The aim of this study was to compare postoperative quality of life (QOL) among different types of surgery for breast cancer. 118 patients at 1 to 3 years after surgery were subjected to two questionnaire surveys; one was the Japanese version of EORTC QLQ-C30 (C30J), and the other was the Hospital Anxiety Depression Scale (HADS). Mann-Whitney U test was used for statistical analysis. For C30J, the social function of patients who had undergone mastectomy was significantly higher than those with breast conservation surgery (BCS) (P=0.048). Fatigue of the patients with axillary lymph node dissection (ALND) tended to be worse than those with sentinel lymph node biopsy (SLNB) (P=0.052). Congnitive function of patients with operation under scope (Scope) tended to be higher than those without scope (Non-scope) (P=0.069). For HADS, a significantly lower HADS-depression score was noted in patients with SLNB than those with ALND (P=0.039). Patients in the Scope group showed significantly lower HADS-anxiety, depression and total scores than those in the Non-scope group. In conclusion, the results suggested that BCS, SLNB and Scope may present better postoperative QOL in patients with breast cancer.

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Background: Pancreatic fistula (PF) is one of serious complications after total gastrectomy (TG). Purpose: The purpose of this study is to identify the clinical significance of amylase levels of drainage fluid (D-Amy) in the patient with PF after TG. Patients and method: Between 2003 and 2005, 128 consecutive patients with gastric cancer underwent TG with splenectomy or pancreaticosplenectomy in our institution. D-Amy was measured on postoperative day (POD) 1, 3 or 4, and 7. Results: PF developed in 17 patients (13%), whose D-Amy on POD1, 3 or 4, and 7 were significantly higher than those in patients without PF. Of these 17 patients, 10 patients (59%) were able to be diagnosed as having PF with purulent drain discharge until POD7. Conclusions: D-Amy on POD 1 and POD 3 or 4 might be useful to predict the development of PF. But no clinical significance was noted in measuring D-Amy on POD 1 and POD 3 or 4, because we do not change postoperative management by D-Amy on POD 1 and POD 3 or 4 as a general rule. In the efficient postoperative management of TG for gastric cancer, it might be effective to measure D-Amy in patient without purulent drain discharge on POD 7.

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From 1986 to 2005, the authors experienced 27 cases of epigastric hernias in children. The aim of this paper is to report these cases, which accuunt for 1.1% of all abdominal hernias operated on during that period in our department. There were 11 boys and 16 girls. Radical operations were performed on children ranging from 2 months to 10 years of age. Hernias were observed in 12 infants less than one month old, and in 21 cases less than one year old. Twenty-six had 1 hernia and 1 had 2 hernias. Five hernias were increasing in size and one patient had local pain and tenderness. Complications were observed in 19 cases. The most frequent complication was bronchial asthma, observed in 6 cases. The diameter of fascial defect averaged 9.0±7.6mm. The contents were preperitoneal fat in 7, omentum in 2, and intestine in 2 cases. Recurrence was noted in one case. Although epigastric hernias are considered more rare in infants and children than in adults, there is no difference in incidence rate. Boys were thought to have more hernias, but we observed more in girls. Onset of most hernias was in infancy. Our findings provide additional support that epigastric hernias are congenital.

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Lymphocytic mastopathy is accompanied by interstitial fibrosis, atrophy of the mammary lobules, and lymphocyte infiltration. Sporadic reports of this mastopathy subtype appearing in the mammary glands of patients with diabetes mellitus and autoimmune disease have appeared, however, that in patients without any underlying disease has been rarely reported. We report 2 cases diagnosed as lymphocytic mastopathy that occurred in patients without evidence of underlying disease. Patient 1, a 62-year-old woman, had a breast tumor in the right C area, which was visualized as an almost homogeneous hypoechoic tumor on ultrasonography and a locally asymmetric shadow on mammography. Patient 2, a 68-year-old woman, had a breast tumor in the right D area, which was visualized as a heterogeneous hypoechoic tumor on ultrasonograhy. No particular findings were noted on mammography. Malignancy could not be denied in either case and biopsies were performed, the results of which led to the diagnosis.
As it can be difficult to clinically differentiate mastopathy from breast cancer, a biopsy is frequently used. We consider it necessary to take lymphocytic mastopathy into account when making a differential diagnosis of a mammarty tumor.

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Medullary carcinoma of the breast is a rare type breast cancer, and shows peculiar clinical features. In a series of 460 cases of breast cancer operated on at the hospital from 1975 to 2004, twelve (2.6%) cases were diagnosed as medullary carcinoma of the breast by postoperative pathological study. When the specimens from the twelve tumors were reevaluated according to the Ridolfi's subtype classification, six tumors were classified into typical medullary carcinoma (TMC) and the remaining six tumors into atypical medullary carcinoma (AMC). On mammography these tumors were visualized as homogeneously enhancing oval masses without calcification and the boundary was comparatively well-defined. US demonstrated well-defied masses with a heterogeneous, hypoechoic texture and with reinforcement of posterior echoes. The rate of lymph node metastasis was 33.3% in medullary carcinomas which was not significantly different from that of infiltrative ductal carcinomas experienced during the same period. The rate of a positivity of a hormone receptor was 8.3% in medullary carcinomas which was low in predominance in comparison with that of infiltrative ductal carcinomas. The positive rate for a HER2/ neu (above2+) by the IHC method was 58%. An average observation period is 11 years, and all patients are alive.

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A 64-year-old man became abasia for the sudden onset of numbness and lumbago of the right foot. When he was admitted to the hospital, strong numbness and cyanosis were observed at the toes. We diagnosed the case as atheroembolism of the lower limbs (Blue toe syndrome), which was originating from an abdominal aortic aneurysm. A Y-grafting was performed aimed at removing the embolic source and preventing rupture on the 11th day after the onset. The postoperative course was uneventful without new thrombotic complications by careful dissection and clamping, and some devises in anastomosis and declamping. He was discharged on foot on the 15th day after the operation.

