In the surgical treatment of breast cancer, it is believed that axillary lymph node dissection (ALND) can be avoided with no evidence of metastasis by sentinel lymph node biopsy (SLNB) that dose not lead to an increase in axillary lymph node metastasis, with a resultant decrease in complitcations. Since 2000, we have avoided unnecessary ALND based on SLNB, and here we report the outcome.
Subjects were 403 patients with primary breast cancer treated until December 2005, from whom we could obtain informed consent about avoiding ALND according to SLNB. Of these 403 patients performed SLNB, SLNs were capable of being detected in 402 patients, the detecting rate being 99.8%. Sixty-one patients (15.2%) of them experienced metastasis. The SLN metastatic rates by tumor diameters measured preoperatively were 4.0% (2/50) in Tis, 12.3% (20/162) in T1, and 20.5% (39/190) in T2. ALND was avoided in 341 patients who showed no evidence of SLN metastasis. The median observation period was 33 months (12-79 months). Five (1.5%) patients experienced axillary lymph node metastasis, and the median time until metastasis was 15 months (9-31 months). Of the five patients, there were there T1 and two T2 patients as for preoperative tumor diameter. Six patients experienced distant organ metastasis. They are still alive after addition of ALND. No complications with SLNB have occurred. It is concluded that avoidance of unnecessary ALND according to SLNB is a safe and useful method.

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A certain consensus on treatment procedure for gastric perforation has not been reached among surgeons as yet. Consecutive 91 cases of gastric perforation treated at the hospital were enrolled in this study of elucidating the selection of treatment procedure for the disease. The 91 cases treated in the hospital in a previous 27-year period were of non-traumatic gastric perforation, including 79 cases of perforated gastric ulcer and 12 cases of perforated gastric cancer. Of the 79 patients with perforated gastric ulcer, 10 patients underwent laparoscopy-assisted surgery and one of the 10 patients was converted to open laparotomy. Conservative treatment was employed in 14 patients, and three of them were converted to open surgical therapy on the way. As for 12 patients with perforated gastric cancer, three out of six patients who underwent closure of the perforation or conservative therapy required surgical operation as the second-stage treatment. In a comparison study between the gastrectomy group before introduction of laparoscopy-assisted surgery and the stomach-preserving group after the introduction, the death rate was 17.9% in the gastrectomy group, versus 2.4% in the preserving group, showing an improved prognosis in the latter group.
In conclusion there is no inevitability of performing gastrectomy for gastric perforation as the initial treatment whether the patient has gastric perforation involving gastric ulcer or gastric cancer.

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Background & Purpose : Patients with advanced distal gastric cancer causing obstruction have classically undergone palliative gastrojejunostomy, but there have been few reports that examined the operation's effectiveness. The aim of the present study was to examine the effectiveness in terms of the overall survival and postoperative food-intake period.
Methods : Data on 38 consecutive cases of gastrojejunostomy performed for advanced obstructing distal gastric cancer from 1993 to 2005 in Shikoki Cancer Center were retrospectively analyzed.
Results : The operation enabled 35 patients (92.1%) to allow oral intake. The median postoperative food-intake period for them was 7.0 months. The median survival time for all patients was 7.3 months. The operation allowed 30 patients (78.9%) to be discharged from hospital due to sufficient oral food-intake. On multivariate analysis, preoperative anemia and acute complications were independently associated with short period of postoperative oral intake and poor survival rate.
Conclusions : The operation as a palliation improved quality of life for the advanced gastric cancer patients with the exception of patients with preoperative anemia and acute complications.

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We evaluated 16 cases of symptomatic Meckel's diverticulum in children, 10 boys and 6 girls ranging in age from 25 days to 10 years. The patients were classified into the following four groups according to the main symptom ; 1) hemorrhage group (5 cases), 2) intussusception group (5 cases), 3) intestinal obstruction group (4 cases), and 4) Littre's hernia group (2 cases). In 4 of the hemorrhage group, the Meckel scan was positive and in one case, a repeated scan was positive. Ectopic gastric mucosa was found in 4 operated cases. Two intussusception cases could not have successful reduction and underwent immediate laparotomy. Intussusception recurred in 3 patients and barium enema was diagnostic in one. Ectopic tissue was present in 4 of 5 intussusception cases. The causes of intestinal obstruction were adhesion of Meckel's diverticulum in 3 and strangulation by mesodiverticular band in one. No ectopic tissue was noted in all obstruction patients. Both of the two Littre's hernia cases were inguinal hernias, and one patient was operated on an emergency basis because of incarceration. Symptomatic Meckel's diverticulum in children represented various symptoms. We cannot determine predisposing factors of symptomatic Meckel's diverticulum. We therefore recommend to resect asymptomatic Meckel's diverticulum found incidentally at laparotomy.

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[Objective] A multi-center survey of the use of synthetic surgical sutures was conducted to investigate the current status of their use in hepatic and pancreatic surgery. [Method] During any consecutive 3 months between April 2005 and December 2006, suture packages used in all of the patients who underwent hepatic resection, liver transplantation, and pancreatoduodenectomy were counted by product code in 10 participating institutions. [Results] The average cost for synthetic surgical sutures was over 50,000 yen in all of the procedures. The percentage of the surgical fee taken up by the average cost of the synthetic surgical sutures was 27% in live donor operation of liver transplantation, 24% in partial hepatectomy and in pancreatectomy with adjacent organs, and 23% in hepatic segmentectomy. [Conclusion] It has been clarified that the cost of synthetic surgical sutures occupies a great percentage of the fee for hepato-pancreatic operations. Based upon the concept of separating the technical fee and device cost, a separate reimbursement for synthetic surgical sutures from the surgical fee is recommended.

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The purpose of this study was to determine the prevalence of breast cancer-related lymphedema (LE), time of onset, and associated predictive factors. The authors measured differences in the upper arm, lower arm and wrist circumference in 348 postoperative patients with breast cancer who visited our hospital between November 2005 and August 2006.
Eighty-eight of the 348 patients developed LE. The 5-year incidence of LE was 31.9%. Factors that were significant in the development of LE as determined with univariate analysis were the following : level of axillary dissection, use of supraclavicular irradiation, clinical T factor, pathologic node status, the number of lymph nodes with positive pathologic findings, age, and BMI. The set of variables that was significant in univariate analysis was entered in a step-wise Cox procedure. The results indicated that the variables significantly associated with the development of LE were BMI, pathologic node status, and use of supraclavicular irradiation.

