We started surgical site infection (SSI) surveillance from December 2003, and studied risk factors of SSI. A total of 1085 patients who had undergone surgery in our hospital were enrolled in the study. Operative emergency, wound contamination, preoperative condition (ASA score and nutrition), operation time, blood loss, and body mass index (BMI) were analyzed. The factors that caused significantly frequent SSI were emergency operation, wound contamination, high ASA scores, low nutrition, operation time, and blood loss. By multivariate studies, emergency operation, wound contamination, ASA score, and operation time influenced SSI significantly. We surveyed 16 patients who were treated for perforated appendicitis and studied the relation between antibiotic sensitivity for cultured bacterium and SSI. The cases of negative antibiotic sensitivity caused a significantly high rate of SSI. In our study, emergency operation, wound contamination, ASA score and operation time were found to be risk factors of SSI, and in contaminated operations, antibiotic sensitivity affected the incidence of SSI.

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A risk of causing cerebrovasucular disorders during hepatic arterial infusion chemotherapy is reported with our own experience. This retrospective research revealed seven cases of cerebrovascular disorders out of consecutive 105 patients undergoing hepatic arterial infusion chemotherapy after hepatectomy for metastatic liver cancer in our institution (6.7%). Disorders were left cerebellar infarction in four cases, left thalamic infarction in two cases, pontine infarction in two cases and transient right hemiparesis in two cases. All seven patients had been placed port-catheter system inserted via the left subclavian artery. These patients had symptoms such as dizziness, double vision, and numbness and cold sensation of the left fingers, other than paralysis. Six of the seven patients were in their fifties of sixties. The incidence of the disorder was significantly high in patients under 70 years of age, compared to the control group.
In conclusion catheter was inferred to cause the vertebrobasilar thromboembolism. Even though all patients recovered from the disorders without major disturbance, the incidence is high and those disorders are potentially hazardous. We must be cautious in determining the indication for hepatic arterial infushion chemotherapy.

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To elucidate the value of sentinel nodes (SN) navigation surgery by dye-guided method in early gastric cancer (EGC), we investigated the micrometastasis in lymph nodes (LN) dissected for EGC with immunohistochemical technique (IHC). Totally 257 SNs were obtained from 57 EGC patients who underwent conventional distal gastrectomy with SN identification by dye method. These LNs were analyzed with IHC using anticytokeratin antibodies (CAM5.2). LN metastases newly detected by IHC were defined as micrometastasis of a wide sense, which were classified into two categories : tumor cell microinvolvement (TCM) was one individual CAM5.2-positive cell ; and tumor cluster (TC) was clusters of two or more tumor cells. In mucosal cancer, TCM was detected in one patients, 2.9% (1/34). In SM cancer, TCM or TC were detected in 14 patients, 60.9% (14/23). SNs were deteced in 57 of 57 (100%) patients, the sensitivity of the SN as an indicator of lymph node micrometastasis was 60%, and overall diagnostic accuracuy was 89.5%. The sensitivity of the sentinel lymphatic basin (SB) as an indicator was as good as 86.7%, and the overall diagnostic accuracuy was 96.5%, which suggests the superiority of SB to SN as an indicator in SNNS for EGC. SB as an indicator will enable us to perform safer limited surgery.

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A total of 402 cases of so-called atheroma including 391 of epidermal cyst (EC) and 11 of trichilemmal cyst (TC) treated at the institution during the past 21 years and 5 months were enrolled in this study. No annual changes in new cases of atheroma were observed during the past 21 years, and about 85% of all EC patients were treated in the surgical, dermatological and orthopedic departments in the hospital, EC commonly occurred in middle aged male population, and the male-to-female ratio was approximately 2 to 1. In about 60% of the EC patients the disease affected the face, neck, and back. An averaged age (20.9±10.2 years old) of patients whose plantar regions were affected by EC was significantly younger than that (47.2±16.8) of those whose lesions were in anywhere except the plantar regions (p<0.0001). TC accounted for about 2.7% of all atheromas. Contrary to EC, there were significantly more female patients among TC patients (P=0.037), and TC commonly affected the head (P<0.0001).

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We report three cases of orbital metastasis from breast cancer. One of these three patients experienced orbital metastasis from breast cancer as the initial metastasis, and a removal of a tumor resulted in most serious outcomes in terms of the quality of life, including blindness and keratitis e lagophthalmos. The remaining two patients were capable of being diagnosed early, and immediate radiotherapy for their tumors provided dramatic symptomatic remission and long-term prevention of recurrence of symptoms.
Orbital metastasis has been considered to be one of multiple metastases which develops during follow-up period of the patient with breast cancer, and to have a poor prognosis. However, our analysis of a total of 27 domestic cases, including our case, has suggested that the orbital metastasis can occur in an early stage of breast cancer in many cases and that radiotherapy might be most useful for it. In recent years patients with metastatic or recurrent breast cancer can expect to live a long time with a recent progression in chemoendocrine therapy. Accordingly it is very important to diagnose and treat this disease early that may cause such a serious outcome as blindness which threatens the patient's QOL.

