Objective: With a recent widespread use of breast-conserving therapy, it has increasingly become important to assess the degree of extension of breast cancer. This study was made to examine the diagnosis of extension of breast cancer, especially for extensive intraductal component (EIC), by multidetector-row CT (MD-CT).
Subjects and Methods: One-hundred and forty-eight resected lesions of invasive breast carcinoma in which MD-CT was performed were subjected to this study. Histological preparations were made of the resected material at intervals of 5mm, the presence of EIC was determined, and then the results were compared to CT findings.
Results: Extending morphologies of tumors on CT were classified into six categories, and abnormal (linear, spotty, or cord-like) stains continuing from the main lesion were designated EIC positive. The sensitivity for EIC was 74.6%, the specificity was 80.0%, and the accuracy was 77.7%. The underestimation (detachment of more than 10mm) was noted in 18 cases and the overestimation, in 24 cases. Sporadic EIC was apt to be underestimated. Difficult cases in evaluation are considered to be of: 1) scirrhous carcinoma (or including scirrhous component) or lobular carcinoma; 2) intraductal component dominant tumor (mainly DCIS); 3) mastopathy; 4) breast cancer including cystic lesion such as mucinous carcinoma; and 5) including necrotic component such as comedo type.

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The continuous vertical mattress technique for anastomoses in the gastrointestinal or colorectal surgery has not been well reported in the literature. We use the technique (“Continuous Gambee's method”) for all hand-sewn anastomoses with a double-armed monofilament absorbable suture. In the 535 consecutive anastomoses, there were 4 anastomotic leakages (0.75%) and 1 anastomotic stricture (0.19%). Intestinal obstruction and peritoneal dissemination of cancer were statistically significant risk factors of the leakege (_??_0.001). The technique is feasible and economical and achieves satisfactory results. It may be used for every case requiring hand-sewn gastrointestinal anastomosis.

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Objective: We have assessed risks of laparotomy in patients with apoplexy.
Methods: This study enrolled consecutive 77 patients undergoing laparotomy at the hospital in a 3-year period from January 2002, who had been hospitalized for apoplexy. For the risk assessment of the surgery, these patients were divided into two groups, one (n=33) with and another (n=44) without postoperative complications, and compared for preoperative factor, blood test findings, surgical factors, and POSSUM.
Results: There were four hospital deaths (5.2%). Significant differences between the two groups were noted in the preoperative factor and 6 test items including age, after cerebral bleeding, with respiratory impairment, more than two in the performance status, albumin level, and cholinesterase level. As for surgical factors, emergency operation and blood loss were significant factors, and significant differences were noted in three items of POSSUM.
Conclusion: The performance status and POSSUM are useful indexes for preoperative risk assessment of laparotomy in patients with apoplexy.

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Fibromatosis of the breast is a rare benign tumor. This entity is very difficult to differentiate from breast cancer, and the local recurrence rate after resection is high. We describe such a rare case of breast fibromatosis diagnosed by mammotome biopsy. A 74-year-old woman was admitted for an abnormal shadow on her mammography and ultrasonography. The tumor was 1.2cm×1.1cm in size and located in C region of the breast and was suspected to be breast cancer. Aspiration biopsy cytology was performed, but did not demonstrate tumor components. Mammotome biopsy under ultrasonic scans was thus performed. The histopathological diagnosis was fibromatosis of the breast without malignancy. Even if the fibromatosis is removed surgically, the local recurrence rate is very high. However, because this patient did not expect a wide resection, this tumor has been observed for two years, and has not increased in size.

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A 55-year-old woman was seen at the hospital for close exploration of breast tumor which was detected at mammography. Mammography showed a nodule exhibiting an unclear margin. Ultrasonographic study showed an oval and hypoechoic tumor. Excisional biopsy was performed. The histopathological diagnosis was tubular adenoma, revealing monotonous glandular formation with no atypism.
Since tubular adenoma of the breast is a benign disease, excisional biopsy is adequate for curative therapy. Tubular adenoma is rare and frequently seems to be malignant, so due care in the diagnosis is important.

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A 48-year-old woman was seen at the hospital because of a left breast mass. A 41×34mm demarcated tumor with smooth surface was present in the AC area of the left breast. No axillary lymph nodes were palpable. CT mammography showed an irregular tumor with ringed enhancement effect at the periphery. Fine needle aspiration biopsy resulted in ductal carcinoma with minute invasion. Left breast cancer (T2N0M0, StageIIA) was diagnosed and breast anserring surgery (Bp) and sentinel lymph node (SLN) biopsy were performed. SLN disclosed metastasis negative. Histopathological studies revealed invasive ductal carcinoma at the periphery and cartilaginous matrix with cancer cells at the center of the tumor. No spindle cells lay between cancer cells and cartilaginous matrix, and thus matrix-producing carcinoma (MPC) was diagnosed.
MPC is a subtype of breast cancers with osteocartilaginous metaplasia, and is an extremely rare entity. We present a review of the domestic cases of the disease as well as our case, making a special reference to the clinicopathological characteristics.

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We present two cases of unilateral multicentric cancer of the breast, showing special type and different pathological carcinoma. The first case involved a 75-year-old woman, who was seen at the hospital for a left breast tumor. There were two palpable tumors comprising a tumor 2.5cm in diameter in the A area and another tumor 1.5cm in diameter in the DC area of the left breast. Mammography visualized a spiculated tumor and branching calcifications, while ultrasonography visualized both lesions as hypoechoic tumors, and CT visualized both lesions as enhanced tumors. Breast-conserving surgery was performed for each tumor (Bp+Ax). Pathologically, the tumor in the A area was invasive lobular carcinoma and the tumor in the DC area was papillotubular carcinoma. The second case involved a 61-year-old woman, who was seen at the hospital for a right breast tumor. A tumor with the diameter of 1.5cm was palpated in the A area of the right breast. Mammography visualized an indistinct tumor, ultrasonography a hypoechoic tumor with slightly accentuating posterior echo, and CT revealed another enhanced tumor in the D area, apart from the tumor in the A area of the right breast. Breast-conserving surgery was performed for each tumor (Bp+Ax). Pathologically, the tumor in the A area was mucinous carcinoma and the tumor in the D area was papillotubular carcinoma.

