Objective : A diagnostic method which is able to pick up easily, rapidly, and precisely patients who have strangulated intestinal obstruction from those with postoperative intestinal obstruction was studied.
Subjects and methods : D Subjects were consecutive 374 patients with postoperative intestinal obstruction, including 32 with strangulated and 342 with non-strangulated, who demanded hospital stay for treatment from January 1999 to March 2005. They were retrospectively studied whether there were significant correlations between clinical findings suggestive of strangulation and the postoperative diagnosis. Then clinical findings showing a statistically significant difference were made into scores to create the strangulation scores. II) A total of 81 patients with postoperative intestinal obstruction who demanded hospital stay for treatment from April 2005 to August 2006 were enrolled in a retrospective study to examine the usefulness of the strangulation scores, using those scores.
Results : D A univariate analysis disclosed significant correlations between strangulation and eight factors, including white blood cell count, CRP value, CK value, B.E. value, characteristic abdominal CT findings, ascites, efficacy of pentazocine for abdominal pain, and peritoneal signs. Referring results of a multivariate analysis of these eight factors, the strangulation scores were made. II) We were able to pick up strangulated cases with the sensitivity of 100% and specificity of 95.4%.
Conclusion : The use of this strangulation scores might be capable of making the correct diagnosis of strangulated intestinal obstruction.

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We studied 88 cases of stromal tumors originating in the gastrointestinal tract treated from 1987 to 2006. The histological diagnosis was defined by positive immunohistochemical staining with desmin, S-100, KIT, or CD34. We found 6 leiomyomas (2 in the esophagus, 1 in the stomach, 1 in the duodenum, 1 in the colon and 1 in the rectum), 6 schwannomas (all 6 in the stomach), and 76 GISTs. The mean tumor size was 7.5 cm for GISTs, 5.9 cm for leiomyomas, and 4.7 cm for schwannomas. Five of leiomyomas and 6 of schwannomas were diagnosed as benign by pathological examination, and 76 GISTs were classified into 20 of low risk, 32 of intermediate risk and 24 of high risk GISTs according to NCCN risk classification. Fifteen patients suffered tumor metastasis or recurrence, all of which were GIST patients. Median observation was 3.7 years, with overall 5-year survival of the 78 GIST patients 85.3%, 10-year survival 79.9%, and 5-year disease-free survival 84.2% and 10-year 74.5%. The occurrence of leiomyoma in the gastrointestinal tract was 6.8%. It should be noted that almost all the malignant stromal tumors that proved to be GISTs had previously been regarded as leiomyosarcomas.

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This paper deals with a patient who received an excisional biopsy with a diagnosis of a fibroadenoma which was histologically diagnosed as stromal sarcoma of the breast, and additional excision of it yielded the definite pathological diagnosis of dermatofibrosarcoma protunberans originated in the skin of the breast. The patient was a 41-year-old woman. She had visited another hospital because of a left breast tumor in August 2004 and had been followed with a diagnosis of a fibroadenoma. In October 2005, she felt an increase of the breast tumor and underwent an excisional biopsy which gave a diagnosis of stromal sarcoma of unknown origin. Thus the patient was seen at our hospital for further treatment. We performed additional resection aiming at radical treatment. It was difficult to determine the resected tumor macroscopically, but microscopical study disclosed the tumor remnant in the dermis and supramammary fatty tissue of the resected material. Based on the localization of the lesion and positive reaction of it to CD34 immunohistologically, dermatofibrosarcoma protunberans originated in the breast skin was definitely diagnosed.
The disease presents difficulties in making differentiation from a fibroadenoma or a stromal tumor of the breast, and thus careful attitude for the diagnosis would be important.

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Two patients with past experience of primary adenoid cystic carcinoma of the breast are reported. Patient 1 is a 59-year-old woman who was examined at another hospital due to complaint of a tumor in the left breast and mastalgia. After a confirmed diagnosis by biopsy, she was admitted to this hospital. Partial resection of the breast and axillary lymph node dissection were performed. It has been eight years now since the operation but the patient has been healthy with no relapse. Patient 2 is a 39-year-old woman who was examined due to complaint of a tumor in the left breast that was not comfirmed by diagnostic cytology. A biopsy was performed and adenoid cystic carcinoma was diagnosed. Partial resection of the left breast was performed but not axillary lymph node dissection. It has been two years now since the operation but the patient has been healthy with no relapse. In both patients, a confirmed diagnosis could not be obtained by diagnostic cytology and so biopsy was required. Adenoid cystic carcinoma originating from the breast is a comparatively rare disease. Reports of cases have increased recently, However, comprehensive reports are few and so the characteristies remain unclear. We have compiled 52 cases reported in Japan for a bibliographical review.

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Case 1 was a 50-year-old woman with a left axillary mass. In the whole body search, any primary focus including the breast was unclear. Lymph node metastasisi from the breast cancer was diagnosed by core needle biopsy, and confirmed by left axillary lymph node dissection (Level III) and pathological examination.
Case 2 was a 66-year-old woman with a left axillary mass. In the whole body search, any primary focus including the breast was unclear. Core needle biopsy was not able to confirm whether the mass was breast cancer, ectopic breast cancer or lymph node metastasis. Axillary lymph node dissection (Level II) was performed, with a surgical margin of 2 cm from the main axillary mass, so as to also cover the axillary region (C'). Pathological examination revealed that there was a lymph-node with metastasis.
There is no established standard therapy for occult breast cancer. Surgical treatment for the breast when a breast lesion is undetected even when diagnostic imaging is used is contentious. When starting treatment, it is necessary to adequately explain to the patient before deciding on the strategy to use.

