The usefulness of mammary ductoscopic biopsy for intraductal papilloma of the breast with abnormal nipple discharge was studied. Subjects were consecutive 73 patients who were performed mammary in the hospital and were diagnosed as having intraductal papilloma from January 1999 to December 2006. Of these 73 patients, 56 patients were able to be diagnosed cytologically and histopathologically by intraductal biopsy of the tumor material collected under ductoscopic observation. Investigating the outcomes by localizations of the papilloma lesions, the resection rate was high in the lactiferous ducts with a short distance from the nipple including the main and first branch, whereas the resection rate became low in the lactiferous ducts after the second branch. In 37 out of the 56 patients in whom total resection was able to be done, improvement of abnormal nipple discharge was noted.
We consider that mammary ductoscopic assisted resection of intraductal papilloma offers a sufficient amount of material for diagnosis non-surgically and provides resultant improvement of abnormal nipple discharge, thereby it is helpful for the treatment as well.

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We investigated the difference in the short-term and long-term outcomes between surgical procedures in 27 patients with peritonitis due to perforetier of the left side colon. We divided these 27 patients into two groups according to the initial operation : the primary anastomosis group (Group A, n=9) and the artificial anus group (Group B, n=18). No significant differences in the clinicopathological characteristics were detected between the groups except for the median time from the onset of the disease to the operation ; it was longer in the Group A (P=0.049). Although there was no statistical difference in the short-term outcomes between the two groups, a poor short-term outcome in the Group B was noted compared to the Group A (morbidity in the Group A vs. B : 66.7% vs. 83.3%, P=0.295 ; mortality : 11.1% vs. 22.2%, P=0.636). Three-year survival rates in the Group A and B were 53.3% and 41.9%, respectively. A multivariate analysis revealed that the primary disease (P=0.049), the presence of systemic inflammatory response syndrome (P=0.021) and number of organ failures (P=0.007) were all significantly associated with the long-term postoperative outcome.
We consider that appropriate selection of surgical procedures and postoperative intensive care may provide a relatively good long-term outcome in patients with peritonitis due to perforation of the left side colon.

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A total of 118 patients who were suspected to ingest or aspirate foreign bodies in our institution in recent 10 years were reviewed. Forty-seven patients in the pediatric group (age ≤ 15 years old) and 18 patients in the adult group (age ≥ 16 years old) were diagnosed as having ingested or aspirated foreign bodies, whereas the remaining 51 patients in the pediatric group and the two patients in the adult group were determined not to have foreign bodies. Younger children and aged adults were apt to have ingested or aspirated foreign bodies. Male cases were more frequent than female ones.
Typical foreign bodies in the gastrontestinal tract included button-shaped batteries and coins in the pediatric group, whereas artificial teeth and PTP (press through pack) in the adult group which were easily diagnosed. Typical foregn bodies found in the esophagus included radiolucent objects such as beans, including peanuts, in the pediatric group, whereas radiopaque foreign bodies such as dental metal in the adult group. Aspiration of peanuts was difficult to diagnose and needed a long hospitalization because of severe complications after the removal. There is a possibility that some cases in which radiolucent foreign body ingestion was suspected and no foreign bodies were found could not be diagnosed correctly.

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Laryngeal injury is relatively uncommon, but potentially lethal. Two cases of traumatic laryngeal injury are reported in this paper. Case 1 ; A 56-year-old man sustained an injury of his upper neck by a cow's horn. He underwent endotracheal intubation following bronchofiberscopy because of dyspnea and bleeding. A thyroid cartilage fracture was diagnosed by bronchoscopic examination and subsequent computed tomography. An emergency operation was performed. His thyroid cartilage had been fractured into four pieces. Considering infection, a two-stage operation was planned. Laryngocutaneous fistula and tracheotomy were performed in the first stage. The postoperative course was uneventful.
The laryngo-cutaneous fistula was closed 22 days after the first operation and he was discharged uneventfully. Case 2 ; A 77-year-old man was admitted to a hospital for traumatic shock caused by a traffic accident. He underwent endotracheal intubation in the ambulance. An epiglottic cartilage fracture and thyroid cartilage fracture were revealed. Since it was difficult to evaluate laryngeal function because of laryngeal edema, the indication for laryngeal plasty was to be evaluated after recovery from laryngeal edema. He has been treated conservatively with tracheostomy. Two months after the injury, he could speak, although he had swallowing dysfunction. A comprehensive approach is required considering laryngeal function for the management of traumatic laryngeal injury.

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Postmastectomy lymphangiosarcoma is a very rare tumor with poor prognosis, occurring in the upper extremity on the affected side with lympedema at 10-odd years after standard radical mastectomy for breast cancer.
The case was a 73-year-old woman. She underwent standard radical mastectomy for left breast cancer in October 1967, followed by postoperative irradiation therapy. Edema developed in the left upper extremity about 10 years ago, and multiple scarlet phymas appeared in the left upper extremity in about December 2000. She visited the dermatological department of our hospital in January 2001, but she was referred to the surgical department because of suspected metastatic skin tumor. Based on the findings of tissue biopsy performed on the same day, she was diagnosed as having postmastectomy lymphangiosarcoma. Her left shoulder girdle was amputated under general anesthesia at about 5 weeks after the initial examination.
This disease is often misdiagnosed as an inflammatory disease because of its extremely low incidence, resulting in a delay in starting the treatment, although early detection and early treatment are crucial for better prognosis. In fact, the mean survival duration after diagnosis is as short as 11-18 months, demonstrating its poor prognosis. We report a case of this very rare disease, postmastectomy lymphangiosarcoma.