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We report two cases of endocrine cell carcinoma that originated from the breast, a very rare phenomenon.
Patient 1, a 32-year-old woman, was seen at the hospital because of a right breast tumor. Aspiration biopsy revealed class III cytology, and the tumor was resected to make a histological diagnosis.
Patient 2, a 67-year-old woman, was seen at the hospital because of a left breast tumor. Aspiration biopsy cytology suggested an endocrine cell carcinoma, and a modified mastectomy was carried out.
Hematoxylin and eosin staining, chromogranin A staining, and electron-microscopic examination led to a diagnosis of endocrine cell carcinoma originating from the breast in both cases.

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A 61-year-old woman was admitted for a lef breast tumor detected by mammography screening. The left breast tumor was palpable and so was the right breast under the tumor. The right breast under the tumor was completely intact a long the milk line. A core needle biopsy of the right breast under the tumor was performed. Histological findings revealed invasive ductal carcinoma. A wide local resection of the right breast under the tumor and left radical mastectomy were carried out. Histological findings revealed invasive ductal carcinoma scirrhous and solid-tubular type left breast and invasive ductal carcinoma scirrhous type of the breast under accessory breast cancer. A very exceptional case of accessory breast cancer associated with contralateral invasive ductal breast cancer is described.

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Noninvasive apocrine carcinoma is a rare disease, and is not defined by the ‘General Rules for Clinical and Pathological Recording of Breast Cancer’ adopted by Japanese Breast Cancer Society. A 72-year-old woman had a periodic checkup for breast cancer, and a lump was pointed out in her left breast. She was given fine-needle aspiration biopsy cytology, and the tumor was diagnosed as malignant, and she visited our hospital for an operation. The tumor was palpated as a hard, elastic, smooth-surfaced, and movable mass measuring 10mm in diameter in the upper (AC-region) of her left breast. Mammography did not reveal a tumor shadow. Ultrasonography showed in hypoechoic mass in the left breast. A wide excision and sentinel lymph node biopsy was performed. The histopathological diagnosis was a noninvasive apocrine carcinoma. There was no metastasis of the sentinel lymph node. Both estrogen receptor and progesterone receptor were negative. The HER2 score was 3. She had no recurrence as of 4.5 years after surgery.

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We report a case of a 61-year-old woman with descending necrotizing mediastinitis (DNM) caused by a fish-bone in the hypopharyngeal region. Chest CT showed an abscess on the right side of the trachea in the middle mediastinum and reached the tracheal bifurcation. No septic condition was noted. Pus was drained under direct observation by mediastinoscopy, and a drain was placed in an appropriate position. Culture of pus showed streptococcus viridans. After operation lavage and injection of antibiotics were performed through the drain. The drain was withdrawn gradually and completely removed on postoperative day 14. The patient improved by degrees, and was discharged on postoperative day 24. Mediastinoscopic drainage should be considered as a surgical treatment for DNM in the absence of serious complication. This technique has a more reliable drainage effect than the conventional transcervical method and is less invasive than the thoracotomy method.

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A 32-year-old man was admitted because of an abnormal shadow on chest radiograph. The chest CT scan revealed a tumor expanding from the left 6th rib. The bone scintigraphy showed positive at the same lesion. Surgical excision was performed to remove the tumor completely. The histopathological findings showed aneurymal bone cyst. Aneurysnmal bone cyst involving the rib is rare. We report this case along with a review of the literature.

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A seventy-year male visited a hospital complaining of lower abdominal pain, and was diagnosed with early sigmoid colon cancer requiring laparoscopic surgery. Laparoscopic observation revealed a great many white nodules disseminated mainly in the intraperitonium of the lower abdominal cavity with tough adhesion between the colon and omentum. Still the laparoscopic colectomy was done curatively. The pathological diagnosis was well-differentiated adenocarcinoma of the colon and granulomatous inflammation from a great number of parasite eggs, later diagnosed as paragonimiasis. After that, the man's consumption of wild boar was confirmed, an animal known to be a paratenic host of Paragonimus westermani. Parasitic disease in the abdominal cavity is rarely reported, so it would be uncommon for a gastrointestinal surgeon to diagnose or recognize such disease. However, ectopic paragonimiasis in the abdominal cavity should be taken into consideration, when multiple intraperitoneal nodules are observed.

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A 68-year-old woman had undergone a right upper lobectomy in March 2003 under the diagnosis of primary lung adenocarcinoma. The pathological stage had been T4N0M0 stage III B because of a metastasis in the same lobe. She was admitted for suspicion of a bone metastasis of lung adenocarcinoma because of coxalgia in April 2005. Bone scintigraphy could show only the iliac bone lesion and FDG-PET did not detect any abnormal findings. Peripheral blood analysis demonstrated hypercalcemia (13.3mEq/l). Urine occult blood and protein were recognized from urinalysis. CT-guided biopsy for the iliac bone lesion did not show any metastasis of lung adenocarcinoma. On the other hand, serum protein electrophoresis and immunoelectrophoresis showed κ-type Bence Jones protein, and proliferation of myeloma cells was found in the bone marrow. When osteolytic lesions were found in lung cancer patients, it is necessary to include multiple myeloma in the differential diagnosis.

