Purpose : We studied and analyzed therapeutic outcomes of a radical surgery under local anesthesia for breast cancer in our department.
Methods & Subjects : Subjects were 53 patients with breast cancer whose diagnoses were definitely made before surgery. Indications were : localized DCIS diagnosed preoperatively ; invasive carcinoma less than 3cm in tumor diameter on ultrasound and magnetic resonance imaging scan ; and clinically tumors with negative axillary lymph nodes. Operative procedures included microdochectomy or lumpectomy associated with sentinel lymph node navigation biopsy (SLNB).
Results : We could perform the operation under local anesthesia in all the 53 patients, and were not demanded to shift from local to general anesthesia. Surgical stumps were positive in 10 patients (18.9 %). Of the ten patients, additional resection was performed in one, and irradiation was added to the remaining nine patients. SLNB was performed in a total of 39 patients, six (15.4 %) patients of them had metastasis and two out of the six patients underwent additional axillary lymph node dissection. None of serious complications were encountered. Local recurrence and hepatic metastasis occurred in each one patient in an averaged observation period of 15.1 months.
Conclusions : This day's radical operation under local anesthesia for breast cancer is a useful procedure as minimally invasive surgery as for the indications employed in this study.

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The differential diagnosis is important for treatment of a solitary pulmonary nodule. Differential diagnosis among primary lung cancer, lung metastasis and benign lung tumor is essential in patients with a history of previous malignancy. For differential diagnosis, it is important to clarify incidences of pathological characteristics of pulmonary solitary nodules. We evaluated the clinical and pathological characteristics of 56 cases (male : 38, female : 18, mean age : 65.3 years old) of solitary pulmonary nodules which were found before and after resections of previous malignancy, and were resected at our hospital from January 2000 to June 2003. The average observation period from the operation for the previous malignancy to the removal of a solitary pulmonary nodule was 33.5 months. The most frequent primary site of the previous malignancy was the large intestine (19 cases), followed by the stomach (18 cases), the breast (7 cases) and the others (12 cases). The pathological examination showed that 11 cases (19.6%) were of benign tumor and 45 cases (80.4%) were of malignancy, including 30 cases (53.6%) of primary lung cancer and 15 cases (26.8%) of pulmonary metastasis. A solitary pulmonary nodule developing in a patient with previous malignancy is most likely to be pulmonary metastasis. However, our results indicate that primary lung cancer occurs more often than pulmonary metastasis even in a patient with previous malignancy. Caution should be paid to that primary lung cancer can occur more than same as often as pulmonary metastasis even in a patient with previous malignancy.

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Three-field lymph node dissection surgery for esophageal cancer was developed in Japan in order to achieve a better survival. However, this surgery needs high skill, and the morbidity and mortality rate of this surgery are higher than with other gastrointestinal malignancies. The aim of this study was to determine the proper indication and actual limitation of this surgery. Lymph node dissection was effective when the number of metastasized lymph nodes was five or less. However, when the number was more than five, mean survival time and 5-year survival rate decreased sharply. The 5-year survival rate after 3-field lymph node dissection surgery for stage 2/3 esophageal cancer was almost 60%, which was superior to that of definitive chemoradiation therapy. The number of metastasized lymph nodes was still selected as the most powerful prognostic factor after 3-field lymph node dissection surgery, and we have to develop a new effective systemic treatment for advanced esophageal cancer with multiple lymph mode metastases in order to control lymph node metastases.

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Treatments of cancer include aggressive and palliative treatments. Management of cancer pain in the palliative therapy greatly affects the quality of life (QOL) of cancer patients. However, the pain control has not been done by experts in the cancer treatment or palliative care doctors, but by general surgeons in most cases. To elucidate problems which might arise from such a condition, we conducted a questionnaire survey. We sent a questionnaire asking 13 items to 89 general surgeons and recovered the filled questionnaire from 55 surgeons.
As a result, they tended to use oral analgesics when opioids were induced, and morphine sulfate or oxycodone hydrochloride was often used. There existed a difference between the ideal pain relieving ratio and the actual ratio. Their self-evaluations on their own pain control were not high.
As a problem in controlling cancer pain, they tended to manage cancer pain without following the WHO pain relieving ladder. We consider that to acquire the knowledge of usage of opioids as well as to use them actually is the first step toward improvement in pain control for cancer patients.

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In this study the usefulness of the postoperative pain control after abdominal surgery was comparatively studied in 31 patients received continuous subcutaneous infusion of buprenorphine (Bu-Sc group) and another 31 patients received continuous epidural infusion of morphine (Mo-Ep group). There was no significant difference in the analgesic effect, the time of obtundent use and the period without flatus between the Bu-Sc and Mo-Ep groups. The period of urethral catheterization in the Bu-Sc group was significantly shorter than that in the Mo-Ep group. PaCO2 examined on patient's return from the operating room in the Mo-Ep group was significantly higher than that in the Bu-Sc group. Side effects observed in the Bu-Sc group immediately improved by withdrawal of the drug. We made another compalison between Bu-Sc and Mo-Ep by surgical sites. In the upper abdominal surgery, the analgesic effect in the Mo-Ep group was significantly superior to that in the Bu-Sc group, and the period without flatus in the Mo-Ep group was significantly longer than the other. In the lower abdominal surgery, PaCO2 examined on patient's return from the operating room in the Mo-Ep group was significantly higher than that in the Bu-Sc group. In conclusion the continuous subcutaneous infusion of buprenorphine is a useful postoperative pain control method, which can be done safely and simply and offers minimal respiratory depression.

