The characteristics of a breast tumor can usually be ascertained by core biopsy prior to treatment. We compared pathologic diagnoses based on preoperative biopsy with those after surgery in 132 breast cancer patients. Though high ER and PR correspondences between surgical and biopsy specimens were confirmed, the rate of HER2 correspondence was only about 70%, tending to be lower in surgical than in biopsy specimens. This discordance might be explained by low dye uptake in surgical specimens, due to unstable fixation as compared with biopsy. There was no difference in pathologic findings, regardless of whether chemotherapy had been administered. Biopsy and surgical diagnoses must be carefully evaluated when there are discordant findings, as tumor background factors can vary markedly.

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We have evaluated the efficacy of vessel sealing system LigaSure^TM Precise (LSP) compared with electrocautery for the prevention of lymophorrhea after axillary dissection in breast cancer. Significant differences were recognized in the average period of drainage tube indwelling between the LSP group (27 cases : 5.8 days) and the electrocautery group (29 cases : 7.2 days). Concerning the average volume of total exudates, the electrocautery group (517.7ml) was significantly greater than the LSP group (399.5ml). In the LSP group, three out of 27 patients (11.1% ) required puncture for seromas after removal of a drain, whereas nine out of 29 patients (31.0%) in the electrocautery group. With this comparison, six out of nine patients in the electrocautery group required more than two times of puncture and three patients from this group required the drainage again. There were no patients who required the drainage again in the LSP group. These results suggest that the use of LigaSure^TM Precise is effective for prevention of lymphorrhea after axillary dissection for breast cancer.

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The object of this retrospective study was to evaluate the possibility as well as necessity for the preservation of the ileocecal valve at the operative procedure like ileocecal resection or right hemicolectomy with respect to clinical outcome and radicality for colon cancer. We examined perioperative changes in serum sodium level, triglyceride level, total cholesterol level, postoperative serum vitamin B12 level and anemia. For evaluation of bowel movements after operation compared with before operation, we performed a questionnaire survey. We also evaluated that whether the preservation of the ileocecal valve could affect lymph node metastasis. A total of 150 patients who were performed such operation in our institution were enrolled in this study. There were no significant changes in serum sodium level during perioperative period, triglyceride, total cholesterol level and serum vitamin B12 level after the operation. There were few patients with macrocytic anemia. In respect of bowel movements no significant changes were noted after the operation. Twenty-five percent of patients who were estimated that their ileocecal valve could be preserved had lymph node metastasis along the ileccecal artery. It is concluded that the presevation of the ileocecal valve could not be recommended.

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We report a case of lactic acidosis after total gastrectomy which appeared to be due to peripheral parenteral nutrition, and was successfully treated with vitamin B1 (thiamine).
A 79-year-old-man, undergone total gastrectomy three months earlier, presented with abdominal pain and abdominal fullness. He was diagnosed as having strangulation ileus and peritonitis and underwent emergency surgery. Although the necrotic portion of the small intestine was excised, acidosis was prolonged, and on the day after the operation, dyspnea developed. The blood lactate level was high, 8.1nmol/l, and we diagnosed the case as lactic acidosis. Vitamin B1 (thiamine) was administered, and the metabolic acidosis and the blood lactate level were subsequently normalized.
Lactic acidosis due to vitamin B1 deficiency generally develops during total parenteral nutrition. In this case, latent vitamin B1 deficiency after total gastrectomy appeared to have incurred lactic acidosis due to peripheral parenteral nutrition.

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A 76-year-old woman was admitted to the hospital because of a mass in the left breast. Physical examination revealed a hard mass measuring 3cm in diameter in the upper inner quadrant of the left breast. Mammography demonstrated a polygonal and microlobulated high density mass. Ultrasonography revealed an irregular shaped hypoechoic mass. Magnetic resonance image demonstrated the tumor parenchyma was enhanced in the early phase. Core needle biopsy showed suspicion of stromal sarcoma. Partial mastectomy with sentinel lymph node biopsy was performed. Microscopical examination revealed that the tumor consisted of spindle cells with pleomorphism with myxoid proliferation. On immunohistochemical examination, the tumor cells showed positive staining for vimentin, CD68 and cytokeratin, negative for desmin, SMA, S-100 and CD34. Thus, the tumor was diagnosed as malignant fibrous histiocytoma (MFH). We report a rare case of MFH of the breast with some bibliographical review.

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We report a case of a descending aortic aneurysm that was difficult to differentiate from an esophageal submucosal tumor. A 78-year-old man was admitted for angina pectoris and coronary artery stenoses in February 2006, and underwent a triple bypass on three branch coronary arteries. A peri-esophageal mass was noted on preoperative CT. He was subsequently admitted to our ward for treatment of the mass in April 2006. CT, MRI, esophagram and endoscopy confirmed the mass, 5 cm in diameter, located on the left side of the middle esophagus, and appeared similar to a submucosal tumor. We proceeded with video-assisted thoracic surgery for resection. The tumor was diagnosed as a saccular descending aortic aneurysm during the operation. We performed aortic stent grafting into the descending aorta because the aneurysm was increased in size after the operation.

