A poor nutritional status is a significant prognostic factor for an increased mortality after esophagectomy or esophagogastrectomy. We have recently developed a newly-designed double elementary diet tube (W-ED tube) and tested to assess its efficacy on the postoperative course of esophageal surgery. The W-ED tube is 16 Fr in width and 150 cm in length and has double lumen. One lumen has its openings at the end of the tube for feeding (head openings). Another lumen has its openings at the side of the tube, 60 cm above the leading edge (upper openings). The upper openings are made for decompression of the gastric tube. We used the W-ED tube for thirty patients after standard subtotal esophagectomy thus far. The tube was put nasally under radiographic guidance. The head openings were put into the jejunum and used for feeding. Tube feeding was started at the first day after surgical operation. In all cases, there was no inconvenience such as reflux of nutritive materials, and nutritional status was kept fine. Even in a case with anastomotic leakage persisted for a long time, the nutritional status was improved promptly and the fistula was closed quickly after using the W-ED tube. We consider this newly-designed tube might be useful for the patients who need both tube feeding and decompression of anastomosis, especially after esophagectomy.

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[Background] We evaluated the treatment strategy of neoadjuvant chemoradiotherapy followed by curative surgery combined with 2-field lymph node dissection for clinical stage IIand III esophageal squamous cell carcinoma (ESCC) in our regional center hospital.
[Patients & Methods] 46 patients with clinical stage II and III ESCC who underwent surgery at our department were enrolled. Among those 34 patients received neoadjuvant chemoradiotherapy (nCRT+S group), and 12 did not (S group). Clinicopathological parameters, prognosis recurrence site and postoperative morbidity were evaluated.
[Results] 1-, 3- and 5-year survival rates of 46 patients were 79.7, 31.2, and 31.2%, respectively. Five-year survival rates of nCRT+S and S groups were 34.8% amd 16.9%, respectively (p=0.80). Multivariate analysis revealed that pathological stage (pStage) was an independent prognostic factor. Among 34 patients in nCRT+S group, clinicopathological characteristics of pStage 0+I+II patients were significantly superior to those of pStage III+IVa patients with respect to venous infiltration (v factor) and CRT Grade, and they showed a significant down staging. In-hospital death was zero and the postoperative morbidity rate was 17.6% in nCRT+S group.
[Conclusions] Our treatment strategy for clinical stage II and III ESCC, neoadjuvant chemoradiotherapy followed by curative surgery combined with 2-field lymph node dissection, proved acceptable. It is necessary, however to develop an effective treatment strategy for patients with pStage III+IVa ESCC after surgery.

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We conducted a questionnaire survey for surgeons in the Hiroshima district asking about their treatments of advanced gastric cancer with either of non-resectable factors including peritoneal dissemination, liver metastasis, or lymph node metastasis (≥N3). In the case of P1, as defined by the 12^th edition of General Rule for Gastric Cancer, in which peritoneal dissemination is limited around the stomach, gastric resection is employed for lesions involving the L region in 97%, and reduction surgery for those involving the U region in 84% of the institutions. It suggests that their treatments slightly differ according to locations of the lesions, even if they are in the same stage. In the case of P2, in which some peritoneal seeding exists in the abdominal cavity, reduction surgery is employed for lesions involving the L and U regions in 56% and 40% of the institutions, respectively. On the contrary, in the case of P2 in which palliative treatments are performed for symptomatic patients due to primary lesions, bypass operation is employed for lesions involving the L region in 33%, but gastric resection is done for such lesions in 94% of the institutions if they bleed. As for the lesions involving the U region, total gastrectomy is employed in approximately 80% of the institutions, regardless of the presence of narrowing or bleeding. In the case of liver metastasis or non-resectable lymph node metastasis, chemotherapy is the front-line treatment for liver metastasis or LN metastasis in only 10% or 23% of the institutions, respectively.

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We have made a study comparing between open surgery and laparoscopic surgery for postoperative adhesive intestinal obstruction in consecutive 90 patients undergone surgery at the hospital in a 12-year period from 1995 to 2006. Of these 90 patients, 20 patients were initially indicated laparotomic surgery, because safe surgery under laparoscopy was considered impossible due to difficulty in holding a good vision with laparoscopy. Fifty-three patients out of the remaining 70 patients were able to undergo laparoscopic or laparoscopy-assisted release of intestinal obstruction. Laparoscopic surgery revealed shortest operating time, earliest initiation of oral ingestion after the surgery, and shortest duration of hospital stay. As for previous history of undergoing surgery, patients whose surgical wounds were larger and those who had demanded more difficult operations had more serious adhesions and thus required open surgery. The main cause of conversion to laparoscopy-assisted or to open surgery was adhesions between intestines each other in which dissections were difficult. Laparoscopic surgery is a minimally invasive operative procedure for postoperative adhesive intestinal obstruction, however, we must not stick to laparoscopic surgery and convert to open surgery early if it entails risks such as organ damage.