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(Case 1) A 47-year-old man, who had IIa+IIc type Barrett's cancer of the lower thoracic esophagus, underwent subtotal esophagectomy with 2-field lymph node dissection. He showed brain metastasis 16 months after operation. Although metastatic brain tumor was resected, he died 5 months later.
(Case 2) A 62-year-old man had an esophageal adenocarcinoma 8 cm in length in his lower esophagus. CT scan showed brain metastases of the light occipital lobe. He underwent gamma knife surgery followed by systemic chemotherapy. However, he died 18 months after first visit.
It is suggested that adenocarcinoma of the esophagus tends to cause brain metastasis, compared to squamous cell carcinoma, so it is important to keep brain metastasis in mind during treatment.

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A 19-year-old man referred for left anterior neck swelling with tenderness, fever, and appetite loss was suspected by neck CT scan and laboratory findings to have acute suppurative thyroiditis associated with piriform sinus fistula. This diagnosis was confirmed by contrast pharyngography, which showed a fistula from the left piriform sinus. Surgery was conducted after liquid dye was ingested and further injected through a catheter inserted into the fistula. During surgery, the fistula was found to pass through the left inferior pharyngeal constrictor muscle and end by the left thyroid lobe from the left piriform sinus. We dissected this fistula at the root and conducted left hemithyroidectomy. The postoperative course was uneventful and no recurrence has been found. CT findings helped to diagnosis acute suppurative thyroiditis associated with piriform sinus fistula in the differential diagnosis. Dye facilitated localization of the fistula and precise surgery. The fistula was thought to be derived from the fourth pharyngeal pouch because it was lined with squamous epithelium and no C cells in the thyroid near the fistula were found in immunostaining for calcitonin.

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We report a case of metastatic malignant lymphoma of the breast. The patient was a 72-year-old woman. She had visited another hospital because of a tumor of the left cheek, been diagnosed as having non-Hodgkin malignant lymphoma, and treated by chemotherapy and irradiation. The patient had gained a relief from the disease for 6 years and 8 months after the treatment, but she was found to have a right breast tumor by a periodic examination. She was referred to the hospital. A non-tender mass was present in the right breast. Mammographic findings showed an indistinct mass with irregular shape. Ultrasonographic image showed the indistinct hypoechoic mass with non-homogeneous internal echoes. Magnetic resonance imaging scan showed the indistinct mass with isointensity on T1WI and T2WI. As a result, breast cancer was suspected, and core needle biopsy was performed. A histological examination revealed malignant lymphoma (non-Hodgkin, follicular lymphoma). The patient received chemotherapy. Since breast metastasis of malignant lymphoma is rare, this case is reported with some bibliographical comments.

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A 47-year-old woman, who was diagnosed as having advanced breast carcinoma on April 2004, was treated with neoadjuvant chemotherapy. During neoadjuvant chemotherapy, metastasis to the femoral bone was detected. As the breast cancer was inoperable, she was treated with chemotherapy and radiation to the primary tumor and bone metastasis. On March 2005, she complained of constipation, and was admitted to the hospital with bowel obstruction at the end of April. Abdominal CT revealed a tumor at the transverse colon, so a laparotomy was performed. Multiple metastasized nodules were found at the surface of the transverse colon and omentum. With the diagnosis of metastasis of breast cancer, ileostomy was carried out. The postoperative course was uneventful and she was treated with chemotherapy as an outpatient. However, metastasis to the brain, multiple lymph nodes and subcutaneous tissue was found on January 2006. She died at the beginning of July 2006. Peritoneal dissemination occurs at the terminal stage of breast cancer and bowel obstruction rarely indicates surgical operation. Surgical operation may improve quality of life in such cases.

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Meningeal carcinomatosis from breast cancer is extremely rare. We report a case of a 67-year-old woman with paralysis of the lower extremities due to meningeal carinomatosis from breast cancer. MRI of the spinal cord showed meningeal thickening of the cervicothoracic cord. Cytology of cerebrospinal fluid suggested adenocarcinoma from breast cancer. We diagnosed this paralysis as spinal cord compression due to meningeal carcinomatosis from breast cancer. Radiation and intrathecal methotrexate therapy were performed. Posttreatment MRI showed remarkable reduction of the compressive spinal cord lesion. Atypical cells of the cerebrospinal fluid also disappeared, but paralysis of the lower extremities did not improve. We believe the prognosis of a patient with meningeal carcinomatosis is poor, but early diagnosis and therapy might improve the QOL of breast cancer patients.

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A 55-year-old man consulted a local clinic complaining of dysphagia, and was referred to our hospital under a diagnosis of submucosal tumor of the esophagus. A barium radiogram of the esophagus demonstrated a giant tumor measuring 20 cm pedunculated from the cervical esophagus and reaching the lower thoracic esophagus. Endoscopy revealed the surface of the tumor to be covered with normal esophageal epithelium and positive cushion sign. Thoracic CT demonstrated that a large mass occupied a dilated esophageal lumen and was heterogeneously composed of enhancing part and non-enhancing fatty part. A giant submucosal tumor developing from the cervical esophagus was diagnosed, and operation was performed. The entire tumor was removed safely through cervical esophagotomy under direct visualization. The macroscopic view of the resected specimen revealed an elastic soft tumor measuring 20×6 cm covered with normal esophageal mucosa. Pathologically, it was diagnosed as a benign fibrovascular polyp composed of various amounts of adipose tissue, fibrous tissue and vascular structures. The patient has been in good health without any evidence of recurrence 2 years after operation.