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The patient was a 36-year-old woman. When she gave birth, she developed systemic lupus erythematosus (SLE). Thereafter she had been treated, but she had bilateral lung abscess. The left lung lesion progressed to puneumothrax and then pyothorax. Staphylococcus aureus (MRSA) was detected by effusion culture. A chest drain was placed and washing by antibiotics was repeatedly conducted at another hospital, but she did not respond to the treatment. So she was referred to the hospital to undergo an operation. The chest drain was withdrawn on the 9th postoperative day.
We report an operated case of pyothorax with SLE.

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A 69-year-old man underwent right pneumonectomy for right lung cancer. Three months after the surgery, he had a right axillar tumor. We performed an extirpation of the tumor, and made a diagnosis of metastasis from the lung cancer. He survived for thirteen years. A 72-year-old man underwent right middle and lower lobectomy for lung cancer. Six months after the surgery, follow-up computed tomography revealed a metastatic lymph node in the mediastinum. We extirpated the mediastinal lymph node, and made a diagnosis of metastatic lymph node from lung cancer. Nine years after the extirpation of the lymph node, the patient is doing well with no signs of recurrence. There are few reports on long survival cases with skin metastasis or lymph node metastasis.

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A 74-year-old male underwent omento-plombage for empyema after left lower lobectomy due to lung cancer. Nine months after the omento-plombage, he developed diaphragmatic hernia, and an emergency laparotomy was performed. The postoperative course was uneventful. Seven months after laparotomy, diaphragmatic hernia recurred, and herniorrhaphy was performed. The omental pedicle flap penetrated through the central tendon. It was thought that the site of the diaphragm, which was cut so as to allow the omental flap to penetrate, became the hernia hiatus.

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We report a rare case of traumatic right diaphragmatic hernia with dislocation of the whole liver and right hemicolon. A 46-year-old man was found to have abnormal elevation of the right diaphragm at a medical check-up six months after a traffic accident. Chest CT scan revealed right intrathoracic hernia, and the asymptomatic patient was followed for 3 years until the intrathoracic hernia was found to have grown. Chest and abdominal CT scans revealed right intrathoracic hernia of which contents were the whole liver, gallbladder, right hemicolon and antrum of the stomach. A 15×10cm rupture was present on the back of the right diaphragm and the ruptured diaphragm was repaired by using mesh through a thoracoabdominal approach.

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A 67-year-old woman, who had undergone perforation of the gastric wall and diaphragma due to ESD for early gastric cancer and developed pneumothorax, was treated by endoscopic suture and thoracic drainage. Eighteen months later, she experienced upper left abdominal pain which worsened over time, Chest X-ray showed air bubbles in the left lower lung field. Chest CT showed that the stomach was incarcerated into the left thoracic cavity. Emergency laparotomy revealed that the stomach had herniated into the left thoracic cavity due to iatrogenic diaphragmatic injury. The diaphragmatic hernia was about 1.5 cm in diameter. After the prolapsed stomach was reintroduced into the abdominal cavity, the hernia orifice was directly closed. Her symptoms disappeared after surgery, and she has since been well with no signs of recurrence.

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An 85-year-old man was admitted to our hospital because of hematemesis. Chest X-ray film and gastrointestinal series provided a diagnosis of diaphragmatic relaxation associated with gastric volvulus. Endoscopic reduction was performed in vain, so an operation was undertaken. We reduced the stomach, made the plication of the diaphragm by transthoracic and transdiaphragma procedures, and thereafter did percutaneous endoscopic gastrostomy fixation. Though the patient was well advanced in years, he has made satisfactory progress. Here we report this case together with some discussion of the literature.

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Small bowel obstruction with bezoar stones in a gastrectomized patient is rare. We report an operated case of this disease successfully diagnosed preoperatively. A 76-year-old man, who had undergone a gastrectomy and Billroth II reconstruction for gastric cancer, was admitted to the hospital as an emergency case with a diagnosis of intestinal obstruction. He had eaten much persimmon fruit a month before the onset of these symptoms. After admission an intestinal fluorography using a long intestinal tube showed an oval shadow in the small intestine. Abdominal computed tomography showed the mass containing large quantities of air in the small intestine. Surgery was conducted based on a diagnosis of small bowel obstruction due to a bezoar stone impacted in the ileum about 60 cm from the ileocecal junction. A 8.4 × 4.6 × 4.4 cm black foreign body was removed through an enterotomy. An analysis of the bezoar stone revealed that 98% of it was composed of tannin acid, and diospyrobezoar was diagnosed, The postoperative course was uneventful, and the patient was discharged on postoperative day 20.

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A 63-year-old woman was admitted for resection of an 8-cm abdominal tumor touching the corpus of the stomach that had been detected by computed tomography. Gastroscopy revealed no remarkable findings, but endoscopic ultrasonography showed a submucosal tumor in an extragastric tract, at the greater curvature of the posterior gastric corpus. Laparotomy revealed the tumor to be located in the lesser peritoneal sac. As the tumor appeared to be connected with the posterior wall of the gastric corpus by a thin pedicle, 5 mm in diameter, it was resected together with a pedunculated lesion of the stomach during a partial gastrectomy. Hematoxylin-eosin staining of the histological specimen revealed round-like or spindle-shaped cells and very few mitotic figures per high power field. An immunohistochemical study showed that the tumor was positive for CD34, c-kit and smooth muscle actin but negative for S-100. Therefore, the tumor was diagnosed as a low-grade malignant gastrointestinal stromal tumor of the stomach.

