We analyzed current status and problems of day surgery, comparing with non day surgery group for clinical path of gastrointestinal indications in our hospital. Two hundred and fifty eight patients who underwent surgery in our day surgery center between November, 1998, and June, 2003, and three hundred and sixty eight patients who underwent surgery being applied to clinical path during the same period, were the subject of this study. In day surgery group, the indications were rectal or anal diseases in 69 cases, inguinal or femoral hernia in 109, gall bladder stones or polyps in 77, and others in 3. In non day surgery group, the indications were rectal or anal diseases in 141 cases, inguinal or femoral hernia in 133, gall bladder stones or polyps in 96.
The mean length of hospital stay was 1.67 days in day surgery group and 6.81 days in non day surgery group. The mean number of visit to out-patient clinic was 2.29 times in day surgery group and 1.69 times in non day surgery group.
The complications were observed in 48cases (18.6%) in day surgery group, and in 29 cases (7.9%) in non day surgery group.
Seventeen cases (6.6%) dropped away from day surgery (extended hospital stay). Twenty three cases (6.3%) dropped away from non day surgery (extended hospital stay). Complications related to spinal anesthesia were the main cause of extended hospital stay in day surgery.

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We have retrospectively evaluated 35 cases of primary hyperparathyroidism (PHPT) treated surgically in the hospital from April 1997 to March 2005. The male-to-female ratio was 4:31, and their average age was 61.7 years. Nineteen out of the 35 cases (54.3%) were detected by asymptomatic hypercalcemia at medical checkup. Histologically, 28 of the 35 cases were of parathyroid adenoma and seven, of hyperplasia. In the 35 cases, the sensitivities of CT, ultrasonogram, 99mTc sestamibi scintigram were 91.4%, 51.4%, 57.1%, respectively. The tumors were predominantly found in the right or left lower portion compared with the upper portions. The adenomas were apt to have a great maximum diameter compared to others. The surgical outcomes were favorable in all cases except five cases including two cases of adenoma and three cases of hyperplasia in which hypercalcemia and high levels of PTH persisted after the operation. Papillary carcinoma was noted in one case as an associated thyroid disorder.

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To reduce the complications after gastrectomy, especially SSI (surgical site infection), we analyzed risk factors of SSI and intervened in the management of gastrectomy. In the first place, we analyzed 76 consecutive patients undergoing gastrectomy for gastric cancer from April 2003 to October 2003 about risk factors of SSI. There were significant differences in age, drain type (closed type or open type), the term up to removing a drain, and the term up to starting meal as risk factors of SSI. In the second place, based on the results, we intervened in the management of 65 consecutive patients from November 2003 to April 2004. We improved the management of gastrectomy in the followings; 1) using the closed type drain, 2) avoiding aimless prolongation of the time for placing a drain (by certifying anastomotic leakage and pancreatic fistula by fluoroscopic examination and measuring amylase in the drain fluid on the fourth day after operation at the latest), and 3) hastening the time to meal intake at 71^th day to 5^th day after operation. In consequence, the rate of SSI was drastically reduced from 27.6% in the first term to 4.6% in the latter term. The decline in SSI resulted in a shortered hospital stay after surgery and a saving of medical cost.

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Dementia is one of the most important problems in performing surgery for elderly patients. We made a retrospective study for surgical patients over 80 years old. Registered patients for this study were collected as “retrospective study” in a part of the research grant; “Treatment and prevention of postoperative dementia in aged patients” conducted by the Japanese Ministry of Health, Labour and Welfare. Of 442 patients operated on under general anesthesia in four participated medical centers, 38 patients (8.6%) who already had dementia at the time of surgery were compared with the remaining 404 patients. These 38 patients with dementia were significantly older than the others (86.4: 83.7 years old; p<0.001), and showed higher preoperative ASA (p<0.001) and PS (p<0.001). The operative time was shorter in patients with dementia (106:130 min; p=0.04). The length of hospital stay in patients with dementia was longer (44.1: 31.3 days; p=0.001), and the morbidity was higher (p<0.001). Pneumonia (p<0.001), respiratory failure (p=0.04) and psychiatric problems (p<0.001) such as delirium and deterioration of dementia were dominantly found in the patients with dementia.
In performing gastroenterological surgery under general anesthesia for elderly patients who already have dementia at the time of surgery, particular attention must be paid for postoperative complications, especially for respiratory complications and deterioration of psychiatric and neurological symptoms.

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Adenomyoepithelioma (AME) of the breast is generally a benign lesion and occurs rarely. Herein we report a case of AME which was accidentally detected by a chest CT scan.
An 85-year-old woman received a routine follow-up chest CT examination after the surgery for a thoracic aortic aneurysm, when a 17-mm sized nodular lesion was accidentally found at the uppermedian region of her right breast. Mammography showed an oval high-density tumor and ultrasonography showed a 1.2×1.4cm hypoechoic and homogeneous tumor. Breast cancer was suspected and a partial mastectomy with surgical margin of about 2cm was performed. Intraoperative pathology demonstrated hyperplasia of the mammary ducts and periductal myoepithelial cells. Since the myoepithelial cells were positive for S-100 and partially positive for α-SMA, the pathological diagnosis was made as AME. Furthermore ER and PgR were both positive, and HER-2 was evaluated as 2+. Since it has beer reported that local recurrence and metastasis to the lung or brain of AME occurred in some cases periodical follow-up studies are necessary for the patient.