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We report a case of CA19-9-producing gastric cancer. A 68-year-old man was admitted to the hospital because of abnormality of the stomach by screening. Gastric endoscopy visualized a type 2 lesion on the antrum following the biopsy result of “poorly differentiated adenocarcinoma.” In the preoperative state, the serum level of CA19-9 was 16000 IU/ml (normal<37). Total gastrectomy was performed. Histologically, the lesion revealed poorly-differentiated adenocarcinoma (T2 N1 H0 M0). From the immunohistochemistry, cancer cells were positively-stained for CA19-9. The serum CA19-9 level deceased within the normal range on the postoperative third month. The patient remains alive 12 months after surgery.

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We report three cases of early gastric cancer developing from the remnant stomach 4 years, 5 years and 9 years, respectively, after proximal gastrectomy for gastric cancer in the upper third of the stomach. Careful endoscopic surveillance allowed early diagnosis of these remnant cancers, and endoscopic submucosal dissection (ESD) with an insulation-tipped electrosurgical (IT) knife was the optimal therapeutic modality for two of the three cases of early gastric remnant cancer. All three had undergone esophagogastrostomy as the initial reconstruction after proximal gastrectomy, which made it easier to insert the endoscope into the remnant stomach to observe it clearly. We also reviewed the data of 42 cases of gastric remnant cancer after proximal gastrectomy for gastric cancer reported previously in Japan. Based on our three cases as well as the clinicopathological characteristics of the previously reported cases, we emphasize the necessity of long-term follow-up by endoscopy after proximal gastrectomy, and of an ideal reconstructive procedure. Careful surveillance of carcinoma of the remnant stomach is warranted after proximal gastrectomy for gastric cancer.

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We report a case of duodenal stenosis due to delayed onset mesenteric hematoma. A 71-year-old male was admitted to our hospital because of frequent vomiting and abdominal fullness 14 days after minor blunt abdominal trauma by a traffic accident. Upper GI examination showed severe stenosis of the fourth portion of the duodenum. An abdominal enhanced CT showed a large cystic lesion in the jejunal mesenterium, and removal of hematoma and gastrojejunostomy were performed because conservative therapy was not effective. The postoperative course was uneventful.

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A 57-year-old man was admitted to the hospital because of abdominal pain and fullness developed after he had eaten sliced mackerel soaked in vinegar and grifola frondosa, a kind of mushroom ‘maitake’, a few days before admission. An emergency operation was performed with a diagnosis of acute abdomen with ileus. Serosal inflammation with petechial hemorrhage of the ileum 100cm to the end of ileum and moderate ascites were found. Because some elastic soft masses were felt in the stenosed ileum, partial resection of the ileum was performed. Grossly, the ileal stricture and a larva of the family Anisakidae which penetrated into the mucosa were confirmed and grifola frondosa were incarcerated in the ileum. Thus the diagnosis of dietetic ileus with anisakiasis of the small intestine was made.

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We report a case of laparoscopic operation for small bowel obstruction caused by anisakiasis. A 56-year-old man was admitted to our hospital for severe abdominal pain and fullness after eating raw fish. Blood examination showed leukocytosis (13200/μl) and elevated C reactive protein level (10.5 mg/dl). Abdominal CT showed fluid collection in the abdominal cavity and dilatation and partial thickening of the small intestine. Suspecting small bowel anisakiasis, we performed an emergency operation, because we could not deny the possibility of strangulation of the intestine. From a laparoscopic view of the abdominal cavity, clouded ascites and dilatation of small intestine were seen about 60 cm from the Treitz ligament. Partial thickening of the small intestine with redness was observed at the anal end of the dilated small intestine. Neither perforation nor necrosis of the intestine was seen. We performed lavage and drainage of the abdominal cavity. His postoperative course was uneventful, and one month after the operation, we made a diagnosis of small bowel anisakiasis with an immunodiagnosis by ELISA.

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We report a patient without a history of abdominal surgery who demonstrated small bowel obstruction caused by a band of lesser omentum. A 31-year-old man presented to our hospital with sudden abdominal pain. Abdominal X-ray and computed tomography of the abdomen showed dilated loops of small bowel with air-fluid level. Therefore, he was admitted to our hospital with a diagnosis of small bowel obstruction. Because symptoms were not improved by conservative treatment, emergency surgery was performed the next day. At laparotomy, we found that the proximal small bowel had become ischemic due to strangulation by a band between the liver and the lesser curve of the stomach. When the band was divided, blood flow of the bowel recovered and we decided not to resect the bowel. The band consisted of lesser omentum and showed mild inflammation on histological examination. Strangulated small bowel obstruction caused by a lesser omental band is very rare and, to our knowledge, this might be the first case reported in Japan.

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A 80-year-old woman with a history of intracoronary stenting due to cardiac angina presented with epigastralgia and nausea on February 8, 2006 and went to a nearby hospital. Because examinations revealed her symptoms were not derived from cardiovascular diseases, she was admitted to our hospital for conservative medical treatment. On admission, she had tenderness in the entire abdomen but not muscular defense. Abdominal CT scan showed distension of small intestine and she was diagnosed with ileus. A long tube was inserted to initiate conservative treatment but was not effective. We diagnosed the case as strangulation ileus in light of her exacerbated symptoms, and conducted an emergency laparotomy. Upon laparotomy we saw large volumes of bloody ascites and the jejunal necrosis strangulated by the great omentum. We partially resected the great omentum and the necrotic jejunum. The patient recovered uneventfully after the surgery. Strangulation ileus is difficult to diagnose, and we considered early surgery to be desired.

