and estrogen and progesterone receptors were negative.
No recurrence of the tumor was seen in the follow up of 8 years and one month.

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We report a case of a recurrence of a breast cancer 27 years after operation. A 69-year-old woman with lumbago, who underwent a standard radical mastectomy at the age of 42, consulted the orthopedics department of our hospital. Since she was suspected to have a pathological fracture of the lumbar vertebra, a bone biopsy guided by computed tomography was performed. Histological examination revealed a case of adenocarcinoma metastasizing to the vertebra. Gynecological and gastrointestinal examinations could not reveal any possible primary lesion of the metastasis. Then the patient was referred to our department, where immunostaining of the biopsy specimen with anti-estrogen receptor antibody was done with positive result. Therefore, the patient was diagnosed as having a metastatic vertebral tumor of breast cancer, which occurred 27 years postoperatively. An abdominal computed tomogram demonstrated metastatic lesion in the liver also measuring 3 cm in diameter. She received radiation therapy for the vertebral metastasis followed by systemic chemoendotherapy with Paclitaxel and Anastrozole. There observed no changes in the size of the metastases at this writing.

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A 51-year-old man, found having an anterior mediastinal tumor by chest CT scan, was diagnosed as to have a thymoma by a CT-guided biopsy. Preoperative screening tests disclosed a prolongation in APTT and close exploration for that showed a declined factor VIII activity and plasma lupus anticoagulant positive. When an extended thymectomy was performed for the thymoma, the declined factor VIII activity was normalized and negative conversion of plasma lupus anticoagulant was noted. Since preoperative findings suggestive of autoimmune diseases were absent and various test results were normalized after the operation, the APTT prolongation and the declined factor VIII activity in this case were etiologically thought to be caused by production of lupus anticoagulant of the tumor.
Lupus anticoagulant is a kind of phosphatide antibodies and is believed to be rarely associated with tumorous lesions. It is thought that the condition poses a clinical problem of thrombosis and demands careful pre-and postoperative management.

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Preoperative CT guided marking has become a popular practice along with the spread of thoracos-copic surgery. This is a report of a case of air embolism we recently experienced during CT guided marking of a pulmonary mass. The patient was a 71-year-old male who was found to have a mass in his left lung, S⁹ segment. A CT guided marking was performed and immediate after the study patient became unconscious when he coughed.
An air embolism was diagnosed as the CT study revealed air in the left ventricle and in thoracic aorta. Immediately the patient was put on head down position and he regained consciousness.
He developed transient left hemipalsy, but recovered completely in an hour. ST segment elevation in ECG reverted in 5 minutes. The patient went through segmental resection of the lung using thoracos-copic technique uneventfully 5 days later and was discharged in 17 days.
Air embolism is a very rare complication but should be considered as a possibility in the procedure.

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A 64-year-old man, diagnosed as having von Recklinghausen's disease about 30 years earlier, was brought into the hospital because of severe pain from the left lateral thoracic region to the back on June 16, 2002. Chest x-ray showed pleural effusion in the left lung and abnormal bone deformity in the left 6^th to 8^th intercostal space. Chest CT scan revealed bleeding from the posterior intercostl artery. Accordingly an emergency operation was performed. Thoracotomy at the 7^th costal bed disclosed about 3200ml of bleeding in the thoracic cavity. The cause was arterial bleeding from a schwannoma of the 6^th intercostal nerve. Besides, multiple schwannomas were seen in the 7^th intercostal nerve, but entire tumors were difficult to be removed so that the tumor of the 6^th intercostal nerve was removed as complete as possible. Then the intercostal artery and veins and intercostal nerves were ligated.
Von Recklinghausen's disease is the most common autosomal dominant hereditary disease and affects one out of 3000 persons. However, the disease associated with hemothorax in so rare that only 10 cases have been reported in Japan. Five patients of them died and hence prompt diagnosis and surgery would be mandatory.

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Approximately half the patients with congenital lobar emphysema present with severe respiratory distress within the first month of life, and 5- to 6-month-old patients are comparatively rare.
A 6-month-old boy with a 2-month-long history of stridor was admitted to the hospital because of an abnormal chest finding detected at another hospital. On admission, he showed mild growth retardation, and had inspiratory retraction and stridor. Chest CT scan revealed hyperlucency of the right middle pulmonary lobe and mediastinal shift to the contralateral side. Bronchoscopy showed relative narrowing of the right middle bronchus. Right middle lobectomy through anterio-lateral thoracotomy was perfor-med because of persistent serious respiratory symptoms. The postoperative course was uneventful and the patient was discharged on the 13th hospital day. Histological examination of the resected pulmonary lobe showed emphysema, but its mechanism was unknown.

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An 80-year-old woman, who had undergone a right radical mastectomy for breast cancer at the age of 42, was referred to the hospital because of a coin lesion on a chest radiograph. A computed tomogra-phy of the chest showed a solitary pulmonary nodule with notch and pleural indentation, suggesting primary lung cancer. Intraoperative frozen section pathological examination provided findings consis-tent with primary adenocarcinoma of the lung. She underwent a lung segmentectomy. However, cancer cells stained positively for both estrogen and progesterone receptors immunohistochemically, and the case was finally diagnosed as metastatic pulmonary nodule from breast cancer. A pulmonary tumor may be solitary metastasis of breast cancer, even if it occurs after a long-term interval over 30 years after therapy for breast cancer and imaging and pathlogical findings of the tumor are compatible with those of primary lung cancer. In diagnosing such a tumor, immunohistochemical examinations are helpful.

