A questionnaire survey was conducted on postoperative use of fresh frozen plasma (FFP) in randomly-sampled 244 departments of the gastroenterological (GE) surgery and 206 departments of cardiac (CA) surgery in Japan. There were 152 GE (62.8%) and 113 CA (55.4%) responses to the questionnaire. FFP was routinely used in 19.7% of GEs and 39.8% of CAs. Ten units per day for three days for hepatic resection or liver cirrhosis was the typical prescription in GEs. Also ten units per day for two days for great vessel surgeries was prescribed in CAs. Coagulation tests were mandatory in 56% of GEs and 53.1% in CAs. The trigger for FFP use according to the guideline in Japan (PT INR≥2.0 or ≤30% and APTT≥twice normal value or ≤25% was considered excessive 46.1% in GEs and 46.0% in CAs. FFP/RCC (consumption ratio of FFP to RCC) in Japan is 0.54, more than twice that (approximately 0.2) in western nations. Since the effect of prophylactic use of FFP for non-bleeding patients is not confirmed, FFP should be used according to the guideline, confirming abnormality of coagulation tests. (185 words)

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Objectives : We tried to clarify the most appropriate management for simple bowel obstruction and effective methods for diagnosis of strangulated bowel obstruction. Method : Consecutive 252 cases of mechanical small-bowel obstruction treated in the hospital from 2000 to 2005 were assessed retrospectively. Results : There were 219 cases of simple obstructions and 33 cases of strangulated obstruction. Seventy-eight percent of simple obstruction cases were treated conservatively (fasting in 82, decompression tube treatment in 88 and operation in 49). The average duration for indwelling the decompression tube was 5.2 days and the amount of discharge from the tube decreased day by day. In the cases of operation, the operation was performed on the 4.5th day after admission on the average, and the average amount of tube discharge before the operation was more than 450ml/day. On the other hand, strangulation was most frequently diagnosed by enhanced abdominal CT scan, followed by physical examination, and the properties of decompression tube discharge in this order, and the blood data were only used for reference. Conclusion : Simple small-bowel obstruction should be treated by surgical therapy if symptomatic remission could not be gained by five days after beginning of the treatment. Enhanced abdominal CT scan is the most useful method for diagnosis of strangulation in an early stage of ischemia.

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Objectives : We studied the clinical efficacy of arterial chemoinfusion therapy through an implanted port system for patients with intrahepatic cholangiocarcinoma (ICC). Methods : Thirty patients with unresectable ICC or intrahepatic recurrence of ICC after surgery were enrolled for the study. A comparison was made for survival rate between patients who received arterial chemoinfusion therapy through an implanted port system with adriacin and lecithin-added lipiodol emulsion (n=5) and those with 5-fluorouracil (5-FU) (n=7). The remaining 18 patients were treated without port system. Results : Disease was stable in five patients with adriacin and lecithin-added lipiodol emulsion and in three patients with 5-FU. Disease progressed in four patients with 5-FU. The mean survival period was 20.8 months in patients with adriacin and lecithin-added lipiodol emulsion (group 1), 9.3 months in patients with 5-FU (group 2), and 10.5 months in patients without port system (group 3). There was a statistically significant difference between group 1 and 2 (p=0.02), or between 1 and 3 (p=0.04). Conclusion : Arterial chemoinfusion therapy through an implanted port system is useful for patients with intrahepatic recurrence of ICC after surgery.

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A 63-year-old woman needed a long term total parenteral nutrition (: TPN) since July 2003 for chronic intestinal pseudo-obstruction. In September 2006, she developed high fever and pancytopenia. DIC due to sepsis was suspected caused by the infection of central venous catheter. She was treated with antibiotics, blood transfusion, platelet infusion and gabexate mesilate without improvement. When serum levels of folic acid and microelements were measured, folic acid and copper were low. Accordingly pancytopenia due to folic acid and copper deficiency was diagnosed. We started the daily administration of folic acid and microelements preparations immediately. Then the pancytopenia was improved. A close follow up is recommended for the patient who undergoes long term TPN with the possibility of folic acid and microelement deficiency in mind. Retrospectively we regret not considering such a clinical possibility in this case.

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We report here a very rare case of intraductal papilloma of a male breast. A 50-year-old man was referred to our hospital with the chief complaint of single-orifice bloody discharge in his left breast. However, no tumor was palpable, and no mass was detected in mammography and US. The cytological report of nipple discharge was class III (suspicious). Areolar preserved skin sparing mastectomy was performed, and the thin-sliced resected specimen macroscopically revealed a 0.5 × 0.3 cm intracystic papillary tumor in the subareolar area. Histological examination detected intraductal papilloma, and no malignant findings were observed. He has evidenced no sign of recurrence for 10 months after the operation.

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We encountered a case of anomalous arterial supply to the left basal lung in which chest rentogenography, enhanced CT and especially 3D CT were effective to reveal the feeding area of normal and abnormal arteries and resected the lesion safely via video-assisted thoracoscopic surgery. A 56-year-old woman was found to have abnormal chest rentogenographic finding without any symptom. She had been diagnosed as pulmonary sequestration by an examination after health screening and had been advised but rejected operation when 46 years old. The chest rentogenography showed a tumorous shadow posterior to the heart. Computed tomography showed volume loss of the left lower lobe, severely dilated vessels and congestion of the whole left lower lobe. Because enhanced 3-dimensional computed tomography revealed an abnormal artery, 13 mm in diameter, arising from the descending aorta inflated to the basal segment posterior to the inferior pulmonary vein, we diagnosed anomalous arterial supply to the left basal lung. We decided to perform an operation because of both volume loss of the whole lobe and severe congestion. Left lower lobectomy was performed via VATS. Postoperative vital capacity and forced expiratory volume in 1 second were diminished a little.