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A 51-year-old woman presented at our hospital with abdominal pain and vomiting. We diagnosed ileus with abdominal Xp. Radiological enteroclysis and CT revealed stenosis of part of the ileum, but there was no tumor around the lesion. As symptoms did not improve with conservative therapy, we performed laparotomy. In operative findings, 3 cm jejunal segment was stenosed, but the cause was not a tumor. The resected specimen showed almost normal mucosa. Pathology revealed a decrease in neurocytes in the stenosed portion, and we diagnosed this case as focal hypoganglionosis of the small intestine.

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Protein-losing gastroenteropathy is a disorder in which plasma albumin is excessively lost from the intestinal wall to the lumen that can cause hypoalbuminemia. We often have difficulties in nutritional management for such patients. We report a case of ischemic necrosis of the small intestine with protein-losing gastroenteropathy together with a review of the literature.
A 72-year-old man who had been treated for atrial fibrillation and cerebral infarction had abdominal pain and vomiting. Conservative treatment improved these symptoms, but he developed severe diarrhea and bloody bowel discharge after initiation of meals. A abdominal scintigram using ^99mTc-labeled human albumin revealed abnormal radioactivity in the left lower abdominal region, suggesting albumin losing from the small intestine including the ileocecum. Protein-losing gastroenteropathy due to ischemic necrosis of the small intestine was diagnosed. Partial resection of the small intestine including the ileocecum was conducted. Severe diarrhea and bloody bowel discharge for which we had difficulties in preoperative management decreased in the frequency and amount after the operation, and hypoalbumiemia improved as well.
There have been no cases of ischemic necrosis of the small intestine with protein-losing gastroenteropathy in the literature. This case is considered to be very interesting in terms of its origin and therapeutic methods.

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A 37-year-old woman was admitted to the hospital because of intermittent abdominal pain. There were tenderness and muscular defense in the right lower abdomen. Ultrasonography and computed tomography showed thickening of the terminal ileum wall and dilatated small intestine. The symptoms did not improve and considering possibly malignancy, an operation was performed. A hard tumor was palpable at the terminal ileum with stenosis. There was no apparent abnormality in the uterus and ovary. Under the diagnosis of stenosis of terminal ileum, ileocecal resection was performed. On the resected material, focal edema on the mucosa and stenosis of the terminal ileum were noted. The serosa and muscle layer were hard like a scar. Microscopical examination revealed endometrial glands surrounded by stroma in the subserosal layer of the ileum, and the histological diagnosis was endometriosis of the ileum.

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A 60-year-old woman was admitted with the chief complaints of abdominal distention, vomiting and loss of appetite. From physical examination and CT findings, superior mesenteric artery syndrome was diagnosed. Following conservative treatment, symptomatic improvement was seen, and she was discharged. However, 7 days later, she was re-admitted due to recurrence of abdominal distention, vomiting and loss of appetite. Abdominal CT revealed a dilated bowel between the body of the stomach and the horizontal portion of the duodenum, and a mass lesion was suspected in coronal section at the distal end, i.e., in the jejunum. This lesion appeared as a high-intensity area in both high and low b-value diffusion weighted images (DWI). A primary small intestinal malignant tumor was diagnosed at the stage. Partial resection of small bowel was performed and a diagnosis of primary small intestinal carcinoma was obtained from the histopathology. We present this report because DWI was useful for a diagnosis of primary small intestinal carcinoma.

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Carcinoma of the small intestine is a rare entity, especially mucinous type. This is a case report of mucinous carcinoma of the small intestine.
A 90-year-old woman was admitted to our hospital because of abdominal pain and abdominal distension. An abdominal X-P showed dilatation of the small intestine and niveau formation. An ileus tube was inserted. It revealed stenosis of the ileum about 5cm proximal to the ileum end. Stenosis caused by adehesion after appendectomy was the most likely diagnosis. After trans endoscopical dilatation, her symptoms disappeared. One month later, the same symptoms developed and chest CT scan showed multiple lung metastasis. Operation was performed with a diagnosis of malignant tumor of the ileum. Ileo-cecal dissection was done, when a tumor was found in the ileum 5cm proximal to the Bauhin valve. Histological findings of the resected tumor were consistent with villous adenocarcinoma at the muscle layer and carcinoma cells in large mucous lakes infiltrated to the subserosal layer and lymphatic metastasis were shown.

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A 76-year-old woman was admitted to our hospital complaining of bloody stool. CT scan of the abdomen showed a mass connecting with the cecum. Magnetic resonance imaging scan showed the mass with low intensity in T1 and T2-weighted images. Colonoscopy demonstrated an ulcer around the appendiceal opening, so we clipped there. Angiography and 99mTc-HSA scintigraphy disclosed that there was no bleeding. The postclipping course was uneventful, and she was discharged from the hospital.
She was re-admitted to our hospital complaining of bloody stool 2 months later. Colonoscopy demonstrated that there was no bleeding and we performed a biopsy from an ulcer around the appendiceal opening. The biopsy suggested no evidence of malignancy. CT scan of the abdomen showed a mass connecting with clip. We diagnosed it as an appendiceal tumor and performed ileocecal resection.
On microscopic examination, inflammatory infiltrate was present in the appendiceal lumen, and the mass around the appendiceal opening was an inflammatory tumor. The findings were compatible with the diagnosis of appendicitis.