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Duodenal obstruction due to an abdominal aortic aneurysm is rare. We experienced a case of duodenal obstruction due to an abdominal aortic aneurysm after transverse colectomy.
An 86-year-old woman was admitted to the hospital because of anorexia and an abdominal mass. Preoperative abdominal CT scan demonstrated an abdominal mass originated from the transverse colon, an abdominal aortic aneurysm and a right common iliac artery aneurysm. Horizontal portion of duodenum ran in front of the infra-renal aortic aneurysm on contrast enhanced CT scan. Because of high probability of malignancy, transverse colectomy was performed as the first stage operation. On the 6th postoperative day obstruction of the duodenum occurred. Abdominal CT scan with contrast demonst-rated a narrowing horizontal potion of duodenum which was compressed by the aortic aneurysm and abdominal wall. Open repair for the abdominal aortic aneurysm and iliac artery aneurysm was performed by using Y graft, resulting in an immediate relief of duodenal obstruction.

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We report a rare case of intramuscular myxoma in the right axilla. The patient was a 75-year-old man who mainly complained of an egg-sized mass in the right axillary fossa. The mass was extirpated with a diagnosis of benign soft tissue tumor. The tumor was covered with a fascia of the pectoralis major, 6.3×4.6×3.6cm in diameter, and weighed 115g. The cut surface revealed a solid tumor with mucus. Histological examination revealed the tumor was hypocellular, hypovascular, intensely mucoid, basophilic and poor in pleomorphism of nucleus using the hematoxylin-eosin stain. The condition was diagnosed as intramuscular myxoma.

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The patient was a 19-year-old woman who was in the 38^th week of gestation and had been suffered from idiopathic thrombocytopenic purpura (ITP). She was admitted to the hospital for the prenatal administration of large doses of immunoglobulin for pregnancy with ITP. During hospitalizaiton she had the abrupt onset of dyspnea and was diagnosed as having right spontaneous pneumothorax on a chest x-ray film. Despite tube thoracostomy, air leakage persisted. Thus the patient was thought to be a candidate for thoracoscopic surgery. The large doses of immunoglobulin were administered preoperatively and cesarean section was performed, followed by thoracoscopic surgery. The both mother and her infant made satisfactory progress after the operation, and were discharged from the hospital on the 10^th postoperative day. As of 4 years after the operation she has had no recurrence of spontaneous pneumothorax and is pregnant of the second child.

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An 85-year-old female was admitted to the hospital with a diagnosis of peritonitis due to perforation of the sigmoid colon and underwent suture of the perforation site and intra-abdominal drainage in November 2005. Drains were placed in the bilateral subphrenic spaces and Douglas'pouch. Pus was drained through the drainplaced in the left subphrenic space, so that the drain was placed for a long term. On the 24th postoperative day, she suddenly complained of chest pain and dyspnea, and a lot of fluid was drained through the drain. Chest X-rayshowed left pneumothorax, and we inserted immediately a chest drainage tube. On the basis of fistulography and chest CT scanning, a cause of pneumothorax was considered to lie in that the placed drain had broken through the diaphragm.
Visceral injury by the drain mostly occurs in the gastrointestinal tract and diaphragmatic perforation with pneumothorax is uncommon. Although it is considered that the inflammation made the diaphragmatic tissue fragile which might be acausative factor for diaphragmatic perforation in this case, we should carefully manage drainage tubes and becareful for complications associated with the drain.

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A 70-year-old man complaining of hoarseness diagnosed as having left recurrent nerve paralysis by anotolaryngologist was referred to our hospital for further examination and treatment.
There were no abnormal findings on physical examination of the head and neck region, cervical ultrasonography and gastrointestinal fiberscopy. Chest CT scan showed a 1.1×1.0cm nodular shadow in the left segment 4b of the lung, but enlarged hilar and mediastinal lymph nodes were absent. Cervical CT scan showed two small nodules 0.8cm in diameter which were adjacent to the trachea. Surgical extirpations were indicated for all lesions because of high accumulation on FDG-PET CT. A wedge resection of the middle lobe of lung was performed by VATS, and the pulmonary nodule was diagnosed as papillary adenocarcinoma by the frozen section. A middle lobectomy with systematic nodal dissection (ND2a) was done. Pathological examination revealed no hilar and mediastinal lymph node metastaseE of adenocarcinoma. The pathological diagnoses of two cervical nodules after the extirpation were metastatic lymph nodes of adenocarcinoma of the lung. FDG-PET CT was useful not only for making biological diagnosis of the pulmonary nodular shadow, but also for identifying distant nodal metastases of adenocarcinoma of lung in this patient.

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A 51-year-old man who had an abnormal shadow on chest roentgenogram by mass screening was admitted to our hospital. Chest CT scan revealed two pulmonary nodules in right S⁹ and left S⁹. CT-guided lung biopsy of the right tumor revealed a kind of sarcoma pathologically. Another lesion was not detected by positron emission tomography. Thoracoscopical partial lung resection and segmental lobectomy were performed for right lung tumor and left lung tumor, respectively. Those tumors were diagnosed as malignant melanoma immuno-histochemically. A systemic examination was done again, but there were no lesions except for the lung. Therefore, we diagnosed this case as melanoma of unknown primary origin or primary melanoma of the lung accompanied with a pulmonary metastasis. There was no recurrence in this patient, 22 months after the operation. Although melanoma with metastases has a poor prognosis, complete resection for malignant melanoma may assure a good prognosis.