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We encountered a patient with secondary hyperparathyroidism which caused recurrent nerve paralysis. The patient was a 61-year-old female introduced to hemodialysis for chronic renal failure at 45 years of age. Misswallowing and hoarseness appeared in July 2003. Right recurrent laryngeal nerve paralysis was observed in laryngoscopy. Cervical CT and echography detected a tumorous lesion in the right lobe of the thyroid and swelling of the bilateral parathyroid glands. As a surgical finding, the right recurrent laryngeal nerve had been incorporated into the swelled parathyroid capsule at the right lower pole of the thyroid. The right recurrent laryngeal nerve was sharply dissected and preserved, and right hemithyroidectomy and parathyroidectomy were performed. On pathological examination, the lesions were identified as papillary carcinoma of the thyroid gland and parathyroid hyperplasia. Hoarseness was improved after surgery. Marked improvement was also observed by laryngoscopy. On a literature review, 11 cases of parathyroid disorder were reported to have developed recurrent laryngeal nerve paralysis, and only 3 of them had secondary hyperparathyroidism.

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We present a case of a 19-year-old man who was treated for gynecomastia by endoscopic subcutaneous mastectomy with good cosmetic outcome. The patient had noticed to have gynecomastia on the right side for more than 2 years. Diagnostic imaging studies could differentiate the lesion from a breast carcinoma, and no specific causes were identified. Since no regression was noted spontaneously and with a hormonal therapy elsewhere, endoscopic breast surgery was considered as the best option for cosmetic improvement. The patient was placed in the supine position with the ipsilateral upper limb abducted and extended. An 11 mm port for camera was inserted into the lateral area of the right breast, and the working space was kept with CO2 insufflation at 6 mmHg. Two 5 mm working ports were placed in both the head and foot sides of an inserted camera, dissection was made between the dorsal aspect of the mammary gland and pectoral major muscle, and then dissection was processed between the skin and mammary gland. In order to avoid postoperative nipple necrosis, tissue of about 1 cm width was left just under nipple areolar complex. Blood loss was minimal during operation and no postoperative bleeding was noted. The patient was discharged from the hospital on the 4^th postoperative day. Favorable surgical outcome in cosmesis was obtained for the operated breast, and no different appearances were seen 1 year after the operation. There has been no recurrence, as of 2 years after the operation. Endoscopic subcutaneous mastectomy which leaves inconspicuous surgical scars and offers patient satisfaction is an effective minimally invasive procedure for gynecomastia.

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A 78-year-old woman visited a hospital because of a left breast mass and nipple retraction was referred to our hospital with a suspicion of breast cancer. We noted a 9×9 mm hard mass with relatively smooth surface in the C area of the left breast as well as an inverted nipple without showing dimpling sign. Mammography showed a tumor shadow with a minute dentate change and findings of tugging the nipple. Thus the lesion was diagnosed as category 5 and solid-tubular carcinoma was suspected. Ultrasonography visualized a lobulated tumor with an almost homogeneous and hypo-echoic internal echoes with hyper-echoic margin, common type breast cancer being suggested. Needle aspiration biopsy cytology disclosed clusters of atypical epithelial cells of mammary duct having small nucleolus, however, myoepithelial cells and luminal epithelial cells were kept intact so that differentiation between them was very difficult. We recommended needle biopsy to the patient because the suspected histological type based on imaging diagnosis was not compatible with those of cytological findings, but the patient selected partial resection. The final diagnosis of ductal adenoma was then diagnosed.
Ductal adenoma is one of lesions which are apt to be diagnosed as breast cancer clinically as well as pathologically, and to make the final diagnosis of the disease is often difficult without biopsy. Having a thorough knowledge of the concept of the disease might be the best and only way not to misdiagrose it as breast cancer.

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A 72-year-old woman visited our hospital with a left breast mass in area D. A chest CT showed that the mass size was 34 mm, the distance from the left nipple was 30 mm and the axillary lymph node was swollen to a size of 34 mm. Informed consent was obtained for 3 courses of neoadjuvant chemotherapy with orally administered drugs (S-1, cyclophosphamide, and medroxyprogesterone acetate : S-1/MpC). The tumor size was decreased from 34 mm to 8 mm as a result. Conservative surgery for the breast cancer could then be performed. Oral combination chemotherapy with doxifluridine, cyclophosphamide and medroxyprogesterone acetrate (DMpC) has usually been used for advanced breast cancer in our hospital. S-1 is a new anti-cancer drug. The response rate among patients with breast cancer treated with this drug was reportedly 21.8%, so we considered that the response rate could be increased if we replaced the doxifluridine of DMpC with S-1. We are now attempting a phase I/II study with this new oral combination chemotherapy (S-1/MpC) which could be effective for advanced breast cancer. (This report described a phase I Study.)

