To diagnose axillary metastasis of breast cancer and to determine the possibility of conserving the axilla preoperatively, we appraised the diagnostic ability of maximum intensity projection imaging of the axilla with enhanced MRI (hereafter referred to as axillary MIP). This provides a bird's-eye view of the axillary fatty tissue from level I to II, just then observing the enhanced lymph node we diagnosed axillary metastasis of breast cancer preoperatively on the diagnostic standard of its shape and enhancement change in course, and compared with the pathological results of dissected axillary lymph nodes. The diagnostic efficiency of axillary MIP was shown by its sensitivity 90.9%, specificity 77.0%, accuracy 80.2%, positive predictive value 54.1%, and negative predictive value 96.6%. Therefore, it follows that, in negative cases of axillary MIP, 96.6% of them could be diagnosed as able to conserve their axilla preoperatively, and we conclude that axillary MIP can produce the basis for selecting an axillary conserving operation. Also, we suspect that preoperative axillary MIP can prevent the sentinel lymph node biopsy method (its sensitivity is 80% by dye method, 89% by RI method and 96% by bipartite method) from being overlooked by skip or minute metastasis and the like.

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Method: We report the result of study in 122 cases of phyllodes tumor of breast, experienced between Nov. 1979 and Feb. 2005, in regard to its age distribution, size of tumor, histopathology, pattern of recurrence and clinical prognosis.
Result: Age distribution was 15_??_73 years old (median age: 42 years old). Size of the tumor was <2cm in 23.0%, 2_??_5cm in 18.0%, 5_??_10cm in 50% and> 10cm in 9.0%. Degree of malignancy was benign in 79.5%, borderline malignancy in 10.7% and malignant in 9.8%. Local recurrence was observed in 26 cases (21.3%) and among them 7 out of 21 originally benign cases showed progression in pathological grade (benign to borderline in 4 cases, benign to malignant in 3 cases), and 1 out of 2 originally borderline cases progressed to malignant. Pulmonary metastasis occurred in 2 out of 16 malignant cases.
Conclusion: In phyllodes tumors of the breast it is important to distinguish malignant from benign tumor by histopathological study. In case of malignant tumors the possible local or distant metastasis should be kept in mind. Even benign or borderline cases, the possible progression in histopathological degree should carefully be watched.

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To evaluate the effect of administration of “Hochu-ekki-to (TJ-41), ” a Japanese herbal medicine, on surgical stress, we studied the effect of TJ-41 on the patients undergoing gastrectomy or colectomy in a prospective, randomized, multicenter clinical trial. Forty-eight patients with stomach (gagstric)/colon cancer undergoing gastrectomy or colectomy were allocated randomly to the two groups; the group receiving 7.5g/day of TJ41 before surgery (n=22) and the control group (n=26). The value of soluble IL-2 receptor (sIL-2R) right before the surgery, the concentration of cortisol on the 1^st day after surgery, and body temperature during the study were significantly controlled in the TJ-41 group compared to those in the control group. It is suggested that preoperative administration of TJ-41 might ameliorate excessive postoperative response and decrease postoperative complications.

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Background: This is the review of our experience in the treatment of intractable ascites using Denver peritoneovenous shunt. Methods: Thirty-five patients with intractable ascites who were treated with Denver peritoneovenous shunts were studied. Results: No technical complication were shown. All patients decreased in body weight and abdominal girth. Symptomatic relief was achieved in 28 patients (80%). Clinical DIC occurred in 14 cases (40%), 6 patients (17.1%) out of these died within 30 days directly related to DIC. Conclusion: Even though serious complication of DIC occurred, Denver peritoneovenous shount is a useful palliative procedure for the selected patients with intractable ascites.

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A case of occult thyroid carcinoma is reported, beginning with the appearance of a cystic mass in the right cervical region. A 54-year-old man was admitted to our hospital because of a mass lesion in the supraclavicular fossa pointed out by physical checkup. A cystic tumor with an inner solid component was detected by ultrasonography and computed tomography, and was diagnosed as adenocarcinoma by fine-needle aspiration cytology. Further examination showed a solid tumor measuring 5×3mm within the thyroid right lobe.
Right hemithyroidectomy with lymphnode dissection was performed. Histopathological examination confirmed thyroid papillary carcinoma with cystic lymphnode metastasis.
Generally, total thyroidectomy and neck lymph node dissection were accepted in such cases, because multifocal intrathyroidal metastasis and/or metastasis to lymphnode in the opposite side frequently occurred. However, these metastases did not always spread to the opposite side. It seems to be open to discussion that the operation method should be considered in terms of each individual case.