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A 46-year-old man who had got a bruise on the anterior thoracic region in a traffic accident at the end of June 2006 was seen at the hospital because of chest pain. Chest CT scan showed a 2.8×2.2cm tumor shadow in the anterior mediastinum as well as fracture of the sternum. Chest magnetic resonance imaging scan disclosed that fatty component was involved in the inner part of the tumor which was heterogeneously enhanced. Thus teratoma of the mediastinum was diagnosed. In November when the fractured portion of the sternum became stable, a total removal of the thymus and the mediastinal tumor was performed by median sternotomy. The removed material showed a usual type of mature teratoma and papillary glandular epitherium with a high-grade atypia inside of it. From these findings the definite diagnosis of mature teratoma of the mediastinum with malignant transformation to adenocarcinoma was made. The postoperative course was uneventful and the patient was discharged from the hospital on the 7^th postoperative day. The patient has been recurrence free up to now and is under clinical observation.
In performing surgical therapy for a mature teratoma, we must keep a possibility of malignant transformation of it in mind, though it is rare.

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A 64-year-old man was admitted to our hospital under a diagnosis of gastric cancer by gastrofiberscopic study without any subjective complaints. A total gastrectomy was perfomed. On laparotomy an elastic soft mass was incidentally found in the left crus of diaphragm and was removed successfully. The histopathological diagnosis was extralobar pulmonary sequestration. This is, to our knowledge, the third reported case of subdiaphragmatic extralobar pulmonary sequestration in an adult in our country.

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The patient was a 66-year-old man who underwent right upper lobectomy and lymph node dissection (ND2a) for adenocarcinoma (clinical-stage IB) of the right upper lung. He developed severe leucopenia (500/μl) and thrombopenia with high fever (38.4°C) three days after the surgery.
At first we considered that the patient might have aplastic anemia induced by intra-or post-operative drug, or disseminated intravascular coagulation (DIC) by infection. And we started the administration of gabexate mesilate (FOY ; 1000mg/day) and G-CSF. Bone marrow aspiration taken on the postoperative day (POD) 6 showed macrophages which phagocytosed not only myelocytes but slso erythrocytes and platelets, and therefore he was diagnosed as having hemophagocytic syndrome. On the same day, pulsed steroid therapy was intiated and thrse days later it was shifted to predonine gradual decrease therapy. Hematological findings improved on the sixth day after the initiation of the steroid therapy and were normalized on the eighth day. Bone marrow aspiration taken on the POD 15 showed the original formation, and hemophagocytosis disappeared.
There have been only 12 cases of hemophagocytic syndrome after the surgical operation in Japan, including this case, and we present this case here together with a review of the literature.

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A 61-year-old woman complaining of a sensation of food sticking was pointed out an abnormal shadow in the left lower lung field on a chest x-ray film. Chest CT and magnetic resonance imaging scans showed a 14cm-sized clearly demarcated tumor which was adjacent to the dorsal aspect of the left diaphragm. The most likely diagnosis was pleural or phrenic tumor from these findings, but we employed surgery because of difficulties in making the definite diagnosis. Thoracoscopic observation of the thoracic cavity revealed that there were no adhesions between the tumor and the diaphragm and thoracic wall, and that the tumor was a 14×9.5×4cm pedunculated tumor arisen from the visceral surface of the diaphragm in the left lower lung. The thoracoscopic surgery was converted to an open surgery because the tumor was large, and the tumor including the peduncle was removed by partial lung resection with sufficient surgical margin, using stapling device. A pathological study revealed proliferation of spindle shaped cells and intermediate stroma of collagen fiber. Immunohistochemically the tumor was CD34 and vimentin positive and keratin negative. Thus solitary fibrous tumor of the pleura was definitely diagnosed.
The disease demands long-term follow-up after the operation because postoperative recurrence and malignant change have been reported in some cases.

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There are three types of esophageal hiatal hernia : sliding, paraesophageal, and mixed types. Sliding type accounts for about 90% of all esophageal hiatal hernias. We report a patient with mixed type of esophageal hiatal hernia whose entire stomach herniated into the mediastinum and who was treated successfully by laparoscopic surgery.
A-70-year-old woman was admitted to our hospital because of pressure on the chest. Upper gastrointestinal series, abdominal CT and magnetic resonance imaging scans revealed a large esophageal hiatal hernia in which the entire stomach was impacted. Because response to medication therapy was unsatisfactory, a laparoscopic Nissen's fundoplication was performed. Under a laparoscopic view, the entire stomach, greater omentum, and a part of the jejunum had prolapsed into the mediastinum. The hernia contents were reduced, the hiatal hernia defect was closed primarily by approximating the crura, and fundoplication was performed by using the gastric fundus. She was discharged from the hospital on the 17th day after the operation without operative complications. Postoperative upper gastrointestinal series showed no esophageal reflux, and the passage was satisfactory. It is considered that laparoscopic Nissen's fundoplication is safe and effective for such a large hiatal hernia as the entire stomach has herniated into the mediastinum.