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We report a successful use of open wet-dressing therapy to a 13×8cm dermal defective wound after operation for breast cancer in a 55-year-old woman.
The patient had a 15×25×5cm cauliflower-like tumor in the left breast and underwent left mastectomy with a diagnosis of breast cancer. As a result, a 13×8cm dermal defective wound with exposure of the 5^th rib was left on her chest. We considered that the defect might entail a high risk of wound infection and did not perform immediate free skin drafting. Instead we washed the defective wound with tap water, then applied and continued open dressing using poly vinyliden chloride food lap-film (open wet-dressing therapy) to the wound. Granulation was started on the postoperative day 8 and the granulating wound became flat on the day 17. Epithelialization was started longitudinally on the postoperative day 14 and horizontally on the postoperative day 37, however, it gradually came to be retarded. So external use of steroid was started on the postoperative day 57 with which the epithelialization was identified on the periphery of the ulcer on the next week and thereafter the epithelialization progressed at a speed of 1 cm per week. Almost complete cure of the defective wound was attained in about 2 months.
This open wet-dressing therapy appears to be an excellent method which is able to cure such a large dermal defective wound as more than 10cm in diameter.

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A 60-year-old woman attempted suicide and stabbed her neck was brought into the emergency room of our hospital. On arrival, the patient was in shock (JCS : III-300, systolic blood pressure : 40 mmHg) and had 7 stab wounds with clots in the neck. Immediately after recovering from the shock with rapid infusion, the patient had excessive bleeding from the wounds and underwent emergency surgery. Both of the internal jugular veins (IJVs) had been injured. The left IJV was removed from the surrounding tissues following resection of the injured part, and extended for suture reconstruction. The end-to-end anastomosis was carried out with 7-0 polypropylene suture. The right IJV could not be reconstructed and ligated. The left IJV reconstruction prevented postoperative cerebral complications and the patient was discharged from the hospital 3 weeks after the operation.

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Three cases of surgically-treated round atelectasis were reported. Case 1 : A 71-year-old man. A nodular shadow detected in a series of follow-up studies of gastric cancer had been increasing in size throughout the past year. Thoracoscopic examination yielded a diagnosis of round atelectasis and decortication was performed. Case 2 : A 72-year-old man. A nodule touching the diaphragm pointed out at a physical check-up was increasing in size. Thoracoscopic biopsy demonstrated that the nodule was round atelectasis and decortication was performed. Case 3 : A 73-year-old man. Three years following lobectomy of the left lower lobe for round atelectasis, a new lesion was detected in the patient's right lower lobe. Decortication was selected to expand the atelectasis and residual lung. In the postoperative course, all three cases maintained good expansion of the atelectatic portion and the residual lung evidenced no complication or recurrence. Round atelectasis often enlarges in terms of follow-up, and it is important to make a differential diagnosis from lung cancer. Thoracoscopic examination followed by decortication is the proper modality for not only accurate diagnosis but also for less invasive treatment of round atelectasis.

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A 71-year-old man was admitted to our hospital because of an abnormal shadow on a chest X-ray film conducted about one year before admission. Chest CT scan revealed an abnormal shadow on the left upper lobe of the lung. We diagnosed the tumor as lung cancer based on his occupational history and pleural plague. Thoracoscopy was performed and the tumor was resected. Frozen section revealed that the tumor was adenocarcinoma and left upper lobectomy was performed. We counted asbestos bodies in the resected lung. There were 27086/g asbestos bodies in the lung. For that, the patient was adapted to ‘the new relief measure from health damage due to asbestos’ Risk factors for lung cancer included smoking other than asbestos. In order to make the diagnosed of asbestos-induced lung cancer, we need to counter asbestos bodies in the affected lung in some cases.

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The patient was a 65-year-old man. He had received radio frequency ablation for HCC in our hospital one year earlier. He was admitted to our hospital again in December 2005 for epigastralgia and nausea with the diagnosis of ileus.
Though he received conservative therapy at first, shock occurred suddenly on the third hospital day. Emergency operation was done with a diagnosis of strangulated ileus. A diaphragmatic hole aligned with the RFA point existed, where the small intestine was strangulated and was necrotic. Though he received necrotic bowel resection and closure of the diaphragmatic hole, he died of MOF on the third operative day. Though trans-diaphragmatic RFA to HCC has increased recently, it is considered that diaphragmatic hernia is a complication requiring care during this operation.

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The case was a 61-year-old woman who underwent a mastectomy for carcinoma of the right breast T3N0. A tumor of 15mm size was revealed by preoperative CT in the liver S8 infradiaphragm region. Because biopsy was difficult in this part, follow-up was performed while enforcing hormone therapy, but we recognized no change of size during about 1 year and six months. Because we agreed on using PET in the same part, and found high accumulation of FDG, we diagnosed it as suspected liver metastasis from the breast cancer and conducted abdominal excision. It was a dome-shaped diaphragm tumor of 2cm size, sinking into the liver parenchyma and was a benign schwannoma by histopathological inspection. There have been reports that even if a schwannoma is benign, high accumulation of FDG may be seen, but in this case, discrimination with liver metastasis was difficult even when we used PET, due to the localized specialty and progress of the disease.

