We investigated the operative procedures, cumulative survival rates, recurrent factors, recurrent patterns and therapies for recurrence in consecutive 82 patients who had undergone hepatic resection for hepatocellular carcinoma (HCC). Partial hepatectomy was done in 66 patients, and systematized hepatectomy in the remaining 16 patients. One-, 3 and 5-year cumulative survival rates in patients who had undergone hepatectomy were 91.4 79.3 and 61.8% respectively. In the univariate analysis, positive HBs antigen in recurrence-free patients and, liver damage B and ICGR15 in recurrent patients were selected as the independent determinants after hepatectomy. In the multivatie analysis, positibe HBs antigen was finally selected as the independent factor. One-, 3 and 5-year cumulative survival rates in patients who had undergone partial hepatectomy were 93.9 87.9 and 71.5%, respectively. In the univariate analysis, positive HBs antigen in recurrence-free patients, positive HCV antibody, liver damage B and perioperative blood loss in recurrent patients were selected as the independent determinants after partial hepatectomy. In the multivariate analysis, positive HBs antigen was finally selected as the independent factor. Patients who experienced solitary recurrence in the same affected lobe after partial hepatectomy, all able to survive for a long time by additional treatments. Considering these recurrent factors, patterns and therapies, partial hepatectomy seems to be valid for primary HCC.

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A total of 37 cases of venomous snakebite injuries treated at the hospital from 1995 to 2004 were enrolled in this clinical study of examining clinical characteristics, the grade classification of swelling, time until appearance of swelling, organic impairment, administration of equine antivenin serum (antivenin), and its effects. The male-to-female ratio was 22:15. Their snakebites were all localized in the extremities. One patient who was seen at the hospital when 40 hours had elapsed since being bitten was associated with multiple organ failure (MOF), and died on the second hospital day. The mean time until the maximum swelling developed was significantly delayed in grade III_??_V swellings compared with that of the grade I_??_II swellings (p<0.001). The incidence of occurrence of organic impairment was significantly higher in grade IV_??_V swellings than that in grade I_??_III swellings (p=0.002). Of eight patients who were administered the antivenin within 4 hours since being bitten, three patients who had grade IV_??_V swelling did not develop MOF. However, all five patients who were administered the antivenin more than 4 hours since being bitten developed grade IV_??_V swellings as well as organic impairment (p<0.02).
It is considered that we must deal with venomous snakebites with a prospect of developing more than grade III swelling, if the swelling persists to enlarge even after a lapse of 3 hours following the bites. And administration of the antivenin, if it can be administered within 4 hours after being bitten, may contribute to a decrease in organic impairment in those whose swellings may progress to the grade IV_??_V.

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The authors encountered a case of early breast cancer with the development of dermatomyositis immediately after radiotherapy that followed breast-conserving surgery. The patient, a 52-year-old female, was diagnosed with cancer of the breast and underwent breast-conserving surgery and sentinel lymph node biopsy in May, 2004. The pathological diagnosis was solid tubular carcinoma T1N0M0, stage I, ER(+), PgR(-). Hormone (Toremifene) administration was initiated from June, and radiotherapy was applied to the remaining breast starting in July. Immediately after the treatment was completed (August), the patient suddenly developed general fatigue, skin eruption and deglutition difficulty, and edema extending from her face to the neck. She was then re-etamined in our department at the end of August. Because hepatic dysfunction was noted, drug-induced hepatitis was suspected, and hormone therapy was interrupted. However, there was no improvement in the symptoms, and the blood creatine kinase level rose without any obvious reasons together with a simultaneous loss of muscular strength of the upper and lower extremities. In September, she was admitted to the hospital, where, following detailed tests, a diagnosis of dermatomyositis was made. It was presumed that stresses, such as surgery and radiotherapy, were responsible for the development of this disease. It is well-known that dermatomyositis is frequently associated with malignant tumors. The current case is introduced because it is rare that the former is preceded by the latter.

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The patient was a 62-year-old female who visited our hospital with the chief complaint of a mass in the left mammary gland. Breast cancer was diagnosed by close examination. On preoperative blood testing, multiple myeloma was suspected because the serum protein and IgG levels were high (13.6 and 11, 900mg/dl, respectively), and urinary Bence Jones protein was positive. The breast cancer was an intracystic carcinoma, and partial mastectomy was performed. Since the postoperative pathological diagnosis was non-infiltrating mammary duct carcinoma, and the stump on the nipple side was positive, additional resection and irradiation were recommended, but the patient did not consent, and the course was followed. Multiple myeloma was treated successfully, but a mass was palpated near the areola of the nipple 6 months after surgery and diagnosed as local recurrence, and mastectomy was performed. Treatment of multiple myeloma has been continued for 4 years thereafter, and no recurrence of breast cancer has been found.