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This paper deals with two cases of rupture of an aneurysm of the abdominal visceral artery probably caused by segmental arterial mediolysis (SAM) in which conservative therapy was successful.
Patient 1 was a 53-year-old man presented with the abrupt onset of abdominal pain. When he was first seen at the hospital, he revealed an increase in the white blood cell count, but otherwise abnormal findings were seen. After admission to the hospital for observation of the clinical course, he developed anemia and abdominal CT scan showed hematoma in the abdominal cavity. Patient 2 was a 58-year-old woman who had the abrupt onset of abdominal pain during hospital stay at another hospital for cerebral infarction, and was brought into our hospital because abdominal CT scan disclosed intra-abdominal hematoma. Abdominal angiographic studies in both patients showed wide-ranging irregularity in vascular diameter and aneurysms. Thus rupture of an aneurysm of the middle colic artery was suggested. No obvious active bleeding points were identified when the angiographic studies were done, so that the two patients were able to be treated conservatively by blood transfusions and depressor therapy.
It is considered that the conservative therapy is an option for rupture of an aneurysm of the intra-abdominal visceral artery due to SAM in accordance with the location of the aneurysm and general condition of the patient.

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The patient was a 73-year-old man with chronic empyema presented with high fever and chest pain. Despite an attempt of administration of antibiotics as well as thoracic drainage, no symptomatic remission was attained. Thus the patient was transferred to our department of surgery. Chest CT scan revealed an about 10 × 7 cm empyemic cavity with gas in it and thickening of the empyemic pleura. We considered that only decortication and thoracic drainage might entail a high risk of causing recurrence, so that a tissue expander was placed in the thoracic cavity after gaining informed consent from the patient. The expander was removed following satisfactory symptomatic remission was gained. These treatments yielded a complete cure for the disease.

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We experienced a patient with a severe gastric ulcer in the reconstructed gastric tube through the posterior mediastinal route after esophagectomy for thoracic esophageal cancer. The ulcer may cause perforation of the descending aorta. We proposed the use of a covered aortic stent, but the patient refused because of paraplegia induced by occlusion of the Adamkiewicz artery. During conservative treatment with a proton pump inhibitor, cardiac tamponade occurred suddenly, and we performed emergency surgical drainage. Ultimately, the patient was cured and was discharged 49 days after admission. We cannot generalize about the best treatment for such patients, but this case highlights the difficulty of preventive indications for aortic stent and occurrence of cardiac tamponade.

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A male patient in his sixties came to his physician's office because of an abnormal finding in the upper gastrointestinal study at routine check-up. A tumor was discovered in esophagogastric junction and the biopsy study revealed a presence of adenocarcinoma. Resection of the lower esophagus, total gastrectomy with D2 dissection, cholecystectomy and splenectomy were performed in Aug. 2006. The operative diagnosis was EU, Less, Type II, 25 × 24 mm in size, T2, N0, H0, P0, CYX, M0, Stage IB (according to the Japanese Classification of Gastric Carcinoma). The pathological diagnosis was esophageal adenosquamous carcinoma (pT2, N0M0, ly3, v2, Guide Lines for Clinical and Pathologic Studies on carcinoma of the Esophagus). CT study six months later revealed an enlargement of upper mediastinal lymph nodes including the pretracheal lymph nodes. PET study also revealed a concentration in the same area. As there was no other recurrence nor metastasis, an operation dissecting the cervical and mediastinal lymph nodes was performed through a reversed T sternotomy incision. The enlarged lymph nodes found preoperatively were pathorogically diagnosed as metastatic adenosquamous carcinoma. The postoperative course has been uneventful without second recurrence.

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A 57-year-old woman who had had recurrent bouts of over-eating and recumbency for depression was found to have a convulsive fit when she was suffocated due to food filled in the oral cavity after breakfast. Then she was brought into the hospital by ambulance. When she arrived at the hospital, her conscious level was III-100 (JCS) and the contents in the oral cavity had already been removed. Although she presented cyanosis, spontaneous respiration was confirmed. Moist rales were heard on the chest. The abdomen was distended but muscular defense was absent. Chest x-ray examination showed faint infiltrating shadows and large quantities of intra-abdominal free air in the bilateral lung fields. Gastrointestinal perforation associated with aspiration pneumonia was diagnosed and immediately operation was performed. Upon laparotomy an about 5-cm sized perforation running through to the lesser curvature aspect of the upper body of the stomach was identified. No organic diseases such as an ulcer and a tumor were present in the perforated site, so that spontaneous gastric perforation was diagnosed and was immediately closed by sutures.
It is etiologically considered that the abrupt increase in the inner pressure of the stomach due to vomiting and convulsion was added to the excessively expanded stomach due to repeated over-eating, causing the rupture of the stomach on the lesser curvature aspect.

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We report herein the case of a 73-year-old man who was admitted to our hospital with a complaint of epigastralgia. CT scan of the abdomen revealed free air and ascites. Endoscopic examination of the stomach revealed an oval, and infiltrative ulcerating lesion in the anterior of the middle body. The results of these imaging studies indicated gastric perforation with panperitonitis, and an emergency laparotomy was performed. At first, simple closure with an omental patch was performed to save his life. The specimen from a perforated ulcerating lesion showed malignant lymphoma. Then, ten days later, total gastrectomy with Roux-en Y anastomosis and lymph node dissection was performed. The final diagnosis was primary gastric lymphoma of diffuse large B-cell type. There was no evidence of lymph node metastases and peritoneal dissemination.

