It is the hardest problem for proximal gastrectomy that reflux esophagitis can occur after the operation. In our institution narrow gastric tube reconstruction has been employed as a safe and convenient method since 2002. In order to evaluate the usefulness of the method, this study was made to examine subjective symptoms due to postoperative reflux esophagitis by using the F-scale interview table, as well as to grasp the status of occurrence of reflux esophagitis objectively based on endoscopic studies. Twenty-two patients who had undergone proximal gastrectomy in our institution from December 2002 to November 2007 were enrolled in this study to compare with 20 patients with early gastric cancer performed total gastrectomy in the same period. In both patient groups more than 70% of the subjects had reflux esophagitis like symptoms based on the F-scale interview table. Eleven out of 16(68.7%) patients who underwent proximal gastrectomy followed by endoscopic studies had findings of reflux esophagitis. However, Grade C or D in accordance with the Los Angeles classification that can create clinical problems was noted in only 18.8% of them.
It is considered that further devices in narrow gastric tube reconstruction are required including development of new evaluation methods for postoperative reflux esophagitis.

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The incidence of appendicitis has been decreasing over the years, but the report of actual studies investigating its incidence are few. Accordingly we performed a survey of the incidence of acute appendicitis seen in the past history at routine physical check-up. The survey according to the age of the examinees grouped in sixties, fifties, fourties, thirties, and twenties revealed fewer incidence in younger group. We concluded that the incidence decreased in adult population with relatively higher incidence in childhood population. Our study revealed the possible tendency that acute appendicitis became predominantly the disease of childhood.

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We evaluated the clinical course and outcome in 10 patients of locally advanced colon cancer with invasion to the duodenum. Patients were classified into three groups according to the radicality of surgery. Four patients in Group A were treated with R0 resection, 4 patients in Group C with R2 resection, and 2 patients in Group N without surgery. There were no differences among the three groups in terms of preoperative clinical findings. The duodenal invasion had been diagnosed preoperatively in 7 patients, mostly by endoscopy, while computerized tomography or other imaging modalities were not sensitive for detecting this type of disease extension. Two patients underwent right hemi-colectomy with pancreatoduodenectomy. The remaining 6 patients were treated with right hemi-colectomy with partial resection of the duodenum, of which 2 patients underwent reconstruction with Roux-Y double tract while 4 other patients were treated with simple closure of the defect. Clinical stage of the patients belonging to Group A were stageII in 2 patients and stageIIIa in 2. One patient in Group C had stageII disease, and stageIV in 3. Both of the Group N patients refused surgery although they had stageII disease. Two patients from Group A are disease-free after 47 months (follow up ; 40 and 53 months). Median survival of the Group C patients was 5.8 months, while all patients died of the disease. Both of the Group N patients died shortly after they were diagnosed (median survival 1.5 months). Duodenal invasion does not always mean dismal outcome, and R0 resection can result in prolonged survival. R2 resection may be relevant only as a palliation, and treatment without surgery results in dismal outcome.

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We experienced a case of terminal state of cancer that responded well to octreotide acetate. The obstruction of the alimentary canal in the patient of terminal state of cancer is seen in about 3% of all the cancer cases according to some reports. The symptom of obstruction, such as vomiting and nausea, becomes not only the cause of giving a patient pain, but also reducing quality of life. Octreotide acetate is effective in the bowel obstruction of the patient in terminal state of cancer. Proper administration of octreotide acetate is considered to improve the quality of life in terminal cancer patients.

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A 58-year-old male patient was seen by his private physician with the complaints of a mass on his left lateral head, right hemiparesis, and disturbed memory. The patient was referred to our neurosurgical department as the image study revealed a tumor in the left frontolateral skull. An emergent surgical removal of the tumor was performed as herniation of the brain was present. Histopathological study of the tumor revealed islet arrangement of the cancer cells and the immunopathological staining revealed positive in thyroglobulin, TTF-I, CK7, and CK18. The diagnosis of skull metastasis of thyroid carcinoma was made and the patient was transferred to our department. A 3×3 cm sized tumor was palpable on the left lobe of thyroid and 4×3 cm sized tumor was detected in the neck by a CT study. Blood study revealed high thyroglobulin level of 220 ng/ml. Aspiration cytology revealed the same type of cells as the tumor of the skull and total thyroidectomy was performed. Poorly differentiated carcinoma of thyroid is a new pathological concept, and a case found after the skull metastasis such as ours is quite rare. We report this rare experience with some review of literatures.

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Case 1 : A 35-year-old woman presented with an 8×5cm mass in the lower inner quadrant of her left breast accompanied by skin redness and tenderness. Purulent nipple discharge, whose culture and cytology showed no microorganisms and no malignant cells, was also observed. Histological diagnosis of the induration was mastitis. As the induration and purulent discharge persisted despite 2 months of antibiotics and drainage therapy, the induration was extirpated. After that, the patient recovered. Case 2 : A 32-year-old woman presented with a 6×6cm mass and skin redness in the upper half of her left breast. A core needle biopsy specimen showed chronic inflammation without any malignant findings. Antibiotics and surgical drainage were performed, but those were not effective. As purulent discharge (no microorganisms) and the local tumor persisted, 3 months later the whole tumor was removed, and the patient recovered. Histologically widespread inflammation extended along the mammary ducts and multinucleated giant cells were seen in both cases. Histological diagnosis was granulomatous mastitis.
There have been 42 Japanese cases of granulomatous mastitis including our two patients. Various effective treatments have been reported including steroids and Seton method, but there is no established treatment at present. So more research is needed regarding this disease.