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A 64-year-old woman was seen at the hospital because of chest pain, coughing, fever, and poor appetite. There were previous histories of undergoing low anterior resection of rectum and adenexectomy for rectal cancer, and lateral segmentectomy of liver for hepatic metastasis. When she was first seen, a chest plain x-ray film showed pneumothorax and pleural effusion in the left chest cavity for which a thoracic drain was placed. Several days later food residue was drained so that gastrointestinal perforation was suspected. Upper gastrointestinal endoscopy showed a scar at the fundus of stomach and air leak from the thoracic drain when air was sent. Upper gastrointestinal series revealed that the leak from the gastric fundus was drained through the thoracic cavity. From these findings, we thought that the stomach prolapsed into the thoracic cavity due to diaphragmatic hernia was impacted there, causing necrosis and perforation. Operative procedures included partial resection of the prolapsed stomach and left lung and a repair of the hernia.
It was etiologically considered that a small asymptomatic Bochdalek hernia had underlain, and then the stomach deviated to a portion where it easily prolapsed into the hernia soon after the lateral segmentectomy of liver, resulting in diaphragmatic hernia. This paper presents this very rare case of diaphragmatic hernia with pyopneumothorax due to perforation of the prolapsed stomach, together with a review of the literature.

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This paper presents a case of Bochdalek's hernia causing gastric perforation in the thoracic cavity with mediastinal displacement in an adult who follwed a serious clinical course.
A 22-year-old woman was admitted to our hospital because of left upper abdominal pain and vomiting. A chest rentgenogram on admission showed niveau in the left pleural cavity. She had an abrupt onset of severe chest pain and dyspnea six hours after admission. A chest rentgenogram showed displacement of the mediastinum. She was diagnosed as having posterolateral diaphragmatic hernia with gastric perforation. Emergency operation was performed via abdominal approach. There was a defect in the posterolateral part of left diaphragm (Foramen Bochdalek). The stomach and spleen were displaced into the left thoracic cavity. Partial resection of the stomach that included the site of perforation was performed. The diaphragmatic defect was closed with interrupted sutures.
The adult patients with Bochdalek's hernia generally have favorable prognosis, however, those who experience perforation or necrosis of the herniated intestine can have unfavorable prognosis. For such patients we should perform surgery as early as possible after making the diagnosis.

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A rare case of gastrointestinal tumor of the esophagus is reported. The patient was a 69-year-old woman who was referred to our department for an abnormal shadow on her chest x-ray and severe anemia. A computed tomography scan of the chest revealed a solid tumor, 8cm in size, adjacent to the esophagus in the left posterior mediastinum. The tumor was resected and measured 10×10×8.5cm in size. Pathological examination revealed that the tumor was composed of spindle cells with moderate cellularity and a high mitotic rate. Immunohistochemically, the tumor cells were positive for c-kit and CD34. The tumor was diagnosed as GIST originating in the esophagus with high-grade malignancy. Esophageal GISTs with high malignant potential are rare, and thus, we need to carefully monitor the patient's clinical course.

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The patient was a 58-year-old man. In June 2004, edematous erythema appeared on the neck and then extended to the face, arms and body. The patient was referred to the hospital because of this erythema, and was diagnosed as having dermatomyositis by a skin biopsy. For the purpose of detecting malignant neoplasm, endoscopic examination and computed tomography (CT) were performed, but there were no abnormal findings at this point. Edematous erythema resolved following treatment with 5mg/day of betamethasone. In January 2005, abdominal CT scan showed LN swelling on the lesser curvative of the stomach and endoscopic examination disclosed squamous cell carcinoma in the lower thoracic esophagus. Because the symptom of dermatomyositis resolved with betamethasone, we performed a subtotal esophagectomy with gastric tube reconstruction via a posterior mediastinal route. Histopathological examination of the resected specimen showed poorly differentiated squamous cell carcinoma, superficial carcinoma of the esophagus, sm3. After the resection of the esophageal cancer, the symptom of dermatomyositis disappeared, and the dosage of betamethasone could be reduced to 3mg/day. Over 10 months after the surgery, he has been doing well and has no recurrent signs.

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A-59-year-old man complaining of abdominal pain was referred to the hospital with a diagnosis of acute general peritonitis. There were tenderness, rebound tenderness, and muscle guarding mainly in the upper abdomen. Abdominal CT scan showed an about 30mm-long linear structure of hyper absorption in the stomach. Gastric perforation due to a foreign body which seemed like a fish bone was diagnosed, and an emergency operation was performed. A laparoscope inserted from the anterior portion of the navel disclosed the perforationg fish bone to the anterior wall of lower part of the gastric body. About 30mm-long incision was added to the incision above the navel, the fish bone was removed under the direct vision, and the perforated site of the stomach was closed by sutures. After we interviewed his family, the fish bone was clarified to be that of gray mullet he had eaten on the evening before admission. The postoperative course was uneventful, and he was discharged from the hospital on the 12^th hospital day.
This is a case in which gastric perforation was diagnosed by abdominal CT scan preoperatively and the laparoscopic surgery offered the minimally invasive treatment as well as the definitive diagnosis at the same time.

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A healthy 72-year-old man was admitted to the hospital because of high fever. Abdominal ultrasonography US and CT scan revealed a 5×4cm solitary liver abscess. Gastric endoscopy revealed an ulcerative lesion in the upper body of the stomach, and a biopsy disclosed fragments of adenocarcinoma. Following administration of antibiotics, his general condition became stable and the liver abscess decreased. Percutaneous liver biopsy was negative for malingancy. Total gastrectomy was performed and histopathologic examinations revealed poorly differentiated adenocarcinoma with lymphoid stroma, and positive in situ hybridization EBER. As of 8 months after the operation, he remains well with no clinical evidence of recurrence. In this patient, bacterial invasion of the liver parenchyma might have occurred through the portal system from the “broken” mucosal barrier in gastric cancer.