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The patient was a 52-year-old man who had been diagnosed as having a gastric ulcer and a duodenal ulcer by upper gastrointestinal endoscopy and received sanitization treatment for Helicobacter pylori in another hospital. He was referred to the hospital because a submucosal tumor of the stomach was detected by a follow-up examination. We performed upper gastrointestinal endoscopy again and diagnosed it as gastric malignant lymphoma by a biopsy. The patient was admitted to the hospital for the purpose of operation. Endoscopic examination of the lower digestive tract disclosed a submucosal tumor in the lower rectum and, as a result of a biopsy, it was diagnosed as rectal malignant lymphoma. On this account we performed total gastrectomy and abdominoperineal resection of rectum at the same time. As a result of histopathological examination, both the gastric and rectal lesitions were follicular lymphoma. After discharge from the hospital, he received chemotherapy in another hospital. Thereafter he has been recurrence-free. It is considered very rare that gastric malignant lymphoma coexists with rectal malignant lymphoma. In the treatment of such condition, we can attempt to perform total gastrectomy and abdominoperineal excision of recturm at the same time. And it appears to be best that chemotherapy is combined with these operative procedures to which the patient may be tolerable.

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A 70-year-old man was admitted to the hospital with diagnoses of gastric cancer and multiple lymph node metastases. Combination chemotherapy (TS-1+CDDP+Lentinan regimen) was started on February 22, 2005. Abdominal pain appeared suddenly on March 2. Abdominal CT scan showed free air and ascites. The patient was operated on with the diagnosis of perforative peritonitis. At laparotomy, we found a 5-cm gastric cancer with a 2-cm perforative hole. Distal gastrectomy and abdominal drainage were carried out. The pathological diagnosis was small cell carcinoma with immunohistochemically positive CD56. Chemotherapy was re-started 28 days after surgery because of progressive lymph node metastases. The size of the metastatic lymph node was reduced remarkably after two courses of the chemotherapy. Since it was enlarged after four courses, second-line chemotherapy (CPT-11+CDDP) was started. The size of the metastatic lymph node was again reduced after two courses of the second-line chemotherapy. However, it became enlarged again after four courses. The patient received immunotherapy at another hospital, but died 331 days after surgery.

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A 62-year-old man, from the age of 58 years old on, had been treated for T cell chronic lymphocytic leukemia (T-CLL) in the Department of Internal Medicine of our hospital. In August, 2002, he developed a chief complaint of oppressive feeling in the abdomen. Then, endoscopy was carried out in the upper digestive tract. The patient showed a tumor at the gastric angle for which a biopsy was conducted (Group V). Then, in October, 2002, a distal partial gastrectomy revealed pT3, pN2, CYO and fStage IIIB. His postoperative course was good, and combination tegafur and uracil treatment was started. In December of 2002, however, he developed digestive symptoms, so the combination treatment was discontinued. In February, 2003, the patient developed ascites which was examined by diagnostic cytology, only to find he was adenocarcinoma cell-positive. Thereafter, his condition rapidly worsened until death in March, 2003. The findings of the present case suggest that treatment of gastric cancer with T-CLL together should be treated very cautiously.

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A 51-year-old woman was admitted to hospital because of tarry stool and hematemesis. A Tumor was palpable in the upper-right abdomen. Examination by Gastro-intestinal fiberscope revealed an ulcerative tumor in the duodenum, and biopsy showed squamous cell carcinoma. A pancreatoduodenectomy was done. Historical findings of the resected tumor were adenosquamous carcinoma, which was mostly squamous cell carcinoma with a little adenocarcinoma. Although she had para-aortic lymph node metastasis, there have been no signs of recuccence to date.

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A 16-year-old man was seen at the hospital because of upper abdominal pain. His symptom once subsided by administration of an antispasmodic agent, but it recurred on the next day and he visited the hospital again. An abdominal x-ray film and an abdominal CT scan showed ileus findings. Despite insertion of a long intestinal tube, his symptom worsened and peritoneal sign appeared as well. Thus strangulated ileus was diagnosed and laparotomy was performed. During surgery, no strangulation of the small bowel was present and the intestinal obstruction was found to have been caused by ‘konbu’. The impacted ‘konbu’ and a Meckel's diverticulum which was accidentally found were removed.
There are some cases of dietetic ileus which presents with findings of peritonitis and demands an emergency operation. Although the pathologic condition in this case also required an emergency operation, postoperative review clarified that our preoperative questioning had been insufficient and the abdominal CT scan had showed findings suggestive of a mass of some ingested material. We must make the best use of our experience with the case in future.

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This paper reports a case of intussusception caused by a long intestinal tube after total gastrectomy. A 73-year-old man who had undergone a total gastrectomy for gastric cancer in 1999 was admitted to the hospital because of pneumonia in 2004. During hospitalization, interstitial pneumonia and adhesive ileus were diagnosed. A long intestinal tube was placed for the treatment of the ileus. Four days later, the patient complained of severe abdominal pain, and a movable tumor was palpable on the abdominal wall. As an abdominal CT scan showed small intestinal intussusception, an emergency operation was performed. An antegrade intussusception roughly 20cm in length was found in the jejnum, and the intussusception which could not be repaired manually required a partial resection of the small intestine.
Out of 57 domestic cases of intussusception induced by the introduction of a long intestinal tube for ileus, 19 cases had a history of undergoing gastrectomy (Billroth I reconstruction in 12 cases and total gastrectomy in 3 cases). As there is little space to make a loop of long intestinal tube in the total gastrectomy cases due to absence of the gastric remnant, intussusception is easily caused in them. But the total gastrectomy cases are lesser than the Billroth I operation cases, because the flexibility is kept intact at the upper abdomen. Full attention should be paid to the potential onset of intussusceptions in the case of total gastrectomy.