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We report a long-term and recurrence-free survivor after repeated surgical resection of liver metastases from lung cancer.
A 60-year-old man underwent a left upper lobectomy with mediastinal lymph nodes dissection for primary lung cancer (pT2pN0M0 StageIB, squamous cell carcinoma) on December 27, 1997. A year later he was found to have an isolated tumor, 6cm in diameter, in S7 of the liver by abdominal CT scan. A partial hepatic resection was carried out on December 17, 1998, and the tumor was pathologically diagnosed as squamous cell carcinoma metastasized from lung cancer. On August 3, 1999, repeated partial hepatectomy was performed for a solitary tumor, with a diameter of 3cm, in S6 of the liver. Pathologic examination of the lesion again showed metastatic squamous cell carcinoma. The patient is presently alive and well without recurrence 65 months after the second operation.

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We report a rare case of esophageal malignant lymphoma.
A 72-year-old man, admitted to the hospital because of pharyngeal pain in June 2003, was found to have a tumor 7cm in diameter on the anterior wall of the cervical and upper thoracic esophagus by endscopy. Biopsy specimen showed diffuse large-sized B cell lymphoma. Esophageal CT scan showed the anterior wall tumor of the cervical and upper thoracic esophagus and the swelling thoracic paraeso-phageal lymph nodes forming a mass. Clinical staging was stage IIEA. Chemotherapy with CHOP (750mg/m² of cyclophosphamide, 50mg/m² of adriamycin, 1.4mg/m² vincristine, and 100mg/body of predonisolone) was started on July 14, and a total of 6 courses were carried out. Besides, 500mg of rituximab was administered 6 times from October 15 to December 24. A follow-up CT showed a complete response after the chemotherapy.
Esophageal malignant lymphoma is quite rare, and it has been reported in only 27 cases in Japan. We report this case with an analysis of accumulated domestic cases.

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It is well known that various vitamin deficiencies may occur in patients after total gastrectomy, but case reports describing polyneuropathy due to vitamin E deficiency are still few. A clinical study was made on three cases of neurological deficits by vitamin E deficiency after total gastric resection with Roux-en-Y reconstruction for gastric cancer. All three patients were seen at the hospital because of a variety of neurological deficits such as loss of deep sensation in the legs, vertigo, Romberg's syndrome, muscle spasm, and sensory disorder a few years after the operation. Because hematological studies disclosed vitamin E and vitamin B12 deficiencies, we thought that their polyneuropathy might be caused by vitamin deficiency. Oral administration of vitamin E supplement was started in all the patients. As the blood level of vitamin E was normalized in them, their neurological symptoms were subsided.
Vitamin E deficiency must be kept in mind as a probable diagnosis for patients presented with various neurological deficits after total gastric resection.

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We describe a surgical case of T-cell malignant lymphoma of the stomach which is rare. A 61-year-old man was admitted to the hospital because of epigastralgia. Gastroduodenoscopy revealed an ulcerative mass involving the lesser curvature of the body of the stomach. Endoscopic biopsies obtained showed malignant lymphoma histologically. Laboratory tests including WBC count and its fraction were normal, and human T-lymphotropic virus type-1 (HTLV-1) antibody was negative. In Ga scintigram, the stomach appeared to be an area of high radiotracer concentration. Computed tomography showed no enlarged lymph nodes in the whole body. The patient underwent a total gastrectomy. Histology revealed non-Hodgkin's lymphoma, diffuse pleomorphic type, ss, n0, and immunostaining showed both CD-3 and UCHL positive.
Only 43 cases of T-cell malignant lymphoma of the stomach have been reported in Japan, and we reviewed the clinical and pathological features of these cases including our case. In these cases, superficial type was rare macroscopically, and pleomorphic type was the most common type histological-ly. Most of them were more advanced clinically with poor prognosis as compared to the cases of B-cell malignant lymphoma.

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We report a case of gastric cancer in a so-called upside down stomach due to hiatal hernia with some considerations. There have been few reports of gastric cancer in such a condition.
A 73-year-old woman complaining of upper abdominal discomfort was referred to the hospital with a diagnosis of gastric cancer. An upper gastrointestinal series showed a so-called “upside down stomach” with organoaxial gastric volvulus, the most part of which was located in the mediastinum. Her barium meal revealed a filling defect on the gastric body. Gastrofiberscopy showed type 0 I gastric cancer on the lesser curvature of the upper gastric body. From these findings, type 0I early gastric cancer with severe esophageal hiatal hernia was diagnosed. She underwent proximal gastrectomy with D1 lymph node dissection and jejunal interposition concomitant with repair of the esophageal hiatal hernia. Pathological examination depicted mucosal moderately differentiated adenocarcinoma without nodal metastasis. Her postoperative course was eventful because of the minor dehiscence of the esophago-jejunostomy. At the drainage operation, sutures of the hiatal hernia orifice were removed. After the drainage operation, her postoperative course was uneventful and she was discharged on 27^th day after the initial operation. She has been alive and well without any complaints.