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A 48-year-old woman was seen at the hospital because she had low back pain 3 months before entry and, 2 months later, noticed a right breast mass as well. When she was first seen, a 25×30mm ill-defined and slightly elastic-hard tumor was palpable in the right breast. Mammography and echography demonstrated no apparent tumor shadow. Although ductal carcinoma was suspected by fine needle aspiration cytology, signet ring cell carcinoma was detected by core needle biopsy (CNB). Considering a possibility of breast metastasis of gastric cancer, gastric endoscopy was performed, when gastric biopsy confirmed poorly differentiated adenocarcinoma including signet ring cell carcinoma. PET examination showed multiple bone metastases, lymph node metastasis, and bilateral hydronephrosis due to peritoneal dissemination. Thereafter the patient also developed carcinomatous pleurisy, and the general condition rapidly deteriorated. Accordingly we could not start chemotherapy and the patient died on the 27^th hospital day.
Since breast metastasis of gastric cancer is clinically rare, we report the case, together with a review of the literature.

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A 39-year-old man was admitted to our hospital because of a tumor shadow in the left lower lung field. CT scan and MRI revealed a mass with well-defined margins and smooth contours contacting the left antero-lateral chest wall. The tumor was diagnosed as a solitary fibrous tumor (SFT) arising from visceral pleura, because it moved with respiratory movement. Thoracoscopic surgery was performed, and a smooth pedunculated tumor was removed. The tumor originated from the visceral pleura of the left upper lobe and was 3.2×1.8×4.2cm in size. Histologically, the tumor was predominantly composed of a random proliferation of spindle cells, intimately admixed with collagen. Immunohistochemical analysis showed that the tumor cells were positive for vimentin and CD34, but negative for keratin, and the tumor was diagnosed as SFT. SFT is a rare tumor that most commonly arises in the pleura, and is thought to originate from mesenchymal cells. Thoracoscopic surgery is useful for the resection of such pedunculated SFT.

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A 44-year-old man complaining of flu-like symptoms and precordialgia was found to have an anterior mediastinal tumor by a chest CT scan at another hospital, and was referred to our hospital. The tumor came in contact with the left pulmonary artery in a broad aspect, and invasions of the tumor into the left superior pulmonary vein and mediastinal pleura were suggestive. Further an about 3.0-cm sized tumor was present in the right lobe of thyroid, which showed class V on echo-guided fine needle aspiration cytology. A ⁶⁷Ga-scintigram showed high radiotracer concentration in both tumors. Thus thyroid metastasis of malignant lymphoma or mediastinal tumor was considered, and we performed surgery for the purpose of diagnosis as well as treatment. A subtotal thyroidectomy and lymph node dissection of cervical lymph nodes were performed, followed by an extended thymectomy in which the mediastinal tumor was excised with the left lobe and pericardium, after a possibility of malignant lymphoma was ruled out by intraoperative frozen section diagnosis. The histopathological diagnosis was atypical carcinoid of the thymus with thyroid metastasis. Multiple metastases to other organs were confirmed 4 months after the operation. It appeared to suggest that the high concentration of ⁶⁷Ga in the tumors might reflect the potent malignant potential of the carcinoid.

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We report 2 cases of pulmonary papillary fibroelastoma. Case 1: A 73-year-old man with a history of medical treatment of hepatic cellular carcinoma was referred to our division because of tumor in the pulmonary artery revealed by chest enhanced computed tomography. Transthoracic echocardiography showed a 26×21mm mobile tumor attached to the pulmonary valve. Case 2: A 68-year-old man with medical treatment of WPW syndrome in our hospital was referred to our division because of incidental transthoracic echocardiographic discovery of a pulmonary valve mass. In both these cases, tumors were surgicallly excised through a transpulmonary arterial approach with cardiopulmonary bypass. The tumors were sea anemone-like in appearance and were diagnosed as fibroelastoma by histopathological examination.
Fibroelastoma is a rare cardiac benign tumor and often asymptomatic. However, lethal embolic events such as stroke, myocardial infarction, and pulmonary embolism are reported in some cases. Surgical excision is important in order to prevent such complications.

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We report a case of breast cancer with multiple lung metastases presented cavities including thin wall cavities on chest CT scans. The patient was a 46-year-old woman who had undergone an operation for breast cancer. Five year after the operation, chest abnormal shadow was shown, which was visualized as multiple cavernous lesions including thin wall cavities on chest CT scan. In following the clinical course by chest CT scans for 2 years, thickening of the cavity wall and solid lesions developed. In order to make the definite diagnosis, thoracoscopy-assisted partial pneumonectomy was performed. The histological diagnosis was pulmonary metastasis of breast cancer, and hormone therapy was started. Three years after the initiation of the therapy, all the pulmonary lesions became thin wall cavities. Thus the hormone therapy was thought effective. The patient is still alive as of 9 years after the therapy, though she is a cancer-carrier.