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An 81-year-old female was admitted to our hospital because of epigastric discomfort in March 2006. GIF depicted pyloric stenosis and a deep ulcer at the body of the stomach. Biopsies of the both lesions indicated inflammatory changes. Abdominal ultrasongraphy and CT scan depicted a solid mass at the antrum of the stomach. We diagnosed the case as pyloric stenosis because of the submucosal tumor with gastric ulcer, and performed partial gastrectomy. Histologically, the tumor was adenocarcinoma and the ulcer was moderately differentiated adenocarcinoma with remarkable lymphatic vessel invasion. The final diagnosis was gastric cancer with pyloric stenosis due to intramural metastasis.
Intramural metastasis from gastric cancer is rare, especially, a tumor causing pyloric stenosis. The etiology in this case was considered blockage due to remarkable infiltration of highly proliferative active malignant cancer cells into the lymphatic vessels.

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A 69-year-old man was seen at the hospital because of heartburn and appetite loss. He was found to have gastric cancer and underwent gastrectomy. The pathological diagnosis was undifferentiated gastric carcinoma. He has remained well without evidence of local recurrence or distant metastasis and has been followed as an outpatient, as of 38 months after the surgery.
Most_-gastric carcinomas are adenocarcinoma, and other types, especially undifferentiated, are rarely seen. Such a rare case is presented here.

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The patient was a 67-year-old man with advanced gastric cancer and multiple lymph node metastases, including a para-aortic lymph node. Since radical resection appeared impossible, we tried neoadjuvant chemotherapy (NAC) expecting downstaging of the tumor. We chose low-dose FP at first, and TS-1/CDDP next. The low-dose FP regimen was the combination of CDDP at a dosage of 10 mg/body and 5-FU at a dosage of 500 mg/body on days 1∼5, 8∼12. After two cycles of this regimen, TS-1 (120 mg/body) administered for 21 days with CDDP (40 mg/day) on days 8, 15 and 22. After NAC, gastrointestinal endoscopy showed that the primary tumor had changed to a scar-like lesion, and a biopsy showed no cancer cells. A CT scan also showed complete disappearance of all lymph node metastases. The response rate was evaluated as CR. Since a radical resection was considered possible, we performed a distal gastrectomy with lymph node dissection (D2+No.16 sampling). Microscopic findings revealed marked fibrous change and no cancer cells in the gastric wall or lymph nodes, which were judged to be grade 3. The patient was administered TS-1 for one year after operation, and he is well without recurrence at two years postoperatively. We considered the TS-1 (or 5-FU) and CDDP in combination useful as preoperative chemotharapy for advanced gastric cancer with multiple lymph node metastases including a para-aortic lymph node.

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We report a rare case of primary duodenal adenocarcinoma of the third portion.
A 57-year-old man was admitted due to vomiting. An abdominal CT scan revealed wall thickening of the third portion of the duodenum. The barium meal examination of the upper GI tract and endoscopy of the duodenum showed stenosis and a circular tumor of the third portion of the duodenum, and biopsy disclosed moderately differentiated adenocarcinoma.
Pancreatoduodenectomy with regional lymph node dissection (R0 resection) was performed. Histological examination disclosed that the tumor was moderately differentiated adenocarcinoma invading through the subserosa to the peri-duodenal fat tissue with lymph node metastasis.

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A 67-year-old man was admitted to our hospital because of general fatigue and jaundice. Computed tomography, magnetic resonance imaging and endoscopic retrograde cholangiopancreatography studies revealed obstructive jaundice caused by Papilla Vater's tumor. Possible existence of malignancy required pancreatoduodenectomy with lymphnode dissection(D2), despite no definitive diagnosis was made in preoperative endoscopic biopsy. Immunohistochemical stainings of the tumor cells with anti-Chromogranin A antibody and anti-Synaptophysin antibody were both positive ; histological diagnosis from the surgically resected specimen was small-cell carcinoma (endocrine cell carcinoma). Small-cell carcinoma originated from the Ampulla of Vater is rare, and the exact definition of this disease was reorganized only a decade ago, and the therapeutic strategy is still contravertial. We report herein a case of small-cell carcinoma (endocrine cell carcinoma) originated from the Ampulla of Vater in which a radical resection was completed.

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A 29-year-old man complaining of sudden abdominal pain was admitted to our hospital. There was muscle guarding and tenderness of the abdomen. Abdominal plain radiography and abdominal CT scan showed intraperitoneal free air and ascites, so we performed an emergency operation under a diagnosis of panperitonitis due to perforation of the intestine. At laparotomy, the perforation was confirmed at the small intestine 8mm in size, located 270cm distally from Treitz's ligament. We observed along the small intestine around 200cm including the perforated lesion to have thickness of the intestinal wall and dark red discoloration of the intestinal serosa. A partial small intestinal resection including the perforated lesion and the segment showing thickness and dark red discoloration was performed. Gross findings of the resected specimen revealed intact mucosal layer near the perforated lesion. Histologically, ischemic lesion, chronic inflammatory lesion or malignant lesion were not seen and mucosal layer did not slide into serosal side. Finally, he was diagnosed as having idiopathic perforation of the small intestine.

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A 73-year-old male was referred to our hospital because of right lower abdominal pain and nausea. Abdominal X-ray and CT examination revealed air fluid level and bowel dilatation. Conservative therapy was started with a long decompression tube insertion. However, no symptomatic remission was attained. On abdominal CT scan performed on the 3rd hospital day, severe bowel dilatation was observed. Therefore, an emergent laparotomy was performed on that day. The small intestine was trapped into a hole which was created by the adhesive omentum to the prosthesis, shaped with the omentum placed into the right lower abdominal preperitoneal space. This prosthesis was a Kugel patch inserted 2 years before this operation. The prosthesis which had involved the testicular artery and vein and ductus deferens was removed, then hernioplasty was done with pre-shaped porypropylen mesh (Bard 3D Max mesh). Recently, in the abdominal wall reinforcement, various types of prostheses have been frequently used, and several complications concerning these prostheses have been reported. Only one previous case of incarceration of the bowel after the use of Kugel has been reported in the Japanese literature. We have to consider postoperative complications like in this case.