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We report a rare case of malignant myoepithelioma of the breast, diagnosed as benigh tumor preoperatively in a 54-year-old woman. The patient was seen at our hospital because of a left breast tumor which was a movable elastic soft tumor, 21 × 13 mm in diameter, in the A area on palplation. Results of ultrasonography, mammography and aspiration biopsy cytology suggested a benigh breast tumor. We excised the tumor under local anesthesia. Hematoxylin and eosin staining, smooth muscle actin and S-100 staining, and electron-microscopic examination led to a diagnosis of breast malignant myoepithelioma. Therefore, quadrantectomy and sentinel lymph node biopsy were done as a curative surgical treatment.

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A 52-year-old woman exhibited calcifications in the right breast on screening mammography. On physical examination, there were no palpable tumors in the breast. Ultrasonography (US) demonstrated a hypoechoic area measuring 7.5 × 7.0 mm in the lower region of the right breast, and US-guided vacuum-assisted biopsy (VAB) was performed. The histological findings showed invasive ductal carcinoma. Prior to undergoing breast-conserving surgery, breast MRI for local staging was performed at our hospital and revealed an 8.8-mm irregular mass at a site different than that indicated by US. This lesion could not be detected by second-look US. MRI-guided VAB was carried out, and additional invasive ductal carcinoma was diagnosed histologically. This procedure was approved by the Institutional Review Board of our hospital, and informed consent was obtained from the patient. The MRI-guided VAB results altered the surgical plans, and mastectomy was performed. In patients with breast cancer who plan to undergo breast-conserving surgery, MRI-guided biopsy is required to definitively diagnose MRI-detected lesions that are suspicious or highly suggestive of malignancy.

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We report three patients with occult breast cancer who underwent axillary dissection as primary surgery. All three patients complained of axillary tumors. Biopsy or fine needle aspiration cytology of the axillary tumors proved adenocarcinoma, and imaging studies could not depict any primary lesions in the mammary gland and other organs. Successively axillary lymph nodes were dissected, and histological examinations revealed metastatic adenocarcinoma of lymph nodes. They were diagnosed as having occult breast cancer, but none of then desired further surgical or radiation therapy. They were closely observed thereafter. In the first case, tamoxifen was prescribed for 5 years but left breast cancer was detected 6 years after the operation. Simple mastectomy was performed. No recurrence has been found 13 years after the axillary lymph node dissection while she has been on hormone therapy. In the second case, chemotherapy was delivered and the patient has been free from recurrence for 9 years and 6 months after the operation. In the third case pancreas head cancer developed 5 years after the operation during hormone therapy. She died of pancreas cancer in the next year, though she had not experienced recurrence of breast cancer for 6 years after the initial surgery. Present observation indicated that occult breast cancer would require axillary lymph node dissection and systemic therapy, and preservation of the breast could be an alternative treatment if followed by adequate systemic therapy and close observation.

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A 65-year-old woman who underwent video-assisted thoracoscopic partial resection of the right upper lobe for lung adenocarcinoma (p-Stage IB) in June 2005 was admitted to our hospital because of a right lung nodule and a right breast tumor revealed by chest CT scan in March 2006. Ultrasonography and mammography also revealed a tumor around 2 cm in diameter in the C area of right breast. FDG-PET showed abnormal accumulation in the right breast tumor and the pleura of pulmonary apex. The breast tumor was pathologically diagnosed as breast cancer with core-needle biopsy. From these findings, we diagnosed the case as double cancer including recurrence of lung cancer (pulmonary metastasis and pleural dissemination) and breast cancer, and started chemotherapy. The chemotherapy resulted in disappearance of the pulmonary metastasis and reduction of the other tumor sites. Thus we performed right breast-conserving surgery with axillary lymph node dissection in September 2006. After the surgery, the resected breast tumor was pathologically confirmed breast metastasis from the lung adenocarcinoma. In the case of a patient with a breast tumor with presence or previous history of malignant disease, metastatic breast tumor should be considered in differential diagnosis.

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A 55-year-old male patient who was treated at an emergency medical center for the trauma inflicted by a suicidal attempt jumping into a train track came to our hospital complaining of abdominal distention and other abdominal distress since 2 weeks prior to the visit. Thoracoabdominal CT study revealed a clear image of the left diaphragmatic hernia orifice and protrusion of the bowel into the left thoracic cavity. With diagnosis of a delayed presentation of traumatic diaphragmatic hernia a semi-emergent operation was performed. The abdominal organs protruded into the thoracic cavity were reduced back to the abdominal cavity and the hernial orifice was repaired by a PTFE patch 40mm in diameter size. The postoperative course was uneventful and the patient was discharged on the 7^th postoperative day. The PTFE patch used in this case for the delayed traumatic diaphragmatic hernia was strong enough for thoracic wall reconstruction and quite effective material.

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We report a case of small cell carcinoma of the esophagus with rapid recurrence after curative resection. A 66-year-old man was diagnosed as having an asymptomatic tumor of the esophagus on an endoscopic examination. A barium meal study and endoscopic examination detected a small elevated lesion in the mid thoracic esophagus. CT scan of the chest revealed lymph node metastasis near right recurrent nerve, and histological diagnosis of the biopsy specimen was moderately differentiated squamous cell carcinoma. Neoadjuvant chemotherapy was administered for the purpose of tumor down staging.
Subtotal esophagectomy with three fields lymph node dissection was performed after neoadjuvant chemotherapy and pathological examination of the whole resected specimen revealed small cell carcinoma of the esophagus. No major postoperative complications occurred, however, general fatigue and liver dysfunction emerged after one month of the surgery. Abdominal CT showed multiple liver metastases with rapid growth, and he died of hepatic failure after 46 days of the operation.
Our experience in this case shows operation for the small cell carcinoma of the esophagus should be prudently selected especially in case of the presence of definitive lymph node metastasis.

