The purpose of this study was to evaluate the therapeutic efficacy and safety of docetaxel monotherapy (DOC) for patients with advanced breast cancer. We enrolled seven patients with locally advanced breast cancer and 12 patients with metastatic advanced breast cancer, who received the primary chemotherapy with DOC from October 1999 to April 2004. DOC was prescribed at a dose of 60mg/m² every 3 weeks. The response rate was 89% (17/19), including 16% (3/19) of complete responses. The prescribing number of DOC (median) until more than 50% decrease in the tumor mass could be achieved was once. As for the adverse event of grade 3, only leucocytopenia (21%) was noted. The effectiveness of the primary chemotherapy with DOC for advanced breast cancer was suggested.

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We analyzed cases after resection of metastatic lung tumors at our hospital during the last ten years. A total of 179 subjects underwent lung resection between January 1995 and December 2004. Clinical features of the cases in each primary organ and the factors which affected survival were analyzed. The disease-free interval was longer in cases of thyroid cancer, malignant melanoma and renal cancer. Lung tumors were found in one lung of 140 cases and in both lungs of 39 cases. In cases of germ cell tumor, thyroid cancer and bone-soft tissue tumor, there were many examples of both lung metastases. As for lung excision frequency, lung resection was done two or more times in tumors with a bone and soft tissue origin. The overall 5-year survival rate since lung resection was 47%. The size of lesions, number of resected tumors, distant metastases to other organs, non-complete excision and postoperative chemotherapy were considered as factors impacting survival in all cases of metastatic lung tumors.

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In patients with unresectable pancreatic or biliary cancer, we assessed procedures for giving disease information and obtaining informed consent, along with detecting problems involved. Such informed consent procedures utilized in Japan encourage active engagement of patient's family members as well as patients themselves. Subjects were 89 patients with pancreatic or biliary cancer to whom the author (S.S) gave disease information over the past 7 years. At first, the author told family members of these patients the importance of accurate notification of the patient's disease and requested them to provide adequate support for the patients. As a result, 73 patients (82%) and 41 patients (46%) were informed about their current diseases and expected prognosis, respectively. Patients recovered relatively early from a depressive state after receiving disease information; however, the recovery was prone to be delayed if the patient's family members were reluctant to engage in informed consent procedures or there was nobody to play an important role in the care of the patient after providing disease information. In Japan, patients have little sense of decision-making for selecting their treatment or other options, and thus need to be supported by their family members even when they make a decision for themselves. In addition, the concept of respecting the intention of the patient as well as the principles of the personal information protection law should be disseminated to the general public.

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A clinical investigation was made on cases of surgical wound infection following surgery for inguinal hernia. In our hospital we have employed Mesh Plug method (MP) under local anesthesia as the first choice for inguinal hernia repair, and performed MP in a total of 1310 cases up to now. These 1310 cases were enrolled in this clinical study. Postoperative infection was noted in six (0.46%) cases, in two of which removal of the prosthesis was required. A significantly higher frequency of infection was noted in cases where surgery was performed for bilateral inguinal hernias simultaneously (p<0.001). The two cases required the removal of the prosthesis were of delayed onset of infection, in which conservative therapy for a very long time was performed until the removal. On the other hand, in the remaining four cases demanding no removal, infection occurred relatively early after the surgery and the period from the onset of the infection up to improvement of the surgical wound was less than 30 days. From these findings, we consider that the removal of the prosthesis may be required in cases in which no signs of improvement are shown by conservative therapy within 30 days or in cases of delayed onset of infection. Further the prevention of postoperative infection may become a serious problem in cases undergoing simultaneous operation for bilateral lesions.

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We report a case of a 41-year-old woman with granulomatous mastitis and erythema nodosum. An elastic hard painful mass 3.8cm in diameter was palpable at the C area of the right breast. Ultrasound examination revealed an irregular hypo-echoic mass and mammography showed an asymmetric shadow. Fine needle aspiration biopsy showed only inflammatory changes without malignancy. A possibility of malignancy could not be ruled out, so excisional biopsies were performed. The pathologic diagnosis was granulomatous mastitis. After a month, she presented erythematous nodules of the leg. She was treated with oral predonisolone, 10mg/day, followed by tapering of the dose. The skin lesions rapidly disappeared. The breast lesion then gradually improved and almost disappeared by four months after the start of treatment. To our knowledge, 6 cases of granulomatous mastitis with erythema nodosum have been reported in the literature, and this is the second report of granulomatous mastitis with erythema nodosum in Japan.

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An invasive cribriform breast cancer (ICC) that has a favorable prognosis was first described by Page et al. in 1983. We herein report a case of ICC, including the clinicopathological features. A 48-year-old Japanese woman visited our hospital, complaining of a lump after long-term observation. The tumor was located in the upper area of the right breast. It was 5cm in size, irregular shaped, elastically firm, accompanied by a dimple and fixation to the muscle was recognized. As its malignancy was suggested by ultrasound, computed tomography and magnetic resonance imaging, a core needle biopsy was performed twice. However, we could not reach the final pathological diagnosis. In 2003, radical mastectomy was performed and we finally obtained a pathological diagnosis of ICC (mixed type). The patient is now being followed up at an out-patient clinic without signs of recurrence. It was thought that ICC was slow-growing and ICC might have stratified to an entity that made pre-operative diagnosis by CNB not feasible.