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A 56-year-old woman, who had been receiving hormone replacement therapy (HRT) for postmenopausal symptoms for one year, found a small mass in the D area of her right breast. The tumor 1.5cm in diameter was diagnosed as mucinous carcinoma by mammography, ultrasonography, MRI, and aspiration cytology. Wide excision and sentinel lymph node biopsy were performed. As the result of sentinel lymph node biopsy was negative, axillary lymph node dissection was not done. Histologic examination revealed that the tumor was pure type of mucinous carcinoma and classified as stage I (pT1c, N0, M0), ER(+), PgR(+), Her2(-).
Although HRT slightly increases the incidence of breast cancer, the HRT-related breast cancers have a relatively low malignant potential with less aggressive histological types of carcinomas and a favorable prognosis. As HRT is important to maintain health of postomenopausal women whose average span of post menopausal life has come to about 30 years, it will be more widely used in Japan. Thus, careful screening of breasts before and during HRT is highly recommended.

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A case of widespread apocrine ductal carcinoma in situ (ADCIS) is herein reported. The patient was a 44-year-old woman who complained of a huge lump in her right breast. The findings of the mammography, ultrasonography and core needle biopsy were compatible with ductal carcinoma in situ (DCIS). The result of sentinel lymph node biopsy was negative, therefore, a simple mastectomy was performed. Histological examination revealed this tumor as ADCIS with immunohistochemically positive for gross cystic disease fluid protein-15 (GCDFP-15) and HER-2 and negative for estrogen receptor, progesterone receptor and androgen receptor. ADCIS has unique morphologic and hormonal profiles, distinct from common DCIS, which would deserve a specific classification.

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The patient was a 62-year-old man complaining of fever and a wet cough. He underwent distal gastrectomy and left adrenalectomy for early gastric cancer and bilateral adrenal swelling, respectively, followed by percutaneous drainage for postoperatively associated left subphrenic abscess, which was successful, in January 2002. In February 2004, he developed a left subphrenic abscess and a bronchial fistula which were treated by incision drainage and bronchial occlusion. In June of the year when chemotherapy was started for newly diagnosed osteomyelodysplasia, the patient experienced recurrent left subphrenic abscess and bronchial fistula associated with pneumonia of the left lower lobe of lung, so that left lower lobectomy of lung and associated resection of the fistula were performed in August. Chemotherapy resumed on the 8^th week after the operation, and the patient was discharged from the hospital in November, 3 months after the operation. In this patient, we aimed to achieve a radical operation by excising the entire lesion including the fistula, in order to maintain the chemotherapy for osteomyelodysplasia.
We report the case here because associated resection of the lobe of lung appears to be an option for cases resistant to therapies like recurrent cases after bronchial occlusion, as the therapy for a left subphrenic abscess with a bronchial fistula.

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Hiatal hernia recurred after laparoscopic Nissen fundoplication for GERD, for which we successfully performed further laparoscopic surgery. The patient was a 32-year-old male who complained of stomachache around 4 months after surgery. Barium esophagogram revealed displacement of the abdominal esophagus and fundic wrap within the mediastinum, and endoscopy revealed enlargement of the esophageal hiatus and displacement of the wrap within the mediastinum. Based on the above findings, the patient was diagnosed with recurrence of esophageal hiatal hernia, and laparoscopic re-surgery was conducted. The wrap prolapsed into the mediastinum, the oral side of the esophagus from the wrap was expanded and exposed, and the enlarged diaphragmatic crus was then 3-sticthed. Then left and right wraps were fixed to the respective diaphragmatic crus on the same side, and surgery was completed. Time of operation was 125 minutes, and the amount of bleeding was small. Oral ingestion was begun on the second day after operation, and the clinical course was excellent. On the 7^th hospital day, he was discharged. As of 1 year and 10 months after surgery, no recurrence has been observed.