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We have treated two patients who developed tracheostenosis after tracheotomy by using the Dumon stent. The causes of tracheostenosis were membranous granulomatous stenosis in one and tracheomalacia in the other patient. Radical operation was impossible in both patients. Thus cauterization and temporary indwelling of a Dumon stent were employed for one patient (patient 1) and semi-permanent indwelling of the stent for the other (patient 2). No apparent re-stenosis has occurred in the patient 1 and no granulation surrounding the stent or dislocation of the stent has occurred in the patient 2 up to now.
We consider that our correct understanding of pathologic condition of the patient may lead to a good therapeutic outcome even by non-surgical therapies.

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The patient was a 53-year-old woman who had had repeated bouts of pneumonia since the age of seven and had been treated by another hospital until December 2001, when she was suspected to have an esophagotracheal fistula by upper gastrointestinal series. Then she was referred to the hospital and was admitted for the purpose of operation in May 2002. Esophagography showed dilatation of the intrathoracic anterior portion of esophagus, efflux of contrast material to the right bronchus, and dilatation of right bronchi lobaris inferior. Further upper gastrointestinal endoscopic and bronchoscopic examinations identified the opening of the fistula. Transvenous pulmonary angiography visualized occlusion of the middle anterior and posterior branches of the right pulmonary artery which were associated with destroyed lung of the lower lobe of right lung. The patient underwent the resection of the fistula and right lower lobectomy of lung under right thoracotomy with the diagnosis of esophagotracheal fistula and destroyed lung of the right lower lobe in May 2002. No efflux of contrast material from the resected portion was demonstrated by postoperative esophagography. The patient was discharged very much improved on the 12^th hospital day.

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A 42-year-old woman, during the treatment of systemic sclerosis, was diagnosed as having esophageal cancer and pharyngeal cancer on mass screening. At first, she had undergone chemoradiotherapy for the pharyngeal cancer which resulted in complete remission. Then she was admitted to our hospital for the treatment of esophageal cancer. Since the esophageal cancer was evaluated as m3 invasion with 8cm-long lesion, we performed transthoracic esophagectomy with two-field lymph node dissection and reconstructed with gastric tube. Histopathological examination showed poorly differentiated squamous cell carcinoma, pT1a (pMM), pN0, M0. Furthermore, the degree of thinness of squamous epithelium and fibrosis of muscle layer in the non-cancerous esophagus was relatively weak, which is typical in the esophagus accompanying systemic sclerosis. Recently, there have been increasing case reports of systemic sclerosis accompanied with malignancy. Although cases of esophageal adenocarcinoma with systemic sclerosis have been reported, patients with esophageal squamous cell carcinoma accompanying systemic sclerosis are extremely rare.

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Pulmonary alveolar proteinosis (PAP) is a rare respiratory disease in which surfactant protein signal aberration leads to alveolar retention of lipids and proteins. In this study, we report a 53-year-old male with esophageal cancer accompanied by PAP. The preoperative diagnosis was type I in the mid-thoracic esophagus (Mt), T2 (MP), N0, M0, and stage II lesion. The patient had a medical history of PAP exacerbation. He had undergone lavage of the bilateral lunge under general anesthesia. Considering that postoperative respiratory complications such as exacerbating PAP may cause respiratory failure, resulting in a fatal outcome, it was difficult to select surgery or chemoradiotherapy (CRT). Now PAP is a disease with a survival expectation, so an adverse event with damage to the lungs from CRT controls the prognosis. We considered the complete response (CR) and recurrence rates of CRT for T2 ∼ T3 esophageal cancer and the risk of salvage surgery after CRT, then chose to perform surgery, after which the patient was discharged. The patient has been treated at the outpatient clinic during the 10-month postoperative follow-up.
We report this patient, and review the literature.

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In order to improve the nutrition and hydration status of patients with amyotrophic lateral sclerosis (ALS), a gastrostomy has been indicated for those patients who have dysphagia. However, to perform endoscopic gastrostomy (PEG) for those patients with respiratory insufficiency is very risky, so sufficient respiratory function is required. Our contra-indication for PEG is 50% or less in %VC. On the other hand, percutaneous transesophageal gastro-tubing (PTEG) can be applied in such cases. In this case report, we performed PTEG for a patient who was under positive-pressure ventilation. It was possible to provide sufficient oxygen by continuing positive-pressure ventilation while we placed a gastro-tube. We had to remove the ventilation mask only during insertion of the catheter via nose. PTEG can be applied in cases of severe respiratory dysfunction such as ALS under positive-pressure ventilation.

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We experienced two cases of ileus caused by persimmon stone. The first case was a 79-year-old man with diabetes mellitus. He was diagnosed as ileus and treated with insertion of a long tube. Because contrast enema and CT revealed obstruction of the ileum by a tumor, laparotomy was done on the 15th day after admission. A 5.5×3.5 cm brownish oval mass was found to be incarcerated with ulceration of the ileum wall and the segment containing the mass was resected. Because he had eaten persimmon daily, we concluded that the mass was a persimmon stone. The second case was an 81-year-old woman. She was diagnosed as ileus and treated with insertion of a long tube. Contrast enema and CT revealed obstruction of the ileum by a tumor and we preoperatively diagnosed ileus caused by a persimmon stone because it had a mottled gas pattern in CT and she had eaten persimmon daily. Laparotomy was done on the 8th day after admission. A 6.0×3.5 cm brownish oval mass was resected by enterotomy. To avoid enterectomy, it is important to diagnose and operate as soon as possible.

