BACHGROUND : It is suggested that the peripherally inserted central venous catheters (PICC) have low complication rates at insertion, and their safety and time –savings are probable. However it is rarely studied in Japan. METHODS : We reviewed the medical records of all patients who had PICC or CVC at the department of surgery in our hospital between the beginning of January and the end of December 2004. Hundred sixty patients, 87 PICC and 73 CVC were analyzed in detail. RESULT : As a complication at the insertion, there was no pneumothorax in both groups, however malposition of the catheters was 12.3% in PICC and 1.1% in CVC. The catheters were in place before removal for a mean of 14.1 days in PICC, 13.4 days in CVC. The rate of catheter sepsis was 4.0% in PICC and 1.0% in CVC, so there was no significant difference between two groups. CONCLUSION : There was no significant difference in the number of days of catheter placement and the incidence of catheter sepsis, but the rate of malposition of the catheter tip was higher in PICC. Therefore, PICC was confirmed in its safety, however further studies are needed to improve its shortcomings.

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(Purpose) The aim of this study was to evaluate our current status and problems in the perioperative management of elderly patients over 80 years old who underwent surgical operations under general anesthesia. (Patients and Methods) Fifty–nine surgeries in 55 patients operated on under general anesthesia from January 2002 to December 2006 were enrolled in this study evaluating the perioperative management and prognosis. (Results) The male–to female ratio was 14 : 41, with the mean age of 84.9. Frequent diseases for operations included malignant diseases in 31 patients, gallbladder or common bile duct stones in five patients and arteriosclerosis obliterans in five patients. Common underlying diseases included hypertension, cerebral infarction, and diabetes mellitus. Postoperative morbidity rate was 67.9% and pneumonia, dementia and wound infection frequently occurred. There was no 30–day mortality, but five postoperative deaths during hospitalization, and three of them underwent palliative surgery. The overall 5–year survival rate was 58.4% and the main cause of deaths was malignancy. Significant poor prognostic factors were palliative surgery and preoperative fasting for more than a week. (Conclusion) From a prognostic standpoint, we must be cautious in indicating palliative surgery for elderly patients with advanced cancer.

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The postoperative condition of patients with early gastric cancer who underwent proximal gastrectomy reconstructed by jejunal pouch interposition (JPI group, n=14) was analized retrospectively in comparison with reconstruction by esophagogastrostomy (EG group, n=22) during the same period, from 1996 to 2006. The operative time of the EG group (131 min) was significantly shorter than that of the JPI group (161 min). No significant difference was seen between the two groups in blood loss and postoperative stay. There was no significant difference in postoperative complications including anastomotic leakage, stenosis, pancreatitis, intestinal obstruction, and pneumonia. No significant difference was seen in clinical symptoms of heartburn, gastric fullness, vomiting, diarrhea, and Dumping syndrome. There was also no significant difference in food intake, nutrition status, and body weight loss change. Endoscopic examination one year after the operation showed no significant differences including reflux esophagitis, anastomotic stenosis, remnant gastritis, and bile regurgitation. A high incidence of food residue in the remnant stomach or jejunal pouch was found in JPI group (80.0%), a significantly higher proportion than that found in EG group (14.3%). JPI group showed no better results for postoperative symptoms than EG group. In terms of operation time and food residue, EG group was superior to JPI group. A simple and conventional reconstructive procedure by esophagogastrostomy should be indicated after proximal gastrectomy.

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Abstract : A patient, 48–year–old male, went to a dermatology clinic near by with the complaint of progression of desquamation of the right nipple that first appeared 10 years ago. The excisional biopsy of the areola revealed carcionoma and therefore he was referred to our clinic. The pathological study of the biopsied specimen did not reveal Paget cells with abundant pale cytoplasm nor large nuclei in the epidermis and a diagnosis of invasive ductal carcinoma infiltrating directly to the nipple and epidermal ridges was made. CT and FDG–PET study revealed metastases to the lymph nodes of of right axilla, mediastinum and bilateral hilar area of lung. After 3 courses of preoperative chemotherapy with FEC (fluorouracil, epirubicin, and cyclophosphamide) the patient was transferred to other hospital as he had to change his job location. Cases of male breast carcinoma with long history of the nipple desquamation due to dermal infiltration is extremely rare. We report this case with some review of literatures.

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The patient was a 1–day–old baby boy. The baby was delivered by normal spontaneous vaginal delivery in the 35th week of gestation and weighed 3100 g. The patient was admitted to the neonatal intensive care unit for severe respiratory distress. A posterior mediastinum tumor with calcified regions was found by chest X–ray and CT. The tumor was surgically resected on the 3rd day after birth. The tumor was situated in the right posterior mediastinal cavity and was wrapped with an amnion–like membrane. Blood was supplied to the tumor by a branch of the right intercostal artery. The tumor removed looked like an incomplete fetus, having parts corresponding to head, trunk, limbs and others. Microscopically, tissues of long bones, arthrosis, nail, vertebrae with medulla spinalis, cartilage, muscle, skin with hair, chorioidea, brain, and alimentary tracts were recognized. To our knowledge, this is the first case of feesees in fatu arising in the posterior mediastinum.