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We report two cases of spontaneous esophageal rupture that were suggestive about treatment. The first patient was a 53-year-old male who vomited after consuming alcohol immediately followed by dorsalgia and dyspnea. A CT scan revealed left pleural effusion, pneumothorax and pneumomediastinum. Nine hours after presentation, the esophageal rupture was closed with a primary suture via a right thoracotomy. Because the patient had severe liver cirrhosis and esophageal varices, controlling perioperative hemorrhaging was difficult. The patient died 6 hours postoperatively with multiple organ failure. The second patient was a 55-year-old male in whom esophageal rupture was suspected under similar circumstances as the first case. Seven hours after presentation the rupture was closed with a primary suture and covered with a pedicled muscle flap of the intercostal muscle via a right thoracotomy. Treatment was complicated by leakage of the sutures and associated bilateral pyothorax. The condition was conservatively recovered with intravenous nutritional management. As for the spontaneous esophageal rupture, early diagnosis and immediate treatment influence the prognosis, but treatment suffered due to the inadequate approach to the underlying disease regardless of an early diagnosis. The treatment for esophageal rupture is standardized, but it is important to treat with low infestation mainly on drainage for the overall case, and to choose on adequate method for the case.

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Esophageal melanosis is a rare disease that is characterized by spotty, band-like, or patchy pigmentation with black or brown esophageal mucosa. We report a rare case of esophageal melanosis with early esophageal cancer. A 63-year-old woman was admitted to our hospital with suspicion of esophageal cancer. Endoscopic examinations revealed black pigmented spots and a slightly depressed lesion at 30 cm distal from the incisor. Histological examination of the biopsy specimen showed squamous cell carcinoma. Based on a diagnosis of esophageal melanosis with early esophageal cancer, we performed endoscopic submucosal dissection of early esophageal cancer. Pathological findings showed melanin granules in the basal layer of the epithelium and cancer cells in the esophageal epithelium.

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We experienced a case of superficial esophageal carcinoma with a giant submucosal tumor (SMT)-like intramural metastasis to the stomach. A 62-year-old man was suspected of an esophageal cancer. Preoperative examinations revealed a giant SMT-like tumor about 80mm in diameter, in the gastric cardia with erosion on its top besides a lesion in the lower esophagus. A subtotal thoracic esophagectomy, total gastrectomy, distal pancreatectomy, and D2 lymph node dissection by Appleby's operation, were performed. The resected specimen showed a type 3 tumor measuring 39×31mm in the esophagus, and an SMT, 85×75mm in size, in the upper and middle lesser curvature of the stomach. Histopathologically, the esophageal tumor was squamous cell carcinoma with a giant intramural metastasis to the stomach. Only 15 cases of superficial esophageal carcinoma with a giant intramural metastasis have been reported in the Japanese literature. We herein report a rare case of superficial esophageal carcinoma with a giant intramural metastasis to the stomach resected by Appleby's operation, together with some bibliographical comments.

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A 61-year-old woman was seen at our department because of low abdominal pain and lumbago in September 2005. A diagnosis of multiple bone metastasis at cervical and lumbar vertebra had been made in the orthopedics department. A diagnosis of multiple liver metastasis was made based on abdominal CT. An image of a category 5 mass was found by mammography in the left C region. A diagnosis of breast cancer (infiltration cancer) was made following aspiration cytology of this lesion. A tumor of type 4 on the greater curvature in the stomach was revealed by gastroscopy. A diagnosis of breast cancer metastasized to stomach was made by immunohistologic dyeing views. Taxol 80mg/m² (Day 1, 8, 15 Every 4 Wks) was administered for 1 cycle until the present. Breast cancer stomach metastasis is rare, and there are reports of 57 cases in Japan. Though the prognosis is bad, There is a long-term survival example in the endocrine therapy group. Though the diagnosis of breast cancer metastasized to stomach is difficult, it is important to consider this when monitoring breast cancer postoperatively.

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A case of the recurrence of gastric small cell carcinoma successfully treated with postoperative TS1/CDDP therapy is reported.
A 48-year-old female was referred to our hospital for elective surgery for carcinoid tumor of the stomach. We performed total gastrectomy and splenectomy with D2 lymph node dissection. The tumor was diagnosed pathologically as a small cell carcinoma. Lymph node metastasis was observed micro scopically. Atypical small cells were positive for immunohistochemical stains of NSE and chromogranin-A. At two years and five months postoperation, metastases to the para-aortic lymph node and liver were detected, and TS-1/CDDP therapy was started. Although the size of para-aortic lymph nodes was not changed, the liver metastases were remarkably reduced. The patient is alive 4.3 years after the surgical operation.
We consider that TS-1/CDDP chemotherapy may be an alternative therapy for small cell carcinoma of the stomach.