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The patient was a 61-year-old woman. She had undergone modified radical mastectomy with axillary lymph node dissection for left breast cancer in 1993, when the histopathological diagnosis was invasive lobular carcinoma, n=8/12, estrogen receptor (ER) (+), and progesterone receptor (PR) (+). Postoperative radiation therapy at a dose of 50Gy was given to the patient (the left supraclavucular area, left axilla, and parasternal area). Postoperative chemotherapy with tamoxifen citrate (20mg/day) and fluorouracil (200mg/day) was conducted for 3 years, and then the patient had been free from recurrence for postoperative 10 years. She became to have lower abdominal pain in August 2003, and her clinical course was followed. However, the symptom became worse, and lower gastrointestinal endoscopy conducted in July 2004 disclosed redness and stenosis encircling the lumen of rectum. A biopsy of the narrowing lesion suggested poorly differentiated adenocarcinoma. It was a diffuse lesion forming no tumor which was non-typical as rectal cancer so that metastasis of breast cancer was suspected as well. Immunostaining resulted in ER (+) and PR (+) which were identical with those of the primary lesion. From these findings rectal metastasis of breast cancer was diagnosed. Oral exemestane (25mg/day) was started which gave a relief of the abdominal symptom 2 months after its initiation. She has been followed in the clinic at present when 22 months have elapsed after the drug regimen.

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Case 1 was a 24-year-old man. His chest X-ray showed a 1.3cm solitary nodule in the right S1+2. Case 2 was a 64-year-old man. His chest X-ray showed a 1.5cm solitary nodule in the left S1+2. They were asymptomatic. In both cases, bronchofiberscopy could not establish a pathological diagnosis, and so a thoracoscopic resection was performed. It revealed that both solitary nodules were Mycobacterium kansasii infection. On chest X-ray and CT scan, the majority of cases showed a thin walled cavitary lesion, but in these two cases CT scan showed solitary nodules without cavity. Differential diagnosis was necessary to distinguish from lung cancer.

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The patient was a 37-year-old woman. In the course of follow-up for SLE, pulmonary arteriovenous fistula was pointed out by means of chest X-P and CT scan. She was transferred to this ward for fear of aggravation. Cyanosis was noted on the whole body. Chest CT scan and angiography revealed a phyma as large as 45×26mm bulged partly into the lobe at right S⁶. Each one of A⁶ and V⁶ was dilated, being as independent inflow and outflow vessels. Since the patient was young, it was planned to perform enucleation. During the operation it was noted that the phyma bulged into the upper lobe from the lower showing turbulent flow. The thick A⁶ and V⁶ were exposed and ligated at their roots, but the phyma was not constricted and venous blood spurted out, suggesting the presence of another inflow vessel. As hemorrhage persisted while we continued enucleation, the mode of operation was changed to segmentectomy of S⁶. Resected material of S⁶ revealed blood vessels bifurcated from A⁷, as if branch vessels in both segments were gathering into the phyma. After the surgery no complications occurred, cyanosis subsided, and blood gas was normalized. Physiologically it was a phyma present mainly in the vein.
We had great difficulties in evaluating those thick inflow blood vessels preoperatively in this case. Accordingly, it is considered safe to employ segmentectomy for a large phyma with thick inflow vessels.

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We report a case of spontaneous rupture of the esophagus in an elderly patient. An 84-year-old woman was seen at our emergency room because of upper abdominal pain. Chest X-ray showed left pleural effusion and wide mediastinum. Chest contrast enhanced CT scan revealed pneumomediastinum around the esohagus and pleural effusion. The diagnosis of spontaneous esophageal rupture was made. Emergency operation was performed about 20 hours after the onset of the disease. During the surgery, we found a longitudinal tear, 2 cm in length, in the left side of the lower esophagus and performed primary closure with reinforcement using intercostal muscle. After the operation anastomotic leakage occurred to form a localized abscess, which was cured by conservative treatments including fasting. However, the patient had MRSA pneumonia just before discharge and died on the 65^th postoperative day.
Spontaneous rupture of the esophagus has relatively rarely been reported in elderly people. The prognosis of the disease is still poor in elderly patients, especially those over 80. In this case, gastroesophageal reflux might induce anastomotic leakage and postoperative pneumonia, and thus several treatment options should be considered.

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A spontaneous esophageal rupture is often repaired under thoracotomy. We successfully treated a case of spontaneous esophageal rupture with a pedicled omental covering and external drainage using a T-tube by trans-abdominal repair. A 44-year-old man was admitted to our hospital because of severe chest pain, back pain and vomiting blood after drinking. The operation was undertaken using an upper middle incision. We confirmed necrotic tissue surrounding perforation of the esophagus, started drainage using T-tube and applied a pedicled omental flap over the perforation. We diagnosed spontaneous esophageal rupture with CT scan and esophagography. T-tube was removed on the 23rd day, and he was discharged on the 39rd day postoperatively. Trans-abdominal repair with a pedicled omental covering and external drainage using a T-tube in spontaneous esophageal rupture is useful and easy compared with trans-chest repair.

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A 59-year-old man presented with abdominal fullness and constipation in January 2003. Abdominal dynamic CT and MRI revealed a huge solid tumor, 40 × 19 cm in diameter, occupying the whole abdomen and the pelvic cavity. GIST was suspected on clinical images and confirmed by percutaneous needle biopsy. At laparotomy, the tumor was located in the left abdomen involving the stomach. The tumor was completely excised by proximal gastrectomy with combined resection of the distal pancreas, spleen, left adrenal gland and the left diaphragm. The resected specimen was 40 × 27 × 20 cm in size, weighing 4860 g. Hepatic metastasis occurred one year after the operation, and tumor extirpation was performed. He received imatinib chemotherapy after the second operation and has lived well for three years without apparent recurrence. The patients with GIST are associated with nonspecific symptoms, and often asymptomatic until the tumor becomes large. We present a case of huge GIST and discuss the management of advanced and metastatic GIST.