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A 61-year-old man was seen at our hospital because of right lower abdominal pain that had persisted for 1 week or longer. Ultrasonographic examination and abdominal CT scan demonstrated a swollen sppendix and a solid mass that included a liquid component was continuous with the appendix. Based on these findings, we diagnosed appendicitis with abscess formation and performed an appendectomy. Laparotomy showed a swollen appendix with a thickened wall, a periappendicular abscess, and retroperitoneum with remarkable inflammatory thickening and sclerosing, to which the appendix adhered. Although a second-generation cephem antibiotic was administered postoperatively by drip infusion, signs of infection such as fever and pus discharge from the abscess persisted. Because histopathological examination demonstrated abdominal actinomycosis, penicillin antibiotics were administered intramuscularly. Thereafter, symptoms soon improved and the fistula closed in 3 weeks. Penicillin antibiotics were administered orally for 3 months postoperatively, and there has not been any recurrence for 1 year and 8 months.
It is important to suspect actinomycosis and select adequate antibiotics when a case of appendicitis is accompanied by mass formation and shows signs of protracted infection such as pus discharge postoperatively.

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A 31-year-old woman was admitted to our hospital because of fever, diarrhea and right lateral back pain. The white blood cell count was 15800/mm³ and the C-reactive protein level was 15.04mg/dl. Abdominal CT scan revealed high density suggestive of enterolith in the right lower abdomen and a retroperitoneal broad abscess from the level of the right kidney to pelvis along the right iliopsoas muscle. Retroperitoneal abscess probably arising from penetrated appendicitis was diagnosed. We performed retroperitoneal drainage by extrapentoneal route on the same day. Twenty-eight days after the drainage when the abscess shrank and inflammation subsided, laparotomy was done. An ileo-cecal resection was performed because we could not identify the appendix. Sixteen days after the latest surgery, the patient was discharged from our hospital. We report a case of a retroperitoneal abscess originating from penetrated appendicitis which was treated first by drainage only, and then by laparotomy.

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We experienced a case of appendiceal endometriosis. A 37-year-old woman underwent surgery for acute appendicitis. After appendectomy, pathohistologic examination of the resected specimen revealed endometriosis in the body of appendix. Appendiceal endometriosis has been reported in only 30 rare cases in Japan.

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The patient was a 58-year-old man with an 8-month history of right lower abdominal pain. He was referred to the hospital with a suspicion of a peritoneal abscess due to chronic appendicitis. Preoperative examinations showed a rise of CA 19-9 level, so that colonoscopy was added. We identified hypertrophy of the opening of the appendix and exudation of mucus from it. Following a biopsy from the lumen of appendix, cancer of the appendix in stage III a was diagnosed. Ileocecal resection was thus performed.
Primary cancer of the appendix presents difficulty in preoperative diagnosis. We report this case with some bibliographical comments.

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A 46-year-old man admitted for acute abdomen was diagnosed with a perforative peritonitis and underwent emergency surgery. Intraoperative findings showed a perforation in the sigmoid colon, colovesical fistula and colorectal fistula. Resection of sigmoid colon, part of the bladder and rectum were performed along with colostomy.

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We report a case of inflammatory fibroid polyp (IFP) of the transverse colon. A woman in her late 40s had a check-up at our hospital for melena. Colonoscopic examination revealed a polyp of Isp type in the transverse colon. Barium enema study demonstrated a 3-cm tumor in the transverse colon. Preoperative diagnosis was colon cancer invading to the submucosal layer. We performed a left hemicolectomy by laparoscopically assisted surgery. A diagnosis of inflammatory fibroid polyp was made based on the histological features consisting of proliferating fibrous connective tissue and small blood vessels, with inflammatory cell infiltration.
IFP of the colon is rare. The 21 cases reported in Japan, including our case, are reviewed.

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This paper deals with a case of cancer of the ascending colon with tumor embolism of the superior mesenteric vein (SMV).
A 78-year-old woman was seen at the hospital because of a right lateral abdominal tumor. Colonoscopy showed cancer of the ascending colon, and abdominal CT scan disclosed tumor cell embolism of the SMV. The patient underwent an operation on June 18, 2003. Operative findings included that the tumor had partly invaded the descending portion of duodenum and involved the right ovarian artery and vein and that the swollen regional lymph nodes were suggestive of metastasis. The tumor embolism of the SMV extended up to the confluence with the splenic vein. Thus the SMV was incised, the tumor emboli which were movable were removed, and the vein which was peripheral since there was excised. At the same time, extended right hemicolectomy with the resection of the small intestine was performed, with which the residual small intestine came to about 1m in length. The patient's postoperative course was mostly uneventful. Oral ingestion was started on the 7^th hospital day. Four courses of postoperative chemotherapy with LV-5FU were conducted, when the patient did not want further chemotherapy and was discharged from the hospital. About 4 months later the patient developed multiple hepatic metastases and died on the 5^th month after the operation.

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We present here two cases of laparoscopic resection for advanced cancer of the right-sided colon with duodenal invasion. After the right colon and its mesentery other than the invasion site were mobilized laparoscopically via medial, lateral and superior approach, a mini-laparotomy was made and the duodenal invasion site was directly identified and resected easily. Postoperative courses were uneventful and systemic chemotherapy was performed with a regimen of mFOLFOX6 and FOLFIRI, respectively. Patients were well tolerated to these regimens.
Indication of laparoscopy-assisted surgery for advanced colorectal cancer involving other organs is debatable. On the other hand, the value of multidisciplinary approach for advanced colorectal cancer has increasingly heightened with a recent introduction of potent systemic chemotherapy with FOLFOX of FOLFIRI. Laparoscopic approach may be beneficial even for the treatment of advanced colorectal cancer because it provides early recovery from the operation with resultant early start of chemotherapy and less impairment of physical activities.