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A 39-year-old man under treatment for depressive psychosis was admitted as an emergency case because of severe abdominal pain since swallowing alkaline dry cells three days before in November, 2004. Patient had tenderness in left abdomen, leukocytosis and CRP was positive. An abdominal radiograph revealed a mass shadow corresponding to dry cells in stomach. To remove foreign bodies, laparotomy was performed on the same day of admission. While incising the gastric wall using diathermy, there was a small-scale explosion with blue and white flames, without visceral damage. Findings in the mucous membrane was corrosive gastritis with multiple ulcers. 29 AA batteries and 2 triple A batteries were retrieved, and the metal of electric poles were almost melted away. He was discharged on 17th postoperative day uneventfully. All the patients who swallowed size AA batteries were affected with psychiatric disorders reported in Japan. Alkali dry cells have risk of mucosal damage causing chemical burn and chemical generation of hydrogen in digestive tract. Explosion at the time of incision of stomach using diathermy mainly occurred in cases of bowel obstruction. All the cases of explosions were reported at the removal of foreign bodies in Japan. To prevent future medical accidents, we do not recommend using diathermy to incise colorectal region at anytime, peritoneum at perforative peritonitis and digestive tract at emergency laparotomy especially at the removal of foreign bodies.

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Some renal cell carcinomas recur several years after curative resection. Many metastatic lesions are found in the lung, liver, bone and brain. We experienced a rare case of gastric metastasis from renal cell carcinoma about 2 years after radical nephrectomy. A 77-year-old man was admitted to the hospital because of hematoemesis. Gastric endoscopy showed type 1 tumor about 5 cm diameter in the upper part of the stomach body. We diagnosed gastric metastasis because the biopsy specimen was similar to the histological findings of the renal cell carcinoma that had been removed 2 years ago. Then we performed total gastrectomy with D2 lymph node dissection. The pathological examination showed that the gastric tumor was metastasis from left kidney because it was constructed of malignant cells, had eosinophilic cytoplasm and proliferated with pseudo-tubular structure the same as the removed renal cell carcinoma.

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We report a case of an 80-year-old woman with duodenal polyp 2 years after distal gastrectomy and reconstruction of Roux-en-Y anastomosis. Follow-up abdominal CT revealed a tumor near the 2^nd portion of the duodenum. Further examination (MRI, abdominal angiography, abdominal angiographic CT) revealed the tumor was hypervascular. Paraganglioma, endocrine tumor of the pancreas, pheochromocytoma or duodenal tumor were suggested, and an operation was performed. Intraoperative findings showed the tumor was a polyp arising from the 2^nd portion of the duodenum, so duodenotomy and polypectomy were performed. It is difficult to find a tumor existing in the duodenal stump. After the operations forming a duodenal stump, careful follow-up was necessary for possible lesions of the duodenal stump.

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Pancreaticoduodenectomy is widely and reasonably regarded as the preferred treatment for pancreato-biliary cancer. However, this technique sometimes causes serious damage to patients. We report a case of carcinoma of the ampulla of Vater treated with transduodenal total papillectomy. A 63-year-old woman was diagnosed as adenoma, 1.5 cm in size, of the ampulla of Vater by gastrointestinal fiberscope and the stripped specimen revealed adenoma. We could not discriminate it from malignant neoplasm but diagnosed it as early stage, so we performed a transduodenal total papillectomy. The resected specimen showed adenocarcinoma including the ampulla of Vater and the surgical margin was negative. She has remained well for more than 5 years after the operation with no evidence of recurrence. In summary, endoscopic papillectomy has recently been performed for early-stage carcinoma and benign tumor of the ampulla of Vater. However it needs skillful techniques for complete resection and has a high risk of inducing bleeding and pancreatitis. Transduodenal total papillectomy can easily be performed and may be adequate for early carcinoma of the ampulla of Vater.

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We report a case of neuroendocrine cell carcinoma of the ampulla of Vater. A 66-year-old man was found by abdominal CT 4 years after an operation for rectal cancer to have a tumor in the lower bile duct. Endoscopy revealed a tumor with ulcer at the ampulla of Vater, and histological examination showed poorly differentiated adenocarcinoma. Tumor markers were within normal levels in CEA and CA19-9. We performed a pyrolus-preserving pancreatoduodenectomy, and found a 35-mm tumor at the papilla. Tumor cells were positive for synaptophysin, CD56 and serotonin, and some diagnosed as neuroendocrine cell carcinoma. He was found to have multiple liver metastases on abdominal CT 4 months after operation, and died 12 months after surgery. Neuroendocrine cell carcinoma of the ampulla of Vater is rare, with a poor prognosis.

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We report a long-term survival case of adenoendocrine cell carcinoma in the papilla of Vater. A 57-year-old woman admitted for jaundice was found to have adenocarcinoma in the papilla of Vater. A pancreaticoduodenectomy was done. Histological findings showed adenoendocrine cell carcinoma in the papilla of Vater. Liver and paraaortic lymph nodes metastases were found 7 months after surgery. Chemotherapy with CDDP and CPT-11 and radiation therapy were given sequentially according to the therapy for small cell carcinoma of lung. The evaluation was PR, but the patient died 18 months after surgery. This case suggested that multidisciplinary treatment including chemotherapy and radiation is effective at least short-term for patients with adenoendocrine cell carcinoma of the papilla of Vater.