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An 81-year-old woman visited our hospital because of an abdominal tumor had a palpable tumor, about 15cm in diameter in the left upper abdomen on physical examination. Abdominal CT scan showed a tumor with cysts in the left upper abdomen. The tumor was heterogeneously and faintly enhanced with contrast medium, and it was connected to the stomach with a pedicle. We diagnosed the tumor as GIST with an extragastric pedunculated growth and performed the laparotomy. The tumor was connected to the posterior wall of the stomach with the pedicle, 1.5×1.5cm in size. The tumor was resected with the gastric wall surrounding the pedicle by a linear stapler. The excised tumor was 16×13×12cm in size. The cut surface revealed white and reddish components with cystic areas of hemorrhagic necrosis. Histopathologically, the tumor was consisted of spindle sells and a few mitoic figures were observed. Immunohistochemically, the tumor was positive for KIT and CD34. Based on these findings, the tumor was diagnosed as GIST. She has been well and recurrence-free, as of 22 months after the operation.
Only 27 cases of GIST of the stomach with an extragastric pedunculated growth have been reported in Japan. In these series, we inferred that the prognosis of these unusual cases might be good against our expectations.

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A 70-year-old woman was admitted to our hospital with the diagnosis of gastric cancer. Upper GI series revealed a type 3 advanced tumor of 11cm in its longer axis in the upper to lower body of the stomach. Abdominal CT revealed thickening of the gastric wall and swelling of lymph nodes in the lesser curvature. We diagnosed the tumor as Stage III (cP0, cH0, cT3, cN1, cM0) gastric cancer, and concludes that curative resection was possible. But the patient refused the operation, thus TS-1/CDDP combination therapy (TS-1 : 100mg/day, 21 days oral administration and 14 days rest, CDDP : 80mg on day 8) was enforced. After 2 courses of chemotherapy, the extension of the gastric wall became good and the tumor longer axis was 5.5cm. Abdominal CT revealed metastatic lymph nodes had become smaller, indicating partial response (PR) to the chemotherapy. After obtaining the patients, total gastrectomy and splenectomy with lymph node dissection (D2) were performed. The pathological specimens showed no cancer cells in the gastric wall and lymph nodes, so the histological effect was judged as Grade 3. This case suggested that TS-1+CDDP combination chemotherapy may prove useful to treat patients with advanced gastric cancer.

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We experienced total gastrectomy with D2 lymph node dissection for a case of advanced gastric cancer after coronary bypass grafting (CABG) using the right gastroepiploic artery (RGEA). A 74-year-old man, who had undergone triple coronary artery bypass grafting 7 years previously, presented with anemia and was diagnosed with advanced cancer in the upper body of stomach. Preoperative angiography showed the RGEA graft remained well patent. Total gastrectomy removing the N2 lymph node was done arter percutaneous transluminal coronary angioplasty for the right coronary artery. We concluded that coronary intervention before gastrectomy is safe treatment for a gastric cancer patient arter CABG using the RGEA.

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The patient was a 52-year-old man who was hospitalized because of upper abdominal pain and vomiting. Upper endoscopy showed circumferential stenosis of the duodenal descending segment. The endoscope could not pass through the stenosis. A cytological examination did not show any tumorous lesion. Abdominal CT showed a duodenal tumor or an inflammatory stenosis with a diameter of 5cm that infiltrated the surrounding fatty tissue. The stenosis was severe, so pancreatoduodenectomy was performed. Based on histopathological findings, the patient was definitively diagnosed with duodenal diverticulitis causing inflammatory cellular infiltration and Brunner's gland hyperplasia.

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We report a case of duodenal stenosis caused by cholecystitis. A 58-year-old man had visited a nearby hospital after developing symptoms of upper abdominal distention and appetite loss five months earlier. The patient was referred to our hospital due to gradual progression of duodenal bulb stenosis during follow-up. Upper gastrointestinal endoscopy revealed a stenotic lesion in the duodenal bulb, but no mucosal abnormalities. Biopsy showed no malignant lesions. Upper gastrointestinal contrast study showed no flow of contrast medium to the duodenum. Mild wall thickening was observed in the antrum on an abdominal CT. Based on the above, the patient was diagnosed as having duodenal stenosis of unknown cause, and underwent surgery involving a planned gastrectomy to determine the cause. Laparoscopic observations revealed strong adhesion of the chronically inflamed gallbladder to the duodenal bulb. As this adhesion was thought to be the cause of stenosis, surgery involving only cholecystectomy and adhesiolysis was performed following confirmation of improvement of the stenosis by intraoperative GTF. Pathological finding of gallbladder was chronic cholecystitis. Duodenal bulb stenosis was caused by adhesion of the gallbladder to the duodenal bulb due to cholecystitis and subsequent atrophy of the gallbladder itself.

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The patient was a 69-year-old woman who was performed pancreaticoduodenectomy for carcinoma of the duodenal papilla of Vater in December 2003, followed by adjuvant chemotherapy with Gemcitabine (1000mg/body) administered biweekly four times. She was admitted to our hospital again because of a lower abdominal tumor in October 2007. Abdominal US revealed a 30 × 30 cm multilocular tumor in the lower abdomen. Abdominal CT scan and MRI revealed lymph node metastases around the superior mesenteric artery and the cystic mass in the pelvic cavity. Left hydronephrosis was demonstrated as well peritonitis carcinomatosa being suggested. The bilateral ovarian tumors were removed to reduce abdominal distension in November 2007. The ovarian tumors were diagnosed as metastases of the carcinoma of the duodenal papilla by histopathological findings. Intraoperative cytology of ascites revealed ClassV (adenocarcinoma). Combined chemotherapy with oral S-1 and Gemcitabine hydrochloride by drip infusion has been administered till now.
We experienced a case of carcinoma of the duodenal papilla presented with peritonitis carcinomatosa and bilateral ovarian metastases 4 years after the primary operation. The case is presented here together with a review of the literature.