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A 59-year-old woman underwent the resection of the transverse colon for cancer of the transverse colon toward the end of April, 2006. Thereafter she had been followed in our outpatient clinic until June of the year, when she was emergently seen at the hospital because of dyspnea and headache. She had severe anemia and thrombocytopenia, and was emergently admitted to the hospital. She rapidly developed disseminated intravascular coagulation syndrome (DIC) and was suspected to have carcinomatosis of bone marrow. Carcinomatosis of bone marrow was thus diagnosed. After obtained informed consent from the patient, we started anti-DIC therapy and chemotherapy with MTX/5-FU immediately. Several days after the initiation of the treatment, improvements in blood data and subjective symptoms became apparent. The patient was discharged from the hospital on the 36^th hospital day because her general condition was stable. Adverse side effect of the chemotherapy was only mild decrease in white blood cell count.
The disease is a rare entity and is often in poor general condition when it is diagnosed, but it is important to try to make the diagnosis as early as possible and to employ aggressive therapy immediately.

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We report a case of adenosquamous carcinoma of the rectum and briefly discuss clinical and histopathological features of the disease.
A 57-year-old man was admitted to our hospital because of abdominal pain and constipation. Abdominal computed tomography showed a tumor of the sigmoid colon. Colonoscopy demonstrated a type 2 tumor of the rectum, and a biopsy specimen showed well differentiated adenocarcinoma. We performed a Hartmann's operation with D2 lymphadenectomy because a rapid growth of the tumor might cause intestinal perforation. The resected tumor was histopathologically diagnosed as adenosquamous carcinoma, consisting of adenocarcinoma and aquamous cell carcinoma. Most malitnant tumors of the large intestine are adenocarcinoma, and adenosquamous carcinoma rarely affects the colon and rectum except the anal canal and lower portion of rectum. Colorectal adenosquamous carcinomas often have a poor prognosis because they have already progressed, formed a large mass, and involved lymph nodes in a high frequency when they are diagnosed. Therefore, Adenosquamous carcinoma of the colon may require better treatments to improve the prognosis and strict follow-up.

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A 72-year-old man had been suffering from an anal fistula and hemorrhoids since his youth. In 2003, he noticed pus discharge from the perianal region. But he experienced no pain and left it alone for two years. Since it grew painful, however, he visited a clinic in March 2005. He was diagnosed as having an anal fistula, and was admitted to our hospital for operation. Physical findings showed a second opening at three o'clock with mucinous substance. And type-2 tumor was present at 5 o'clock of the anus. Biopsy specimens from the fistula and tumor showed adenocarcinoma (mucinous carcinoma), so we performed an abdominoperineal resection.
Early discovery of a cancer of the anal fistula is very difficult, and very often it is uncovered in the advanced stage, and even that is difficult. When a patient with an anal fistula experiences worsening of his symptoms, further studies are needed to confirm the diagnosis.

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We present 2 cases of hepatic inflammatory pseudotumor (IPT), which were resolved with conservative treatment. Case 1 : A 77-year-old man admitted to our hospital due to high fever and vomiting. Abdominal ultrasonography (US) revealed an 8.5-cm solid lesion with polycystic area inside at the left lobe of the liver. MRI and CT, carried out 2 weeks after the admission, revealed that the size of the tumor had reduced to 5 cm and the hepatic artery was penetrating inside the tumor. Five months later, CT disclosed that the tumor had disappeared. Case 2 : A 75-year-old man was referred to our department because of an irregular low-density area detected by CT, which had been carried out 3 weeks earlier. Ultrasound did not disclose any tumors at his first appearance to us. MRI, which was carried out 4 weeks after the first CT, also disclosed nothing. CT was carried out 2 and 4 months later, which disclosed that the tumor had been resolved. It is usually difficult to make a definite diagnosis of hepatic IPT because of its diversity in imaging diagnosis. It seemed to be useful in the diagnosis of hepatic IPT to repeat image diagnosis with some interval and to identify the morphological change.

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We present a case of seeding recurrence of needle-tract on the thoracic wall after percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC). The patient was a 72-year-old man who underwent RFA, using a cool-tip type electrode for the HCC in liver segment 6 in January 2003 and June 2004. In October 2004, a metastatic lesion was detected in the liver segment 3, and partial resection of the liver was done in March 2005. However, after the operation, the serum alpha-fetoprotein level continuously increased. Abdominal computed tomography (CT) showed a tumor, 3 cm in diameter, at the intercostal site which was the punctured site of RFA. In May 2005, we performed a resection of the thoracic tumor. Pathologic examination revealed well-differentiated hepatocellular carcinoma, and we diagnosed it as needle-tract seeding recurrence on the thoracic wall after RFA. Further study and surveillance are necessary for needle-tract seeding after percutaneous RFA.