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An 88-year-old man was admitted for bloody stool. The upper gastrointestinal series and endoscopic examination revealed a type 3 tumor in the cardia and a 0-II c lesion in the upper third of the lesser curvature of the gastric body. Biopsy examination showed a well-differentiated adenocarcinoma and a papillary adenocarinoma, respectively. Abdominal CT examination revealed lymph node metastasis in No.1. Total gastrectomy (D1+No7, 19) with cholecystectomy was performed considering his old age. Histological examination revealed a type 3 tumor which was diagnosed as a primary endocrine cell carcinoma of the stomach because it was immunohistochemically positive for chromogranin and Grimelius. Microscopic histological examination accidentally revealed a tumor thrombus in the vessel of gallbladder (pT3N2M1 Stage IV). Despite the fairly good postoperative course, 8 months after the operation, a para-Aortic lymph node recurrence was detected and is now being followed.

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A 75-year-old man complaining of right hypochondrial pain was admitted to the hospital because he was pointed out a huge tumor in the pancreatic head and duonenal domain elsewhere. Abdominal CT scan revealed a huge tumor which had cystic and solid parts. The tumor was 14×13cm in diameter and displaced the liver and gallbladder. Gastric fiber examination revealed a prominent area like a submucosal tumor in the 2^nd portion of duodenum. Following a biopsy, we suspected that the tumor was schwannoma. Ulcer was formed at the wound of the biopsy and bleeding from the ulcer was so serious that blood transfusion was demanded. Despite endoscopic and interventional hemostatic efforts, bleeding persisted and we performed sub-emergency operation. We could stop bleeding and resected the tumor radically. The tumor was pathologically diagnosed as GIST arisen in the duodenum. Huge duodenal GIST with bleeding is rarely reported. CT scan is useful in establishing the diagnosis of GIST. We should perform biopsy of a huge duodenal GIST carefully because we can have great difficulties in controlling the bleeding from the GIST.

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Food-induced ileus is a relatively rare antity. We report a case of food-induced ileus due to a dietary supplement constituted by sea grass (Kanten).
A 55-year-old man without any history of abdominal surgery was admitted to our hospital because of abdominal fullness and nausea. He had been eating a large quantity of a dietary supplement “konakanten” constituted by sea grass over these three years. He was diagnosed as having ileus by abdominal X-ray and CT, and was inserted a long tube conservatively. However abdominal distention was not improved and radiography from the long tube revealed a complete obstruction of the ileum. Laparotomy was performed on the 7th hospital day and we found a 4×4×4cm induration in the ileum at 30cm proximal to the terminal ileum, which the almost occupied the lumen. Partial resection of ileum was performed. There was a 3×3×2cm yellowish white solid mass in the surgically resected specimen. It was composed at “Kanten”.

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A 45-year-old man who had undergone both ileocecal resection for Crohn's disease and extensive gastrectomy for duodenual ulcer was admitted for abdominal pain and vomiting. A plain abdominal X-ray examination showed distension of the small intestine, and an enhanced abdominal CT showed the stenosis with the presence of a foreign body in the oral intestine in the right lower part of the abdomen. Gastrointestinal radiography from an ileus tube revealed a stenosis of the small intestine locating 30cm orally from the ileocecal valve with an oval defect, and also revealed a stenosis of the ileocecal lesion. The patient was diagnosed as having bowel obstruction of the small intestine due to either Crohn's disease or postoperative adhesion with the presence of a foreign body. Laparoscope-assisted surgery revealed two scar-like stenoses of the small intestine in accord with the pre-operative findings. Partial resection of the two stenotic lesions was performed respectively. The foreign body was found to be the seed of a Japanese apricot, and the stenoses were pathologically due to Crohn's disease. Laparoscope-assisted operation for food-induced ileus was suggested to be useful in consideration of the substantial disease.

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A 70-year-old man was seen at the hospital because of difficulty in breathing, whole-body edema and appetite loss. When he was seen, laboratory data revealed hypoproteinemia, dehydration and hypercapnia in the arterial blood. A chest X-ray film showed cardiac hypertrophy and pulmonary emphysema. Abdominal CT scan showed a dilatation of the small intestine and many stone-like shadows in it. The patient was admitted with the diagnosis of heart failure, chronic respiratory failure secondary to enphysema, and subileus. We successfully treated the whole-body edema, heart failure, and hypercapnia with fasting intravenous, hyperalimentation and diuretics. We performed surgery because the subileus and stone-like shadows in the small intestine persisted. During surgery, we observed a stricture of the small intestine 50cm distal to the Treitz'ligament, and also five strictures of the small intestine between 150 and 190cm distal to the Treitz'ligament. We performed a stricture plasty for the 50-cm part distal to the Treitz'ligament and also resected the intestinal segment of 150-190cm distal to it. The resected specimen contained five annular strictures and 23 true enteroliths. In this paper we discussed 43 case reports of true enterolith including our case in the Japanese literature.

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An 83-year-old woman was seen at the hospital for sudden vomiting and a sense of abdominal discomfort. The patient was diagnosed with primary small intestinal volvulus when abdominal computed tomography (CT) demonstrated a “whirl sign” in the small intestine loops around the superior mesenteric artery (SMA). In emergency surgery, the jejunum and ileum were twisted 360° counterclockwise around the SMA, and the intestine caused ischemic change. The blood flow recovered quickly after detorsion, eliminating the need for intestine resection. But three months later, the patient was seen at the hospital for the same symptom again. We diagnosed primary small intestinal volvulus recurrence because abdominal CT demonstrated the “whirl sign”. Again, the jejunum and ileum twisted 360° counterclockwise around the SMA. The blood flow recovered quickly after detorsion, but we added bowel fixation to prevent a recurrence. There are a few reports of recurrence, but the necessity of small intestine fixation was suggested in cases of primary small intestinal volvulus.

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An 81-year-old man presented with the abrupt onset of abdominal pain. A contrast-enhanced CT scan of the abdomen showed a “whirl sign” in the small intestine loops around the superior mesenteric artery. The patient was diagnosed as having secondary small bowel volvulus and underwent surgery. At surgery, the jejunum and ileum were twisted 360° clockwise around the superior mesenteric artery. There was no circulatory compromise in the rotated segment. A solitary tumor, about 6cm in diameter, was found in the jejunum about 110cm from the Treiz' ligament. This tumor might have caused the volvulus. We performed a wedge resection of this tumor. The histopathological diagnosis was high-grade malignant gastrointestinal stromal tumor (GIST) of small intestine.
GIST of the small intestine associated with small bowel volvulus is a very rare disease.