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Mixed glandular-endocrine cell carcinoma of the duodenum is extremely rare. This is the fourth case reported in the duodenum as far as we are aware. A 63-year-old woman presented with postprandial epigastralgia. Physical examination and pre-operative imaging studies revealed a mass 4.5cm in diameter between the head of the pancreas and the proximal duodenum. Pancreatoduodenectomy was performed. The tumor arose from the proximal duodenum invading the head of the pancreas with the ampulla of Vater intact. Microscopic examination revealed an admixture of two components. Most tumor cells were composed of small atypical cells with rounded hyperchromatic nuclei, remarkable atypia and frequent mitotic figures. These anaplastic cells grew in a solid nest, in a trabecular pattern or arranged in sheets with remarkable vessel invasion. These cells showed a strong positivity for chromogranin A and synaptophysin. On the other hand, small areas with histological features of well-defferentiated tubular adenocarcinoma with positive reaction for CEA were observed. The patient died of widespread metastasis 7 months postoperatively.

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We report a long-term survival case of adenoendocrine cell carcinoma of the papilla of Vater.
An 83-year-old woman was admitted to the hospital because of obstructive jaundice. Preoperative diagnosis was adenocarcinoma of the papilla of Vater, and pancreaticoduodenectomy was performed. The postoperative histopathological diagnosis was adenoendocrine cell carcinoma of the papilla of Vater. The patient has had no signs of recurrence, as of 2 years after the surgery. Adenoendocrine cell carcinoma arising in the papilla of Vater is extremely rare, and only 9 cases, including our case, have been reported in the literature. The tumor involves high grade malignancy and carries an extremely poor prognosis, even though postoperative adjuvant therapy has done in addition to radical surgery. In this case, only the surgical treatment without adding postoperative adjuvant chemotherapy, to our Knowledge, provided the longest disease-free survival.
This case suggests that surgical treatment may provide a survival benefit for some patients with adenoendocrine cell carcinoma of the papilla of Vater.

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A 84-years-old woman was referred to our hospital because of severe abdominal pain. When she was 80-years-old, she was operated because of perforation of small intestine due to simple ulcer.
Abdominal CT scan showed edema and ischemic changes of the small intestine and presence of ascites. We diagnosed as peritonitis due to intestinal perforation by ischemic enteritis and urgently operated. Because her intestine became necrotic due to ischemia, we performed partial resection of the small intestine. After operation, she was moved to the previous hospital without any complication.
Nineteen months later, she was referred to us because of severe abdominal pain again. Because the result of abdominal CT scan was similar to the last CT, we also diagnosed as peritonitis due to intestinal perforation by ischemic enteritis and urgently operated. Her small intestine became necrotic due to ischemia, and we also performed partial resection of the small intestine. The pathological findings of those two occasions were ischemic enteritis together.

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Here we report a rare case of intestinal (ileal) duplication with peritonitis and granulation tissue formation. A 18-year-old male was admitted to the hospital with the symptoms of lower abdominal pain, fever and vomiting. Abdominal echo and CT scan showed a cystic tumor at lower abdomen, and a blood study showed elevated inflammatory reaction. Surgery was performed with the most probable diagnosis of abdominal abscess and peritonitis. At surgery, two tumors with abscess formation were presented at ileal mesenterium. Upon dissection of the tumor, extra alimentary tracts which jointed ileum and the tumors were found. The tumors were removed and ileocecal resection was performed with the consideration of possible recurrence of tumor formation. The pathological diagnosis revealed that the extra tracts had normal intestinal structure and the tumors were composed of granulation tissue. Intestinal duplications are rare congenital anomaly, especially in adults. They cause various symptoms such as abdominal pain, vomiting, and abdominal mass, but few cases were reported that presented with peritonitis. It is rare, but we should think the anomaly as one of differential diagnoses of acute abdomen.

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A 63-year-old woman was admitted to our hospital with lower abdominal pain. Ileus was diagnosed by abdominal X-ray examination. The X-ray study through a long intestinal decompression tube indicated a tumor of the ileum. Partial resection of the ileum including the tumor was performed because of the intussusception due to the tumor. Histological examination of the tumor showed proliferation of spindle-shaped cells with infiltration of plasma cells and lymphocytes. Immunohistochemically, the tumor cells were positive for vimentin and α-SMA, but negative for CD34, desmin and S-100. The characteristic microscopic findings led us to a diagnosis of inflammatory myofibroblastic tumor (IMT).

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A 53-year-old man complaining of tarry stool and palpitation was found to have progressed anemia and was admitted to the hospital for close exploration as well as treatment. Upper and lower gastrointestinal endoscopy failed to reveal bleeding points. Multidetector-row CT (MDCT) scan showed an enhanced tumor 15mm in diameter in the upper portion of the small intestine. FDG-PET showed no abnormal accumulations. Double-balloon endoscopy of the small intestine disclosed a 15 mm-sized submucosal tumor at the jejunum. Gastrointestinal stromal tumor (GIST) of the small intestine was suggested which might have caused anal bleeding. With laparoscopic study, we recognized the preoperatively infused marking carbon black ink and redness on the serosa due to the tumor in the jejunum about 20cm apart from the Treitz' ligament. The location of the tumor was thus easily identified. A small incision was made on the midline and partial resection of the jejunum was performed by means of extracorporeal operations. GIST was diagnosed by immuno-histopathological studies.
Here we present a case of gastrointestinal bleeding of unknown origin, in which the diagnosis of jejunal GIST was made by MDCT and double-balloon endoscopy and resected by laparoscopy-assisted surgery.

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A 55-year-old woman consulted our hospital for intestinal endoscopy. A small intestinal tumor was detected by ultrasonography and the abdominal computed tomography. Intestinal endoscopy revealed an elevated elastic tumor occupied half of the lumen of the jejunum. The biopsy specimen revealed a malignant jejunal neoplasm, histologically, so a jejunectomy was performed. The jejunal tumor had a lymph node metastasis and peritoneal dissemination. Histopathologically, the tumor was diagnosed as a jejunal carcinoid tumor.
The incidence of small intestinal carcinoid tumors is quite rare 1.38% among small intestinal tumors in Japan. This case of an intestinal carcinoid tumor in the jejunum, a lymph node metastasis and peritoneal dissemination requires close follow-up.

