The ratio of “truth telling” to terminally ill patients is 78% in our hospital. The aim of this study was to analyze “non-truth telling” from the viewpoint of cancer patients and physician factors. A total of 566 terminally ill patients intervened during 2 years from April 2005 were divided into four groups ; “non-truth telling”, truth telling “until originated cancer”, “until metastases”, and “until prognosis”. The ratios of “non-truth telling”, truth telling “until originated cancer”, “until metastases”, and “until prognosis” to patients were 11%, 28%, 52%, and 9%, respectively. A mean age of patients in “non-truth telling” group was 77, and was the significantly (p<0.01) highest one among the four groups. The ratio of females was 68% in “non-truth telling” group, though the ratio of males was greater than females in other 3 groups. Our team intervened in “non-truth telling” patients for 16 days on an average. On the other hand, interventional periods in other groups were significantly (p<0.01) longer than “non-truth telling” group except for that in “until prognosis” group. The ratio of death in “non-truth telling” group was high in comparison with other groups, and that of discharge for home care was low. As to physicians in “non-truth telling” group, the working period after getting the doctor's license was significantly (p<0.05) shorter than those in “until metastases” and “until prognosis” groups. Our questionnaire survey on “truth telling” to physicians in our hospital disclosed that all the physicians thought that “truth telling” was necessary, but they told the truth to 41% of all patients, including those to whom physicians told the truth after hearing their hopes or intentions. Physicians with less experience were apt to entrust the matter of “truth telling” to the patient's family. There may be a tendency of deciding the truth telling to elderly patients by physicians and their families. We need the education and enlightenment to physicians about the truth telling in near future.

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To evaluate the validity of short-stay surgery (SSS) for inguinal hernia in children, we investigated 236 cases of SSS (less than 2 days admission) from clinical outcomes (safety, risk management and complications) and medical economic outcomes (standardization, hospital stay and diagnosis procedure combination (DPC)). There were no significant differences for the safety and complications from the former procedures (3 days admission). The lighter burden may increase patient satisfaction. Standardization of the management using clinical pathways may help shorten the mean hospital stay and decrease the risk management issues. However, the DPC system may tend to shift to outpatient management because of its cost-effectiveness. One-day SSS would be better management in the short term.
To improve medical services, we have to build up a better system, considering the balance of risk management, cost-effectiveness, and QOL for the patients.

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A 69-year-old man was performed distal gastrectomy⁺ R-Y anastomosis for gastric cancer (type 4) at the department of gastroenterological surgery in our hospital in January 2006. Pathological examination revealed poorly differentiated adenocarcinoma T3 N0 P1 H0 M0 CY1 Stag 4. In addition to persistent itching and arthralgia, hypercalcemia and high level of serum intact-PTH were recognized and then he was referred to our department. He had experienced renal stone three times. No recognizable mass in his neck was palpable. Laboratory data showed high serum values of Ca and intact-PTH, 10.2mg/dl and 128pg/ml, repsectively. From US findings of the neck, a parathyroid cyst was suspected. He underwent an operation in February 2006. Not only the light lower parathyroid (PT) but also the left upper PT were diagnosed as cystic mass by intraoperative frozen section diagnosis. We could not rule out a possibility that they were hyperplasia of parathyroids, and performed total parathyroidectomy. Hypercalcemia was improved and intact-PTH level was kept within normal range after the operation. Pathological findings showed that the left lower PT was cyst, and the others were hyperplasia. Despite chemotherapy for gastric cancer, he died 3 months after the first operation for gastric cancer.

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We experienced a case of papillary carcinoma of thyroid with metastasis to liver and bone that responded well to the administration of I-131. The patient was a 34-year-old female who noticed a mass in her neck which gradually increased its size since 20 years old. The study of the mass revealed a intracapuslar papillary to cauliflower like tumor 9 cm in size without calcification in the right lobe of thyroid and a multifollicular tumor with unclear margin in left lower corner of the gland. Cytological study revealed class II in both tumors, but the serum thyroglobulin value showed extremely high level of 3670ng/ml (normal : <32.7ng/ml). CT study of cervico-thoracic area revealed no other lesions. With the preoperative diagnosis of adenoid thyroid tumor an operation was performed in March, 2002. Subtotal thyroidectomy was performed and the intraoperative frozen section study turned out to be negative in malignancy, however the postoperative pathological study revealed thyroid carcinoma (follicular type). The value of serum thyroglobulin returned to normal immediate postoperatively, but it was elevated again to 134ng/ml 16 months later. In July, 2005 the value went up to 4370ng/ml and new metastasis or recurrence of the tumor was suspected. A metastasis to the liver was found and total thyroidectomy was performed. I-131 scintigraphy revealed multiple bone metastases, for which administration of I-131 was done twice, resulting in decrease of serum thyroglobulin value and significant reduction of the size of liver metastasis and sclerotic changes of bone metastases and decreased accumulation in PET-CT study.

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We report a case of juvenile tubular adenoma of the breast, diagnosed as breast fibroadenoma preoperatively, in a 15-year-old female. The patient was presented at our clinic because of a right breast tumor which had an easily movable tumor 25×23 mm in diameter in the AB area of the right breast on palpation. Magnetic resonance imaging study showed an enhanced tumor with smooth surface. Results of aspiration biopsy cytology suggested fibroadenoma. Because the tumor was growing, we excised it under local anesthesia. The histopathological diagnosis was tubular adenoma, revealing monotonous glandular formation.
Tubular adenoma of the breast is a rare benign epithelial tumor of the breast. Only three cases, including our case, involved juvenile women aged 15 years or less, accounting for about 6.7% of all cases.