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We report a resected rare case of Dieulafoy's vascular malformation of the small bowel. A 44-year-old man was admitted to our hospital for repeated melena and hypotension requiring blood transfusion, but the bleeding point was not detectable by gastrointestinal examinations. Angiography revealed an extravasation of the small bowel vessel, and we placed a microcoil in the bleeding artery as an index for surgery. At laparotomy, we identified the coil by intraoperative abdominal X-ray examination, and performed a segmental resection of the small bowel. The resected specimen showed the protruded lesion with a red color macroscopically and an abnormal ruptured vessel microscopically. The final pathological diagnosis was Diuelafoy's vascular malformation of the small bowel with rupture. When a bleeding source is not identified in a case of gastrointestinal bleeding, a rare disease such as Dieulafoy's vascular malformation should be considered.

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Small bowel volvulus without malrotation of organic causes is uncommon, and making an accurate diagnosis preoperatively is difficult. We report a case of intrauterine intestinal volvulus without malrotation in a newbom. A 2,062g infant boy was delivered by emergency cesarean section at 33 weeks and 2 days gestation due to decreased fetal movement and poor variability on cardiotocography. Apgar score was 2 at 1 minute, and he was intubated and resuscitated immediately. The abdomen was extremely distended and he was transferred to our hospital. Abdominal ultrasonogram and computed tomography showed markedly dilated loops of bowel filled with fluid. On exploration, he was found to have volvulus of the small bowel twisted clockwise by 540°, 40 cm in length, at 60 cm from Treitz' ligament. The gangrenous bowel was resected, and primary anastomosis was performed. Postoperative course was uneventful and he was discharged on the 20^th postoperative day.

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A 49-year-old woman with malignant lymphoma (ML) was admitted to the hospital with nausea, vomiting, and 9-kg weight loss. Two tumors were identified in the jejunum, 30 cm and 80 cm, respectively, from Treitz's ligament. An enteroclysis study and abdominal CT and MRI revealed jejunal fistulas at 20 cm and 80 cm from the proximal tumor, and also incasion of the uterus and bladder by the distal tumor 50 cm from the proximal tumor. The serum level of soluble IL-2-reseptor (sIL-2R) was elevated to 4,290 U/ml. At laparotomy, partial resection of the jejunum, resection of the uterus, and partial resection of the bladder wall were carried out. Macroscopic examination of the resected specimens revealed that one of the jejunal tumors was ulcerative and the other was aneurysmal. Histological exmanination revealed aggregates of large atypical lymphocytes which showed positive immunostaining for CD 20 and CD 79a. Based on these findings, a diagnosis of diffuse large B-cell lymphoma of the jejunum was made. By postoperative day 47, the serum level of sIL-2R had returned to nearly the normal level, at 557 U/ml. The patient is currently receiving chemotherapy with the R-CHOP regimen.

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The patient was a 73-year-old woman who had undergone the resection of the small intestine with postoperative chemotherapy for small bowel stricture due to malignant lymphoma at another hospital in May 2002, and chemotherapy for recurrence to the cervical lymph node which resulted in disappearance of the lymph node recurrence in November 2005. She had experienced bouts of ileus symptoms since January 2006 until October of the year, when she was admitted to the hospital with a diagnosis of intestinal obstruction. A long tube was inserted but no symptomatic remission was attained. The tube was placed from the upper portion of the jejunum to descending colon. An abdominal CT scan disclosed that the jejunum and descending colon produced a fistula via an abscess cavity. Recurrence of malignant lymphoma of the small intestine was strongly suggested and the patient was operated on. During surgery, a tumor was identified in the vicinity of the jejunum near the Treitz' ligament and it had invaded the jejunum, transverse colon and descending colon. Each intestine formed a fistula via the tumor. An enbloc resection of the tumor, jejunum and colon was performed. The pathological diagnosis was recurrence of malignant lymphoma. The patient's postoperative course was uneventful, and adjuvant chemotherapy was done.

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We report a case of intestinal obstruction associated with invagination due to ileal metastasis of renal cell carcinoma (RCC). A 66-year-old man with a history of distal gastrectomy for duodenal ulcer, was admitted to our hospital due to intestinal obstruction. Chest plain X-ray film revealed a coin lesion in the right middle lung field. Enhanced CT showed a mass in the left kidney and dilatation of the small intestine and pool of a little ascites. He had once recovered from intestinal obstruction by conservative therapy, so we started interferon treatment of the renal tumor. But he was hospitalized again for recurrence of intestinal obstruction. Conservative therapy was not effective, so a laparotomy was performed. The tumor presented in the ileum 100 cm from the ileocecal region with invagination, and a partial resection of the ileum was performed. The histopathological diagnosis was metastasis of RCC to the small intestine. The postoperative course was uneventful, but he died seven months after the operation.
Metastasis of RCC to the small intestine is rare, and only 27 cases including this case have been reported in Japan.