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A patient, 73–year–old female, who was referred to our clinic in Dec. 2005 for the first time for the investigation of an abnormal shadow in her left chest found by a chest X–ray. A 13 cm diameter mass was present in the lower posterior mediastinum, left side of thoracic aorta extending to widen the posterior mediastinal space but without clear sign of infiltration. The preoperative diagnosis was a nonepithelial tumor with high content of fat inside and it was thought most probably to be a kind of liposarcoma. She was operated on in Feb. 2006. There was no infiltration to the surrounding organs and excision of the tumor was carried out without removing near by organs. She was discharged 12 days after the operation without complications. The pathological diagnosis was undifferentiated liposarcoma. At present no recurrence is seen 15 months after the surgery without additional treatment. Undifferentiated liposarcoma is rare and we report this case with some review of literatures.

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A 79–year–old man with effort angina was admitted. Coronary angiography showed progressive stenosis of left anterior descending (LAD) artery. Coronary artery bypass grafting without cardiopulmonary bypass was done. The left internal mammary artery (LIMA) graft was anastomosed to LAD. Postoperative transesophageal echocardiography (TEE) detected in the right atrium (RA) a highly mobile structure moving during diastole into the right ventricle. CT scan showed a small pulmonary embolism in the right peripheral pulmonary artery. Thrombolytic therapy was started with heparin and urokinase. Eight days after the beginning of thrombolytic therapy, the clinical status of the patient was quite normal. TEE and CT scan showed no mobile structures in the RA or pulmonary embolism in the pulmonary artery. The LIMA–LAD bypass was patent. He was followed as an outpatient. However, this case was investigated by transthoracic echocardiography (TTE) and TEE simultaneously, as TTE could not detect the thrombus in the RA. As in this case, clinical symptoms such as postoperative slight dyspnea may not be associated with pulmonary embolism, and asymptomatic RA thrombus or small pulmonary embolism may not be detected usually. Evan if heparin was used perioperatively, we should use intermittent pneumatic compression and elastic stockings for the prophylaxis of pulmonary embolism and deep venous thrombus for all cardiovascular surgery patients.

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An asymptomatic 70–year–old man was admitted to our hospital for evaluation of an abnormal lung shadow. Chest X–ray film and computed tomographic (CT) scan showed a 32mm–sized mass shadow with a cystic lesion in the left upper lobe. Transbronchial lung cytology of brushing and washing failed to make a diagnosis. Cultures of sputum and specimen of transbronchial lung brushing and washing grew nothing. No definite diagnosis was made. ¹⁸F–fluorodeoxyglucose positron emission tomography (FDG–PET) showed abnormal uptake in the left upper lobe of the lung and rectum. Preoperative diagnosis was advanced rectal cancer and left lung metastasis. Laparoscopy–assisted super low anterior resection of the rectum and left upper lobectomy of the lung were performed simultaneously. Histopathological diagnosis was pulmonary actinomycosis. The patient has been well without any complaints or recurrence of actinomycosis for 7 months after the surgery. We conclude that pulmonary actinomycosis which resembles lesions produced by lung cancer and lung metastasis should be included in the differential diagnoseis of a pulmonary mass lesion in an asymptomatic patient.

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A 17–year–old previously healthy boy was admitted to the hospital with dyspnea and sore throat. He did not have neurological findings. Physical examination revealed evidence of subcutaneous emphysema in his neck, upper chest and this was comfirmed on chest radiography. Laboratory investigations were unremarkable. Computed tomography of his chest showed extensive subcutaneous air throughout the neck and chest associated with pneumomediastinum. Epidural air also was noted within the spinal canal. There was no pneumothorax visible. It is difficult to recognize the areas of emphysema by simple roentogenogram because of its poor discriminative ability. A computed tomography study, however, reveals its expanding boundary, the mediastinum, and the spinal epidural spaces.
In this report, computer tomography study successfully demonstrated the area of epidural emphysema.
He stayed at rest and was treated conservatively and his symptoms improved within a few days. Four days later, he could be discharged.