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We present a case of intraductal apocrine carcinoma of the breast. A 51-year-old woman visited our hospital because of an echoic abnormal lesion of the right breast. The lesion in her right breast was not palpable and was pointed out by screening ultrasonography. Mammography showed no abnormal lesion. Diagnostic ultrasonography revealed multiple hypo-echoic lesions in the upper part of the right breast. Histopathological examination by core needle biopsy revealed a intraductal apocrine carcinoma. Nipple sparing mastectomy was done and axillary dissection was not performed because no lymphatic metastasis was diagnosed by sentinel lymph node biopsy. The specimen examination showed intraductal apocrine carcinoma with the size of the tumor 5.1 × 4 cm and estrogen receptor and progesteron receptor were negative. Four years after operation without any adjuvant treatment, this patient has no recurrence of lesion.

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We experienced an extremely rare case of cystic thymoma. A 56-year-old woman was referred to our hospital for an abnormal shadow on CXR. CT scan and MRI showed a cystic mass, 10 cm in diameter, located at the anterior side of cardiophrenic angle. We thought it was a pericardial cyst, and resected it via video-assisted thoracic surgery. However, it was a so-called cystic thymoma, histologically, with thymoma cells around the cyst. In past reports, cystic lesions usually exist in a solid tumor and have thick walls. This kind of case with thin walls is rare and difficult to diagnose before operation. We must keep this disease in mind, even when it looks like a congenital cyst.

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A 57-year-old man with an abnormal shadow on a chest X-ray film was admitted. Lung biopsy revealed that the tumor was large cell lung cancer. Right upper lobectomy and chest wall resection was performed. Histological examination revealed that the tumor invaded to chest wall (p-T3N0M0 stage IIB). Four months after operation, marked leukocytosis was found. Abdominal CT revealed a tumor in the pelvis. Enzyme immunoassay demonstrated an apparent increase of serum G-CSF. Immunohistological examination of the lung tumor cells showed positive staining for G-CSF. We diagnosed that the tumor was G-CSF producing tumor.

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A 51-year-old man who visited a hospital because of epigastric pain was found having a type 2 tumor of the esophagus located 32-34cm apart from the incisor line and at the direction of six to seven o'clock by upper gastrointestinal endoscopy. A biopsy of the tumor provided a diagnosis of squamous cell carcinoma. The patient was admitted to the hospital and underwent a subtotal esophagectomy through laparotomy followed by a right thoracotomy and retrosternal reconstruction of gastric tube. The pathological diagnosis was small cell carcinoma, and then 3 courses of adjuvant chemotherapy with VP-16 and CDDP were carried out. Thereafter these chemotherapeutic agents were exchanged for nedaplatin and another 10 courses with it were performed. The patient has been alive without recurrence, as of 6 years 2 months after the operation.
Small cell carcinoma of the esophagus produces general metastasis even in an early stage that carries a poor prognosis. This case is reported with some bibliographical comments because long-term survivors with the disease for more than 5 years after diagnosis are rare.

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A 39-year-old woman who had drunk 50ml of brandy daily for 20 years was admittitted to the hospital because of hoarseness due to left reccurent nerve paralysis. Cervicothoracic CT scan, MRI scan and esophagogastroscopy showed type 3 upper thoracic esophageal cancer, 6 cm in diameter, which invaded the posterior wall of the trachea. In addition, she had type 0-II b squamous cell carcinoma in the middle thoracic esophagus, three lesions of type 0-II c signet ring cell carcinoma in the middle∼lower stomach, and Helicobacter pylori (HP) infection in the noncancerous region of the stomach. She was diagnosed as having double cancer of multiple esophageal cancer and multiple gastric cancer. After disapearance of upper thoracic esophageal cancer by chemoradiation therapy, she underwent subtotal esophagectomy and total gastrectomy for resistant esophageal cancer and gastric cancer. Resected specimen showed five lesions of type 0-II c signet ring cell carcinoma in the stomach. She revealed heterogenous loss of aldehyde dehydrogenase 2 gene (ALDH2) after the operation. Our case suggested the possibility that complication of field cancerization due to heterogenous loss of ALDH2 in addition to HP infection would be a factor for multiple gastric cancer, as for multiple esophageal cancer.

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An 80-year-old woman complaining of appetite loss was admitted to our hospital. Gastroscopy showed a type 3 tumor in the cardia portion of the stomach, and the biopsy demonstrated group V, well-differentiated adenocarcinoma. She underwent total gastrectomy (Roux-en Y) under the diagnosis of gastric cancer. Gross findings of the resected specimen showed a 120×100mm type 3 tumor in the cardia and five type 1 tumors next to it. Pathological evaluation confirmed 3 types of collision tumos, well-differentiated adenocarcinoma (tub1), poorly-differentiated adenocarcinoma (por) and malignant lymphoma diffuse large cell type (T cell). A collision tumor is a very rare neoplasm, and only 16 cases of collision tumor with adenocarcinoma and malignant lymphoma of the stomach hava been reported in Japan. T-cell malignant lymphoma of the stomach allounts for only 6% of malignant lymphomas of the stomach. All report of collision tumors with adenocarcinoma and malignant lymphoma have been B-cell malignant lymphomas, and there has been no case of collision tumor with T-cell malignant lymphoma. Many of collision tumors include advanced malignant lymphomas, and the vital prognosis is controlled by malignant lymphoma. The prognosis of T-cell lymphoma of the stomach is poorer than that of B-cell lymphoma.

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Hemophilia A is a relatively rare disease with congenital deficit of blood coagulation factor VIII resulting bleeding tendency. We report a successful case of laparoscopic proximal gastrectomy in a hemophilia A patient under administration of factor VIII perioperatively. The patient was a 58-year-old male with diagnosis of hemophilia A since 1964. A gastroscopic study performed for detecting the cause of his anemia revealed a cancer in the cardiac portion of the stomach. He underwent Iaparoscopic gastrectomy of the cardiac portion. The preoperative study revealed prolonged APTT of 48.0 sec. and decreased value of factor VIII activity of 12 %. 2500U/xl of factor VIII was scheduled to be given peri-, intra- and postoperatively and slso through 21^st day of operation. Oral feeding was started on the 9^th day of operation, but withheld on the 12^th day as bleeding from the anastomotic site was suspected, and so the dosage of factor VIII was increased and continued until 25^th day. Oral feeding was restarted on the 21^st day. No further bleeding occurred. The patient was discharged on the 26^th postoperative day with satisfactory recovery.