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A case of recurrent common bile duct stones containing a metallic clip a nidus following laparoscopic cholecystectomy and common bile duct exploration in a 71-year-old woman is reported. She had received cholecystectomy and choledocholithotomy with a diagnosis of cholelithiasis 1 year and 6 months earlier. She visited our hospital because of epigastric pain and nausea. Abdominal ultrasound showed common bile duct stones. Endoscopic retrograde cholangiography demonstrated five stones in the extrahepatic duct and one of them contained a central metallic clip, which had been used to fix the drainage catherter through the cystic duct to the common bile duct on the previous operation. Endoscopic papillotomy with lithectomy using a lithotric basket clamp was performed and the clip and stones were removed.
Although the formation of gallstones around surgical clips is a rare complication, it must be kept in mind as a probable one following laparoscopic procedure. Metallic clips should not be used for biliary surgery to prevent the formation of clip stones, if possible.

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An 77-year-old man who had undergone a pancreatoduodenectomy 17 years previously was admitted to our hospital because of fever and abdominal pain. An abdominal CT scan revealed dilatation of the intrahepatic bile duct. Percutaneous transhepatic cholangiography revealed a biliary stricture and a filling defect. Percutaneous transhepatic cholangioscopy demonstrated a brown fragile stone, which was pushed into the jejunum after disintegration. A silicone tube was then placed through the hepaticojejunostomy and left in place to dilate the stricture for 3 months. The patient has been doing well for 3 years after the treatment. Biliary stricture after pancreaticoduodenectomy occurs within 5 years in most cases, but there are some cases in which the stricture occurred after more than 10 years had elapsed. Percutaneous transhepatic cholangioscopy is considered useful for the diagnosis and treatment of this uncemmon condition after pancreaticoduodenectomy.

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We performed right hepatectomy for intrahepatic cholangiocarcinoma involving vena cava using Belghiti's liver hanging maneuver. A 76-year-old woman had undergone an operation for lung carcinoma. During follow-up by a chest CT scan, a 4-cm cholangiocarcinoma involving vena cava was found in the right lateral sector. Dissection between liver and vena cava was possible and nasogastric tube was inserted into this space. The liver was then transected on the Cantlie line using the hanging maneuver and then the involved vena cava was finally resected. The liver hanging maneuver is a useful technique for anterior resection of the liver in patients with liver tumor involving surrounding organs.

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A 53-year-old man was admitted to our hospital with complaints of thirst and body weight loss. Laboratory tests revealed impaired glucose tolerance (HbA1C 12.2%) and elevation of tumor markers (CEA 4.9 ng/ml, CA19-9 325 U/ml). Abdominal computed tomography (CT) detected a mass in the pancreas head, although endoscopic retrograde cholangiopancreatography (ERCP) revealed a short smooth stenosis of the main pancreatic duct, and the cytology of pancreatic juice was negative. ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) was performed. Pancreatic cancer was highly suspected because of focal FDG uptake in the pancreatic tumor (standardized uptake value ; SUV=3.62). Pancreaticoduodenectomy was performed, and operative findings revealed diffuse pancreatic sclerosis and ill-defined tumor. Pathological findings showed acute and chronic pancreatitis. No malignant findings were revealed.
FDG-PET is useful for differentiating between malignant and benign lesions of the pancreas, although both false-positive and false-negative results can occur in the diagnosis. Further accumulation of clinical data should be required.

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The patient was a 50-year-old man, who had stayed inside his home without going out for about 25 years, had drunk alcohol heavily, and had noticed to have frequent bouts of abdominal pain. In May 2005, his upper abdominal pain suddenly became serious and he was emergently admitted to the hospital. On admission he had a high fever, 38.1°C, and there were tenderness and muscular guarding mainly in the upper abdomen. Abdominal CT scan revealed an about 60-mm sized pancreatic cyst which had formed a mass with the pancreas tail and transverse colon and had an inner portion suggestive of hemorrhage. Thus peritonitis due to a ruptured pancreatic cyst was diagnosed, and excision of the pancreatic body and tail with associated splenectomy and extended right hemicolectomy was performed on the same day.
At present when techniques of non-surgical intervention have developed, pancreatic pesudocysts which do not disappear spontaneously are treated by non-operative treatments such as percutaneous drainage under US/CT guidance, and rarely demand emergency operation like our case. However, in the case in which abrupt and severe peritonitis develops due to intracystic bleeding or rupture of the cyst, we have to decide therapeutic guideline including surgical therapy as prompt as possible.

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We report a case of pancreatic metastases from renal cell carcinoma 19 years after nephrectomy. A 74-year-old man underwent a right nephrectomy in 1986. Nineteen years later, he was admitted to our hospital with a pancreatic tumor. Abdominal CT and angiography demonstrated multiple hypervascular tumors at the pancreatic body and tail. Magnetic resonance cholangiopancreatography showed abrupt occlusion of the main pancreatic duct. Pancreatic metastasis from renal cell carcinoma was suspected, and a distal pancreatectomy and splenectomy were performed in 2005. Histological examination confirmed it to be clear cell type renal cell carcinoma that had metastasized to the pancreas. The patient is doing well 11 months after the second operation. We think that resection of the pancreas for metastatic lesions from renal cell carcinoma could improve the prognosis.

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We report a case of isolated splenic metastasis of gastric cancer, 6 years after excision in a 74-year-old woman. A total gastric resection was performed in October 1999 due to progressive gastric cancer. After surgery, the patient received low-dose FP theapy (5-FU+CDDP) for 1 year and oral immunochemotherapy (UFT+PSK) for 3 years. In January 2005, she started experiencing pain in the left hypochondrium and her CEA levels were elevated (239 ng/ml). A radiological image revealed a 6-cm shadow of an isolated tumor which was diagnosed as a splenic metastasis of gastric cancer, and her diaphragm and spleen were excised in April 2005. Histological findings were the same as the previous gastric tumor. Her CEA levels returned to normal after surgery, and she is currently taking TS-1.
Although splenic metastases of gastric cancer are considered distant metastases, excision should be encouraged since long-term survival is possible when isolated splenic metastases are excised.