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A 78-year-old woman admitted to the hospital because of anemia was found to have a huge neoplasm in the 2nd portion of duodenum with a gastroendoscope. I was diagnosed as Brunner's glanad adenoma by a biopsy. Abdominal CT and magnetic resonance imaging scans revealed a neoplasms about 7cm in diameter. It was difficult to grasp the whole image of the tumor by gastroendoscopy and upper gastrointestinal series. The tumor was extirpated under laparotomy. It was 7.2×3.8cm huge Brunner's glanad adenoma which had a stalk on the duodenal bulb. The patient's postoperative course was uneventful. Brunner's glanad adenoma exceeding 7cm in diameter is so rare that only four cases including this case, have been reported in Japan. Some bibliographical comments are also reported.

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A 77-year-old woman without any history of abdominal surgery was admitted to the hospital because of abdominal pain. She had had repeated episodes of ileus with unknown origin over a period of 15 years. A plain abdominal X-ray and CT examinations showed distention of the small intestine and the presence of calcified bodies in the intestine. Gastrointestinal radiography from an ileus tube revealed two stenoses of the small intestine with an oval defect in the midpoint of the stenotic lesions. The patient was diagnosed as having stenoses of the small intestine with the presence of calcified bodies. Laparotomy showed two stenotic lesions in the ileum locating approximately 40cm orally from the ileocecal valve. Partial resection of the ileum was performed. Incision of the resected segment of the intestine revealed several pieces of shiitake and two hard seed-like calcified bodies. The calcified bodies were found to be calcified seeds of pickled Japanese apricot impacted in the ileum between the stenotic lesions. The patient's postoperative course was uneventful.

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This paper deals with a case of small bowel perforation with the resultant acute general peritonitis caused by extracorporeal shock wave lithotripsy (ESWL) for ureteral stone. The patient was a 64-year-old man with a history of undergoing laparotomy for a tumor of the left abdominal wall. He developed abdominal pain 3 hours after the 9^th ESWL in a prone position for a coral-shaped stone of the left kidney. The symptom persisted and the patient was seen at the hospital on the next day. Abdominal x-ray and abdominal CT scan revealed free air and ascites. Gastrointestinal perforation was diagnosed and an emergency operation was performed. A small laceration was detected in the small intestine which was adherent to a portion right under the ESWL site, and a wedge resection with closure was carried out. The patient's postoperative course was uneventful.
Intestinal perforation is a rare complication of ESWL and only 14 cases have been reported in both the English and Japanese literature. The complication must be kept in mind in patients who have a history of undergoing laparotomy and receive ESWL in a prone position, though it rarely occurs.

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We report a 53-year-old man presented with massive jejunal hemorrhage, who had intestinal tuberculosis with multiple minute ulcers in the jejunum, in an early stage of pulmonary miliary tuberculosis. The patient experienced massive tarry stool about a month after the diagnosis of pulmonary miliary tuberculosis, went into shock and underwent an emergency surgery. The bleeding point was identified in the small intestine by intraoperative segmental clamping method and a partial resection of the small intestine was performed successfully. The resected specimens exhibited multiple minute ulcers in the jejunum. Microscopic examinations demonstrated epithelioid granulomas and tubercle bacillus at the bottoms of all the ulcers, of which one lesion in 3mm in size exhibited an exposed and ruptured artery. Therefore, we assumed that the hemorrhage was caused by the minute tuberculous ulcer involving the small submucosal artery in the jejunum as a part of the development of miliary tuberculosis. The patient was treated with chemotherapy for tuberculosis starting on the 9th postoperative day and was discharged from the hospital on the 146^th postoperative day. We herein report this rare case of intestinal tuberculosis with massive jejunal hemorrhaging.

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We experienced a case of peritonitis due to jejunal perforation caused by intestinal tuberculosis.
A 55-year-old man complaining of pharyngeal discomfort and poor appetite was admitted to the hospital with a diagnosis of pulmonary tuberculosis. Antituberculous regimen with 4 types of drugs (INH, REF, EB and PZA) was started, but he had the sudden onset of abdominal pain 16 days after admission. A chest X-ray examination revealed free air below the diaphragm. Gastrointestinal perforation was diagnosed and an emergency operation was performed. A perforation 10mm in diameter was located about 50cm proximal to the ileocecal valve, and 6 ulcers completely encircling the bowel were present in the vicinity of the perforation. A diagnosis of generalized peritonitis due to jejunal perforation was made, and the resection of the perforated intestine, including 4 out of the 6 ulcers, was performed. The other 2 ulcers were not resected because there were far from the perforation. Antituberculous therapy was resumed. The postoperative course was uneventful and the patient was discharged from the hospital 5 months after the operation. Intestinal tuberculosis is primarily treated with antituberculous drug regimen, however, emergency surgical resection must be indicated if intestinal perforation occurs. In performing the resection, the volume of the bowels to be removed should be decided carefully, considering both residual stenosis and the function of the remnant intestine.