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The patient was a 56-year-old female who came to the medical department of our hospital with chief complaint of nausea and vomiting. An endoscopic study of upper gastrointestinal tract revealed an easy bleeding bulging tumor of 5 cm in diameter on the posterior wall of descending part of duodenum. The patient was admitted for further evaluation and an upper gastrointestinal study revealed a well demarcated tumor of 5 cm in size in the descending part of duodenum. A CT study also revealed the same tumor with heterogeneous contrast with cystic parts. Because of the above findings in image studies and significant melena after the admission, a laparotomy was performed. A soft elastic mass was palpable on the wall of descending part of duodenum and so the anterior wall was opened. A duodenal tumor with a pedicle of 2 cm in length arising from duodenal wall close to pyloric ring was found. The tumor was thought to be benign and was excised by just cutting the pedicle. A pathohistological study of the tumor revealed hyperplasia of Brunner gland with duct like lumina.
The reports of duodenal adenoma larger than 4 cm are extremely rare and we report here with some review of literatures.

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A 69-year-old woman had undergone curative pancreatoduodenectomy for stage II carcinoma of the papilla of Vater. Eighteen months later, partial hepatectomy was performed for multiple merastases. Histologic study confirmed the presence of metastatic liver tumors from the carcinoma of the papilla of Vater. Five years and three months later after the first operation, right middle lobectomy was performed for solitary pulmonary metastasis, and the pathological diagnosis was also metastatic adenocarcinoma. At present, no sign of recurrence have been observed, and six years and nine months have passed from the first operation. Although the prognosis of the postoperative metastases of the carcinoma of the papilla of Vater is extremely poor, it is desirable to perform repeated surgeries aggressively if complete resection is possible.

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Intestinal malrotation with midgut volvulus occurs most commonly in the neonatal period and is rarely seen at older ages. We present two cases of this anomaly in older children.
Patient 1, a 6-year-old boy, and patient 2, a 12-year-old boy, were admitted to our hospital with a complaint of abdominal pain and bilious vomiting. An abdominal color Doppler ultrasonography revealed Whirlpool sign, and they were diagnosed with intestinal malrotation with midgut volvulus. For patient 2, 3D-CT scan had a diagnostic role as well.
Although in the last 15 years we have had only four cases of intestinal malrotation, it has been the third most common cause of vomiting and abdominal pain among children 1 to 15 years old after appendicitis and intussusception. Only one of these four cases was an infant. We thus highlight the possibility of an intestinal rotation anomaly as a cause of vomiting and abdominal pain in older children who are referred to general hospitals.

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A 36-year-old man who had complication of respiratory failure because of Duchenne's muscular dystrophy had been managed by respirator at home. The Chief complaint was abdominal pain and abdominal distention and vomiting. He was admitted, and abdominal X-ray photography revealed acute gastric dilatation. Upper GI series presented stenosis of the duodenum in 3rd parts. Computed tomography showed as duodenum lay between the superior mesenteric artery and aorta, so this case was diagnosed as acute gastric dilatation with superior mesenteric artery syndrome (SMA syndrome). Conservative treatment had no effect, so gastrojejunostomy was performed on the 35th day after admission. There has been no recurrence for one and a half years, since the surgery. Gastrojejunostomy is an effective technique for SMA syndrome complicated with disorder of gastric peristalsis such as this case.

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We report a case of ischemic intestinal stenosis after repositioning of strangulation ileus. A 68-year-old man was admitted to the hospital because of abdominal pain and vomiting and diagnosed with having ileus. An abdominal CT scan revealed significant dilatation of the small intestine and ascites. Aspirated ascites including a blood component indicated surgery with a diagnosis of strangulation ileus of the small intestine. During surgery an ischemic change about 1 m in length was seen in the small intestine caused by a band. After repositioning, the ischemic change improved as seen in bowel color and movement. No intestinal resection was done. However, on the 25th day after the surgery, he had abdominal pain and vomiting. An abdominal CT scan showed another intestinal obstruction. Examination using a long tube with gastrografin showed a stenotic small intestine near the terminal ileum. No symptomatic remission was gained. We conducted ileoceal resection and partial intestinal resection due to cicatracial stenosis of the small intestine on the 26th postoperative day.
The pathological diagnosis was small intestinal stenosis due to the ischemic change.
Bowel preservation after repositioning of the strangulation ileus thus requires follow-up, considering the late onset of small intestinal stenosis caused by intestinal ischemia.

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A 76-year-old man was admitted to another hospital for the treatment of cerebral infarction and hypertension and was then transferred to our hospital because of abdominal pain and the finding of intraperitoneal free air on abdominal CT. At admission, physical examination revealed board-like rigidity with rebound tenderness over the entire abdomen. His abdominal CT showed intraperitoneal free air and ascites, therefore, a diagnosis of gastrointestinal perforation was made and emergency surgery was performed. At the surgery, the site of perforation was identified, and also the edge of a PTP (press-through-package) at a site 50 cm proximal to the ileal end was found. A Meckel's diverticulum was identified 10 cm proximal to the site of the perforation. Partial resection of the ileum along with Meckel's diverticulum was performed.
There have been other reports of patients presenting with gastrointestinal perforation caused by PTPs. Most of these were elderly patients who accidentally ingested the PTP without realizing it. Thus, attention must be paid to the drug packaging when prescribing medication to elderly patients.