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A 27-year-old woman was brought into the hospital by ambulance because of neck pain, precordialgia, and fever. Chest CT scan showed an abscess localized in the mediastinum from the chest to the right side of abdominal esophagus. No apparent perforation was revealed and inflammation was localized in the mediastinum by esophagogram, so that conservative therapy was employed. Upper gastrointestinal endoscopy showed an about 15-mm sized deep esophageal ulcer in the intrathoracic superior portion of esophagus, 22cm distal from the incisor line. No foreign body or perforation was seen. She had eaten a chicken's wing whole and the mediastinal abscess was identical with the location of the esophageal ulcer. Thus we inferred that the esophagus was injured and perforated by the swallowed chicken wing. The fever subsided on and after the 4^th hospital day, and chest CT scan showed almost complete disappearance of the mediastinal abscess on the 13^th hospital day. The patient was discharged from the hospital on the 16^th hospital day.
Although esophageal perforations often demand invasive surgery, conservative therapy was successful in this patient.

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True carcinosarcoma is extremely rare and is characterized by a mixed tumor composed of a carcinoma and a genuine sarcoma. We describe here a case of true carcinosarcoma of the esophagus and review some literature on the subject. A 55-year-old man was admitted to our hospital with complaints of chest pain. Barium swallow esophagogram showed a large polypoid lesion in the upper-middle thoracic esophagus. Endoscopic examination showed a type 1 tumor at the upper thoracic portion of the esophagus. Subtotal esophagectomy with cervical, thoracic, abdominal nodes dissection was performed. Histologically, the tumor was composed of a squamous cell carcinoma part and a sarcomatoid part which showed positive staining for α-smooth muscle actin. No transitional area between the two components was observed. Therefore, it was diagnosed as a true carcinosarcoma according to the Gvideline for Clinical and Pathological Studies on Carcinoma of the Esophagus. The patient died three months after the operation because of multiple metastasis to the bones, liver, and cervical lymph nodes.

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Resection of ectopic bile duct with opening in the stomach followed by hepaticojejunostomy was conducted on a 73-year-old woman with ectopic bile duct. Her chief complaints were abdominal pain and vomiting. As a small orifice was detected at the lesser curvature of the stomach with flow of bile juice from the small orifice by gastrointestinal fiberscopy, leading to the diagnosis of gastrocholedocal fistula, she was referred to us and admitted to Hiroshima City Hospital.
Pancreatic duct was visualized be ERCP but not the bile duct. When visualized from the small orifice of the lesser curvature of the stomach, ectopic bile duct and stone were detected in the minor omentum together with intrahepatic bile duct. As for operative findings, an ectopic bile duct measuring 1.5cm in diameter was observed in the minor omentum from the left hepatic duct to reach the stomach. At the common bile duct in the hepatoduodenal ligament, a cord-shaped stricture was observed from the porta hepatis. Following resection of the ectopic bile duct, Roux-en Y hepaticojejunostomy was conducted for reconstruction. We present this case report because an ectopic bile duct with opening in the stomach not accompanied by double bile duct is extremely rare in the literature.

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A 74-year-old man, who had been diagnosed as having diabetes mellitus 20 years earlier but had let it alone ever since, underwent coronary artery bypass grafting using the right gastroepiploic artery (RGEA) with a diagnosis of ischemic heart disease (three affected branches) in February 2006. Thereafter he visited another hospital because of tarry stool in December 2006, and was admitted to the hospital with a diagnosis of gastric cancer. Early gastric cancer of type IIc was identified in the posterior wall of the upper body of stomach. Biopsy of the tumor showed poorly differentiated adenocarcinoma. Following CT angiography which confirmed the patency and course of the grafts made of the RGEA, partial gastrectomy was performed without injuring the grafts. Histopathological study revealed por2, pT1 (SM2). ly0, and v0.
In the treatment of gastric cancer like in this case, a problem that can arise from a safety standpoint is a possibility of injuring grafts at surgery. We present this case because CT angiography was very helpful to assure the safety for the grafts at gastric resection.

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A 59-year-old man was examined for epigastralgia. Gastric endoscopy visualized an giant ulcer from the corpus to the antrum of the stomach. A histological diagnosis of malignant lymphoma (diffuse large B cell type CD 20 antibody-positive) was made based on the biopsy specimen, after which he was admitted to our hospital for chemotherapy. After 3 cycles of treatment, he was admitted for nausea and vomiting after eating frequently. Endoscopy revealed a significant diminution of the ulcer and gastric outlet stenosis in the lesion. From these studies, we diagnosed this as gastric outlet stenosis due to a tumor and performed distal gastrectomy with D1+α lymph node dissection. Histopathologically, no lymphoma cells were detected through all sections of the specimen and regional lymph nodes. We regarded it as a case of complete remission. This case suggests that chemotherapy is effective in treating malignant lymphoma of the stomach, and demonstrates the possibility that primary lesion may form a scar as gastric outlet stenosis after chemotherapy.

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We report a case of left paraduodenal hernia diagnosed preoperatively by magnetic resonance imaging (MRI). A 30-year-old woman was admitted with intermittent left upper abdominal pain and nausea. There was tenderness in the left upper abdomen, but no peritoneal signs were present. Computed tomography showed a mass lesion in the stomach dorsum. MRI clearly showed intestinal wall structure and intensity. Therefore, she was diagnosed as left paraduodenal hernia. A laparotomy was performed, and the hernia orifice and hernia sac were detected. We closed the hernia orifice after removing small intestine. Repeated intermittent obstructive symptoms were often observed with paraduodenal hernia. But preoperative diagnosis was difficult. In this case, MRI may therefore provide useful information for the diagnosis.