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This paper presents a case of thoracic empyema caused by a reconstructed gastric tube ulcer after esophagectomy for esophageal cancer, together with a review of the literature.
The patient was a 55-year-old man, who had undergone total excision of the thoracic esophagus with gastric tube reconstruction through the mediastinum for cancer of the middle intrathoracic esophagus 2 years before admission. This time the patient was seen at the hospital because of the abrupt onset of dyspnea, and was admitted with a diagnosis of right thoracic empyema by a chest x-ray film and a chest CT scan. Following a chest CT scan, upper gastrointestinal series, and endoscopic study after admission, perforation of a huge peptic ulcer at the lower part of gastric tube into the thoracic cavity was diagnosed. The patient was treated with administration of optimal antibiotics and daily lavage and drainage using a chest tube, and at the same time central venous nutrition and nasal feeding were used for the purpose of nutritional improvement. The gastric tube ulcer improved to the cicatrical phase 2 months after admission, when his nutritional state improved and thoracic empyema as well as pneumonia disappeared. The patient was discharged very much improved on the 119th hospital day. It is etiologically inferred that he might have experienced traumatic and physical stress because he suffered from depression after surgery for esophageal cancer and he had undergone another surgery for gallstone and cholecystitis one month before admission; under these conditions medication of NSAID started after the surgery for gallstone facilitated occurrence of ulcer causing perforation.

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We report a case of intractable reflux esophagitis due to proximal gastrectomy. A 62-year-old man had undergone proximal gastrectomy reconstructed by esophagogastrostomy for early gastric cancer in another hospital in 1999, and was admitted to our hospital in December 2003 because of heartburn. He was already diagnosed with reflux esophagitis and given several medications, but his symptoms were not improved. Esophagoscopy showed reflux esophagitis and esophageal ulcer in his lower esophagus. Since his subjective and objective symptoms were not ameliorated, he underwent lower esophagectomy and remnant gastrectomy reconstructed by the Roux-en Y method via a left thoracotomy and laparotomy in December 2004. Now, he does not suffer from reflux symptoms. This procedure was effective for reflux esophagitis post proximal gastrectomy.

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We report the case of a 78-year-old woman with small finger tip-sized reddish nodules in the skin of her chest wall. Her past history showed total gastrectomy for gastric cancer (T1N2MO: stage2) 17 months previously. Abdominal CT showed multiple lymph node enlargement in the right supraclavicular lesion and no evidence of any other organ metastasis. The biopsy of the skin lesion demonstrated a metastatic skin cancer of papillary adenocarcinoma. Therefore, we diagnosed this lesion as skin metastasis originating from adenocarcinoma of the stomach. Chemotherapy treatment with a combina-tion of TS-1 and Paclitaxel proved ineffective, and the patient died 3 months after the diagnosis of skin metastasis. Although the primary focus showed the early stage of gastric cancer, the cancer cells progressed via lymph tract in line with the nature of the lymph invasion. Moreover, the prognosis for the skin metastasis is poor, most cases have no treatment effect, and they die within 1 year. This case also followed a similar course.

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We report a case of advanced gastric cancer with tumor thrombus in the portal vein. A 57-year-old man was admitted in May 2005 for gastric cancer. Gastrointestinal fiberscopy showed a type 2 tumor in the stomach. Computed tomography showed the tumor thrombus in the portal vein. We performed a total gastrectomy with combined resection of the pancreas body, spleen and partial transverse colon, a long with removal of the tumor thrombus. He underwent adjuvant chemotherapy with TS-1, and is doing well without any recurrence more than 12 months after surgery.

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A 90-year-old woman was referred and admitted to our hospital for pneumonia. After admission, anorexia and vomiting occurred, and an endoscopy of the upper digestive tract using the bulb inversion method revealed a granular nodular tumor measuring 4cm, which prolapsed from the pyloric antrum into the duodenal bulb. It was impossible to reduce the tumor from the duodenal bulb into the stomach. Contrast-enhanced radiography of the upper digestive tract showed a lobular tumor measuring 4cm and prolapsing into the duodenal bulb. The gastric mucosa was extended from the pyloric antrum to the duodenal bulb. Preoperative respiration training and total parenteral nutrition (TPN) management resulted in a stable general condition. Therefore, distal gastrectomy (D2) and Roux-en-Y anastomosis were performed. Macroscopically, a semipedunculated tumor measuring 7.5×4.5×4.0cm was observed on the posterior wall of the pyloric antrum. The histopathological findings suggested tubl, m, ly0, v0, INFα, n0, and stage I A. The postoperative course was uneventful, and the patient was discharged 10 days after the surgery. In Japan, only 5 elderly patients (over 85 years) with gastric cancer prolapsing into the duodenal bulb, including our patient, have been reported.

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Small cell carcinoma of the stomach is a very rare neoplasm with a poor prognosis. We present a case of small cell carcinoma of the stomach which was diagnosed preoperatively.
An 85-year-old woman was found by endoscopic examination to have a type 2 tumor at the upper body of the stomach, which was diagnosed as small cell carcinoma with a biopsy. The patient underwent a total gastrectomy with regional lymph nodes dissection. Surgical findings were T2, N0, H0, P0, M0, and Stage IB. Gross findings of the resected specimen showed a 36×36mm tumor with a submucosal tumor-like appearance in the cross section. Pathological evaluation confirmed pure type of small cell carcinoma (medullary type, INFβ, T2 (MP), ly2, v3, nl, PM(-), DM(-), and Stage II). Immunohisto-chemically, these small cell carcinoma cells were stained for positive for CD56, NSE, synaptophysin, and chromogranin A. Adjuvant chemotherapy was not performed in consideration of her advanced age. Ten months after the operation, multiple liver metastasis was detected by abdominal CT scan. However, the patient was followed in our outpatient clinic without reduction in the quality of life.