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In an 84-year-old man with fever of unknown origin for 2 months emergency operation was done with diagnosis of gastrointestinal perforation and peritonitis. Necrosis of undifferentiated carcinoma of the small intestine caused gastrointestinal perforation. Mesenteric lymph node metastasis was extensively found. He was discharged on postoperative day 25 and admitted again presenting as peritonitis carcinomatosa with high-grade fever on postoperative day 39. He died 45 days after the operation. It is difficult to differentially diagnose undifferentiated carcinoma of the small intestine from malignant lymphoma, mesenchymal tumor including GIST and leiomyosarcoma by routine pathological examination. The reported case was diagnosed as undifferentiated carcinoma because immunohistochemical examination revealed the tumor to be positive for CK CAM 5.2 and vimentin. Diverse symptoms of undifferentiated carcinoma of the small intestine cause delayed diagnosis. Fever of unknown origin seems to be one of the symptoms.

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We report a case of ileus due to an incarcerate seed in anastomotic stricture of the descending colon which had been operated on about twenty years ago. A 57-year-old woman was referred to the hospital and was admitted because of left abdominal pain. Enhanced computed tomography showed an allotrio with circular calcification in the descending colon. Although a descending colonoscopy was performed, the allotrio could not be extracted because of the stenosis of the descending colon, so she received descending colectomy including the allotrio. Histological examination showed fibrous thickness below the submucosa, plasmotomy of muscularis propria, and foreign-body reaction to the material which was suspected to be suture thread. We diagnosed the stenosis as anastomotic stricture due to the previous operation. Most of the previously reported cases about ileus due to seeds had a narrowed bowel where the seeds were delayed. Therefore, it is necessary to consider the underlying disease which causes stenosis of the bowel in these cases. Moreover, for diagnosis of this disease it is very important to gain information about bolting a seed or any previous operation.

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We report a case of sigmoid colon diverticulitis with a visicosigmoidal fistula treated by laparoscopic surgery. A 32-year-old man who had repeated abdominal pain and diarrhea from November 2004 received medicinal treatment with a diagnosis of gastroenteritis in other hospital. He had intensified abdominal pain and nebulous urine in June 2005. Scrutinization revealed colonic stenosis and a vesicosigmoidal fistula caused by diverticulitis of the sigmoid colon. Barium enema X-ray study and cystoscopy could not confirm the existence of the vesicosigmoidal fistula. The urinary excretion of medicinal charcoal was most sensitive to make the accurate diagnosis. Laparoscopic-assisted sigmoidectomy was performed in July 2005. He was discharged from the hospital on the 17th post-operative day. He has been asymptomatic up to now. It was a great benefit for the patient treated by less invasive surgery. Recently laparoscopic surgery has been increasingly employed for diverticulitis of the large intestine, but laparotomy is often selected when the disease is associated with a vesicosigmoidal fistula. However, the laparoscopic surgery may be one of the methods to treat colon diverticulitis with a vesicosigmoidal fistula.

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The patient was 44 years old when he was operated on at another hospital with a diagnosis of appendicitis with perforative peritonitis in July 1994. In March 1995 the patient was seen at the hospital because of left lower abdominal pain. There was an irregular stricture covering a wide range from the sigmoid colon to rectum, of which lumen noted redness and swelling. An abdominal CT scan disclosed prominent pelvic inflammation and a biopsy provided a diagnosis of ischemic enteritis. No symptomatic remission was attained by one-month fasting. A low anterior resection of the rectum was thus performed, and the pathological diagnosis was non-specific enteritis. After the operation, the patient developed stricture at the anastomotic center and anal pain. Re-examination of the pathological preparation disclosed actynomycosis. Sustained i. v. administration of large doses of penicillin G (PCG) provided symptomatic remission, but oral administration of PCG substituted for i. v. PCG resulted in exacerbation of the disease to from a rectovesical fistula. Considering the patient's QOL, we buried a CV port to administer PCG at home in April 2000. In addition to the intestinal narrowing, however, retroperitoneal abscess and subcutaneous abscess at the lumber region appeared and then worsened. Associated use of oral clarithmycin (CAM) was started in February 2003, which greatly improved the symptoms.
Oral administration of CAM was very helpful for intestinal actinomycosis resistant to large doses of PCG.

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We present our surgical experience with abdominal stapling rectopexy using the Endopath^® EMS stapler for complete rectal prolapse. Subjects were consecutive nine female patients (median age of 78 years) who underwent stapling rectopexy using the Endopath^® EMS stapler at our hospital from July 2004 to May 2007. Two patients had dementia and one had diabetes mellitus. Three had previously been operated on with perineal approach and three had undergone gynecological surgery. No recurrence was seen in any patients. None reported increased problems in bowel management. Although follow-up length of time was short, continence improved after stapling rectopexy in all patients. We suggest that abdominal stapling rectopexy using the Endopath^® EMS stapler is easy, safe, and effective in managing complete rectal prolapse.