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Primary angiosarcoma of the breast is a rare disease, accounting only for 0.04% of all malignant breast tumors. This paper describes a patient with angiosarcoma of the breast administered interleukin-2 (IL-2) for two years as an adjuvant therapy and the patient has no evidence of recurrent disease for six years after the operation to date. A 32-year-old woman was seen at our hospital because of a mass of the right breast. The right breast tumor was 8.5cm in size, and elastic hard in consistency. On ultrasonography and cytology, hemangioma or angiosarcoma were suspected, and an incisional biopsy of the tumor was performed. Histlogically it was angiosarcoma. Consequently a modified radical mastectomy and axillary dissection were performed. The patient received an adjuvant therapy (interleu-kin-2, 400 thousands JRU/2 weeks×2 years), and has no evidence of recurrent disease for six years. According to the literalure review, 86 cases of angiosarcoma of the breast have been reported in Japan.

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We report a case of congenital complete left pericardial defect that was incidentally diagnosed on video-assisted thoracoscopic surgery (VATS) in a 24-year-old man with left spontaneous pneumothorax. When patient was examined at our hospital for chest pain, the chest X-ray film and chest computed tomography showed left pneumothorax and pneumopericardium. Under the diagnosis of left sponteneous pneumothorax, VATS was performed. Intraoperatively, congenital complete left pericardial defect was noted. We did not perform any surgical repair for this case because the defect was complete. The postoperative course was uneventful and the patient was discharged 3 days postoperatively. Congenital pericardial defect is an abnormality that is rarely found incidentally on thoracotomy or at autopsy. Recently VATS has been a common approach for the treatment of pneumothorax. We should perform a careful examination and keep congenital pericardial defect in mind in the differential diagnosis of pneumopericardium in a patient with pneumothorax.

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A 59-year-old male patient was admitted with pulmonary thromboembolism. A temporary inferior vena cava filter (TIVC-F) was inserted to prevent new thromboembolism before starting anti-coagulant therapy. After lmonth of anti-coagulant therapy, the thrombi were found in the TIVC-F and distal inferior vena cava (IVC), with complete occlusion. So we thought it was not possible to withdraw the filter percutaneously, and operation was performed and we could successfully remove the filter from IVC. No severe complications were seen.

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A 52-year-old woman, who underwent left nephrectomy for left renal cell carcinoma 6 years earlier, was referred to our department because of a pulsatile mass in the right supraclavicular region. Angiogram revealed an aneurysmal formation of proximal site of the right subclavian artery. For the exposure of the proximal right subclavian artery, median sternotomy with extension of skin incision into the right supraclavicular fossa was made. The aneurysm was completely resected and reestablishment of arterial continuity with an end to end anastomosis was performed. The patient's postoperative course was uneventful. Histopathological examination of the aneurysmal wall was consistent with atherosclerotic degenerative changes.
We think that allowance must be made for the maintenance of intraoperative blood flow in the brain in performing operation for aneurysms arisen in the proximal site of the right subclavian artery.

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A 72-year-old man complaining of fever and nausea was transferred to the hospital because an abdominal aortic aneurysm (AAA) was confirmed at another hospital. He showed prominent inflammatory findings. Bacteroides fragilis was identified by a culture of the blood. Abdominal CT scan revealed a true AAA with the maximum diameter of 50mm, but no infectious findings were seen and then conservative therapy with antibiotics was started. However, no improvement of infection signs was attained after admission and new appearance of a cystic aneurysm and abscess formation around the AAA were identified by an abdominal CT scan conducted on the 12^th hospital day. Imminent rupture of the infected AAA was diagnosed, and an emergency operation was performed. After the AAA and infected tissues were removed as possible as we could, the defect was replaced with a Y-shaped graft and the omentum was used to fill up around the graft. The patient's postoperative course was uneventful. There have been no signs of recurrence of infection, as of 17 months after the operation. This case in which the formation course of the infected AAA was able to be observed is thought to be rare.

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Bronchogenic cysts are foregut malformations during embryonic development. They are generally found in the lung or in the posterior part of the mediastinum, and are rarely found in the retroperitoneal region.
A 44-year-old woman complained of left lower abdominal pain, and a tumor was found near the left adrenal gland by abdominal CT. The tumor was diagnosed as a retroperitoneal cyst by MRI, and the cyst was extirpated by open laparotomy. The tumor was multi-locular, 4.5×3.5×2.0cm in size, and contained grayish yellow-white mucinous fluid. Histologically, the cyst was lined by pseudostratified ciliated columnar epithelium, containing some glands resembling respiratory type. These findings were consis-tent with a bronchogenic cyst.
The patient has been followed up for 5 years without evidence of recurrence.

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We report a case of dirofilariasis of the lung which was diagnosed by a thoracoscopic partial excision of the lung.
A 51-year-old man seen at the hospital because of hypertension was pointed out a nodular shadow in the right lower lung field on a chest x-ray film. Chest CT scan showed a 1.8-cm sized nodular shadow in S10 of the right lung. Since a possibility of lung cancer could not be ruled out, a thoracoscopic partial excision of the lung including the tumor was carried out. The tumor was a well-defined granuloma with center necrosis. Worms of Dirofilaria immitis were identified in the pulmonary artery and dirofilariasis of the lung was diagnosed.
This disease is comparatively rare, but it will increase in future with a recent spread of medical checkup and pet boom. Moreover the disease manifests as a solitary round tumor in the lung fields on imaging methods in most cases, so that we have great difficulties in differentiation between the disease and lung cancer or metastatic pulmonary tumor. To make the difinite diagnosis, thoracoscopic partial excision of the lung is a useful method.