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A case of successfully treated Lemmel syndrome in an 82-year-old diabetic woman is reported. Since October 2000, she had complained of occasional bouts of right hypochondralgia and high fever. Laboratory studies suggested inflammation and congested biliary system but showed normal levels of serum total bilirubin and amylase. Imaging studies showed a dilated biliary system and multiple diverticula around the duodenal papilla. We diagnosed the case as Lemmel syndrome and treated her conservatively in accordance with her wishes. After eighteen recurrences of the disease, she finally developed obstructive jaundice. We decided on surgical treatment after percutaneous transhepatic biliary drainage, and chose choledochoduodenostomy because the diverticulum was not apparently compressing the main pancreatic duct, as evidenced by the consistently normal level of serum amylase. She has not experienced any recurrence of symptoms, as of 2 years 10 months after the surgery. Lemmel syndrome is a benign disease, and no clear guidelines for indication of surgery as well as selection of surgical procedure for it have been established as yet. We would have to select most appropriate procedure case by case.

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Most cases of cancer of the duodenal papilla are of adenocarcinoma. Adenosquamous cell carcinoma of the duodenal papilla is very rare and so far only 22 such cases have been reported in Japan as far as we could review. In this paper we report a case of adenosquamous cell carcinoma of the duodenal papilla.
A 75-year-old woman was seen at the hospital because of high fever and general fatigue. Following close exploration, cancer of the duodenal papilla was diagnosed and pylorus preserving pancreatoduodenectomy was performed. There were no findings suggestive of hepatic metastasis and peritoneal dissemination, and a 27×15mm tumor of tumor-like ulcerative type was identified at the duodenal papilla. Histopathological exploration disclosed well differentiated tubular adenocarinoma in the center of the tumor which had arisen from around the common duct as well as well differentiated squamous cell carcinoma at the infiltrating periphery of the tumor. Thus adenosquamous cell carcinoma arisen in the duodenal papilla was diagnosed. The patient was discharged from the hospital on the 48^th hospital day. There have been no signs of recurrence as of 9 months after the operation.

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Postoperative ileus is an unavoidable problem. When treating ileus, it is imperative that surgery is performed during an appropriate period and all methods are utilized to ensure that the involved intestines remain intact. We treated a boy aged 3 years 11 months, admitted to our hospital because of abdominal pain and vomiting. There were previous histories of undergoing surgery for retroperitoneal neuroblastoma at the age of 8 months and laparotomy for ileus at the age of 3 years 6 months. Although signs of intestinal obstruction were not serious on admission, an emergency laparotomy was performed due to worsening acidosis and abdominal pain on the hospital day 3. Laparotomy revealed severe intestinal ischemia, which extended 150 cm in length in the ileum and further 20 cm in the ascending colon. Twenty hours after the first operation no improvement of the ischemia was attained so that we adopted our contingency plan conceived at the time of the first surgery. Thus a follow-up ileostomy was performed on the normal intestine in the hope of avoiding massive resection.
Twenty-two days after the follow-up operation, another laparotomy revealed that the intestine had completely recovered and we closed the ileostomy. Preserving the intestinal function reduces the probability of severe complications such as sepsis, hepatic failure, and developmental retardation. Follow-up surgery with colostomy is an effective procedure to avoid short bowel syndrome due to massive intestinal resection.

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A 62-year-old woman was admitted to our hospital because of abdominal pain and distention followed by a common cold symptom. She had underlying diseases of atrial fibrillation and cerebral infarction, so she took Warfarin potassium and Bucolome to increase the anticoagulant effect. Plain abdominal radiography and abdominal computed tomography showed dilatation of small intestine with niveau formation. An emergency laparotomy was performed under a diagnosis of intestinal obstruction with ischemia. On laparotomy, we found an ischemic change and partially necrotic lesions at the intestine from the terminal ileum to the cecum. Ileocecal resection was carried out. The resected terminal ileum was filled with blood clots and obstructed. We hound multiple ulcers in the terminal ileum, suspected to be bleeding site. Ischemic enteritis was the most suspicious cause of terminal ileitis from histopathological examination and underlying diseases.
Gstrointestinal bleeding is one of the common complications of anticoagulation therapy. However, intestinal obstruction due to blood clots caused by this complication is very rare.

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A 57-year-old man was referred to the hospital with a suspicion of general peritonitis because there was tenderness with muscular guarding mainly in the upper abdomen. An abdominal x-ray film showed free air as well as cystic emphysema in the entire intestinal wall. Abdominal CT scans disclosed free air, ascites, dilatation of the intestine, and multiple occurrence of cystic emphysema along the intestinal wall. Upper gastrointestinal endoscopy demonstrated gastric ulcer in the posterior wall of the gastric body, but no perforated site was identified due to large quantities of residual materials. The patient was operated on with a diagnosis of general peritonitis associated with intestinal cystic emphysema. During surgery, the perforated site was identified on the anterior wall of the gastric fundus, as well as turbid ascites. Multiple emphysematous changes were seen in the subserous structure of the small intestine from 150cm to 430cm apart from the Treitz' ligament, but no perforated site was present there. The gastric perforation was patched and filled with the greater omentum and emphysematous parts in the intestine were kept intact. The postoperative course was uneventful and disappearance of multiple occurrence of cystic emphysema was confirmed.
Intestinal cystic emphysema with intestinal perforation is a relatively rare condition, and this case is the 7^th case of such condition and the 2^nd case which was associated with gastric perforation. Accordingly this case is presented here, together with some bibliographical comments.

