Purpose : A retrospective study was made to elucidate the effect of previous history of balloon dilatation on laparoscopic Heller myotomy and Dor fundoplication (LHD) in patients with achalasia. Subjects and methods : We enrolled 25 patients undergone LHD operations for achalasia in our hospital from July 2003 to December 2006. Fifteen patients of them underwent LHD as an initial treatment (LHD-first group), and the remaining 10 patients had the previous history of balloon dilatation prior to LHD with unsatisfactory outcome (BD-first group). Perioperative complications and long-term outcomes were compared between the two groups. Results : The operation time of the BD-first group was significantly longer than that of the LHD-first group (p=0.021). Injury of the esophageal mucosa during myotomy was recognized in three patients only in the BD-first group (p=0.037). In the long-term follow-up study, the LHD improved dysphagia in 95 % of all patients and there was no significant difference between the both groups. In one patient from the BD-first group who had sigmoid type achalasia with serious esophageal dilatation, dysphagia persisted after the treatment. Conclusion : the LHD is a reliable method to relive dysphagia in patients with esophageal achalasia. Myotomy following balloon dilation entails a greater risk of injuring the esophageal mucosa. Thus the LHD is desirable as the initial treatment for achalasia.

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The incidence of Clostridium enteritis and MRSA enteritis in surgical inpatients who were treated with oral administration of vancomycin were analyzed. In 4867 patients admitted in the surgical ward in our hospital between January 2001 and April 2005, 41 patients received oral administration of vancomycin due to suspected pseudomembranous colitis or MRSA enteritis.
These infection occurred postoperatively in the majority of the patients. In these 41 patients, 10 cases were diagnosed as pseudomembranous colitis by CD toxin test, and 10 cases diagnosed as MRSA enteritis by stool cultures. As a result, only 49% of patients were diagnosed correctly. On the other hand, 51% of the patients received unnecessary medication of vancomycin. In terms of antibiotics used to these patients before the attacks, carbapenems had about two fold higher risk of incidence of these enteritis than cepharosporins. MRSA enteritis mainly occurred after upper GI tract surgery, whereas no inclination was seen in clostridium enteritis in terms of site of operation.
Guideline for oral administration of vancomycin is necessary for prevention of infection caused from vancomycin resistant organelle, such as VRE.

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Purpose : The purpose of this study was to evaluate the usefulness of a 4-day admission clinical pathway (CP) for laparoscopic cholecystectomy (LC), comparing with a 7-day admission CP. Patients and Methods : We compared 42 patients who had undergone LC by the 7-day admission CP (Group A ; from January 2002 to June 2004), with 55 patients by the 4-day admission CP (Group B, from July 2004 to May 2006). Results : Incidence of variance was almost the same in both groups (Group A vs Group B=19.0% vs 21.8% without significant difference). There was no rehospitalization within 30-days after discharge in both groups. Total hospital fee, and hospital fee per day in Group A versus Group B were 575,507 vs. 491,003 yens and 95,603 vs. 157,466 yens, respectively (p<0.05). Conclusions : The 4-day admission CP was comparable with the 7-day admission CP in terms of the incidence of variance and re-hospitalization episode. The 4-day admission CP for LC is safe even though it shortens the duration of hospital stay and is useful from a medical cost-performance aspect.

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We often experience case in which pelvic malignant tumors infiltrate neighboring organs and are forced to perform combined resections for the purpose of complete cure. In an extensive bladder invasion case, total extirpation of the bladder or total pelvic exenteration is performed, and it is remarkable often to see the loss of postoperative QOL by extinction of urinary mechanism. In 51 cases we performed combined bladder resection up to now. Extensive bladder resections were performed in 8 cases of large bowel cancer, one case of ovarian cancer and one case of uterine sarcoma, in total of 10 cases. We performed bladder enlorgement operations in these cases. We used pedicled ileal flaps for reconstruction and performed cystoplasty by Goodwin method. We observed increase of vesical capacity in one month to a year postoperatively by cystometrogram. High compliance was attained with hypobaric urinary retention. The complication of lithogenesis was seen in 2 cases. In the follow up study, the comparison of total exenteration and total bladder extirpation cases did not show significant differences. This operative method seemed to be superior operative method with complete cure characteristics and functions.