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We encountered a case of early gastric cancer complicated with Morgagni foramen hernia. The patient was a 71-year-old woman, who presented with complaints of epigastric pain, nausea, and vomiting. ECG was normal and endoscopic study revealed a deformed portion of the stomach with redness and mucosal swelling. The biopsied specimen revealed carcinoma. The patient was admitted on urgent basis because of vomiting. The chest X-ray at the time of admission showed an abnormal shadow with an air fluid level in the right lower lung field and a mass at the right cardio-phrenic angle. A final diagnosis of early gastric cancer complicated with Morgagni foramen hernia was made after CT, echo and gastrografin studies. Since the clinical condition of the patient was stable, an elective operation was performed. Recently, in cases like this gastroscopic study is often performed first, depending upon the symptoms of the patient, however it is recommended to suspect malignancy or the presence of hernia when gastric antral stenosis or deformity is observed.

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A 56-year-old man treated for schizophrenia accidentally swallowed fish bones on September 29, 2003. Two days later, he started to run fever, so he was treated conservatively with an antibiotic, but he didn't recover, and he was referred to our hospital on October 6, 2003. A CT scan revealed a big air density extending to the mediastinum from the neck. On the same day, an emergency operation was performed under the diagnosis of acute mediastinitis caused by esophageal perforation due to fish bone. We attempted to drain pus out by making a transverse incision in the neck, but the inflammation extended along the mediastinum, so we made a right thoracotomy incision. Five drainage tubes were put in the chest beside cervical esophagus and mediastinum. After the operation, continuous irrigations through the drains were done and he responded well to the treatment and he was discharged on the 38th hospital day. Some cases of esophageal perforation could be successfully cured with conservative therapy, but most of the cases complicated with mediastinitis should be treated with emergency operations. It is important to diagnose as soon as possible and treat appropriately, because shorter the time from the perforation the prognosis is better.

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A patient, 72-year-old male, came to the hospital with the chief complaints of hematemesis, melena and anorexia. On endoscopic examination a irregular protruded lesion with verrucous appearance was detected on the lower esophagus at 35cm from incisors down to the cardia. Endoscopic biopsies revealed squamous cell carcinoma and esophago-gastrectomy was performed with the diagnosis of esophageal cancer. Operative procedures included distal esophagectomy, proximal gastrectomy, splenectomy and D2 lymph node dissection. Macroscopic findings of the resected specimen showed a cauliflower-like appearance with irregular surface, measuring 8.0×7.0cm. Histological examination revealed a well-differentiated squamous cell carcinoma with papillary proliferation of epithelium. From these findings, the pathologic diagnosis was verrucous carcinoma of the esophagus. The histological stage was pT3, pN0, M0, ly0, v0, pPM0, pDM0, pEM0. and stage II. No signs of recurrence have been observed for two years after the operation. Verrucous carcinoma of the esophagus is extremely rare, and only 19 cases have been reported until today. The author discussed the clinical and histopathological characteristics of esophageal verrucous carcinoma reviewing some published literatures.

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Postoperative cerebral infarction is one of the major complications after cardiovascular surgery. Although it's incidence is not so high, there is a probability of postoperative cerebral infarction even after gastrointestinal surgery, especially in patients with generalized arteriosclerosis. We experienced a case of cerebral infarction complicated in the operation for thoracic esophageal cancer. After further examinations, the disease turned out to be caused by severe stenosis of left internal carotid artery. Preoperative evaluation of important cerebrovascular lesions should be done in cases of major gastrointestinal operations for poor risk patients.

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A 62-year-old man with diarrhea and a loss of weight over a period of several months was referred to the hospital for further evaluation. There were previous histories of undergoing a distal gastrectomy with Billroth II reconstruction for perforation of a duodenal ulcer at the age of 48. The physical examination showed extreme emaciation and mild anemia. The serum level of total protein was 4.1g/dl, the albumin was 2.2g/dl, the hematocrit was 31.0%, and the hemoglobin was 10.4g/dl. The serum levels of CEA and Ca19-9 rose to 7.8ng/ml and 48U/ml, respectively. A colonoscopic examination and a barium enema study revealed stenosis in the transverse colon with double orifices on the oral side of the stenotic lesion which had formed a fistula in the small intestine. On the other side, diagnostic examination of the upper gastrointestinal tract revealed multiple peptic ulcers in the gastro-jejunostomic region penetrating the transverse colon. The preoperative diagnosis was gastro-jejuno-colic fistula due to penetration of a stomal ulcer. We performed a right hemicolectomy including the resection of the remnant stomach and fistula because we could not rule out a possibility of malignant lesion in the colon.
Stomal ulcer after gastrectomy is sometimes observed, however, the penetration of such a stomal ulcer to the transverse colon is extremely rare. We herein report an interesting case of the disease presented with defecation disturbance for that it was difficult to make the accurate diagnosis.

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A 51-year-old man involved in a head-on collision while driving a car just after heavy drinking was transferred to the hospital. He was in shock upon arrival. The abdomen was board-like and there was severe tenderness. Abdominal CT scan showed fluid collection in the abdominal cavity and pancreatic head injury. Emergency laparotomy was performed under a diagnosis of intraabdominal bleeding and hemorrhagic shock due to pancreatic injury. Laparotomy showed that the stomach had been completely transected at the antrum and very close to the pylorus and the pancreas had been partially transected at the uncus. A distal gastrectomy and reconstruction by the Billroth II procedure were performed. The transection of the pancreas was closed directly. We assumed that a shearing stress between the wheel and the vertebrae had caused the injuries of the stomach and pancreas. The patient was discharged from the hospital on the postoperative day 64 after treatment of postoperative complications of disseminated intravascular coagulation (DIC) and pancreatic fistula.
We think that, in the treatment of traumatic gastric transection, the precise intraoperative estimation of other organ injuries, best selection of operative procedure according to the patient's general condition and local findings, and adequate postoperative management are important.