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A 61-year-old man consulted his doctor for severe pain and swelling of his left lower leg. The doctor doubted that the pain was due to deep venous thrombosis and advised him to consult our department for treatment of the complaints. Physical findings of the patient showed that the left lower leg was larger than the right lower leg in circumference. There were grasp pain on his calf and Homans sign on his left leg. The laboratory data on admission demonstrated severe inflammation but no leukocytosis. Lower leg CT scan demonstrated that the lower leg muscle was surrounded by fluid. Contrast enhanced CT scan showed the most likely diagnosis of fascitis of unknown origin. Intravenous drip infusion therapy was started. On the next morning after urgent admission, he perspired abnormally and complained of chest discomfort. He exhibited cyanosis on the extremity. The left thigh was swollen, the epidermis of the left tight peeled, and purpura appeared. But blood pressure was in the normal range at that time. The laboratory data showed that the WBC count was within normal range, but he had renal dysfunction, severe metabolic acidosis, and remarkable elevations in CPK and CRP. Despite available treatments his condition dramatically deteriorated. The patient finally died within 12 hours after the admission. We could not understand the dramatic progression in this case, and hence performed an autopsy to grope for the cause of his death. The disease was not diagnosed as toxic shock-like syndrome by Streptococcus pyogenes until the bacteria were isolated from blood, subcutaneous tissue, and skin.

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The patient was a 56-year-old female. We developed a new technique of skin flap formation in breast conserving surgery for early breast cancer. After the tumor was detected and marked using ultrasonogram, an isotonic sodium chloride solution containing epinephrine was injected into the subcutaneous layer. The incision was made halfway around the areola. Hegar type uterine cervical dilator No. 5 was inserted into the subcutaneous tissue, directing its apex toward the skin side, for making small tunnels at intervals of 1.5 cm radially about 150 degrees. Tunnels were then dilated with No. 10 and 15, and the septum between tunnels was dissected by an ultrasonic coagulator to form a skin flap. A thin skin flap was made safely and easily for the dull apex, with a curved shape, using in turn small to large. Hegar type uterine cervical dilators, which were reusable and economical.

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Phyllodes tumors of the breast account for 0.3∼1% of all breast neoplasms. Tumors larger than 5 kg are extremely rare with only seven having been reported to date in Japan. We report a case with an 8 kg phyllodes tumor. The patient is a 60-year-old woman who presented with a malodorous, ulcerated, and infected left breast tumor. The tumor occupied the whole of the left breast (35 cm in diameter). Because of severe anemia and malnutrition, she was hospitalized immediately and received systemic treatment within our intensive care unit. She underwent simple mastectomy for left breast without skin graft. Surgical resection revealed a phyllodes tumor with sarcomatous lesion. The patient has not experienced either local recurrence or distant metastasis after nearly two years of follow-up.

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A 55-year-old man complaining of chest discomfort was referred to the department of cardiology in our hospital for the treatment of atrial fibrillation. The patient was diagnosed as concealed WPW syndrome by electrophysiological study (EPS). Echocardiography showed a tumor attached to the posterior leaflet of the mitral valve. Based on these findings, he was transferred to our department, and simultaneously underwent tumor excision, mitral valvuloplasty, and cryoablation of Kent bundle in December 2005. The histopathological diagnosis was papillary fibroelastoma. After the operation, the electrocardiogram showed sinus rhythm and the dissection of Kent bundle by cryoablation was confirmed by EPS.
There have been no signs of recurrence, so we believe the simultaneous operation was effective.

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We report two cases of heparin-induced thrombocytopenia (HIT) who successfully underwent off-pump coronary artery bypass (OPCAB) using argatroban as an alternative anticoagulant. They were diagnosed as HIT type I during the prior treatment of acute myocardial infarction, because of severe thrombocytopenia after two or three days of heparin exposure. Patient 1 was a 74-year-old man who underwent OPCAB with a saphenous vein graft to the posterolateral artery. Argatroban was chosen as an alternative anticoagulant to heparin, with activated clotting time (ACT) kept over 200 sec at the rate of 5 μg/kg/min of argatroban infusion. Patient 2 was a 72-year-old man who underwent OPCAB with a left internal mammary artery to the left anterior descending artery. He was put on argartoban infusion at 2 μg/kg/min after a bolus shot of 10 mg argatroban. ACT did not return to the pretreatment level over 60 min after cessation of the infusion. Their postoperative courses were uneventful, and graft patency was confirmed by coronary angiography.

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A 71-year-old woman visited the emergency clinic in our hospital because of abdominal pain and syncope. When she was seen, she was in shock. Abdominal CT scan showed massive hemorrhage in her retro-peritoneal space from the inferior margin of the uncus of the pancreas to right side of the superior mesenteric artery. An aneurysm with the diameter of 6 mm was revealed on the inferior pancreaticoduodenal artery by an emergency angiography. Embolization was performed with coils into proximal and distal portions of the aneurysm. On the angiography, the celiac axis had remarkably flexed and canulation via the superior mesenteric artery revealed the celiac axis with retrograde filling. She was discharged from the hospital. Thereafter she was admitted for treatment of pneumomnia, which was clarified to be asipiration pneumonia caused by stenosis of the third portion of the duodenum compressed by hematomas. The pneuomonia improved by the management with a ventilator and drainage of the digestive juice with a nasal stomach tube. The hematoma became smaller and drained juice from the nasal stomach tube decreased as well. She was able to start taking meals and was discharged.
In cases of a ruptured aneurysm of the inferior pancreaticoduodenal arery, we have to notice a possible occurrence of stenosis of the duodenum compressed by hematomas.