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We report two cases of jejunal angiodysplasia in which bleeding sites were diagnosed by intraoperative enteroscopy. Patient 1 was a 76-year-old man. He was referred to our hospital for gastrointestinal bleeding of unknown origin. Abdominal angiography showed no prominent bleeding site. He underwent emergent laparotomy. Enteroscopy, which was introduced into the jejunum via enterotomy, revealed a red mucosal lesion with pulsating bleeding located at the jejunum. A 10-cm-long segment of the jejunum containing the lesion was resected. Histopathologically, he was diagnosed as having anigodysplasia. The bleeding has not recurred. Patient 2 was a 28-year-old man. He was admitted to our hospital for a tarry stool. The diagnostic procedures, including upper gastrointestinal endoscopy, colonoscopy and abdominal angiography, were performed but failed to identify the bleeding site. He underwent emergent laparotomy. Enteroscopy, which was introduced into the jejunum via enterotomy, revealed an elevated lesion with bleeding located at the jejunum. A 10-cm-long segment of the jejunum containing this lesion was resected. Histopathologically, he was diagnosed as having anigodysplasia. The bleeding has not recurred.

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A 51-year-old man was admitted to the hospital because of a 2-month history of left lateral abdominal mass with anemia. On admission physical examination showed a movable mass with smooth surface. Contrast-enhanced abdominal CT scan showed a 12×10×20 cm mass consisting of heterogeneously enhanced solid and giant cystic lesions located in the mesenteric side of the jejunum. At laparotomy, the noninvasive cystic tumor was found to have originated from the jejunum. The content fluid was brown in color and bloody accompanied with blood clots. Pathologically, the solid part of the tumor was composed of proliferated spindle-shaped cells with intricate pattern and mitotic figure in a 5/50 high power field. Immunohistochemically, the tumor was positive for c-kit and CD34, but negative for desmin and S-100 protein. We diagnosed the case as gastrointestinal stromal tumor (GIST) with a cystic change. The patient has been disease free as of 6 months after the operation.
This case is presented, together with some bibliographical comment on a total of 37 cases, including ours, of GIST with cystic components in Japan.

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A 66-year-old man had presented with intermittent abdominal pain for 6 months. One month ago, he was referred to an emergency room because of severe abdominal pain and vomiting. X-ray and CT scan showed a remarkably dilated small bowel and small bowel obstruction was suspected. He was admitted and effective conservative therapy was performed. However, after being discharged, his symptoms and small bowel obstruction soon recurred. Therefore, laparoscopic surgery was performed in order to diagnose and treat the small bowel obstruction. The laparoscope revealed small intestinal cancer that had a serosal invasion. Resection of the small bowel and anastomosis were done under a 4-cm minimal incision of the abdominal wall. Small bowel cancer is a rare disease and it is often difficult to diagnose since the small bowel is usually hard to identify by fiberscope. Recently, minimal invasive surgeries for small bowel disease have often been reported. We also report a case of small bowel cancer for which laparoscopic surgery was very useful.

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Here we report a case of acute appendicitis appeared five hours after a barium fluoroscopic examination of the upper gastrointestinal tract.
A 75-year-old male patient was admitted to our hospital because of left abdominal pain and nausea which appeared five hours after an abdominal fluoroscopic examination. There was slight tenderness in the left lower quadrant of the abdomen. On an abdominal X-ray film, the whole appendix and a number of diverticula along the large intestine were filled with barium. We started conservative medical treatment with a diagnosis of sigmoid colon diverticulitis. After a gradual symptomatic remission, the patient showed symptoms of peritoneal irritation 48 hours after admission, when abdominal X-rays revealed leakage of a barium meal from the appendix and a serrated contour of the appendix. An emergency laparotomy revealed perforative peritonitis due to acute appendicitis with appendicolith.
We must keep in mind that appendicitis can develop rapidly in the presence of appendicolith, even if the contour of the appendix is clearly delineated with a barium meal.

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A 31-year-old man complaining of lower abdominal pain was treated under the diagnosis of acute prostatitis by the urology department. After 2 years, pneuumaturia was observed, and he was referred to our department. The patient was diagnosed with a vesicosigmoidal fistula due to sigmoid colon diverticulitis by abdominal CT. A partial resection of the sigmoid colon was performed. Vesicosigmoidal fistula due to sigmoid colon diverticulitis is very rare in a young person.

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A 76-year-old woman was transported to our hospital emergency room for right flank pain with hematochezia. Abdominal CT examination revealed portal venous gas in the left lobe of the liver and wall thickness of the ascending and transverse colon. General condition of the patient was stable. A follow-up CT, 2 days later, showed portal venous gas was decreasing. Because of the persistent localized abdominal pain, we performed colonoscopy 3 weeks later and severe stenosis was detected in the ascending colon and cecum. We performed laparoscopy-assisted right hemi-colectomy and the histopathological study revealed ischemic changes at the stenotic lesion.

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A 96-year-old woman complaining of bleeding on defecation was found to have a tumor by digital examination of the rectum at another hospital, and was referred to the hospital with a suspicion of rectal cancer. When she was first seen, we felt reversed intestinal mucosa located about 3cm proximal to the anal verge and a hard tumor at the tip on digital examination of the rectum. Combined with abdominal CT findings, intussusception of sigmoid colon cancer in the lower portion of the rectum was diagnosed. There were no findings suggestive of intestinal obstruction on clinical as well as imaging findings, and the intussusception was successfully reduced by enema. Operative procedures included partial sigmoidectomy and D1 dissection under lumber and epidural anesthesia. The patient's postoperative course was uneventful.
In treating intussusception caused by colorectal cancer, whether the intussuscepted portion is reduced is debatable. Preoperative reduction of the intussusception in this case enabled us to perform an elective surgery, to prevent edema associated with congestion of the involved intestines, and resultantly to avoid excessive removal of the intestines. In addition the reduction appears to be available to improve the general condition of elderly patients who often have complications.