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We report a case of nodal malignant lymphoma detected at a gastrectomy for gastric cancer which was thought very rare.
A 64-year-old man was admitted to the hospital because of a depressed lesion in the body of the stomach that was a recurrent disease after endoscopic mucosal resection. A biopsy of the tumor revealed well differentiated adenocarcinoma. An Abdominal CT scan revealed lymph nodes swelling around the abdominal aorta. The patient was suspected to have early gastric cancer and malignant lymphoma, and underwent a laparoscopic distal gastrectomy and disection of the lymph nodes. Pathological diagnosis was early gastric cancer and malignant lymphoma. The patient's postoperative course was uneventful. He underwent chemotherapy (CHOP) for malignant lymphoma after surgery, and is still alive without signs of recurrence as of 30 months after the operation.

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A 52-year-old woman under treatment for chronic obstructive pulmonary disease (COPD) at home was admitted to the hospital because of gastric cancer with outlet stenosis. Since her pulmonary function was in a very low level due to severe COPD, the operation had to be postponded and pulmonary rehabilitation with pharmacotherapy was performed for 2 weeks. However, her pulmonary function was not reached to the safety level for surgery. Then, an expandable metallic stent was inserted in the stenotic lesion. After that, she became possible to intake solid diet, and was released from intravenous drip infusion. Her activities in daily life and nutritional status were gradually improved. Three months later, her pulmonary function reached within the safety level for surgical treatment. Distal gastrectomy with lymph node dissection (D1) and Billroth-II reconstruction was performed without any complications. She was discharged from the hospital and is enjoying her life now.

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We report a case of left paraduodenal hernia diagnosed preoperatively and treated laparoscopically. A 20-year-old man with acute epigastralgia and vomiting consulted to the hospital. Based on the findings of an abdominal CT scan, which revealed regional dilatation of small bowel in the left upper abdomen and stretched inferior mesenteric vein (IMV) located at the ventral edge of dilated intestinal loops, he was diagnosed to have a left paraduodenal hernia. After bowel decompression with short tube for two days, laparoscopic hernia repair was performed. On the paraduodenal fossa at the left side of the Treitz ligament, the hernial orifice was identified. The small bowel in the hernia sac was easily reduced into the abdominal cavity. However, in order to confirm the complete reduction of clustered small bowel in the sac and to avoid the IMV injury, the hernia repair was performed under the direct vision with mini-laparotomy. Based on typical findings of the abdominal CT scan, this disorder can be diagnosed preoperatively. Thereafter, an elective laparoscopic repair is recommended if the bowel decompression has been effectively performed.

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A 70-year-old woman referred for the examination of right upper abdominal pain. Abdominal US showed a tumor located at the head of the pancreas, and the tumor mimiced pancreas cancer. For diagnosis, tumor biopsy was performed, and the tissue expressed KIT slightly at the first stain of KIT. However, she did not respond to imatinib mesylate, and died of rapid tumor progression. Second immunohistochemical stain of the tumor expressed KIT negative, α-SMA positive and desmin positive, and the result indicated that the tumor was leiomyosarcoma. It is difficult to diagnose the stromal tumor when the tumor showes very low expression of KIT, then additional immunohistochemical stain or c-kit mutation assay is thought to be needed in such a case.

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An 83-year-old man was admitted for right abdominal pain and an abdominal tumor was detected by CT scan, and endoscopic study revealed an irregular-shaped ulcer in the duodenal bulb. Endoscopic biopsy of the ulcer showed a histological diagnosis of adenocarcinoma. The duodenal tumor was partially resected. Macroscopically, the tumor which had mucus, was seen from the duodenal bulb to the second portion, with a Borrmann II appearance.
Histologically, it was diagnosed as mucinous carcinoma accompanied with adenocarcinoma. Mucinous carcinoma of the duodenum is rare in gastrointestinal carcinoma. Our case showed uncommon tumor growth of extramural progression of duodenal mucinous carcinoma.

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We experienced a case of ileus caused by multiple persimmon gastric stones in a patient who had previous gastric resection. An 82-year-old, female patient who had previous gastric resection due to duodenal ulcer, came to our hospital with a complaint of sudden onset of abdominal pain and vomiting. An oval black foreign body, 4cm in size, was found in her stomach by a gastroscopic study. Even after removal of the foreign body crushed into small pieces, the above mentioned symptoms persisted. Therefore, a CT study was done which revealed a mass with heterogeneous content at the distal end of the dilated jejunum. A diagnosis of ileus due to a translocated gastric stone was made and an operation was performed. A stone was found in the jejunum 200cm distal from the ligament of Treitz. The stone was removed through an incision made on jejunal wall. The gastric stone removed was oval shaped and black in color, 3.0cm in size composed of tannic acid in 98%, and diagnosed as persimmon gastric stone. The cause of gastric stone is believed to be due to over ingestion of persimmon with delayed excretion from the stomach, especially after gastrectomy. A careful management of diet and administration of proper medications is thought to be helpful. Occasionally it is difficult to make correct dignosis. A detailed chech of the dietary habit of the patient is very important.

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The volvulus occurred in three male neonates in an early neonatal period within day 2. Their birth weights ranged from 2286g to 1500g and all of them were low-birth-weight infants. Abdoninal distension was recognized in all cases. A coffee-like emesis was found in case 1, and respiratory disturbance in case 3. Barium enema study disclosed no dislocation of the colon. Laparotomy showed that the distal ileum was twisted clockwise by 360° and the color of the affected portion of intestine was normalized by repositioning in case 1 and 2. In case 3, the proximal part of the jejunum was stangulated in the direction of 720°counter-clockwise, and a partial bowel necrosis was found which required bowel resection.
Although no definite diagnosis could be made in all three cases preoperatively, their lives were saved by performing laparotomy in an early stage, because they had marked dilatation of the small intestine as well as intestinal obstruction which resisted being reduced by conservative therapy.