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The patient was a 66–year–old man who underwent subtotal esophagectomy and retrosternal route esophagogastric tube anastmosis at the cervical region for esophageal cancer in January 2001. In January 2006, he was seen at the hospital because of general fatigue and admitted with a diagnosis of pericardial effusion. By endoscopic study and contrast–enhanced X–ray examination he was diagnosed as having a gastroepicardial fistula caused by perforating ulcer of the reconstructed gastric tube. He was treated with fasting, protonpump inhibitor, antibiotics, and percutaneous drainage in the pericardial space. The function of the heart was kept good and the infection was well controlled. At about one month after the initiation of conservative systemic treatment, the perforating fistula was confirmed to be closed on endoscopic and contrast–enhanced X–ray examinations.
With recent progression in the treatment of esophageal cancer, long–term survivors after operation have been increasing and ulcer of the reconstructed gastric tube has not been uncommon. However, cases of ulcer of the reconstructed gastric tube due to a gastroepicardial fistula, especially cured by conservative therapy, are relatively rare. So we report this case with some notes on the relevant literature.

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A 44–year–old man, who had been pointed out having multiple gastric polyps by a screening barium study 4 years earlier which had been unchanged until one year before entry, revealed an increase in the number and size of the polyps and coexisting gastric cancer at a follow–up study. Juvenile polyposis limited to the stomach with gastric cancer was diagnosed, and total gastrectomy was performed. The final findings according to the Japanese classification of gastric carcinoma were : ML type3, 50×40mm, T2N3M1 (LYM), and Stage IV. The histological diagnosis was poorly∼moderately differentiated adenocarcinoma, and polyps were hyperplastic. Despite adjuvant chemotherapy with TS1, the patient experienced lung metastasis 5 months and died 10 months after the operation. Since gastric polyposis has been reported to have malignant potential and early diagnosis may be difficult as seen in this case, it is suggested that total gastectomy should be considered even in an asymptomatic patient.

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We report a case of gastric cancer with tuberous sclerosis and a liver angiomyolipoma (AML). A 35–year–old woman was diagnosed as having progressive gastric cancer. In the process of an avaluation of gastric cancer, we reached a diagnosis of tuberous sclerosis by finding adenoma sebaceum on her face and subendymal nodule by head CT image. Another complications that are characteristic of tuberous sclerosis are such as kidney AML and lymphangiomyomatosis. In addition, a liver tumor was found by abdominal ultrasonography. It had a component of fat and blood vessels and liver AML was suspected, but differentiation from liver metastasis was necessary. For gastric cancer, we performed distal gastrectomy and for liver tumor, liver partial excision for diagnosis. The liver tumor was diagnosed as liver AML. When a liver tumor is found in a case of gastric cancer having tuberous sclerosis, it may be important to suspect not only liver metastasis but also liver AML. In addition, it is often overlooked especially in adult cases without convulsions, stroke or retardation of mental development. This case was one example of tuberous sclerosis diagnosed at 35 years old coincidently with a close inspection of gastric cancer.

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A case of erythema gyratum repens (EGR) associated with early gastric cancer in a 97–year–old man is presented. EGR in the trunk had appeared with erythematous papules, which had spread peripherally to extremities 3 years before, and a malignancy work–up revealed an early gastric cancer in the lower corpus and antrum. Distal gastrectomy was performed and histological findings showed moderately differentiated adenocarcinoma invading to the submucosal layer of the stomach wall with locoregional lymphnode metastasis. The final stage was IB. Curative resection of the cancer lesion resulted in clearing of the erythema in 2 months.
Figurate erythemas, such as EGR and erythema annulare cantrifugum (EAC), are supposed to arise from hyper–sensitivity reactions to infectious agents, drugs or malignant tumors. To date, only 39 cases of EGR, EAC and other figurate erythemas associated with internal malignancy have been reported in the Japanese literature. The clinical features and postulated etiology are discussed.

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A 45–year–old woman underwent a modified radical mastectomy for left breast cancer. After 1 cycle of chemotherapy, she was admitted for nausea and vomiting after eating frequently. Abdominal computed tomography revealed thickening of the wall of the duodenum. Histological study revealed that tumor calls in the duodenum were similar to the breast cancer cells. Because of the loss of oral ingestion, a laparoscopy–assisted gastro–intestinal bypass and oophorectomy were performed. No symptoms of recurrence were noted at an 18–month follow–up study after the operation, and continued chemotherapy.

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A 32–year–old male with right lower abdominal pain was admitted to our hospital. The patient received a preoperative diagnosis of acute appendicitis, and underwent appendectomy. Since the patient had right lower abdominal pain as well as fever on the 12 th postoperative day, he received emergency reexploration due to the suspicion of intra–abdominal abscess. During the second operation, we observed an inflammatory long band as well as necrotic cystic mass with abscess. The mass including the affected ileum was resected. The histopathological report indicated that the mass was due to the inflammation of large Meckel's diverticulum.
Our present case was an extremely rare example of Meckel's diverticulum with a band–like shape of 10 cm in length. We think that it is very difficult to make a precise diagnosis of diverticulm even during laparotomy. Therefore, we should consider the existence of Meckel's diverticulum like our present case when we do not observe the typical macroscopical findings of appendicitis.