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We report a case of capillary hemangioma of the small intestine preoperatively diagnosed by abdominal CT. A 14-year-old man was admitted to the hospital for melena, severe anemia and dizziness. The focus of bleeding was not seen in examinations such as upper gastrointestinal endoscopy colonoscopy and an abdominal enhanced CT (1st). After a few days we performed hemorrhagic scintigraphy and an abdominal enhanced CT (2nd) because of massive melena again. The abdominal CT revealed the focus of bleeding to be from the small intestine with invagination in the right lower abdomen, so we conducted emergency operation. During the operation we found invagination of the small intestine with a tumor about 150cm oral to the terminal ileum. A partial excision of the intestine was carried out. The resected specimen showed an elastic soft 20mm tumor. Histopathological diagnosis was capillary hemangioma of the small intestine. An abdominal enhanced CT examination may be a first choice because it is an allpurpose and easy method in comparison with other examinations if the disease is suspected to be intestinal bleeding of unknown origin.

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A 78-year-old woman underwent a sigmoidectomy for cancer of the sigmoid colon, followed by insertion of a duple drain (10mm in diameter) to the Douglas' pouch. When the drain was removed on the 5^th postoperative day, abdominal pain, nausea, and vomiting developed about 6 hours later. A fistsized subcutaneous tumor was found at a portion where was identical with that from which the drain was removed, and there was tenderness there as well. Abdominal CT scan showed the small intestine prolapsed to the subcutaneous structure. Prolapsed and incarcerated small intestine from a portion through where the drain was inserted was diagnosed, and an emergency operation was performed. During surgery we identified the impacted and necrotized small intestine in the opening left after removal of the drain and performed resection of the small intestine. The postoperative course was uneventful. The patient was discharged from the hospital on the 15^th hospital day after the initial operation.

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The case was a 50-year-old woman. She was hospitalized with the chief complaint of bloody bowel discharge on January 20, 2005. The bloody bowel discharge was alleviated on the next day. We suspected hemorrhage from the lower digestive tract and performed colonoscopic examination, but the hemorrhage source was not clear. We let her start a meal, but we suspected a small intestinal lesion and performed radiological enteroclysis because she produced bloody bowel discharge again. A polypoid lesion of about 20mm in diameter was found in the ileum and diagnosed as ileal tumor. There were no abnormal findings on upper gastrointestinal tract endoscopy, abdominal CT, and abdominal angiography examination. We performed an operation on February 18. Because the mass could be left palpating in the ileum of about 120cm oral side from the terminal ileum, we performed partial excision of the ileum. By a pathological study, it was diagnosed as ectopic pancreas of Heinlich type III. The postoperative course was good and there has been no recurrence of bloody bowel discharge for one year post operation.

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We report two cases of inflammatory fibroid polyp (IFP) of the ileum presented with bloody stool and intussusception respectively. Case 1 was a 61-year-old man, who was admitted to the hospital because of bloody stool. Colonoscopy showed reddish intestinal contents in the terminal ileum and small intestinal bleeding was suggested. While various examinations were performed, no other abnormality was found. Case 2 was a 59-year-old woman, who was admitted to the hospital because of lower abdominal pain and constipation twice. In the first admission, no abnormality was found. In the second admission, X-ray study through a long intestinal decompression tube and abdominal CT scan indicated intussusception due to tumor of the ileum. On laparotomy, intussusception due to the tumors of the ileum was identified and partial resection of the ileum including the tumors was performed in both cases. The histopathological diagnosis was IFP. IFP of the small intestine is rare, frequently presents with intussusception, and rarely with bloody stool. It is very difficult to make a qualitative diagnosis of IFP pre-or intraoperatively, and so it is diagnosed by pathological examination of the resected specimen.

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A 59-year-old man was admitted to our hospital with severe lower abdominal pain. Under the diagnosis of perforative peritonitis, emergency laparotomy was performed. There was a tumor (10cm in diameter) of the ileum and invasion of the sigmoid colon, which already was perforated. We performed a partial resection of the ileum, sigmoidectomy and colostomy. Histopathological findings showed that the tumor was composed of spindle cell proliferation. Because tumor cells were positive for c-kit and CD34, and negative for α-smooth muscle actin and S-100 protein immunohistochemically, we diagnosed the tumor as GIST of the small intestine, uncommitted type. The patient was treated with imatinib mesylate as an outpatient.

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A 58-year-old man visited our hospital because of fecal occult blood. A cecum colon cancer was detected by colonoscopy and barium enema, and an ileocecal resection was performed. Histopathological examination revealed mixed composition of adenocarcinoma and neuroendocrine cell carcinoma (adenocarcinoma with neuroendocrine cell carcinoma). Generally, neuroendocrine cell carcinoma grows rapidly with a high incidence of metastasis. It is biologically a tumor with a high malignant potential. Radical treatment can not be achieved only by surgical therapy, and further studies of effective chemotherapies are warranted.