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A 53-year-old man was admitted to the hospital because of epigastric pain. The next day he had right lower abdominal pain and high grade fever (40°C). Abdominal CT scan demonstrated a 35×25mm sized cystic lesion containing gas. Emergent laparotomy revealed a 5cm in size tumor in the ileocecal mesentery and ileocecal resection was carried out. Because pathologic examination showed a diverticulum at 4cm orally from the ileum end and intramesenteric abscess formation, it was diagnosed as ileal diverticulitis penetrating into the mesentery. Because ileal diverticulum commonly occures at the terminal ileum and on the mesenteric side, it is localized in the mesentery even if it is perforated. Ileal diverticulum is relatively rare and intramesenteric abscess formation caused by penetration is very rare.

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A 48-year-old woman was admitted to the hospital because of nausea and abdominal fullness. On abdominal ultrasonography, tumors were detected in the median upper abdomen, and right hepatic lobe. CT, X ray and abdominal angiography showed a submucosal tumor in the upper jejunum, measuring 6cm in diameter, and liver tumor in the right lobe, measuring 10cm in diameter. Partial resection of jejunum and right hepatic lobectomy was performed. Histologically, the tumor cells consisted of spindle-shaped cells. Immunohistochemical analysis was positive for c-kit and CD34, but negative for α-SMA and S-100P. The GIST of the jejunum and its metastatic tumor in the liver showed a uncommitted type. The cases of surgical resection for GIST of the small intestine with liver metastasis are very rare. Including our case, only 7 cases were treated out of 51 cases of GIST reported so far in Japan. We report our case with some review of literatures.

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Gastrointestinal arteriovenous malformation (AVM) is a relatively uncommon disease, and is almost found by the investigation of GI bleeding. We report a case of cecal AVM with massive hemorrhage. A 50-year-old man was admitted to the hospital because of massive melena and hemorrhagic shock. Although colonoscopic examination detected a submucoal tumor of the cecum, obvious bleeding point was not identified. Emergent abdominal angiography, however, revealed a cecal AVM. Ileo-cecal resection was quickly and successfully performed. For the patient presenting with massive melena, emergent abdominal angiography is highly recommended when the bleeding point is not identified by endoscopic examination.

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We recently treated a 77-year-old man for acute appendicitis caused by an accidentally swallowed tooth 8 years earlier. He was seen at the hospital because of right lower abdominal pain and a slight fever lasting for 10 days. A tumor in the right lower quadrant of abdomen was palpable on physical examination. An abdominal CT scan revealed that the lump was forming lime. Calculus appendicitis was suspected and preservative treatment was conducted. We then waited until the condition of the lump on the intestinal wall was improved before carrying out an interval appendectomy. We removed a stone, which seemed to be a tooth, from the tube of the appendix. Pathologically, nonspecific chronic inflammation was seen in the entire appendix with parts where seemed to be acute inflammation in places. Since it is rare that appendicitis is caused by accidentally swallowed teeth and occurs after a long time has elapsed following the accident, this rare and interesting case is reported.

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We report two cases of small bowel obstruction caused by an appendix epiploica. The first case involved a 26-year-old man complaining of abdominal pain. An emergency laparotomy was performed with a diagnosis of small bowel obstruction and perforative peritonitis. An appendix epiploica of the sigmoid colon was adherent to the urinary bladder forming a cord. The ileum was strangulated by the appendix epiploica and perforated. The perforated ileum was resected. The second case involved a 67-year-old woman complaining of vomiting and abdominal pain. An emergency laparotomy was performed with a diagnosis of panperitonitis due to small bowel obstruction of unknown origin. The ileum was strangulated by an appendix epiploica of the sigmoid colon adhering to the mesenterium to form a wireloop cord; the impacted small intestine became necrotic. The necrotic intestine was removed. The postoperative course was uneventful in the two cases.
Intestinal obstruction due to an appendix epiploica has been reported in 12 cases in japan, including these two cases, and 33 cases in the world. We here report our two cases with some bibliographical discussion.

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A 61-year-old woman had been diagnosed as ulcerative colitis since 1981, and had been treated with salazosulfapyridine and steroid. She was hospitalized in January, 2004 because of increasing body weight loss and anemia. Barium enema and colonoscopy revealed circumferential stricture of the descending colon. Though we had no evidence of malignancy on biopsy of the stricture, left hemicolectomy was performed because possible association of malignant tumor could not be ruled out. No malignancy was seen pathologically. The cause of the stricture was due to fibrosis of submucosa and hypertrophy of muscle layer.

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A 21-year-old woman underwent one port gasless laparoscopy assisted ileostoma creation through stoma site with the diagnosis of colonic inertia. The operation time was 21 minutes and the blood loss was negligible. Postoperative hospital stay was 15 days. Sense of fullness disappeared and abdominal pain was alleviated. She got weight gain of 5kg in 3 months of postoperative days.
Our method enables us to perform a safe, fast, simple stoma creation without need of special equipments. It also has a cosmetic advantage and would be useful for young women. It would be also useful as a minimum invasive surgery which works for the improvement of the symptoms and the assessment of the function after operations such as total colectomy and subtotal colectomy.