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A 29-year-old man, presented with abdominal pain, nausea and vomiting in the evening of September 7, 2003 followed by intestinal obstruction on the next day, underwent an emergency operation at the hospital. During surgery a segmental stricture was confirmed in the small intestine about 100-130cm distal from the Treitz' ligament, and the small intestine by 40cm in length including the narrowing portion was excised. On the excised material a longitudinal ulcer and five annular ulcer scars were identified but no tumor lesion was present. Histopathologically they were Ul-III ulcer. Ulcer lesions due to Crohn's disease or intestinal tuberculosis were unlikely and non-specific multiple ulcer of the small intestine was diagnosed. The patient has been followed on an ambulant basis without signs of recurrence.
Non-specific multiple ulcer of the small intestine presented with intestinal obstruction is comparatively rare and so far 21 cases have been reported in Japan. It is etiologically thought that five annular ulcer scars were formed in a short portion of the small intestine, about 30cm, that might lead to intestinal obstruction.

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A 59-year-old man was admitted to our hospital because of vomiting. Abdominal CT, MRI and X-Ray studies showed multiple tumors in the abdomen causing small bowel obstruction so he went through an operation. In the abdomen, there were many tumors with diameters from 5mm to 10cm on the small bowel: from the deuodenum to the ileum. In particular, a 10cm tumor was strangling the small bowel. We performed resection of the segment of small bowel where larger tumors concentrated, avoiding a massive resection of the small bowel to preserve the quality of life of the patient. Pathologically the tumors were vimentin(++), CD34(++), C-kit(++), α-SMA(-) and S100(-)_??_(±), accordingly they were thought to be uncommitted type of GIST. Their degree of malignancy was considered to be borderline because of the presence of few cell divisions in spite of large size of the tumors. After the operation, he was prescribed imatinib mesylate. We could not find growing tumors or metastasis during the follow up of 22 manths.

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A 57-year-old man with a history of undergoing an operation for acute appendicitis at the age of 45 was seen at the hospital because of abdominal pain. Abdominal plain x-ray examination revealed small intestinal gas. Adhesive ileus was suspected and a long tube was inserted for the treatment but no symptomatic remission was attained. Abdominal CT scan offered findings suggestive of intussusception. Colonofiberscopy showed that the ileum was prolapsed into the lumen of the ascending colon which was led by an elevated lesion. Intussusception caused by the small intestinal tumor was diagnosed and an ileocecal excision under laparotomy was carried out. On the excised material a type Ip elevated lesion was identified in the ileum 15 cm proximal to the ileocecal valve. The histological diagnosis was well differentiated adenocarcinoma with adenoma components. The cancer lesion was localized in the lamina propria mucosae and no lymph nodes were involved.
Early cancer of the small intestine is a rare entity. We report this case, together with some bibliographical comments including recent reported cases.

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Cases of cecal volvulus in two patients are reported. In case 1, a 73-year-old man was admitted to our hospital because of left lower abdominal pain. In a plain abdominal X-ray, a giant colonic gas shadow appeared like coffee beans in the middle abdomen. Abdominal CT revealed distended colon occuping the lower abdomen, and the sigmoid colon could be traced from the rectum, therefore the involved segment was thought to be the cecum. On laparotomy, the cecum and ascending colon were found to be not attached to the retroperitoneum and rotated 360 degrees clockwise. There was no circulatory compromise in the rotated segment. However, since a part of the bowel wall was very thin, the ileocecal resection was performed. In case 2, a 78-year-old man was admitted to our hospital because of nausea, vomitting and dyspnea. In a plain abdominal X-ray, a giant colonic gas shadow appeared like coffee beans beside the loop of small intestine filled with gas. Abdominal CT revealed empty sigmoid colon beside large bowel which looked like displaced cecum, so a volvulus of this segment of proximal colon was suspected. On laparotomy, the cecum was found to be unattached to the retroperitoneum and rotated 360 degrees clockwise, and dilatation and hemorrhagic necrosis extending from the ileal end to cecum were present. A ileocecal resection was performed.
Cecal volvulus is a relativery rare disease. Since it is very difficult to improve by conservative treatment, immediate operation must be performed as soon as possible.

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We report a rare case of torsion of an unusually large vermiform appendix. A 36-year-old man was admitted to our Medical Center complaining of lower abdominal pain. His family and past histories were noncontributory. Abdominal palpation revealed tenderness in the whole abdomen without sign of muscle guarding. The X-ray examination and the computed tomography scan showed a distended intestine. The next day the abdominal pain got worse. Because muscle guarding appeared, an emergent laparotomy was performed. The distended intestine was found out to be a large swollen appendix 28cm in length. The vermiform appendix showed 360 degree clockwise torsion at its root. An appendectomy was preformed. On pathological examination the appendix showed ischemic necrosis. The patient was discharged from the hospital 10 days after operation.