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Myelolipoma is a benign tumor mostly found in the adrenal gland incidentally by imaging. It is nonfunctional, and seldom leads to a clinical diagnosis. Follow-up observation is indicated, but excision is reserved for tumors over a certain size, which is still under discussion, and those that grow during a period of observation.
A 72-year-old man was transferred to our hospital with a diagnosis of myelolipoma in the right adrenal gland. We performed laparoscopic right adrenal resection, which took 135 minutes with slight bleeding. The tumor was not invasive and did not require a complex and extensive operation. Therefore, a laparoscopic approach could be considered.

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A total of 10 cases of acute superior mesenteric arterial occulusion (SMAO) treated in our department in a previous 11-year period were divided into the survival (n=4) and death (n=6) groups and studied for the diagnosis, treatment, and postoperative management. An averaged age of them was as high as 81 years. All the patients had some cardiovascular disorders as underlying diseases, and seven patients of them had atrial fibrillation. The time from the onset of SMAO to the treatment ranged from 4 to 96 hours, in that no significant difference was noted between the survival and death groups. Contrast enhanced abdominal CT was conducted preoperatively in all the patients. It was retrospectively considered that preoperative diagnosis had to be made by the CT scans in eight of them who had developed occulusion at the center of the superior mesenteric artery. Except one patient who could be treated by IVR using a balloon-tip catheter, the remaining nine patients underwent laparotomy and six out of the nine patients underwent the resection of massive intestines. Seven patients overcame postoperative acute phase, however, only four of them were able to recover their social activities.
In order to improve the prognosis of the disease, we are required not only to avoid massive intestinal resection by making early diagnosis, but also to conduct long-term postoperative intensive therapies including those for underlying diseases as well as prevention of recurrence and nutritional management.

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A 57-year-old woman presented with upper abdominal pain. Abdominal ultrasonography showed a hypoechoic mass, 45 mm in diameter. Computed tomography revealed a well-defined mass adjacent to the inferior surface of the liver and lesser wall of the stomach. Preoperative diagnosis was extramural gastrointestinal stromal tumor (GIST) of the stomach. Intraoperatively, the tumor approximately 25 × 20 mm in size arose from the lesser omentum and adhered to the inferior surface of the liver and lesser wall of the stomach. The tumor was resected without any resection of the adjacent organs. Histologically, the tumor was composed of short spindle shaped cells, which lacked particular arrangement, capsulated by myofibroblastic cells with extensive central necrosis. Immunohistochemically, the tumor was positive for vimentine and partially positive for smooth muscle actine (SMA) and CD68 (Kp1), but negative for c-kit and CD34 antibody. It was diagnosed as mesenchymal tumor of the lesser omentum. The patient had an uneventful postoperative course. It was difficult to categorize this rare tumor originating from the lesser omentum in one classification.

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A 24-year-old man visited our hospital complaining of abdominal pain and nausea. Abdominal X-ray films showed distended small-bowel gas at the height of L1 vertebrae. Enhanced abdominal CT scan visualized the dilated intestine in the space between the portal vein and inferior vena cava from the Winslow foramen. Sagittal and coronal sections of abdominal CT scan also visualized small intestine in the omental bursa between the portal vein and inferior vena cava. With the diagnosis of Winslow foramen hernia, and emergency operation was performed. Upon laparotomy, the ileum had become in carcerated about 30 cm into the omental bursa. Manual reduction was performed without intestinal resection since the herniated bowel was viable. In this case, we made an early diagnosis preoperatively and effective treatment using MD-CT.

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A 30-year-old woman complaining of a left lower abdominal tumor was suspected to have an ovarian cyst by abdominal CT scan elsewhere and then underwent laparotomy at a gynecological hospital. However, no abnormal findings were seen at the ovary and she was referred to our hospital. Following abdominal US, CT and MRI, she was diagnosed as having a retroperitoneal cyst and was operated on. The tumor was present in the retroperitoneum, from caudad to the left kindney to dorsal aspect of the descending colon. So the retroperitoneum was incised and the tumor was removed. The removed tumor was 17 × 12 × 10cm in dimension and elastic soft. Incision of the tumor yielded 660cc of serous fluid, and it was an almost homogeneous monolocular cyst. Histopathologically it was a cyst covered with monolayer ciliated epithelium, in which there were cells looked like interstitial cells of the ovarian tube and salpingian like endocrine cells concomitantly, with a part of incomplete smooth muscle fascicle. Thus the definite diagnosis of a cyst of retroperitoneal müllerian duct was made from these findings including immunohistological findings.

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We report two cases of adult sacrococcygeal tumor. Case 1 : A 40-year-old female visited our hospital. At first, she had dysfunctional uterine bleeding. Case 2 : A 27-year-old male had hematoohezia and lumbago. Before operation, we judged those were benign tumors. Two tumors were completely resected by transsacral resection. Histologically, Case 1 was diagnosed as epidermoid cyst. Case 2, the pathological diagnosis was mature teratoma.
Though adult sacrococcygeal tumor is a rare site, there are some reports of malignant change. A follow-up is required.

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