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A 53-year-old man was transported to our hospital because of intraperitoneal apoplexy with a complaint of epigastralgia. Previously, he had undergone diatal gastrectomy (B-I) for a bleeding gastric ulcer. Abdominal CT revealed a fluid in the epigastric region and a sentinel clot sign. Emergency abdominal angiography examination showed swollen aneurysm in the left gastroepiploic artery 3 mm in size. No clear hemorrhaging was recognized. It was diagnosed from the above as a ruptured aneurysm of the left gastroepiploic artery. Because his general condition was comparatively stable and apoplexy was controlled, elective ablative surgery was performed on the left gastroepiploic artery aneurysm. An epiploic branch from the left gastroepiploic artery had an aneurysm 20 mm in diameter and was removed surgically. Pathologic findings revealed a pseudoaneurysm in an abscission specimen. The clinical course was good, and he was discharged on the seventh postoperative day.
We discussed an aneurysm of gastroepiploic artery from Japanese literatures.

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A 42-year-old man, who had been followed for a submucosal tumor at the esophagogastric junction which had been detected at a medical checkup in 2000, was referred to the hospital for the purpose of surgery, because an increase of the tumor in size was identified at a periodic examination in October 2004. Ultrasonic endoscopy-guided needle aspiration biopsy offered a diagnosis of leiomyoma and thus enucleation of the tumor under laparoscopy was performed. During surgery a S-B tube was inserted and pulled by a gastric balloon, when the tumor was first identified. The tumor in a 7 cm-long horseshoe shape was present in the hemi-circumference of the esophagogastric junction. After the removal of the tumor, the muscular tonics of the His angle was lacked so that the defect was repaired by sutures, and cardioplasty was added to only the left side of the esopnagogasthic junction. The postoperative course was uneventful. No passage disturbance or regurgitation has been demonstrated by postoperative gastrointestinal series.
Horseshoe leiomyomas which develop at the esophagogastric junction are good indication of laparoscopy-assisted surgery. Since the esophagogastric junction plays an important role as the preventing mechanism for regurgitation, an addition of cardioplasty after removal of a tumor is considered appropriate.

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A 65-year-old man visited his family physician with the chief complaint of appetite loss, general fatigue, and melena on 15 March 2006, and then was referred to our hospital. At the time of admission to our hospital his body pressure was around 70 mmHg, and a blood examination revealed severe anemia and metabolic acidosis. Emergency gastroduodenoscopy revealed old bloody fluid and a black large bezoar. After his general condition improved we examined him, but there was no special mention except the bezoar, and on 6 June we incised the stomach and extracted the bezoar by open surgery. The bezoar measured 13×10 cm and presented as a stomach mold. The analysis of the stone revealed absorption similar to tannic acid in part.
We suspect that in this case the large bezoar injured the mucosa of the stomach, caused bleeding and severe anemia, and that disturbance of passage caused malnutrition, shock and metabolic acidosis. Gastric ulcer, ileus, and other complications of bezoar exist, and some of them progress seriously as in this case, so we must keep this disease in mind in case of bleeding of the digestive system.

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We describe our experience of a case who had metastatic gastric cancer caused by recurrent hepatocellular carcinoma (HCC).
[Case] The patient was a 70-year-old male who had undergone successive radio frequency ablation therapy (RFA) for recurrent HCC after the intial partial hepatectomy three years earlier. In November 2004, when HCC recurrences were found, an endoscopy revealed a type II tumor at the stomach body during an examination for anemia. The biopsied specimen showed metastatic gastric cancer caused by HCC. Partial gastrectomy and RFA were performed in December 2004.
[Operative findings] The serosal surface of the tumor was smooth, and it was movable and round shaped, and had a gentle upheaval. Histopathological examination showed the gastric tumor was solid with a clear margin, and reached the submucosal layer with venous involvement. The biopsied liver specimen revealed poorly differentiated hepatocellular carcinoma and Edmondson IV type. These findings supported the fact of the hematogenous metastasis of HCC to the stomach.
[Summary] Metastasis of HCC to the stomach is rare and hematogenous metastasis is particulary rare as only 27 cases have been reported in Japan. Along with further discussion of this case, this paper reviews the literature.

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A 62-year-old man presented with general edema and ascites with remarkable hypoproteinemia was found have multiple elevated lesions in the stomach by close exploration. Following a biopsy, signet ring cell carcinoma of the stomach was diagnosed and fresh frozen plasma/protein preparation and diuretics were administered before surgery. General edema improved and ascites disappeared, but hypoproteinemia showed an unsatisfactory improvement. Total gastrectomy with dissection of lymph nodes of group 2 was performed. The removed material involved five cauliflower-like lesions, all of which were signet ring cell carcinoma. Postoperative administration of fresh frozen plasma/protein preparation resulted in remission of hypoproteinemia. Threre have been no signs of recurrence, edema, ascites, and hypoproteinemia up to now.
We present here this case of multiple occurrence of elevated type signet ring cell carcinoma of the stomach which is wery rare, together with a review of the literature.

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A 69-year-old man was admitted to the hospital for stiffness of the gastric wall pointed out on upper G-I series. Endoscopic examination showed irregular folds and stiffness of the wall from the upper corpus to the antrum. Poorly differentiated adenocarcinoma was detected in the biopsy specimens. Direct invasion to pancreas was suspected by enhanced CT scanning. Since a curative operation was not feasible, a combination chemotherapy of TS-1/CDDP was selected to be repeated (TS-1 ; 120 mg/body at day 1∼21 and CDDP ; 90 mg/body at day 8 and an interval of 2 weeks, afterwards). As the adverse effects appeared soon, TS-1 was reduced to 100 mg/body and the interval period was postponed for three weeks. The first cycle was then satisfactorily performed. Gastric endoscopy after the second cycle showed only scar-like lesions with convergent folds. Malignant cells were not detected in the biopsy specimens. The invasion to pancreas disappeared in CT scanning. At this time, the patient strongly insisted on surgery, so total gastrectomy with lymph node dissection (D2) was performed. Neither hepatic metastasis, nor peritoneal dissemination was observed on laparotomy. Histologically, the gastric lesion was replaced by fibrosis in which xanthogranulomas suggesting degenerated tumor tissue were scattered. No viable malignant cells were detected anywhere either in gastric wall or regional lymphnodes. Final chemotherapy efficacy was evaluated as Grade 3.
Therefore, it is considered that the chemotherapy using TS-1/CDDP is hopeful to the far advanced gastric cancer and further results would be expected by changing the doses or combination of the drugs.