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The patient was a 92-year-old man who had undergone distal gastrectomy with Billroth II reconstruction for gastric cancer 40 years earlier.
The patient was admitted to the department of internal medicine in our hospital because of a one-week history of vomiting and aspiration of vomited gastric content. On the 4^th hospital day, massive hemorrhage from the jejunum of unknown origin developed and hemostasis was achieved by coil embolization under x-ray fluoroscopy. Thereafter endoscopic study was performed to identify the bleeding site, when a huge foreign body was detected on the afferent loop side of the jejunum. The foreign body could not be removed by endoscopy. The patient developed jejunal perforation 6 hours after the endoscopic study, and an emergency laparotomy was performed. It disclosed that a Braun anastomosis had added to Billroth II reconstruction in the former operation, and that a perforated site 5mm in diameter was present 10cm distal to the Braun anastomosis. And the foreign body 6.5cm in diameter was identified in the perforated jejunum. Partial resection of the perforated jejunum was performed to remove the foreign body, and end-to-end anastomosis was performed. The intestinal foreign body was revealed to be a bile acid enterolith. The patient's postoperative course was uneventful. No recurrence has occurred after the last operation.

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A 66-year-old man was admitted to our hospital complaining of abdominal pain and diarrhea 43 days after ileocecal resection due to perforative appendicitis. Laboratory data indicated elevated WBC (18,100/μl) and eosinophilia (44.4%), and abdominal CT scan showed thickening of the intestinal wall near to intestinal anastomosis. Under a diagnosis of eosinophilic enteritis, symptoms improved by administration of steroid. Eosinophilic gastroenteritis is a relatively rare entity that characterizes peripheral eosinophilia and inflammation with eosinophilic infiltration into the gastrointestinal tract. We report a case of eosinophilic enteritis after operation for perforative appendicitis.

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A 92-year-old woman was admitted to the hospital because of recurrent vomiting and abdominal pain. The patient had no previous history of undergoing abdominal surgery. Abdominal plain X-ray films showed the dilatation of the small intestine. Abdominal CT scan revealed small quantities of ascites and the dilated small intestine on the dorsal aspect of the cecum and ascending colon. Intestinal obstruction due to an internal hernia near the ileocecal region was diagnosed, and an emergency surgery was carried out. Considering her age and underlying diseases, we employed epidural anesthesia. During the operation, a hernia opening was present at retrocecal position, through which the terminal ileum was incarcerated. The incarcerated ileum was about 30cm in length, and was located 20cm proximal to the ileum end. Partial resection of the ileum was carried out, and the hernia opening was plicated. Internal hernia must always be kept in mind as one of possible causes of intestinal obstruction in patients with no previous history of abdominal surgery.

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Carcinoma of small intestine is a rare disease, especially developing from Meckel's diverticulum. This is a case report of carcinoma of Meckel's diverticulum.
A 55-year-old man was admitted to our hospital because of abdominal pain and vomiting.
The abdominal X-P showed dilatation of small intestine with niveau formation. An ileus tube was inserted and a contrast study revealed stenosis of the ileum.
Because of resistance to conservative therapy, operation was performed. Partial small intestinal resection was done, and in the resected segment a tumor was found in the ileum 60cm above Bauhin valve. Histological findings of the resected tumor were consistent with moderately differentiated adenocarcinoma at the diverticulum which was considered to be Meckel's one and also there was lymphatic metastasis.

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An 18-year-old woman was admitted to our hospital because of right lower abdominal pain. Because contrast-enhanced CT scan of the abdomen showed an enhanced mass connecting with the cecum with calcification and gas. An emergency operation was performed with a diagnosis of acute appendicitis. The appendix which looked like an inflammatory tumor was dissected and an appendectomy was performed. On microscopic examination, acute inflammatory infiltration was present in the appendiceal lumen, and intraserosal fibrous tissue involving neural cells proliferated. Immumohistochemical studies showed that the tumor cells were positive for s-100 and NSE and negative for Glimerius and Chromogranin A.
Neoplasms of the appendix are uncommon, and the most common of them is carcinoid followed by mucinous adenoma and adenocarcinoma, however, the other benign tumors are very rare. We report this rare case of an appendiceal neuroma diagnosed by immunohistochemical studies.

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We report a case of vesicosigmoid fistula complicated with diverticulitis of sigmoid colon. The patient was a 48-year-old male with a history of previous hospital admission due to diverticulitis of colon. He had recurrent episodes of urinary tract infection since around 2003. He came to our hospital with complaints of mixture of air in the urine and episodes of fever in February 2005. A CT study revealed an inflammatory mass at the site of adhesion of sigmoid colon with multiple diverticulae to upper left side of bladder. Air was present in the bladder. A barium enema revealed multiple diverticulae of sigmoid colon with fistula formation, however bladder was not visualized in this study. A cystoscopic study revealed a compression of the bladder wall larger than the tip of thumb from outside. The bladder mucosa around the area showed chronic inflammation. With diagnosis of vesicosigmoid fistula due to diverticulitis, the patient was operated on in April 2007. The sigmoid colon and part of the bladder was resected with the fistula en bloc. Post operative course was uneventful without further recurrence of urinary tract infection.

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We report a case of sigmoid colon tubulovilloous adenoma detected by PET concomitant with PET-negative advanced ascending colon cancer. An 82-year-old woman was admitted for further examination of an abnormal shadow in a chest X-ray. Chest computed tomography (CT) revealed an atelectasis of the left upper lobe and an obstruction of the left main bronchus. Her serum Pro GRP level was high. A bronchoscopic examination did not permit a definite histological diagnosis, and she underwent FDG-PET. It indicated two FDG accumulations on the left lower abdomen and the left lung field. Bronchoscopy and colonoscopy were performed. The tubercle bacillus was detected from the clearing solvent of bronchoscopy with re-examination, and the diagnosis was bronchial tuberculosis. She was found on endoscopic examination to have a tumor-like type Ip on the sigmoid colon and a tumor-like type 2 on the ascending colon. The former accorded with the PET accumulation, but the latter did not. Endoscopic mucosal resection was performed on the tumor of the sigmoid colon. One month later, a laparoscopic-assisted right hemicolectomy was performed on the tumor of the ascending colon. Histopathologically, the tumor in the sigmoid colon was diagnosed as tubulovillous adenoma, while the tumor in the ascending colon was diagnosed as well-differentiated adenocarcinoma.