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Background : We analyzed postoperative morbidity and mortality in patients undergoing abdominal surgery based on age, whether emergency or elective surgery, and presence or absence of preoperative comorbidities to evaluate the risk of the patients exceeding 90 years of age. Methods : From April 2003 to March 2006, abdominal surgeries were performed on 1,534 patients, of whom 240 were 80-89 and 52 were 90 years or older. Results : More preoperative comorbidities were seen in patients 90 years of age or older, and postoperative complications were significantly higher than in those less than 90 years old (44% vs. 20%, P<0.05). Postoperative mortality was 9.6% in patients aged 90 years or older, significantly higher than in those less than 79 years old or 80-89 years of age, regardless of whether the surgery was emergency or elective. We noted that postoperative mortality in patients 90 years or older was significantly higher in the group of patients with both preoperative comorbidities and postoperative complications, particularly when pulmonary complications were present (P<0.05). Conclusion : The high mortality in patients 90 years or older makes careful operative indications and perioperative management essential in the presence of preoperative comorbidities and postoperative complications.

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A 74-year-old female with BMI of 28.6% came to our hospital complaining of epigasric pain. Abdominal echo and CT study revealed a tumor of 9cm in its largest diameter, anteriorly to the abdominal aorta and inferior vena cava. Incisional biopsy was performed under a laparotomy with operative time of 92 minutes and blood loss of 50gr. Pathological diagnosis was malignant lymphoma. Intermittent pneumatic compression (IPC) was used until immediate postoperative period. The patient could stand up on the 1^st postoperative day and could walk on the 2^nd postoperative day without problem. On the 4^th postoperative day the patient developed dyspnea, loss of consciousness and hypotension. Echo study revealed dilatation of the right ventricle and thrombus in bilateral peroneal vein. CT of the chest revealed a defect of shadow at the bifurcation of the pulmonary artery trunk. Management with t-PA and heparin was started improving the general condition of the patient and a CT study on the 10^th postoperative day revealed only a small thrombus in the left pulmonary artery. This case was thought to be in the middle risk level according to the guide-line of thromboembolism prevention protocol and so IPC was applied, but considering the compression of inferior vena cava by a large malignant tumor causing venous stasis, it might have been necessary to adopt a more aggressive preventive measures in the face of added risk factors.

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We report our experience with a case of bilateral axillary accessory breasts and mammary pseudoangiomatous stromal hyperplasia (PASH). The present patient was a 45-year-old woman who presented with chief complaints of swelling and redness of both breasts as well as the left axilla. In addition to swelling of both breasts, a tumor was observed in the left axilla. Chest CT showed diffuse swelling of both mammary glands in addition to an approximately 10 cm-soft tissue tumor in the left axilla. The left axillary tumor was resected for diagnostic purposes. The patient was subsequently diagnosed with axillary accessory breasts and PASH, and underwent bilateral tolal mastectomy in addition to resection of the left and right axillary tumors due to further swelling of both mammary glands as well as development of tumors in both axillary regions. HE staining showed slit-shaped, vessel-like spaces in the mammary stroma. The inner surface of these spaces was covered by a layer of spindle-shaped cells, which tested positive for CD34 and negative for factor VII-related antigen on immunohistochemical staining. Based on these findings, the patient was diagnosed with bilateral axillary accessory breasts and mammary PASH. We report the present case with reference to literature.

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The patient was a 50-year-old woman who had undergone breast-conserving surgery for right breast cancer (C area, Bp+Ax, T2N0M0, StageI, and scirrhous carcinoma), followed by irradiation at a total dose of 50Gy in 1998. When 6 years 5 months had elapsed after the operation, redness and induration developed in the A area of the right breast. A biopsy via wedge resection was performed and the histopathological diagnosis was angiosarcoma. We could not rule out a possibility of positive surgical stump, and performed additional resection + skin grafting. No sarcoma remnant was demonstrated in the material resected additionally, but 2 years later, the patient experienced recurrence. Thus mastectomy + extended resection of the full thickness of the skin + skin grafting were performed.
Postirradiation sarcoma involving the skin and vessels is a rare entity and occurs in 0.03-0.8% of all cases after radiation therapy. It metastasizes to the distant organs in an early stage and carries poor prognosis. No standard therapy for the disease has been established as yet. Early detection and extended resection are considered to contribute to an improvement of the prognosis.
This paper deals with such a rare entity as postirradiation angiosarcoma developed in the residual breast after breast-conserving surgery.