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A 77-year-old man underwent a sigmoidectomy with a diagnosis of sigmoid colon cancer on November 24, 2004. He developed high fever on the day of surgery, and thereafter the fever persisted and pancytopenia appeared. At first we thought that the patient had serious infection and disseminated intravascular coagulation (DIC) associated with wound infection, and gave therapies appropriate for the diseases. No tendency to improve, however, was noted at all. Blood examination conducted on November 30 reported that ferritin level was high. Emergency bone marrow biopsy offered a diagnosis of hemophagocytosis. Although the origin of hemophagocytosis was obscure, we thought that postoperative infection had induced the onset of the disease and maintained therapies for infection. But no symptomatic remission was obtained. For that, mini-pulse therapy with steroid was started on December 6 that resulted in subsidence of fever, remarkable decrease in CRP, and rapid improvement of his general condition. Later close exploration disclosed no evidence of infection. Since the patient was suspected to have autoimmune disease as an underlying disease, hemophagocytosis might abruptly occur due to addition of surgical stress to the autoimmune disease.

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A 77-year-old woman was admitted to the hospital because of melena and anemia. Digital examina-tion, pelvic CT scan and barium enema revealed a mass 6cm in diameter in the lower rectum about 2cm distal from the anal verge. We performed a Miles' operation and diagnosed the tumor as leiomyosarcoma pathologically, In the 14^th month after the operation, vertebral bone metastases (Th10, L3) with lunbago were identified and she died in the 20^th postoperative month. The immunohistochemical study showed that the tumor cells were positive for CD34 and c-kit and negative for SMA and S-100. The tumor was diagnosed as rectal gastrointestinal stromal tumor (GIST) finally.
We report the case of rectal GIST with bone metastases that is extremely rare, together with some bibliographical comments.

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A 40-year-old woman was seen at the hospital with the chief complaint of abdominal pain. The patient was previously treated with chemotherapy since the age of 38, with the diagnosis of inoperable invasive ductal carcinoma of the breast with metastasis to the liver, lung and bone: T4c. N3. M1, in stage IV. The patient was admitted to the hospital with diagnosis of carcinomatous ileus on January 2005. Symptoms of bowel obstruction was not relieved by a long tube. Barium enema examination revealed stenosis of the transverse colon. An ileo-descending colon by-pass operation was performed with the diagnosis of metastasis of breast cancer to transverse colon. The postoperative course was uneventful and the patient was discharged from the hospital on the 21st postoperative day. She is alive, as of 2 months after the operation.

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An 85-year-old woman was admitted with chief complaints of diarrhea and pretibial edema. The laboratory data showed the presence of extreme anemia, hypoproteinemia and hypoalubuminemia (Hb 7.7g/dl, Ht 23.6%, total protein 4.6g/dl, albumin 1.2g/dl). A barim enema and a colonofiberscopy demonstrated a 10cm sized advanced cancer in ascending colon. Total parenteral nutrition could not improve the hyponutrition state and the hypoproteinemia progressively got worse. As fecal clearance of alpha 1 antitrypsin was high and ^99mTc-HSA scintigraphy showed high uptake in the tumor of the ascending colon, protein-losing colon cancer was diagnosed. A right hemicolectomy was perfomed. Histological study revealed poorly differentiated adenocarcinoma with marked involvement of lymphatics. The clinical symptoms improved following the operation.

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An 86-year-old woman was admitted to our hospital because of abdominal pain. Palpation revealed a hard tumor, 10cm in size in the right abdomen. Barium enema study showed irregular stenosis of the ascending colon and oppression of the transverse colon. Abdominal CT scan revealed a large multilobular tumor from the ascending to the transverse colon. We performed an operation under diagnosis of an extramurally growing cancer or GIST of the colon. Right hemicolectomy was performed with resection of the duodenum and the fat tissue around the kidney. The tumor was an extramurally growing type. 12×10cm in size. Pathological findings showed the tumor consisted of large abnormal cells without gland formation and mucin production. Immunohistochemical study showed positive in EMA and keratin, however chromogranin A and synaptophysin were negative. Therefore, we diagnosed this case to be an undifferentiated carcinoma. We report such a rare case of undifferentiated carcinoma of the colon with extramural progression and did some review of the literatures.

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A 68-year-old woman underwent an abdominoperineal resection for type 2 cancer located in the lower part of the rectum. Increases in serum levels of tumor markers were observed in 15 months after the first surgery. CT showed a tumorous lesion, associated with dense soft tissue, from the floor of the pelvis to the sacral wall, indicating that local recurrence of the cancer might occur. CT-guided biopsy was performed to assess the extent of tumor spread as well as to obtain the definite diagnosis of the recurrent cancer. Then, surgical resection of the tumor was done, following CT-guided dye marking at the expected surgical margins. Sufficient tumor clearance was achieved at the sites where the marking was performed.
To our knowledge, there has been no similar case of recurrent rectal cancer applied these CT-guided techniques in the English and Japanese literature.

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A 54-year-old woman with a 3-year history of pressure ulcer on the left gluteal region received a biopsy of the ulcer due to its deterioration which offered a diagnosis of adenocarcinoma at another hospital. She was admitted to the hospital, and rectal cancer was found by a colonoscopy. It seemed that the rectal cancer had spread to the left gluteal tumor (10cm in size) including the pressure ulcer, with bilateral inguinal lymph node metastases. For the first treatment, sigmoid colostomy construction was performed, and neoadjuvant chemotherapy with CPT-11/LV/5FU was followed. After 3 cycles of chemotherapy, she was performed a Miles' operation and perineal reconstruction with a myocutaneous flap. Intraoperative findings showed that the upper rectal cancer and the inguinal tumor were apart, and their histological findings were the same as well differentiated adenocarcinoma. We thus diagnosed this case as rectal cancer and its metastasis at an anal fistula. It is extremely rare that anal fistula was implanted from colorectal cancer. So far only 8 cases have been reported. The prognosis might be determined by the progression of those primary and metastatic tumors. In treating colorectal cancer with a large metastatic tumor at an anal fistula like in this case, not only surgical intervention but also multidisciplinary treatment is required to attain appreciable outcomes.