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A 32-year-old woman was seen at our department because of abdominal pain and hematochezia. There was tenderness in the entire abdomen. Abdominal ultrasonography and abdominal CT scan showed target sign in the vicinity of the hepatic flexure. Intussusception was thus diagnosed. The patient was admitted and performed an emergency operation on the same day. At surgery we saw that an about 20cm-long portion of intestine from the cecum to terminal ileum had invaginated into the ascending colon, suggesting an ileo-colic intussusception. Manual reduction disclosed that the intussusception was caused by the cecum, at where an elastic-hard tumor about 3.5cm in diameter was palpated. A malignant neoplasm could not be ruled out, and then right hemicolectomy (D3) was performed. Histopathologically it was a 4 × 3.5cm ridging lesion on the cecal wall, and there were erosions, bleeding and necrosis in the mucosal layer, and prominent edema, infiltration of inflammatory cells, and proliferation of fibroblast in the submucosal layer. Accordingly inflammatory fibroid polyp (IFP) was diagnosed. The postoperative course was uneventful and the patient was discharged from the hospital on the 13^th hospital day. There have been no signs of recurrence, as of 3 years after the operation.
Although IFP of the gastrointestinal tract is a rare entity, it must be considered as a probable cause of intussusception in adults.

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A 65-year-old man was admitted to our hospital with a tentative diagnosis of cancer of the cecum based on colonoscopic findings detected during a cheek up for epigastralgia. The colonoscopic examination revealed a protruded lesion with small ulceration on the orifice of the appendix and findings of the biopsy specimen were compatible with the diagnosis of poorly differentiated adenocarcinoma. Abdominal CT scan disclosed a 3×2 cm tumor in the appendix. Thus, preoperative diagnosis of primary appendiceal cancer was obtained. We performed ileocecal resection with D3 lymph node dissection. The pathological examination showed invasion of the serosal surface without metastasis to lymph nodes. Tumor marker elevation was detected six months after the radical operation. CT findings indicated peritoneal dissemination and we treated the patient with chemotherapy. The patient showed partial response to the chemotherapy, and one year after the operation he is still alive. Primary appendiceal poorly differentiated adeno carcinoma is rare. This case was diagnosed preoperatively based on the results of a thorough colonoscopic examination.

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A 72-year-old man came to our hospital because of melena and abdominal distension. Under colonoscopic examination, rectal cancer was suspected and the patient was admitted for marked increase in melena. A month after admission, his general condition deteriorated and the second colonosopic examination revealed necrotic colitis. An emergency left hemicolectomy with abdomino-perineal resection of the rectum was performed to remove all necrotic areas of the colon and rectum. Trophozite ameba was found in the preoperative biopsy of the colonic mucosa, and metronidazol was administered from the day after surgery for fulminant amebic colitis.
His general condition improved and he was discharged from the hospital 62 days after surgery.
Forty cases of fulminant amebic colitis have been reported in Japan. Early diagnosis followed by early chemotherapy is the key in treating this disease.

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We report a case of acute colonic pseudo-obstruction whose life was saved by an emergency operation. An 82-year-old man who came to our hospital with the chief complains of abdominal pain and vomiting. Abdominal X-ray showed remarkable dilatation of the sigmoid colon. The colonoscopy showed ischemic changes of the part of the sigmoid colon but no mechanical obstruction was present in anal side of the dilated colon. We diagnosed it as acute colonic pseudo-obstruction and performed an emergency operation. We removed the dilated sigmoid colon which contained the part of necrotic mucosa and made a descending colostomy. There was no problem with defecation and the patient received an operation of stoma closure a months later. Acute colonic pseudo-obstruction has good prognosis if an adequate treatment is given at an appropriate time. There are few reports in Japan, so we report this case with some review of the relevant literatures.

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The present patient was a 91-year-old man who had developed sigmoid volvulus a total of seven times during an approximately one-year period since his first visit to the Department of Internal Medicine at our hospital. The patient had undergone endoscopic reduction after each onset.
The patient was referred to our department after endoscopic reduction could no longer be performed due to progression of stenosis of the rectosigmoid region during follow-up. In the present study, we report our experience with this patient, who had a favorable course following elective laparoscopy-assisted surgery. High anterior resection was performed with the objective of resecting the sigmoid, including the site of stenosis. Surgery was modified as follows : 1)a small incision (4cm) was made in the lower abdomen at the start of surgery, 2) the proposed resection lines on the oral and anal sides were marked using a ligature, and 3) the intestinal resection site and anastomotic site were intraoperatively confirmed by endoscopy. Pathological tests of the resected sample revealed inflammatory cell infiltration and proliferation of collagen fibers in the submucosa of the site of intestinal stenosis. The patient followed a favorable postoperative course and was discharged on day 15. Presently, at seven months after surgery, no relapse has been confirmed.

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A 72-year-old man presenting with diarrhea accompanied by fever was admitted to the hospital. An abdominal computed tomography scan revealed free gas in the perirectal and perirenal space. Gastrografin enema study showed contrast medium leakage outside the rectal tract in the presacral space. Colonoscopy showed perforation of the posterior wall of the rectum without any other pathological lesion. An elective operation was carried out with diagnosis of retroperitoneal emphysema caused by the idiopathic perforation of the rectum. Low anterior resection of the rectum and transverse colostomy were performed. As many cases of idiopathic perforation of the colon are accompanied by peritonitis, emergency surgery was performed. However there are only a few reports of idiopathic perforation of the rectum in which elective operation was carried out because penetration into the retroperitoneal space only caused emphysema.