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A 90-year-old woman was admitted to our hospital because of ileus. Colonoscopy revealed severe stenosis in the ascending colon. Gastrografin enema study showed an apple core sign up to 5cm at the ascending colon. The pathological diagnosis of a biopsy specimen showed moderately differentiated adenocarcinoma. Right hemicolectomy with D2 lymphadenectomy was performed under a diagnosis of ascending colon carcinoma. The resected specimen showed that the tumor was solitary and localized ulceration type. Histological examination identified that the tumor was composed of two distinctive components, carcinoid and adenocarcinoma. In the area of carcinoid, the tumor cells were arranged in a solid or small tubular pattern with rosette formation. Immunohistochemical staining revealed positive reaction to CEA, CA19-9 and p53 in the area of adenocarcinoma. In the area of carcinoid, there was positive reaction to synaptophysin and p53, but negative reaction to chromogranin A and gastrin. We report this rare case of composite adenocarcinoma-carcinoid tumor of the colon, together with a review of the literature.

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This paper presents a case of rectal cancer with a solitary liver abscess. The patient was a 47-year-old woman complaining of fever, upper abdominal pain, and appetite loss. She visited a hospital because of a high fever of 38°C and abdominal pain which started on July 26, 2002, and was seen at our hospital after unsuccessful treatment with drip infusion at that hospital. Abdominal ultrasonography and CT scan demonstrated a multilocular tumor 4.5cm in diameter in the lateral segment of liver, and thus hepatic abscess was diagnosed. PTAD for the purpose of drainage as well as diagnosis was performed and antibiotics were administered. These conservative treatments were successful. On August 23, colonoscopy to explore causes of the hepatic abscess revealed a type 2 rectal cancer in the rectum (Rb). Following a biopsy of the liver that confirmed absence of hepatic metastasis, a low anterior resection of rectum preserving the autonomic nerve was performed. The patient has been free from recurrence of hepatic abscess or rectal cancer, as of 3.5 years after the operation. Although it is reported that a solitary hepatic abscess without being associated by hepatic metastasis is comparatively rare, we must carefully decide the therapeutic plan after sufficient exploration of the presence of hepatic metastasis based on biopsy results and imaging findings.

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Ovarian metastasis is a comparatively rare mode of metastasis for rectal carcinoma. The patient was a 75-year-old woman complaining of lower abdominal pain and constipation. She was diagnosed as having bilateral ovarian metastasis from rectal carcinoma and underwent a Hartmann operation. Since she had bilateral ovarian metastasis and omental and peritoneal dissemination, P3 Stage IV was diagnosed. While most ovarian metastases from rectal carcinoma show a histological type of moderately or well differentiated adenocarcinoma, this tumor in this case had components of neuroemdocrine tumor which were positive for synaptophysin, NSE, and chromogranin. Moderately differentiated adenocarcinoma with neuroendocrine differenatiation was thus diagnosed. Ovarian metastasis of rectal carcinoma often develops peritoneal dissemination when it is detected, and neuroendocrine cell carcinoma has poor prognosis compared to adenocarcinoma. From these facts, it is considered that the patient might have a poorest prognosis in terms of its mode of metastasis and histological type.

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We evaluated the antitumoral efficacy and safety of CPT-11 60mg/m² (days 1, 8 and 15) combined with UFT (oral combination of tegafur and uracil) 300mg/body/day plus leucovorin (LV) 75mg/body/day (days 1-21) every 4 weeks as first-line chemotherapy of metastatic and advanced colorectal cancer. Nine patients with diagnosis of advanced colorectal cancer were enrolled. Five patients showed PR (Response rate=55.6%). Stable disease was reported in 4 patients (tumor control rate=100%). The most reported grade 3/4 toxicities were fatigue (33.3% of patients). Other G3/4 toxicity were neutropenia (11.1%) and nausea (11.1%). Severe diarrhea was not observed. Weekly CPT-11 plus UFT/LV was found to be effective and safe as first-line chemotherapy for metastatic colorectal cancer.

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We report a case of laparoscopic surgery for Mirizzi syndrome with severe liver cirrhosis. A 57-year-old male was admitted to our hospital because of jaundice. MRCP revealed two 20mm stones fixed in the cystic confluence and the neck of the gallbladder. ERCP showed that the common bile duct was obstructed at the confluence and the common hepatic duct was not visualized. Percutaneous transhepatic biliary drainage (PTBD) was performed for treatment of jaundice and further investigation. Surgery was scheduled after the decrease of jaundice, however it was put off because of liver dysfunction (ICG residual rate at 15 minutes was 55%). Then he was diagnosed as having a pharyngeal cancer, and received chemoradiation which resulted in complete response. Six months later, the liver function had so improved that surgery was performed. The gallbladder was cut open from its neck to the cystic confluence longitudinally. After extraction of the fixed stones, the gallbladder was sewn up. The postoperative course was uneventful. We describe laparoscopic surgical procedures due to their applicability to selected cases of confluence type Mirizzi syndrome.