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We report two cases of descending mediastinitis. Case 1 was a 58-year-old woman. The inflammation due to a hypopharyngeal abscess spreading continuously from the cervical region to the mediastinum. CT also revealed a low density area with gas formation continuing from the cervical region into the mediastinal level of 4cm under the tracheal bifurcation. Descending necrotizing mediastinitis was diagnosed. The patient was cured by cervical and mediastinoscopic drainage. Case 2 was a 78-year-old man. At Neck and chest MRI demonstrated high intensity continuously from the neck to the mediastinum on T2-weighted image. Necrotizing mediastinitis was diagnosed. However, mediastinoscopy revealed the presence of only mediastinal inflammation and no abscess. The patient was cured by drainage of the cervical abscess.
The diagnosis of descending necrotizing mediastinitis should be made not only by the high intensity on T2-weighted MRI, but also by the presence of a gas shadow or niveau formed by anaerobic organisms on chest CT. Furthermore, cervical mediastinoscopy is useful for the drainage of a mediastinal abscess presenting under the tracheal bifurcation.

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A 75-year-old man complaining of intermittent claudication was found to have an abdominal aortic aneurysm by magnetic resonance imaging scan at another hospital, and was referred to the hospital for further exploration. Abdominal CT scan showed an abdominal aortic aneurysm 5.5cm in the maximum diameter, extending from a portion under the renal artery to bilateral iliac arteries. In addition the right common iliac artery, internal and external iliac arteries were occluded and a stenosis of the left external iliac artery was also present. Aortography which was performed when coronary arteriography was done also present. Aortography which was performed when coronary arteriography was done about one month after the abdominal CT scan revealed that the abdominal aortic aneurysm under the bifurcation of the renal artery was completely occluded, and the bilateral common femoral arteries were visualized via collateral circulation. From these examinations, abdominal aortic aneurysm associated with thromboembolism was diagnosed, and replacement with a Y-shaped artificial vessel was performed. The postoperative course was mostly uneventful, and the patient was discharged from the hospital on the 16^th postoperative day.

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We recently encountered a case of small aorta syndrome (SAS) associated with occlusion of the lower part of the abdominal aorta. The patient was a 57-year-old woman with a chief complaint of intermittent claudication. Abdominal computed tomography (CT) showed that the aorta measured 12mm in diameter just below the branch point of the inferior mesenteric artery, and there was no calcification suggestive of arteriosclerosis. The aorta/lumbar ratio was 24%. Magnetic resonance angiography (MRA) of the abdominal aorta showed complete occlusion distally from the branch point of the inferior mesenteric artery to the bilateral common iliac arteries, with distal flow through collateral vesseis. The patient was diagnosed with occlusion of the abdominal aorta due to SAS. Vascular reconstruction was performed with a 14×7mm knitted Dacron graft. The postoperative course has been satisfactory, but because of the low rate of bypass patency in SAS, careful long-term follow-up will be necessary.

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A 58-year-old man with a 98-mm abdominal aortic aneurysm and crossed-fused ectopia of the kidney is reported. Preoperative enhanced CT and 3D-CT revealed the absence of the right kidney, and crossed-fused ectopia of the kidney was located on the left side of the aortic aneurysm. There was apparently no accessory artery to the lower part of the left kidney from the aneurysm. Intravenous pyelography showed the crossed ureter from the lower renal pelvis. Fortunately, the patient underwent elective repair of the aortic and right common iliac aneurysm without aberrant renal artery reconstruction. The postoperative course was entirely uncomplicated, and the patient was discharged on the 15th postoperative day.

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We report the case of a 59-year-old woman who underwent conserving surgery for the left breast, and received chemotherapy and radiation therapy to the remainning part of the left breast. About five months after the termination of irradiation, cough and fever developed. Chest radiography and computed tomography showed an infiltrative shadow in the left lung. Various antibiotic therapies were performed but the laboratory data and radiographs showed detenoration. We clinically diagnosed this case as having Bronchiolitis Obliterans Organizing Pneumonia (BOOP) syndrome after radiation therapy. Corticosteroid treatment resulted in rapid clinical improvement. Thereafter, oral predonisolone was administered and gradually decreased. Nevertheless, new infiltrative shadows developed in the right lung. An increased dose of predonisolone resulted in rapid improvement of the clinical symptoms and chest radiograph abnormalities. Although the etiology of BOOP syndrome is unknown, it is important to remember that the BOOP syndrome may occur as a complication of breast-conserving therapy.

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The patient was an 80-year-old man who underwent the resection for right lung cancer 7 years after a thoracotomy for right pneumothorax. The patient started to complain of dyspnea on the 4^th day after the resection. Findings of interstitial infiltration appeared on CXP and chest CT scan. Steroid pulse therapy was initiated on the 14^th postoperative day. Although the patient's dyspnea was relieved, contralateral pneumothorax developed on the 33^rd postoperative day. A thoracic drain was immediately inserted, and then air leakage ceased on the 53^rd postoperative day. The patient was discharged from the hospital on the 90^th postoperative day. As of about one year after the resection for lung cancer, the patient has been doing well without relapse of pneumothorax and lung cancer, while he has been receiving oxygen therapy at home.

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The prognosis for p-stage IV a thymic cancer (squamous cell carcinoma) is generally poor. We report a case of p-Stage IV a thymic cancer with long survival of more than 6 years. He underwent reduction surgery for the main tumor, disseminated tumors in the left pleural cavity, mediastinal lymph nodes, and lung and vein with direct invasion from tumor, followed by systemic chemotherapy for the residual tumors. Although he once achieved complete remission, the tumors redeveloped in the left pleural cavity and at the left axillary lymph nodes about 3 years after the first operation. He recieved chemotherapy, and showed a good response, with disappearance of axillary lymph nodes and reduction of pleural tumors. After this chemotherapy, he has continued systemic chemotherapy with Irinotecan+ CDDP+UFT regimen on an outpatient basis, and showed no more significant growth and no systemic metastasis.
FDG-PET (/CT) is also suggested to be a significant tool for the diagnosis of thymic cancer, distant metastasis, and clinical stage.