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The patient, a 65-year-old man was found to have early gastric cancer of the antrum on endoscopy for examination of anemia in April 1999. The biopsy specimens were classified as Group V (tub1).
The patient did not wish to undergo surgery, and did not visit our hospital for about five years despite an early gastric cancer left untreated. In January 2004, he had a medical examination for common cold at our hospital, and it became clear that the patient had left the early gastric cancer untreated for about five years. He had been found to have early gastric Cancer (IIc) in 2004. Because the appearance of the lesion had changed, a subtotal gastrectomy was performed in April, 2004. The final diagnosis was an early gastric cancer (0-IIc, tub1), and the depth of invasion was pT1 (sm2). Cases of early gastric cancer are rarely followed for such a long time. We herein describe this type of early gastric cancer and review the literature in this regard.

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The case was an 81-year-old woman. She had sudden abdominal pain on January 31, 2006, and the pain continued for two days, whereupon she was brought by ambulance and admitted to our hospital. We recognized free air in an abdominal X-ray examination. Abdominal CT revealed a distended ascending colon and fluid collection around it. An emergency laparotomy was performed with a diagnosis of panperitonitis due to colonic perforation. The perforation site was the small intestine which was located 50cm on the oral side of the terminal ileum. There was a 25-cm-long wire-cord connected with the perforated serosa. We performed partial resection of the ileum. Operative findings showed a 2-mm perforated hole but no other mucosal abnormality macroscopically. Postoperative course was uneventful and she was discharged on February 14, 2006. This was a very interesting and rare case of ileal perforation caused by the wire cord tracted and bridging across the intestinal mesentery. We present the case with a review of the literature.

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A 63-year-old man was referred to our hospital complaining of abdominal pain and vomiting. His abdomen was distended, and there was diffuse tenderness. An abdominal radiograph revealed air-fluid levels in the small intestine. Computed tomography revealed a dilatation of the small intestine. Based on these findings, he was diagnosed with adhesive small bowel obstruction. Long-tube decompression of the intestine was performed, and five days later the tube was removed because the symptoms disappeared and bowel movements were noted. However, because abdominal pain and vomiting appeared again, laparotomy was performed. A small amount of ascites was present in the abdominal cavity. The narrowed ileum was about 5 cm in length and located about 120 cm from the ileocecal valve. The ileum proximal to it was remarkably dilated. A partial iliectomy was therefore performed. The resected specimen exhibited a ring scar. Histopathologically, there was a shallow ulcer (UL-II) in the intestinal mucosa. We diagnosed non-specific ulcer of the small intestine. The postoperative course was uneventful, and he was discharged from the hospital on the 19th day. He has been asymptomatic for 4 months after laparotomy.

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We report herein an adult case of gastrointestinal stromal tumor with intussusception of the jejunum. A 58-year-old man was admitted to our hospital with epigastralgia.
He was diagnosed as jejunal obstruction on abdominal imaging. Abdominal computed tomography demonstrated a mass of the jejunum. Surgery confirmed intussusception due to tumor of the jejunum, and a partial resection of the jejunum was carried out. Histopathological examination revealed gastrointestinal stromal tumor of the jejunum. Although the tumor cells invaded from mucosa to serosa, there was no evidence of mitosis. We did not add any chemotherapy after the surgery. No recurrence has been observed one year after the surgery.

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We present here a case of lymphangioma of the cecum with intussusception. A 30-year-old woman with epigastric pain was admitted to our hospital. Laboratory tests on admission revealed a slight increase in WBC count and CRP. However, there were no noteworthy abnormalities in her other blood data including tumor markers (CEA and CA19-9). Abdominal ultrasonography (US) and computed tomography (CT) showed a target sign in the right colon suggesting intussusception, which was reduced correctly during emergency colonoscopy. Colonoscopy showed a soft, dark brown submucosal tumor with a smooth surface at the cecum, located on the opposite side of Bauhin's valve. Ileocecal resection was performed under a diagnosis of submucosal tumor of the cecum a week later. The patient's postoperative course was uneventful. The mass measured about 3 cm in diameter. Macroscopically, its cut surface was cystic and it contained yellowish, serous fluid. Histopathologically, this tumor was diagnosed as cystic lymphangioma of the cecum. We reviewed 16 cases including our case of cecal lymphangioma with intussusception together with some discussion of the Japanese literature.