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The patient was a 66-year-old woman who had underwent laparoscopy-assisted cholecystectomy, incision of the common bile duct and C-tube drainage at another hospital 7.5 years earlier. She was seen at the hospital because of fever, serious upper abdominal pain, and nausea. Close exploration has disclosed a common bile duct stone involving a metal clip as its core. Hence we have performed incision of the common bile duct and T-tube drainage under laparotomy. The removed stone was an 18×11mm bilirubin calcium stone in the center of which a metal clip was identified. During surgery we identified only one clip in the surgical stump of the cystic artery at where two clips had to be, and the lost clip might cause the stone. The patient's postoperative course was uneventful, and she has been followed in the clinic without having recurrence.
There have been 27 cases of common bile duct stone caused by a metal clip as the core in this country. It was inferred from intraoperative findings that either of two clips at the surgical stump of the cystic artery might be drawn into the common bile duct in this case

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We experienced a case of cystic biliary hamartoma with difficulties in making the preoperative diagnosis, because the tumor marker levels of the cystic fluid were high and the wall of the tumor became thick. A 77-year-old woman was seen at the hospital because of right hypogastalgia in 2004. 3. We performed percutaneous transhepatic cyst drainage and injected mynocycline into it with a diagnosis of a simple cyst in the posterior segment of the liver. After this therapy, the pain was reduced. But, after 11 months, she developed right hypogastalgia again. The laboratory findings at admission showed high inflammatory score and CA19-9, so we diagnosed it as a recurrent contagious liver cyst and performed PTCD. CEA, CA19-9 and DUPAN-2 level were high in the cystic fluid. The wall of the cyst became thick, so it was undeniably a neoplasm with malignant potential. We performed atypical right lobectomy of the liver. Pathologically, it was diagnosed as a biliary hamartoma. It showed no malignancy.

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von Meyenburg complex is described as a hemartomatous lesion affecting the bile duct. In this report, we present a patient with von Meyenburg complex requiring differential diagnosis from diffuse liver metastasis detected in preoperative examination for advanced gastric cancer. The patient was a 59-year-old female in whom preoperative examination for advanced gastric cancer by ultrasonography and CT revealed multiple nodular lesions in both lobes of the liver, and their differentiation from multiple liver metastases was difficult. We evaluated the lesions by MRI and MRCP and confirmed small cysts in the liver not communicating with the biliary system, and diagnosed the lesions as typical von Meyenburg complex. We also performed FDG-PET, which showed no accumulation of FDG and excluded liver metastasis. On gross intraoperative examination of the liver, cystic lesions about 5mm in diameter were scattered on the liver surface, allowing an intraoperative diagnosis of von Meyenburg complex. Liver biopsy was performed to pathologically confirm the diagnosis, but the sampling site and the size were inadequate. Improvements in the biopsy technique are considered necessary for the future.

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Endocrine cell carcinoma of the gallbladder is a very uncommon disease with a poor prognosis, and effective chemotherapy has not been established as yet. We here report a rare case of endocrine cell carcinoma of the gallbladder who was performed right trisegmentectomy. A 59-year-old female who had appetite loss, was admitted to our clinic. The tumor was palpable at the right upper abdomen. Abdominal US, CT, and angiography showed the tumor of the gallbladder and a huge mass that was located in the right lobe and satellite multiple masses in segment 4 of the liver. Laboratory data showed mild liver dysfunction and slight elevation of CEA (5.5ng/ml). We diagnosed it as a gallbladder carcinoma and performed surgery. Trisegmentectomy of the liver was performed, because lymphnode involvement and invasion to extrahepatic biliary tract were not evident. Postoperative histological findings demonstrated that tumor consisted of endocrine cell carcinoma which was positive for chromogranin A and NSE stainings. The postoperative course was uneventful. However, multiple metastases in the remnat liver were shown two and half months after operation. Infusion of CDDP and CPT-11 was performed immediately through the hepatic artery but the chemotherapy was not effective. She died 3 and a half months after operation.

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A 53-year-old female with obstructive jaundice was found in abdominal ultrasonography to have a papillary type lesion, about 4.5cm in diameter, with stones in the fundus and body of the peritoneal side of the gallbladder (GB). Enhanced CT demonstrated slightly enhanced homogeneous protruded lesion of the GB, swollen pancreas head (PH), and enhanced inferior-biliary duct with a wall thickness. MRCP showed distal stenosis of the lower bile duct. The patient was diagnosed with synchronous carcinoma of the GB and inferior bile duct and so underwent resection of the GB bed and extrahepatic bile duct and subtotal stomach preserving pancreatoduodenectomy. Histopathologic diagnosis of the gallbladder was poorly differentiated tubular adenocarcinoma with extensive spreading to the lymphatic canal and stroma, resulting in biliary stricture owing to marked transmural extension of the tumor and cancer positive cut margin of the left hepatic duct, anterior and posterior branch of the right hepatic duct, and the pancreas, whereas the mucosa of each biliary duct and MPD were not invaded. On the 62^nd postoperative day, the patient died of the carcinomatosis. The autopsy revealed marked lymphatic and interstitial spread in several organs. It should be noted that the clinical strategy must be decided prudently because of the diffuculty in diagnosing the evolution of such a rare carcinoma.