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A 68-year-old man visited our hospital with the chief complaints of abdominal pain and distension. Ileus was diagnosed based on the findings of abdominal plain X-ray, and the patient was then admitted. A long intestinal tube was inserted, but delirium occurred, and the patient cut the tube by himself. The whole tube remained in the small intestine, so a laparotomy was performed. The whole small intestine then showed a change of color that suggested impaired circulation. Mesenteric lymphadenopathy and gall bladder swelling were observed. We carried out removal of the long intestinal tube, a biopsy of the small intestine, and a cholecystectomy. Histopathological examination revealed remarkable eosinophilic infiltration in the small intestine, gall bladder and mesenteric lymph node. Vascular necrosis and surrounding eosinophilic infiltration were observed in part of the small intestine and gall bladder. This patient had suffered from bronchial asthma, and laboratory tests highlighted an increase in eosinophil count, IgE and rheumatoid factor. Thus, we diagnosed this patient as allergic granulomatous angiitis (AGA). Then he showed symptomatic improvement in response to the administration of steroid hormone postoperatively. At present this patient is followed with steroid hormone maintenance therapy.

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We describe a case of multiple jejunal gastrointestinal stromal tumors (GIST) accompanied with von Recklinghausen's disease. A 63-year-old man presented with melena at a local clinic and was referred to our hospital for further evaluation because of anemia. Upper gastrointestinal series and abdominal CT scans revealed a jejunal tumor. Surgery was performed for the tumor in October, 2004. An outside protruding lesion of 5.5cm in diameter at the beginning of the jejunum was confirmed, and a smaller jejunal mass was also found near the lesion. Resection of partial jejunum was done for the main tumor, and wedge resection of jejunum was performed for the smaller one. Histopathological findings revealed a fascicular proliferation of spindle-shaped cells in the tumors. Immunohistochemical findings demonstrated that both tumors' cells were positive for c-kit, CD34 and S-100, and negative for SMA. The pathological diagnosis was multiple GIST, since both tumors were located between the submucosa and subserosa. There are no signs of recurrence to date.

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A rare adult case of intussusception caused by malignant lymphoma of the ileum is reported. The patient was a 46-year-old man who was admitted to our hospital with intermittent abdominal pain. USG showed a multiple concentric ring sign with a hypoechoic area in the center. He was diagnosed as intussusception in an adult. Colonoscopy showed an incarcerated round mass with ischemic change of the mucosa in the ascending colon, and a segmental resection of the ileum with regional lymph node dissection was performed. Ileocolic intussusception was due to a tumor 23×25mm in diameter protruding into the ileum, about 18cm proximal to Bawhin's valve. Histopathological examination resulted in a diagnosis of non-Hodgkin lymphoma of diffuse, large cell type, a B cell phenotype. The patient had an uneventful postoperative course, and after one course of CHOP therapy was discharged on postoperative day 25. No recurrence has been observed as of 7 months after surgery.

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We report a rare case of caecum necrosis accompanying fecal stone obstruction in a 70-year-old woman. Abdominal X-P and CT revealed an air fluid cystic lesion accompanying a fecal stone of 3cm in diameter located near Bauhin' s valve, and emergency surgery was performed because of suspected acute diverticulitis with abscess formation due to fecal stone obstruction. An obvious diverticulum in the ileocecal region was not seen, and it was thought that the cecal necrosis was caused by fecal stone obstruction. Postoperative component analysis of the fecal stone revealed that the stone contained 53% calcium carbonate and 47% calcium phosphate, suggesting that the fecal stone was formed by excessive ingestion of coral calcium granules as a health supplement over a period of 15 years.

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Schistosomiasis japonica is an infectious disease caused by Shistosoma japonica. In the past, this parasite had been prevalent in five restricted regions in Japan, but it had been eradicated completely about 30 years ago. Its old eggs are occasionaly found in the histopathological specimens. We report a case of acute appendicitis associated with Schistosomiasis Japonica.
A 67-year-old man who had been in the Kofu Basin, Yamanashi Prefecture since his birth was referred to our hospital because of right lower abdominal pain in March 2005. Abdominal CT scan and ultrasonography (US) revealed the presence of an ileocecal mass lesion, 6cm in diameter, containded a low density area and calcification. The lesion was diagnosed as pericecal abscess secondary to acute appendicitis or diverticulitis. The operative findings showed the ileocecal mass with abscess caused by gangrenous appendicitis. An ileocecal resection was performed. Microscopically, multiple calcified eggs of Schistosoma japonica were found in the lumen of the appendix.
In recent years, some imported cases of Schistosorniasis japonica have been reported, furthermore, the Ouchomelania nospphora that is a intermediate host still has been found in the past endemic region even now. Considering these facts, the new infection cases may be seen in Japan.

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A 75-year-old man complaining of diarrhea was referred to the hospital because an abdominal huge mass in the entire abdomen was pointed out at another hospital. When he was first seen, he had diarrhea and his abdomen was bulged. The hematological tests showed inflammation and an elevation of serum CEA level (13.7ng/ml). Abdominal CT scan revealed a cystic mass which extended to the pelvic cavity from the inferior surface of the lives. A barium enema showed an extraluminal lesion in the distal cecum with irregular demonstration of the appendix. Colonoscopic examination showed mucus efflux from the appendix orifice. We performed laparotomy with a suspicion of mucinous cystadenocarcinoma of the appendix. At the operation, there was no ascites and mucinous gelatinous fluid in the abdominal cavity, and a huge cyst continued to the swollen appendix was found. Partial resection of the cecum and removal of the cyst were performed. The cyst was filled with yellow gelatinous mucus. Although the appendix had mucinous cystadenocarcinoma histologically, no epithelial cell was seen in the lumen of the eyst. Mucinous cystadenocarcinoma of the appendix is a causative disease of pseudomyxoma peritonei, and this case is considered to be interesting from the standpoint of the formation of pseudomyxoma peritonei. We report the case with some discussion and a review of the relevant literature.