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A 55-year-old female presented in end-stage renal failure. She developed dyspnea soon after starting a program of continuous ambulatory peritoneal dialysis (CAPD) in April 2004. Chest X-ray showed a right-side massive pleural effusion. We diagnosed pleuroperitoneal communication, because the glucose concentration of pleural effusion was higher than blood glucose. We performed video assisted thoracoscopic surgery. Using indigocarmine containing peritoneal dialysis fluid through a CAPD catheter, we found a fistula on the diaphragm from which blue dialysis solution flowed out like a fountain. The defect of the diaphragm was directly closed and covered using polyglycolic acid felt and fibrin glue. She could restart CAPD at 7 days postoperation, and no recurrence of hydrothorax has been detected for a year after the surgical treatment.

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We experienced a very rare case of traumatic direct diaphragmatic hernia without pneumothorax, A 68-year-old woman was injured the left chest and flank by a brad of a sickle and then transferred to our hospital as an emergency case. The examinations showed that the left chest and flank were injured, but no pneumothorax had occurred although the stomach escaped through the intercostal space in the left chest. Emergency operation was performed with a diagnosis of open injury of the left chest and traumatic direct diaphragmatic hernia with escape of the stomach. Intraoperative findings showed traumatic diaphragmatic hernia with the stomach penetrating through the intercostal space, but either lung injury or pneumothorax was absent. The patient recovered without any complications after the operation. This case was considered very rare in lacking pneumothorax despite traumatic direct diaphragmatic hernia with such a huge open injury of the chest wall as the stomach had ruptured through the intercostal space. We report the case with a review of the literature.

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We report a case of multiple gastric carcinoids associated with type A gastritis and hypergas-trinemia. Multiple tumors, measuring 5 to 10mm, were observed on the upper and middle stomach in a background of atrophic mucosa. These tumors were histologically diagnosed as gastric carcinoids based on total biopsy samples obtained by endoscopic mucosal resection. Our patient showed gastric parietal cell antibody positive, achorhydria and secondary hypergastrinemia. These findings showed that he was diagnosed as multiple gastric carcinoids associated with type A gastritis. We treated the patient by distal partial gastrectomy in order to downregulate serum gastrin, which can stimulate enterochromaffin-like cells and induce endocrine cell micronests and carcinoid tumors. Therapeutic effects of the operation were that 12 hours later normogastrinemia was acquired, 6 months later the tumors remaining on the remnant stomach had disappeared, and for 3 years no relapsed tumors were found clinically. We speculate that not major surgery such as total gastrectomy but minimally invasive surgery such as distal partial gastrectomy may have enough therapeutic effects against multiple gastric carcinoids associated with type A gastritis.

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Adachi classified branches from the celiac axis into six types. In Adachi type VI, we could not reveal common hepatic artery (CHA) in the superior edge of the pancreas. During surgery for gastric cancer we usually dissect No.8a lymph node by exposing CHA but this procedure is impossible in cases of Adachi type VI.
In usual cases we take preoperative multidetector-row computed tomography and 3D-angiography to understand the vascular anatomy precisely. By these radiological examinations, we could make preoperative diagnosis with Adachi type VI vascular anomaly in five patients and could perform gastrectomy without any trouble. We consider that a preoperative understanding of the precise vascular anatomy is important to perform surgery safely, and that multidetectorrow computed tomography and 3D-angiography are very useful for this purpose and for diagnosing vascular anomaly prior to surgery.

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A 73-year-old man complaining of right hypochondralgia and fever was pointed out having jaundice at another hospital and was referred to the hospital for further exploration. On admission he had a temperature of 39°C with chill and trepidation and severe yellow stain was noted in the bulbar conjunctiva. Laboratory data on admission included T-Bil level of 6.2mg/dl showing jaundice, and increased levels of ALP, γ-GTP, AST, ALT, LDH, WBC, and CRP. We considered that the pathologic condition in this case might be caused by impaired excretion of bile juice due to para-papillary diverticulum which was induced by eating meals, and diagnosed the case as Lemmel syndrome. We determined that the patient was a candidate for surgery and performed it on June 13. During surgery cholecystectomy and papilloplasty were performed by using Kocher's procedure. The pyloric ring was preserved, the duodenum was resected at the bulb, a Roux-en-Y reconstruction was made in the jejunum about 20cm distal to the Treitz' ligament, pyloroplasty being carried out. After the operation, the patient developed ulcer at the anastomosis, but it was conservatively treated. The patient was discharged from the hospital.
Since Lemmel syndrome is not malignant, we must select a surgical procedure after consideration of postoperative QOL for the patient.

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A case of papilla of Vater cancer with separated orifices of common bile duct and main pancreatic duct is reported. The patient was a 67-year-old female. She consulted the hospital with severe abdominal pain and nausea. Because of increase in neutrophils and serum pancreatic enzymes, and swelling of the pancreas revealed by ultrasonography and computed tomography, we diagnosed the case as acute pancreatitis. We found separated orifices of the common bile duct and main pancreatic duct during the procedure of ERCP, and we also detected the proliferation of mucosa on the papillae. Papillary adenocarcinoma as diagnosed by histological examination of a biopsy specimen. Pyrolus-preserving pancreatico-duodenectomy was performed. A tumor was localized in the mucosa of papilla Vater and completely resected. Separated orifices are one of the variations and there are few problems in clinical cases because there are no symptoms. In this case, we derected the problem in the course of treating pancreatitis due to papilla of Vater cancer.

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This paper deals with two cases of anisakiasis of the small intestine, which is rare, causing strangulated ileus in which emergency surgery was performed.
Patient 1, a 37-year-old woman, was seen at the hospital because of epigastralgia and vomiting. Patient 2, a 57-year-old man, was seen at the hospital because of lower abdominal pain. Both patients were suspected to have strangulated ileus by abdominal CT scan and underwent emergency surgery. During surgery for the patient 1, we saw an induration with inflammation in the ileal wall which was adherent to the greater omentum to form a band, through where the small intestine herniated to be strangulated. In the patient 2, the ileum herniated through a band, which had been formed due to adhesions after an operation for appendicitis, and was strangulated there; an induration was found at part of the herniated ileal wall which had caused the herniation. Postoperative pathological studies disclosed larvae of family of Anisakidae in the indurations in both patients. Strangulated ileus caused by anisakiasis of the small intestine was definitely diagnosed.