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A patient, 54–year–old female, started to have a systemic chemotherapy for the metastasis of breast cancer to cervical nodes, bones and appearance of malignant left pleural effusion two years after the left mastectomy for breast cancer. The patient developed acute peritonitis three months after starting the chemotherapy and an emergent laparotomy was performed. A perforation of the small bowel by metastatic cancer was the cause of the peritonitis. The patient showed temporary improvement of the clinical picture, but soon developed malignant meningitis and died. Perforation of small bowel due to metastatic breast cancer is extremely rare, but it is important to consider its possibility in case of prolonged prognosis in breast cancer as the potential metastasis of the cancer to intestinal tract is not rare.

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Intestinal malrotation is usually asymptomatic in adults so that it is often incidentally detected during examination or at laparotomy for a digestive tract disease in many cases. Recently, we experienced a case of acute appendicitis in which the correct diagnosis was difficult to not made preoperatively but incidentally it was obtained during the operation for patient with acute abdomen due to intestinal malrotation. A 78–year old man was admitted to our hospital because of abdominal pain. A laparotomy was performed under the diagnosis of ileus related to intestinal malrotation. The intra–operative diagnosis was paralytic ileus due to perforative appendicitis. It is necessary to consider the possibility of appendicitis as a diagnosis before the operation of acute abdomen when intestinal malrotation is associated.

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Mucocele of the appendix is a cystic,dilated appendiz filled with mucin. We report a case of strangulation ileus caused by a mucocele of the appendix without any adhesions.
A 94–year–old woman visited our hospital because of acute abdominal pain was diagnosed as having intestinal obstruction. At emergency laparotomy, the ileum was surrounded and strangulated by the appendix itself, and there was a cyst at the top of the appendix. The cyst had played a plumb of the pendulum and made the appendix itself wound around the ileum, causing ischemia. Histopathological study revealed that the cyst was composed of column epithelium.
It is rare that mucocele of the appendix causes strangulation ileus and this is the 16^th case of the disease in Japan, as far as we could review.

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A 57–year–old man was admitted to the hospital because of recurrent abdominal distention and diarrhea. Ileus due to stenosis of the terminal ileum, was diagnosed and conservative therapy was initiated. No symptomatic remission was attained and ⁸F–fluorodeoxyglucose–positron emission tomography (FDG–PET) showed high FDG accumulation in the terminal ileum with a standardized early–phase uptake of 3.06 and late–phase of 3.48. Operation was thus carried out. Laparotomy revealed swelling of lymph node No.202, but no malignancy was demonstrated by intraoperative frozen section diagnosis. Therefore, ileocecal resection with lymph node dissection was performed. The histopathological diagnosis was poorly differentiated appendiceal adenocarcinoma in StageII.
The diagnosis of appendiceal adenocarcinoma is difficult to make preoperatively. To our knowledge, no cases have been reported in the Japanese literature describing FDG–PET findings of appendiceal adenocarcinoma. FDG–PET appears to be a helpful tool for making the diagnosis of colonic type appendiceal adenocarcinoma.

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We report a patient with a ruptured aneurysm of the accessory middle colic artery who successfully underwent emergency transcatheter arterial embolization. A 54–year–old man with left upper abdominal pain and vomiting visited our hospital. The next morning after admission, the patient was in hemorrhagic shock. Emergency abdominal computed tomography showed a high–density area, 25 mm in diameter, which was consistent with large hematoma in front of the pancreas. An aneurysm of the accessory middle colic artery was consequently diagnosed by abdominal angiography and transcatheter arterial embolization with microcoils was performed. A ruptured aneurysm of the accessory middle colic artery is very rare and this report is the sixth case in the Japanese literature.

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We report a case of retrograde intussusception caused by a lipoma of the sigmoid colon. A 68–year–old woman admitted to the hospital was found to have a palpable left–abdominal mass associated with tenderness. Abdominal X–ray showed a dilated transverse colon shadow and a crescent of gas outlining a tumor–like mass on the distal side of the colon. Computed tomography revealed a mass with multiple concentric rings. We diagnosed retrograde intussusception of the colon and mechanical ileus. Laparotomy showed the sigmoid colon had invaginated retrogradely into the descending colon. After reduction of intussusception, we resected the sigmoid colon. The histopathological diagnosis was lipoma of the submucosal layer of the colon. The postoperative course was uneventful. The patient was discharged from the hospital 15 days after the operation.

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A 50–year–old Japanese woman had a 1.5–year history of ulcerative colitis (UC). At the age of 49, total colectomy and ileostomy were performed and mucus fistula of the rectum was also made, because of deterioration of UC. One month after the operation, skin eruption with pain was found near the stoma, and it became larger day by day. She was diagnosed with peristomal pyoderma gangrenosum (PPG). Oral steroids and stoma management temporarily relieved the PPG. However, exacerbation of PPG was found with deterioration of UC. She underwent a resection of the remnant rectum and ileo–anal anastomosis. A new stoma was also made in the left lower quadrant. After the second operation, she has had no trouble with PPG.