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A 75-year-old woman was admitted to our hospital because of vomiting occurred 2 to 3 hours after a meal. Abdominal plain X-ray showed no abnormalities. Recovered conservatively, she felt nausea and vomited after she ate again. Small bowel follow-through showed a clustered and stenosed small intestine around the ligament of Treitz and the dilated duodenum. No mass lesion that had caused the stenosis was detected in an abdominal CT scan. Operation was performed with a preoperative diagnosis of right paraduodenal hernia. About 12cm segment of the jejunum which was just anal of the duodenojejunal flexure was incarcerated into the intermesocolic fossa of Broesike. We diagnosed that because the orifice was cranial of the ascending part of duodenum and away from the inferior mesenteric vein. After repositioning of the jejunum, we closed the orifice of the herniation. Postoperative small bowel follow-through revealed smooth passage without any stenosis. We reported a rare case of right paraduodenal hernia into the fossa of Broesike.

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A 24-year-old man with acute abdominal pain was admitted to the hospital because of ileus. He had no previous laparotomy. Abdominal roentgenogram revealed intestinal dilatation with niveau and computed tomography scan revealed a mass contained in the small bowel in the right upper abdomen. A contrast radiography with long tube showed the upper small bowel was located on the right side of the abdominal cavity. An emergency operation was performed with a diagnosis of strangulation ileus due to internal hernia. We found a hernia orifice about 5cm in diameter between the mesentery of the transverse colon and retroperitoneum, and the small bowel had invaginated through the orifice under the right side of the mesentery of the transverse colon. The small bowel had no necrosis, so it was returned to the normal position and the orifice was closed. We report this rare case of paraduodenal hernia originated in the intermesocolic fossa of Broesike, together with a review of the literature.

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Duodenal diverticulum is usually detected at the 2nd portion without symptoms. We experienced a rare case of duodenal diverticular perforation at the 4th portion. A 61-year-old woman was admitted to our hospital due to abdominal pain with severe inflammation.
Abdominal X-ray revealed neither niveau nor free air. Abdominal CT showed intra-mesenteric abnormal air. Upper gastrointestinal radiography showed a duodenal diverticulum at the 3rd portion and contrast medium leakage outside intestinal tract.
From an emergency operation, a perforated duodenal diverticulum of 1 cm diameter at the 4th portion was confirmed on the left-dorsal side of superior mesenteric artery near the Treitz ligament, and an abscess was formed, extending, from the perforated portion to the intra-mesenteric area of the small intestine. After drainage of the abscess, debridement and simple closure of the diverticulum were performed. The patient was discharged on the 36th postoperative day without major complication.

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A 75-year-old woman with a pelvic tumor measuring 13 cm in diameter, which was found by follow-up abdominal CT after extended right lobectomy and partial lateral segmentectomy for metachronous liver metastases from leiomyosarcoma originated duodenum, was referred to our hospital. Chest CT also showed a solitary nodule in left lower lobe measuring 1.5 cm. Resections of pelvic tumor and a small peritoneal nodule following left lower lobectomy of lung were performed subsequently. Pathological examination revealed that all of the resected tumors consisted of spindle-shaped tumor cells which were positive for c-kit immunohistochemically. Thus, it was diagnosed as metastases of GIST. Aggressive resection of metastases from GIST, especially in cases with a long disease-free interval between initial resection and recurrences might contribute to prolonged prognosis.

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A 57-year-old man with no past history of laparotomy was admitted for sudden onset of severe upper abdominal pain. Plain X-ray of the abdomen showed a little gas in the small intestine. Abdominal contrast-enhanced computed tomography demonstrated a so-called “whirl-like pattern” by which the small bowel loops around the superior mesenteric artery. We suspected volvulus of the small bowel, and undertook an emergency operation. It was found that the small intestine, from 210 cm anal to the Treiz ligament, rotated 180° clockwise under mesenteroaxic torsion. Because there were neither anatomical abnormalities, nor adhesions, we diagnosed primary volvulus of the small intestine. The strangulated intestine was removed and a jejunojejunostomy was perfomed. The patient was discharged on day 9 after the operation. Primary volvulus of the small intestine is reportedly rare in Japan, and difficult to diagnose preoperatively. But early diagnosis and treatment were possible in this case, because we could identify the charactevistic whirl-like pattern.

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We report a case of amyloidosis which presented with intractable intestinal obstruction due to severe narrowing of the small intestine and was definitely diagnosed as amyloidosis by pathological exploration of the excised material.
The patient was a 74-year-old woman who had recurrent bouts of symptoms of intestinal obstruction including abdominal pain, abdominal distension, and vomiting as well as diarrhea. She was referred to our department of surgery after unsuccessful conservative therapy at the department of internal medicine in our hospital. Small intestinal fluoroscopy showed severe narrowing of the middle small intestine. Abdominal contrast enhanced CT scan disclosed narrowing of the small intestine and dilatation and wall thickening of the small intestine proximal to the narrowing. The patient was considered probably not to have strangulated ileus, but any cause of the narrowing was still unknown. Thus the patient was operated on with a diagnosis of intractable intestinal obstruction. During surgery the small intestine was shortened to the total length of about 200 cm, when two areas showing severe narrowing were seen. Following small intestinal resection, a side-to-side anastomosis between the jejunum and transverse colon was carried out. Histopathological exploration offered the diagnosis of amyloidosis.
Although intestinal amyloydosis can cause functional intestinal obstruction due to impairment of intestinal movement, it rarely causes mechanical intestinal obstruction due to intestinal narrowing. Accordingly this case is reported here, together with some bibliographical comments.