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We report a rare case of myxofibrosarcoma of the diaphragm.
A 45-year-old woman complaining of dull pain in the left hypochondrium was admitted to our hospital, because she was pointed out a left abdominal tumor on ultrasonography at another hospital. Abdominal CT and MRI revealed a discrete tumor about 17cm in diameter in the left hypochondrium, which compressed the stomach, spleen, pancreas, and left kidney. Angiography disclosed that the tumor was fed from the left subphrenic artery. Operative findings showed that the tumor had arisen from the diaphragm, and we performed the tumor resection combined with the spleen and part of the diaphragm. The histopathological diagnosis was myxofibrosarcoma (myxoid malignant fibrous histicytoma). She is under adjuvant chemotherapy with MAID (MESNA+ADM+IFM+DTIC), and has no recurrence, as of two months after the surgery.

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A 78-year-old man was seen at the hospital because of feeling heavy in the stomach and loss of appetite in July 2004. He was found to have an easily bleeding submucosal tumor which was full of the lumen at the lower esophagus by endoscopy. Biopsy specimen from the ulcer of the tumor showed growth of spindle cells. Immunohistochemically, the tumor cells were positive for kit and negative for desmin and s-100 protein. Therefore, the tumor was diagnosed as esophageal GIST. Esophago-cardiectomy was performed on August 9, and reconstruction was made by using the stomach tube in the right thoracic cavity. During the operation another tumor 1cm in diameter was found in the segment 2 of the liver. It was diagnosed as a metastatic liver tumor from the esophageal GIST and partial resection of the liver tumor was perfomed at the same time. The removed tumor was 5×6×4cm in diameter, and was composed of spindle cells pathologically. Immunohistochemically, the tumor cells were diagnosed as GIST. The liver tumor was diagnosed as metastasis from the esophageal GIST.
Esophageal GIST is a rare disease and accounts for less than 2% of all GISTs. Only 28 cases of esophageal GIST have been reported in Japan. We report this case with some bibliographical comments.

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A 50-year-old man who had been staying in an institution for cerebral palsy from his childhood underwent percutaneous endoscopic gastrostomy (PEG). After one and a half years, the patient presented with anemia and fecal occult blood. GIF and fistulography revealed prolapse of the gastro-button and formation of a jejunal fistula, respectively. After removal of the gastro-button, the puncture site of the stomach was closed naturally and anemia improved. However, the jejunal fistula still existed and was intractable, so that he was referred to the hospital. We found that gastrojejunal fistula and jejunal fistula coexisted sequentially following surgical repair.
Formation of gastrojejunal fistula is a very rare complication of PEG, although some gastrocolonic fistulae have been reported previously. Such formation might be related to the anatomical position or skeletal structure prior to progressing to PEG.

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We report a case of gastric cancer with malrotation of intestine required re-operation for refflux esophagitis after total gastrectomy. A 64-year-old man found to have an elevated lesion at the gastric cardia by screening endoscopy. He admitted to the hospital with a diagnosis of well differentiated adenocarcinoma of the stomach. Abdominal CT scan showed non-anatomic displacement of the small intestine and colon and SMV rotation sign as well. We conssidered that he had gastric cancer with intestinal malrotation. During surgery, the duodenum was not fixed to the retroperitoneum and the Tritz's ligament was absent. The small intestine was located on the right side and the colon on the left, the cecum and ascending colon did not fixed to the retroperitoneum. The findings of the bowel indicated malrotation of nonrotation type. A total gastrectomy with Billroth II reconstruction was carried out because the jejunum was lifted to the esophagus easily. Intestinal fixation was not conducted. Postoperatively he complained of heartburn, nausea and vomiting. Endoscopic examination revealed esophagitis caused by bile reflux, and upper esophagointestinal series revealed that the lifting jejunum was fallen at the left upper abdomen to become a lump. The procedures for re-operation included cut of the afferent loop of jejunum and anastomosis to the ileum with 30cm anal side. Then we fixed the afferent jejunum to abdominal wall for prevention against shortening and volvulus. His symptoms as well as esophagitis on endoscopy disappeared after the re-operation.