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Anemia was pointed out during screening examinations of a 77-year-old man. Abdominal CT and MRI scan showed a dumbbell-shaped tumor existing in the pancreatic head and protruding to the lumen of the second portion of the duodenum. Angiography revealed that a branch of the dorsal pancreatic artery fed this hypervascular tumor. Pylorus preserving pancreatoduodenectomy was performed. Histologically, the tumor showed spindle cells arranged in fascicles and whorls, with a focal epithelioid pattern. Immunohistologically, the tumor was positive for c-kit and S-100, but negative for CD34, α-SMA, cytokeratin and HHF-35. A diagnosis of duodenal GIST was made. He showed no signs of recurrence during approximately 1 year of follow-up. Preoperative diagnosis was difficult due to the supply of blood to the tumor.

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The patient was a 60-year-old man who had undergone total gastrectomy for gastric cancer with Roux-en Y reconstruction in 1994. The patient was seen at the hospital because of abdominal pain, when his abdominal pain was mild so that we decided to follow his clinical course at home. However, his symptom became worse and close exploration disclosed remarkable dilatation of the afferent loop, cholangitis, and pancreatitis. Afferent loop obstruction was thus diagnosed. As a result of upper gastrointestinal endoscopy, we determined that decompression from the lumen was impossible and performed an emergency operation. At laparotomy the afferent loop had significantly dilated due to obstruction at the anastomosis. The afferent loop by about 8cm in length including the obstructed anastomosis was removed, and re-anastomosis of the afferent loop was made by side-to-side anastomosis. After the operation the patient was associated with DIC due to severe pancreatitis, acute circulatory failure and acute respiratory failure, and demanded an 8-day intensive care under management with artificial respirator. His general condition became gradually stable, and he was discharged from the hospital on the 46^th postoperative day.
Afferent loop obstruction after total gastrectomy is rare, but when it once occurs, cholangitis and pancreatitis are associated in an early time and delayed treatment can induce serious general condition. We report this case here as a pathologic condition which requires early diagnosis and treatment.

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A 65-year-old woman was referred to our hospital because of suspected paralytic ileus. She had begun to have an abdominal full sensation and abdominal pain five months ago. Also, she noted turbidity and air in the urine. CT revealed a thickened wall of the ileum and air in the urinary bladder. Cystoscopy showed mucosal injection and a small tear of the bladder. A diagnosis of ileovesical fistula was made on the basis of physical examinations, CT and cystoscope findings, so an emergency laparotomy was performed. The operative findings included multiple diverticula of the ileum, and a perforation with severe adhesion was identified. We performed partial resection of the ileum including partial urinary bladder wall. Histopathological examination of the resected specimen revealed multiple diverticula in the ileum. Enterovesical fistula associated with diverticulitis of the ileum is extremely rare. We report our case with a review of the literature.

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This paper presents a case of schwannoma of the jejunum that was found by an opportunity of melena. A 71-year-old woman who had been coming to the hospital was found to have melena and anemia. She was also found to have a gastric ulcer, so the focus was placed on the gastric ulcer. In spite of curing the gastric ulcer, she was later found to have melena, so an examination was performed. A tumor was detected in the abdominal cavity by abdominal ultrasonic examination. The tumor was solid by ultrasonic examination and quickly enhanced strongly, then maintained the effect of enhancement that was washing out by computed tomography. Examination of small intestinal clairvoyance showed exclusion from out of the wall of the jejunum and ulcer surface inside of the part. Upon operation, a tumor was observed from the jejunum to the mesentery and so partial resection of the jejunum was performed. Histologically, the tumor was diagnosed as schwannoma. A case of schwannoma of the small intestine is rare, we report this rare case of schwannoma of the jejunum.

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We report a rare case of peritoneal dissemination from a gastrointestinal stromal tumor (GIST) of the jejunum 10 years after surgical resection. A 34-year-old man was admitted with severe abdominal pain and fever. Emergency operation was carried out with a diagnosis of peritonitis. There was pus contamination in the abdominal cavity and a submucosal tumor of the jejunum was identified. The tumor, about 5 cm in diameter, was confirmed 70 cm distal from Treitz' ligament and was perforated the histological diagnosis was leiomyosarcoma at that time. Ten years later in 2005 he was admitted with a complaint of melena. Computed tomography (CT) showed multiple masses in the abdominal cavity, so we conducted laparotomy and performed partial resection of the ileum with the disseminated peritoneal tumors as for as possible. Microscopically, the tumor morphologically resembled the previous intestinal tumor and immunohistochemical testing revealed KIT (+) and CD34 (+). Thus, the disseminated peritoneal tumor was diagnosed as recurrent intestinal GIST. Oral administration of imatinib mesylate was started after operation. An abdominal CT showed the remnant disseminated peritoneal tumor decreased. Imatinib mesylate may be effective for treating recurrence of malignant GIST.

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A 67-year-old man was admitted to our hospital because of exertional dyspnea. Abdominal CT and angiography studies showed multiple tumors in the abdomen and so he was operated on. Upon laparotomy, there were many tumors with diameters from 5mm to 10cm on the entire small bowel, from the duodenum to ileum. Most tumors had grown as they projected from the serosa extramurally and some tumors had invaded the bladder wall. Relatively large tumors concentrated in the small bowel about 100cm apart from the Treitz' ligament, and two of them with the diameter of about 10cm might have caused intestinal obstruction and bleeding. We performed resection of the segment of small bowel where those large tumors concentrated, avoiding massive resection of the small bowel to preserve the quality of life of the patient. Pathologically the tumors were C-kit (+++), CD34 (+), vimentin (+), SM-actin (-), desmin (-), and s-100 (focally+). Accordingly they were thought to be gastrointestinal stromal tumor (GIST) in the narrow sense. This case was considered to be of clinical malignancy because of the presence of peritoneal metastasis and invasion to the bladder. After the operation, he was prescribed imatinib mesylate. No growing of the residual tumors have seen demonstrated for 8 months after the operation.