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A 71-year-old woman, who had undergone a ileotransversecolostomy at 20 years old, was seen at our hospital because of right lower abdominal pain. As a result of close examination, an ascending colon cancer and left renal cancer were observed. During the operation, the ascending colon cancer was found to be in a blind loop, and so a right hemi-colectomy with the blind loop and left nephrectomy were performed. Histopathologically, diagnosis was moderately differentiated adenocarcinoma of the ascending colon and abscess with severe inflammation of residual appendix vermiformis. Colon cancer that has developed in a blind loop tends not to show hematochezia and/or ileus symptom because of bypass. Therefore, it is thought that making a blind loop should be avoided if possible.

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A case of curative resection for Douglas' pouch recurrence 11 years after operation for ascending colon was reported, whereas most cases with colon cancer recurrent within 5 years after surgery. A 69-year-old woman underwent right hemicolectomy for ascending colon cancer which pathological examinations revealed to be moderately differentiated adenocarcinoma. Postoperative oral adjuvant chemotherapy (fluoropyrimidine drugs) was performed for 7 years, and the CEA and the CA19-9 level remained within normal range. However, the CEA and the CA19-9 level increased 11 years after the first surgery, and a tumor was detected 8 cm from the anal verge of the rectum by colonic endoscopy. The tumor was also confirmed by computed tomography and PET examinations. These data indicated rectal cancer or Douglas' pouch recurrence of ascending colon cancer, and she underwent low anterior resection and adnexectomy. Pathological study revealed metastatic adenocarcinoma from ascending colon cancer invading in the rectum and vagina. The CEA and CA19-9 level reduced to the normal range postoperatively, and oral adjuvant chemotherapy (fluoropyrimidine drug) has been carried out.

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A 75-year-old man was seen at the hospital because of anal bleeding on defecation in April 2005. Colonoscopy showed a type IIa lesion at the lower rectum, and then endoscopic mucosal resection (EMR) was performed on June 9. The histopathological diagnosis was moderately differentiated adeocarcinoma, SM (800μm), ly1, and v0. Low anterior resection of rectum was performed on June 30. The clinical stage was SM, N0 (0/8), H0, M0, P0, and Stage I. After discharge, the patient was seen at the hospital because of the abrupt onset of high fever and unconsciousness. Abdominal CT scan showed an increase in a tumor in the vicinity of the lower part of ureter and left internal iliac artery which had been diagnosed as thrombotic aneurysm at the former abdominal CT scan. A part of the ureter upward from the tumor remarkably dilated, so that obstruction of the ureter and acute pyelonephritis were diagnosed. Following drainage of the ureter, FDG-PET examination and CT-guided needle biopsy were performed for exploration of the tumor. The histopathological diagnosis was metastasis of rectal carcinoma to the obturator lymph node, and the metastatic lesion was diagnosed as solitary because no other metastatic lesions were seen. No more increase in the tumor size had been observed with chemoradiotherapy, but he died of respiratory failure due to multiple lung metastases on June 16, 2006.
It is very rare that submucosal invasive cancer of the rectum metastasizes solitarily to the main lymph nodes like in this case.

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The patient was a 45-year-old man who had been suspected to have Crohn's disease because of rectal stricture, anal pain, and a complicated anal fistula since 8 years earlier, but had been treated repeatedly only for the anal fistula. The anal fistula had not improved, and a colostomy was performed 3 years earlier. The anal fistula showed an improvement, but the patient was admitted to the hospital because anal pain recurred and the amount of mucus discharge started to increase one year before admission. Following close exploration we could not make the definite diagnosis of Crohn's disease. Cancer in the anal fistula associated with Crohn's disease was suspected from the complicated anal fistula and mucus discharge, and amputation of the rectum was performed. Histopathologically, cancer cells were found in the anal fistula, and the adjacent tissue was affected by Crohn's disease.
We often have difficulties in diagnosing cancer in an anal fistula associated with Crohn's disease. However, if cancer in an anal fistula is suspected because of mucus discharge or changes in the affected anal area, and it informed consent is obtained from the patient, rectal amputation should be considered.

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A 73-year-old female was admitted complaining of edema and general fatigue at the end of March, 2006. She had been diagnosed as nephrotic syndrome since 1979. She received steroid therapy, which reduced the symptom of nephrotic syndrome but led to diabetes mellitus. She had been treated as an outpatient. Recurrence of nephrotic syndrome occurred in March 2006. Laboratory data in admission were as follows ; serum albumin, 1.9 mg/dl ; creatinine, 1.47 mg/dl ; and total urine protein, 8.69 g/day. She began treatment with Cyclosporine A (CyA) for steroid-resistant nephrotic syndrome, which improved her clinical symptom. In her hospital stay, she had a colon examination, and was diagnosed with colon cancer. She underwent right hemicolectomy with D3 lymph node dissection. We considered that her inadequate CyA blood level might lead to infectious complications, tissue fragility and deteriorated tissue curability, so we measured the blood CyA levels to adopt the best-fit dose. Nevertheless, the patient's renal function exacerbated after the operation, and it took about seven weeks until her renal function recovered the preoperative level.