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A 36-year-old woman diagnosed as having ulcerative colitis had been treated with 5-aminosalicylic acid since 2002. In 2004, she experienced recurrence of ulcerative colitis and developed autoimmune hemolytic anemia as well. Medical treatment with cyclosporine and intraarterial infusion of predonisolone was unsuccessful and she had massive bloody diarrhea and abdominal pain. Her anemia was aggravated. She underwent hand assisted laparoscopic splenectomy, subtotal colectomy, ileostomy and colostomy in the first emergency operation. In the second operation, she underwent laparoscopic total colectomy and ileal pouch-anal anastomosis.
These operations are recommended for young patients with severe ulcerative colitis because they are safely performed and offer cosmetic benefits.

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The patient was a 43-year-old homosexual male with HIV-positive, and had been under treatment with higyly active antiretroviral therapy (HAART) in our outpatient clinic. He had anal pain and bleeding on defecation. There was a tumor at his anal region. Biopsy showed moderately differentiated squamous cell carcinoma. Imaging study revealed a 40mm×53mm×50mm tumor extended from the anal canal to the perianal subcutaneus tissue with perirectal lymph node swelling and no distant metastasis. The tumor was diagnosed stage IIIA (T3N1M0). His immune system was stable with a CD4 count of 372cells/μl and CD8 count of 2320cells/μl. He was treated with combined modality approach consisting of low dose radiation (30Gy in 15 fractions delivered 5days/week), and chemotherapy (1000mg/m² of 5-fluorouracil delivered on days 1-4 and 29-32 as a continuous infusion over 96 hours, and 10mg/m² of mitomycin C delivered as a bolus injection on day 1). Almost complete clinical response was achieved without severe toxicity, and an additional 10 Gy boost dose was delivered at the local site. The lesion completely disappeared, and there was no evidence of recurrence for 40 months after completion of treatment.

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A 52-year-old man was emergently admitted to our hospital for acute cholecystitis. After successful conservative management, he was readmitted for elective cholecystectomy 1 month after development of cholecystitis. The initial approach via laparoscopy was converted to open cholecystectomy due to injury of the transverse colon. The operative procedures included cholecystectomy and partial resection of the transverse colon. He developed biliary fistula after surgery which was treated by temporary endoscopic nasalbiliary drainage(ENBD). One month after discharge he was admitted again because of hematemesis. An aneurysm 2cm in diamexer in the right hepatic artery was demonstrated by enhanced CT scan. We diagnosed the case as post-operative pseudoaneurysm which ruptured and caused hemobilia. Following transarterial embolization, Hre patient was discharged very much improved.
Postoperative pseudoaneurysm is a comparatively rare and life-threatening disease. Recently many cases of the disease in which the patients' lives were saved by transarterial embolization have increasingly reported. Early diagnosis is important for the disease, so that it must be kept in mind in treating the biliary tract or postoperative gastrointestinal and abdominal bleeding.

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We report a case of a hepatic abscess due to penetration of the stomach by a fish bone, which is the 17th case in Japan.
A 77-year-old man was admitted to our hospital because of high fever and epigastralgia lasting for 2 days and vomiting which ocurred in the day before admission. The white blood cell court and the CRP level were high. Abdominal CT scan on admission revealed a huge liver tumor 7cm in diameter and a cystic mass at the antrum of stomach. Gastrofiberscopy showed a huge submucosal tumor and an ulcerative lesion with fur at the anterior wall of antrum of the stomach. After fasting and administration of antibiotics, the liver tumor and the cystic mass of the stomach disappeared, so that the huge liver tumor was considered to be abscess. The ulcerative lesion was clarified to be 0-II c type early gastric cancer. Distal gastrectomy was performed for the early gastric cancer on the 40th hospital day. The antrum of stomach was firmly adhered to the lateral segment of liver. During the lymph node dissection a fish bone was found to have penetrated the lateral segment of the liver through the gastric wall as the antrum. We diagnosed that the fish bone was the cause of the hepatic abscess and the cystic submucosal tumor at the antrum of stomach. The postoperative course was uneventful, and no recurrence of gastric cancer has been observed 19 months after the surgery.

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Acute emphysematous cholecystitis is a serious disease caused by gas-forming bacteria, in which characteristic bubbles of gas appear in the gallbladder lumen and wall. We experienced such a case successfully treated by laparoscopic cholecystectomy.
A 73-year-old man was admitted to the hospital because of abdominal pain. He had undergone distal partial gastrectomy for gastric ulcer at the age of 29, and had been treated for diabetes since 57. We performed laparoscopic cholecystectomy on an one-step approach because his general condition was relatively stable. E. coli, Klebsiella and Clostridium were identified in cultivation of bile juice. Only six cases of laparoscopic cholecystectomy for emphysematous cholecystitis without percutaneous transhepatic gallbladder drainage have been reported, including our case. We consider that laparoscopic cholecystectomy is a useful procedure for treating acute emphysematous cholecystitis.

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Double gallbladder which is a congenital malformation in the biliary area is a rare entity. Recently we experienced a case of double gallbladder with common bile duct stone in which MRCP was helpful for preoperative diagnosis.
A 63-year-old woman was suspected to have double gallbladder by DICCT and ERCP before surgery, and was diagnosed as having double gallbladder with common bile duct stone and accessory gallbladder stone by MRCP. The bilateral gallbladders and common bile duct stone were removed under laparotomy. Intraoperative fluoroscopic study of the bile duct offered the diagnosis of Boyden's classification H and Gross's classification B type double gallbladder.
In a review of a total of 76 domestic cases of double gallbladder, 51 (67%) cases were definitely diagnosed preoperatively and biliary fluoroscopic study was reported to be useful for making the diagnosis. In this case, however, we were not able to make the definite diagnosis by biliary fluoroscopy due to the associated common bile duct stone and impaction of a stone in the cervical part of the gallbladder, and we achieved it following MRCP. In addition intraoperative biliary fluoroscopy was useful to confirm the run of accessory cystic duct.
We consider that evaluation by MRCP as well as biliary fluoroscopy is helpful to make diagnosis in patients who are suspected to have biliary malformation with biliary obstruction due to a stone.