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A 63-year-old man was seen at our hospital because of abdominal pain. In addition to anemia, temporal low blood pressure was observed. Although no anal bleeding was seen, abdominal CT scan showed intraabdominal fluid collection, and it was confirmed to be blood by aspiration. Abdominal CT scan showed an aneurysm-like structure in the right upper abdominal cavity, but angiogram could not show any aneurysm nor bleeding point. Because the patient had no past medical history other than a blunt abdominal injury 5 years earlier, and his general condition was stable, we follwed up his clinical course. Two weeks later, angiography showed an aneurysm in the peripheral area of middle colic artery. As the catheter embolization had a risk of generating necrosis of the colon, a 3-cm sized hematoma containing the aneurysm and the right colon were resected under laparotomy. Microscopically, peripheral small artery in the hematoma had partial deficit of tunica media and internal elastic layer, replaced by fibro-cellular tissue. As no other vascular lesion was identified, the blunt trauma 5 years earlier was considered to be the cause of psudoaneurysm. There have been only four Japanese cases of traumatic pseudoaneurysm of the branches of superior mesenteric artery (including our case), but such a long interval between abdominal blunt trauma and rupture of pseudoaneurysm has not been reported except our case.

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Thrombosis of the superior mesenteric vein is a relatively uncommon entity which is sometimes silent and sometimes causes abrupt bowel necrosis. We report two cases of thrombosis of the superior mesenteric vein which was diagnosed by contrast enhanced abdominal CT scan and treated by surgical operation, with the resultant life-saving outcomes. Case 1 and 2 involved a 50-year-old woman and a 28-year-old man, respectively. Both two patients were seen at the hospital because of abdominal pain. Abdominal CT scan showed translucent images in the superior mesenteric and portal veins. Further intestinal edema and ascites were demonstrated, and thus thrombosis of the superior mesenteric vein with intestinal necrosis was diagnosed. The patients underwent lapaotomy. At surgery, the necrosed intestines were removed, and intestinal anastomosis was done through a two-step approach in the case 1 and a one-step approach in the case 2, respectively. After the operation sustained intravenous administration of heparin was conducted for them, and it was switched to oral anticoagulation therapy with walfarin after initiation of oral ingestion. No abnormal findings were recorded in examinations of blood coagulation and fiblinolytic agent, so that idiopathic thrombosis of the superior mesenteric vein was diagnosed in them. These patients did not show any impairment of hepatic function or increase in thrombosis, and their postoperative courses were uneventful. They are followed in the outpatient clinic in our hospital.

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We report two cases of sigmoidovesical fistula caused by diverticulitis of the colon. Case 1 : A 71-year-old man was admitted to the hospital because of fecaluria. We diagnosed a sigmoidovesical fistula caused by diverticulitis according to the preoperative examination and managed with total parenteral nutrition. On the 19th day after admission, partial resection of the sigmoid colon and the bladder was performed. A sigmoidovesical fistula was verified on the macroscopic finding. There was no major problem during the postoperative course, but on the 15 postoperative day, interstitial pneumonia exacerbated and on postoperative day 42 the patient died. Case 2 : A 66-year-old man was admitted to the hospital because of fecaluria. We diagnosed a sigmoidovesical fistula caused by diverticulitis, and partial resection of the sigmoid colon and the bladder was performed. According to the macroscopic examination and findings, the fistula was obstructed. The postoperative couse was uneventful and the patient was discharged. We discussed especially the indication of operation for sigmoidovesical fistula using these two cases.

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We report the case of a 19-year-old woman of familial adenomatous polyposis treated by one-stage restorative proctocolectomy with ileal J pouch anal anastomosis with the bikini line skin incision approach (BIAA) using laparoscopy. After a 10-cm curved transverse skin incision under the bikini-line, a flap was developed on the rectus sheath to the level of the umbilicus. Then longitudinal minilaparotomy was completed. RPC with IAA was completed with direct visualization of the operative field by a small retractor and gauze packing of the small intestine. Visualisation of hepatic and splenic flexure was difficult because they are located high up. We used a laparoscope inserted directly from the wound and got a better view which enabled us to perform the procedure more safely and easily. The duration of surgery was 262 minutes and blood loss was only 60 ml. Time to start oral intake was 2 days and postoperative hospitalization was 11 days. BIAA has cosmetic merit and is useful for young female patients. Laparoscopy is suggested to be useful in conducting BIAA more safely and easily especially when managing a difficult case in which hepatic or splenic flexure would be located high up.

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We report a case of rectosigmoid cancer associated with Japanese Schistosomiasis. A 69-year-old man visited our hospital following bloody stool. Colonoscopy showed a circled type 2 tumor of the rectosigmoid (RS). Laparoscopy assisted high anterior resection was performed. Pathological findings demonstrated tub1, SS, med, INFb, ly1, v2, N1, PM0, DM0, RM0. Furthermore, ova of Japanese Schistosomiasis were also seen in the resected colon tissue.
The patient had lived in Numazu, Shizuoka prefecture, an endemic area of Japanese Schistosomiasis. Prevalence in Japan ended over twenty years ago, therefore this case was considered to be an old lesion.

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We report a case of metachronous multiple cancer of the digestive tract with metastases to the multiple organs, several operations for which resulted in a long-term survival of the patient. The patient was a 32-year-old woman. She was operated on for cancer of the transverse colon in 1999. Thereafter a total of 4 operations with chemotherapy were performed for cancers of the small intestine and rectum, and metastases to the liver, bilateral ovaries, and uterus. At present when about 7 years have elapsed after the initial operation, the patient is under treatment while her quality of life has been kept favorable.