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A 53-year-old woman was seen at the hospital because of lower abdominal pain and abdominal distention. A solid and irregular shaped tumor measuring 13 cm was found in the pelvic cavity by abdominal CT and MRI. Surgery was conducted in February 2006. The main tumor was detected on the sigmoid colon showing extra wall growth. Another tumor was touching the cecum and a few small nodules on the omentum. We performed sigmoidectomy, ileocecal resection and partial omentectomy, without residual tumor. Pathological findings in the sigmoid colon lesion showed spindle-shaped cells with malignant osteoid formation, and the final diagnosis was extraskeletal osteosarcoma and its intraperitoneal dissemination. There were non-epithelial malignant cells in the operative ascites sample. Though we performed post-operative chemotherapy according to standard osteosarcoma, she died of intraabdominal recurrence 13 months after the surgery. We report this rare case of extraskeletal osteosarcoma of the intestine with a review of the literature.

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A 69-year-old man was admitted to our hospital complaining of a huge mass in his right abdomen. It was bigger than the head of a child and it was difficult to move smoothly. Barium enema revealed a stenotic lesion in all of the ascending colon, but the luminal space of the intestine had been maintained. We guessed it was a non-epithelial tumor from some images, and the patient underwent a right hemicolectomy. The tumor was made up of white nodular lesions. It extended from the appendix to the hepatic flexure, wrapping around the ascending colon. Only a small ulcerous lesion was observed in colonic mucosa. The histopathologic diagnosis was moderately differentiated adenocarcinoma. Colon cancer rarely shows extramural development without luminal development. Histopathologically, it is widely regarded that poorly differentiated adenocarcinoma and mucinous cancer tend to show extramural development. This is a case report of primary colon cancer, which showed marked extramural development. It did not have mucinous components. Instead, it contained marked hyalinization.

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Combined hepatocellular carcinoma and cholangiocarcinoma (HCC-CC) is rare. In the case of recurrence of HCC-CC, both HCC and CC can recur. We report a recurred case of HCC-CC in which HCC recurred 10 years after surgery for HCC-CC. The patient was a 68-year-old man who had undergone hepatectomy of S4 and S5 for a liver tumor 10 years earlier, when the histological diagnosis of the resected material was HCC-CC. This time he was referred to the hospital because a new lesion developed in the lateral segment of the liver for which we performed a lateral segmentectomy. The tumor was histologically diagnosed as hepatocellular carcinoma derived from HCC-CC. The patient has been free from recurrence for these 2 years.
HCC-CC has been reported to metastasize via the systemic circulation and lymphatics and to carry poor prognosis. We present this case of HCC-CC with metastasis to the remnant liver 10 years after the operation which was removed successfully, because it is considered interesting that the recurred component was clarified to be HCC. Some bibliographical comments are also presented here.

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A 76-year-old woman was admitted to our hospital because of recurrent bouts of right hypochondralgia with a gallstone. Abdominal ultrasonography and computed tomography demonstrated a gallstone about 1 cm in diameter with a mildly thickened gallbladder wall. Computed tomography during drip infusion cholangiography showed that the cystic duct had joined to the right posterior hepatic duct. The patient underwent cholecystecomy. Despite the absence of particular findings macroscopically, except for the thickening of the gallbladder wall, on tne operative specimen, a histopathological examination revealed papillary adenocarcinoma localized within the Rokitansky-Aschoff sinus (RAS). This was in part of adenomyomatosis, which was diffusely present on the body and fundus of the gallbladder. This is a rare case of early carcinoma arising from the RAS in adenomyomatosis of the gallbladder associated with an anomalous junction of the cystic duct.

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The patient was a 62-year-old man with no complaint of note. He underwent sigmoid colectomy for sigmoid colon cancer (mod. ss, n0, ly0, v0, stage II) in this department on February 7, 2001, and left lung lower lobectomy for metastases from the sigmoid colon cancer on July 18, 2003. After discharge, he was followed at a local clinic until April 2006, when his CEA rose to 116ng/ml. He was referred again to the Department of Gastroenterology of our hospital due to the suspected recurrence of colon cancer. Upper and lower gastrointestinal endoscopy showed no abnormalities, but abdominal CT visualized a 25-mm mass in the pancreatic body, and ERCP revealed blockage of the main pancreatic duct in the pancreatic body. These findings led to a diagnosis of pancreatic cancer or pancreatic metastasis from colon cancer, and the patient was referred to the Department of Surgery. At surgery on July 7, the pancreas from the head to the tail was of a club-like consistency, with no tendency to invade the surrounding tissue or nerve plexuses ; therefore, corporeal-caudal pancreatico-splenectomy was performed. The histopathological diagnosis was pancreatic metastasis of colon cancer. His postoperative course was uneventful, and he was discharged on the 16th postoperative day. Pancreatic metastasis of colon cancer is so rare that our search of the literature revealed only 20 cases reported in Japan, including this case, which we report with a review of the literature.

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A 74-year-old man was seen at the hospital because of fever and abdominal pain. On physical findings of the abdomen peritoneal signs were noted. An abdominal CT scan showed a small amount of ascites and multiple low density areas in the spleen. An emergency operation was performed with a diagnosis of peritonitis due to rupture of a splenic abscess. During the operation we confirmed a moderate amount of cloudy ascites and the spleen which had formed a mass involving the pancreas tail. The ruptured abscess cavity was identified at the lower pole of the spleen, and then splenectomy, distal pancreatectomy, and abdominal drainage ware performed. Histopathological studies of the resected material disclosed the splenic abscess formation with invasion of moderately differentiated tubular adenocarcinoma arisen in the pancreas tail.
Splenic abscess associated with pancreatic carcinoma is a rare entity so that we report this case, together with a review of the literature.