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We report two cases of endometriosis of the sigmoid colon and rectum in women who wished to become pregnant. The patient, case 1, is a 34-year-old woman. She took anti-inflammatory medication, anodyne, for ten years to alleviate lower abdominal pain. She experienced symptoms of bowel obstruction when menstruating beginning in early 2003. On June 13, 2003, she was admitted to our hospital with the complaints of severe stomachache and vomiting. The patient, case 2, is a 29-year-old woman. A gynecologist in another hospital diagnosed her illness as endometriosis and treated her with pseudo-menoposal therapy from February of 2000 until June of 2001. She then stopped receiving therapy because she got married and moved to different locations. Since beginning of May of 2003, she experienced symptoms of bloody stool hematochezia and pain on defecation when menstruating. She was admitted to our hospital. After acertaining the diagnosis of endometriosis with further examinations, we perfor-med low anterior resection for the disease in both cases. The women were then able to become pregnant, and both successfully gave births. We believe that the treatment for this situation with low anterior resection is reasonable in order to preserve the uterus and ovaries of the patients who wish to become pregnant.

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The patient was an 84-year-old woman who had been unconscious of dislocation of the anus which had been pointed out by her mother from her childhood. She noticed of prolapsed mucosa from the vagina one year ago and was seen at the hospital because of a gradual enlargement of the mucosal prolapse. On physical examination no anus was identified at its natural position in the perineum and only a slight concavity was seen. A digital examination confirmed that the rectum opened at the posterior wall of the vagina, through which rectal mucosa prolapsed into the vagina in a shape of a polyp. Magnetic resonance imaging scans confirmed the orifice of the rectum opened on the vaginal posterior wall. Accordingly rectovestibular fistula was diagnosed. At surgery only excision of the prolapsed rectal mucosa was performed. The histopathological diagnosis was tubular adenoma showing mild atypia.
Imperforate anus generally requires surgical therapy in newborn babies, but it is rarely held intact until adulthood. This is an extremely rare case of imperforate anus (rectovestibular fistula) presented with mucosal prolapse after an 84-year asymptomatic period. In the case of anorectal anomaly held until the patient's adulthood, surgical therapy might be sometimes unnecessary if he or she does not have symptoms which disturb his or her daily activities.

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This paper deals with a patient with sigmoid colon cancer who was diagnosed as having acquired von Willebrand (vW) disease preoperatively and whose hemostatic management was successfully attained by intra-and postoperative administration of a factor VIII consentrate including the factor vW (Confact F^®).
The patient was a 78-year-old man who had been suggested to have vW disease following examina-tions for abnormal bleeding at prostatectomy performed at the age of 67. In July 2003, the patient, complaining of anal bleeding, was found having sigmoid colon cancer at another hospital and was referred to the hospital. Preoperative infusion test of coagulation factor suggested a short half life period of vW factor activity, and thus acquired vW disease was diagnosed. In order to maintain the ristocetin cofactor (RCo) activity at more than 40% during and after the operation, sustained administration of Confact F was carried out until the 12^th hospital day. The factor VIII coagulation activity as well as RCo activity was favorably maintained, resulting in good hemostatic management.
This is the second case report on surgical management of acquired vW disease under general anesthesia in Japan. Some bibliographical comments are also presented here.

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The patient was a 57-year-old male, who was found to have occult blood in his stool and was diagnosed as having cancer of rectum (Rb: 1/5 circumference, Type II), in Oct. 2003. The clinical stage was in stage I; MP, N(-), PO, HO, M(-). Low anterior resection (central D2, lateral D3) was performed on Jan. 2004. A submucosal tumor of 4mm in size was found in the anal side of the main tumor after resection and fixation of the specimen. The pathological diagnosis of this small tumor was carcinoid tumor. A metastatic carcinoid tumor was also found in para-rectal lymphnode (251) but no lymphnode metastasis of the adenocarcinoma was present. The pathological stage of the main cancer was in Stage I; mp, n(-) P0, H0, M(-), ly1, v2. Grimelius staining was positive in carcinoid tumor, both in original and metastatic tumor. We report this case with some review of the literatures.

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Perianal Paget's disease is identified to have two types by the origin of cancer cells. Paget's disease originated from the skin gland is known as non-invasive carcinoma and has a good prognosis. On the other hand, the one originated from the anal canal adenocarcinoma is known as invasive carcinoma and has a poor prognosis. Accordingly making differentiation between these two types is clinically important, but occasionally difficult with hematoxylin-eosin (H-E) stain. In such cases, immunohistochemical study is very useful. Gross cystic disease fluid protein 15 (GCDFP15) stain is positive only for carcinoma originated from the skin gland, and cytokeratin 20 (CK20) stain is positive only for adenocarcinoma originated from the anal canal mucosa. In our two cases, we suspected of Paget's disease derived from the skin gland judging by the specimens with H-E stain, but the immunohistochemical stains showed positive for CK20 and negative for GCDFP15. We finally diagnosed the case as anal canal adenocarcinoma with Pagetoid spread. Although most cases of anal canal cancer with Pagetoid spread are of advanced cancer as the primary lesion, our cases are of carcinoma in situ.

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We report a rare case of delayed hepatic rupture after a blunt hepatic trauma.
A 46-year-old woman fell down during bicycle entrainment, landing on her left flank. She had no medical examination on this occasion. Two months after the accident, she was admitted to the hospital because of the sudden onset of upper abdominal pain. On admission, she remained stable hemodynamically with tenderness in the left upper quadrant of the abdomen. Abdominal CT scan revealed a low density lesion 7cm in diameter in the left latelal segment. Thereafter, her abdominal findings improved. But, 7 days after admission she complained of abdominal pain. Abdominal CT scan during arteriography revealed ascites around the tumor. Close exploration revealed a ruptured tumor in the left lateral segment of the liver. Left lateral segmentectomy was performed. She recovered without complications. Pathological findings revealed hepatic injury and no tumor cells were found. We diagnosed the case as delayed hepatic rupture due to re-bleeding from the blunt hepatic injury sustained 2 months before admission.