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Malignant cystic tumors of the liver are relatively rare. We herein report an 80-year-old female with cholangiocellular carcinoma with cystic formation of the liver who had been followed for 4.5 years.
The patient was detected to have a liver cyst 4cm in longer diameter in the left lobe of liver in December 1997, but she refused to receive close exploration. She had been followed until February 2002, when she was seen at the hospital for close exploration for the liver cyst. Abdominal CT scan showed a papillary projection in the cystic tumor of the left segment. Abdominal magnetic resonance imaging (MRI) scan showed a well-circumscribed cystic tumor revealing low and high intensity on T1-and T2-weighted images, respectively. Abdominal angiography revealed a hypovascular tumor, and no tumor stain was observed. No elevations in tumor markers were noted. A left lobectomy of the liver was carried out with a diagnosis of cystadenoma or cystadenocarcinoma. During surgery communication between the tumor and the bile duct was observed so that a left lobectomy of the liver was employed. Histopathologically, the tumor was cholangiocellular carcinoma with cystic formation. The patient is alive 48 months after the operation.

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An asymptomatic 70-year-old man was pointed out liver dysfunction at a medical checkup in January 2005, and consulted another hospital. Because intrahepatic biliary dilatation was revealed by abdominal ultrasonogram and CT scan, he was referred to our hospital in February. When he was first seen, he had no jaundice with the serum total bilirubin of 0.5mg/dL and liver enzymes within normal limits but showed elevated biliary enzyme levels; ALP of 580IU/L and γ-GTP of 191IU/L. On abdominal CT scan and endoscopic retrograde cholangiogram, he was diagnosed as having hilar cholangiocarcinoma of the left hepatic duct (B1), suggestive of intramural spreading of cancer toward the lower bile duct. In March 2005, he underwent left hepatectomy, coudate lobectomy and extrahepatic bile duct resection. The suspected intramural spreading of the common bile duct was pathologically comfirmed to be inflammatory wall thickness.
In a review of 12 reported cases of resected hillar cholangiocarcinoma without jaundice, any symptoms were seen in six (50%), elevated biliary enzyme in 12 (92%), and intrahepatic biliary dilatation in 11 (92%) cases. The cancer deeply invaded to subserosal layer (ss) or more in six (50%) cases.

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Gallstone ileus is a relatively rare entity. It often affects elderly people and its definite therapeutic methods have not been established as yet cancerning on the cause of this entity, a fistula between the gallbladder and GI tract. Recently we experienced a case of gallbladder carcinoma which was detected after an internal biliary fistula had been left alone in a woman in her eighties. She was seen at the hospital because of vomiting in 2000, when abdominal CT scan disclosed an impacted gallstone in the small intestine and gallstone ileus was diagnosed. Partial excision of the small intestine was performed for the part where the gallstone was impacted, considering her advanced age. The patient developed anemia in 2003. The gallbladder wall was thickened and invasion of gallbladder carcinoma to the duodenum was revealed. Bleeding from the portion of duodenum to where gallbladder carcinoma invaded was diagnosed, and cholelcystectomy under laparotomy and partial duodenectomy including the invaded portion were performed. The histopathological diagnosis was poorly differentiated adenocarcinoma of the gallbladder with a cholecystoduodenal fistula. No continuity between the fistula and cancer was noted.
A total of five cases of gallbladder carcinoma complicated with internal biliary fistula, including our case, have been reported in Japan. From the standpoint of preventing gallbladder carcinoma, internal biliary fistula must be treated by cholecystectomy and closure of the fistula as active as we can.

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In November, 2001 A 73-year-old man received a laparoscopic cholecystectomy for cholelithiasis. During the operation, the gallbladder perforated and the bile spilled into the abdominal cavity. Because macroscopically no tumor was identified in the gallbladder, only one section was examined histologically which revealed no malignancy. The gallbladder was discarded because of no malignant findings. In June, 2003, he came to the hospital for umbilical pain. Abdominal US and CT scan showed an irregular-shaped mass in the rectus abdominis muscle closely caudal to the umbilicus. An excisional biopsy was performed, which revealed metastasis of adenocarcinoma. He was hospitalized, and the tumor was removed in August, 2003. During the operation, we could not see any sign of peritoneal dissemination. The histological diagnosis was metastasis of well-differentiated adenocarcinoma. Despite the whole body examination, we could not detect any primary tumor site. In January, 2004, the tumor recurred in the lower abdominal area, and from February, radiation therapy was initiated (58 Gy/41 times/29 days). Although the tumor size once reduced, it soon became larger. Despite the chemotherapy (CDDP+5FU), no remarkable effect was seen. The patient died in July, 2004.

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To best of our knowledge, 69 cases (including our case) of lymphoepithelial cyst (LEC) of the pancreas have been reported in Japan. We herein report a case of this comparatively rare disease.
A 39-year-old man with a several-month history of bloody bowel discharge was admitted to our facility for the purpose of exploration and treatment. Close exploration disclosed cancer of the rectum and a pancreas tumor. Blood examination showed no abnormality in particular. Imaging studies revealed a 55×35mm demarkated cystic lesion at the body and tail of the pancreas, but no definitive diagnosis was made. Because we were not able to rule out a possibility of malignancy, we conducted resection of pancreatic body and tail with splenectomy. In addition, low anterior resection of the rectum was performed against cancer of the rectum. Histologically, the cystic space was lined with squamous cells, and it was diagnosed as LEC by having lymphoid tissue which had germinal center on the wall.