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We report a case of endometriosis of the ileum, a comparatively rare disorder. The patient was a 40-year-old female, who was seen at an another hospital with a complaint of abdominal pain. She was referred to our department because her symptom did not improve. Because contrasting with the ileus tube showed a constriction in and around the terminal ileum, we performed an operation. Laparoscope revealed two places with a narrow segment in the terminal ileum under observation. We performed ileectomy using a small laparotomy. The diagnosis was endometriosis of the ileum based on the histopathology. In a mature woman with no history of laparatomy, we found it necessary to consider this as a case for differential diagnosis.

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Recently methotrexate (MTX) has been increasingly administered to patients with rheumatoid arthritis (RA) in its early phase. However, some of these patients have been reported to develop MTX-related lymphocytic disorder (MTX-LPD). This paper deals with a case of ileal perforation caused by a malignant lymphoma which developed during treatment with MTX for RA.
A 63-year-old man had developed RA in 1976, and then administration of MTX was started in September 2000. Late in December of 2005, he was seen at the emergency clinic in our hospital because of abdominal pain. Abdominal CT scan showed free air in the abdominal cavity. An emergency operation was performed with a diagnosis of panperitonitis caused by intestinal perforation. During surgery an edematous change and a perforation were identified in the ileum, so that an ileocecal resection was performed. The histopathological diagnosis was malignant lymphoma, diffuse large B cell type, associated with epstein-barr virus R1 (EBER1).
Improvement can be expected by withdrawal of MTX in some cases of MTX-LPD. There have been no signs of recurrence in this case as well, as of 6 months after the postoperative withdrawal of MTX.

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A 79-year-old woman, who had previous histories of ovarian adhesion and appendectomy at the age of 20, was seen at the hospital because of lower abdominal pain and vomiting after a supper. There were abdominal distention and tenderness mainly in the lower abdomen. Based on abdominal CT findings, strangulated ileus associated with an intra-abdominal tumor in the right lower abdomen was diagnosed, and an emergency surgery was performed on the same day. Surgical findings included that the small intestine was twisted and strangulated at the adhesion between the mesentery of small intestine and the tumor as the base. Histopathologically the tumor was intra-abdominal foreign-body granuloma due to gauze.
Although it is believed that ultrasonography, CT and magnetic resonance imaging are useful for making the diagnosis of foreign-body granuloma, sometimes we have difficulties in making the diagnosis because few cases present typical imaging findings. In addition we must be careful that the disease is asymptomatic in some cases, and can rarely cause septicemia, ileus, and intestinal perforation. In this case, foreign-body granuloma presented with strangulated ileus after a lapse of 59 years following surgery. This case, which recorded the longest interval from surgery to the onset of the disease in Japan as far as we could review, is reported here together with some bibliographical comments.

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We report a case of intrapelvic gastrointestinal stromal tumor (GIST) of the small intestine with a 540° small intestinal volvulus. To our knowledge, this is the first reported case in the literature of intrapelvic GIST of the small intestine with volvulus.
A 79-year-old woman complaining of right lower abdominal pain was admitted to Hokkaido Prefecture Esashi Hospital. She was found to have an intrapelvic tumor about 10cm in diameter and a spiral intestine by abdominal enhanced computed tomography (CT). The intrapelvic tumor was first suspected to be a gynecologic tumor, and she was diagnosed as volvulus of the small intestine and the greater omentum. However, the intrapelvic tumor had been enhanced by superior mesenteric artery (SMA) angiography and was then diagnosed as an intestinal tumor.
At laparotomy, we found the 540° small intestinal volvulus. The intestine did not show necrotic changes and adhesions, and was easily moved to the normal position. The intrapelvic tumor measured was 14-10cm, and was located in the ileum 100cm from the end of Bauhin's valve. Partial resection of the small intestine involving the tumor was carried out. Postoperative pathological diagnosis was GIST of the small intestine. The immunohistochemical stainings of c-kit and CD34 were positive. Because she had no metastasis and had to undergo a radical operation, adjuvant chemotherapy such as STI571 was not performed. Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed no recurrence and no metastasis 4 months after the operation.

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A 48-year-old woman complaining of left lower abdominal pain was admitted to the hospital with a diagnosis of intestinal obstruction. Abdominal CT scan showed an irregular shaped tumor in the pelvis. Barium enema study, however, showed only extrinsic pressure to the sigmoid colon. The patient was operated on with the diagnosis of an intra-abdominal tumor on September 6, 2005. At surgery we saw an about 7-cm sized tumor in the small intestine invading the left pelvic peritoneum, and then performed partial excision of the small intestine. Peritoneal dissemination was also seen in the right subdiaphrag-matic space. In 3 weeks after the operation the patient experienced rapidly aggravating pleural metastasis, pleural effusion, hepatic metastasis, and peritoneal dissemination. The pathological diagnosis was small cell carcinoma of small intestine. Then CDDP (60mg/m²)+CPT-11 (60mg/m²) regimen was started on October 4. When 2 courses of the regimen were completed, a reduction of the tumor and improvement of general condition were observed. However, the regimen had to be withdrawn after the completion of 4th course because she had influenza, when the tumor mass abruptly started to enlarge. The patient died on February 27, 2006.
Since a possibility that CDDP+CPT-11 regimen might contribute to life prolongation for patients with small cell carcinoma of small intestine is suggested, we report this case together with some bibliographical comments.