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A 62-year-old male received chemotherapy and radiation therapy for lung small cell carcinoma and was under follow-up in Internal Medicine at our hospital. Since his fever continued, he visited our Internal Medicine Department, where he was diagnosed with pneumonia and was received inpatient care using antibiotics. A pain appeared in the right lower quadrant of his abdomen the day after admission. Abdominal CT was performed, resulting in a diagnosis of acute appendicitis, and surgery was performed on the same day. Pathologic findings revealed a small cell carcinoma in the central area of the appendix, causing blockage of the lumen. The peripheral area became necrotic and perforated, resulting in a diagnosis of appendicitis due to metastasis of lung cancer. Since metastasis of malignant tumors to appendix has been treated with abscess formation or perforation at the time of surgery in many cases and the development of inflammation is rapid, it is considered necessary to determine the timing of the operation promptly.

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We report a case of intussusception caused by cecal carcinoma in villous adenoma in a 90-year-old woman. The patient was admitted to our hospital with a 3-week history of diarrhea. Abdominal ultrasonography and computed tomography revealed ileocolonic intussusception. Ileocecal resection was performed, and the resected specimen contained a 38 × 33 mm protruded tumor with shaggy surface. Pathological examination revealed a well-differentiated adenocarcinoma in villous adenoma with invasion to the muscularis propria. Adult intussusception is an unusual condition, and villous tumor is a rare cause of intussusception. We review the medical literature available on this topic.

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A 20-year-old man presented with intermittent bouts of right lower abdominal pain. Abdominal CT scan showed a concentric structure in the ileocecum. Intussusception in the ascending colon was diagnosed by the findings and laparotomy was performed. After successful reduction of the intussusception with Hutchinson's maneuver, ileocecolectomy was performed. No organic change that might have caused the intussusception was found at the ascending colon, and it was considered idiopathic. The majority of intussusceptions in adults occur as a result of organic diseases, and idiopathic intussusception is rare. This rare case in reported here together with a review of the literature.

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We present a case of an intra-abdominal abscess due to penetration of diverticulitis of the ascending colon in which right hemicolectomy via inside approach under laparoscopy was successfully done after confirming by colonoscopy that the abscess was drained into the intestinal tract. Laparoscopic surgery via inside approach can be safely performed even for abscess formation due to diverticulitis. This case is reported, together with some bibliographical comments.

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We report a case of anal canal cancer associated with Crohn's disease (CD). A 74-year-old man was diagnosed as CD at the age of 61 years when he underwent ileocecal resection and sigmoidectomy with intractable intestinal fistula. He complained of bloody stool in october of 2005. He was examined by colonoscopy. A biopsy of the erythrogenic elevated portion showed well-differentiated adenocarcinoma. He was diagnosed with anal canal cancer, and underwent abdomino perineal resection. Pathological finding was P, type1, 30×25 mm, tub1, MP, N0, ly1, v0, H0, P0, M0, Stage I.
There was an infiltration of a few inflammatory cells into the rectal mucosa. But no characteristic lesions, epithelioid granulation or full-thickness inflammation lesions associated with CD, were found. He was discharged on the twenty-sixth day after surgery. Long-term patients after development of CD generally have a higher probability of contracting cancer as well as patients with ulcerative colitis (UC). Thus, in long-term patients after developing CD, surveillance similar to UC is needed.

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Liver cysts complicated by intracystic hemorrhage are rare. A 50-year-old woman was admitted suffering from a sense of fullness. Abdominal ultrasonogram showed a large cystic lesion with a hyperechoic papillary mass in the medial segment of the liver. Abdominal MDCT scan revealed a low-density mass with a nodule measuring 7 mm. MR image demonstrated a hyperintense lesion of the liver. Laboratory examinations disclosed thrombocytopenia (10.8×10⁴/μl), liver dysfuntion, and an increase in serum CA19-9 (107 U/ml). A left lobectomy of the liver was performed with the preoperative diagnosis of cystadenocarcinoma of the liver. The resected cystic lesion with a diameter of 12 cm had a smooth internal surface and was filled with a blood clot. Histologically, the lesion was diagnosed as a liver cyst with intracystic hemorrhage.

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A 61-year-old man was admitted to the hospital complaining of appetite loss and vomiting. Endoscopy demonstrated stenosis of the descending part of the duodenum and dilatation of the duodenal bulb. Abdominal CT showed enlargement of the pancreatic head encircling the descending part of the duodenum. MRCP revealed a long common channel of pancreatic duct and CBD. A surgical operation was performed under diagnosis of annular pancreas complicated with pancreaticobiliary malfusion. An intraoperative cholangiogram demonstrated a long common channel (1.5cm) without dilatation of CBD. We performed cholecystectomy and side-to-side duodenoduodenostomy. We report herein a rare case of annular pancreas with pancreaticobiliary malfusion in an adult.