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The patient was a 60-year-old man who developed a lump in the left breast in 2003. He visited our clinic in March 2007 due to the gradual enlargement of the lump. Physical findings on examination included a well-defined, smooth, near-spherical tumor (diameter, 4cm) that was palpable around the left areolar region. The axillary lymph nodes were not palpable. Needle biopsy indicated a class III papillary lesion that was diagnosed as a possible case of intraductal papilloma. A left mastectomy was performed in April 2007. Histopathological examination showed that the proliferative cells were negative for CK5/6, p63, CD10, CK14, and SMA. In addition, the cells were negative for SYN, CGA, and CD56, while diffuse positive staining was observed for ER and positive nuclear staining was sporadically observed for S-100P in very few cells. Cells positive for 34βE12 were observed in a mosaic-like pattern within the tumor, while an increased proliferative activity was observed on MIB1 staining. Based on these findings, the patient was diagnosed with non-invasive, ductal carcinoma of male breast. Male breast cancer is a rare condition, particularly in its non-invasive form. We report the present case with reference to literature.

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This is a 66-year-old man who had been diagnosed breast cancer and had undergone radical mastectomy by Halsted's method (Br+Mj+Mn+Ax), when he was 39 years old. Pathologically, he had scirrhous carcinoma of the breast in stg1 (T1cn0M0). He had been regularly examined at the outpatient ward for 8 years after the operation but had subsequently discontinued his visits to hospital. Twelve years from operation and after a prolonged interruption, he visited the outpatient ward for examination when he was 51 years old. A tumor was palpable immediately below the right nipple and aspiration biopsy cytology was positive for malignant cells with features consistent with breast carcinoma. Accordingly, he underwent modified radical mastectomy (Br+Ax). Pathologically, he had a solid-tubular carcinoma, in stageI, T1bn0M0 with positive hormone receptor status for both ER and PgR. At last following, 27 years from the first operation and 15 years from the second operation, no sign of recurrence is observed.

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Mammary carcinoma containing osteoclast-like giant cells (OCGC) is an extremely rare tumor. We have encountered nine additional cases of this tumor, so we investigated is clinico-pathological and immunohistochemical characteristics. Four cases were in StageI, three were in StageIIA, and two were in StageIIB. The tumor size varied from 1.5cm to 6.0cm. Lymph node metastasis was observed in four cases (44%). In all cases, histopathological examination revealed invasive ductal carcinoma containing OCGC among the tumor cell nests. The tumors were grade 2 in all cases, according to the modified Bloom-Richardson classification. Immunohistochemically, estrogen receptor, progesterone receptor and HER2 receptor were positive in five cases, six cases, and one case, respectively. One patient died of the disease five years and ten months after surgery while no signs of recurrence have been seen in the other cases. According to these results, it is possible that the prognosis of mammary carcinoma charaeterized by the piaeuce of OCGC is better than that of ordinary mammary carcinoma.

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An 83-year-old woman who had undergone radical mastectomy with bilateral oophorectomy under the diagnosis of left breast cancer at the age of 45 was seen at the dermatological department in our hospital because of a left cervical tumor. A hard tumor measuring 3 by 4 cm with skin invasion was confirmed at her supraclavicular region. Skin biopsy of the lesion revealed diffusely invasive tumor cells that were positive in immunohistochemical staining with CEA, cytokeratin, estrogen receptor and progesterone receptor. Moreover, blood examination revealed high serum levels of CEA (6.9 ng/ml) and NCC-ST-439 (490.2 U/ml). According to these findings, she was diagnosed as having late recurrence of breast cancer. Hormonal therapy using anastrozole was started and the tumor disappeared 7 months after the beginning of the chemotherapy. Thereafter CR has been kept for more than 8 months. To the best of our knowledge, this case is of the latest recurrent breast cancer reported in the Japanese literature.

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We report a case of metastasis to the tail of the pancreas from breast cancer. The patient was a 74-year-old woman who underwent left modified mastectomy at age 68. Histopathological study revealed it to be an invasive ductal carcinoma, estrogen receptor (-), progesterone receptor (-), and Herceptin 2 (+++). Although the breast cancer had been controlled with chemotherapy, abdominal computed tomography revealed a tumor in the pancreatic tail 6 years after the surgery. Examinations suggested it to be primary pancreatic cancer, and a distal pancreatectomy with splenectomy was performed. Histopathological study of the resected tumor revealed it to be invasive ductal carcinoma which was similar to the specimen of previous breast cancer, and immunohistochemical examination showed it to be estrogen receptor (-), progesterone receptor (-), and Herceptin 2 3+. Therefore we concluded that this tumor was a pancreatic metastasis from the breast cancer. Although pancreatic metastasis from breast cancer is rare, that possibility should be considered in treating pancreatic tumors. And we also should consider aggressive surgery in the case in which the metastasis is solitary and safely respectable, for that might prolong prognosis and improve quality of life in some cases.