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A 34-year-old woman was admitted to our hospital by ambulance because of sudden onset of right chest pain. The chest computed tomography revealed a mass shadow on the right side of the mediastinum, and fluid and air in the right pleural cavity. Her X-ray film taken 2 years ago in our hospital revealed a mass shadow with an air-fluid level in the right lower chest.
With a diagnosis of perforation of the incarcerated diaphragmatic hernia, the patient underwent thoracoabdominal exploration. During surgery, the tubular duplicated bowel arising from the second portion of the duodenum extended through the diaphragm into the right chest. The tubular duplicated bowel in the right chest was cancerous and perforated. The duplicated bowel was excised, with drainage from the right pleural cavity.
A tubular duodenal duplication extending through the diaphragm into the chest is very rare. To the best of our knowledge, there has been no case of malignant change in tubular duodenal duplication reported in the literature to date.

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Morgagni-Larrey hernias are congenital diaphragmatic hernias, rarely observed and generally identified accidentally due to the lack of symptoms. We experienced a case of incarcerated ileus in an elderly patient caused by Larrey hernia who was successfully treated with an emergency operation. An 85-year-old man was referred to the Emergency Room for left chest pain, and symptom of intestinal obstruction. A simple X-ray photograph and chest CT revealed herniation of the small intestine into the left thoracic cavity. Under the diagnosis of strangulated Larrey hernia, the surgery was performed by the transabdominal approach. We found an anterio-medial defect of the left side diaphragm, through which the ileum and omentum were incarcerated. As a part of the ileum was necrotized, we performed a partial ileotomy, and the hilum of the hernia was closed by a horizontal mattress suture. The patient has been well without any complications after surgery. This case was the oldest ever reported in Japan accorcling to our search of the Internet. Late-stage Morgagni-Larrey hernia is quite rare, but it can cause severe disturbance when complicated. We conclude that an operation should be carried out as soon as this disease is discovered.

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We performed surgical resection for a case of ischemic enteritis in an acute phase.
A 61-year-old man was referred to our hospital because of abdominal pain and vomiting. Abdominal CT scan revealed strangulation ileus and an emergency operation was performed. Upon laparotomy, there were no findings of strangulation ileus, but ischemic change was found in the small intestine and the lesion was resected. Although conservative therapy is generally indicated for ischemic enteritis in the acute phase, the disease lacks in characteristic findings and it is difficult to diagnose preoperatively. Particularly in cases in which strangulation is suspected like in our case, an emergency operation is required.

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A 65-year-old man complaining of nausea and abdominal fullness was admitted to our hospital. An upper gastrointestinal endoscopic study revealed consecutive erosion, ulcer and bleeding in the second portion of the duodenum. Abdominal CT scan showed widespread inflammation of small intestine. Endoscopic biopsy from duodenal mucosa did not reveal a definite diagnosis. After admission, the patient passed massive blood in his stool repeatedly. Because angiography revealed bleeding from a branch of iliocolic artery, TAE was performed. But massive melena recurred, so partial resection of the ileum was performed. The pathological diagnosis was polyarteritis nodosa. Although steroid pulse therapy and CHDF for renal failure were begun, melena recurred and the patient died. In a case of uncontrolled hemorrhagic enteritis, arteritis including PN must be taken into account for rapid diagnosis and proper therapy.

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A 60-year-old female with an abnormal mass on the right lower abdominal wall was diagnosed to have metastatic adenocarcinoma with excisional biopsy. Gastrofiberscopy, colonofiberscopy and jejuno-graphy could not detect the original lesion, however, PET-CT revealed the lesion in the left middle abdomen. Small intestinal endoscopy indicated the tumor with ulceration and severe stenosis in the jejunum about 15cm from the Treitz ligament. The biopsy specimen revealed moderately differentiated adenocarcinoma histologically. Partial resection of the jejunum was performed, and the postoperative course was uneventful, and chemotherapy was adapted from 17 postoperative days. PET-CT and small intestinal endoscopy were effective in detecting and diagnosing jejunal cancer.

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The patient was a three-year-old boy. On August 6, 2005, when he was playing with a toy which moves by 2 dry cells (single No. 5), the cover over the cells was off. His mother watched that her son picked up one of the dry cells and swallowed it at 7: 20 p.m. and brought him into our emergency clinic at 7: 30p.m. When he arrived at the hospital, he had neither dyspnea nor abdominal findings. An abdominal plain X-ray film showed a 1×3cm shadow of the accidentally swallowed dry cell. Fluoros-copic study revealed that the cell had already moved up to the upper portion of the small intestine, and an emergency operation was performed. Through an abdominal midline incision at the lower abdomen, we identified the dry cell which had progressed to the small intestine under direct vision. We moved the cell to the ileocecal region by hands, and performed an appendectomy, and then removed the dry cell from the surgical stump of the appendix. There have benn few cases of accidentally swallowed dry cell in the shape of a cylinder in infants and hence the therapeutic method has not been established as yet. We report an infant case of an accidentally swallowed cylindrical dry cell in which the cell was removed by performing an appendectomy.

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A 49-year-old man presented in our hospital with right lower-quadrant pain, tenderness and peritoneal sign in the right lower quadrant. A simple abdominal X-ray examination revealed a metallic foreign body in the right lower abdomen, and CT scan showed the same foreign body in the expanded appendix. Acute appendicitis caused by a denture ingested two months earlier was suspected, and the patient underwent an emergency operation. A denture was observed to have perforated the expanded root of the appendix, necessitating appendectomy and intraabdominal lavage and drainage. Reports of foreign bodies in the appendicitis are very rare. We report here a case of acute appendicitis caused by an ingested denture with reference to the literature.

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We reported two cases of femoral hernia with incarceration of the appendix. A 59 and 50-year-old woman, respectively, with right groin tumor and pain were operated with a diagnosis of incarcerated femoral hernia. Intraoperative findings showed that the appendix was strangulated with the femoral ring at a point 2cm from the tip of the appendix, from where ischemic change was recognized at the periphery. Appendectomy and hernioplasty (Moschcowitz procedure with iliopubic tract repair, and McVay procedure) were performed. Pathological findings revealed that the orifice side of the appendix from the strangulated point was normal, while the tip side showed dilation of blood capillaries and transmural, diffuse bleeding due to circulation insufficiency caused by the strangulation. In both cases, the ileocecum was not fixed to the retroperitoneam and thus the appendix moved close to the femoral ring where it was strangulated.
Intestinal obstructions are rarely caused by the incarceration of the appendix. Clean-contaminated operations, such as appendectomy and hernioplasty in these cases have to be performed without using mesh repair to avoid mesh infection.