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A 78-year-old man was admitted to the hospital because of a liver tumor detected by abdominal CT. He had a history of undergoing a S5 subsegmentectomy of the liver for hepatocellular carcinoma. The tumor was measuring 1.5cm in size in the residual liver S4 and shown to be a hypervascular lesion by enhanced CT and angiography. Either diagnosis of recurrence of hepatocellular carcinoma or liver cell adenoma was likely for the tumor, because of early demonstration of homogeneous accumulation of contrast material for small well differentiated hepatocellular carcinoma. Accordingly a S4 partial hepatectomy was performed. Macroscopically the tumor was homogeneously white in color with a clear border. Histological examination showed that the tumor consisted of low grade atypical cells proliferat-ing like cobblestone appearance. The tumor was difficult in differentiating from liver cell adenoma and finally diagnosed as well differentiated hepatocellular carcinoma because of its thick trabecular pattern and an increase in nuclear/cell ratio. In conclusion, well differentiated hepatocellular carcinoma can appear as a hypervascular lesion even if it is still small.

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With the concept that advanced breast cancer is a typical generalized disease, liver metastasis is generally treated by multimodal approach such as chemotherapy and endocrinotherapy.
A 55-year-old woman with metachronous liver metastasis from breast cancer was first treated by an anti-estrogen drug because of her rejection of chemothrapy. As a rapid growth of the metastasis was confirmed by CT scan one year after the use of the drug, we performed right hepatic lobectomy and oophorectomy based on its possible curability. The patient was followed by 5 courses of adjuvant chemotherapy with CMF. Two years after the first hepatectomy, however, intrahepatic recurrence was detected and treated by repeated hepatectomy for the caudate lobe and segment 3. Thereafter another intrahepatic recurrence with extrahepatic lesions such as lung and bone metastaeis appeared again, but the prognostic factor in this case was considered to lie on the liver metastasis. Based on this, US-guided radiofrequency ablation therapy was applied to the intrahepatic recurrence. Finally, a long survival of 5 years and 9 months was achieved.
Although multimodal approach is widely accepted for the treatment of advanced breast cancer, it is conceivable that aggressive surgical approach including hepatectomy and radiofrequency ablation therapy is sometimes most effective for liver meastasis from breast cancer.

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An 80-year-old woman was brought into the hospital by ambulance, because she had sustained a blunt abdominal impact in a bicycle accident. She complained of RUQ pain with no visible skin abrasions. Ultrasound and CT of the abdomen demonstrated accumulation around the gallbladder and in the Morison's pouch, which led to a diagnosis of liver injury. As her condition was stable, expectant observation was decided. Meanwhile, the pain began to increase. Subsequent abdominal ultrasound and CT revealed accumulation in the Douglas' pouch besides increased accumulation in the two regions. Laparotomy was performed 8 hour after the accident. There was about 200ml of free blood in the peritoneal cavity. The gallbladder was completely detached from the liver bed, lying free in the abdomen suspended only by the cystic duct and cystic artery, both of which were intact. Assessment revealed no other organ injuries, hemorrhage and bile leakage. Clots on the liver bed and gallbladder surface determined the definite diagnosis of gallbladder avulsion following the blunt trauma to the abdomen. Cholecystectomy was performed. A 2-mm cholesterol polyp was found on the gallbladder mucosa but no other abnormalities. Injury to the gallbladder due to a blunt abdominal trauma is a very rare surgical entity. Knowing it, imaging modalities are helpful for the correct diagnosis.

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A 64-year-old woman was referred to the hospital because of right upper abdominal pain in August 2002. On physical examination, supraclavian lymph nodes were palpable, and laboratory examinations revealed a high level of a tumor marker (CA19-9: 3280U/ml). Abdominal CT scan with intravenous contrast showed remarkablly swollen lymph nodes around the porta hepatis. Gallbladder stone was detected, but the mucosa of the gallbladder was evaluated normal on abdominal CT and magnetic resonance imaging scans. ⁶⁷Ga-scintigraphy revealed a hot spot in the lesion of the supraclavian space and also in the porta hepatis. Microscopic examination of a biopsy specimen of supraclavian lymph nodes revealed epithelioid granuloma. As we could not make definitive preoperative diagnosis, an exploratory laparotomy was performed on December 10 when a cluster of enlarged lymph nodes was found at the hepato-duodenal ligament. An intraoperative biopsy specimen obtained from the lymph nodes revealed epithelioid granuloma. Cholecystectomy was also perfomed and gallbladder cancer was detected in frozen sections. Mycobacterium tuberculosis was confirmed by culture of a lymph node specimen 8 weeks later. The definite diagnosis of gallbladder carcinoma with tuberculous lymphadenitis was made.
We report this clinically rare case in which we had difficulty in preoperative diagnosis of gallbladder cancer due to assosiated tuberculous lymphadenitis, together with some bibliographical comments.