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We report a case of Meckel's diverticulum with torsion at its neck, resulting in peritonitis. Torsion is a rare complication of Meckel's diverticulum, and a total of 28 cases including ours have been reported in Japan. A 7-year-old boy, who had been operated on for double outlet right venticle and ventricular septal defect at the age of 5 months, was admitted to the hospital because of abdominal pain and vomiting. The entire upper abdomen was board-like and hard. Abdominal CT scan showed a loop which looked like a dilated intestine. Emergency laparotomy was perfomed with a suspicion of strangulation ileus. Meckel's diverticulum, 10cm × 2cm in size, was found on the ileum about 40cm proximal to the Bauhin's valve. It was voluvulated at its base and connected to the navel. Then diverticulectomy was performed. Histopathological studies demonstrated that the epithelium was small intestinal mucosa, showing acute inflammation with hemorrhage, and no ectopic gastric mucosa was present. The postoperative clinical course was uneventual and he was discharged from the hospital on the 9^th hospital day. The diagnosis and treatment of Meckel's diverticulum are also discussed.

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We report a case of suture line ulcer in the interposed jejunal pouch which arose 8 years and 9 months after surgery, and this is the first case. A 40-year-old man underwent a lower esaphagectomy and a proximal gastrectomy for giant leiomyoma in the esophagogastric junction in March 1997. Reconstruction was performed by interposition of a jejunal pouch. The postoperative course was uneventful, but the patient visited our department because of severe epigastric pain on November 27, 2005. An emergency endoscopy examination revealed a white mossy and deep ulcer in the posterior wall of jejunal pouch interposition. Abdominal pain disappeared after about 3 days by oral administration of proton pump inhibitor.
Healing of the tumor proceeded steadily, however, parts of the silk suture were found to have been exposed. Seven months after occurrence of the condition, the silk thread disappeared. The ulcer was consequently completely healed. This silk thread was used in jejunal pouch interposition formation to make the sero-muscular layer suture, which reinforced the area sutured and severed by linear cutter GIA. The ulcer is believed to have been caused by the suture line.

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A 78-year-old male had small intestinal GIST with liver and peritoneal metastases and underwent surgical resection of the small intestine and some disseminated masses. He remained well for 20 months owing to the treatment with 400mg of imatinib before PET/CT disclosed a solid mass with a high FDG uptake in the left upper abdomen. Under a diagnosis of secondary resistant GIST, the PET-positive mass was selectively removed with the adjacent intestine as surgical intervention. The resected tumor was classified as KIT positive GIST and had KIT exon9 mutation (6bp insertion) on gene type analyses. Treatment with 400mg of imatinib restarted after operation and the patient's disease has been stable for six months since imatinib was restarted. As PET/CT imaging can provide early and precise local information for secondary resistant GIST, it enables surgical resection of local progressing lesions and continuation of imatinib. This might be the most rational therapeutic strategy among those currently available for secondary resistant GIST.

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A 69-year-old man who had undergone a total gastrectomy for gastric cancer five years earlier presented himself for follow-up study although he had no symptoms. A hen's egg-sized tumor was found on abdominal CT, which was also palpable from outside. Intestinal radiography showed a multiple concentric ring sign characteristic of intussusception in the ileocecal region. Colonoscopy revealed a polypoid tomor, 5 cm in diameter, protruding from the opening of the ileum. Biopsy of the tumor showed well-differentiated adenocarcinoma.
On laparotomy, the intussusception in the ileocecal region and a tumor in the ileum were confirmed. Ileocecal resection with regional lymph node dissection was performed. Histological examination of the tumor revealed well-differentiated adenocarcinoma whose cells were toller than that of the previous gastric cancer and less atypical. The tumor was considered to be primary.
A review of the Japanese literature regarding adult intussusception due to malignancy disclosed that a case with double cancer is very rare.

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We report two patients with ulcerative colitis (UC) discovered to have deep vein thrombus (DVT) by preoperative CT scan, and implanted inferior vena cava (IVC) filter. Patient 1, a 33-year-old woman, was diagnosed with UC four years earlier, followed and treated. She was admitted to our hospital because of melena and lower abdominal pain. Although she was treated by an internist, her symptoms were not well controlled. Consequently, she was referred to us for operation. Preoperative CT scan revealed DVT from right internal iliac vein to right common iliac vein, and lung scintigraphy revealed a pulmonary embolism (PE). An IVC filter was implanted before operation. Patient 2, a 59-year-old woman, was diagnosed with UC seven years earlier, followed and treated. She was admitted to another hospital because of diarrhea and fever. Then she was referred to our hospital due to steroid resistance. She experienced abdominal pain after admission to our hospital, and CT scan revealed free air and DVT from the right common iliac vein to the IVC. After the emergency operation, an IVC filter was implanted. We should pay attention to DVT and PE for patients with UC, especially in the perioperative period.