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We report a case of a true enterolith containing dental implant developed in the cecum. An 81-year-old man was admitted to the hospital for midline incisional hernia. During laparotomy, seven enteroliths were found in the cecum and dilated loops of proximal ileum. Infrared analysis and cross section of the stones revealed all enteroliths containing bile acid. One stone contained a dental implant as its core. We concluded this enterolith was primary enterolith due to the dental implant and enterostasis.
True enterolith is relatively rare. So far 43 cases, including our case, have been reported in Japan. In addition, this is the 2nd case report of true enterolith containing foreign materials in Japan. The side-to-side anastomosis created by a previous operation for appendicitis provided a static environment for the formation of enteroliths in the cecum.

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A 69-year-old man was admitted to our hospital complaining of a right inguinal swelling. Inguinal hernia repair was performed, when ascites was noted. Postoperative abdominal CT showed a retroperitoneal mass containing gas, and a barium enema revealed perforation of the cecum. Under the diagnosis of abscess around the cecum, a right hemicolectomy was performed. Histopathological examination showed small atypical lymphocytes invading the muscularis propria. Immunohistochemical examination revealed that the lymphocytes were positive for anti-CD3, indicating a malignant T-cell lymphoma (diffuse small type). To our knowledge, 19 cases of T-cell lymphoma of the colon and rectum have been reported in the English and Japanese literature.

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A 73-year-old man was referred to our hospital for the evaluation of right lower abdominal pain. Computed tomography examination revealed a cystic mass with solid lesion in the appendix. We performed laparotomy under the preoperative diagnosis of appendiceal abscess. We found a primary appendiceal tumor with severe adhesions to the ileum, retroperitoneum and urinary bladder. We performed appendectomy and resection of the ileum. Histological examination revealed a poorly differentiated adenocarcinoma of the appendix and inflammatory adhesions. Computed tomography examination after 14 months revealed two masses of 4cm in diameter in the right lower abdomen. A right hemicolectomy involving dissection of D3 lymph node and two masses were performed, which were diagnosed as local recurrences. The patient has shown no further recurrence or metastasis for 62 months since the second operation.

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Intestinal injuries due to abdominal blunt trauma commonly present with acute onset of perforation, rupture, or bleeding, but rarely with delayed onset of intestinal stricture. This time we have experienced a case of an abdominal blunt trauma with delayed onset of colonic stricture, which is very rare.
A 77-year-old woman fell from a movable atair and then the stair dropped to her body when she sustained a strong bruise on the thoracicoabdominal region. She was brought into the hospital by ambulance. No findings of organic injuries and intestinal perforation were noted, conservative therapy was successful and the patient was discharged from the hospital on the 31^st day after injury. Thereafter she developed symptoms like intestinal obstruction on the 51^st day after injury and was admitted to the hospital again. Close exploration disclosed a severe narrowing of the transverse colon from the hepatic flexure. The patient was diagnosed as having the delayed onset of stricture of the large intestine and underwent laparotomy on the 69^th day after injury. During surgery, we saw that the right-side colon, mesentery, and greater omentum had formed a mass to be an inflammatory tumor in the right upper abdomen, and a severe stricture was present in the transverse colon. A partial resection of the transverse colon was performed. Histological study showed granulation in the entire layers of the intestinal wall and appearance of foreign body giant cells, so that the presence of penetration was suggested as well.
The possibility of the disease must be kept in mind in the treatment of cases of an abdominal trauma.

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Alpha-fetoprotein (AFP) is a reliable marker for the diagnosis and monitoring of primary hepatocellular carcinoma and yolk sac tumors. Elevated serum AFP levels have also been occasionally reported in patients with carcinoma of the gastro intestinal tract, such as of the stomach, pancreas, duodenum, colon, or rectum. Most of these diseases are of foregut origin, thus, AFP-producing colorectal carcinoma, which is of hindgut origin, is rare. We report a case of AFP-producing carcinoma originating in the sigmoid colon. A 58-year-old man was referred to us because of bloody stool and a sigmoid colon lesion diagnosed as carcinoma by barium enema and colonic fiberscopy. His serum AFP level was 873.8ng/ml upon admission. Abdominal computed tomography showed swollen intermediate nodules but no liver lesions. Sigmoid colon resection was performed. Histologic examination showed moderately differentiated adenocarcinoma, and immunohistochemical staining revealed AFP-producing cells. The serum AFP level rapidly decreased after surgery. The patient has been recurrence-free for 14 months.

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A 72-year-old woman was admitted to the hospital because of general fatigue and fever. She had multiple liver cysts which had been seen at another hospital for two years. Abdominal CT scan revealed multiple liver cysts and an enlarged large cyst containing two layers of fluid in the lateral segment of the liver. Ultrasonography revealed a layer of debris in the cyst. Because of unsuccessful antibiotics administration for her inflammation, percutaneous transhepatic drainage of the cyst guided by ultrasonography was carried out. The cyst contained 40ml of a yellow dark fluid in which no clusters for bacteria or fung were identified. Inflammatory findings were improved after drainage of the cyst. Cystography was unable to detect any communication between the cyst and the biliary tract. After drainage, two ethanol injections successfully reduced the fluid production of the cyst.
We report a rare case of a infected liver cyst which was successfully treated with percutaneous transhepatic drainage and ethanol injections.

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An 88-year-old woman visited our hospital due to upper abdominal pain, and abdominal CT showed common bile duct stones. We conducted ERCP successfully, though she had undergone gastrectomy with Billroth II reconstruction at 28 years of age and cholecystectomy at 76. According to choledochography, the common bile duct twisted due to adhesion of the past operations and several common bile duct stones about 1cm in diameter were observed. However, we could not remove the stones by endoscopic methods, so we inserted a biliary drainage tube in the common bile duct through the papilla of Vater. Cholangitis healed by this treatment. But after 1 month, the drainage tube fell off, and the cholangitis recurred, so we decided to operate. First, choledocholithotomy was performed, then, the afferent loop of the jejunum was cut off and moved up in front of the transverse colon. Finally, choledochojejunostomy was done by end-to-side anastomosis using one layer of interrupted suture of 4-0 Vicryl. It is necessary to operate for biliary drainage for primary common bile duct stone when the endoscopic method cannot be used. In this case, we could do choledochojejunostomy for common bile duct stones by using an afferent loop after gastrectomy with Billroth II reconstruction and cholecystectomy.