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Carcinoid tumor of the appendix and mucinous cystadenoma of the appendix are rare diseases which are found accidentally with appendectomy. We report a case of coexistence of adenocarcinoid and mucinous cystadenoma of the appendix. The patient was a 22-year-old female with a chief complaint of right lower abdominal pain, who had had a similar symptom three times. Our diagnosis was chronic appendicitis, and she underwent an appendectomy. The pathologic findings were carcinoid tumor and mucinous cystadenoma. This is the third such case reported in Japan.

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A 47-year-old woman was seen at the emergency clinic in our hospital because of dizziness. She had been suffered from chronic constipation and had had no bowel movement for these 3 days. Dizziness occurred from unknown cause. The patient just complained of mild discomfort when the left lower quadrant of abdomen was pressed. However, abdominal CT scan showed intraabdominal free air, retoperitoneal emphysema, mediastinal emphysema, and subcutaneous emphysema at the neck. Intestinal perforation was thus suspected and an emergency operation was performed. Upon laparotomy, no contamination was seen in the abdomen and retroperitoneal cavity, but a perforated portion was present in the rectum. A Hartmann operation was performed. The postoperative course was uneventful. Pathological studies revealed no diverticula and malignant findings at the perforated portion, so that stercoraceous perforation of the rectum was diagnosed. Since no fecal leakage from the rectal perforation had occurred due to extremely hard stools in this case, striking abdominal findings were absent and the patient did not follow serious postoperative course.

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A 68-year-old woman visited her orthopedist complaining of swelling and hot feeling around her right waist back, and was referred to our hospital with a diagnosis of a rt. lumbar part abscess. It was detected as a high intensity area in the rt. retroperitoneal space on MRI T2 study. And on abdominal CT, a low density area with irregularly enhanced wall was found in the abdominal wall muscle and retroperitoneal space. The abscessography revealed a communication to the ascending colon. Colonoscopy showed a type 2 ulcer lesion with mucinous component. These were no definite findings as adenocarcinoma on the biopsy specimen. Barium enema study revealed a type 2 lesion around the cecum and ascending colon. With a clinical diagnosis of mucinous carcinoma of the ascending colon with a retroperitoneal abscess due to the penetration of the cancer, operative treatment was performed. The ileocecal mass penetrating to the retroperinoneal space formed retroperitoneal abscess, and it seemed to have developed into a retroperitoneal pseudomyxoma. Rt. hemicolectomy and ileostomy were performed. The abscess wall and surrounding muscle tissue were resected, and the omentum was replaced into this dead space.

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The patient was a 61-year-old man who had undergone sigmoidectomy, partial hepatectomy and cholecystectomy for sigmoid colon cancer with liver metastasis and cholelithiasis at the age of 60. Five months after the surgery, he was admitted to another hospital because of a ten-years history of recurrent anal pain. He was performed incision and drainage with a diagnosis of a perianal abscess. Pathological study of pus discharged from the abscess showed adenocarcinoma, and so he was referred to our hospital. At the left side of the anus, we found a tumor 5cm in diameter which was flare and swelling with an irregular skin ulcer. We diagnosed the case as metastatic carcinoma in an anal fistula caused by implantation from sigmoid colon cancer, and conducted abdominoperineal resection including the flare part of circumanal skin. The defect of skin in the anal region was repaired using a gluteus maximus muscle. The perianal tumor showed the same histological appearance as the sigmoid colon cancer. We concluded that free tumor cells from the sigmoid colon cancer might have been implanted in the anal fistula. Since metastasis of sigmoid colon cancer to an anal fistula is relatively rare, we report this case with some bibliographical comments.

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The patient was a 68-year-old woman, who had undergone a total gastrectomy for type 4 advanced gastric cancer about 5 years earlier which was poorly differentiated adenocarcinoma involving signet ring cell carcinoma, pT3 (se). pN0, H0, P0, M0, Stage II, scirrhous type, ly1 and v0. Thereafter she had been given oral anticancer agent 5'-DFUR for 2 years as postoperative adjuvant chemotherapy. This time she was seen at the hospital because of lower abdominal pain and abdominal distension. Lower gastrointestinal series showed apple core sign in the transverse colon at the splenic flexure. Lower gastrointestinal endoscopy revealed a remarkable narrowing encircling the lumen and the mucosa showed redness and was edematous and easily bleeding. The histological diagnosis was poorly differentiated adenocarcinoma involving signet ring cell carcinoma. The patient was operated on with the diagnosis of primary or metastatic colonic carcinoma. Immunohistologically the tumor was positive for CK7, CK19, and MUC5AC and negative for CK20, MUC1 and MUC2. Reviewing the preparation of gastric cancer which was thought to be the primary focus disclosed that the both preparations were the same in the histologic type and results of immunohistological stainings. Thus metastatic carcinoma of the colon from gastric carcinoma was diagnosed.

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A 72-year-old woman who had been undergoing hemodialysis for renal failure due to rephrotuber-culosis underwent modified radical mastectomy for right breast cancer, which was histologically invasive lobular carcinoma in stage III (T2N2M0). Nine months after the surgery, she was seen at the hospital because of right lower abdominal pain and constipation. Imaging methods revealed a narrowing and wall thickening at the splenic flexura, indicating metastasis of breast cancer to the transverse colon. Histopathological study of endoscopic biopsies revealed no evidence of metastasis. Laparoscopy showed wall thickening in the vicinity of the splenic flexura, a mesenteric nodule, and regional lymph node swelling. We excised the nodule and lymph nodes and confirmed the diagnosis of metastatic breast cancer.
Colon metastasis of breast cancer commonly occures in the terminal stage of breast cancer, and is rarely recognized as the initial metastasis. To make the definitive diagnosis of metastasic breast cancer is difficult even after endoscopic biopsies. Laparoscopic biopsies would be helpful in making the diagnosis and in avoiding unnecessary surgical treatment with early initiation of chemotherapy.