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A-33-year old male who had been diagnosed with ulcerative colitis 2 years previously was admitted to our hospital with lower abdominal pain and bloody stool. Despite the administration of various types of conservative therapies over a 3-month period, the symptoms did not improve. Furthermore, colonofiberscopy and a barium-enema showed severe stricture at the rectum and sigmoid colon. As a result, he underwent hand-assisted laparoscopic total colectomy and ileal J-pouch proctostomy. The histological findings revealed an irregular thickness of the proper muscle layer, thus resulting in severe stricture of the rectum and sigmoid colon. The inflammation of ulcerative colitis tends to mainly occur in the mucosa and submucosa, therefore the occurrence of severe stricture is rare. In Japan, previous cases of ulcerative colitis with severe stricture have only been reported in 10 other cases. The indications of the surgical treatment of ulcerative colitis can be separated into two types, namely absolute and palliative. In the absolute indication cases, almost all operations are carried out as emergency operations, for patients with such symptoms as major hemorrhaging, perforation, peritonitis, and toxic megacolon. In the palliative indication cases, operations are carried out as elective operations for persistent disease, and these operations are selected for both the curability of disease and to maintain the patient's quality of life. The case reported herein is thus considered to be a good candidate for an elective, hand-assisted laparoscopic total colectomy and ileal J-pouch proctostomy.

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A 76-year-old woman was admitted to the hospital because of anal discomfort and bleeding at defecation. An elastic hard tumor was palpable near the anal margin. Pelvic CT and magnetic resonance imaging scans showed a submucosal tumor about 2cm in diameter with clear margin in the ventral aspect of rectum. Colonoscopy showed a submucosal tumor with ulceration placed oral side of the anal margin, and the tumor was diagnosed as low grade malignant rectal gastrointestinal stromal tumor (GIST) by biopsy. No invasive sign was found in various preoperative examinations. Local resection was performed through the anus. The removed tumor was 1.8cm in longer diameter, and showed central necrosis accompanied with bleeding on section. The positive staining for c-kit and CD34 was confirmed by immunohistochemical staining, and the proliferation rate was high (60/50HPF). The final pathological diagnosis was rectal GIST with high grade malignancy. A large part of rectal submucosal tumors smaller than 2cm in diameter are followed up without treating in clinical cases. However, careful and adequate diagnosis is required because of high malignant potential in some tumors.

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A 26-year-old woman was admitted to our hospital because of transverse colon cancer which was pointed out at another hospital when she visited for constipation. Laboratory data showed thrombocytopenia, myelocytes in the peripheral blood, and increase in the tumor marker (CEA, CA19-9). Barium enema study revealed long stenosis of the transverse colon. Abdominal CT scan demonstrated peritonitis carcinomatosis. Bone scintigraphy revealed multiple abnormal uptake of isotope in the entire skeleton. We diagnosed bone marrow carcinosis, peritonitis carcinomatosis, and DIC due to colon cancer. Anticancer treatment and thrombolytic therapy were started. One time, improvement of the symptom and decrease in the tumor markers were seen, but she died 6 months later. We report this a rare case of juvenile colon cancer with bone marrow carcinosis with a review of the literature.

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A 57-year-old man underwent partial resection of the colon cancer and double stapling technique anastomosis. Intraluminal lavage was not performed. Twelve months later, anastomotic recurrence was rocognized. Resection of anastomosis was performed.
Adenocarcinoma was seen around the anastomotic line. At first operation, the tumor was resected with sufficient margin, and adenocarcinoma was not seen at the edge of the specimen, the anastomotic recurrence seemed to be because of the implantation. Although a anastomotic recurrence is a rare event for anastomosis of a colon cancer, in case of double stapling technique anastomosis, intraluminal lavage and routine follow-up are important.

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A 46-year-old woman was admitted to the hospital because of right lower abdominal pain. There were spontaneous pain and tenderness shifting from the umbilicus to the right lower quadrant of abdomen, but no rebound tenderness and muscle guarding were present. Acute appendicitis was thus suspected. Conservative therapy resulted in disappearance of inflammatory findings, but abdominal distention and constipation persisted. Abdominal CT scan suggested a possibility of tumorous lesion, and tumor markers including CEA and CA19-9 were high. Barium enema study and colonoscopy showed type 2 colonic cancer in the sigmoid colon almost encircling the lumen. When performed a sigmoidectomy with D3 dissection, we saw that the tumor had involved the appendix and right oviduct so that these organs were removed as well. Histopathologically this cancer directly invaded subserosa of the appendix. We considered that the symptoms of appendicitis appeared because the tumor involved the appendix in this case.

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A 42-year-old woman was admitted for abdominal distension and constipation. She underwent subtotal colectomy, distal gastrectomy and management with home parenteral nutrition for intractable anal fistula due to Crohn's disease for over 10 years. CT and MRI showed rectal stenosis. She was diagnosed as anal canal cancer by incisional biopsy for perianal inflammatory polyp. Posterior pelvic exenteration followed by latissimus dorsi musculocutaneous free flap reconstruction were performed. In the specimen, there was a type-5 tumor at around the primary opening of the anal fistula on the anterior wall of the rectum, the maximum diameter of which was 35 mm. Pathologically it was well differentiated adenocarcinoma, and mucin-producing tumor cells were involved in the posterior wall of the vagina. However, there was no continuity of cancer lesion to the anal fistula, so the final diagnosis was anal canal cancer with Crohn's disease.

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We experienced a patient with hemorrhage due to ruptured common hepatic artery after pancreatoduodenectomy whose life was saved by ligation of the hepatic artery and arterialization of the portal vein.
A 54-year-old man underwent subtotal stomach preserving pancreatoduodenectomy with a diagnosis of lower bile duct carcinoma. Discharge of pancreatic juice from a drain started 36 hours after the operation, and then 2 hours later the patient went into shock due to abdominal hemorrhage. An emergency laparotomy was performed when the bleeding point was identified to be an opening about 8mm in diameter in the common hepatic artery and the vascular wall became fragile. Suture repair was considered impossible, so that the common hepatic artery was ligated which yielded hemostasis. Ileocolic arteriovenous shunt was performed to compensate for the lack of hepatic arterial blood. After the emergency laparotomy the patient developed jaundice, impairment of the hepatic function, suture failure at the stenosis between the stomach and pancreas which needed intensive care, but gradual symptomatic remission was attained and the patient was discharged very much improved on the 60^th hospital day.
Hemorrhage from the common hepatic artery is a life-threatening complication after pancreatoduodenectomy, and thus it is significant to save the patient's life by reoperation like in this case. From this viewpoint we present the case here.