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A 76-year-old man was admitted for upper abdominal pain. An ultrasound examination revealed a hypoechoic region in the pancreatic head. Computed tomography revealed a low density mass, which was a hypervascular lesion. Angiography showed tumor vessels supplied by the anterior superior pan-creaticoduodenal artery. Pancreatoduodenectomy was performed. Histologically, the tumor showed a proliferation of neoplastic cells with hyperchromatic nuclei of various sizes. Immunostaining method showed some tumor cells to be reactive for somatostatin. We therefore diagnosed this case to be an asymptomatic somatostatinoma of the pancreas.

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A 58-year-old woman who received close exploration for diarrhea and poor appetite was found to have a retreperitoneal tumor by abdominal CT scan. Tumor markers were within normal ranges. From various imaging diagnoses, gastrointestinal stromal tumor (GIST) arisen in the posterior wall of duodenum was suspected, and we decided to perform surgery. Upon laparotomy the tumor had grown from the pancreatic parenchyma of the posterior surface of the pancreas to outside of the pancreas, so that the tumor with part of pancreatic parenchyma was removed. Histopathologically the tumor showed a proliferation in trabecular and tenioid arrangement of atypical cells which were small and revealed appearance of nucleolus and an increase in chromatin. On immunohistochemical studies, the tumor was positive for synaptophysine and chromogranin and negative for Grimellius stain, c-kit, and CD34. As for hormones, it was positive for gastrin but negative for glucagon, insulin, and somatostatin. From these findings the tumor was diagnosed as gastrinoma. An endocrinoligical study which was reported on other day showed a high blood gastrin level, 2400pg/ml. The patient is strictly followed in the outpatient clinic.

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A 77-year-old woman was diagnosed as having advanced carcinoma of the pancreatic head. During work-up for surgery, selective angiography of the celiac axis (CA) was impossible because of severe occlusion at the proximal portion of CA. A three-dimentional computed tomographic angiography (3D-CTA) showed a focal narrowing of the proximal CA with being devoid of “hooked appearance”, a characteristic finding for CA compression by median arcuate ligament (MAL). During the operation, however, CA was successfully revascularized only by division of its surrounding fibrous tissues including MAL.
We reviewed 39 patients with CA occlusion who underwent pancreaticoduodenectomy. As for 27 patients who were described in detail, arterial reconstruction was primarily necessary for arteriosclerosis, but only division of MAL was sufficient in 10 of 11 patients with extrinsic compression of the CA. Thus, the etiology of the CA occlusion is an important determinant for the relevant revascularization procedure.
The difficulty in preoperative evaluation for CA occlusion in our case might be due to the 3D-CTA that had been scanned at inspiration, because the finding of focal narrowing or “hooked appearance” of CA is typically obtained during expiration. Although 3D-CTA is a safe and useful assessment for CA occlusion the accurate diagnosis should be made under the optimal condition, such as scanning during expiration.

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A 30-year-old man with flu-like symptoms for two weeks visited our hospital and was medicated. But two days later, his symptoms became worse, and laboratory findings showed marked liver dysfunction. He was then admitted with the diagnosis of acute viral hepatitis, including infectious mononucleosis caused by Epstein-Barr virus (EBV). On the 2nd day after admission, left hypochondralgia occurred, and the next morning, he fell into hypovolemic shock. Ultrasonography and computed tomography revealed intraabdominal hemorrhage due to splenic rupture. An emergency operation was performed and a splenectomy was done. After several days, based on the results of examination for antibody of EBV, we diagnosed him as infectious mononucleosis.
Rupture of spleen is a very rare complication of infectious mononucleosis.

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We report a case of internal hernia through a defect in the broad ligament of the uterus. A 51-year-old woman, who had experienced delivery but had no surgery, was admitted to our hospital under the diagnosis of ileus. Supportive therapy with draining of the intestinal fluid by a long intestinal tube was done. Abdominal computed tomography demonstrated a dilated small bowel loop in the pelvic cavity, and displacement of the uterus toward the right side. By a contrast medium study of the small intestine, we suspected stenosis of the ileum in the pelvic cavity. Because of the repetition of symptomatic agility and deterioration, an operation was performed. After laparotomy, we found that a 15cm long segment of the ileum approximately 30cm proximal to the ileocecal valve was herniated into a defect of the left broad ligament of the uterus. The obstruction was released without bowel resection because the incarcerated bowel was intact. The defect of the broad ligament was closed. The postoperative course was uneventful.
We emphasize the importance of considering this disease for early diagnosis and treatment when a woman suffers from agnogenic intestinal obstruction.

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A case of mesenterium commune presented with volvulus of the sigmoid colon is reported.
A 38-year-old man complaining of abdominal pain showed dilatation of the intestine with air-fluid level formation on an abdominal plain x-ray film. Barium enema study demonstrated bird beak's sign at a portion where was compatible with the sigmoid colon. We gave up conservative therapy because there was a risk that ischemic change might occur, and performed an emergency operation. It disclosed a condition of severe mesenterium commue, in which incomplete fixation had extended from the duodenum to descending colon, the sigmoid colon was twisted, and the transverse colon was impacted in the Winslow's foramen, showing a complicated run of the intestines. Since the volvuls was able to be reduced manually due to absence of ischemia, no intestinal resection was needed and part of the mesentery was fixed to the retroperitoneum.
Mesenterium commone associated with volvulus of the sigmoid colon is so rare that only 11 cases, including our case, have been reported in Japan.