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The patient was a 75-year-old man who had been suffered from constipation and had been administered α-glucosidase inhibitor for diabetes since the age of 65. At the age of 74, he was found having right lung cancer, rectal carcinoid, and cerebral infarction ; and the right lung cancer was treated by irradiation and the clinical course of the rectal carcinoid was under observation. When he visited another hospital for a periodic exploration after treatment of right lung cancer, abdominal distention was pointed out and an abdominal CT scan disclosed intraabdominal free air. Thus he was referred to the hospital with a diagnosis of gastrointestinal perforation. No recognizable findings on hematological and physical examinations were revealed. Abdominal CT scans showed intraabdominal free air and intestinal mural air in the small intestine and ascending colon, but no apparent findings suggestive of gastrointestinal perforation were seen. Intestinal emphysema with pneumoperitoneum was thus diagnosed. It was etiologically considered to be caused by an increase in internal pressure of the intestine in which α-glucosidase inhibitor might participate. Conservative therapy including withdrawal of the drug provided symptomatic remission.
Intestinal emphysema associated with pneumoperitoneum in which α-glucosidase inhibitor might participate is so rare that only five cases including ours have been reported in Japan.

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A 76-year-old woman was admitted to the hospital because of anorexia. Gastric endoscopy showed a type 3 tumor at the antrum of the stomach, and the histopathological diagnosis of the biopsy specimens was poorly-differentiated adenocarcinoma involving signet ring cell carcinoma. A barium enema showed polypoid lesions in the transverse colon. Total colonoscopy showed multiple elevated lesions of 5-15 mm in size from the ascending colon to the rectum. Biopsy specimens from these lesions histologically demonstrated signet ring cell mixed with poorly-differentiated adenocarcinoma. Metastatic colon cancer from the gastric cancer was suspected, but distal gastrectomy only was performed because of bleeding from gastric lesion and stenosis. Intraoperative findings showed no peritoneal dissemination and no liver metastasis. In the present case, the most probable mode of metastasis to the colon and rectum appeared to be lymphogenic. In case of advanced gastric poorly-differentiated adenocarcinoma, we considered that routine examination is necessary to evaluate colorectal metastasis before an operation for gastric cancer.

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A 74-year-old woman underwent sigmoidectomy followed by functional end to end anastomosis for sigmoid cancer. Twenty months later, colonoscopy revealed a recurrence on the suture line. Chest CT scan showed a metastasis of sigmoid colon cancer on the right upper lobe of the lung. High anterior resection including the recurrent site with lymph node dissection, and VATS right upper lung lobe resection were performed. Histologically, the suture site tumor was composed of moderately differentiated adenocarcinoma the same as the primary tumor, and implantation metastasis was suggested. The tumor of the right upper lobe of the lung was diagnosed as metastasis of the sigmoid colon cancer. The patient was treated with chemotherapy (FOLFIRI), and eight months later, is still alive with no sign of recurrence.

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An 81-year-old female patient was diagnosed to have idiopathic thrombocytosis and had been treated with hydroxyurea and aspirin. The patient was referred to our hospital after being diagnosed as having rectosigmoid carcinoma by an endoscopic study at another hospital where she visited with chief complaint of melena. The diagnosis of rectosigmoid carcinoma with multiple metastases to her lung was made after several studies at our hospital. Administration of hydrourea and aspirin was stopped and when the platelets count became 46.9 × 10⁴/μl high anterior resection with appendectomy was performed. Hydroxyurea and aspirin were resumed on the 13^th operative day as the platelets count increased to 71.6 × 10⁴/μl. The postoperative course was uneventful without complications of hemorrhage or thrombosis. The patient received 9 courses of treatments with 5-fluorouracil (5-FU), levofolinate calcium (1-LV), and irinotecan hydrochloride (CTP-11). At present, 12 months after the operation, the patient is doing well without recurrence of the tumor or new metastasis. The foci of lung metastases decreased in size.

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We report a case of a patient who underwent laparoscopy-assisted low anterior resection of the rectal cancer associated with dermatomyositis. A 52-year-old man was admitted to the hospital because of general fatique and muscle weakness. Erythemia and heliotrope eyelid rash were confirmed. CPK, LDH and ALD levels were abnormally high. A diagnosis of dermatomyositis was made from the facts. He needed corticosteroid therapy to control symptoms of dermatomyositis. When a barium enema and colonoscopy were simultaneously performed, a rectal cancer was found. Laparoscopy-assisted low anterior resection was carried out for the rectal cancer. Histologically, the tumor was classified as mp, ly3, v2, nl (251), stage III a, and Cur A. After surgery, he has had a slight improvement of symptoms of dermatomysitis. And also decrease in the myogenic enzyme rate was found. He had survived for 1 year after the operation without any sign of recurrence. Some possible correlation between rectal cancer and dermatomyositis is suggested. The prognosis of rectal cancer with dermatomyositis is generally poor. The surgical approach described here has benefits with respect to the patient's quality of life, and therefore should be considered when deciding on therapy.

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We report a case of granular call tumor of the anus. A 57-year-old woman who complained of anal pain and difficulty of defecation was admitted to our hospital in September 2006. She had noticed the tumor about a year earlier. A nodule of diameter 65×25mm was observed on the subcutaneous area near the anal verge. She was preoperatively diagnosed as benign granular cell tumor by a biopsy. After obtaining adequate informed consent, we extirpated the tumor while preserving as much anal function as possible. The postoperative histopathological examination indicated a benign granular cell tumor, however, the pathologist reported that tumor calls probably still existed near the stump edge of the sample. It is reported that 2% of granular cell tumors have malignancy, so we have to observe this case carefully in the future.