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Subhepatic duct and aberrant peripheral intrahepatic bile duct injuries have been reported as causes of bile leakage after laparoscopic cholecystectomies; thus, surgeons should avoid injuring these struc-tures. We report a Luschka duct that was recognized during a laparoscopic cholecystectomy (LC). A 61-year-old man underwent a LC for the treatment of cholecystlithiasis. After surgery, we detected a bile juice-like substance in the patient's drain after his anesthesia had worn off. Aeroperitoneum was re-established, but bile leakage from the cystic duct stump or the common bile duct was not detected; at this time, however, a Luschka duct was noticed. A clip was used to close the opening successfully. When performing LCs, the possible presence of aberrant divisional bile ducts like Luschka ducts, subhepatic ducts, or aberrant peripheral intrahepatic ducts must be kept in mind. Dissection should be performed at the plane closer to the gallhladder, and any string-like tissue should be clipped and cut.

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A 63-year-old man was admitted to our hospital because of abdominal pain. Abdominal CT scan showed gallbladder stones, common bile duct stones, and a slight swelling of the pancreatic body and tail. There were no peripapillary tumors. Gallstone pancreatitis was thus diagnosed. After amelioration of gallstone pancreatitis, cholecystectomy, and choledocholithotomy, and c-tube drainage were performed. Discharge from the C-tube drainage amounted to about 1000ml per day, which was light yellow in color. The value of amylase of the drained CBD bile via the C-tube was high, 68550IU/L. Intra-and postoperative cholangiography revealed no remnant stones and anormalous arrangement. We considered that there was pancreaticobiliary reflux without abnormal pancreaticobiriary ductal junction. The C-tube was removed on the 23rd day after the operation. The histopathological diagnosis was chronic cholecystitis.

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We report a case of obstructive jaundice due to delayed-onset bile duct stenosis after laparoscopic cholecystectomy responding to internal biliary drainage following PTCD.
A 42-year-old woman was seen at our hospital because of nausea and appetite loss about one month after laparoscopic cholecystectomy for cholelithiasis. The patient was admitted to the hospital because hyperbilirubinemia and liver dysfunction were noted. Abdominal magnetic resonance imaging scan showed a stenosis at the cystic ductal portion of the common bile duct, and then we performed PTCD and internal biliary drainage. An about one month later, the stenotic lesion showed a gradual relief and it was completely relieved about 4 months after the initial biliary drainage. Thereafter the patient has been recurrence free for about one year.
We speculated that the stenosis of the common bile duct in this patient might be caused by rather secondary sclerosing cholangitis due to the obstruction of the blood stream of bile duct wall or traumatic neurinoma of the bile duct than some bile duct injury or clipping at the operation.

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An 83-year-old man was admitted to the hospital for close exploration for a hepatic tumor which was found at a medical checkup. Abdominal ultrasonography (US) showed a 9-cm sized hyper-echoic tumor in the lateral segment of the liver, and a hypo-echoic area which lay in its interstice. Contrast enhanced abdominal CT scan visualized it as a demarcated solid tumor, as well as an area of lower absorption which lay in the center of the tumor as the US showed. The tumor parenchyma was faintly enhanced in the early phase and was washed out in the later phase. The tumorous lesion progressed into the left bile duct which was considered biliary tumor embolus. A left lobectomy of the liver was performed with a preoperative diagnosis of non-typical hepatocellular carcinoma. It was found that the tumor had grown from the inferior surface of lateral segment to outside the liver and invaded the gastric body. Then associated resection of part of the gastric wall was carried out. Following confirmation of the extent of the tumor embolus with intraoperative biliary fluoroscopy, we resected the bile duct and confirmed that the surgical stump was negative. Histopathological studies revealed that the tumor was papillary proliferating adenocarcinoma, there was mucus in the interstice, and a part of the tumor showed findings of mucinous carcinoma. The patient experienced intrahepatic metastasis 3 months and died 17 months after the operation.

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A 23-year-old man, who had suffered repeated episodes of acute pancreatitis since 2001 and had been treated by a doctor, was referred to our Department of Gastroenterology with suspected pancreas divisum by ERCP in 2003. He was followed after symptomatic improvement by fasting. Abdominal pain recurred in November 2004, and he was referred again with severe dilatation of the main pancreatic duct of the pancreas body and tail, and calcification of the pancreas head by MRCP & abdominal CT scan at another hospital. The ventral pancreatic duct curved and was occluded halfway by ERP from the major papilla. ERP from the minor papilla was unsuccessful and he consulted us because of difficult endoscopic therapy. Duodenum-preserving pancreas head resection was performed on February 4, 2005. Fibrous overgrowth was observed in the ventral and dorsal pancreas, therefore, the histopathological diagnosis was chronic pancreatitis with pancreas divisum. He was discharged on postoperative day 37 after temporary duodenal obstruction. Duodenum-preserving pancreas head resection is a good indication for the treatment of pancreas divisum with chronic inflammation of ventral and dorsal parts.

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We report a case of a 59-year-old man who had undergone a pancreatoduodenectomy for pancreatic cancer one year before. He was admitted to our hospital because of a rapidly progressing consciousness disturbance. HB blood ammonia level was also high. Abdominal computed tomography revealed a portal occlusion with local recurrence of pancreatic cancer, and hepatofugal collateral vessels were recognized. He was diagnosed as portal-systemic encephalopathy (PSE), and the symptom improved immediately by administration of branched-chain amino acid / lactulose. PSE with pancreatic cancer has been only rarely reported. In this case, the cause of PSE was the interception of the hepatopetal collateral route by the operative dissection around the pancreas.