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Hepatic portal venous gas (HPVG) is a rare condition whose mortality rate is very high. We report a case of HPVG due to mesenteric panniculitis after exploratory laparotomy. The patient was an asymptomatic 76-year-old man, who was pointed out an elevated CA19-9 level (486.6U/ml) at a health checkup. A para-aortic mass (sized 8×3cm) was revealed by abdominal CT and MRI scan. The patient received exploratory laparotomy, because the origin of this tumor was unknown. As a result, pancreas cancer showing extrapancreatic growth with severe fibrosis was diagnosed. On the 7^th hospital day the patient suddenly developed abdominal pain, high fever over 39°C, and sepsis and went into endotoxin shock. Abdominal contrast enhanced CT scan showed intra-hepatic portal and mesenteric venous gas. The wall of the transverse colon and its mesentery were thick and edematous. Preoperative diagnosis was HPVG due to ischemic change of the transverse colon resulting from invasion of pancreas cancer to the mesenteric vein. We performed transverse colectomy and ascending colostomy 8 hours after the onset of the disease. The patient's general condition was improved following the emergency operation.
The histopathological diagnosis was panniculitis of the mesentery and omentum. This is the first case of HPVG due to mesenteric panniculitis in Japan. HPVG with sepsis is a gravely ill condition, but not always lethal. Early detection of HPVG by CT scan and prompt treatment can improve the mortality of HPVG.

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The patient was a 71-year-old woman who was diagnosed as having pancytopenia due to liver cirrhosis, hepatocellular carcinoma (S8), and splenomegaly. A hepatic segmentectomy (S8) and splenectomy were performed. The patient had a fever of around 39°C and diarrhea on the 8th hospital day. These symptoms resolved in response to symptomatic treatment. On the 30th hospital day, however, the patient had another fever and abdominal pain, and an abdominal CT scan revealed extensive thrombosis involving the splenic vein to the right and left branches of the portal vein. Thrombolytic therapy consisting of intravenous urokinase and heparin was initiated. Contraction of the thrombi in the portal vein was evident on the abdominal CT scan performed on the 37th hospital day. Therefore, the regimen was replaced with anticoagulant therapy with oral warfarin. As the abdominal CT scan performed on the 69th hospital day revealed that the portal vein thrombi had almost completely resolved, the patient was discharged. The CT scan performed after discharge, on Day 113 post-operation, also demonstrated that the portal vein thrombi had resolved almost completely, so warfarin was discontinued. About 14 months after the operation, the patient was recovering uneventfully and is now receiving treatment on an outpatient basis. Case reports of portal vein thrombosis after splenectomy and hepatectomy are rare and, to our knowledge, ours is only the third case reported in Japan.

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A-58-year-old woman was admitted to the hospital because of right lower abdominal pain in May, 2006. Abdominal ultrasonography, CT scan and DIC-CT scan revealed a unilocular cystic tumor 7 cm in size derived from liver (Segment 6). The tumor was constructed by thin wall and had no protruding lesion in the inner wall. We considered that the tumor was a liver cyst or hepatobiliary cystadenoma and performed a complete resection by laparoscopic surgery. The resected specimen had the thin wall, however, on histological examination, the wall consisted of cylindrical epithelium. Therefore, we finally diagnosed the cystic tumors as hepatobiliary cystadenoma ; they were benign cystic tumors having potential malignancy, so a complete resection was required. The indication of laparoscopic surgery for hepatobiliary cystadenoma must be circumspect, because laparoscopic surgery carried with it the possibility of rupture of the cystic wall. The current case, however, had good indication for laparoscopic resection, because the tumor was mainly located in the extrahepatic portion and the size was comparatively small.

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We report a case of a cystic tumor of the liver with cancerous change presumably arisen from a hepatic cyst of the caudate lobe that had been followed for about six years. A 76-year-old male who had been followed for a hepatic cyst elsewhere since 1996 was referred to our hospital in January 2003 because abdominal CT scan demonstrated a solid component within the hepatic cyst. Abdominal CT scan showed a solid component within a 4.5-cm cyst in the caudate lobe of the liver. Endoscopic retrograde cholangiography showed communication between the duct in the left hepatic lobe and the cystic lesion. Fine -needle aspiration of the cystic lesion was conducted under ultrasonography and the cytological diagnosis was class V. An extended left lobectomy with caudate lobectomy was performed under a diagnosis of cystic tumor with cancerous change arisen from a hepatic cyst. On gross examination of the resected specimen, a 2-cm solid projection was present in a 5.2-cm cystic lesion. Pathologically high columnar atypical epithelial cells proliferated in a papillary form in the cystic wall and the solid component was composed of well differentiated adenocarcimoma. The patient is alive bearing multiple liver metastases and para-aortic lymph node metastasis 3 years and 1 month after the surgery.
It is very important to detect every small change in hepatic cysts early by abdominal ultrasonography and CT scan, because the hepatic cystic have a potential to degenerate into cystic tumor with cancerous change.