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We report a case of liver metastasis of gastric gastrointestinal stromal tumor (GIST) resected after administration of imatinib mesylate. A 78-year-old woman underwent proximal gastrectomy for gastric submucosal tumor in February 2001. Histopathologically, the tumor was composed of a proliferation of spindle-shaped cells. Immunohistochemically, the tumor cells were positive for c-kit and CD34. The tumor was diagnosed as a GIST. An abdominal CT scan showed a liver metastasis in December 2002. Partial hepatectomy was performed. An abdominal CT scan showed a liver metastasis in March 2005. Administration of imatinib mesylate at a dose of 400mg/day was started. An abdominal CT scan 3 months after treatment with imatinib mesylate showed no shrinkage of tumor bulk. Adverse effects of imatinib mesylate were minimal, including NCI grade 1 anorexia, stomatitis, diarrhea and facial edema. Partial hepatectomy was performed in June 2005. Histopathologically, most of the tumor was replaced by fibrotic tissue with hyalinization and some viable GIST cells remained. The patient remains alive with no recurrence.

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We experienced a case of emphysematous cholecystitis that we could reach the diagnosis in the early stage of this disease by checking the abdominal CT daily. We report this case in detail and six other cases experienced in the last four years.
A man in his fifties came to the hospital complaining of abdominal pain in the right upper quadrant since the day after a colonoscopy. He was suspected as having ileus by abdominal CT and a long tube was inserted. But the pain continued to develop gradually, so we checked the abdominal CT the next day. We found gas formation in the gallbladder, and diagnosed it as emphysematous cholecystitis. Open cholecystectomy was performed, and the patient was discharged on the eighth post-operative day.
Emphysematous cholecystitis needs early treatment, because it sometimes causes severe complications. Abdominal CT findings can play an important role for the diagnosis, but diagnosis in the early stage is very difficult. In our cases, it takes 3 days on average before detecting air in the gallbladder. If the symptoms of cholecystitis continue to develop, the abdominal CT must be checked repeatedly for an early diagnosis.

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A 73-year-old man was referred to the hospital with a diagnosis of acute cholecystitis with thrombocytopenia. He was diagnosed as having idiopathic thrombocytopenic purpura (ITP) by preoperative blood examination. Although steroid therapy, high-dose transvenous γ-globlin therapy and eradication of Helicobacter pylori were performed, his platelet count did not increase as expected. Moreover, frequent chest oppression appeared after admission, and coronary angiography revealed severe triple vessel disease. Combined operation of off-pump coronary artery bypass graft (OPCAB) with cholecystectomy and splenectomy was performed safely with platelet transfusion, and he was transferred to another hospital for rehabilitation on the 29^th postoperative day. Intraoperative platelet transfusion and selection of OPCAB were useful to prevent perioperative complication of bleeding. This is the first report of combined surgery in a patient with ischemic heart disease complicating by cholecystitis and ITP.

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We present a case of cholecystitis in a pregnant woman who was safely delivered a baby with percutaneous transhepatic aspiration of the gallbladder. The patient was a 40-year-old woman in the 31^st week of gestation, and a para. She was seen at the emergency clinic in our hospital because of abdominal pain and was found having cholecystitis. She was treated by percutaneous transhepatic aspiration of the gallbladder, followed by conservative treatment with fasting and high calorie transfusion. Then the patient was induced to deliver at the 37^th week of gestation with resultant transvaginal delivery. The postpartum clinical course was uneventful for both the mother and her infant. Laparoscopy-assisted cholecystectomy was performed one week after her delivery, and she was discharged very much improved.
Since different therapeutic methods are employed depending on different gestation period and conditions of the mother and her fatus or fatuses, the case is reported together with some bibliographical comments.

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Adenoendocrine cell carcinoma of the gallbladder is a rare and highly malignant tumor. A 75-year-old man was admitted due to the right upper abdominal pain and fever. Abdominal ultrasonography and CT scan showed thickening of the gallbladder wall, intraluminal debris, and a high echoic mass in the neck of the gallbladder. Inflammation did not improve by conservative medical treatment and PTGBD was performed. After resolution of the inflammation, cholecystectomy was done, and additional wide excision was performed because the intraoperative frozen section diagnosis was adenocarcinoma. Histological features of the tumor were those of endocrine cell carcinoma with solid nests (carcinoid). There was a transition between adenocarcinoma and endocrine cell carcinoma. Immunohistochemistry showed that neuron specific enolase, chromogranin A, and synaptophysin were positive in the endocrine cell carcinoma, Grimelius staining was positive in the neuroendocrine carcinoma and focally in adenocarcinoma. The final pathological diagnosis was adenoendocrine cell carcinoma of the gallbladder. The patient had been well until 6 months after the surgery when tumor marker increased and a liver metastasis was detected.