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Cecal volvulus is a relatively uncommon cause of intestinal obstruction. Cecal volvulus is considered to develop by some causes added to a mobile cecum, and pregnancy is one of the causes. This paper deals with a case of a 38-year-old pregnant woman who developed cecal volvulus at 23 weeks of gestation when she was not conscious of becoming pregnant.
The patient was seen at the hospital because of abdominal pain and vomiting. A plain abdominal X-ray showed a significantly dilated colon with a single fluid level in the left upper abdomen and distended loops of the small intestine. Abdominal CT scan revealed marked dilatation of the colon in the left upper guadrant of abdomen, “whirl sign” and the gravid uterus. The patient was diagnosed as having intestinal obstruction, especially colonic volvulus, and an emergency laparotomy was performed. Upon laparotomy, we saw a mobil cecum that was twisted clockwise by 360 degree. Since the intestinal wall was to be necrotic, an ileocecal excision was performed.

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We report a rare case of an coloappendiceal fistula following acute appendicitis after chemotherapy of AML.
A 36-year-old man complaing of fever and abdominal pain after chemotherapy for AML was suspected of acute appendicitis because of a slight Blumberg's sign, but the final diagnosis was not definite. We preferred conservative therapy to surgery due to the aguranulocytic status, but the patient had frequent recurrences. Colonoscopy showed an irregular elevated lesion at the ascending colon and Ga accumulation. We conducted laparotomy to comfirm the diagnosis, which was retrocecal appendicitis forming a fistula in the ascending colon.
Because a definitive diagnosis of ileocecal syndrome is difficult in leukemic patients owing to lacked specific symptoms, careful observation would be mandatory in the case of patients suffering from prolonged inflammation.

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An 18-year-old woman consulted our hospital for right lower abdominal pain without improvement on December 20, 2004. Mild fever was found on admission, and pressure pain and rebound tenderness were found in the right lower abdomen. The inflammatory change was slight in the blood sample, but abdominal ultrasound and CT revealed that the mass continued with caecum and inflammation finding in the right lower abdomen, so we performed an operation based on a diagnosis of acute appendicitis. Surgical findings showed the appendix was swollen and continued to the caecum and omemtum, but the caecum and surrounding lymph nodes were not abnormal, so we performed only an appendectomy. The appendix was enlarged, and remarkable wall thickening was found, but the change of mucosa side was slight. The histopathology was malignant lymphoma of diffuse large B cell type. It is necessary to consider this disease in a case with acute appendicitis with formed mass and with slight inflammatory reaction.

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We report a case of carcinoma from the vermiform appendix with obstructive appendicitis. An 81-year-old man visited our hospital for right lower abdominal pain continuing from 4 days before. Blood examination showed leukocytosis (12500/μl) and elevated C reactive protein level (10.5 mg/dl). Abdominal CT and ultrasonography showed a tumor-like lesion of cecum. After recovery from appendicitis by antibiotics, colonoscopy was performed to ascertain the tumor from the vermiform appendix. With a diagnosis of primary tumor from vermiform appendix, we performed ileocecal resection with D3 lymph node dissection. Resected specimen showed a subpolypoid tumor from the orifice of the vermiform appendix and necrosis of the distal appendix. The depth of the carcinoma was SM 1 mm. Although vermiform appendix carcinoma is rare and it is difficult to diagnose this tumor preoperatively, colonoscopy following the abdominal CT and ultrasonography enabled preoperative diagnosis and an adequate resection.

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We report a case of ileus caused by a fibrous band formed by coloenteric fistula due to diverticulitis of the sigmoid colon. A 64-year-old man who had undergone an appendectomy was admitted to our hospital with the complaint of abdominal pain. The patient had been diagnosed as coloenteric fistula due to diverticulitis of the sigmoid colon two years earlier. Abdominal plain X-ray film revealed a dilated small bowel loop with air-fluid level formation. Enhanced computed tomography also demonstrated stenosis of the small intestine with dilatation of the oral side. We diagnosed ileus and started conservative therapy by ileus tube, but it was not effective and so an operation was performed. Intraoperative findings revealed that a coloenteric fistula due to diverticulitis of the sigmoid colon was formed like a fibrous band. Resection of this fistula was performed, but resection of the small intestine was not needed. The postoperative course was uneventful.
Ileus caused by a fibrous band formed by coloenteric fistula due to diverticulitis has not been reported previously in Japan.

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A 78-year-old man developed a perianal abscess with a high fever of 39°C after undergoing an operation for hemorrhoids. He was transferred to our medical center on the 12th postoperative day. Upon transfer, we observed a giant ulcer in the anal region, and an elastic hard mass of about 10 cm in diameter was observed palpating in the lower right abdomen. An abdominal computed tomographic scan revealed wall thickening of the ileocecal bowel and rectum. On the third day of illness, aggravation of his infection and cardiorespiratory failure were noted, and a laparotomy was performed. Operative findings showed multiple perforations and abscesses from the cecum to sigmoid colon. Subtotal colectomy and ileostomy were performed. Because fulminant amebic colitis was suspected due to macroscopic findings of the resected specimen, enteral and enema administrations of Metronidazole were initiated. Numerous Entamoeba histolytica trophozoides were also confirmed upon histopathological examinations. Improvements were observed through intensive care, and the patient was transferred from our medical center on the 65th day of illness. Amebic colitis should be considered as one of the differential diagnoses for patients with perianal ulcer.