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A 47-year-old woman was admitted because of abdominal pain, nausea, and vomiting. She had received non-steroidal anti-inflammatory drug (NSAID) for migraine and tension headache. Plain abdominal X-ray and computed tomography of the abdomen showed dilated loops of small bowel with air-fluid level. As symptoms were not improved by conservative treatment, she underwent laparotomy. In operative findings, a hard nodule was palpated in the small bowel 20cm from the end of the ileum. Partial resection of the ileum was performed. The resected specimen showed a circular ulcer and a circumferential stricture that caused luminal stenosis. Histopathologically, the ulcer was non-specific. We diagnosed this case as diaphragm disease associated with the use of NSAID.

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We report a case of necrotic Meckel's diverticulum due to torsion at its neck, resulting in ileus. A 6-year-old boy was admitted with complaints of nausea and abdominal pain. Emergency laparotomy was performed under the suspicion of torsion of small intestine. A huge diverticulum, 90×60mm in size, was found on the ileum about 60cm proximal to Bauhin's valve. It was twisted about 360° clockwise at its neck and was necrotized. Wedge resection of the ileum with the Meckel's diverticulum was performed. Torsion is a rare complication of Meckel's diverticulum, and we found reports of only 17 other cases in Japan. Those diverticula were also large, greater than 6cm in length, and had narrow necks. In our case, we thought that the ileus was the result of torsion of Meckel's diverticulum, associated with peritoneal inflammation, and oppression by this huge diverticulum.

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We report a case of cystic GIST of the ileum showing pedunculated and extraluminal growth. A 60-year-old man had pan-abdominal pain, abdominal muscular defense and hypotension suggestive of a pre-shock state. After admission to our hospital, abdominal CT revealed a mass 10 cm in diameter in the right lower abdomen, and high-density ascites. Emergency laparotomy was performed. Approximately 900 g of bloody ascites with clot formation was observed in the abdominal cavity. Bleeding due to rupture of superficial vessels was observed in the pedunculated tumor of the ileum which showed extraluminal growth. Macroscopically, a huge cystic intratumoral hematoma was suspected. Histopathological examination revealed findings consistent with a GIST with cystic degeneration. Thus, GIST of the small intestine must be borne in mind in the differential diagnosis of intraabdominal cystic tumors.

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A 68-year-old female patient had sigmoid colon resection and partial hepatectomy for the cancer of sigmoid colon with liver metastasis in Nov. 2004. The postoperative course was uneventful until Oct. 2005, when the value of CEA elevation was noted. CT study of thoracoabdominal area, an endoscopic study of upper and lower gastrointestinal tract and a PET-CT study did not reveal clear signs of recurrence. CEA value continued to elevate. The patient started to have symptoms of repeated ileus since around Oct. 2006. This time, repeated PET-CT study could reveal an abnormal concentration in the small intestine in the pelvis. Laparotomy was performed in Nov. 2006 with diagnosis of metastasis of the tumor from the sigmoid colon or a possible primary small intestinal malignancy. A type II tumor infiltrating to the serosal surface of the ileum was found and partial resection of the intestine was performed. Pathological finding proved to be a solitary metastasis of the sigmoid cancer to the ileum. Solitary metastasis of the colon cancer to the small intestine is rare and report of successful use of PET-CT study is extremely rare. We report this case with some review of literatures.

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There have been reports on primary goblet cell carcinoid of the vermiform appendix, whereas no cases of goblet cell carcinoid originating from a remnant of the vermiform appendix following appendectomy have been reported. We histopathologically detected goblet cell carcinoid, probably originating from a remnant of the vermiform appendix. Thus we herein report this case of a 50-year-old man with a history of appendectomy 30 years ago. He visited a nearby physician in March 2000 because of right lower abdominal pain, and he was referred to the department of gastroenterology of our hospital with suspicion of a tumor in the cecum at colonoscopy. A submucosal tumor-like lesion surrounded by a red area was colonoscopically detected at the opening of the vermiform appendix, and the third biopsy yielded a diagnosis of signet ring cell carcinoma. Surgery was performed on May 2000. Although Schnitzler's metastasis was noted, the ileocecal region was resected to avoid ileus. The resected lesion was histopathologically diagnosed as goblet cell carcinoid originating from the remnant of the vermiform appendix following appendectomy. Chemotherapy with 5-FU and CDDP was conducted after surgery, but this patient died of carcinomatous peritonitis.

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The ileosigmoid knot is a rare cause of intestinal obstruction in which the ileum wraps around the base of the sigmoid colon. A 59-year-old man was admitted to our hospital with severe abdominal pain of sudden onset. Abdominal computed tomography revealed the dilatation of the sigmoid colon and small intestine, ascites, and medial deviation of the descending colon. A dilated loop of the sigmoid colon like a volvulus was located in the right hemiabdomen and distended loops of the small intestine in the left hemiabdomen. We suspected an ileosigmoid knot and performed an emergency operation. Laparotomy demonstrated a sigmoid volvulus surrounded by a gangrenous loop of small bowel. We resected the sigmoid colon and small intestine. These were key findings to make the preoperative diagnosis that both sigmoid colon and small intestine were dilatated and the loop of the small intestine lay an the left side of the abdomen, with the loop of the sigmoid colon an the right side.