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A 67-year-old man was referred to the hospital with a diagnosis of carcinoma of the duodenal papilla. He had been medicated for hyperammonemia resulting from enormous intrahepatic portsystemic shunt. Considered a possible risk of deterioration of hyperammonemia, we tried transcatheter embolization using an interlocking detachable coil. Serum ammonia decreased within a normal limit on the next day, and we performed a pancreatoduodenectoy. The patient's postoperative course was uneventful.
In the case of portsystemic shunt in which invasive surgery is scheduled like in this case, preoperative embolization is recommended.

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A 48-year old woman underwent a modified radical mastectomy for right breast cancer in November 2002. Pathological diagnosis was papillo-tubular carcinoma, T2, N0, M0, Stage IIA, ER(-), PgR(-), Hercep Test 3(+)). In April 2004, in spite of normal levels of the other tumor markers, an abnormally high level of serum HER-2/neu protein was noted, and abdominal CT scan revealed two metastasized lesions in the lateral segment of the liver. In July 2004, we performed lateral segmentectomy of the liver for hepatic metastases of breast cancer. Trastuzumab and Docetaxel were administered for post-operative adjuvant therapy. Relapse sign was not seen during the follow-up of one year. In HER-2 positive breast cancer, serum HER-2/neu protein has a high sensitivity and specificity compared with other tumor markers and has ability to detect post-operative local recurrence and to forecast therapeutic effect of Trastuzumab. Hepatectomy for liver metastasis from breast cancer is limited in efficacy, so postoperative adjuvant therapy using Trastuzumab is recommended when serum HER-2/neu protein level is high.

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Lymph node metastasis from small hepatocellular carcinoma is rare. A 66-year-old woman was followed up as an outpatient at previous hospital since 1999 for chronic hepatitis C. On November 2002, she was detected having two masses of the liver 1.8cm and 1.5cm each in diameter and solitary mass around common hepatic artery 4.2cm in diameter at medical check up. The tumors were located at left lateral segment of the liver. The patient was referred to our hospital for surgical treatment. In preoperative examination, another liver mass was detected in lateral segment. In addition to the liver mass, she had an early gastric cancer. We performed partial liver resection for two HCC, microwave coagulaton therapy for dysplastic liver tumor, resection of the lymph node around the common hepatic artery, and partial gastrectomy. One of the resected liver tumors was poorly differentiated hepatocellur carcinoma, and the other was moderately differentiated hepatocellular carcinoma. The swelling lymph node was involved with poorly differentiated hapatocellular carcinoma. One year and 6 months after operation, the patient in well, and there is no evidence of recurrence.

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An 84-year-old woman was admitted to the hospital because of right upper quadrant abdominal pain and jaundice. Abdominal CT scan, MRCP, and US detected the dilated gallbladder with multiple stones and bile duct obstruction of unknown origin. During endoscopy for ERCP, a coexisting duodenal ulcer was perforated that demanded emergency surgery. Following operative packing for the perforation with the omentum, an inspection proved that bile duct stones caused bile duct obstruction. After cholecys-tectomy and removal of bile duct stones intraoperative cholangiography showed bile leak from a hole of the gallbladder liver bed. It was diagnosed as injury of Luschka duct (one of aberrant biliary ducts) after further examinations. Closure of the hole resulted in the patient's uneventful postoperative cource.

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We present a case of resected serous cystadenoma of the pancreas inducing marked dilatation of the main distal pancreatic duct.
An 80-year-old woman was admitted to the hospital because of upper abdominal pain and a low grade fever. Examination of the blood disclosed elevations in transaminase, total birilubin and CRP. An abdominal CT scan disclosed the group of small cysts with partial calcification at the pancreatic head and dilatation of the main peripheral pancreatic duct. Remarkable stenosis of the proximal main pancreatic duct and dilatation of the main peripheral pancreatic duct were demonstrated on endoscopic retrograde cholangio-pancreatography (ERCP) and magnetic resonance cholangio-pancreatography (MRCP). The patient underwent medial pancreatectomy under the diagnosis of serous cystadenoma of the pancreas. Postoperative course of the patient was uneventful excellent without showing impaired glucose tolerance. The patient was discharged from the hospital on 22nd day after the surgery.

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A 58-year-old man was incidentally found to have a cystic tumor in the tail of pancreas by abdominal ultrasonography on a medical checkup. The patient had had upper abdominal discomfort 4 years before, when no abnormality was found by abdominal CT scan. After admission to the hospital, contrasted CT scan revealed a tumor measuring 4.5cm in diameter with slight ring-enhancement in the tail of pancreas. Abdominal angiography showed irregularity of the splenic artery and hypervascularity at the capsule of the tumor. In addition to these findings, serum CA19-9 level was remarkably elevated. The tumor was diagnosed as cystic tumor of the pancreas with malignant potential. A distal pancreatectomy with a splenectomy was performed subsequently. Macroscopically, the tumor was capsulated by thick wall and contained keratinizing substances. Microscopically, the cyst wall was lined by stratified squamous epithelium with abundant lymphoid tissue. These pathological findings were compatible with the diagnosis of lymphoepithelial cyst of the pancreas. In the present case, the tumor enlarged in a relatively short period of 4 years with remarkable elevation of serum CA19-9 level and several radiological findings indicating a malignant disease.
Although lymphoepithelial cyst of the pancreas is a rare benign disease, it is desirable to resect the tumor in cases in which the differentiation between the disease and malignant pancreatic cystic neoplasm is difficult from clinical and radiological findings.