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Meckel's diverticulum is silent in the clinical course in most cases. It sometimes casuses various complications, but perforation due to a foreign body is rare. We report a case of Meckel's diverticulum perforated by a fish bone.
A 59-year-old man, who received hemodialysis due to chrnonic renal failure, was admitted to the hospital because of the sudden onset of right lower abdominal pain. There were tenderness and muscular defense in the right lower abdomen. Leukocytosis and an elevation of CRP were noted. Abdominal CT scan showed a linear high density shadow in the intestine and free air as well as abscess formation in the mesenterium. We undertook an emergency surgery with a diagnosis of intestinal perforation by a fish bone. At laparotomy, Meckel's diverticulum at 30cm oral side from ileocecal region with a perforation caused by a fish bone was found. The diverticulum was removed.
There have been only 22 cases of perforation of Meckel's diverticulum by a fish bone in the Japanese literature. This case is thought to be very rare.

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We present a case of idiopathic perforation of the small intestine with a review of 38 case reports in Japan. An 83-year-old woman visited our hospital because of lumbago, and after medical treatment returned home. But she revisited the same day because of no improvement of the lumbago and was then admitted for observation of her clinical course. The next morning, abdominal X-ray films revealed right subphrenic free air, and endoscopic examination upper digestine that revealed no special lesion. An emergency laparotomy was performed with a diagnosis of perforation of the large intestine. At the laparotomy, the perforation was confirmed at the ileum, located 80cm from Bauhin's valve. A partial ilial resection including the perforated lesion measuring about 25cm was then performed. Histologically, the mucosa, muscle and serosa layer were completely cleft, and special lesions were not seen around the perforated lesion. The cause of the perforation was not specified from any findings, and the patient was definitely diagnosed with idiopathic small bowel perforation. The postoperative course was good, and she was discharged on the 61th postoperative day.

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A 45-year-old woman suffering from constipation and using laxatives consistently received conservative treatment twice for ileus. An abdominal X-ray showed dilated intestine with air fluid level. Enhanced abdominal CT showed dilated intestine with air fluid level and sudden loss of the ascending colon. A CT-colonography to identify the pathway of the intestine revealed a looped, dilated ileo-cecal portion with the bird's beak sign on the bilateral edge of the left upper abdomen and a dilated ileum on the oral side of the ileo-cecal portion of the right lower abdomen. MPR (coronary section) showed a whirl-like pattern in the center of the lower abdomen. Under the diagnosis of ileus due to cecal volvulus, we performed emergency laparotomy. At surgery, the cecum was bent 180 degrees in relation to the left upper abdomen and rotated counterclockwise 180 degrees around the mesentery. The findings were completely in accord with the preoperative CT-colonography. After we reduced these changes and confirmed recovery of blood circulation, we performed cecopexy to the paracolic gate. The postoperative course was uneventful.

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We report a case of metastatic tumors of small intestine, regarded as hematogenous spread of the rectal cancer, causing bowel obstruction after 2.5 years from the operation of rectal cancer. The patient was a 60-year-old man. We performed low anterior rectal resection and hepatectomy of lateral segment for rectal cancer and liver metastases in May 2000 (Rs, circ, type2, 5.2×4.5cm, moderatelly differentiated adenocarcinoma, ss, ly1, v1, n3(+), H(+), M(-)). After 1.5 years from the operation, metastases in the remnant liver, lung and paraaortic lymph nodes appeared, so chemotherapy was started as an outpatient and metastatic lesions were controlled. After 2.5 years from the operation, bowel obstruction developed and did not improve by conservative treatment, therefore, we performed operation. We found two metastatic tumors in the ileum, and one of them was a submucosal tumor on the mesenteric side, therefore, it was thought that the cancer of the rectum spread to small intestine by blood circulation. Postoperative clinical course was good and chemotherapy was started as an outpatient. Now, after 2.5 years from the operation of ileal metastases, even the patient lives with cancer, visits outpatient clinic for medical treatment and maintains good QOL. While hematogenous metastasis to small bowel from colorectal cancer is rare, good prognosis and QOL may occasionally be attained.