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We report two cases of colouterine fistula which is an extremely rare complication of diverticular disease.
Case 1 : A 72-year-old woman was admitted to the hospital because of fecal vaginal discharge. CT scan showed wall thickness of the sigmoid colon and gas in the uterine cavity suggestive of communication with the intestine. On barium enema examination, multiple diverticula were found in the sigmoid colon. Although no fistula was identified, The patient was suspected to have a colouterine fistula secondary to diverticulitis. Case 2 : A 75-year-old woman was admitted to the hospital because of fecal and blood-tinged vaginal discharge. Barium enema examination revealed multiple diverticula and fistula formation between the sigmoid colon and uterin cavity. The patient was diagnosed as having a sigmoid-uterine fistula caused by diverticulitis.
Both patients underwent a one-stage, en bloc resection of the uterus and sigmoid colon. Histopathological examination showed diverticulitis of the sigmoid colon with the abcess which drained into the endometrial cavity through the fistula tract.

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Malignant schwannoma of digestive tract is very rare in the large intestine. Recently, we experienced a case of malignant schwannoma of the transverse colon. A 61-year-old female came to our hospital on December 7, 2005 because of a tumor pointed out in her upper abdomen when she went into a hospital for a complete physical examination. The tumor was diagnosed as a gastrointestinal tumor with CT colonography. She was admitted to our hospital on January 11, 2006, and a radical right hemicolectomy and partial resection of the pancreas and duodenum were done on January 11. Histological diagnosis of the tumor revealed it to be a neurogenic malignant schwannoma, because immunostaining for S-100 protein showed a positive reaction, but c-kit and actin showed negative reactions.
In this study, a case of malignant schwannoma of the transverse colon was reported because the reported cases have been very rare.

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Our experience with a rare case of sigmoid colon carcinoma with minute submucosal invasion and lymph node metastasis is presented. The patient was a 77-year-old male. His stool showed occult blood on a health checkup. He visited our hospital, where X-ray and endoscopic examination revealed transverse colon tumor and sigmoid colon tumor. A biopsy revealed that the sigmoid colon tumor was well-differentiated adenocacinoma. Transverse colectomy and a sigmoid colectomy with dissection of group 1 and 2 lymph nodes was performed, because the preoperative diagnosis was deep submucosal invasion. Histological examination showed that the resected sigmoid colon tumor was a moderately-differentiated adenocarcinoma, SM (sm1), ly1, v0, N1. The depth of the submucosal invasion was 500 μm, however, there was a metastasis in No. 241 lymph node. The patient has been receiving adjuvant chemotherapy. Minute submucosal invasive carcinoma rarely has lymph node metastasis. To make therapeutic decisions, it seems necessary to evaluate the risk for lymph node metastasis such as tissue type and vascular invasion.

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A 61-year-old man was seen at the hospital because of a recently enlarging tumor of the gluteal region which had first been noticed about 6 months earlier but had not been treated. An easily hemorrhagic circumanal tumor with the size of an infant's head was present in the gluteal region. Abdominal pelvic CT scan showed thickening of the wall of sigmoid colon and skin metastasis of sigmoid colon cancer was considered to be the most likely diagnosis. However, endoscopic exploration was difficult for the gluteal tumor, and excision of the gluteal tumor preceded the endoscopic study. Various examinations including endoscopic study of the lower digestive tract performed thereafter provided the diagnosis of sigmoid colon cancer with hepatic and inguinal lymph node metastases. Thus a Hartmann operation was performed. Histological findings of the gluteal tumor indicated adenocarcinoma which was similar to that of sigmoid colon carcinoma, and metastasis of sigmoid colon carcinoma to the gluteal skin was considered. After adjuvant chemotherapy, the patient has been followed in our clinic, as of 7 months after the operation.
Dermal metastasis of visceral cancers, especially colorectal cancer, is rare. There have been only nine cases of colorectal carcinoma with metastasis to the gluteal circumanal skin. Although dermal metastasis has been considered to manifest general metastasis of malignancy and to suggest poor prognosis, improvement of the prognosis can be expected by multidisciplinary therapy including recently progressed chemotherapy for colorectal cancer.

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A 76-year-old man was admitted to our hospital for abdominal distension. Colonic ileus due to sigmoid colon carcinoma was suspected by abdominal X-ray and CT. Colostomy was performed. Subseqent colonoscopy and histopathological examination of the biopsy sample revealed carcinoid. Then we performed sigmoidectomy with D2 lymph node dissection. Histopathological examination of the sigmoid colon lesion showed a composite tumor of goblet cell carcinoid and adenocarcinoma. The patient is alive as of one year following surgery Goblet cell carcinoid is mainly found in the appendix, and the occurrence in other organs is very rare. In this case, the coexistence of goblet cell carcinoid and adenocarcinoma was observed in one lesion. We report this case along with a review of the literature.

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A 76-year-old man was admitted to our hospital because of ileus. Colonoscopy revealed severe stenosis caused by carcinoma in the sigmoid colon and so we inserted a transanal ileus tube for decompression. Lavage of the colon via the tube was conducted every day. Left lower abdominal tenderness and high fever appeared on the 10th day after the insertion and he lapsed into sepsis. Abdominal CT showed air bubbles and inflammatory shadow in the colonic wall and retroperitoneum adjacent to the tube balloon. We performed an operation on the 12th day after the insertion, suspecting complications associated with the tube. During the operation we found the sigmoid colon to be edematous and reddish, so a sigmoidectomy was performed. On the resected specimens type Ul-IV ulceration was observed in the slightly oral side of the tumor, possibly caused by the compression of the balloon.
Recently some complications associated with the use of the tube have been reported, so it is important to observe the patient carefully after the insertion and to perform the operation as soon as possible after the intestine has been decompressed.

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A 50-year-old male, admitted to our hospital with the complaint of vertigo, had severe anemia (Hb 2.7 g/dl). Colonoscopy, histological examination, double contrast barium enema examination and abdominal CT confirmed the diagnosis of rectal adenoma 8 cm in diameter. We planned a low anterior resection of the rectum. The day before operation, the tumor was prolapsed from the anus. Then excision of the rectal tumor was carried out with a transanal approach using an automatic suture device. In histopathology, it was carcinoma in tubullovillous adenoma, and was confined to the mucosa. Local excision was sufficient therapy for this patient. The patient was free from recurrence of rectal cancer 1 year and ten months after surgery.