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Mucus producing cholangiocarcinoma secrets large amount of mucus and is often difficult to make diagnosis accompanied with varieties of symptoms and pictures in image studies. We report a case of mucus producing cholangiocarcinoma in which PTCS was useful in making diagnosis and selecting the choice of surgical treatment. The patient was 78-year-old female who presented to us with general malaise, anorexia and fever. The blood test revealed the presence of mild inflammation, mild elevation of hepatic enzymes and CEA. The intrahepatic and common bile ducts revealed significant dilatation in US and CT studies and abnormal images in ERCP. The study with PTCS revealed mucoid and granular disease in the intrahepatic ducts of posterior segment and common bile duct. Accordingly, the diagnosis of mucus producing cholangiocarcinoma was strongly suspected and resection of posterior hepatic segment, extrahepatic bile duct and removal of D2 lymphnodes were performed on Dec. 10^th, 2001. The pathological diagnosis was well differentiated adenocarcinoma arising in papillomatosis. The patient is surviving without sign of recurrence three years after the operation.

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We encountered a very rare case of cholangio cell carcinoma (CCC) with ovarian metastasis. A 52-year-old woman visited our hospital with a complaint of abdominal distension and admitted to obstetrics and gynecology department, because of massive ascites and 12cm in diameter ovarian cyst by computed tomography examination. A further examination revealed a 30mm tumor in maximum diameter in the lateral lobe of the liver and swollen mediastinal lymph nodes. Total hysterectomy, omentectomy and appendectomy were performed because of suspicion of malignant ovarian tumor. Pathological diagnosis of ovarian mass was borberline malignancy and the specimen of aspiration biopsy of cervical lymph node revealed adenocarcinoma and that of liver revealed CCC. No ascites and lymph node swelling were encountered after the gynecological operation without chemotherapy and the liver tumor was localized only in S 2/3, and left lobe and Spiegel leaf resection were performed. As a result of precise pathological study of the liver and ovarian tumor, the ovarian cyst was thought to be a metastasis of CCC. Generally, the metastatic ovarian tumor originate from stomach or colon, accordingly we reported this rare case with review of literatures.

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A case of minute squamous cell carcinoma of the gallbladder, which is very rare, is reported.
A 71-year-old man, diagnosed as having cholelithiasis in September 2003, was seen at the hospital because of occasional episodes of right hypochondralgia since the beginning of April 2004. Abdominal ultrasonography and CT scan revealed a gallstone and wall thickening of the gallbladder. We diagnosed the case as cholelithiasis and chronic cholecystitis and perforemed a cholecystectomy. A small and hard nodule was palpated in the gallbladder wall. Intraoperative frozen section diagnosis of it showed atypical squamous epithelial cells. Since the nodule did not adjacent to the gallbladder bed, no additional resection was performed. Histopathological study revealed atypical layered squamous epithelial cells showing infiltrating proliferation only in a 7×4×1mm portion where was affected with chronic cholecystitis. Early squamous cell carcinoma was thus diagnosed. Metaplastic changes were absent in the surroundings of the tumor.
Although the etiology of squamous cell carcinoma of the gallblader has not been clarified as yet, this case may be a precious case to elucidate the mechanism.

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A 77-year-old woman pointed out abnormalities on chest X-rays inspection by a primary physician was seen at the hospital. Chest and abdominal CT scans showed a cystic tumor 3cm in diameter in the pancreas body. The tumor was well-circumscribed and the inside showed almost homogeneously low dencity. The enhancement was recognized in the structure like a septum and capsule. On magnetic resonance imaging scan, the tumor showed low intensity on T1WI and T2WI. Endoscopic retrograde pancreatography and abdominal angiography showed no remarkable findings. As a possibility of malignancy could not be ruled out, distal pancreatectomy was performed. The cystic tumor was well circumscribed and multilocular cyst containing keratinizing material. Intraoperative stump cytology of cut surface revealed benign squamous cells and lymphocytes. Histologically, the cyst walls were lined with squamous epithelium which was surrounded by lymphoid tissue. It was diagnosed as lymphoepithelial cyst of the pancreas. Lymphoepithelial cyst of the pancreas occurs predominantly in men. We report this rare female patient who is the oldest among those reported in the literature as far as we could review.

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We report a very rare case of lipomatous pseudohypertrophy of the pancreas.
A 69-year-old man hospitalized for the control of diabetes was found to have gastric cancer. He was transferred to our department and underwent a distal gastrectomy. During the operation, we found a yellowish tumor-like fat tissue arising from the retroperitoneum near the body and tail of the pancreas. Liposarcoma was suspected, and the tumor was excised with the body and tail of the pancreas. It was 22×17.5×5cm in dimention, weighed 2kg, surrounded by a thin membrane, and was connected to the pancreatic tissue. Cut sections showed marked increase in adipose tissue, and no parenchyma of the pancreatic body could be seen. Histological examination of the tumor showed diffuse replacement of pancreatic parenchyma by adipose tissue. The pancreatic duct disappeared, but the islets of Langerhans were relatively preserved. No tumor change was observed, and so the pathological diagnosis was lipomatous pseudohypertrophy. We report this case with a review of the literature.