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The patient was a 59-year-old male with malignant lymphoma (non-Hodgkin's lymphoma) mainly located in the ileocecum. After 2 courses of chemotherapy with CHOP for the malignant lymphoma, the patient developed intestinal obstruction on June 22, 2004. Although surgical treatment was indicated, he presented myelosuppression (WBC count=1, 800/μl) at the onset of ileus. Therefore, myelosuppression was treated by G-CSF, and when the WBC count became to above 3, 000/μl, he underwent ileocecal resection on August 26, 2004. Pathohistological findings included severe fibrosis and inflammatory cells infiltrating in the stenotic region, as well as some concentration of large atypical lymphocytes, resulting in the diagnosis of diffuse large B-cell lymphoma. The postoperative course was favorable, and oral food ingestion and medical treatment for the lymphoma were resumed. Along with recent advances in chemotherapy, we are demanded to establish careful therapeutic strategy for condidates of operation for malignant lymphoma with myelosuppression, after considering whether elective surgery can be selected or not.

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A 70-year-old woman was admitted to our hospital, complaining of right lower abdominal pain. She underwent appendectomy with the diagnosis of acute gangrenous appendicitis. Histopathological examination revealed small atypical cells with a high nuclear to cytoplasmic (N/C) ratio in the mucosa and submucosa of the appendix, in which a portion was composed of well-differentiated adenocarcinoma. Immunohistochemical examination of an area with a high N/C ratio was positive for NSE, synapto-physine, and Ki-67 and p53 staining in the tumor tissue, indicating endocrine cell carcinoma. She then underwent right hemicolectomy, but died five months later with multiple liver metastases. Endocrine cell carcinoma has an aggressive clinical course and a poor prognosis.

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An elderly man in his seventies visited our hospital by bicycle complaining of abdominal distention and left lower quadrant pain. A CT scan showed free air, the thickening wall of the descending colon, and a 4-cm linear, high-density shadow in the descending colon. Following much discussion, we assumed that the perforation of the large bowel had been caused by a fish bone. An emergency operation was performed. There were two perforations, one at the transverse colon and the other at the descending colon due to the stuck fish bone. There was a state of general peritonitis. Left hemicolectomy, lavage, and transverse colostomy were performed. Upon removal of the specimen, the shape of the fish bone resembled the shapes of both holes it had left. Thus, one fish bone apparently caused two sequential perforations of the large bowel, causing both chronic and acute symptoms.

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Anal canal duplication (ACD) is an extremely rare anomaly of the gastrointestinal tract. We present a case of cystic ACD diagnosed in an adult. The patient was a 41-year-old female who had been noticed to have two holes in the anus, the one hole of which was a blind fistula 20 years earlier. She was seen at the hospital because of persistent consitipation and increasing menstrual pain. Transvaginal ultrasonography and pelvic MRI showed two cysts at the posterior aspect of rectum. She was admitted for close exploration. Through anal inspection, we detected an orifice located at the dorsal aspect of the anal canal below the dentate line. CT showed two tear-drop shaped cysts located beside the rectum. We recognized a low intensity nodular lesion within the dorsal cyst in MRI. CT and MRI findings showed no other anomalies. A barium enema showed a fistula 25mm in length along the posterior anorectum. The fistula had no communication with the anorectum and sacrum. Pinching biopsy from the bottom of the fistula disclosed stratified squamous epithelium. Removal of these cysts was performed through a sacral approach. Firm restiform tissue was connected with the ventral cyst and fistula. Histopathological findings showed stratified squamous epithelium and smooth muscle. These cysts were of multilocular type. The postoperative clinical course was uneventful and the anal function was satisfactory. This case is the seventh reported case in adults all over the world, and the first in Japan.

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This paper presents a case of Fournier's gangrene developed one year after surgery for rectal prolapse using procedure for prolapse and hemorrhoids (PPH).
A 71-year-old woman was seen at the hospital because of anal pain. She had been administered adrenocortical steroid orally for rheumatoid arthritis for a long time, and had undergone an operation using PPH for rectal prolapse one year before entry. Local findings when she was seen included redness and swelling from the right gluteal region to right labia majora with tenderness. Pelvic CT scan revealed extensive subcutaneous emphysema at the same region. Fournier's gangrene was diagnosed and a colostomy and debridement were performed. Operative findings disclosed perforation at the rectal wall which was identical with the area where the mucosa was transected by stapling anastomosing device.
To the best of our knowledge, this is the first case of Fournier's gangrene developed after surgery with PPH for rectal prolapse in Japan. It should be hept in mind that Fournier's gangrene may occur in such patients an their immune systems are suppressed or compromised.