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Extramammary Paget disease is rare. We present a case of rectal adenocarcinoma complicated with perianal extramammary Paget disease and a review of the literature. A 79-year-old woman presented with hematochezia. Work-up of the patient revealed distal rectal adenocarcinoma, and an abdominoperineal resection was performed. Pathology of the specimen showed rectal adenocarcinoma with perianal extramammary Paget cells, and additional wide local resection was performed later. Review of literature showed that the five-year survival rate of the patients who had anorectal adenocarcinoma with secondary extramammary Paget disease that was treated with abdominoperineal resection was only 26%, which is quite poor compared with solitary rectal adenocarcinoma. Therefore, more aggressive treatment methods, such as adjuvant chemoradiation, should be sought.

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A 59-year-old man was seen at the department of internal medicine in our hospital because of general fatigue, and was referred to our department after abdominal CT scan showed a tumor of the pancreatic head and obstructive jaundice. To relieve obstructive jaundice, the confluence of B2 and B3 intra hepatic bile duct was punctured via the epigastrium and a PTCD (7.2Fr, polyethylene) catheter was placed. On the 20^th day after the placement of the catheter, drainage interrupted without any causes, when abdominal x-ray examination and abdominal CT scanning disclosed rupture of the catheter in the body. On the same day we performed an emergency surgery in which removal of the ruptured catheter and pancreaticoduodenectomy which had been scheduled on the day were immediately done. During surgery, we identified that no leakage of bile juice into the abdominal cavity had occurred due to an already formed fistula of the catheter, and hence we were able to perform pancreaticoduodenectomy.
It was etiologically thought that friction between the xiphoid process and the placed catheter which had been moving due to respiration might have caused the material fatigue. We present this case with some bibliographical comments because rupture of the PTCD catheter itself is a rare complication of the catheter.

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A 56-year-old woman who had undergone a proximal gastrectomy for gastric cancer and postoperatively received TS-1^® 80mg/body, was admitted to the hospital because of relapse 9 months after the operation. Abdominal CT and MRI scans showed a metastatic liver tumor, however, abdominal ultrasonography (US) did not. US guided radiofrequency ablation (RFA) was performed for the tumor successfully after CT guided PEIT and injection with lipiodol. She is doing well without recurrence or relapse for 7 months after RFA. US guided RFA after CT guided injection with lipiodol may become an effective and minimal invasive modality in the case that a metastatic liver tumor can not be detected by US.

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A 59-year-old man pointed out as having liver dysfunction by a medical checkup was admitted to our hospital for further examination. As a result of the thorough examination, the diagnosis was hepatocellular carcinoma (HCC) caused by non-alcoholic steatohepatitis (NASH). A radical operation was performed. A decrease in lower extremities muscular power developed suddenly three months later. It was diagnosed as due to compression of the spinal cord by metastasis to the eighth thoracic vertebrae the man was emergency-hospitalized. Emergency surgery and radiation therapy were performed, and the neurological symptoms disappeared promptly. The incidence of bone metastasis in HCC is assumed to be rare at only about 3%. In most cases, multiple tumors exist in the liver or a main tumor has large diameter. The metastasis and recurrence type caused by NASH are different from the usual case of HCC.

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This is a case report of cholecystolithiasis in an 8-year-old girl with myelodysplastic syndrome (MDS). She had been diagnosed as having MDS at another hospital at the age of 1 year and cholecystolithiasis at the age of 4 years. At the age of 8 years, she was admitted to our hospital because of fever and bone marrow transplantation for MDS. Abdominal CT scan to identify the cause of fever revealed a gallbladder stone and wall thickening of the gallbladder. We considered that cholecystolithiasis and cholecystitis had caused her fever. Laparoscopic cholecystectomy was performed for prevention of infection to prepare for bone marrow transplantation. A bilirubin-calcium stone was found in the removed gallbladder. The pathological diagnosis was chronic cholecystitis. The patient became active and well after the surgery, and bone marrow transplantation was performed. No complications including cholangitis occurred after the bone marrow transplantation.

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We report a case of 15-year-old boy with gallbladder torsion. The patient consulted the hospital because of right hypochondralgia and he was admitted with a suspicion of acute abdomen. Abdominal US and CT showed enlargement of the gallbladder. Conservative therapy was started, but severe abdominal pain continued. After nine hours, enhanced CT revealed that the swelling of the gallbladder progressed, but the wall of the gallbladder was not enhanced, suggesting gallbladder torsion. An emergency laparoscopic surgery was performed on the same day. The gallbladder was free-floating and twisted 360 degrees clockwise. Following untwisting of the gallbladder torsion, laparoscopic cholecystectomy was performed successfully. No postoperative complications occurred, and the patient was discharged seven days after operation. Pediatric cases of gallbladder torsion are quite rare in Japan. Many reports have indicated that preoperative diagnosis is difficult, but accurate preoperative diagnosis has been increasing in recent years. Both US and CT are useful in making the diagnosis of gallbladder torsion. In a case of acute abdomen in a child especially with gallbladder torsion, exploratory laparoscopy may be useful to obtain a successful outcome.

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A 57-year-old man was admitted for conscious disturbance, hemolytic anemia, thrombocytopenia and renal dysfunction. According to the result of ADAMTS 13 activity, he was diagnosed with thrombotic thrombocytopenic purpura (TTP). Plasma exchange and hemodialysis filtration with the use of steroid improved his condition. Thirty days later, sudden epigastralgia occurred, and the symptoms progressed in spite of several drug therapies. Abdominal computed tomography showed an air shadow in the gallbladder and intrahepatic bile duct. Under a diagnosis of emphysematous cholecystits, percutaneous transhepatic gallbladder drainage was performed ; nevertheless, his condition worsened. The cholecystectomy was selected by open laparotomy. The patient recovered without any events and was transferred to the division of hematology on the 11th postoperative day.