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Laparoscopic resection of an urachal remnant has benefits compared to open surgery. Three patients, with a mean age of 25 years old, all complicated by omphalitis, underwent laparoscopic excision of the umbilical urachal remnant. We ligated the urachus using absorbent thread instead of metal clips. Using three 5-mm ports, the umbilical urachal remnant was divided from the bladder and separated from the abdominal wall. The caudal side of the urachus was ligated by an Endoloop^® in the first case and by absorbable threads in the other two cases. The specimen was extirpated from the small incision under the umbilicus. Mean operative time was 92 minutes, and average postoperative hospital stay was 2.7 days. Laparoscopic resection for an urachal remnant is useful as a minimally invasive and cosmetically beneficial technique especially for young patients, and should become the treatment of choice.

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We encountered two patients with intraperitoneal spontaneous rupture of the urinary bladder due to radiation cystitis many years after receiving postoperative irradiation for uterine cancer. Case 1 : A 79-year-old woman was admitted to our hospital with chief complaints of appetite loss and abdominal pain. She had received postoperative irradiation for uterine cancer 30 years earlier. Because panperitonitis was suspected, emergency laparotomy was performed. At laparotomy, perforation was identified on the bladder. It was too difficult to suture the perforation site directly, so enterocystoplasty was performed using the ileum. Case 2 : An 85-year-old woman was hospitalized in the Department of Intermal Medicine because of malignant hypertension. She had undergone postoperative radiotherapy for cancer of the uterus 40 years previously. After admission, she developed bladder bleeding because of the hemorrhagic cystitis following irradiation, which required transurethral coagulation. Three days later, she suddenly presented with lower abdominal pain. Under suspicion of intestinal perforation and panperitonitis, emergency laparotomy was performed. Laparotomy demonstrated rupture of the bladder. The site of the perforation was sutured. In a review of the Japanese literature, 44 cases of intraperitoneal spontaneous rupture of the bladder associated with radiation cystitis, including our cases, have been reported. Some bibliographical notes are also presented.

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A 78-year-old man, who had undergone resection of an inguinal tumor in 1998 which was diagnosed as desmoid tumor, was admitted to our hospital because of an inguinal swelling in 2003. The inguinal tumor had grown rapidly, so that resection of the tumor was performed. Pathological examination of the tumor demonstrated dedifferentiated liposarcoma. The specimen resected at the former operation 5 years earlier was reexamined and diagnosed as well differentiated liposarcoma. Thereafter the tumor recurred repeatedly and caused non-islet cell tumor hypoglycemia (NICTH). Finally the patient died of the cancer 15 months after the second operation.
Well differentiated liposarcoma occasionally recurs as dedifferentiated type after many years have elapsed following the first operation. Dedifferentiated liposarcoma is a clinically rare entity, accounts for about 5% of all liposarcomas, and carries a poor prognosis. We report a case of dedifferentiated liposarcoma arisen from the spermatic cord with repeated local recurrences.

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A 28-year-old man was admitted to our hospital because of right lower abdominal pain. Physical examination revealed strong tenderness and rebound tenderness in his right lower abdomen. His white blood cell count and C-reactive protein were 14500/μl and 1.32mg/dl, respectively. Computed tomography visualized a swollen appendix and hyperattenuating fat density in a concentric pattern. An emergency operation was performed under the diagnosis of acute appendicitis. The twisted and dark hemorrhagic omentum was covering his swollen appendix. A small amount of serosanguinous fluid was found in the peritoneal cavity. The necrotic omentum was excised and an appendectomy was performed. The postoperative course was uneventful. Secondary omental torsion is associated with intra-abdominal pathology. Secondary omental torsion with acute appendicitis is a very rare case ; only one such case has been reported in Japan.

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This paper deals with a case of torsion of the greater omentum secondary to a recurrent inguinal hernia, which is a comparatively rare entity.
A 61-year-old man with a 2-day history of intermittent pain in the left lower quadrant of abdomen was seen at the hospital because the pain gradually intensifiied and appetite loss, nausea and vomiting appeared as well. An abdominal CT scan visualized a tumorous lesion mainly composed of fatty tissue on the left side of the abdominal cavity. Vessels in the fatty tissue followed a screw-shaped course and a right inguinal hernia was present. On the same day an emergency operation was performed with a diagnosis of acute abdomen. At surgery the greater omentum was twisted by three turns and the omentum which became necrotic was impacted in the right inguinal hernia. Secondary torsion of the omentum was diagnosed, and the resection of he greater omentum and radical repair for the right inguinal hernia were performed. The postoperative course was uneventful and the patient was discharged from the hospital on the 12th hospital day.

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A 32-year-old woman who had dull, left-sided abdominal pain was admitted to our hospital in August 2005. Close examination revealed multiple cystic lesions derived from the pancreas or retroperitoneum. We performed an operation for diagnosis and to alleviate the pain. The laparotomy revealed multiple cystic lesions spreading over the distal pancreas and spleen. The surgical diagnosis was retroperitoneal cystic and cavernous lymphangioma. The diameter of the cysts ranged from a few mm to 70 mm. Although they were easily separated from the mesentery of the transverse colon, distal pancreatectomy and splenectomy were necessary for the cavernous lymphangioma lying on the surface of the pancreas and the spleen. Histopathologic examination found many micro lymphangioma within the pancreatic tissue. No recurrence has been found as of May 2007.