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A 21-year-old woman, complaining of epigastric pain, was found to have a cystic mass at the tail of the pancreas. Abdominal CT scan and ultrasonography demonstrated that the cystic mass had a comparatively thick capsule and thin septum-like structures inside. ERP revealed the interruption of the main pancreatic duct at tho body of the pancreas, with no communication to the cystic mass. Selective angiography showed the occlusion of the root of the splenic artery and no tumor stain at the mass. Serous fluid collected by a percutaneous transgastric puncture of the cystic mass had no malignant cells on a cytological examination. We could not rule out a possibility that the cystic mass was neoplastic with malignant potential, and performed distal pancreatectomy. Pathological studies disclosed that the lumen of the cyst was lined with monolayer of non-neoplastic epithelium, and that a nodular elevation toward the lumen was composed of subepithelial granulation tissue. Hence, the cystic mass was diagnosed as non-neoplastic true cyst of the pancreas.
We also present some discussions of etiological factors and the classification in this case with a review of the literature.

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We report a case of metastasis to the body of the pancreas from breast cancer. The patient was a 75-year-old woman who underwent right modified mastectomy at age sixty-six. Pathologic examination of the resected breast revealed a solid-tubular carcinoma (estrogen receptor (+++), progesterone receptor (+) and Herceptin test score 0). Nine years postoperatively, she was examined because of an abdominal mass. CT scan and MRI revealed a tumor in the body of the pancreas around 2.5cm in diameter, and a resection of pancreatic body and tail was performed with splenectomy. Pathologic examination of the resected tumor revealed it to be metastatic pancreatic carcinoma, while immunohistochemical examination showed it to be estrogen receptor (+++), progesterone receptor (+) and Herceptin test score 0. We therefore concluded that this tumor was a pancreatic metastasis from breast cancer. Although metastasis to the pancreas from breast cancer is rare, a past history of malignancy in the other organs should be considered in treating pancreatic tumors.

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A 56-year-old woman who clashed head-on with a car while driving her car was brought into our hospital by ambulance. She had past histories of rheumatoid arthritis, Sjögren syndrome, antiphospholipid antibody syndrome and deep vein thrombosis, and had treated with glucocorticoid, immunosuppressant and anticoagulant. Shock was not observed, but she wheezed. She was obese, but had no symptoms of peritonitis. Contrast enhanced computed tomographic (CT) scan showed splenic injury of type IIIb. A splenic angiogram showed multiple intraparenchymal bleeding, and partial splenic embolization was conducted. CT scan on 12th hospital day showed a marked shrinkage of the hematoma. On the 18th hospital day, she was discharged. On CT scan conducted 4 months after the injury, the low density area in the spleen had almost disappeared. A year has passed, and no delayed complications were seen.
Partial splenic embolization is a safe and effective method for splenic injury in patients under immunosuppressants and anticoagulant therapy, and should be attempted before surgery if hemodynamic state can be kept stable.

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A 69-year-old female patient, who had been treated in our outpatient clinic for chronic DIC and a residual dissection of the descending aorta after replacement of the ascending aorta for acute aortic dissection, had a sudden onset of abdominal pain without any specific cause and went into shock. The patient was thus brought into our hospital. Abdominal CTscan detected hemorrhage in the peritoneal cavity. On the same day, an emergency surgery was performed. At laparotomy, 2500ml of hemorrhagic ascites were found and a persistent hemorrhage was seen from the subsplenic polar site. Although the inside of the peritoneal cavity was thoroughly observed, no other hemorrhagic sites were found. Thus, a splenectomy was performed. Pathological findings and examination results of the whole body showed no underlying disease causing a splenic tumor. Although any history of injuries was absent, a coagulopathy called DIC was present and spontaneous splenic rupture was ultimately diagnosed.
In patients with a sudden onset of abdominal pain, spontaneous splenic rupture must be kept in mind as a possible differential diagnosis, even in those without any apparent injury.

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We report a case of mesenteric fibromatosis with incomplete Gardner's syndrome and total situs inversus. A 34-year-old female was found to have a history of polyposis coli and dextrocardia in childhood. Intraabdominal tumor was detected at the time of left oophorectomy in July 2002, and she was referred to our hospital. Abdominal CT and MRI showed total situs inversus and a 10×5×4cm tumor in the abdomen. Barium enema roentgenogram showed numerous small polyps. Laparotomy was performed in August 2002. In the operation we paid close attention to the mirror image. The tumor was located in the mesostenium and had invaded the small intestine and duodenum. The entire tumor and segment of the small intestine and duodenum were resected. This case had polyposis coli but no osteoma, and the histological findings of the tumor revealed a mesenteric fibromatosis. Thus, we made a diagnosis of incomplete Gardner's syndrome. The tumor recurred one year after the operation. Laparotomy revealed unresectable recurrent mesenteric fibromatosis.

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Lesser omental hernia is an extremely rare disease. No cases of the disease associated with malrotation like in this case have been reported so far.
A 76-year-old woman was admitted to the hospital because of abdominal pain and distension. Abdominal plain X-rays and CT scan showed increased small intestinal and colonic gas in the right upper abdomen and dilation of the cecum. Serum CEA level was elevated. The abdomen was markedly distended, and abdominal pain was severe so that emergency operation was needed. At laparotomy the cecum was dilated and twisted counterclockwise. A fissure 5cm in length in the lesser omentum was found to be an internal hernia orifice and gastrocolic ligament was lacked. Almost the entire small intestine and right colon were herniated through the fissure from the dorsal side of stomach. The small intestine and colon showed no evidence of necrosis. The fissure was closed simply after repair of malrotation. Transverse colon cancer was also detected, for which partial transverse colectomy and loop colostomy were performed. The patient was discharged from the hospital on 40 POD without any postoperative complications.

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