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Isolated splenic metastasis from colorectal cancer is rare. The long-term prognosis after splenectomy is uncertain. A case of long-term disease free survival after splenectomy for splenic metastasis from rectal cancer is reported.
A 39-year-old female underwent low anterior resection for rectal cancer without obvious distant metastasis. However cancer cells were detected from samples of ascites intra operatively. Two months after operation, metastatic splenic tumor was detected by computed tomography (CT). Splenectomy was performed ten months after former operation, as there was no evidence of peritoneal recurrence and other metastasis. She is still in good health without tumor recurrence eight years and five months after splenectomy.
This case gives us significant suggestion that splenectomy following metastatic splenic tumor from colorectal cancer may sometimes provide good prognosis.

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Adrenal rest tumor is a rare tumor which arises from an ectopic adrenal tissue. Here we report a case of adrenal rest tumor of the liver which mimicked hepatocellular carcinoma. a 72-year-old woman was found to have a liver tumor on her medical check-up. A blood test revealed hepatitis B antigen was positive. Computed tomography showed a 5cm hypervascular tumor in segment 7 of the liver. We diagnosed it as a typical hepatocellular carcinoma and performed posterior segmentectomy of the liver. At the time of surgery, the right adrenal gland was ascertained to be present independently from the tumor. The tumor was well circumscribed and yellowish in colour. Histologically, the tumor was predominantly composed of pale cells. Immunohistochemically, AFP and Hep Par 1 were negative and Melan A was positive, which confirmed the tumor to be adrenal cortex in origin. We concluded this hepatic tumor was an adrenal rest tumor of the liver.

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We report a case of thrombosis of cranial mesenteric vein caused by protein S deficiency, together with a review of the Japanese literature.
A 54-year-old man, who had had tenderness and spontaneous pain mainly in the lower abdomen since March 2004, complained of abdominal pain and vomiting and was admitted to the hospital with a diagnosis of acute abdomen. Abdominal plain CT scan visualized localized thickening of the small intestine, ascites, and an increased density of the superior mesenteric vein. Enhanced CT scan showed radiolucency in the superior mesenteric vein under the confluence of splenic vein. Intestinal necrosis due to thrombosis of cranial mesenteric vein was thus diagnosed, and a laparotomy was performed. Operative findings included bloody ascites and congestive changes and necrotized portions of the ileum. A partial excision of the small intestine by about 40cm in length, 120cm distal from the terminal ileum was performed. Blood coagulation tests revealed a low level of protein S. It is thought that protein S deficiency might cause thrombosis of cranial mesenteric vein with intestinal necrosis in this case.

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Non occlusive mesenteric ischemia (NOMI) accounts for 20% of all cases of acute mesenteric ischemia, and to diagnose the disease is difficult. Because the mortality rate ranges from 60% to 100% and emergency treatment is demanded to save the patient's life, we must consider NOMI in diagnosing acute abdomen. We report two surgical cases of NOMI. Case 1: A 77-year-old man was brought into the hospital by ambulance because of the sudden onset of abdominal pain. Colonoscopy showed mucosal necrosis and erosion in the left hemicolon, sigmoid colon and rectum, and IMA thrombus/embolism was doubted. But blood flow of IMA was recognized on CE-CT. Peritoneal irritation developed, and an emergency surgery was performed. The pulsation of IMA was palpable and Doppler echo showed the flow of IMA, but advanced mucosal necrosis was confirmed with intraoperative endoscope. We excised 2/3 of the left transverse colon to rectum where showed necrotic color, and constructed a colostomy. The postoperative course was uneventful, and the patient was discharged from the hospital 3 weeks after the surgery. Case 2: A 56-year-old woman on hemodialysis for chronic renal failure developed abdominal pain. The pain became severe on the next day, and abdominal CT scan showed gas in the portal vein and liver. Muscular defence gradually developed. Bowel necrosis due to NOMI was diagnosed and an emergency surgery was performed. We removed the small intestine by 230cm in length, and made a double barreled colostomy. The postoperative course was eventful, and the patient died of MOF on the third postoperative day. Pathological study showed absence of arterial and venous thrombi.

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An 83-year-old woman who visited the department of internal medicine in our hospital because of nausea was admitted immediately under a diagnosis of bowel obstruction. Evaluation of the pelvic floor by CT examination on admission was difficult for an artifact caused by an artificial femoral head, as she had undergone a left femoral head replacement. Abdominal ultrasound examination confirmed that the small intestine and a hernia orifice were incarcerated dorsally to the left femoral region and femoral artery and vein, leading to a diagnosis of left obturator hernia incarceration. Emergency abdominal surgery was then performed. Upon opening the abdominal cavity, the ileum exhibited a Richter type incarceration in the left obturator foramen. Since ischemic change was found in the incarcerated intestinal tract, the small intestine was partially resected and the hernial orifice was closed by peritoneal suture.
Ultrasound examination is useful for diagnosing an obturator hernia, which is a relatively rare disease and frequently develops in lean, elderly, and prolific women. It was particularly useful for establishing the diagnosis in the patient reported herein, who could not easily be evaluated by abdominal CT because of artificial materials placed in and around the abdominal cavity.

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