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A 66-year-old man underwent pylorus-preserving pancreaticoduodenectomy (PPPD-III a) for common bile duct carcinoma after ENBD for reduction of jaundice. Six months later, multiple liver metastases were detected by abdominal CT scan. Hepatic arterial infusion chemotherapy (HAI) with 5FU 400 mg, MMC 16 mg, Epirubicin 48 mg bolus injection/20minutes was performed with minimal side effects. Liver metastases were regressed completely in CT scan and the level of CA19-9 was normalized after three times (at two-month intervals) of HAI.
He was admitted with pancytopenia (WBC3300/mm³, RBC2.26×10⁴, Hb7.6g/dl, 4.7×104/mm³) after 19 months complete regression of multiple liver metastases by HAI. On admission, no bleeding spot could be detected by gastroscopy or colonoscopy. Bone marrow aspiration revealed acute myeloid leukemia. Chromosomal anomalies were classified as Type I secondary leukemia, which is often induced by alkylating agents. Because he was old, hematopoietic stem cell transplant or other chemotherapy was not indicated. He died 10 months after onset of leukemia. Chromosomal anomalies induced by chemotherapeutic agents for gastrointestinal malignancies may cause second malignancies.

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A 76-year-old man with jaundice and a one-year history of self-reported epigastralgia was admitted to the hospital. Abdominal CT showed gallstones and dilation of the common hepatic duct and intrahepatic biliary tree. Gallstones were impacted in the neck of the gallbladder and compressed the right wall of the common hepatic duct. Endoscopic retrograde biliary drainage (ERBD) alleviated jaundice, but complicating cholangitis occurred, and ERBD was then replaced by endoscopic nasobiliary drainage (ENBD). In surgery, the gallbladder was opened and the stones impacted in the neck were extracted, confirming a diagnosis of Mirizzi syndrome with cholecystohepaticodochal fistula. Cholecystectomy was performed, and a common hepatic duct defect was covered with a part of the ligamentum teres hepatis, through which a common hepatic duct drainage tube was put in place. On postoperative day 50, the drainage tube was removed. There was no hepatic dysfunction, and the patient was discharged on postoperative day 69. In surgery of Mirizzi syndrome with biliary fistula, it is necessary to choose an appropriate method of biliary drainage based on the intraoperative findings.

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We report a case of an insulinoma of which localization was identified by selective arterial stimulation and venous sampling (ASVS) as well as pre- and intra-operative imaging diagnoses, with resultant surgical resection. The patient was a 67-year-old woman. She was brought into the hospital because of unconsciousness by ambulance, when the blood glucose concentration was low, 36mg/dl. Rapid intravenous injection of glucose yielded prompt improvement of unconsciousness. Dynamic CT scan, magnetic resonance imaging scan, and abdominal angiography showed a tumor 1.5cm in diameter at the uncus of the pancreas. ASVS disclosed a remarkable increase in blood immunoreactive insulin (IRI) in the superior mesenteric artery. We identified the tumor by intraoperative ultrasonography and palpation, and then enucleated the tumor. Further we measured peripheral blood sugar concentration, IRI, portal IRI before and after the enucleation, and confirmed that the tumor was completely removed. No symptoms such as hypoglycemic episodes were seen after the operation.
Since insulinomas are benign and are expected to have favorable prognosis by surgical resection in most cases, the treatment of choice for them is surgical resection while the pancreatic function is preserved as possible as we can. For that, correct diagnosis of the localization of the tumor and intraoperative confirmation of complete removal are important, and from this standpoint, further accumulation of clinical cases is expected.

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A 57-year-old man was hit by an automobile, and was transferred to our hospital. A chest X-ray revealed left hemothorax associated with multiple rib fracture. An abdominal CT disclosed a small laceration on the upper portion of the spleen. Non-operative management was done since his general condition was stable. Three days after admission, we confirmed a hemostat of the spleen by a CT. He was discharged on the 16^th day after admission. Twenty days after the discharge he was re-admitted with an acute abdominal pain. A CT scan revealed a rupture in the lower half of the spleen and enormous hemorrhage in his abdominal cavity. An emergency laparotomy and splenectomy were performed.
Recently splenic rupture due to blunt trauma is managed non-operatively if the condition permits. We should consider the possibility of delayed splenic rupture. The exact mechanism of delayed splenic rupture is not yet known, though intrasplenic hematoma might have perforated into the peritoneal cavity in our case. Since delayed splenic rupture is reported to occur within 2 weeks of the initial injury in most cases, patients should be observed very closely for 2 weeks after injury, and a scheduled examination might be recommended.

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A 22-year-old man was admitted to our hospital because of acute gastroenteritis. Abdominal ultrasonography incidentally detected a right adrenal mass. The laboratory data showed a slightly elevated serum noradrenaline level, and selective blood sampling from the right adrenal vein revealed very high catecholamine levels. Abdominal ultrasonography showed a well-defined 5.5×2.7 cm hypoechoic mass with smooth surface, regular margin, and homogeneous inner portion in the right adrenal gland. Abdominal CT scan demonstrated a 5×5×3 cm low-density mass in the right adrenal gland. A preoperative diagnosis of a tumor of the right adrenal gland was made, and laparoscopic adrenalectomy was performed. The resected tumor was a white solid mass on section, and the pathological diagnosis was ganglioneuroma. The patient was discharged from our hospital on the 7th postoperative day and his postoperative course has been uneventful.