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Retroperitoneal liposarcomas are remarkable because of their frequently large size and histological variability. Herein we describe the treatment of a patient with a giant retroperitoneal dedifferentiated liposarcoma. A 53-year-old man was admitted, complaining of abdominal pain and distension. Preoperative diagnosis was liposarcoma invading the liver and the kidney. Tumor excision with posterior segmentectomy of the liver, right nephrectomy and partial phrenectomy was performed. The weight of the tumor was 9.7kg. The pathological diagnosis was a dedifferentiated liposarcoma. Half of the tumor was filled with spindle cells with high-grade nuclear atypia. Well-differentiated liposarcoma areas that contained lipoblasts also existed. Three years after the first surgery, local recurrence was detected and a tumor was removed. Despite two more recurrences, he has survived for 5 years due to aggressive surgical treatment. There is little precise information as to the effectiveness of various therapies, such as chemotherapy and radiotherapy, the efficacy of which is still controversial. The “gold-standard” of treatment remains aggressive surgical procedure.

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A 63-year-old woman was admitted to the hospital because of irregular bowel movements. Pelvic CT scan and MRI showed an invasive tumor in the Douglas pouch. The biopsy samples of the depressed lesion in the rectum were histologically diagnosed as poorly differentiated adenocarcinoma. Although barium enema showed invasion outside the rectal wall and serum CA-125 and SCC levels were elevated, no malignant findings on genecological examination and biopsies of the endometrium were found. We considered various differential diagnoses of cancers arisen in the Douglas pouch, but could not made the definite diagnosis. In operation the tumor in the Douglas pouch had invaded the rectum and uterus, therefore super low anterior resection, extensive uterectomy and dissection of the pelvic lymph nodes were performed. Postoperative histological diagnosis was rectal invasion of adenocarcinoma of the uterine cervix. The difficulty in making preoperative diagnosis by the biopsy of the endmetrium was because the cancer cells had derived mainly from under the mucosal lesion of the uterine cervix and progressed toward the rectum and uterine body. It has been reported that adenocarcinoma of the uterine cervix is most apt to metastasize hematogenously and lymphogenously rather than invade directly. And rectal invasion of adenocarcinoma of the uterine cervix is extremely rare. We report the case with a review of the literature.

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We report a case of right femoral hernia in which an epiploic appendage of the sigmoid colon was incarcerated.
An 82-year-old man with a 5-day history of a right inguinal bulge was seen at the hospital. An eggsized tumor with tenderness was identified at the right inguinal region, but abdominal symptoms were absent. Incarceration of the greater omentum in the right femoral hernia and hemorrhage in the hernia sac were suspected from the above findings together with abdominal CT findings. The patient was admitted to the hospital on the next day and underwent an operation. At operation, incarceratiom of an epiploic appendage of the sigmoid colon in a right femoral hernia was diagnosed. The swollen hernia sac was dark red in color and bloody ascites was identified in the hernia sac, but inflammation of the epiploic appendage was mild. Thus the epiploic appendage was resected and the hernia was repaired by using PROLENE^® hernia system.

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We report a case of adenosquamous carcinoma of the stomach and bladder cancer after operations for rectal and renal cancers. A 71-year-old male was admitted to our hospital for close exploration of a gastric tumor. Upper gastrointestinal endoscopy and roentogenography revealed a giant lesion of Type 3 cancer extended from the upper body to the angle of the stomach. Preoperative biopsy demonstrated poorly differentiated adenocarcinoma and signet ring cell carcinoma. Total gastrectomy with lymph node dissection was performed. The pathological diagnosis of the tumor was adenosquamous carcinoma with lymph node metastases in stage IIIB (T3 N2 P0 H0 M0 CY0). Adjuvant chemotherapy was performed after the operation for bladder cancer, but multiple liver metastases appeared 6 months after the operation and he died 8 months after the operation. Prognosis was poor in this patient. This case was considered to be relatively rare because of quadruple cancer including adenosquamous carcinoma of the stomach.

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A 43-year-old woman underwent sigmoidectomy and appendectomy for cancer of the sigmoid colon when a pleat drain was inserted from the left lower abdomen to the Douglas' pouch. The patient's postoperative course was uneventful. On the 6^th postoperative day we attempted to remove the drain but had to abandon the attempt, because we encountered resistance to the removal on the way and the patient complained of pain. Further efforts of removing the drain were unsuccessful due to the resistance and her complaint of pain. Following various examinations, it was inferred that incarceration of abdominal fatty tissue into the drain's lumen might cause the difficulty in removing it. Thus laparoscopy-assisted surgery to remove the drain was performed on the 9^th postoperative day. During surgery we saw that the greater omentum had been incarcerated from the side opening of the drain to its lumen, so that we pulled out the greater omentum and removed the drain. After carefully observed the presence or absence of injuries to the intra-abdominal tissues and hemorrhage, we completed the surgery. The postoperative course was uneventful and the patient was discharged from the hospital on the 14^th postoperative day.
In this case we were able to observe the abdominal cavity carefully and remove the drain safely by employing laparoscopy-assisted operation.

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