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A 75–year–old male patient came to our hospital with the complaint of continuous abdominal pain of 3 days. The examination of his abdomen revealed a fist sized mass in the upper abdomen with tenderness. A blood test showed mild inflammatory reaction. A CT study revealed target sign and the diagnosis of intussusception of transverse colon was made. Barium enema revealed a 3 cm diameter sized reddish, smooth surfaced protruding tumor in the transverse colon. The intussusception was thought to be caused by this tumor and laparotomy was performed and pathological diagnosis of colitis cystica profunda was made. There is no report of colitis cystica profunda causing intussusceprion up to this time. We report this case as it is thought to be an extremely rare case.

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Primary endocrine cell carcinoma of the large intestine is very rare, and the rectum is the primary lesion in most cases, if present in the large intestine. However, we encountered a case of primary endocrine cell carcinoma of the cecum with the onset of ileocecal intussusception. We herein report rare case of a 56–year–old man, who visited the department of internal medicine at our hospital with a chief complaint of abdominal pain on October 1999. He was diagnosed as having an intussusception at CT scanning. Because multiple liver tumors were detected at the same time, a malignant tumor was thought to account for his intussusception, and a right hemicolectomy was performed. The resected lesion was histopathologically diagnosed as primary endocrine cell carcinoma of the cecum. Althogh postperative chemotherapy, including hepatic artery infusion therapy, was performed, he died 6 months after surgery. Endocrine cell carcinoma is highly malignant, and it remains to determine what therapeutic modality is effective for this type of malignancy.

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An 82–year–old woman was seen at the hospital because of abdominal distension and vomiting. Target like sign was successively detected from ascending, transverse through descending colons, and the oral side was continuous with the distended intestine on abdominal CT scan. Enema study detected beak–like stenosis, and colonoscopy detected a protruding lesion in the descending colon which was covered with nomal mucous membrane, necessitating surgery under a diagnosis of intussusception. At laparotomy, we saw that the cecum had invaginated into the lumen of the descending colon which was led by a protruding tumor of the cecum. Repositioning by Hutchinson procedure and right hemicolectomy for the cecal tumor were carried out. Pathologically, the cecal tumor was diagnosed as well differentiated adenocarcinoma involved within proper muscular layer.

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We report a case of huge lymph node metastasis from early sigmoid colon carcinoma operated on 6 years earlier. The patient was a 69–year–old man who underwent endoscopic mucosal resection (EMR) for early sigmoid colon carcinoma in 2001. At that time pathological study showed that the carcinoma had submucosal extent and the cut end was unclear, so that laparoscopy assisted sigmoid colon resection (D1) was added. He was admitted to the hospital because of the sudden onset of high fever in 2007. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a huge mass (10×10 cm in diameter) in the pelvic cavity, colonofiberscopy showed mucosal erosion on the sigmoid colon, and barium enema showed the compressed sigmoid colon. Because echo–guide needle biopsy for the tumor showed moderately differentiated adenocarcinoma, sigmoidectomy including the tumor (Hartmann's operation) was performed. Pathological examination showed tumor metastasis of No. 241 lymph node from sigmoid colon carcinoma. After the operation CEA and CA19–9 which were elevated before the operation fell to normal ranges. The patient is now on chemotherapy with UFT/UZEL.
Lymph node metastasis from colon carcinoma invaded the submucosal layer is rare. But is instanced in which risk factors including low histologic grade and lymphovascular invasion are observed, periodical surveillance should be done to detect postoperative recurrence.

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It is known that a variety of causes induce bacterial translocation (BT), but we rarely experience clinical cases of BT resulting in septic shock. This paper presents a case of ileus after surgery for colon cancer in which septicemia due to BT was suspected.
A 59–year–old man underwent right hemicolectomy for transverse colon cancer. On postoperative day 3, he was diagnosed as having ileus and treated with insertion of a long intestinal tube. The long intestinal tube was removed on postoperative day 9, because the patient's condition became stable. On postoperative day 17, he suddenly developed high fever of 40°C with hypotension and was diagnosed as having septic shock. Enterobactor aerogenes was detected in a peripheral blood specimen. Because there was no evidence of leakage peritonitis, BT was the most likely cause of septicemia. After treatment by systemic antibiotics, symptomatic remission was attained. On postoperative day 24, he developed high grade fever with severe chills, and Enterobactor aerogenes was detected in a peripheral blood specimen again. BT was strongly suspected as the cause of septicemia. After treatment by systemic antibiotics for a long time and early enteral nutrition, the patient's symptoms improved.
Our case suggests that treatment by long–term systemic antibiotics and early enteral nutrition are important for the management of patients with a high risk of BT.