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A 24-year-old female, who underwent a surgical resection for a ruptured ovarian teratoma 7 years ago, suffered from right back pain and consulted our hospital requesting further examination of liver tumors pointed out by abdominal CT. The level of all tumor markers examined was within normal limits. CT and MRI findings demonstrated cystic tumors with calcified wall and fat contents. Angiography showed only compressed finding. She was suggested as having disseminated tumors derived from an ovarian teratoma. On laparotomy, the tumors on the liver surface which compressed the liver, were excised. All of these tumors were diagnosed as mature teratomas histologically. This case is of interest in that disseminated tumors of an ovarian mature teratoma were composed of well-differentiated derivatives of three germ layers.

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A 69-year-old woman was admitted for abdominal pain and vomiting. Abdominal computed tomography showed significant dilation of the jejunum in omental bursa. Under diagnosis of hernia of the jejunum into omental bursa, conservative therapy was initiated. However, the herniation did not remit, so an operation was carried out. Laparotomy revealed an oval hernia hilus about 3 cm in diameter in the mesentery of the transverse colon. The small intestine was reverted by manipulation and had no necrosis, so the hernia hilus and sac were repaired by suture. It is thought that preoperative diagnosis of transmesocolic hernia is difficult, but we must consider the possibility of the disease when carrying out therapy.

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Castleman Disease is a rare disorder characterized by benign lymph node hyperplasia involving lymphatic tissue in the mediastinum, neck and retroperitoneal space. We report herein a case of mesenteric Castleman disease with cholelithiasis which was confirmed on pathology.
A 34-year-old woman was seen at the hospital because of epigastralgia. Computed tomography findings revealed gallstones and a mesenteric tumor.
Surgical treatment for gallstones and diagnosis of mesenteric tumor were carried out. The histological diagnosis of the mesenteric tumor was hyaline-vascular type Castleman disease. The prognosis for a localized form of Castleman Disease of hyaline-vascular type is good. Surgical excision is both diagnostic and therapeutic.

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Transomental hernia is rare, but known to be difficult to diagnose preoperatively. We report a rare case of transomental hernia, which suffered from recurrent ileus for several years. An 86-year-old woman had noticed an abdominal tumor several years before, and had suffered recurrent ileus conditions. This time, the woman was admitted for abdominal pain and vomiting, and a fist-sized tumor was palpated in the lower abdomen. An abdominal CT revealed a dilatation of the jejunum, but could not detect the pathogenesis. Under a diagnosis of ileus, we conducted conservative long tube therapy but to no effect, so Surgery was undertaken 7 days after admission. Laparotomy disclosed that about 30 cm of the jejunum was incarcerated through a defect of the greater omentum 3 cm in diameter. It seemed that this incarcerated intestine was the preoperative abdominal tumor itself. The defect of the greater omentum was opened, and the incarcerated jejunum was reverted. The impacted intestine was not necrotic, so it was not resected. The postoperative course was uneventful, and the preoperative abdominal tumor disappeared. The possibility of a transomental hernia should be kept in mind when treating ileus patients with surgery, because it often progresses to fatal necrosis of the intestine.

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An 86-year-old woman was admitted to the hospital because of vomiting and abdominal pain. She had been found having obturator hernia by abdominal CT scan while she had been hospitalized in another hospital for pneumonia. Examinations on admission disclosed no inflammatory findings, so that a long tube was placed and her clinical course was observed. However, no symptomatic remission was attained and she was indicated surgery. Upon laparotomy, the ileum (70cm up to the Bauhin's valve) was incarcerated into the left supravesical fossa with a type of Richter's hernia. We performed partial resection of the ileum and the fossa was closed with a few stitches.
Pelvic hernia in supravesical fossa is so rare that only 15 cases, including our case, have been reported in Japan. There have been no cases in which the correct diagnosis was made before surgery. The disease shows very similar symptoms and imaging findings to those of other hernia in the inguinal region, or it is often associated with them. Internal supravesical hernia is considered to be an important disorder for elderly people, though it is not so common for them. We present this case, because it is rare in that an elective surgery could be done for absence of necrosis despite the prolonged incarceration.

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A 44-year-old woman with right abdominal pain and fever was seen at our hospital. There were tenderness and muscular defense at that point, and computed tomography showed a mass about 6 cm in size between the gallbladder and transverse colon. As the symptom and anemia were slight, she was treated by conservative therapy for 10 days, and discharged. While the mass became smaller on computed tomography after a month, laparoscopic surgery was performed for the diagnosis and treatment with the patient's consent. Intraoperatively, a hematoma measuring 2 cm was observed in the greater omentum on the right side. Partial omentectomy with the hematoma was performed. Histologically, it was diagnosed as organized hematoma without infarction, neoplastic lesion, endometrial cell etc. Because of no history of abdominal injury, it was diagnosed an idiopathic omental hematoma.
Idiopathic omental hematoma has been reported in 12 cases in Japan including our case. When we diagnose a cryptogenic intraabodominal hematoma, an idiopathic omental hematoma should be taken into consideration.