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A 53-year-old man visited our hospital following a medical check-up that detected a submucosal tumor-like lesion of the stomach. An enhanced CT scan showed the aneurysm (25×25mm in diameter) in the main trunk of the splenic artery, and a transcatheter arterial embolization with interlocking detachable coil (IDC^®) was performed. We inserted a microcatheter into the aneurysm and packed it with IDC^®. The postembolic course was uneventful, an no deviation was seen. Interventional radiology is less invasive than surgery. Therefore, we consider this procedure is the treatment of choice for splenic artery aneurysm on a case-by-case basis.

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Case 1 was a woman in her forties with a high CA19-9 value. CT revealed a tumor in the pancreas tail, and a cystic area was confirmed, which contrasted with the rim, and a solid area, which contrasted with the interior, in both the portal and equilibrium phases. MRI showed a high signal contrast on the Tl-weighted image inside the cystic area, while a T2-weighted image confirmed an intramural node with a signal equal to that of the solid area. It was diagnosed to be a pancreatic mucinous cystic tumor, and partial pancreatectomy was performed. An epidermoid cyst was found in the intrapancreatic accessory spleen. Case 2 was a man in his fifties who was found to have a pancreatic tumor by ultrasound. A plain CT revealed a low-density area in the pancreas tail. MRI confirmed an intramural node measuring 3mm in size. Based on a dynamic study, the densely-stained pattern of the intramural node closely resembled that of the spleen, and there was a signal decline in SPIO contrast. The mass was considered to be an epidermoid cyst in the intrapancreatic accessory spleen, and the process is now under observation. The SPIO contrast medium is absorbed by the reticuloendothelial cells, and since it reduces the signal from a normal spleen, it thus makes it possible to diagnose the presence of the accessory spleen. We experienced a case that was determined to have an epidermoid cyst in the intrapancreatic accessory spleen based on the findings from a dynamic study and SPIO-MRI. This case is presently under observation, and in the future we plan to make a more detailed description of her, including surgical treatment.

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We report two rare cases of gallbladder metastasis from renal cell carcinoma. A 76-year-old man who had undergone left nephrectomy for left renal cell carcinoma 7 years previously was diagnosed as gastric cancer and polypoid tumor of the gallbladder. We performed a subtotal gastrectomy and cholecystectomy. Histologically the gallbladder tumor was diagnosed as metastasis from renal cell carcinoma because the tumor was found in the submucosal layer and showed the same characteristics as primary renal cell carcinoma. A 60-year-old female who undergone left nephrectomy for left renal cell carcinoma 8 years previously was admitted to the hospital because of right hypochondralgia. The patient was dignosed as gallbladder cancer with liver metastasis and we performed cholecystectomy, with liver bed resection, and hepatic tumor enucleation. The gallbladder cancer showed irregular elevated lesions and infiltrated the liver bed. We diagnosed it as metastasis from renal cell carcinoma because it was growing mainly around intestitial tissues and showed the same histological fingings as primary renal cell carcinoma. Gallbladder metastasis from renal cancer is very rare, and there are reports of only 15 cases in Japan.

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We experienced five operated cases of bowel obstruction due to adhesions during pregnancy between 1995 and 2005. The ages ranged from 28 to 36 years old. Bowel obstruction occurred in the second trimester in two cases and in the third in three cases. Previous laparotomies were performed for gastrointestinal disease in one patient, gynecological disease in three and both in one. All the first physicians could not make the diagnosis of bowel obstruction. All apatients were referred to gynecolo-gists. On admission the correct diagnosis was made only in one patient. Our data showed difficulty in diagnosing the disease in the initial stage. The total course of each patient was analyzed and we showed that closed observation, consultation and serial plain abdominal radiography were effective for making the correct diagnosis without delay. Conservative treatment was selected in two patients and laparotomy on an emergency basis was performed in three. In the former two patients, after conservative management laparotomy with partial resection of the small bowel was necessary. In the latter, lysis of adhesions and/or incision of strangulations were undertaken. Caesarean section was performed in three patients simultaneously. It was concluded that patients should be operated on as soon as possible when the diagnosis was made. There noted no morbidity nor mortality.

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An 82-year-old man was seen at the hospital because of abrupt onset of lower abdominal pain. There were previous histories of diabetes mellitus, hypertension, choronic heart failure, cerebral infarction, and bronchial asthma. When he was first seen, there was prominent spontaneous pain in the entire abdomen, but no muscle guarding and rebound tenderness were noted. Abdominal CT scan visualized the root of superior mesenteric artery; intrahepatic portal gas was shown in the bilateral lobes of the liver. The patient was operated on with a diagnosis of hepatic portal venous gas caused by ischemic intestinal disease. During surgery pulsations were palpable at the root of the upper mesenteric artery, but there were dilatation, edema, and mesenteric edema in the small intestine staring at a portion about 210cm distal from the Treitz' ligament, and a portion from the cecum to ascending colon. These lesions were removed and functional end-to-end anastomosis was performed. The patient gradually recovered after the operation and was discharged from the hospital on the 111^th day after the operation. On pathological studies, hemorrhagic necrosis was seen in the intestinal mocosa but there were no abnormal findings such as thrombus in the mesenteric artery and vein, so that nonocclusive mesenteric ischemia was diagnosed.
Although the disease has a poor prognosis, simultaneous surgery can be expected when laparotomy is decided in an early time after the onset of the disease.