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A 46–year–old woman complaining of anal bleeding an defecation and an anal tumor was referred to the hospital. Colonoscopy revealed a circular type2 rectal tumor, for which biopsy revealed moderately differentiated adenocarcinoma. On examination of the perianal region, a hard mass 2cm in diameter was found at the anus, and biopsy of the anal tumor also showed moderately differentiated adenocarcinoma she had had an anal fistula and then metastatic carcinoma in the anal fistula from rectal cancer was diagnosed. She underwent abdominoperineal resection (D3) of the rectum with a wide excision of the perianal lesion. Because the histological findings of both tumors were identical, we considered that free cancer cells from the rectal cancer had been implanted intraluminally to form a metastatic tumor in the anal fistula.

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A 77–year–old–man had undergone coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) 6 years previously and laparoscopic sigmoidectomy 4 years previously. He was diagnosed as having a metastatic liver tumor of the colon cancer in the lateral segment. Lateral segmentectomy was performed while preserving the RGEA graft. The patient had no complication both in and after the operation. In our hospital 7 operations of the upper abdomen after CABG using RGEA were done successfully preserving the RGEA grafts in all cases.
In any surgical case of upper abdominal operation after coronary bypass grafting using the RGEA, a careful preoperative examination must be done for ascertaining whether or not possible to preserve the RGEA graft.

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Little has been reported on liver abscess as a complication of laparoscopic cholecystectomy. This paper deals with a case of a liver abscess caused by temporary circulatory disturbance of the hepatic artery after laparoscopic cholecystectomy. The patient was a 74–year–old man complaining of right hypochondralgia. He was seen at the hospital after several boats of right hypochondralgia. Following close exploration, he was found to have cholecystolithiasis, cholecystitis, diabetes, and fatty liver. Laparosccopic cholecystectomy was performed with the diagnosis of cholecystolithiasis. High fever and mild degree of retarded hepatic impairment occurred after the operation, but they subsided spontaneously. The patient was discharged from the hospital on the 10^th postoperative day, but he was seen at the hospital again because of abdominal pain on the 24^th postoperative day. Ultrasonography and CT scan of the abdomen offered a diagnosis of abscess in the anterior segment of the liver. Favorable blood flow in the hepatic artery and portal vein were revealed and no dilatation of the bile duct was demonstrated. Inflammatory reaction was mild and internal use of antibiotics was started on an ambulant basis. Thereafter symptomatic remission was attained and a remarkable shrinkage of the tumor was identified on an abdominal CT scan done on the 46^th postoperative day.
It is etiologically considered that temporary circulatory disturbance of the hepatic arteriole in the right anterior segment of the liver had caused the liver abscess.

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A 63–year–old woman undergone endoscopic retrograde cholangiography for dilatation of the common bile duct which was detected by abdominal CT scan was found having dilatation of the common bile duct and a protruding cauliflower–like lesion with the maximum diameter of about 3 cm in it. A possibility of a malignant neoplasm could not be ruled out completely in terms of the tumor diameter, and operation was performed. Following excision of the common bile duct, a part of the tumor was extirpated and examined by intraoperative frozen section diagnosis. It was reported that the obtained material was suggestive of findings of adenoma but a possibility of well–differentiated adenocarcinoma could not be ruled out completely. Accordingly cholecystectomy, choledochectomy, and cholangiojejunostomy were performed after no malignant findings were confirmed at the surgical stumps of the bile duct. The histopathological diagnosis was papillary adenoma, and there were no malignant findings.
Benign tumorous diseases arisen in the extrahepatic bile duct can recur even they are benign, so that we must consider surgical treatment if we can not determine whether such a lesion is benign or malignant.

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We report a case of extrabiliary adenoma that progressed to the duodenum. The patient was a 52–year–old man who came to our hospital with the chief complaints of nausea and inappetence. A giant tumor was detected in the duodenum by endoscopy, so the patient was hospitalized. In the laboratory data on admission, liver function was elevated only slightly, and the tumor marker was negative. In diagnostic images, the tumor was 4.0 cm in diameter in the duodenum and was localized in the duodenal wall. Thus, we performed a pancreatic head resection with segmental duodenectomy. It was a papillotubular adenoma which had progressed in a bile duct in the duodenum to a lumen of the duodenum, but pathological diagnosis did not show malignancy. A common bile duct adenoma is rare, and we could find no report of a giant bile duct adenoma progressing to the duodenum.

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Although tumor metastases to the pancreas are often found in case of small cell carcinoma of the lung, acute pancreatitis induced by metastasis is a rare initial manifestation. A 52–year–old man was diagnosed as acute pancreatitis because of his back pain in November 2004. Abdominal CT scan showed a pancreatic head tumor with paraaortic lymph nodes metastases. He was diagnosed as having unresectable pancreatic cancer. Although chemotherapy was started after recovering from pancreatitis, he suffered from pneumonitis and chemotherapy was stopped at the first week. He visited our hospital for the further treatment of his pancreatic tumor at the end of December 2004. At admission, his neck lymph nodes were swollen and he was suffring from superior vena cava syndrome. Biopy of the lymph nodes revealed a metastasis of small cell carcinoma of the lung. Finally, he was diagnosed as having small cell lung cancer with multiple metastases including pancreas. He underwent chemotherapy with Cisplatin (60mg/m²) and Irinotecan (60mg/m²) and radiation therapy to the neck region. Although these treatments were effective for more than 6 months, he died 11 months after the initial admission. In conclusion, we experienced a patient with small cell carcinoma of the lung who was initially diagnosed as pancreatic cancer.