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A 77-year-old man was admitted to our hospital because of heart failure and anemia. On admission, he had no symptoms of intestinal obstruction. Pre-colonoscopy treatment (laxative administration) induced abdominal pain and melena. Colonoscopy revealed a circumferential tumor in the lower rectum. The following day he developed massive melena with hemorrhagic shock, for which emergency surgery was performed. At laparotomy, purulent ascites and a fecal odor were noted. A tumor was present in the lower rectum, the proximal portion of which was markedly distended, and its mesenterium was grayish-white, and was discharging pus. Intestinal obstruction due to rectal cancer had caused rupture and perforation of the sigmoid colon into the mesenterium, and the perforated portion had ruptured, resulting in peritonitis. Therefore, we performed abdominoperineal resection of the rectum. The resected specimen contained a circumferential type-2 tumor of the lower rectum, and penetration with an opening of 7 × 5—cm into the mesenterium, which contained free vessels. From the presence of a large amount of blood clot in the rectum proximal to the tumor and the finding of free vessels in the mesenterium, we speculate that blood vessels in the perforated mesenterium were the source of bleeding.

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Mucinous colon carcinoma grows rapidly and often disseminates, so its prognosis is relatively poor. We herein report a case of mucinous colon cancer that invaded the abdominal wall. The wall was repaired with a groin flap after the curative resection. A 70-year-old woman was admitted because of a tumor of the abdominal wall. The diagnosis after examination was mucinous carcinoma of the ascending colon. The tumor was growing rapidly and pain worsened, so an emergency operation was performed. Hemicolectomy of the right colon including resection of the abdominal wall was performed. The defect of the abdominal wall after the operation was repaired using a groin flap. After the operation, the patient has been disease free, and her quality of life has inproved.

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A 73-year-old woman was admitted to our hospital because of tenesmus. Barium enema study disclosed a long stenotic lesion and extramural compression of the rectum. Colonoscopic examination revealed an elevated tumor in the rectum. Biopsy and histopathological examination suggested an undifferentiated carcinoma. Abdominal CT scan showed the tumor might have invaded the sacral spine. Low anterior resection included resection of the tissue in front of the sacral spine. Immunohistochemical examination of the resected specimen confirmed the diagnosis of undifferentiated carcinoma and no malignant lesion in front of the sacral spine. Abdominal CT scan carried out 6 months after surgery revealed remarkable swelling of paraaortic lymph nodes and lymph nodes around the common iliac artery. The patient is at present under chemotherapy with bevacizumab and FOLFOX4.

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The management of patients with concomitant abdominal aortic aneurysm and gastrointestinal malignancy is controversial. We report a case of advanced rectal cancer concurrent with abdominal aortic aneurysm treated with endovascular aneurysm repair followed by abdominoperineal rectal resection. A 71-year-old man was admitted because of occult fecal blood and diagnosed as having advanced rectal cancer and abdominal aortic aneurysm 57mm in diameter. Both diseases needed to be treated. At first, endovascular graft repair was performed for the aneurysm. After uneventful recovery, abdominoperineal rectal resection was safely done on the 16^th day of the first treatment. Postoperative course was quite uneventful. He was discharged 22 days after the surgery and is doing well without any signs of recurrence of the cancer or graft complication. We conclude that an endovascular aneurysm repair is very efficient treatment for the patients with synchronous abdominal aortic aneurysm and gastrointestinal malignancy.

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A 40-year-old woman visited our hospital because of bouts of tarry stool in April 1996. Blood examination showed marked anemia (Hb5.3g/dl). Bleeding scintigraphy showed extravasation of RI in the right lower abdomen, and technetium scintigraphy showed focal uptake on the right side in the pelvis. A bleeding Meckel's diverticulum was suspected, and an emergent operation was performed. At laparotomy, no Meckel's diverticulum was found but a tumor 7cm in diameter was found about 160cm oral side from the ileocecal valve. A partial resection of the small intestine was performed. Immunohistochemically, the tumor cells were positive for c-kit, and the diagnosis of GIST was confirmed. Liver metastases were observed 3 times in the next 7 years and the recurrent tumors were surgically removed. We started chemotherapy with imatinib mesylate at a dose of 200 mg/day for two years in August 2003. She had been free from relapse during undergoing the chemotherapy. Eleven months after withdrawal of the chemotherapy, metastasis to the liver remnant occurred again, and then forth hepatectomy was peformed. The patient is now alive and well, as of 10 years after the initial operation.

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A 65-year-old woman with a tumor at segment 5 of the liver which was found during examination for an abnormal chest shadow was subrequently found by abdominal ultrasonography (US) to have a 20 mm tumor with a low, and slightly high echo. Abdominal computed tomography (CT) showed an irregular, marginally enhanced tumor at segment 5 of the liver. Abdominal magnetic resonance imaging (MRI) showed a low signal SOL in a T1-weighed image and a high signal SOL in a T2-weighed image. No other GI tract examinations showed abnormal findings. We first diagnosed the tumor as intrahepatic bile duct carcinoma or metastatic liver tumor. We performed anterior segmental resection of the liver in January 2006. Histpathological analysis yielded a definitive diagnosis of liver-sclerosed hemangioma. Case reports of hepatic sclerosed hemangioma are rare, and to our knowledge only 11 have been described in the literature.