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We report a case of bile peritonitis due to bile leakage caused by acalculous and nonperforative cholecystitis.
A 75-year-old man was admitted to our hospital because of abdominal pain and vomiting. We doubted that he had acute cholecystitis by abdominal ultrasonography (US), computed tomography (CT) and abnormalities in the liver and pancreas functions. The day after admission he showed a defensive sign at the abdomen and ascitis by abdominal US and CT scan. Puncture-exudate of ascites revealed that he had bile peritonitis. So we conducted emergency laparotomy. We found bile retention in the abdominal cavity despite absence of abnormal findings in the liver, common bile duct and duodenum. There were localized thinning parts in the neck, body and corpus of the gallbladder, bile leakage from where was not identified macroscopically. However, we considered that bile leakage occurred from the parts, and performed cholecystectomy and abdominal drainage. Histopathologically, the gallbladder was in an acute phase of chronic cholecystitis. Erosion ulcer, and even autolysis on the mucusa were seen at the parts of the thinning walls of the gallbladder. We thought that the injury of the gallbladder wall might be caused by autolysis due to regurgitated pancreatic juice.

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Patient 1 was a 68-year-old man who underwent total gastrectomy and cholecystectomy for gastric cancer in January 2005. The gastric cancer was in stage IIIA. Tumor markers started to increase in February 2006, and abdominal CT scan revealed the appearance of right hydronephrosis. Recurrence was suspected and then a ureteral stent was placed. In April 2006, he became to feel a nodule of the navel and CT scan showed a tumor in the umbilical region. Aspiration cytology provided the diagnosis of adenocarcinoma. The patient has been treated with chemotherapy on an ambulant basis.
Patient 2 was a 93-year-old woman who was operated on for gastric cancer with pyloric stenosis in January 2006, when peritoneal dissemination was found and gastrojejunostomy was performed. Redness of the navel appeared in March 2006, and abdominal CT scan showed a tumor in the umbilical region as well as multiple hepatic metastases. Adenocarcinoma was diagnosed by aspiration cytology in April 2006. Despite supportive treatments, she died in May 2006.
Although metastasis of gastric cancer to the umbilical region (Sister Mary Joseph's nodule) is rare, its detection and diagnosis are easy. It would be important to treat postoperative patients with advanced gastric cancer by keeping a possibility of the disease in mind.

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A 72-year-old woman who had been treated for paroxysmal atrial fibrillation was brought into the hospital by ambulance because of abdominal pain and distension. When she arrived at the hospital, she was in a shock state with blood pressure of 80mmHg and impaired renal function. Plain CT scan showed ascites and dilatation of the small intestine. Emergency laparotomy was performed 4 hours after her arrival. A diagnosis of superior mesenteric artery embolism was made, and almost the entire small intestines and right colon which were necrotic were resected. Three days after the operation, she complained of severe pain of her left lower extremity. A diagnosis of acute arterial occulusion was made, and thromboembolectomy for the left lower extremity was performed. After the second operation, anticoagulation therapy with heparin was started. Two weeks later, abdominal CT scan revealed multiple infarction of the liver, spleen and bilateral kidney, indicating so-called shower embolism. She was discharged from the hospital on 47th postoperative day. In the treatment of the ischemic intestine with atrial fibrillation, early start of anticoagulation therapy with heparin is essential for prevention of recurrence or multiple occurrence of arterial thrombosis after the operation.

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A 60-year-old man came to our hospital because of left great toe gangrene and infection. Angiography showed three arterial obstructions of the left lower limb, and short segmental opening of the distal anterotibial artery. Angioechogram revealed a suitable great saphenous vein graft (SVG) and graftable segment in the distal anterotibial artery. Below-knee popliteal to distal anteroibial artery bypass was performed with reversed SVG, followed by great toe amputation and debridement. Under strict infection control, the patient was discharged on the 47th postoperative day, and then came to the hospital for wound irrigation. Skin plantation to the defect was performed three months later.
Paramalleolar bypass for a patient with severe ASO with toe gangrene and infection is thought to be effective to improve quality of life, if a suitable vein graft and graftable arterial segment are present.

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We report a case of a 54-year-old man transferred to our center because of thoraco-abdominal multiple penetrating injuries (involving the right diaphragma, small intestine, liver, gallbladder, and right kidney). During emergency operation, he presented progressive enlargement of a retroperitoneal hematoma around the right kidney. We evaluated his condition pre-lethal-triad, and decided to change the strategy to damage control (DC). We performed simple sutures of the injured sites in the liver and gallbladder, and gauze packing on the liver and kidney, followed by transcatheter arterial embolization (TAE) for the right renal artery, resulting in successful temporary hemostasis. On the second postoperative day, we performed planned reoperation including removal of the gauze and cholecystectomy.
Although DC is an unusual and escaping strategy, it is thought to be useful to save critically ill patients with massive hemorrhage and shock resulting in lethal metabolic catastrophe. In severe emergency cases in shock, we immediately have to judge the treatment strategy without consulting with a supervisor and without adequate preoperative conference. To correspond to these emergency conditions, we should be able to make decision to adopt and perform DC.

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We report a case of a 67-year-old woman who was admitted following the discovery of a mass lesion in the pancreas on abdominal ultrasonography. The patient had undergone right nephrectomy for renal cell carcinoma (RCC) 11 years previously, and bilateral partial lobectomy of lung for metastasis tumor from RCC 7 years ago. Abdominal echo showed hypervascular masses in the pancreatic body that were mostly probably metastatic lesions from RCC. She underwent a distal pancreatectomy. Histological examination of the specimen revealed metastatic tumor from RCC, which was diagnosed as clear cell carcinoma. She has been treated by IL-2 for recurrent lung lesion and has been living for 25 months after the operation with no evidence of metastasis. For a patient with hypervascular mass who has undergone surgery for RCC previously, we should consider that it might be metastasis from RCC. It takes a long time after surgery for RCC for pancreatic metastasis to occur therefore a long period of observation is neaded. It is suggested that aggressive surgery for metastatic pancreatic tumor from RCC would be a favorable option.

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