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A 69-year-old man, visited a hospital because of abdominal distention and was pointed out having a giant abdominal tumor in August 2004, was referred to our hospital for further examination and treatment. Abdominal CT and MRI disclosed a giant tumor locating mainly in the vicinity of the omental bursa which had heterogeneous trabecular structure in the center and compressed the surrounding abdominal organs. We performed an operation to remove the tumor, which disclosed that the tumor extended from the subphrenic space to pelvic cavity and compressed the stomach, spleen and liver in the upper abdomen and did the transverse colon and transverse mesocolon in the lower abdomen. The tumor was firmly adhesive to the lesser curvature of the stomach where was thus considered to be the origin. The removed tumor was 10.2 kg in weight and showed a variety of appearances like fat, jelly, and necrosis. The histopathological diagnosis was well differentiated liposarcoma.
This paper deals with this case of a giant abdominal liposarcoma weighing over 10 kg, together with some bibliographical comments.

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A 35-year-old woman was referred for examination of upper abdominal pain. Abdominal ultrasonography showed a low echoic tumor in the retro-peritoneal space. On admission, no particular abnormal findings were noted on biological studies of blood. Contrast-enhanced CT and abdominal MRI showed an enhanced, round-shaped tumor in the space between right kidney and vena cava. Abdominal angiography revealed a highly enhanced tumor fed by the artery branched from the right renal artery. Although MIBG-scintigram showed no hot lesion, surgical resection was performed for suspected retroperitoneal malignancy or accessory non-functional adrenal tumor. The resected 60 × 40 × 30 mm tumor proved histopathologically to be hyaline-vascular type Castleman's disease. The patient's postoperative course was uneventful, and she was discharged from the hospital on the 20^th postoperative day. Since Castleman's disease arising from retroperitoneal space is relatively rare, this case is presented together with a review of the literature.

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We report a case of retroperitoneal liposarcoma with disappearance of a liver cyst.
A 71-year-old woman visited our hospital with abdominal fullness and vomiting.
Six years previously, she had been found to have a liver cyst, 12×9 cm in size. CT scan and MRI revealed a huge retroperitoneal tumor, and a liver cyst was not detected. The tumor was resected with the spleen, 6.4 kg in weight and 32×30×14 cm in size. During the operation, a liver cyst was not encountered. Upon pathological examination of the resected specimens, a mucinous, partially dedifferentiated type of liposarcoma was diagnosed.
In this case, it was thought that the liver cyst had disappeared because of necrosis or ischemic changes of secretory cells by increased pressure resulting from a large retroperitoneal tumor.

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The patient was a 53-year-old man who underwent laparotomy with a diagnosis of a retroperitoneal liposarcoma on June 12, 1998, followed by laparotomies for local recurrence elsewhere on October 15, 2001 and October 12, 2004. Abdominal CT scan performed on July 5, 2006 revealed a tumor shadow with air-fluid level formation in the lumen. Thus the patient was admitted to the hospital to receive surgery. When he was admitted, the body temperature was 38.5°C, the white blood cell count and CRP were high, 8730 and 8.5, respectively. The patient was diagnosed as having local recurrence of the retroperitoneal liposarcoma and abdominal abscess formation. He was considered to be a possible candidate for operation and was operated on August 8, 2006. The tumor was found to have penetrated the descending colon, so that a partial excision of the descending colon including the tumor was performed. Histopathological study showed that all tumors of the removed materials were well differentiated liposarcoma. The postoperative course was uneventful and he was discharged from the hospital.
We report this case of a retroperitoneal liposarcoma which invaded and penetrated the descending colon, together with some bibliographical comments.

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Retroperitoneal liposarcoma is a rare tumor, but it is the most common subtype of retroperitoneal tumor accounting for approximately 20% of all retroperitoneal sarcomas. Good prognosis can only be achieved through a complete resection at the initial operation, and its outcome is greatly determined by the histological subtype. We report a case of retroperitoneal liposarcoma that dedifferentiated in a long period of time. A 51-year old woman experienced a total of 9 operations in 16 years, and along the way, the histological subtype changed from a mix of myxoid and well-differentiated type to a dedifferentiated type. Dedifferentiated liposarcoma has a poor prognosis, and our case relapsed 3 months after the operation. Because the recurrent tumor caused ileus, we carried out the operation once again. Even though we tried sequential chemotherapy (high-dose ifosfamide) after the operation, the disease became uncontrollable, and the patient died six weeks after the last operation. As a conclusion, we find it important to pay strict attention to the histological subtype when treating a retroperitoneal liposarcoma.

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A 28-year-old man, who had not injured his left hand, was admitted to our department for pain and swelling in his left third finger for about a year. His left 3^rd finger was 3 mm shorter than the right one. A continuous murmur was heard on the left 3^rd finger with a Doppler stethoscope. Digital subtraction angiography (DSA) revealed abnormal shunt vessels that looked like a corkscrew, between the artery and vein of the 3^rd finger. We diagnosed this as congenital arteriovenous malformation (AVM) of the left 3^rd finger. We determined that surgical resection of the abnormal vessels under general anesthesia was the optimal therapeutic approach. After the operation, the pain and swelling of the finger reduced remarkably.
There are several methods for treating AVM in a finger. However, the choice of an appropriate method and its indication remain controversial.

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