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We report a case of hepatic pseudolesion mimicked metastatic liver tumor. A 40-year-old woman, who had undergone total gastrectomy with splenectomy for gastric cancer 14 months ago, was referred to our hospital because of a suspected metastatic liver tumor. Abdominal CT showed a low density, poorly enhanced lesion with unclear margin, 1.4 cm in its diameter, within segment VIII. The lesion was low intensity on T1 weighted images (WI), slightly high intensity on T2W abdominal MRI, and high intensity on T2*WI of SPIO MRI. This lesion was hypointense on arterial phase images and isointense on delayed phase by T1-weighted dynamic MRI. Both CTHA and CTAP showed obscure, low density lesion relative to the surrounding liver. On laparotomy, no tumor was detected within the liver by palpation. Intraoperative ultrasound showed a mixed echoic lesion in segment VIII, so limited hepatectomy including this lesion was performed. The cut surface of the specimen showed a vessel-like structure with dendritic pattern. A microscopic examination showed hepatic sinusoidal dilatations with nodular regenerative hyperplasia-like changes, probably due to localized circulatory disturbance of the liver.

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We report a case of hepatic angiomyolipoma (AML) with growth in the follow up. A 60-year-old man was admitted because of a hepatic tumor found during a general hospital examination. On admission, the patient showed no symptoms of abdominal pain or jaundice. Laboratory data showed no elevations of hepatic enzyme and tumor markers, Virus marker of hepatitis was negative. An Abdominal ultrasonography and CT examination showed a solid tumor, 40 mm in diameter, with a distinct border in the internal segment of the liver (S4). The tumor was biopsied and it was diagnosed as an angiomyolipoma microscopically. The tumor grew up to 55 mm in diameter after one year of observation. We performed a resection of the internal segment of the liver considering the possible danger of bleeding, rupture and malignant transformation. Macroscopically, the tumor was solid and encapsulated. Microscopically, it was diagnosed as an angiomyolipoma. The patient has been well for 12 months without recurrence. Forty-three cases of AML were domestically reported over the past 7 years and 7 of these cases presented with tumor growth. AML should be observed principally, but it would be worth considering resection when the tumor is growing.

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A 72-year-old man was performed liver biopsy because he had been pointed out abnormal hepatic function at medical checkups since the age of 65 and then screening abdominal ultrasonography disclosed a tumorous lesion in the liver. The liver biopsy provided a diagnosis of hepatocellular carcinoma (HCC). The patient underwent subsegmentectomy of the liver. The excised material slso provided the histopathological diagnosis of well differentiated HCC, but the background liver showed swelling of hepatic cells, lipid deposit, fibrosis extending to the surroundings, and other changes, non-alcoholic steatohepatitis (NASH) being diagnosed.
In recent Japan where we have entered the days of gluttony, it is considered that NASH tends to increase. Although case reports of NASH are still few, a risk of malignant change of NASH to HCC is high. Accordingly allowances must be for the risk of malignant change to HCC in treating patients with NASH.

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A 67-year-old woman was admitted to the hospital because of jaundice and right hypochondralgia, and was diagnosed as having hepatocellular carcinoma (HCC) accompanied with Dubin-Johnson syndrome (DJS) after close exploration. The preoperative T. bilirubin level was 3.8mg/dl, but other hepatic functional reserves were kept in normal. Thus a S5 sub-segmentectomy of the liver was performed. The T. bilirubin level rose up to 5.2mg/dl after the operation but it gradually decreased. The patient was discharged from the hospital on the 17^th hospital day. Multiple lung metastases occurred 13 months after the operation but were successfully treated by 14 courses of FAP therapy with fluorouracil, doxorubicin, and cisplatin. She is in a stage of PR as of 5 years after the operation.
So far eight cases of HCC associated with DJS in which hepatic resection was performed have been reported in Japan. All the patients had hyperbilirubinemia as well before surgery, but they did not develop hepatic failure and well tolerated their operations. In performing hepatic resection to patients who carry a constitution liable to have jaundice, however, caution is advisable for a fact that massive resection of the liver under serious jaundice can prolong the ailing time, though T. bilirubin level is not a direct index to show the degree of hepatic impairment.

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We report a case of cholecystoduodenal fistula and gallstone ileus diagnosed preoperatively by multi-detector computed tomography (MDCT). An 86-year-old female with dementia was admitted to our hospital due to right lower abdominal pain. MDCT findings at admission showed no evidence to explain her symptoms but a gallbladder stone (25mm in diameter). After hospitalization, she was symptom free. Four days after, she developed middle abdominal pain and vomiting. Emergency MDCT was performed, and its findings showed presence of gallstone ileus and cholecystoduodenal fistula. Only removal of the impacted stone with ileotomy was performed, because of her aging and dementia. Using MDCT for diagnosis of “gallstone ileus and cholecystoduodenal fistula” is recommended, because it is easy, quick and less invasive examination. We believe MDCT may be promising and possibly make simultaneous operation of enterolithotomy, cholecystectomy, and closure of the internal biliary fistula feasible, because its diagnosis is accurate and can be acquired before patient's general condition gets worse.

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A man in his seventies was admitted to the hospital because of dyspnea and epigastralgia in April 2005. Following thorough examination, he was diagnosed as having acute cholecystitis and perforated gastric ulcer.
We judged that the operation under general anesthesia was hazardous because he had a series of asthma attacks, and conservative treatment preceded surgical operation. Percutaneous cholecystostomy was also abandoned for his so severe asthma and a narrow gallbladder bed, as he could not stop breathing even for a brief moment. Then we performed a mini-laparotomic cholecystostomy under local anesthesia.
It provided symptomatic remission of asthma and stable general condition so that he could undergo an elective laparoscopic cholecystectomy under general anesthesia.
Although mini-laparotomic cholecystostomy has scarcely been indicated in recent years, this case has suggested that there are some high-risk patients with acute cholecystitis to whom mini-laparotomic cholecystotstomy under local anesthesia is as useful and effective as percutaneous cholecystostomy even now.