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The case of ileus due to impacted gallstones in the duodenal bulb is comparatively uncommon condition, and the case is called Bouveret's syndrome. We discribe a case of Bouveret's syndrome with spontaneously closed biliary-enteric fistula. A 65-year-old female was diagnosed as cholecystolithiasis 20 years ago, but was untreated and the patient kept on having occasional abdominal cramp. The patient was admitted to the hospital because of vomiting and abdominal pain. Subsequent abdominal CT revealed pneumobilia and a gallstone in the duodenum. Gastro-duodenal endoscopy study revealed a impacted gallstone in the duodenal bulb. With these findings, we diagnosed as Bouveret's syndrome. Five days after the admission, the symptoms improved. We performed gastro-duodenal endoscopy which revealed a fistula at the posterior wall of the duodenum. Fistulography from the fistula visualized both gallbladder and bile duct. Two weeks after the admission, the patient was taken to surgery for cholecystectomy. At operation, we divided the adhesion between gallbladder and duodenum, however the bilary fistula was undetected. We thought that the bilary-enteric fistula closed spontaneously, therefore from this experience we must perform the operation carefully considering the possibility of spontaneous closure.

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Pseudoaneurysm of the cystic artery is a rare cause of hemobilia, with only 9 cases having been reported in the Japanese literature. A 71-year-old man was admitted for sudden epigastralgia and right hypochondral pain. The laboratory test showed marked liver dysfunction without jaundice. On emergency gastroduodenal endoscopy, hemorrhage from the papilla of Vater was identified and the bile duct was drained endoscopically. Angiography of the hepatic artery demonstrated an aneurysm of the cystic artery. Under the diagnosis of ruptured aneurysm of the cystic artery, laparoscopic cholecystectomy was carried out. Histopathologically, the lesion was diagnosed as ruptured pseudoaneurysm of the cystic artery associated with severe cholecystitis. It is thought that first bleeding should be stopped and then cholecystectomy be performed as radical operation is the preferred strategy for ruptured pseudoaneurysm of the cystic artery.

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This report presents a 68-year-old woman, complaining of right hypochondralgia, with high level of serum alpha-fetoprotein (AFP) with a bulky tumor near caudate lobe of the liver which was detected by a computed tomography. The serum level of AFP was 8520.9ng/mL, computed tomography and magnetic resonance imaging studies showed irregularity of the gallbladder wall and a lymph node metastasis between caudate lobe of the liver and pancreas head 10 cm in a diameter. We suspected carcinoma of the gallbladder with a lymph node metastasis. Upon laparotomy, we performed retropancreatic lymph node dissection. Then, sampling of the para-aortic lymph nodes was done and a metastasis was proven by intraoperative pathological examination. Therefore, we added lymph nodes dissection along common hepatic artery and hepato-duodenal ligament. We resected the part of the liver (S4a+5) and the gallbladder. The tumor of the gallbladder was papillary adenocarcinoma.
Immunohistological examination using AFP antibody was done and it showed that the cancer cells in the main tumor of the gallbladder was positive less than 10%. The AFP staining of lymph nodes metastases were strongly positive. The patient died after 11 months because of the recurrence.

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A 62-year-old woman admitted to the hospital for a liver tumor detected by computed tomography (CT) had a history of hypertension and lung emphysema. Abdominal CT scan showed a low-density tumor 83 mm in diameter in the right hepatic lobe (S7-S8), with invasion to the right lung. At surgery, the liver tumor was found to have invaded the right lung, necessitating right hepatectomy with partial resection of the inferior vena cava, the diaphragm, and the right lung. The definitive pathological diagnosis of the liver tumor was adenosquamous carcinoma. She was discharged from the hospital 25 days after the operation. Mediastinal lymph node metastasis was found three months after the surgery. Despite radiation therapy, she died of cancer progression 6 months after the operation.
Intrahepatic cholangiocarcinoma with invasion to the diaphragm has been reported in seven patients in Japan. But this is, to the best of our knowledge, the first report of lung invasion. Early postoperative adjuvant chemotherapy should be considered for cholangiocarcinoma in a far advanced stage like in this case.

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A 60-year-old woman who was incidentally detected having a tumor in the tail of pancreas by abdominal CT scan at a medical check-up was admitted to the hospital for further evaluation. She was asymptomatic. Serum level of each pancreatic hormone was within a normal limit. Tumor markers were within normal limits as well. Abdominal CT scan showed the tumor consisted of solid and cystic parts which were 1.5cm in diameter and spherical in shape, and were adjacent each other. The density of the solid part had a higher density than the pancreatic tissue. As an asymptomatic pancreatic endocrine tumor with hemorrhagic cystic change was suggested, a spleen-preserving distal pancreatectomy was performed. Histopathological examination of the tumor revealed pseudocyst in an intrapancreatic accessory spleen. It should be considered as a probable differential diagnosis of a mass with a cyst in the pancreatic tail.

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A male patient in his sixties with complaint of left lower abdominal pain was admitted for further studies and treatment of his complaint. The patient had previous history of diabetes and cholecystectomy for cholelithiasis. An abdominal echo study revealed a 42 × 40mm size tumor in the tail of pancreas but an enhanced CT did not give clear image. The part of the tumor was invading to the Gerota's fascia. With preoperative diagnosis of pancreatic cancer, a combined resection of the pancreatic tail and spleen with Gerota's fascia was performed. Immunopathological study revealed chromograninA (+) and synaptophysin (-), and a diagnosis of neuroendocrine carcinoma was made with Pt, 50 × 40 × 40mm, nodular type, medurally, INF b, lyo, vo, pT4 {pS (-), pRP (+), pPL (+), pOO (+), PCM (-), DPM (-)}, pN1, sMO and fStageIVa. The edge of resection and the surface of dissection was negative for cancer cells. A local recurrence and liver metastasis was found 3 months postoperatively and the patient died 4 months after the operation. Pancreatic neuroendocrine cell carcinoma is rare and the prognosis is poor with usually advanced stage at the initial diagnosis. Therefore, to establish the early diagnosis and start effective adjuvant therapy is urgently important.