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A 57-year-old man had had anti-HCV antibody since 10 years earlier. A high echoic mass 2.6cm in diameter was showed in the S2 area by ultrasonography. The mass had been followed as a hemangioma. Seven months later, the mass increased slightly and CT scan demonstrated a low density mass. The Tumor was visualized as a hypointense mass on T1-weighted MR images, and as a hyperintense mass on T2. We presumed the tumor to be a hemangioma or hepatocellular carcinoma and the tumor was surgically resected. The tumor was composed of spindle-shaped and epithelioid smooth muscles, adipose tissues and proliferating blood vessels, and these histological findings confirmed the diagnosis of hepatic angiomyolipoma (AML). In a review of 79 cases of hepatic AML reported in Japan, 11 cases were of hepatic AML showing an increasing tendency. In all 11 cases a possibility of malignant neoplasm could not be ruled out and surgical resection was done. In cases of hepatic AML in which chronic hepatitis is associated and the tumor grows like in this case, surgical resection to obtain the definite diagnosis would be required.

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The patient was a 73-year-old man, who had undergone total gastrectomy and low anterior resection of rectum for gastrointestinal stromal tumor (GIST) of the stomach and rectal cancer on February 26, 2001. Histopathological studies disclosed that the greater part of the primary lesion of gastric GIST was c-kit (+) and CD34 (+), but deep part of the tumor was c-kit (-) and CD34 (-). Multiple hepatic metastases were noted in March 2003, and oral administration of imatinib mesylate was started in September that resulted in shrinkage of the metastatic foci. Abdominal CT scan conducted in August 2004 showed enlargement of the hepatic metastatic foci and abscess formation, and then percutaneous hepatic drainage was performed when discharge mixed with blood and pus was drained. The patient died of septicemic shock on October 16. At autopsy the hepatic metastatic foci showed coexistence of cystic lesion which was associated with hemorrhagic necrosis and almost lacked proliferation of tumor cells and solid component with the same histological findings of c-kit (-) and CD34 (-) as the deep part of the primary tumor had. It was considered that these negative components were resistant to imatinib mesylate and survived persistently.

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Biliary cystadenocarcinoma is a rare disease. We report an elderly case of huge biliary cystadenocarcinoma. An 84-year-old man was admitted to our hospital because of upper abdominal discomfort. US, CT and MRI revealed that he had a 20×16cm tumor in his left lobe. Lateral segmentectomy was performed because he was old and a high-risk patient, and there was no invasion around the tumor. A diagnosis of biliary cystadenocarcinoma was made based on the histopathological finding of an adenoma in the cystic wall and a well-differentiated adenocarcinoma.

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Intraductal growth (IG) type of intrahepatic cholangiocarcinoma (ICC) is a rare disease of hepato-biliary malignancy. We report here a patient who had a double cancer consisting of hepatocellular carcinoma (HCC) and GI type of ICC.
A 67-year-old man was referred to our hospital because of hepatic tumors. Preoperative computed tomography (CT) and angiography demonstrated two discrete masses in the medial-to lateral segments and segment 8 of the liver. An extended left-hemihepatectomy was performed. Pathological findings revealed that one tumor was typical HCC, and the other was IG type of ICC associated with hepatolithiasis. The postoperative course was uneventful. The patient has been well without any evidence of recurrence of hepatic tumors as of 2 years after the operation. Although the prognosis of the intraductal growth type of cholangiocarcinoma has been quite good after complete surgical resection, our surgical patient should be carefully observed for recurrences because he had hepatocellular carcinoma as well.

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We experienced a case of benign intrahepatic strictures which was difficult to differentiate from cholangiocellular carcinoma.
A58-year-old man was referred to our hospital with intrahepatic bile duct dilatation. Laboratory data showed no abnormalities. Ultrasonography (US) showed dilatation of left intrahepatic bile duct, and a low echoic mass of 15 mm at the central portion. Cholangiograms demonstrated irregular narrowings of the left intrahepatic bile duct and cystic dilatations of the peripheral bile duct, and aspiration cytology of bile indicated class I. The second US after 6 months showed growth of the low echoic mass to 27 mm. With suspicion of cholangiocellular carcinoma, left hepatectomy was performed. Pathological findings revealed fibrosis and inflammation of the intrahepatic bile duct without malignancy. Benign intrahepatic bile duct stricture is rare and sometimes difficult to differentiate from malignancy, therefore hepatic resection should be considered for this condition with suspicion of malignancy.

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A 77-year-old man was admitted to our hospital because of acute progress of cholecystitis which had been treated conservatively at another hospital. He had undergone distal gastrectomy with Billroth II reconstruction for duodenal ulcer. Abdominal US showed cholecystitis with small stones. Abdominal CT scan showed cirrhosis and splenomegaly, but did not visualize the right lobe of liver, right portal and hepatic veins. MRCP did not visualize the right biliary ducts. Therefore, we diagnosed the case as cholecystitis without right hepatic lobe. We performed laparoscopic cholecystectomy plus T tube drainage after percutaneous drainage of the gallbladder. The diagnosis of lack of the right hepatic lobe was corrected to atrophy of the right lobe because intraoperative cholangiography detected the right intrahepatic bile ducts. The patient's postoperative course was almost satisfactory except bile leak.

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A 74-year-old woman having a history of recurrent attacks of hypoglycemia attributable to insulinoma was admitted to our hospital. The findings of biochemical examinations, computed tomography, and arterial calcium stimulating with venous sampling (ASVS) resulted in the diagnosis of a solitary insulinoma of pancreatic tail. Laparoscopic distal pancreatectomy was performed with preservation of the spleen and splenic vessels. The operation time was 105 minutes and blood loss was only 13ml. No complication and conversion to open surgery occurred. Serial blood sugar measurements revealed normal levels after operation. Postoperative course was uneventful, and the length of postoperative stay was 9 days. Laparoscopic distal pancreatectomy with preservation of the spleen and splenic vessels is a safe and feasible option for the treatment of insulinoma in the tail of pancreas.