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The patient was a 72-year-old woman who had previous histories of varicose vein of lower extremity, old myocardial infarction, liver cirrhosis, and diabetes mellitus. In January 2006, the patient was admitted to another hospital because of abdominal pain and anal bleeding, but she was referred to the hospital after unsuccessful treatment as well as the further development of peritoneal signs on the next day. Abdominal enhanced CT scan showed partial and serious thickening of the small intestinal wall, and there existed remarkable peritoneal sign. Thus an emergency laparotomy was performed with a suspicion of generalized peritonitis due to partial ischemia of the small intestine. Upon laparotomy the jejunum by about 60cm in length became congestive and necrotic, and thrombi were seen in the mesenteric vein. Mesenteric venous thrombosis (MVT) was diagnosed and the intestine was removed at a normal area and anastomosed simultaneously. Anticoagulant therapy was started early after the operation. Another abdominal enhanced CT scan revealed remnant thrombi in the portal vein, but no increasing tendency was noted and the blood flow was kept favorably. MVT is a relatively rare entity in acute abdomen and its symptoms are non-specific so that early diagnosis is often difficult. This paper deals with our experience with a case of MVT with liver cirrhosis.

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We report a long-surviving case of liposarcoma arising from the mesocolon requiring five opera-tions. A tumor 10cm in diameter arising from the mesentery of the sigmoid colon was removed from a 58-year-old female in November 1989. The pathological diagnosis was a well-differentiated liposarcoma. The follow-up CT scan disclosed local recurrence of the tumor in the retroperitoneum in January 1994. The tumor was removed with partial resection of the adjacent rectum. Thereafter, we performed resections three times for recurrences of retroperitoneum and buttocks after the second operation. Pathological examination of the resected specimens at the second and fourth operation yielded a diagnosis of dedifferentiated liposarcoma. There is no evidence of recurrence after the fifth operation, 16 years after the first one.
In principal, surgery is the treatment of choice for liposarcoma, so one should perform acurative operation repeatedly in the case of postoperative local recurrence without distant metastasis.

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A 93-year-old woman presented with abdominal distention and appetite loss in October 2000. Her CEA level was high, and an abdominal CT scan revealed low-density areas measuring 12cm in diameter in the lower abdominal area. She was diagnosed to have pseudomyxoma peritonei, but she refused operation because of her advanced age. However, after six months, the abdominal distention and low-density areas on CT both slightly increased, and she therefore consented to undergo an operation in May 2001. At laparotomy, jelly-like ascites were found in the upper-left area and pelvic region. A mucinous cyst and solid tumor were found in the left ovary. An ovariectomy was performed and as much as possible of the jelly-like mucus was removed. A histological examination revealed pseudomyxoma peritonei arising from a mucinous cystadenocarcinoma of the ovary. The postoperative course was uneventful. She is doing well as of 9 months postoperatively without any CT evidence of an increase in ascites. Pseudomyxoma peritonei treated by surgery in a woman of advanced age is rare. Operative treatment should therefore be considered as an option for pseudomyxoma peritonei even if the patient is over 80 or 90 years of age.

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The patient was a 73-year-old woman with a history of sigmoidectomy for sigmoid colon cancer in 1991 and left lobectomy of liver for metastatic liver tumor in 1996. Following abdominal CT, in 2005 she showed a tumor beneath the lower abdominal wall. FDG-PET presented an abnormal accumulation in the same part. The possibility of metastatic abdominal wall tumor of the colon cancer could not be ruled out, so the tumor was removed in October 2005. Histopathologically, the tumor showed inflammatory changes and generation of elastic fiber without malignancy so it was diagnosed as a Schloffer tumor.
It was suggested that Schoffler's tumor should also be taken into consideration as a differential diagnosis in patients with a past history of operation and FDG-PET reveals cumulative operative wounds of the abdomen.

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A 79-year-old woman complaining of epigastralgia and dyspnea was referred to our hospital. Computed tomography revealed a diaphragmatic hernia with incarcerated transverse colon and fat tissues. Laparoscopic repair for the hernia was attempted. Laparoscope showed the Morgagni-Larrey hernia, and the size of the hernia orifice was 5×3cm in diameter. The defect was closed by laparoscopic direct sutures and reinforced with a Composix Mesh^® fixed by a hernia stapler. We also made it easy to suture the hernia orifice by decreasing tension of the hernia orifice. The patient recovered promptly after hernia repair, and there was no recurrence in a chest X-ray film 1 year after the operation. Laparoscopic repair for Morgagni-Larrey hernia presents an attractive alternative to open surgery. Furthermore, the Composix Mesh^® makes the procedure easier and recovery certain.

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