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A 54-year-old man with constipation found to have serious sigmoid colon cancer with multiple liver metastatic tumors underwent sigmoidectomy to avoid colon obstruction. Pathological examination of the specimen showed a high nuclear cytoplasmic ratio with increased nuclear chromatin. Immunohistochemical staining showed positive chromogranin A and CD 56, indicating small cell carcinoma. Based on the chemotherapy regimen for small cell lung cancer, we chose CDDP+CPT-11 as first-line therapy, which clearly shrank the multiple liver tumors. After detection of a pelvic tumor 7 months later, we changed the treatment to CDDP+etoposide with radiation. And after the use of hydrochloric acid amurubicin for the regrowth of the hepatic tumor CDDP+CPT-11 was administered again and the patient was put under observation. Small cell carcinoma has dismal prognosis, but different treatments may provide long-term survival while maintaining good quality of life.

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A 40-year-old woman was admitted to our hospital because a medical check up revealed liver dysfunction and a tumor in her liver. An abdominal US showed a high echoic mass surrounding the right and middle hepatic vein in front of the inferior vena cava. A well-enhanced tumor was observed in the S1 and S4 of the liver by computer tomography. Abdominal angiography showed tumor stain in the A1 and A4 of the liver, and no spoke wheel appearance was found. She had taken oral contraceptives for seven years. We suspected that the liver tumor of the caudate lobe was liver cell adenoma (LCA), and partial resection of the caudate lobe was performed. Histopathological examination showed bile duct proliferation in the Glisson without atypism. Finally, it was diagnosed as focal nodular hyperplasia (FNH). We report a case of FNH of hepatic caudate lobe difficult to differentiate from LCA, because of taking contraceptives and demonstrating the spoke wheel appearance.

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Case 1 : A 65-year-old female patient was observed for cryptogenic liver cirrhosis by a local physician. She presented at our hospital with a decreased level of consciousness and a flapping tremor in August 2007.
Case 2 : A 73-year-old male patient was observed for HCV-related liver cirrhosis by a local physician. He presented at our hospital with a decreased level of consciousness in June 2007. Dynamic computed tomography (CT), ultrasonography and abdominal angiography detected three tumors compatible with hepatocellular carcinoma in segments 2 and 6 and 8 of the liver. Radiofrequency ablation (RFA) therapy for segment 8 of the liver was done. CT and abdominal angiography also showed the presence of a paraumbilical venous shunt and the reduction of volume of portal vein in both cases. We surgically ligated the paraumbilical vein during an open laparotomy in both cases, and conducted RFA therapy for segments 2 and 6 of the liver in case 2. After surgery, serum ammonia levels were reduced rapidly to the normal range and chronic encephalopathy improved in both cases. Dynamic CT performed after surgery showed the disappearance of paraumbilical venous shunt in both cases. No incidences of hepatic encephalopathy, esophageal varices, and ascites occurred during the follow-up period till now in both cases.

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A 54-year-old man was admitted to our hospital because of a liver tumor pointed out at another hospital when he visited for right hypochondralgia. There was a previous history of right hemicolectomy with a diagnosis of ascending colon cancer. Abdominal CT scan demonstrated a giant tumor about 15 cm in diameter in the right lobe of the liver. We performed right hepatic lobectomy with a preoperative diagnosis of metastatic liver tumor or cholangiocarcinoma. Pathological findings of the liver tumor showed the same pathological image as the primary colon cancer. Immunohistochemical study of the both tumor showed similar findings (EMA, CK20 and CEA were positive ; CK7 was negative). Therefore, we diagnosed this as a case of hepatic metastasis. Hepatic metastasis from colon cancer has rarely occurred over 5 years after colectomy of the primary cancer. We report such a rare case of liver metastasis from colon cancer 10 years and 6 months after a colectomy with a review of the literature.

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A 58-year-old female was admitted for sudden upper abdominal pain and vomiting. Spontaneous pain and tenderness without muscular guarding of the upper abdomen was present. Blood chemistry was normal except for WBC of 13200/μl and CRP of 0.2 mg/dl. Ultrasonic study showed the gallbladder was deviated to medially and the cystic duct was not visualized. CT showed the gallbladder was deviated to medially, and the wall of it was not enhanced. Torsion of the gallbladder was diagnosed and laparoscopic cholecystectomy (LC) was performed. During surgery, it was found that the gallbladder was Gross type-I floating gallbladder and was twisted counterclockwise by 180 degrees around the cervical portion and cystic duct, developing necrosis. Torsion of the gallbladder is caused by the floating gallbladder and LC is regarded as the most useful way to treat this condition.

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A 58-year-old woman was admitted to the hospital because of right hypochondralgia. An abdominal US and CT disclosed a thickened gallbladder wall with multiple cystic lesions in the fundus of the gallbladder. The level of CA19-9 was elevated. Preoperative diagnosis was chronic cholecystitis, but gallbladder cancer (GBC) was also suspicious. In operative findings, the gallbladder showed extensive adhesions to the transverse colon. Under the diagnosis of GBC with invasion to the adjacent organs, an extended cholecystectomy with partial resection of the colon was done. Histopathologic final diagnosis was xanthogranulomatous cholecystitis (XGC) without GBC. XGC presents difficulty in differential diagnosis from GBC on imagings. Intraoperative frozen-section examination is useful, but there are cases of both XGC and GBC simultaneously. Accordingly, in instances in which gallbladder cancer is suspected, we must bear a possibility of XGC in mind and select operative procedure carefully based on the imagings or intraoperative findings. It is also important to oftain an adequate informed-consent should radical surgery be needed, in case the final pathologic diagnosis is GBC.