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A 9-year-old boy was found to have severe anemia when he visited a clinic for the treatment of asthma. No bleeding lesion was found in the upper and lower gastrointestinal tract while colonoscopy revealed many polyps in the large intestine. He was diagnosed as having familial adenomatous polyposis by genetic examinations as he had a family history of the disease. Small intestinal endoscopy under general anesthesia demonstrated a bleeding lesion in the distal duodenum and also many polyps in the jejunum which were marked using India ink. Surgery was indicated for those duodenal lesions as they were not able to be treated endoscopically. The entire area of the small intestine was examined through intraoperative endoscopy and all duodenal lesions and small intestinal polyps, a total of 18 lesions, were resected. Restorative total proctocolectomy was not performed at the same time because it might be too invasive for this case. The patient's postoperative course was uneventful and then oral administration of selective cyclooxygenase-2 inhibitor was started. Further we will follow the patient by annual endoscopic study of the upper and lower gastrointestinal tract and perform total removal of the large intestine when his body weight increses to permit it.

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The patient was a 51-year-old woman. In 1985, 19 years earlier, she had undergone an excision of the total colon and rectum for familial adenomatous polyposis (FAP) with cancer of the sigmoid colon, when multiple gastroduodenal adenomas had already been detected. In 1997 one of gastric adenomas in the gastric body showed a rapidly increasing tendency to be the diameter of 6cm, so that the gastric adenoma was excised under laparotomy. The pathological diagnosis was tubulovillous adenoma. Thereafter she received long-term observations by endoscopy once or twice a year. In 2004, an endoscopy examination and biopsy revealed a type 3 gastric cancer in the fundus. Abdominal CT scan disclosed #10 and #11d lymph nodes swelling. Therefore we performed proximal gastrectomy with distal pancreatectomy and splenotomy. Pathological diagnosis was porl, ly3, v2, mp, pm(-), dm(-), n2, m0 and stage 3A. The patient was prescribed S-1 and followed as an outpatient, but 6 months after the operation tumor markers elevated rapidly and abdominal CT scan revealed multiple liver and lymph nodes metastases. Chemotherapy was ineffective, and she died 8 months after the operation. It is very important for gastroduodenal lesions of FAP to be observed carefully for a long term, because the frequency of carcinogenesis of gastric and duodenal lesions associated with FAP is not low.

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The patient was a 54-year-old female who had left hemicolectomy for gastrointestinal tumor (GIST) found in 1994. The recurrence of the tumor was not seen until May, 2003, 9 years after the initial operation when a tumor of 2cm in size was discovered in S7 of her liver by CT study. With suspicion of metastasis from the GIST, partial hepatectomy was performed and the diagnosis was established by pathological study. The postoperative course was uneventful and 2 years has passed without recurrence. The incidence of GIST originating in colon is quite rare and the reports of cases of hepatic metastasis after original resection is also rare. Therefore, we report this case with some review of literatures.

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A 49-year-old woman was diagnosed as having a rectal cancer. We performed low anterior resection. Histological findings revealed carcinoid tumor with lymph node metastases. About 4 years later, we diagnosed multiple liver metastases from rectal carcinoid tumor. Intrahepatic arterial infusion with 5-FU and TAE was performed. A complete response was attained on computed tomography after the therapy. We diagnosed a metastatic tumor in liver (S7) and performed RFA to the tumor. Ater the therapy, another metastatic tumor in liver (S4) was found and we performed RFA again. RFA was repeated to the tumor (S7) again. The patient lived for 5.5 years after we diagnosed multiple liver metastases. The multidisciplinary therapy was effective for multiple liver metastases from rectal carcinoid tumor.

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An 89-year-old man visited the hospital near his house due to abdominal pain on May 31, 2003. Plain chest X-ray film showed free air in right subphrenic space. He was referred to our hospital with diagnosis of perforation of intestine. He was admitted to our hospital, and abdominal CT scan revealed free air, ascites, and the wall thickening of sigmoid colon. We made diagnosis of peritonitis secondary to perforation of intestine, and performed emergency laparotomy on May 31. The operation revealed sigmoid colon perforation due to press through package (PTP) and presence of sigmoid colon cancer. The partial resection of the sigmoid colon with sigmoid colostomy was performed. Septic shock complicated postoperatively, but absorption of endotoxin and other treatments improved his condition.
The early diagnosis and the prevention of accidental swallowing are important to avoid bowel perforation caused by PTP.