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We report a case of a serous cystadenoma of the pancreas.
A 70-year-old woman who had been followed in the outpatient clinic for a multilocular pancreatic cyst in the pancreatic body for 11 years was admitted to the hospital because the size of the cyst increased recently. Abdominal enhanced CT scan showed multilocular cysts with the maximum diameter of about 3.0cm, a high desity lesion and calcification in the pancreatic body. ERCP did not demonstrate compression and obstruction of the main pancreatic duct. Pancreatic segmental resection was performed with the most likely diagnosis of mucinous cystic tumor of the pancreas. Histopathological studies revealed serous cystadenoma of the pancreas with single cuboidal epithelium. No malignant findings were seen, and thus serous cystadenoma of the pancreas was diagnoced.
Gnerally speaking, serous cyst adenoma of the pancreas has microcysts, but the adenoma in our case had macrocysts. Macrocystic type of this tumor is rare and our case is presented here with a review of the literature.

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A 78-year-old woman complaining of epigastric discomfort and nausea was suspected to have a tumor of the pancreas head on abdominal CT scan at another hospital, and was referred to the hospital. When she was first seen, a clearly demarcated and well movable tumor was palpable on the right side of the navel on physical examinations. Abdominal ultrasonography showed a 68 × 43mm clearly demarcated and solid tumor with an enhanced posterior echo in the lateral aspect of the pancreatic head. Abdominal CT scan disclosed a clearly demarcated and solid tumor 6.5cm in diameter with heterogeneous enhancement at the periphery and inner portion. Magnetic resonance imaging scan showed heterogeneous high signal intensity on T2-weighted images. From these findings, the patient was operated on with the most likely diagnosis of serous cystadenoma of the pancreas or duodenal gastrointestinal stromal tumor. During surgery, a 6-cm sized and elastic hard tumor was identified at the pancreatic head, so that pylorus preserving pancreatoduodenectomy was performed. The histopathological diagnosis was serous cystadenoma.
Since serous cystadenoma which appears as a movable tumor showing extrapancreatic growth is considered very rare, this case is presented here with some bibliograohical comments.

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A 54-year-old man was admitted with abdominal pain and vomiting without a history of abdominal surgery or abdominal injury. Tenderness and mild rebound pain were recognized in the abdomen without muscular defense. Abdominal computed tomography revealed a dilated small bowel and suspected presence of internal hernia, but the symptom was so mild that conservative therapy with an ileus tube was performed. However, no symptomatic remission could be achieved. Intestinal contrast study through the ileus tube was conducted on the 4th day after admission. This study showed a loop-shaped small intestine in the left lower quadrant. A laparoscopic operation was carried out with a diagnosis of ileus due to internal hernia, especially mesosigmoid hernia. There was incarceration about 4 cm of the ileum into a mesenteric defect 3 cm in diameter on the left leaf of the sigmoid colon. The incarcerated small intestine was reduced, and the defect of the sigmoid mesocolon was closed by laparoscopic surgery. The postoperative course was uneventful, and the patient was discharged on the 12th day after surgery.

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Mesenteric panniculitis is a non-specific inflammatory disease arisen in the mesenteric adipose tissue of unknown origin. We report an operated case of mesenteric panniculitis of the small intestine.
A 79-year-old woman was seen at the hospital because of abnormal bowel movement and epigastric discomfort. Abdominal CT scan showed a tumor of the small intestine. The patient was admitted for the purpose of operation. Upon laparotomy, no tumorous lesion was present in the small intestine, but multiple nodules were strung out like a band. Partial resection of the small intestine was performed. The pathological diagnosis was mesenteric panniculitis. The postoperative course was uneventful, and after received rehabilitation, the patient was discharged on the 27^th postoperative day. No recurrence has been seen up to now.
In the case of a patient who has abdominal symptoms and an abdominal tumor on abdominal CT scan, the disease must be kept in mind.

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A 32-year-old man had been found to have elevated levels of C reactive protein (CRP) at a medical examination severed years previously. Blood examination in our hospital also showed elevation of CRP (7.95mg/dl) and hypergammaglobulinemia (2,200mg/dl). Abdominal CT scan demonstrated a well circumscribed tumor measuring 3.7 × 3.4 cm located in the hepato-duodenal ligament. The tumor showed a relatively hypointense signal similar to that of muscle on T1-weighted MR image, and enhanced to the same extent as the liver. Endoscopic ultrasonography (EUS) suggested that the tumor originated in the duodenal proper muscle and had grown to the extra-duodenal lumen. From these findings, duodenal gastro-intestinal stromal tumor (GIST) was suspected and laparotomy was performed. An isolated, elastic soft tumor measuring 5.5 × 4.5 × 3.0 cm was revealed in the hepato-duodenal ligament. Because intraoperative rapid pathological examination suggested malignant lymphoma, only the tumor was excised. The histopathological diagnosis was hyaline vascular type Castleman's disease. The patient shows no signs of recurrence as of 1 year 3 months postoperatively. We report here the first case of Castleman's disease arising in the hepato-duodenal ligament.

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A 57-year-old woman was admitted because of abdominal pain. The Computed Tomography (CT) showed a lobulated mass in the left lower abdomen, which was 15×9×14 cm in diameter. Comparison with the result of the CT at the previous hospital demonstrated that the mass had enlarged rapidly. We diagnosed it as a malignant tumor of the mesenterium or retroperitoneum and conducted left hemicolectomy with en bloc resection of the tumor with no apparent metastasis or peritoneal metastasis. Immunohistochemistry showed leiomyosarcoma because α-SMA and vimentin were positive, but KIT, CD34, S-100 proteins and desmin were negative. This leiomyosarcoma indicated 20 to 30 mitoses/10 high-power fields (HPF) and 56% of Ki-67 labeling index with an extremely high proliferation potential. The patient was discharged from this hospital 23 days after surgery, but died of peritoneal metastasis after three and a half months.