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Torsion of the spleen is a rare disease and an unusual entity. The most common etiology is wandering spleen. Here, we report a case of splenic torsion with splenic cyst during observation. A 32–year–old woman visited our hospital with left upper abdominal pain in August of 2002. She was found to have a splenic cyst at 20 years of age, but was not concerned because it caused no symptom. Abdominal ultrasound and CT revealed a splenic cyst measuring 7.0 cm in diameter. She obtained relief from pain after examination, and we chose conservative therapy as an outpatient. However, she was admitted with severe left abdominal pain three months later. Abdominal CT revealed a malrotated spleen, and laparoscopic splenectomy was performed in a view of splenic torsion. Intraoperative findings showed backward malrotation of the spleen at a 45–degree angle. She recovered uneventfully and was discharged on the 9th postoperative day. The histological diagnosis was splenic pseudocyst, and histological findings revealed acute infarction of splenic parenchyma induced by torsion of the spleen.

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We experienced a case of a CA19–9 producing splenic cyst, which is comparatively rare, in which laparoscopic dome resection (LDR) was successfully performed.
A 23–year–old woman was seen at the hospital because of left hypochondralgia. Close exploration disclosed a 13 × 9cm cyst in the upper pole of the spleen as well as abnormally high serum CA19–9 level of 414 U/ml. No apparent findings of malignancy were identified, so that CA19–9 producing splenic cyst was diagnosed and LDR was performed. The removed cyst was lined with squamous cells and then it was diagnosed as true cyst. The elevated CA19–9 level was normalized to be 12 U/ml after the operation. The patient has been free from recurrence and is followed strictly.

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A 70–year–old man who had had douts of mild omphalitis from his childhood presented with abscess formation extending from the umbilicus to lower abdominal wall in April 1993. Abscess of a urachal remnant was diagnosed and he underwent total removal of the urachus, when a histopathological study revealed adenocarcinoma. Thus re–operation was indicated and additional resection of a part surrounding the bladder which seemed to be urachal remnant tissue and the head of the bladder was performed. No malignant tissues were demonstrated in the removed material. Thereafter, in October 1999, the patient developed an induration in a location where the umbilicus had been removed ; swelling of the right inguinal lymph node in January 2000 ; and induration of the right lower abdominal wall and bilateral inguinal lymph node swelling in April 2007. All lesions were suggestive of local recurrences and were removed which were histopathologically diagnosed as recurrence. In August 2007, bilateral multiple lung shadows as well as mediastinal lymph node swelling developed, multiple lung metastasis being suggested. Despite 8 courses of chemotherapy with tegafur, gimeracil and oteracil, no changes in size of the multiple lung shadows were revealed. The patient is still on treatment.

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A 41–year–old woman, had been aware of a mass in the right inguinal region for 5 years. She visited the hospital because of periodical increase in size of the mass. An elastic hard mass in 3cm diameter was detected in the right inguinal region on palpation. From images of pelvic ultra sonography and CT scan hydrocele of the canal of Nuck or myxoma was suspected. After obtaining informed consent, surgery was performed for both diagnosis and treatment. The mass existed in the distal part of the round ligament of the uterus. Resection of the mass including the round ligament of the uterus was performed.
Histopathologic examination showed mixed endometrium–like tissue in the mass, which was diagnosed as endometriosis. This case was a relatively rare external endometriosis (about 0.8%), which often makes the diagnosis difficult. This entity should be considered as one of the differential diagnosis for a case whose chief complaint is an inguinal mass, and to take a clinical history carefully in relations with the menstrual cycle was important for the final diagnosis.

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A patient, 67–year–old male, came to our emergency department with the chief complaints of nausea and abdominal distention. A CT study revealed thickness of the wall and stenosis of the second and the third portion of duodenum. The retroperitoneal area outside the duodenal wall revealed low absorption density shadow of wide extension. An endoscopic study of upper gastrointestinal tract revealed hyperemia of the duodenal mucosa and stenosis, but no definite evidence of a tumor. A laparotomy was performed on the 8th day of admission to release the duodenal obstruction, to perform incidental cholecystectomy and to establish the diagnosis. Intraoperative frozen section study of the specimen did not reveal malignancy. The operation was done only for the release of obstruction without resection of the surrounding organs. The pathological diagnosis was retroperitoneal panniculitis. The postoperative course was uneventful and the patient started to take oral diet on the 18^th day after the operation.