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We describe a technique for the treatment of hepatic encephalopathy with a large spontaneous splenorenal shunt. A 64-year-old woman presented at our hospital with a decreased level of consciousness and a flapping tremor. Her serum laboratory data included as ammonia level of 158μg/dl. Ultrasonography, computed tomography and angiography showed the presence of a large splenorenal shunt. Therefore, the portal flow could potentially be improved by reducing portal-systemic shunting, thereby reducing fasting serum ammonia levels and improving the patient's chronic encephalopathy. We surgically ligated the splenorenal shunt during an open laparotomy. No incidences of hepatic encephalopathy occurred during the 7-month follow-up period.

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A 61-year-old woman was referred to our hospital for evaluation and treatment of a hepatic mass detected by health examination. She exhibited no symptom. Initial laboratory tests were normal, and all tumor markers examined were within normal remits. Abdominal ultrasound showed a hypoechoic lesion, measuring 1.1cm in diameter, in the posterior inferior segment of the liver. Computed tomography (CT) showed a low-density area and a slightly high-density area in the arterial phase in the posterior segment of the liver. By magnetic resonance imaging (MRI), the mass showed a lowintensity on Tl-weighted imaging and moderate-to-high-intensity on T2-weighted imaging. Superparamagnetic iron oxide (SPIO)-MRI showed high-intensity lesion in the posterior inferior segment of the liver. ¹⁸F-fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed a hot nodule in the liver. Angiography detected a slight hypervascularity in the posterior inferior segment of the liver. The mass showed a perfusion defect in CT during arterialportography (CTAP) and ring enhancement in CT during arteriography (CTA). We performed a partial resection of the posterior inferior segment of the liver and cholecystectomy under the diagnosis of cholangiocellular carcinoma. The resected specimen contained a yellowish-white mass, 1.1cm in diameter. The final histological diagnosis was inflammatory pseudotumor of the liver. The patient's postoperative course was favorable, and she was discharged on postoperative day 12.

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We performed surgical resection for a case of hepatic metastasis of adenoid cystic carcinoma from the submaxillary gland. A 71-year-old female under went a submaxillary tumor resection on October 2003. The pathological diagnosis was adenoid cystic carcinoma of the submaxillary gland. She was given chemotherapy with 5-FU 300mg by oral administration for about two months. FDG-PET was performed for follow-up of the recurrence, and it showed hepatic metastasis at the caudal lobe. On October 2004, one year after the primary tumor resection, we performed extended left hepatic lobectomy after closer examination. Hepatic tumor was histologically diagnosed to be a 3.1-cm solid type adenoid cystic carcinoma compatible with metastasis from the submaxillary gland.

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A 33-year-old woman who had the abrupt onset of right upper abdominal pain during pregnancy visited a hospital on October 17, 2003. Following abdominal ultrasonographic study which disclosed dilatation of the intrahepatic bile duct, she was referred to our hospital for close exploration. Abdominal ultrasonography at our hospital revealed cystic dilatation of the common and intrahepatic bile ducts and an about 45mm-sized well-defined and solid tumor in the left intrahepatic bile duct. After other examinations bile duct cancer at the left porta hepatis associated with congenital dilatation of bile duct was suspected, and left lobectomy of liver and excision of the extrahepatic bile duct were performed on February 4, 2004 when she had been delivered. On the removed material we confirmed an elastic-soft and solid tumor, with a yellowish white section, projecting into the dilated left intrahepatic bile duct, and then diagnosed it as small cell carcinoma of the bile duct histopathologically. Abdominal CT scan performed one year after the operation showed recurrence at the surgical stump of liver. She has been followed under chemotherapy at present.
Small cell carcinoma of the bile duct is a rare entity and a total of 13 cases, including ours, have been reported, but only our case is of the intrahepatic origin. Many patients have poor prognosis even after radical surgery so that aggressive postoperative adjuvant therapies must be considered.