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An 81-year-old man complaining of jaundice and brownish urine was found having a multilocular cystic lesion about 6cm in diameter at the pancreas head by abdominal ultrasonography and contrast-enhanced CT scan. Direct invasion of the tumor to the duodenum and dilatation of the common bile duct were suggestive, but no dilatation of the main pancreatic duct was demonstrated. Upper gastrointestinal endoscopic study showed a tumor exposed in the lumen of the duodenal bulb as well as large volumes of mucus. PTCD showed a tapering narrowing at the lower portion of bile duct. Adenocarcinoma was diagnosed by cytodiagnosis of bile juice. From these findings, we performed an operation with the most likely diagnosis of pancreatic mucinous noncystic carcinoma or invasive carcinoma derived from a branch-type intraductal papillary mucinous tumor (IPMT). Histopathological study after the operation revealed acinous pattern of adenocarcinoma in the mucinous node, and thus pancreatic mucinous noncystic carcinoma was diagnosed. In this patient, preoperative examinations showed a multilocular tumor with poor enhancement arising from the pancreas head and invading the duodenum, and a biopsy of the tumor disclosed large volumes of mucus and high columnar and mucoepitheloid cells. Because of these findings, we had great difficulties in differentiating mucinous noncystic carcinoma of the pancreas from invasive carcinoma derived from an IPMT.

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The patient was a 61-year-old woman who had undergone high anterior resection of rectum for rectal cancer in June 2005, and the histological diagnosis of the tumor was Rs, type 3, 43×50mm in diameter, moderately differentiated adenocarcinoma, SE, N2, H0, P0, M0, and stage IIIb. The CEA level increased on the 7^th month after the operation, but no apparent findings of recurrence were revealed by abdominal CT scan. FDG-PET conducted for a purpose of general exploration disclosed abnormal accumulation in the right adrenal gland. Another abdominal CT scan showed a tumor about 2.5cm in diameter in the right adrenal gland. Blood biochemical studies revealed that catecholamine levels and adrenocortical hormone activities were in normal ranges so that a possibility of functional adrenal tumor was ruled out. From these findings, solitary adrenal metastasis of rectal cancer was diagnosed, and a right adrenalectomy was performed. The histopathological diagnosis of the removed tumor was adrenal metastasis of rectal carcinoma. The CEA level was normalized after the operation.
Solitary adrenal metastasis of colorectal carcinoma is rare and has no characteristic clinical symptoms, and thus early diagnosis based on imaging findings is difficult. Here we present a case of solitary adrenal metastasis of rectal carcinoma which was capable of being diagnosed by FDG-PET and operated on.

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A 59-year-old man underwent a total gastrectomy for gastric cancer invading esophagus via celiotomy and left thoracotomy accompanied with splenectomy and cholecystectomy in October 2001. The tumor showed Stage III A composed of T4 (diaphragma and liver), P0, H0, N0, and well-differentiated tubular adenocarcinoma histologically.
TS-1 100 mg was given as postoperative adjuvant chemotherapy for only 10 days because of side effects and then UFTE 1.5 g for 6 months. Abdominal CT scan 1 year and 7 months after gastrectomy revealed left adrenal metastasis, 18 mm in size. Despite 10 courses of chemotherapy with 5-Fu+Paclitaxel, the size of the adrenal metastasis increased to 27 mm. In June 2004, left adrenectomy (translumbar) accompanied with resection of left 11th rib was performed. Histological examination revealed adrenal metastasis from gastric cancer. The patient did well without recurrence or metastasis for 2 and a half years. We report a rare case of resected adrenal metastasis from gastric cancer.

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A 30-year-old female with sacral agenesis had a history of operation for horseshoe kidney and bilateral double kidney. She developed a fever and hip pain on December12, 2005, and visited the emergency room because of acute swelling, pain and red flare in the right perineum and right lower abdominal quadrant on December18. CT scan showed fluid retention at the dorsal aspect of the rectum and wide range of gas retention from the subcutaneous left femur, bilateral hip, perineum to right abdomen. She was diagnosed with Fournier's gangrene, and an emergency operation was performed. At surgery, all parts of the gas-containing area were opened and all the necrosed tissues were debrided. We washed the open wound everyday, and four more operations were performed before closing the wound. On the 81st postoperative day, with a slight raw area on her hip, she was discharged from the hospital. Fournier's gangrene is a disease that occurs mainly in men. A case of Fournier's gangrene in a patient with sacral agenesis has not, to our knowledge, been reported in Japan. Here, we report the case of a young woman with sacral agenesis who was successfully treated for an advanced case of Fournier's gangrene.

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A 67-years-old woman was admitted to the hospital with a diagnosis of intestinal obstruction due to coprostasis in October 2006. The patient's condition deteriorated 12 hours after admission. She was suspected to have intestinal necrosis and underwent an emergency operation. At the operation a portion of the large intestine from the transverse colon to rectum was excised. On the 2^nd postoperative day, mucosa of the artificial anus became necrotic and thus reoperation was performed, when the residual colon and terminal ileum by 30cm were removed. Non-occlusive mesenteric ischemia (NOMI) was diagnosed, because the intestinal necrosis was discontinuous and there were histopathological necrosis and intramural hemorrhage in the involved intestines.
NOMI has nonspecific physical findings and the symptoms progress slowly and gradually that often give us an impression that the disease might not be serious. This is a reason to lead to the delayed diagnosis and the resultant poor prognosis of the disease. In order to improve the life-saving ratio of the patients, it is important to keep the disease in mind and to start making diagnosis and treating when intestinal ischemia is in a reversible condition.