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A 55–year–old woman visited the department of gynecology in our hospital because of abrupt onset of atypical genital bleeding in July 2005. He was referred to our department for the purpose of operation for a huge tumor in the pelvis which was found on abdominal MRI scan. The tumor was sharply demarcated from the surrounding tissues on MRI, and thus a possibility of uterine– or rectum–origin tumor could almost be ruled out. Both high and low intensity areas were seen in the tumor, which were suggestive of and hemorrhagic necrotic foci, respectively. From these findings, intrapelvic tumor with bleeding was diagnosed and the tumor was removed. At surgery the tumor which had been fixed to the retroperitoneum at the sacrum was a 15.0×13.5×7.7cm elastic–hard to –soft mass and was sharply demarcated from the surrounding tissues. On immunostaining the resected was KIT positive. The definite diagnosis of extragastrointestinal stromal tumor (EGIST) was made. The postoperative course was uneventful, and the patient was discharged from the hospital on the 10th postoperative day.
Little cases of EGIST have been reported so far. Further accumulation of clinical cases as well as animated discussion about the etiology, treatments and prognosis would be required.

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We report a case of herniation of the small bowel through the foramen of Winslow diagnosed preoperatively and treated by laparoscopy–assisted surgery.
A 35–year–old man visited an emergency hospital because of abdominal pain and vomiting. Medical treatment with a diagnosis of acute gastritis provided no symptomatic remission. Thus he was referred and admitted to our hospital. Abdominal CT scan showed a dilated bowel incarcerated through the foramen of Winslow into the lesser sac. The patient was diagnosed as having strangulation ileus duo to herniation through the foramen of Winslow, and underwent an emergent operation. It was difficult to release the incarceration under laparoscopy, so that we pulled the incarcerated bowel out of the lesser sac by hand–assisted procedure. Since the herniated bowel was necrotic by about 15 cm in length, the affected small bowel was resected. No marked enlargement was found in the foramen of Winslow and no plication suture for the foramen was done.

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The aim of this study is to assess the contribution of dynamic cystocolpoproctography for the evaluation of female pelvic organ prolapse. Perineal hernia was classified levator hernia, urogenital hernia and anorectal hernia, and urogenital hernia was divided to anterior peritoneal hernia and genital hernia. Anorectal hiatus hernia was divided to internal rectal prolapse, complete rectal prolapse and massive rectal prolapse. The cystocolpoproctography was retrospectively analyzed in 46 consecutive patients. Sigmoidecele classified as levator hernia was detected in 4.5% of the patients, postvaginal hernia in 19.7%, cystocele in 3.0%, complete rectal prolapse in 53.0%, massive rectal prolapse in 10.6%, and incomplete rectal prolapse in 4.5% of the patients on cystocolpoproctography.
Perineal hernia can include a combination of cystocele, rectocele, uterine prolapse, enterocele and rectal proplapse. Accurate diagnosis of the coexisting abnormalities is essential in planning reconstructive procedures so that the risks of recurrence and reoperation can be minimized.
In conclusion, dynamic cystocolpoproctography provides direct visualization and quantification of female pelvic organ prolapse, and information that usually can only be inferred by physical examination.

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We report a case of bilateral subscapular elastofibroma that was difficult to differentiate from a desmoid tumor. A middle–aged man had undergone surgical resection of a right subscapular tumor, pathologicaly diagnosed as a desmoid tumor 6 years before. He presented with left subscapular mass and back pain. Elastofibroma was suspected by chest computed tomography and magnetic resonance imaging. The mass was excised and diagnosed as elastofibroma. The right subscapular tumor was pathologically examined again, and the diagnosis was ehanged to elastofibroma from desmoid tumor. Elastofibroma usually arises subjacent to an inferior angle of the scapula. Recognition of the lesion is important as the differential diagnosis from other tumors, especially desmoid tumor.

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A 44–year–old female had a gynecological cancer examination She had been suspected to have a myoma uteri. She came to the hospital for a close examination. The pelvic MRI scan showed a pelvic tumor and a gynecologist consulted us for the treatment of this tumor. She did not have any symptom. By digital examination, we found a tumor at anterior wall of Rb as protruding from the external wall. With physical examination MRI scan and CT scan images, we diagnosed it was a soft tissue tumor at the perineum. We performed tumor resection under the lumbar anesthesia. A hard and solid tumor was completely separated and resected from the surrounding soft tissue. She spent the post operative days with good condition and she was discharged from the hospital at post operative day 3. By the pathological examination this tumor was diagnosed as grade 1>2 hemangiopericytoma. This tumor is recognized as a potentially malignant neoplasm and it is very difficult to discriminate between benignancy and malignancy. We report a case of hemangiopericytoma of perineum with some literature review and discussion.

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