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We report a case of multiple carcinoma of the gallbladder showing different histological types with pancreaticobiliary maljunction. A tumor of the gallbladder was detected by abdominal ultrasonography in a 58-year-old female previously diagnosed with gastric ulcer. A contrast CT scan of the abdomen revealed a thickened enhanced wall at the bottom of the gallbladder and swelling lymph nodes around it. A pancreaticobiliary maljunction of category IIa of the new Komi classification was disclosed by ERCP. A diagnosis of carcinoma of the gallbladder with pancreaticobiliary maljunction was made and a full thickness cholecystectomy, resection of extrahepatic bile duct and level 2 lymph node dissection were performed. We found three tumors in the gallbladder specimen. Based on pathological examination, a diagnosis of multiple carcinoma in three different histological types was made. This is the first reported case in Japan.

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We report a case of early cholangiocarcinoma with congenital biliary dilatation in a young adult. A 28-year-old male was checked for upper abdominal pain. His laboratory data indicated acute cholangitis and pancreatitis, so a further examination was performed. Endoscopic retrograde cholangiopancreatography showed cystic dilatation of the common bile duct with pancreaticobiliary maljunction and a dilated pancreatic duct with pancreatolithiasis. A wall irregularity was seen in the inferior part of the common bile duct. We diagnosed it as congenital biliary dilatation with pancreaticobiliary maljunction. Cholecystectomy and resection of extrahepatic bile duct with choledochojejunostomy were performed. The epithelium of bile duct and gall bladder showed hypertrophy and scattered erosion. Histologically, hyperplasia, metaplasia and dysplasia of epithelium were scattered in the bile duct. A small carcinoma in situ (2 mm) had developed in the inferior part of the bile duct accompanied with a mucosal lesion in the background. In immunohistochemical staining, p53 was overexpressed in the nucleus of carcinoma cells and dysplastic cells. Hyperplastic change was recognized in the epithelium of gall bladder, but there was no apparent malignant change. The patient is doing well without any symptoms and signs of recurrence.

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A 56-year-old woman visited our hospital because of heart burn. Abdominal ultrasonogram demonstrated a hypoechoic mass in the dorsal portion of the pancreas head. Abdominal computed tomography (CT) showed a low-density, well-circumscribed solid mass in the same area. Magnetic resonance imaging (MRI) scan revealed a homogeneous mass of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Endoscopic retrograde pancreatography gave normal findings in the main pancreatic duct. No abdominal tumor stain or vascular encasement was found on angiography. A definite diagnosis could not be made preoperatively, so we performed a pylorus preserving pancreatoduodenectomy. Histopathological examination of the pancreatic mass revealed schwannoma and no sign of malignancy. The S-100 protein by immunohistochemical stain was positive. Pancreatic schwannoma is very rare : only 29 cases of pancreatic schwannoma have been reported in the Japanese literature. It is very difficult to diagnose schwannoma of the pancreas preoperatively.

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A 46-year-old man with von Recklinghausen's disease was treated for carcinoid tumor of the papilla of Vater with pancreas divisum. The patient had been diagnosed with von Recklinghausen's disease at the age of 15 years and had been followed for the last five years due to chronic pancreatitis with main pancreatic duct dilatation. He was admitted to our hospital for evaluation of elevated ALP and γGT associated with common bile duct dilatation. The patient was diagnosed to have carcinoid tumor of the papilla of Vater measuring 2 cm in diameter with pancreas divisum by panendoscopy and endoscopic retrograde cholangiopancreatography. Endoscopic ultrasonography and abdominal CT revealed the tumor had invaded the pancreatic duct without obvious lymph node metastasis. Thus, pylorus-preserving pancreaticoduodenectomy (PpPD) was performed. Histopathologically, the tumor was diagnosed as invasive carcinoid tumor with lymph node involvement. Although the optimal surgical treatment for carcinoid tumor of the papilla of Vater is yet to be determined, from the standpoint of size, depth of invasion, and umbination with pancreas divisum, PpPD seems to be reasonable treatment for this case.

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A 53-year-old woman was referred to our hospital with tumor of pancreas head, which had been detected on abdominal CT at the other hospital. The patient was asymptomatic. All her laboratory investigations, including serum hormones were within normal limits, except for a slightly raised urinary 5-hydroxyindole acetic acid. Abdominal enhancement dynamic CT scan showed an enhanced round nodular tumor approximately 15 mm in diameter occupying the pancreatic head. The tumor was well enhanced from early to late phase, and the hypervascularity was a typical sign of an endocrine tumor. Endoscopic ultrasonography showed a hypoechogenic tumor in the pancreas. These findings strongly suggested a pancreatic endocrine cell tumor. We performed pyloric ring preserving pancreatoduodenectomy (PPPD) because the preoperative diagnosis was a non-functional pancreatic endocrine cell tumor. The tumor was successfully removed and immunochemical stains were positive for serotonin. The final diagnosis was pancreatic carcinoid tumor. We report a case of a pancreatic carcinoid tumor detected at an early stage by abdominal CT and endoscopic ultrasonography.

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A 72-year-old man, who had undergone distal gastrectomy with Billroth-I reconstruction for a diagnosis of early gastric cancer elsewhere 8 years earlier, underwent total resection of the gastric remnant, splenectomy, and Roux-en Y reconstruction for cancer of the gastric remnant in December 1999. The removed tumor was 5cm in diameter, type 2, T2, N0, H0, P0, and Stage IB. Abdominal CT scan conducted in July 2000 detected a 1-cm sized tumor in the pancreatic body, which increased to 3.0cm in diameter 4 months later and at the same time tumor markers increased. MRCP showed no abnormalities in the main pancreatic duct, so that metastatic pancreatic cancer or a tumor of the pancreatic islets was diagnosed preoperatively. During surgery we saw that the tumor of the pancreatic body had invaded the 4^th portion of duodenum. Thus partial duodenectomy with associated resection of the pancreatic body and tail was performed. Histologically it was moderately differentiated adenocarcinoma which was the same histologic type as the cancer of gastric remnant had. There was no atypia in the epithelium of pancreatic duct. Pancreatic metastasis of cancer of the gastric remnant was definitely diagnosed. Thereafter the patient experienced hepatic metastasis, local recurrence, and lung metastasis, however, he responded well to intensive care mainly with S-1. He died of recurrence of the disease 6 years after the resection of the pancreatic metastasis.

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