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A 50-year-old woman, with a retroperitoneal cyst discovered by a medical checkup, visited our hospital. Abdominal computed tomography showed a large multilocular cystic mass which located on the left side of the abdomen. MRI was performed but a definitive diagnosis was not made. At laparotomy, a giant cystic tumor with a smooth surface was located in the small bowel mesentery. It adhered to the jejunum 10 cm from the Treitz ligament, but it was completely resected. It contained chylous fluid. Pathological examination of the surgical specimen revealed endothelial cells on its internal wall. The final diagnosis was cystic lymphangioma. The postoperative course was uneventful, and no evidence of recurrence has been seen in the 1 year after surgery. Although mesenteric lymphangioma is rare, it should be taken into consideration in the differential diagnosis of abdominal cystic tumor.

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A 53-year-old man complaining of abdominal pain was admitted to our hospital. CT showed a mesenteric tumor, measuring 8.0 cm in diameter, in the mesenteric root. Because of severe abdominal pain, an emergency laparotomy was performed. The operation revealed a mesenteric tumor adjacent to a trunk of the superior mesenteric artery and lymphnode swelling around the tumor. Extirpation of the tumor with partial resection of the ileum was done. The pathological diagnosis was malignant lymphoma, diffuse mixed B cell type. The postoperative course was uneventful, and the patient received R-THP-COP chemotherapy. He is alive without recurrence 6 months after operation.

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We report two cases of primary omental torsion that we resected for laparoscopic operation. A 52-year-old man was admitted due to sudden onset of right upper abdominal pain. An emergency laparoscopic operation was performed under a diagnosis of acute abdomen. We found dark red ascites and torsion of the greater omentum, and resected the twisted omentum. In the second case, a 44-year-old woman was admitted for right abdominal pain. By abdominal helical CT, torsion of the greater omentum was diagnosed preoperatively. We resected the necrotic part of the omentum in a laparoscopic operation. Torsion of the greater omentum is a rare disease, and it is generally difficult to diagnose preoperatively. But in some cases, we can diagnose it by helical CT, and perform resection of the twisted omentum by laparoscopic operation.

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The present case was a 72-year-old female with colon cancer recurrence in the abdominal wall who had earlier undergone hemicolectomy for transverse colon cancer. For this recurrence, a large defect of the abdominal wall was repaired using a Composix Kugel Patch^®. The size of the patch was 34.9 cm wide and 27.4 cm long. The repair technique was simple with no use of plastic surgery. The postoperative course was uneventful, and the patient left the hospital three weeks after the operation. We think that the present method using a Composix Kugel Patch^® is very useful for repairing a large defect of the abdominal wall.

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An 88-year-old woman was admitted to our hospital with the chief complaint of right lower abdominal pain and fever of 38°C. Detailed evaluation using multi-detector computed tomography (MDCT) with volume rendering (VR) and multiplanar reconstruction (MPR) images showed a foreign body corresponding to a press-through package (PTP) in the ileum with wall thickening and air bubble near the PTP. We diagnosed peritonitis due to perforation or penetration. Urgent laparotomy under general anesthesia found the PTP, which had penetrated the mesenterium 40 cm proximal from the end of the ileum. We resected the clustered ileum for a length of 30 cm, and constructed ileo-ileostomy. The treatment strategy for mis-swallowed PTP differs with the location. It is important to identify the location of PTP exactly using VR and MPR images obtained by MDCT, and it is necessary to perform urgent laparotomy in patients suspected of perforation or penetration in the gastrointestinal tract. Abdominal MDCT examination is useful to decide the treatment method for a foreign body in the gastrointestinal tract.

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A 78-year-old man was seen at the hospital because of a bulge at the left inguinal region which had been there for 20 years. On physical examination a fist-sized swelling was identified at the left inguinal region. No repositioning of the swelling was observed by changing the body position. There were no spontaneous pain and tenderness. Ultrasonography of the inguinal region visualized the swelling as an irregular low echoic lesion continuing to the inguinal canal. At surgery, there existed a tumor which was yellow in color and continued to the scrotum from inguinal canal ; no apparent hernia sac was seen ; and the tumor had few influx vessels. Thus we relatively easily dissect the tumor and removed it in the vicinity of the internal inguinal region. It was diagnosed as lipoma arisen from the inguinal canal. A wide range of posterior wall of the inguinal canal became fragile after the removal, so that a direct Kugek patch was placed to reinforce. The removed material was 17×12×5cm in dimension and 600g in weight. The histopathological diagnosis was benign lipoma.
There have been some differences between domestic and foreign reports on inguinal lipomas, and they have not been well defined as yet. Further studies of the definition of the disease including therapeutic significance would be necessary.

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A 21-year-old man who had suffered a bruise on the left breast and the right back was carried from another hospital to our hospital by ambulance, because he had traumatic blunt hepatic and renal injury diagnosed by CT. We found an increase of hematoma in several hours on CT, but his vital signs and laboratory data did not worsen and we chose a conservative therapy. On the third hospital day, he had an acute growth of subcapsular hematoma and suffered hepatic and renal failure. Findings by angiography using iodinated contrast material suggested arterioportal shunt (AP shunt). However, we could not detect active bleeding points and we chose conservative therapy again such as a blood transfusion and continuous hemodiafiltration (CHDF), not transcatheter arterial embolization (TAE). As a result, his condition recovered gradually. In patients suffering from subcapsular hematoma by traumatic hepatic injury, hepatic failure caused by an growth of hematoma or treatment of TAE is rare. However, we consider that perhaps in this case we could have prevented the increase of subcapsular hematoma by earlier angiography and interventional radiology (IVR) including carbon dioxide intraarterial digital subtraction angiography (CO₂-IADSA).

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