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An 82-year-old woman was admitted to our hospital because of sudden onset of abdominal pain. Abdominal CT scan showed edematous convergence of the mesentery and small intestine loops deviated the uterus to the left side in pelvic space. We thus diagnosed broad ligament hernia, and performed an emergency operation. At laparotomy, ileum was herniated through an abnormal defect in the right broad ligament. Round ligament was cut and the incarceration was reduced. The necrotic portion of ileum was resected. In addition, a similar abnormal defect was observed in the left broad ligament. Left round ligament was cut and the abnormal defect was opened. The patient had an uneventful postoperative course and was discharged from our hospital on 15^th postoperative day. Hernia of broad ligament of uterus which have abnormal defects bilaterally is very rare, and we report our case with some literature review.

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It is relatively rare that colon cancer metastasizes to the ovary. We have experienced a case of ovarian metastasis after curative resection of colon cancer.
A 46-year-old premenopausal woman underwent a right hemicolectomy for moderately differentiated adenocarcinoma se, 1y2, v0 and n(-). The 5-FU (500mg/week)/levofolinate (250mg/week) therapy was conducted three times for a 6-week course since 3 weeks after the surgey and then oral 5-FU (150mg/day) was maintained. Seventeen months after the first surgery, a right ovarian tumor and myoma uteri were found and bilateral oophorectomy and hysterectomy were performed under a histological dignosis of right ovarian metastasis from colonic cancer. Histopathologically the ovarian tumor was well or moderately differentiated adenocarcinoma, but immunohistochemical analysis for cytokeratin 7/20 resulted in 7(-) 20(+) for the ovarian tumor. She received chemotherapy with oral S-1 (80mg/day) daily following CPT-11 (100mg/week) intravenously for 3 weeks. At present, she remains disease-free 14 months after the ovarian surgery.

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A 51-years-old woman received an examination complaining of the right abdominal pain. Abdomi-nal computed tomography showed a homogeneous, non-enhanced cystic tumor of about 10cm in diameter in the ileo-cecal mesentery. Colonoscopic study did not reveal mucosal lesion, nor luminal compression from outside. Angiography showed non-vascular area of the ileo-cecum. An operation was performed under the diagnosis of mesenteric lymphangioma. In operative findings, the tumor was 9×8×7cm in size and existed in the ileo-cecal mesentery. We performed ileo-cecal resection including 100cm of ileum, because the tumor had severe adhesion to the ileal wall. The resected specimen had multi-cystic lesion in part and contained green mucinous fluid. The histopathological diagnosis was mucinous cystadenoma. ER, PgR, and CA125 staining was positive that suggested the tomor originated from the female reproductive organ, such as ectopic ovarian tissue or secondary Mullerian system. We report a rare case of mucinous cystadenoma originated from ileo-cecal mesentery with a review of the literatures.

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A 20-year-old man was admitted to our hospital suffering from abdominal pain, diarrhea, and vomiting. On admission, he looked pale and the epigastrium was tender on pressure. Laboratory tests revealed leucocytosis and anemia. The abdomen of the patient gradually distended after admission. Abdominal CT showed a large amount of intraperitoneal fluid, and a high density mass between the greater curvature of the stomach and the spleen. An emergency operation was carried out 4 hours after admission under the diagnosis of hemoperitoneum. After removing 2, 400ml of hemorrhagic ascites, a hematoma measuring 5×4×4cm was found lying in the greater omentum adjacent to the greater curvature of the stomach. Partial omentectomy including the hematoma and partial gastrectomy were performed. The patient had an uneventful postoperative recovery, and he was discharged from the hospital on the 13^th postoperative day. Histopathological examination of the resected specimen revealed hematoma surrounded by collagenous granulation tissue, and no tumor or vascular lesion was detected. The patient had no history of trauma, anticoagulant therapy or vascular disease, so he was diagnosed as idiopathic omental hemorrhage.

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A 71-year-old man, who had been followed in the clinic after total gastrectomy for gastric cancer, was found to have a 12×6×8cm multilocular cystic lesion with a partial calcification in the pelvis by an abdominal CT scan in July 2004. Retroperitoneal lymphangioma was suspected and the tumor was excised on October 6. The tumor was present in the retroperitoneum, which was multilocular with a thick capsule and was strongly adherent to the urinary bladder, seminal vesicle, and left seminal duct. The section was composed from both cystic and solid parts, and the cystic liquid was slightly bloody. Histopathological diagnosis was benign schwannoma involving Antoni type A and B concomitantly. In addition a great number of sperms were identified in the cystic liquid so that the communication between the seminal vesicle and seminal duct was suspected. There have been no signs of recurrence as of 6 months after the operation.

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We report a case of a pseudocyst of the retroperitoneum.
A 47-year-old woman was admitted to the hospital for the treatment of a palpable upper abdominal mass. Abdominal ultrasonography and CT scan revealed a unilocular cyst about 10cm in diameter below the left kidney. The preoperative diagnosis was a cyst of the mesentery, and a cystectomy was performed. The 12×9×10cm cyst with a yellowish white capsule was originated from the retroperitoneum. The surface of the 12-cm diameter cyst was white and smooth. The cyst contained a serous yellowish fluid. Microscopically, the wall of the cyst was composed of thick, fibrous tissue, lacking an epithelial lining. Pseudocyst of the retroperitoneum was definitely diagnosed.
Pseudocysts of the retroperitoneum are rare, and there have been only ten reports including ours in Japan.

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