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We report a case of a patient who was operated on for an ovarian cancer and who presented with rectal metastasis 22 years later. In July, 2004, a 57-year-old woman was admitted to our hospital for investigation of positive stool for occult blood pointed out at a medical checkup. This patient had earlter undergone a total hysterectomy, bilateral adenexectomy, and partial omentectomy for an ovarian cystadenocarcinoma in 1982, and adjuvant chemotherapy had been performed. The patient's follow-up showed no abnormality until February 1991. Although the physical examination revealed no abnormality, a colonoscopy revealed elevated irregular lesions in the upper and middle rectum. Biopsies of both lesions showed group V, a well-differentiated adenocarcinoma. A low anterior resection with lymphadenectomy was performed. The resected specimen showed two polypoid lesions in the rectum, which appeared to be invaded from the serosal side. The pathological diagnosis was papillary serous cyst adeocarcinoma. The pathological findings of the specimen from the partial omentectomy performed in 1982 were consistent with those of the resected specimen. The patient was treated for recurrent ovarian cancer with paclitaxel and carboplatin, and has been well without any evidence of recurrent disease.

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A 74-year-old woman with hyperlipidemia was found to have a hypoechoic mass lesion about 3cm in size in a lateral segment of the liver by abdominal ultrasonography. A lateral segmentectomy was performed under a diagnosis of hepatocellular carcinoma. Pathological examination of the mass revealed malignant lymphoma (MALT type). The absence of other neoplastic lesions suggested it should be a primary hepatic lymphoma. Forty-four cases of primary hepatic lymphoma reported in the Japanese literature were reviewed. The ratio between male and female was 1. The age of the patients ranged from 29 to 87 years with the mean of 59 years. Pathological diagnosis of all cases was non Hodgkin lymphoma (B cell type, 39 cases; T cell type, 3 cases). In almost all cases the tumor was hypoechoic on ultrasonography, low density on CT, and hypo- and hyperintense on T1- and T2-weighted images, respectively. Statistical examination was performed about madical treatments, and no significant difference was obtained (excision group, n=20, 21.8±20.6m vs no excision group n=10, 18.8±17.3m; log rank test: p=0.5024). Since there were few cases, examination about chemotherapy, adjuvant chemotherapy and radiation was impossible. Therefore, further study is needed to establish a suitable treatment policy.

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We reported a rare case of hepatocellular carcinoma (HCC) with spontaneous complete necrosis. A 71-year-old man who was followed for chronic hepatitis type C was admitted to our hospital because a tumor was pointed out at the anterior-inferior segment of the liver (S5). Under a diagnosis of HCC, the partial resection of the liver was performed. The lesion was a yellowish mass, measuring 1.7×1.0cm, with a capsule. Histopathologically, the nodule was surrounded with a thick fibrous tissue, and fell into complete necrosis. No viable cancer cells were recognized. Finally, this case was considered to be spontaneous complete necrosis of HCC, because Ag stain of the resected specimen demonstrated the remains of reticulin fiber, and immunohistochemistry revealed a positive finding of antihepatocyte antibody. It was supposed that a decline of arterial feeding due to the endothelial injury by angiography or an immunological reaction may be associated with a mechanism of spontanenous complete necrosis of HCC. Only six cases of spontaneous complete necrosis of HCC were found in the literature.

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We report a case of primary adenosquamous carcinoma of the liver.
A 61-year-old man was seen at our hospital because of pain in the right flank. Blood tests showed a ALP value of 1, 140IU/mL, CEA of 20.6ng/mL, CA19-9 over 10, 000 U/mL, and AFP within normal limits (1.4ng/mL). Hepatitis virus markers were negative. Abdominal ultrasonography and abdominal CT scan detected a mass 90mm in diameter in the right lobe of the liver, and a diagnosis of liver'cancer was made. The right lobe of the liver was resected, and the histopathological diagnosis was primary adenosquamous carcinoma of the liver. The patient died of recurrence in the form of bone metastasis three months after the operation. The tumor in this patient, which has variously been called adenoacanth-oma, adenosquamous carcinoma, and mucoepidermoid carcinoma, has been reported in a total of 127 cases in Japan since 1982. The histogenesis of the disease has been speculated to be ectopic squamous epithelium, metaplasia of glandular epithelium into squamous epithelium, and metaplasia of adenocar-cinoma into squamous epithelium, although none of these have been established. The prognosis is poor, and the disease still poses many challenges in terms of operative procedure and multidisciplinary treatment meaning unclear.

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A 66-year-old man was admitted with a huge liver tumor. Laboratory studies showed elevated levels of hepatobiliary enzymes. Tumor markers were within normal limits. Computed tomography (CT) of the abdomen showed a low-density tumor about 5cm in diameter in the posterior hepatic segment. The periphery was irregularly enhanced. Abdominal angiography showed a hypovascular tumor and incomplete obstruction of the right portal vein. Endoscopic retrograde cholangiopancreatography revealed a smooth narrow segment in the right hepatic duct. Under a diagnosis of intrahepatic cholangiocarcinoma, we performed extended right hepatectomy with portal vein resection. Histological examination showed adenocarcinoma and sarcomatous components. Immunohistological examination showed that adenocarcinoma components stained for epithelial markers, and sarcomatous components stained for mesenchymal markers. We diagnosed this as cholangiocarcinoma with sarcomatous change. The patient was discharged on postoperative day 29. Para-aortic and hilar lymph node recurrence took place 10 months after the operation, and the patient died 16 months postoperatively. Cholangiocarcinoma with sarcomatous change is rare, with only 15 cases including ours, reported thus far in the Japanese literature.