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A woman in her sixties with intermittent high fever and right hypochondralgia was referred to our hospital under the diagnosis of gall bladder cancer with acute cholecystitis and liver abscess. Enhanced CT revealed a low density mass 7cm in diameter which extended from the body of gall bladder to anterior and medial segment of the liver. This main tumor was surrounded by small low density lesions, and some of them were enhanced in ring-shaped forms. The patient was diagnosed as hoving gall bladder cancer with extensive hepatic invasion and liver metastasis, combined with acute obstructive cholecystitis and liver abscess, causing high fever. For carrying out extensive liver resection safely, percutaneous transhepatic gall bladder drainage was performed. However, high fever continued. In addition, causative bacteria was detected neither in bile juice nor in blood. Finally, right trisegmentectomy of the liver was performed under the condition with severe inflammation. Contrary to our presumption, liver abscess was not detected in the removed specimen. The histopathological examination revealed adenosquamous cell carcinoma of gall bladder. Uncontrollable inflammation improved dramatically immediately after liver resection.

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A 48-year-old man with reporting general fatigue was found in enhanced abnominal CT scan to have an irregular tumor at the pancreatic head, dilatation of the peripheral main pancreatic duct and two tumor lesions in the liver, S1R and S8. Surgery was done under a diagnosis of pancreatic head cancer with liver metastasis in April 2003. After a pyrorus preserving pancreatoduodenectomy, radio frequency thermal ablation (RFA) and core needle biopsy were performed for two liver metastases. As adjuvant chemotherapy, gemcitabine (GEM) 1400mg/body was administrated 21 times for 14 months after the surgery. In January 2006, enhanced abnominal CT scan revealed two tumor lesions in the liver, S8 and S2. So chemotherapy with GEM was resumed. In March 2006, RFA for the S8 lesion and partial hepatectomy for the S2 lesion were done. All tumor lesions in the liver were demonstrated to be metastasis of pancreatic cancer by postoperative histopathological studies. The patient disliked chemotherapy with GEM after the second operation, and then he is now on TS-1 regimen. The patient has been recurrence free as of 45 months after the initial surgery.

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Malignant lymphoma with rupture of spleen is quite a rare entity. According to Index Medicus it is only 14 cases reported so far. The patient was 34-year-old male who visited his private physician with complaints of left shoulder ache and epigastric pain that had lasted for one week with some progression of symptoms without any history of trauma. The initial study at the clinic revealed slight anemia and accumulation of fluid around the spleen with enlargement to 9 cm. Because of this he was referred to our hospital with the diagnosis of bleeding from splenic tumor. A laparotomy was performed and massive intraperitonial hemorrhage with blood clot was found. Splenectomy was carried out (700gr). Upon examination of the specimen it was revealed that there was a thin reddish tumor in the spleen and a hematoma around the tumor. It was diagnosed as the bleeding from rupture of splenic capsle at the hilum.
Pathohistological diagnosis was malignant lymphoma (non-Hodgkin, diffuse large cell type). The postoperative course was uneventful and the patient received adjuvant chemotherapy and was discharged. Twelve months after the operation the patient is doing well without sign of recurrence of the tumor.

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A 58-year-old male who presented with the chief complaint of abdominal pain and a palpable mass in the lower abdominal region, was admitted to another hospital, and then was referred to our hospital for a workup and treatment. A hen's egg-sized tumor was palpated in the right lower quadrant of the abdomen, and an inflammatory myofibroblastic tumor (IMT) was thus suspected based on the results of a biopsy. As the result, the tumor was removed under general anesthesia. During surgery the tumor was found in the right lower quadrant of the abdomen which also invaded rectus abdominis muscle. The tumor measured about 50 × 55 × 30 mm in size, and resection was carried out with the surrounding fat tissue and the rectus abdominis muscle. The tumor demonstrated a mixture of yellowish and whitish elements with an unclear margin. A histological examination showed the tumor consisting of spindle-shaped cell bundles, inflammatory cells comprising lymphocytes and plasma cells, and histiocytes. An immunohistochemical examination showed positive staining for HHF-35, α-SMA and negative staining for β-catenin. Based on the above findings, the tumor was diagnosed as IMT. IMT is an inflammatory and neoplastic lesion which consists of myofibloblastic cell bundles and also invasion of inflammatory cells such as lymphocytes and plasma cells. This tumor has recently attracted attention regarding the mechanism of tumor formation.

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A 51-year-old man was seen at the emergency clinic in our hospital because of gradually enhancing epigastralgia which suddenly appeared in the evening. There were no abnormal physical findings except tenderness from the epigastric region to right lower quadrant of the abdomen. An abdominal CT scan showed retention of ascites covered in a wide range from around the liver and the pancreas to the Douglas' pouch. Also a localized low density area just under the right abdominal wall compressed the intestine dorsad and a high density area detected within it, which was suggestive of leakage of contrast medium. Abdominal puncture disclosed bloody ascites, and abdominal angiography showed leakage of contrast medium from peripheral branches of the omental artery. Hence intraabdominal hemorrhage due to omental bleeding was diagnosed. An emergency operation was done on the same day, when laparoscopic observation of the entire abdominal cavity revealed massive hematoma on the greater omentum at the right lower abdomen. After a small incision was made on the midline in the vicinity of the bleeding site, the greater omentum was pulled out outside the body, and the bleeding site was identified, and was stopped by sutures.
Idiopathic omental hemorrhage of unknown origin is a rare entity. This disease must be kept in mind as a probable differential diagnosis for sudden onset of intraabdominal hemorrhage.