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Massive bleeding may complicate the course of acute pancreatitis. Bleeding occurs usually after operation including necrosectomy, and the main pathogenetic mechanism of bleeding is mediated by pseudocysts or abcess. Spontaneous bleeding due to acute pancreatitis is a rare, but frequently fatal complication of acute pancreatitis. Especially, intraperitoneal hemorrhage is a distinctly less common manifestation. Severe inflammation and/or regional necrosis may cause erosion of major vessels or peripancreatic vessels, and their eventual rupture may result in massive bleeding into peritoneal cavity. Symptoms appeared just before lethal bleeding, too late to even hazard a diagnosis. A rapid and accurate diagnosis is critically important. We report a case of massive intraperitoneal bleeding owing to disruption of peripancreatic vessels in a patient recovering from acute pancreatitis. Diagnosis of bleeding was made by computed tomography and ultrasound-guided blood aspiration. The source of the bleeding was identified intraoperatively, and a distal pancreatectomy and a splenectomy were performed. Our case confirms the necessity to add massive intraperitoneal venous bleeding to the list of differential diagnoses for sudden deterioration in patients with acute pancreatitis.

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We report a case of juvenile acinar cell carcinoma of the pancreas with multiple gastrointestinal polyps. A 22-year-old man admitted for fever was found on physical examination to have an elastic, hard mass measuring 10 cm in diameter in the left upper quadrant of the abdomen. Abdominal CT scan showed a large tumor consisting of solid and cystic components in the pancreatic tail. Laboratory data showed marked increase of serum elastase 1, however, the serum CEA and CA19-9 were normal. Endoscopic examination revealed multiple polyps of the stomach and colon. Malignant tumor of the pancreas was diagnosed, and distal pancreatectomy, splenectomy and transverse colectomy were performed. The histological diagnosis was acinar cell carcinoma. The patient remains alive without recurrence 4 years after the surgery.

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A 72-year-old woman was referred to the hospital for close exploration of a splenic tumor which was detected by an abdominal CT scan performed for a follow-up survey for a renal cyst at another hospital. The patient was asymptomatic. Hematological studies revealed only mild inflammatory reaction. Abdominal ultrasonograohy, CT scan, and magnetic resonance imaging scan disclosed a 7-cm sized tumor in the spleen. The inner part of the tumor was heterogeneous, with a cystic part. The patient was operated on with the most likely diagnosis of aigioma or angiosarcoma arisen in the spleen. The pathological diagnosis was splenic angiosarcoma. Hepatic metastasis occurred on the 3^rd month after the operation. Despite chemotherapy with paclitaxel, the patient died on the 172^nd postoperative day.
Angiosarcoma arisen in the spleen carries poor prognosis and is rare, so that effective therapies for the disease have not been established as yet. The establishment of useful chemotherapy as well as immunotherapy is expected in future.

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A 56-year-old man was transferred to our center with a diagnosis of peritonitis due to gastrointestinal perforation. The patient's plane x-ray and CT showed intraperitoneal free air. Although biochemical examination revealed an increase in blood urea nitrogen (BUN) and serum creatinine, we initially thought that this indicated complications of renal dysfunction ; urinary bladder rupture was discovered during operation. After operation, we learned that air had been injected from a urinary catheter in the previous hospital, and that the patient had hit his lower abdomen after heavy drinking. The pathophysiology of this case was typical of cases of urinary bladder rupture into the free peritoneal cavity, pseudo-renal failure, and iatrogenic intraperitoneal free air. It is important in preparing for and performing an operation that accurate information be communicated without prejudice, given that diagnosis in the destination hospital can be made only according to the urgency of the patient's condition. If additional information is available, operation should not be performed based only on superficial diagnosis and/or obvious indications of operation such as peritonitis.

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A 27-year-old woman was seen at our hospital because of a fist-size mass localized in the left abdomen. Abdominal US showed a well-defined 6.5×5×5cm hypoechoic mass with regular margin and homogeneous inner portion. CT scan demonstrated a homogeneous enhancement. The tumor showed a hypointense signal similar to that of muscle on T1-weighted MRI, a relatively high-intensity signal on T2-weighted MRI and a homogeneous high enhancement on enhanced MRI. We suspected lymphoma, leiomyoma or gastro-intestinal stromal tumor. Laparoscopic surgery was performed. A solid tumor measuring 6.5×6.0×4.0 cm was revealed in the mesentery of the transverse colon. The histological diagnosis was unicentric Castleman's disease of hyaline vascular type. She was discharged on the 7th postoperative day and shows no signs of recurrence as of 4 years postoperatively.
Castleman's disease localized in the abdomen is very rare, especially in the mesentery. We report herein a case of mesenteric Castleman's disease resected by laparoscopic surgery with some bibliographical comments.