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We reported a case of adeno-endocrine cell carcinoma of the gallbladder. A 64-year-old man, diagnosed to have gallbladder tumor from ultrasonographic findings, was admitted to our hospital complaining of epigastric pain. As the result of a detailed investigation, we diagnosed it as gallbladder carcinoma with a liver invasion and performed extended cholecystectomy and bile duct resection. The tumor size was 20 × 12 mm in the fundus. Histological findings demonstrated that the tumor consisted of adeno-endocrine cell carcinoma. Immunostainings were positive for Grimelius staining, CGA, CY and NSE but negative for Fontana Masson staining and AE1/3. The patient died 9 months after surgery in spite of gemcitabine chemotherapy.
The purpose of our report is to describe clinical and histological characteristics of this disease. Only 45 cases of adeno-endocrine cell carcinoma of the gallbladder have been reported in Japan. We consider that this disease might have highly malignant potential and must be distinguished from the classical carcinoid.

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Undifferentiated carcinoma of the pancreas is comparatively rare and carries a poor prognosis. We experienced this carcinoma which appeared as a well demarcated solid tumor with an extrapancreatic growth. Such a growth appearance is atypical as undifferentiated pancreatic cancers so that we had difficulty in making preoperative diagnosis.
A 58-year-old woman was admitted to the hospital in August 2004 because of close exploration for an abdominal tumor, which was detected in the ventral side of the pancreas body by abdominal CT scan. Abdominal US, MRI and angiography demonstrated a solid tumor about 3cm in diameter with an extrapancreatic growth, which was stained weakly. The serum CEA and CA19-9 levels were within normal limits, and the main pancreatic duct was normal. Endocrine tumor of the pancreas was suspected clinically, and distal pancreatectomy was performed on October 8, 2004. The tumor was a 5.5-cm sized solid tumor showing an extrapancreatic growth. Pathologically the tumor cells were spindle-shaped and did not show apparent differentiation. From these findings as well as those of immunohistochemical studies that were cytokeratin positive and vimentin negative, undifferentiated pancreatic carcinoma was diagnosed.

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A 77-year-old man had sigmoid colon and pancreatic tail carcinoma. In August 2003, we performed sigmoid colectomy and distal pancreatectomy with splenectomy, transverse colectomy and wedge resection of the left kidney. Histologically, the pancreatic carcinoma involved the renal panrenchyme. Fourteen months later, serum CA19-9 level was elevated, and 29 months later, CT revealed local recurrence of pancreatic carcinoma in the prerenal space. Left nephrectomy with associated resection of the colon, jejunum and stomach was carried out. Local recurrence was confirmed by histological examination. The patient is doing well at 19 moths after reoperation. Although recurrence of pancreatic carcinoma occurs mainly in the distant site such as liver and peritoneum and offers poor prognosis, the present case suggests that it is important to gain an appropriate surgical margin during pancreatic resection, and that a prolonged survival could be afforded by the repeated operation for a rare solitaly local recurrence like our case.

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A 70-year-old man who had previously been diagnosed leukocytosis was admitted to our hospital because of abdominal pain and in unconscioustate. We diagnosed intraperitoneal bleeding caused by spontaneous splenic rupture due to leukocytosis by abdominal CT. After emergency abdominal angiography we performed selective splenic embolization, which proved successful. The postoperative course was uneventful and the patient was discharged from the hospital on the 30^th hospital day. Myelodysplastic syndrome was the cause leukocytosis. The patient died four months after the operation because of cerebral hemorrhage.
The treatment of choice for spontaneous splenic rupture in a patient with a hematologic malignancy is splenectomy, and this is the first report of a survival case managed by splenic embolization.

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Primary inflammatory pseudotumors rarely occur in the spleen. Only 62 cases have been reported in Japan since 1985. In this case, a primary inflammatory pseudotumor was detected in the spleen by FDG-PET and a splenectomy was performed. We report this case with some discussion based on the literature. The patient was a 70-year-old female. The splenic tumor was detected by abdominal echography at the time of a health check-up in November 2005. The patient visited this hospital in January 2006. A tumor measuring about 4.5cm in diameter was detected by CT below the spleen, and she was placed under observation. However, tumor growth was observed in January 2007. Due to the FDG uptake in FDG-PET, the tumor was suspected to be malignant. Accordingly, a splenectomy was perfomed in February the same year. Based on the histopathological findings, the patient was diagnosed as having an inflammatory pseudotumor.

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A primary adrenal non-Hodgkin malignant B-cell lymphoma with large bilateral mass formation is presented. A 72-year-old male was referred for anorexia. Abdominal-enhanced CT detected two masses measuring 8 cm and 5 cm in the right and left adrenal glands, respectively. On MRI, the bilateral adrenal masses were revealed to be low and homogenous in intensity on T1-weighted images, and the masses were slightly high in intensity on T2-weighted images. Plasma ACTH level was markedly elevated and plasma cortisol level was low, which suggested adrenal failure. Considering the large size of bilaterally malignancy was suspected, and bilateral adrenectomy was performed. Histological examination revealed infiltration of large, round atypical cells in the dilated vessels within the tumor masses. Immunohistochemical staining demonstrated that most tumor cells were positive for B-cell markers, CD20, and negative for epithelial markers, AE1/AE3. The final diagnosis was intravascular large B-cell lymphoma (IVL), characterized by the presence of lymphoma cells in the lumina of small vessels. The postoperative course was uneventful. The patient underwent R-CHOP (Rixuximab, Cyclophosphamide, Doxorubicin, Vincristine, Predonisolone) chemotherapy, and no recurrence is evident to date. This is only the 6^th case, with the longest survival of the reported cases in Japan.