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A 50-year-old woman was admitted to the hospital because of abdominal pain and back pain. Contrast-enhanced CT scan of the abdomen showed a soft density in the vicinity of the superior mesenteric artery (SMA). We suspected dissection of SMA, but on the next day, 3D-CT did not show dissection of SMA. MRI showed high signal intensity on T2-weighted image. Tumor marker, antinuclear-antibody, immunoguloburin, IL-2-receptor levels were within normal ranges. There were no malignant findings on GIF, colon-fiber, and PET. We diagnosed the case as retroperitoneal fibrosis (RPF) and started predonisolone regimen 30 mg per day. Thereafter the size of RPF was reduced and symptomatic remission was attained. After withdrawal of predonisolone regimen, size up of RPF has not been observed up to now. Usually RPF tends to arise from the hilum of kidney to the sacrum. There have been few reports on RPF arisen from the SMA. Accordingly this case is considered to be valuable.

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A 65-year-old man noticed an abdominal mass in January 2006. He was admitted to an affiliated hospital in February and was referred to our hospital with suspicion of having a huge liver tumor. An immobile mass, 25cm in diameter, was palpated in the right abdomen. Contrast-enhanced abdominal CT showed a 24 × 16 × 9cm irregular shaped tumor beneath the right liver and on the ventral side of the ascending colon, displacing the gall bladder, pancreas and duodenum. Abdominal gastrointestinal stromal tumor or liposarcoma was suspected, and an operation was performed on March 14, 2006. The tumor was originated from the retroperitoneum. Because it was closely attached to the liver and transverse colon, partial liver resection of segment six and resection of the transverse colon was combined with tumor resection. Although liposarcoma was suspected from the operative findings and post-operative gross examination, the final histological diagnosis was malignant mesenchymoma with a combination of different mesenchymal components such as liposarcoma and chondrosarcoma in a single tumor.

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We report two cases of presacral epidermoid cyst in an adult. Case 1 is a 51-year-old female, complaining of constipation, who was found to have a cystic tumor with solid change by CT scan. Case 2 is a 36-year-old female, complaining of dysuria, who was found to have a presacral cystic tumor by MRI. In both cases, developmental cysts were suggested, and were operated on using the transsacral approach. Histopathological examination showed cysts lined by keratinized squamous epithelium with no cutaneous adnexal structures, and subsequently the tumors were diagnosed as epidermoid cysts.
Adult presacral epidermoid cyst is rare, and some patients are asymptomatic. Once diagnosed, however, surgical resection is mandatory because of the tumor's malignant potential.

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A 31-year-old female was referred to our hospital under the diagnosis of myoma uteri. Enhanced abdominal CT revealed a mass lesion with cystic components. The tumor, 53mm × 32mm in diameter, was located behind the right common iliac artery and vein. Angiography showed tumor stain around the aortic bifurcation, but no encasement was present in common iliac arteries. Resection of the tumor was performed, although we could not make definite diagnosis preoperatively. The resected specimen was found to be a hyaline vascular type of Castleman disease. She was discharged from the hospital without any complications. According to the previous reports Castleman disease commonly arises in mediastinum or neck, but rarely in pelvic space, and that most of the tumors are reectable without difficulty.

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A 63-year-old woman, preveously received right hemicolectomy for colon cancer, was admitted to our hospital because of febrile and abdominal pain. Abdominal CT scan revealed a low density area with many small gas lesions in the abdominal wall, that meant the late of infection a composix mesh. Initially, we performed incision and drainage, but infectious signs were persistent and needed surgical removal of the composix mesh. Streptococcus intermedius was cultured from the abscess cavity, which was drained and washed completely. She was discharged from the hospital at the 35th day after the removal operation. No recurrence of hernia and abscess formation have been observed.
We report this case of late infection of the composix mesh used for incisional hernia of the abdominal wall.

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Linea alba hernia is a form of abdominal hernia. This paper reports a case of strangulation of linea alba hernia due to the development of ascites in renal failure. The patient was a 45-year-old female who weighed 103 kg. She had been found to have an egg-like mass in the midline of the upper abdomen before, but she had left it alone. She was admitted to our hospital for advanced renal failure due to diabetic nephropathy. She had massive ascites, and the mass in the upper abdomen was enlarged. After that, she complained of nausea and abdominal pain, and tenderness around the mass. We diagnosed her as ileus due to strangulation of linea alba hernia, and an emergency operation was performed. The hernia sac was found to be protruding through the defect of linea alba in the upper abdomen. The hernia was found to contain the small intestine, and the intestinal tract was excised because damage to the intestinal tract due to ischemia was found. A simple closure of the defect was performed. 12 months after surgery, she remains well. We considered that abdominal extraordinary high pressure by development of ascites might have caused strangulation of the abdominal linea alba hernia.

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A 61-year-old man who had had right inguinal bulging for 2 years was brought to our hospital due to sudden enlargement and pain of the right inguinal region. The bulging was 5×10 cm in size and was diagnosed as incarcerated indirect inguinal hernia. Manual reduction of the incarceration was not successful. A CT scan revealed incarcerated solid mass with fat tissue in the inguinal canal and no sign of bowel obstruction. Since his abdominal finding was normal, we suspected that the content of hernia was greater omentum. Operation was performed on the next day according to his wish. Swollen appendix was disclosed when we opened the hernia sac. Normograde appendectomy was carried out and the surgical site was rinsed with enough amount of normal saline. The posterior wall of the inguinal canal was repaired by Bassini's procedure. Pathologically the appendicitis was diagnosed as phlegmonous and a focal abscess was found on the top of the appendix. Since the surgical site was infected postoperatively, open drainage was required. Four months after the operation, the infected wound was completely healed. We here report this case of inguinal hernia with an incarcerated appendix, which is a rare entity, together with some bibliographical comments.

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