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We report a case of undifferentiated carcinoma of the gallbladder in a 74-year-old woman who was admitted to our hospital with an abdominal tumor. Aparatomy was performed under the preoperative diagnosis of gallbladder tumor, based on imaging findings. The tumor had invaded the transverse colon, transverse mesocolon, descending part of the duodenum, and uncus of the pancreas. We performed a cholecystectomy considering the patient status. Histological examination showed the undifferentiated carcinoma cells were spindle type. The patient died 72 days after operation. Undifferentiated carcinoma of the gallbladder is a rare neoplasm in Japan. In many cases, the neoplasms grow to become a large mass and invade the adjacent organs. The prognosis is very poor, because patients in the advanced stages die within one year after operation.

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A monolocular cystic tumor in the tail of the pancreas was detected incidentally by ultrasonography during a medical check-up of a 57-year-old female. Abdominal computed tomography showed the tumor consisted of cystic and solid parts. The density of the solid part had a higher density than pancreatic tissue. On endoscopic ultrasonography, the tumor was cystic mass with thick and irregular walls. As an asymptomatic pancreatic endocrine tumor with cystic change was highly suspected, combined resection of the tail of the pancreas and spleen was performed. The pathological diagnosis was epithelial cyst in an intrapancreatic accessory spleen.

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A 53-year-old woman underwent a pylorus preserving pancreatoduodenectomy (PPPD) with intestinal reconstruction by means of modified Child method for a submucosal tumor in the descending part of the duodenum in August 1994. Two years later, dilatation of the main pancreatic duct became apparent on an abdominal CT scan. Thereafter the diameter of the main pancreatic duct increased to 3cm in 2000 and then 4cm in 2003. Since a mucin-producing tumor of the pancreas was considered probable, the patient was operated on again in 2004, 10 years after the first operation. During surgery adhesions at the pancreatojejunostomy in the former operation was easily dissected, and no anastomotic opening was identified in both the pancreas and jejunum. An incision of the main pancreatic duct disclosed the retension of yellowish white cloudy fluid. Inraoperative frozen section histology showed absence of pancreatic tumor, so that anastomosis of pancreatic duct to jejunum was performed again. The patient's postoperative course was uneventful.

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A 66-year-old man visited another hospital because of upper abdominal discomfort. Gastroduodenal fiberscopy revealed gastric cancer, so he was admitted to our hospital for surgical treatment. Gastroduodenal fiberscope revealed the type IV tumor, and a diagnosis of signet-ring cell carcinoma was made by subsequent biopsy. Abdominal CT and ultrasonography revealed a tumor in the body and tail of the pancreas. MRCP showed only a stone in the common bile duct, but 3D-CT angiography detected disruption of the splenic artery and vein. From these findings, a diagnosis of double cancer with carcinoma of the pancreas tail and gastric cancer was made, and total gastrectomy with combined resection of pancreas tail and spleen, and choledocotomy was performed. Pathologic examination showed that the pancreatic tumor was adenosquamous carcinoma. The frequency of double cancer with gastric cancer is considered to be higher than that of other malignant disease, but double cancer with pancreatic cancer and gastric cancer is rare. To the best of our knowledge, this is the first report of a double cancer with adenosquamous carcinoma of the pancreas and gastric cancer. We present this extremely rare case with a review of the literature.

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We reported a case of solitary splenic metastasis that recurred after chemotherapy from ovarian cancer, together with a review of 14 of our own metastatic cases through November 2005.
A 70-year-old woman underwent performed hysterectomy, adnexectomy and partial omentectomy with intraperitoneal chemotherapy (IP) by CDDP for a left ovarian cancer in July 2002. Although a splenic metastasis and dissemination appeared on preoperative CT, they disappeared after postoperative chemotherapy (Paclitaxel+Carboplatin: TJ therapy). A solitary splenic metastasis was detected in September 2003. Splenectomy was pertormed because of the gradual increase of the tumor size in January 2005. Our chemosensitivity test for the metastatic splenic tumor revealed, no chemosensitivity to Paclitaxel. We suggest that Paclitaxel-resistant metastatic cells had regrown in this case, in spite of the completely controlled dissemination by IP and TJ therapy.

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Spontaneous visceral arterial dissection, in particular, isolated dissection of the celiac artery is quite rare. We reported here two cases of isolated dissection of the celiac artery treated successfully. Case 1. A healthy 50-year-old man felt sudden left abdominal pain. Abdominal CT scan demonstrated a splenic infarction. A subsequent CT scan after admission showed dissection of the celiac artery and its branches such as hepatic, splenic, and left gastric arteries. Case 2. A 46-year-old man had sudden epigastralgia after eating lunch. As the pain disappeared by taking NSIAD, he underwent no further examinations. A follow-up CT scan for his previous colonic cancer operation was performed 18 days after this episode. It showed dissection of celiac and splenic arteries. Both patients were successfully managed by medical surveillance. They still have no symptoms, and their false lumens are becoming smaller. We focused on the serial imaging change of the arterial dissection in this report.

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We report a case surviving acute superior mesenteric artery occlusion with hepatic portal venous gas, which has a grave prognosis Only 9 survivors including this case have been reported in Japan. An-85-year-old woman with a past history of brain infarction complained of severe abdominal pain. Abdominal X-ray revealed a severe ileus image. Plain abdominal CT performed the next day showed hepatic portal venous gas. The physical examination indicated severe peritonitis. An emergency operation laparotomy, performed about 53 hours after onset, revealed severe necrosis of the small intestine from Treitz's ligament to the splenic flexure. All of the necrotic bowel was resected and a jejunostomy was performed. The length of the residual jejunum was about 20cm. Because of the length of the residual small intestine, a short bowel syndrome occurred. Other than that, the postoperative course was uneventful. The patient was discharged 20 days after the operation.