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Hernia of the broad ligament of the uterus is attributable to a tear of the broad ligament and it is a comparatively rare pathological condition. We report a case of laparoscopic repair of a hernia of the broad ligament of the uterus that caused ileus. The patient was a 46-year-old female. She visited a clinic nearby with abdominal ache as the chief complaint. She was referred to this hospital and was admitted under the diagnosis of ileus. On the plain X-ray of the abdomen, niveau sign and enlargement of a segment of the small intestine were observed. CT findings of the abdomen at the time of admission indicated enlargement of the small intestine within the pelvis and deviation of the uterus to the left. In view of repeated onset of ileus despite the absence of history of operation and based on the tomographic image, the patient was assumed to have a hernia of the broad ligament of the uterus. However, for a definite diagnosis and treatment, it was decided to conduct a laparoscopic operation. Although the pre-operative diagnosis suggested a hernia of the right broad ligament of the uterus, the small intestine was actually incarcerated (Richter's hernia) in a defect of the left posterior lobe of the broad ligament. The operation was completed by reduction of the incarcerated small intestine and suture of the defect. The post-operative course up to remission was favorable, and the patient was discharged after 11 days.

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We present a case of right paraduodenal hernia with strangulation of the small intestine. An 82-year-old woman with no history of surgery was admitted to our hospital with severe upper abdominal pain and vomiting. An emergent enhanced abdominal multi-detector computed tomography (MDCT) revealed that almost all small bowel was encapsulated and strangulated through an opening below the ligament of Treitz, and that the mesenteric artery was sifted to anteriorly in the abdominal space, and was diagnosed as right paraduodenal hernia causing strangulation of the small intestine, and an operation was performed. As diagnosed preoperatively, the hernia orifice was located in the mesentericoparietal fossa and the small intestine was incarcerated in the hernia sac located in the right retroperitoneal space and the part of the intestine was strangulated. The incarcerated bowel was reduced and the defect of transverse mesocolon was closed by suturing. Early diagnosis, however, enabled to avoid the surgical resection of the strangulated small intestine. Thus, paraduodenal hernia should be considered in the differential diagnosis of intestinal obstruction, and enhanced abdominal MDCT plays a significant role for the quick diagnosis and in establishing the indication of an emergent surgical operation.

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Desmoid tumor is a rare tumor of the soft parts. It is histopathologically benign, but recurs repeatedly so that we often have great difficulties in treatment. In this paper we present two cases of intra-abdominal desmoid tumor which might have arisen in the mesentry, together with a review of the literature.
Patient 1 was a man in his sixties. He visited a hospital because of abdominal distention and then was referred to the hospital because abdominal CT scan showed an intra-abdominal huge tumor. A mesenteric tumor was diagnosed and excision of the tumor and associated resection of the transverse colon were performed. The histopathological diagnosis was desmoid tumor arisen from the mesentery.
Patient 2 was a woman in her fifties. She was seen at the department of gynecology in our hospital because of abdominal distention. Pelvic CT scan disclosed absence of a tumor in the pelvic cavity. She was thus referred to our department with a suspicion of a tumor arisen from the intestinal tract. An intra-abdominal tumor was diagnosed and excision of the tumor and associated resection of the jejunum were performed. The histopathological diagnosis was mesenteric desmoid tumor.

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A 58-year-old man was referred to our hospital for retroperitoneal tumor (23 mm in diameter) showing a high fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET). Two years earlier, the presence of this tumor (15 mm in diameter) had been demonstrated on plain abdominal CT, and he was closely followed because there had not been any FDG uptake on PET. Abdominal CT and MRI after hospitalization showed a retroperitoneal tumor in the area adjacent to the celiac axis and the common hepatic artery. Since this tumor demonstrated high FDG uptake on PET along with an increase in tumor size, we could not deny the possibility of a malignant tumor. Laparotomy was thus performed under preoperative diagnosis of a retroperitoneal tumor, including neurilemmoma. A firm tumor measuring 23 mm in diameter adhered to the nerve plexus around the common hepatic artery, and the tumor was excised along with the surrounding capsule. Pathological diagnosis was Antoni A type schwannoma consisting of spindle cells presenting a palisade arrangement without malignant change. From the intraoperative findings, this neurilemmoma was considered a rare lesion arising from the nerve plexus around the common hepatic artery.

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The patient was a 66-year-old male who visited our hospital with the chief complaint of a sudden, strong abdominal pain. The patient had loss of appetite for the past month. The abdomen was plate-like hard, suggesting general peritonitis. Abdominal simple roentgenogram showed free gas images in the abdominal cavity, and abdominal CT revealed a high volume of ascites. Perforation of the digestive tract was diagnosed and emergency laparotomy was performed. Surgical findings included the retention of high-volume cloudy ascites and diffuse multiple grayish-white nodules in the abdominal cavity. Nodes were felt in the ileum, where there was a perforation 3 mm in diameter. As a tumor encircling the caecum was felt, a perforation of the small intestine due to peritoneal dissemination of malignant tumor was diagnosed. Partial resection of approximately 7 cm of the small intestine including the portion with the perforation was performed. In the histopathological examination, granulomas were seen in the serous membrane of the small intestine, in the parenteral wall and the greater omentum. Ascitic culture proved tubercle bacilli. Tuberculous peritonitis was diagnosed. Even though tuberculous peritonitis is rarely encountered, it cannot be ignored even now.