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The patient 85-year-old male with underlying diabetes was hospitalized with compression fracture of thoracic vertebrae from a fall. Even though the patient's general condition had improved with conservative treatment, fever with temperatures of 39 degrees C continued and labo data showed significant inflammatory response on the 10th day hospitalization. CT (computerized tomography) revealed right pleural effusion, swelling of the gallbadder, some gallstones, and fluid accumulation in the lateral right lobe of the liver, indicating possible presence of biloma. The patient was transferred to our department for puncture-drainage treatment. The biloma and gallbladder decreased in size with no surgical treatment, and subsequently spontaneous remissions occurred. The patient was scheduled to be discharged, but biloma recurred. Considering repeated recurrence of biloma, cholecystectomy under laparotomy and intraoperative contrast studies of biloma were performed. We identified fistula between liver bed of gallbladder and biloma. Thus, liver injury caused by trauma and internal pressure elevation of gallbladder caused by cholelithiasis/cholecystitis was likely to be the cause of repeated recurrence of biloma. At three years after operation, the patient is in good condition with no recurrence of biloma.

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A 79-year-old woman was admitted to the hospital for abdominal pain and abdominal X-ray and computed tomography (CT) showed markedly distended colon on the right side accompanied by tenderness on the right upper abdomen without muscle guarding. We managed the patient by fasting and intravenous feeding. The next day, signs of peritoneal irritation increased. Therefore, we conducted an emergency laparotomy under a diagnosis of acute peritonitis. Surgical findings demonstrated the perforation and necrosis of the gallbladder on the body, necessitating cholecystectomy. Gall stones did not exist and bile juice did not demonstrate infectious signs. Histological findings revealed necrosis and small coagulations in the gallbladder wall with abscess formation, but there was no sign of cholecystitis. Finally, we diagnosed idiopathic perforation of the gallbladder.

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An 81-year-old woman was examined at an affiliated hospital because of nausea and weight loss and found to have an abdominal mass. She was referred to our hospital. Contrast-enhanced abdominal CT showed a 14×14cm cystic mass consisting of a heterogeneously enhanced thickened wall. The tumor made extensive contact with the head of the pancreas, but the main pancreatic duct was not dilated. 3D-CT showed that the tumor was fed from the right gastroepiploic artery and the vessel arising from the bifurcation of the common hepatic artery and the gastroduodenal artery. Pancreatic cystic tumor was suspected based on the imaging findings. Laparotomy showed a mass that tightly adhered to, but did not invade, the lesser curvature of the stomach. Simple resection of the tumor was performed. Histopathology showed the tumor was composed of proliferated spindle-shaped cells with fascicular patterns and mitotic figures in a 1_??_2/10 high power field. Immunohistochemically, the tumor was positive for c-kit and CD34 but negative for S-100 and alpha-smooth muscle actin, indicating a gastrointestinal stromal tumor (GIST) of the lesser omentum.

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Proliferative fasciitis has been reported as a rare disease and its retroperitoneal occurrence is quite rare.
A 51-year-old man was admitted to the hospital because of a painless hard tumor in his right hypogastrium. Abdominal CT scan showed a 9cm-sized retroperitoneal tumor which was adjacent to the right iliopsoas muscle and displaced the cecum. A malignant tumor of the retroperitoneum was suspected and laparotomy was performed. The tumor 11cm in diameter was present in the retroperitoneum involving the ureter and invading the iliopsoas muscle. The removal of the tumor with right ureterectomy was performed. The tumor was diagnosed as proliferative fasciitis histologically and immunohistochemically. Proliferative fasciitis commonly occurs in the extremities, and in a benign disease characterized by the appearance of ganglion-like cell. Some spontaneously involuted cases have been reported. But the retroperitoneal occurrence of the disease like in this case is quite rare, and we consider the case is interesting.

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A 73-year-old man noticed a subcutaneous tumor of the left brachium during hospitalization for acute arterial obliteration of the right upper limb. The tumor was 3×2×2cm in diameter and clearly demarcated, there being no tenderness. No abnormalities were seen in the surrounding veins. No vascular murmur was heard. The tumor was easily diminished by compression and changed in size with locations of the upper limb. Venogram showed localized cystic dilatation of the cephalic vein where was identical with the position of the tumor. The tumor removed under local anesthesia was histopathologically explored. It showed that the tumor wall composed of thinning venous wall, in which both tunica intima and externa were mostly normal but the number of smooth muscle cells as well as amount of elastic fibers was decreased in the tunica media. Consequently venous aneurysm was diagnosed.

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