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A 48-year-old woman was seen at the hospital because of abdominal pain, vomiting and diarrhea in January 2006. There was mild tenderness in the right lower quadrant of abdomen without peritoneal stimulating signs. Abdominal X-ray and CT scan showed small intestinal gas and fluid image. We diagnosed the case as small intestinal obstruction, and conducted conservative therapy using a long tube. Radiological study via the long tube with contrast agent showed stenosis of the ileum at the right lower abdominal region. Internal hernia was suspected and surgery was carried out on the 9^th hospital day. Incarceration and adhesion of the ileum were found about 2m proximal from the terminal ileum into a posterior mesenteric defect of the ileum. The adhesion was loosened because the impacted ileum was not necrotic and stenotic. The oval defect, 3.5×2.0cm in diameter, was observed in the posterior mesentery of the ileum and did not penetrate into the anterior one. Its defect was closed with sutures. Operative findings clarified the diagnosis of small intestinal intramesenteric hernia of Richter's type. The postoperative course was uneventful and she was discharged 8 days after the operation.

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A 94-year-old woman was admitted to our hospital because of vomiting and abdominal distension. Although laboratory examination indicated relatively non-severe condition, abdominal plain X-ray film and CT scan showed dilatation and wall thickening of the small intestine. On admission, the woman went into shock. An emergency surgery was initiated with a diagnosis of acute abdomen. Operative findings showed regional necrosis of the small intestine extending 150cm from a point 50cm distal from the Treitz's ligament. The total resection of the necrotic small intestine and jejuno-ileostomy by side to side was performed. Pathological examination showed no signs of thrombus, fibrinoid degeneration, or angitis in blood vessels of the small intestine, and non-occlusive mesenteric ischemia (NOMI) was diagnosed. The patient, in septic shock and multiple organ failure before surgery, was managed with respirator, direct hemoperfusion using polymyxin-B immobilized fiber (PMX-DHP), and hemodiafiltration (HDF). Consequently, the patient could take food orally on postoperative day (POD) 7, and she was discharged on POD 48.

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A 45-year-old man complaining of abdominal distension and upper abdominal pain was referred to the hospital with a diagnosis of intestinal obstruction in the last 10 days of January, 2005. Following abdominal CT scan, the patient was diagnosed as having a hernia through foramen of Winslow. A long tube was placed in expectation of spontaneous reduction of the hernia, but the treatment was unsuccessful. On the next day an emergency operation was performed. Operative findings showed that a 50-cm portion of the small intestine about 200cm distal to the ligament of Treitz was herniated through the foramen of Winslow into the omental bursa, and was strangulated there. Manual reduction of the hernia was easily done by introducing the long tube to the herniated part and sucking the intestinal content into the tube. No intestinal resection was needed, because no intestinal necrosis was seen. The Winslow foramen was slightly enlarged to be two fingerbreadths, but no plication suture was made. Other abnormalities were present.
Hernia through foramen of Winslow is so rare and it accounts for about 8% of all internal hernias. We analyzed a total of 39 domestic cases, including our case, and discussed its clinicopathological characteristics.

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Desmoid tumors are divided into three groups by location, as abdominal, extraabdominal and intraabdominal desmoid. Intraabdominal desmoid generally originates from the mesenterium. We experienced a case of omental desmoid tumor discovered as the content of an inguinal hernia. Omental desmoid tumor is very rare and we report the case.
A 70-year-old man, who had undergone radical prostatectomy for prostatic cancer at the age of 67, was admitted to our hospital because of a fist-sized swelling in the right inguinal area. Abdominal CT scan revealed that the swelling was an inguinal hernia and the contents were the omentum and a 2.5×2.5cm isodencity tumor. Operation (Mesh-plug method) was performed with the diagnosis of non-reducible inguinal hernia. The prolapsed omentum and the tumor were resected. Histologically, the tumor was desmoid originated from the omentum. Only two cases of omental desmoid tumor have been reported in Japan.

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A 21-year-old woman was seen at the hospital because of right lower abdominal pain. Abdominal CT scan and US showed a tumor 5cm in longer diameter which was mainly composed of fat in the right lower quadrant of abdomen. A teratoma was suspected. An emergency operation was performed, because a possibility of circulatory disturbance or infection due to torsion could not be ruled out. During surgery, we identified a tumor arisen from the greater omentum outside of the cecum, which was twisted around the omentum. The tumor with part of the greater omentum was resected. No abnormalities were noted in the bilateral ovaries. Histopathological studies revealed corpus albicans and hair inside the tumor and keratinized component in the cystic wall. Thus mature cystic teratoma composed of mature tissues was diagnosed.
This paper presents a case of torsion of a mature cystic teratoma of the greater omentum, which is extremely rare.

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A 64-year-old woman underwent a low anterior resection of rectum for rectal carcinoma (Rs) in November 2005. One month later she suddenly had lower abdominal pain and low back pain. Moreover the sudden onsets of oliguria and increases BUN and creatinine occurred, and bilateral hydronephrosis was demonstrated by an abdominal CT scan. Retrograde radiography disclosed annular stricture in the bilateral ureters and medial deviation of the ureters. Medication with oral prednisolone at a dose of 10mg/day was started with a diagnosis of retroperitoneal fibrosis, and a stent was placed in the right ureter. Then the urinary output promptly increased, BUN and creatinine levels were normalized, and low back pain was relieved.
Retroperitoneal fibrosis is characterized by extensive fibrotic encasement of retroperitoneal tissue. It causes stricture and obstruction of the ureters and vessels. It often presents with hydronephrosis. Although about 70% of cases are idiopathic, possible correlations with malignant tumors, infection, and drugs have been suggested. This disease must be suspected for bilateral hydronephrosis of unknown origin and early treatment is important in that case.

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