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A 52-year-old woman suffering from reccurence of ovarian cancer was referred to our department. She underwent hysterectomy and bilateral oophorectmy but tumor marker rose in spite of administration of chemotherapy. And her platelets decreased at the same time, so the chemotherapy had to be discontinued. Computed tomography revealed metastatic tumors of the ovarian cancer to the spleen and its hilar lymph nodes, and we suspected that secondary hypersplenism was induced by those tumors. So we resected the tumors including the spleen and the regional lymph nodes. After the operation, platelet count returned to normal value and tumor marker decreased remarkably. Luckily hypersplenism was dramatically improved and the chemotherapy for the ovarian cancer was resumed. Reports of the surgical treatment for metastatic splenic tumors were not rare. However there is no report about hypersplenism induced by metastatic splenic tumors, and we believe this secondary hypersplenism can be controlled by surgical approach.

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A 65-year-old woman was admitted to Inazawa City Hospital for further examination of a right adrenal tumor detected by abdominal US during a health check up of diabetes mellitus.
Abdominal CT and MRI showed a solid mass with fat component 6cm in diameter in the right adrenal gland. The tumor was diagnosed as benign right adrenal myelolipoma. So we performed laparoscopic right adrenalectomy. Histopathological examination of the tumor confirmed the preoperative diagnosis. She was discharged on the 5^th postoperative day. Laparoscopic adrenalectomy proved useful for this condition because of the cosmetic result and the short hospitalization.

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An 88-year-old woman who had a history of undergoing laparotomy for prolapse of uterus at the age of 42 was admitted to the hospital because of the abrupt onset of lower abdominal pain and frequent vomiting. Abdominal multi-detector CT (MDCT) scan revealed a dilated small inetestine with ascites and vascular convergence behind the uterus. Coronal reformatted MDCT image showed the right broad ligament of uterus close to the small bowel loops. Intestinal strangulation through the broad ligament of uterus was suspected and emergency operation was performed on the same day. At laparotomy, we found strangulated ileum with partial ischemic changes through an abnormal defect 3cm in diameter in the right broad ligament. After the manual reduction of the herniated ileum, ischemic change of the ileum was recovered without any necrotic findings. We incised the broad ligament and opened the defect. Inspection of the contralateral broad ligament revealed no defect. Postoperative course was uneventful and she was discharged on 11^th postoperative day.
Internal hernia through an abnormal defect in the broad ligament of uterus is a rare cause of intestinal obstruction. Preoperative diagnosis is generally difficult. MDCT is a quite useful tool for the preoperative assessment of internal hernias because it can precisely delineate hernia type, location, signs of strangulation, and poor bowel wall enhancement.

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A 30-year-old woman who had undergone cesarean section at the age of 24 was seen at the hospital because of a gradually enlarging subcutaneous tumor with pain along the surgical scar in the abdominal wall. Imaging findings disclosed the tumor located on the right side of the surgical scar and extended almost total length of the scar. Symptoms were related to her menstrual cycle and the tumor had grown gradually. We diagnosed the case as endometriosis of the abdominal wall and removed the entire growth with an enough margin, that required the mesh sheet repair. She has been free from relapse in symptoms and diagnostic imagings over one year after the operation. Although endometriosis of the abdominal wall is a rare entity, it must be kept in mind as a probable diagnosis for an abdominal wall tumor developed at the surgical scar in a patient who has a previous history of undergoing gynecological surgery and complains of periodical symptoms relating to menstrual cycle.

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The patient was a 54-year-old female who had total hystrectomy and bilateral removal of the adnexal organs for internal endometriosis at the age of 40. The patient came to our hospital with complaint of recurrent right lower abdominal pain and a mass in the same region. CT and MRI study revealed a mass of approximately 1cm in size in the right lower abdomen. The image studies and blood chemistry could not lead to a definite diagnosis and the possibility of malignancy was not excluded, and the pain in the right lower abdomen continued. Therefore a surgical removal of the mass was performed. A hard tumor of approximately 1cm in size was found in the great omentum in the right lower quadrant of the abdominal cavity and was excised with the surrounding omentum. Histopathological study revealed proliferation of endometrial glands and interstitial tissue replacing adipose tissue in the nodule. Based on these findings a diagnosis of external endometriosis was made.

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We experienced two cases of superior mesenteric artery syndrome that developed from a different cause. Case 1 : 29-year-old woman. She was admitted to the hospital because of epigastralgia, vomiting and weight reduction. Passage disturbance of the horizontal portion duodenum was recognized by abdominal CT and upper gastrointestinal series, and the diagnosis was superior mesenteric artery syndrome. As the conservative treatment failed to improve her condition duodenojejunostomy was performed on day 22 of her disease, and the outcome was successful. Case 2 : An 80-year-old man. We diagnosed him as a case of double cancer of the descending colon and rectum because of hematochezia. Left colectomy and low anterior resection with D3 lymph node dissection were performed. Anastomosis was by transverse colon, and the rectum was reconstructed. We performed abdominal CT and upper gastrointestinal series because he vomited on postoperative day 11. As a result, he was diagnosed with postoperative superior mesenteric artery syndrome and treated with conservative therapy. He started to eat after postoperative day 34, and showed a successful outcome.

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The patient was a female in her twenties, and she suffered from right lower-quadrant abdominal pain following preceding epigastralgia in April 2007, and it made her to be referred to our hospital. In addition to the clinical course and the physical findings, she underwent thorough examinations such as CT scan and ultrasonography, and was diagnosed as having peritonitis due to the right ovarian teratoma with existence of the cyst containing fat and tooth-like calcification. And then, laparotomy was carried out. The cyst which was in the pelvis measuring 10.5 × 9 × 6.5 cm in diameter, had the pedicle of 20 cm length from the greater omentum, and ruptured due to the torsion of 720 degree. It was accompanied with ileus of the terminal ileum caused by the pressure of the cystic tumor and inflammatory adhesion resulted from the leakage of its content, but there were no difference and abnormality in her bilateral ovaries.
This case is the 11^th case of mature cystic teratoma of the greater omentum and the 1^st case which was associated with a pedicle's torsion and its rupture reported in Japanese literature.

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