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Four patients with intractable ascites due to gastrointestinal carcinomas were studied who had been treated with Denver peritoneovenous shunts. All patients decreased in body weight and abdominal girth. Symptomatic relief was achieved in all of them. Postoperative complications like clinical DIC, wound hematoma and catheter occlusion did not occur. Postoperative mean survival was 73 days, and one patient was discharged and could stay tentatively at home. The Denver peritoneovenous shunt was useful for improving the quality of life for the cancerous patients with intractable ascites.

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Perforation of the gastrointestinal tract is rarely caused by an accidentally ingested toothpick. The diagnosis is often defined after laparotomy because most of the patients do not remember swallowing a toothpick and it is difficult to identify it by the various imaging studies. Here we present an unusual case of perforation of the sigmoid colon induced by an accidentally ingested toothpick with incarcerated left inguinal hernia.
The patient was 63-year-old man suffering from irreducible left inguinal hernia. On admission, laboratory studies revealed acute inflammation and imaging studies showed the signs of perforation of the gastrointestinal tract. But he did not remember swallowing a toothpick and we could not detect it by imaging studies then. We diagnosed him as having perforation of the digestive tract induced by incarcerated left inguinal hernia and performed an emergency operation. At laparotomy, we found a toothpick located near the portal of the hernia. To our knowledge, this is a very rare case of perforation of the sigmoid colon induced by an accidentally ingested toothpick with incarcerated left inguinal hernia. We review some literatures associated with injuries from toothpick and discuss our case.

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There are clinical reports of inguinal hernia repair using the Direct Kugel patch^®, but femoral hernia repair using the Direct Kugel patch^® repair has not been reported previously. We presents here that incarcerated femoral hernia repair was done using the Direct Kugel patch^® after cutting the femoral ring through femoral approach.
Patient 1, a 72-year-old woman with a several-year history of sustaining swelling of the inguinal region, was referred to our hospital because of suspected incarcerated hernia in June 2007. When she was first seen, she had right inguinal swelling with tenderness. She was diagnosed as having right incarcerated femoral hernia by abdominal CTscan. On the same day, emergency operation was performed. Patient 2, a 90-year-old woman complaining of nausea, was referred to the department of medicine in our hospital for the treatment of paralytic ileus in August 2007. Two days later, abdominal CTscan showed left incarcerated femoral hernia. She underwent emergency operation. In these two cases, the incarcerated hernia was released by cutting the femoral ring through femoral approach. The hernia sac was treated by low ligation after confirmed contents of the hernia sac. After dissecting the preperitoneal cavity, we inserted a Direct Kugel patch^® into there. Their postoperative courses were uneventful and they were discharged from the hospital.

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We report a case of von Recklinghausen's disease associated with gastric cancer, colonic cancer and small intestinal leiomyoma. The patient was a 73-year-old man complaining of epigastric discomfort. Upper gastrointestinal endoscopy showed a type I tumor at the angular notch of the stomach which was diagnosed as adenocarcinoma by biopsy. During surgery for the gastric carcinoma, advanced cancer in the transverse colon as well as leiomyoma in the jejunum was found. Distal gastrectomy, transverse colectomy, and wedge resection of the jejunum were thus performed. One and a half years later, early cancer was detected in the descending colon and partial colectomy was done.
It has been reported that von Recklinghausen's disease is frequently associated with non-epithelial tumors including neurogenic tumors, but sometimes cases of the disease with malignancies of the digestive organs have recently been reported. This case is so rare that gastric cancer, colonic cancer and small intestinal leiomyoma were associated with the disease.

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A 66-year-old woman (a Jehoval's Witness) was seen at the hospital because of positive fecal occult blood test. Barium enema X-ray and colonoscopic examinations revealed a type 2 tumor in the ascending colon. Histological findings of the biopsy specimen showed poorly differentiated adenocarcinoma. Furthermore, gastroscopic examination revealed early gastric cancer in the gastric antrum, which was histologically moderately ∼ poorly differentiated adenocarcinoma. We diagnosed the case as double cancer and parformed laparoscopic surgery after obtained informed consent from the patient. Operative procedures involved laparoscopy-assisted distal gastrectomy (D1 + β) and laparoscopy-assisted right hemicolectomy (D3) simultaneously. The postoperative course was uneventful without blood transfusions, and she was discharged from the hospital on 21^st hospital day.
Laparoscopic surgery is considered useful for patients who desire not to receive blood transfusions like a Jehovah's Witness because it offers minimal operative bleeding, however, we must not hesitate to convert it to open surgery when unexpected hemorrhage has occurred.

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The patient was a 64-year-old man who was referred to our hospital with a chief complai of a mass in the lower left abdomen. His past history included a high anterior resection for rectal carcinoma at age 53. There was no family history of malignant diseases. We observed 4 lesions in the colon at the preoperative colonoscopy. All biopsy specimens showed adenocarcinoma. The serum CEA level on admission was 425.2ng/mL. Another tumor was also found in the jejunum at the operation. Therefors, subtotal colectomy and partial resection of the jejunum were performed. Histological findings showed a total of 8 cancerous lesions: two in the ascending colon (Type2, 0-Is), three in the transverse colon (Type2), two in the descending colon (Type2), and one in the small intestine (Type2). The postoperative serum CEA normalized, but systemic lymph node metastases from the jejunum cancer were observed 15 months after the operation.

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