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The patient was a 47-year-old man undergone low anterior resection of the rectum with D3 lymph node dissection for rectal cancer in November 2005. Abdominal CT scan conducted in November 2006 disclosed a tumor 18mm in diameter on the lower abdominal midline surgical wound. FDG-PET revealed accumulations of contrast material in the same area as the CT scan showed and in the vicinity of the intraperitoneal abdominal wall. As for tumor markers, both CEA and CA19-9 were in normal ranges. Metastatic tumors of rectal cancer were suggested and the tumors were removed in December 2006. One of the two tumors was located in the abdominal wall being adjacent to the bladder and other one was enveloped by the greater omentum. The histopathological diagnoses of them were Schloffer tumor and Braun tumor, no malignant cells being demonstrated.
In the treatment of tumors at where accumulations of contrast material are seen on FDG-PET, Schloffer tumor and Braun Tumor must be kept in mind as differential diagnoses of metastatic tumors.

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A 70-year-old man was admitted to our hospital because of upper abdominal pain and nausea. An abdominal X-ray revealed a niveau. Long-tube enterography detected coffee bean sign. Computed tomography showed the dilated small intestine on the ventral side of the transverse colon with radial distribution of the mesentery. So we diagnosed a case of transomental hernia and performed an open laparotomy. At surgery, about 30 cm of the small intestine (at a site 150 cm from the Treitz' ligament) had herniated through the hiatus about 4 cm in diameter of the greater omentum. The small intestine was congested but did not necrose. The incarcerated small intestine was released, and the hiatus was closed. The patient had an uneventful postoperative course and was discharged on the twelfth day after the operation.

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This paper deals with a case of von Recklinghausen's disease (VRD) associated with gastrointestinal stromal tumor (GIST) of the jejunum and pheochromocytoma.
A 33-year-old woman who had been diagnosed as having VRD at the age of 30 was seen at the department of obsterics & gynecology in our hospital because of pale complexion and abdominal pain. Abdominal CT scan showed an about 13-cm sized tumor with calcification in the pelvis and a 3-cm sized tumor in the left adrenal gland. Close exploration offered a suspicion of GIST for the pelvic tumor and a diagnosis of pheochromocytoma for the left adrenal tumor. The patient was referred to our department of surgery for operation. The pelvic tumor was found to have arisen from the jejunum and then partial excision of the small intestine and left aderenectomy were performed. The small intestinal tumor was pathologically diagnosed as malignant GIST, and the adrenal pheochromocytoma showed findings suggestive of malignancy. There have been no recurrences as of one year after the operation.
We sometimes encounter reports describing VRD associated with multiple malignant tumors when these associated tumors can determine the prognosis of the patients. Accordingly we consider that general exploration to detect them early is important.

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An 87-year-old man who had undergone excision of an anal fistula at the of 32 was seen at the hospital because of bloody stool and anal pain. Physical examination revealed surgical scar for and the second opening of the anal fistula at three and nine o'clock, respectively. On a digital examination, a painful and elastic-hard tumor with the size of a tip of the thumb was palpated in the anal canal at the direction of six o'clock. And an unmovable tumor with induration was felt on the left lateral wall to anterior wall of the rectum, about 4cm proximal to the anal verge. No pusclearing from the fistula was noted. As a result of close exploration, the diagnosis of moderately differentiated adenocarcioma was gained by a biopsy of the rectal Rb tumor. A biopsy of the nodule of the anal fistula provided no malignant findings. Rectal carcinoma with anal fistula was diagnosed and abdominoperineal resection of the rectum with D2 dissection was performed. The histopathological diagnosis of the rectal cancer was moderately differentiated adenocarcinoma, type 2, 40×45mm, pA, pN1 (1/7), sH0, cP0, cM0, and fStage IIIa. Mucinous carcinoma was also identified in the anal fistula, and no histological continuity between the rectal cancer and cancer in the anal fistula was confirmed.
In this paper we present this case of double cancer involving the rectum and anal fistula which is rare, together with a review of the literature.

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A 61-year-old woman was admitted to Wakayama Medical University hospital with severe lower abdominal pain and fever. Emergency laparotomy was performed under the diagnosis of intra-abdominal abscess caused by diverticulitis of the sigmoid colon. About 15 minutes later, blood pressure and oxygen saturation (SO₂) decreased suddenly. Urticaria occurred, and she went into a state of anaphylactic shock. However, she recovered within one hour following treatment. We initially suspected that the onset of anaphylaxis was caused by either the anesthetic or the intravenous antibiotic administered. Following thorough investigation, we concluded that the anaphylaxis was not drug-induced. She had a history of itching when using rubber gloves. The specific test for IgE antibody against latex was positive at 0.56 UA/ml. Judging from these results, the final diagnosis was anaphylactic shock caused by latex (probably medical gloves). Therefore, second operation was performed under a latex-free environment. Anaphylactic shock was not seen during the second surgery. Thus, examining the precise history for latex allergy is necessary and a latex-free environment should be prepared for patients with a suspected latex allergy or in a high-risk group for latex allergy.

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