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An 86-year-old woman was admitted to our hospital because of periumbilical pain. On admission she had a sign of peritonitis. Abdominal CT scan showed an enlarged gallbladder and fluid collection around the gallbladder. Neither gallstones nor free air were observed. An emergency operation was performed under a diagnosis of acute cholecystitis with suspected perforation. Laparotomy showed biliary ascites around the Morison's pouch, but we did not identify bile leakage from the gallbladder or gallstones. Cholecystectomy and intraoperative choledochography were performed. Culture of biliary ascites yielded no bacterial growth. Histologically, neutrophil infiltration and necrosis were observed at the serosal site, and purulent peritonitis due to bile leakage through the gallbladder was revealed. The definitive diagnosis was biliary panperitonitis due to bile leakage through the gallbladder.

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A 75-year-old man suffering from chronic pulmonary emphysema underwent a chest CT scan which revealed an 8-cm mass under the left diaphragma. Ultrasonography, gastrointestinal endoscopy, endoscopic ultrasonography and abdominal angiography were performed, but a definite diagnosis was not made. The most likely diagnosis was a tumor arising in the peritoneum. The patient then underwent surgery for treatment and diagnosis of the abdominal mass. The mass was separated from the stomach and the pancreas. The mass was diagnosed as a tumor arising in the retroperitoneum at the hilum of the spleen. The tumor, 9 cm in diameter, was removed together with the spleen. There were many cystic parts in the tumor. On histopathological and immunohistological studies, tumor cells showed c-kit positive and CD34-positive characteristics. The tumor was not a metastasis from a gastrointestinal stromal tumor (GIST) arising in the gastrointestinal tract, but rather a GIST that had arisen in the peritoneum. GIST arising in the extra-intestinal tissue is rare and is sometimes called EGIST. We report the case here together with some bibliographical consideration.

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A 31-year-old woman was seen at the department of gynecology in our hospital because she was found to have an intraabdominal tumor at a medical examination for uterine cancer elsewhere. Close exploration showed a cystic tumor, and she was referred to our department of surgery for further exploration and treatment. However, we could not gain her consent for operation and decided to follow her clinical course. Thereafter teratoma was suggested by aspiration cytology and thus surgical resection was employed. Because the diameter of the tumor was 10cm, surgery was done through the transsacral approach, together with associated coccygectomy. The histopathological diagnosis was mature cystic teratoma, without malignant findings.
Here we report this case with some bibliographical comments because presacral mature teratoma in adults is rare.

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A 71-year-old man had been diagnosed as type II c early gastric cancer at cardia and so a proximal gastrectomy with D1 lymph node dissection was performed under general and epidural anesthesia. Early post-operative course was uneventful except for mild fever, however, on the 23rd post-operative day (POD), he noticed muscle weakness of the lower limbs, which generally worsened. Findings of Ga-67 scintigraphy and MRI revealed spondylitis at the lower thoracic vertebrae and blood culture showed methicillin-resistant Staphylococcus aureus (MRSA). These findings suggested MRSA spondylitis, so epidural catheter removal, intravenous vancomycin administration and complete bed rest for decompression of the vertebrae were carried out. He was discharged on the 111th POD. MRSA spondylitis is a rare but serious complication. Once it occurs, it takes a long time to cure and occasionally requires orthopedic surgery, so meticulous check including neurological findings for early diagnosis and adequate treatment is mandatory during and after epidural catheter usage.

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We report a case of femoral hernia with ovarian incarceration in a four-month-old girl. The patient was brought to the hospital with a chief complaint of a mass in the right inguinal region. We suspected an inguinal hernia with incarceration. We performed emergency surgery, and diagnosed a femoral hernia with ovarian incarceration and necrosis. We carried out right adnexectomy and repaired the hernia from inside the abdominal cavity.
An incarcerated femoral hernia is a rare disease in children, and only five cases have been reported. In addition, this is the first case in which an adnexectomy was performed. However, since preoperative diagnosis of a femoral hernia in children is difficult, when an incarcerated femoral hernia is suspected, diagnostic surgery should be performed before manual reduction is considered.

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We report a case of acute renal infarction after blunt abdominal trauma. A 13-year-old boy was seen at our hospital for severe abdominal pain and high fever after hitting his left-side abdomen during skiing. No open injury or subcutaneous hemorrhage was observed on his body. Laboratory examination showed elevation of WBC count, ALT (alanine aminotransferase), LDH (lactate dehydrogenase) and serum creatinine. Microscopic hematuria and proteinuria were also present. Plain abdominal CT examination could not offer any abnormal finding. On the 2nd hospital day, CT examination revealed interruption of left renal arterial blood flow and infarction of left kidney. After observation for several days without specific therapy, abdominal pain and fever were decreased, and he was discharged from the hospital. However, 6 months later, CT examination demonstrated complete atrophy of the left kidney. In cases of acute renal infarction, early diagnosis by CT scan and anticoagulant therapy or surgical procedure are critical to preserve renal function.

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An 81-year-old woman was admitted to our hospital because of yellowish discharge with hair and oil from a fistula in her right inguinal region. She had long complained of a painless lower abdominal mass and pollakisurea. We diagnosed a 9 × 8 cm mature cystic teratoma with inguinal abdominal fistula after further examination. In the operation, we confirmed that the primary lesion of the tumor was in the right ovary and that the tumor had adhered tightly to the right and back side of intra-pelvic cavity. In two fistulas in the right inguinal lesion, one was connected to the tumor through aponeurosis of external oblique muscle and internal inguinal ring, and the other was connected directly through the external inguinal ring. Right oophorectomy, excision of fistula, and hernia repair with the Bassini method were performed. No malignant lesion was seen from the pathological findings. Her complaint disappeared postoperatively. This is the first report of a mature ovarian cystic teratoma with inguinal abdominal fistula.

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