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The subxiphoid approach was used to close an atrial septal defect (ASD) complicated by a severe restrictive ventilatory dysfunction. A 78-year-old female had ASD complicated by a severe restrictive ventilatory. The subxiphoid approach was chosen to do the closure in order to avoid aggravating her ventilatory function. The patient's postoperative course was uneventful. This paper deals with the successfull treatment of an ASD that was complicated by a severe restrictive ventilatory dysfunction.

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A 72-year-old man stabbed his left chest 20 times by himself with an engraving knife was brought into our hospital by emergency service. His vital signs were stable. The stab wounds were superficial. No bleeding from the stab wounds was confirmed. Chest CT scan showed an anterior mediastinal hematoma and massive left hemothorax. Emergency angiography revealed no active bleeding from the left internal thoracic artery and the left intercostal artery. The origin of the bleeding was unclear, but the 2 ∼ 4 intercostal arteries were suspected as the bleeding sites. We placed a thoracostomy tube into the left thoracic cavity due to the left hemothorax. Plain chest CT scan on the 7th day showed improvement of the anetrior mediastinal hematoma and left hemothorax. He was discharged from our hospital without any complications 10 days after the injury. He was seen at the hospital again because of breathlessness 18 days after the injury, when chest enhanced CT scan showed a 5cm-sized pseudoaneurysm of the left internal thoracic artery and increased left pleural effusion. Arterial embolization was performed. Chest CT scan on the 11th day after the embolization showed no abnormal findings, and the patient was transferred to the previous hospital.

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A 66-year-old woman was admitted to the department of Orthopedic Surgery of our hospital in June 2007 for treatment of a comminuted fracture of the left lower leg, compressed fracture of a lumbar vertebra and bilateral rib fracture, she had suffered in a traffic accident. She complained of respiratory discomfort and a chest CT taken on posttraumatic day 1 showed massive left pleural effusion. A chest drain was inserted and bloody pleural effusion was discharged. On posttraumatic day 2 the drainage fluid turned clouded white after she drank milk. The concentration of triglycerides in the drainage fluid was 333mg/dl and higher than in serum (107mg/dl). An enhanced CT revealed compression of the left subclavian artery at the level of the left first rib fracture. The condition was diagnosed as traumatic chylothorax due to thoracic duct injury. She was administered octreotide acetate at the dose of 150μg/body/day by subcutaneous injection for 5 days under fasting treatment. The drainage fluid turned clear and yellowish on posttraumatic day 5. The chest drainage was removed on posttraumatic day 10. To the best of our knowledge, this is the first case of a chylothorax caused by blunt trauma successfully treated with octreotide acetate reported in Japan.

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A 38-year-old male was admitted due to a low grade fever and pain at the site of a previous postero-lateral thoracotomy. When the patient was 27 years old he developed a bronchial schwannoma located in the intermediate trunk area. The lesion was resected ; bronchial plasty without a lung parenchyma resection was done. Four months prior to the current admission the patient developed, a low grade fever and pain in the operative scar. On chest X-ray and CT images, a chest wall mass was noted in the right chest wall along with osteolytic changes in the 7th rib. A malignant chest wall tumor was suspected. Based on the pathology of a CT-guided chest wall mass needle biopsy, a diagnosis of inflammatory granuloma was made. Specimens sent for culture grew Staphylococcus aureus. The diagnosis of a chest wall abscess, and a possible malignant tumor was made, for which surgery was done in February 2007. A chest wall abscess near the 6th costal bed was identified ; no tumor was found. Debridement and drainage were performed. The patient did well postoperatively, and was discharged home on the 32nd postoperative day.

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A 72-year-old woman had been treated as pneumonia. One month later she was admitted to our hospital because of fever and an abnormal shadow in a chest X-ray. Chest CT revealed an abnormal shadow in the mediastinum. Mediastinal abscess was clinically suspected, so drainage was performed under thoracoscopy. Nocardia asteroides was detected in the drain discharge. Sulfamethoxazole-trimethoprim and minocycline were administered, and the clinical findings improved. It is difficult to diagnose pulmonary nocardiosis early, but prompt use of a gram-staining test may be useful for making diagnosis clinically.

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A 72-year-old man visited our hospital because of cough and right inguinal swelling was performed radical operation with a diagnosis of right inguinal hernia, when ascites was identified. The cytologic diagnosis of the ascites was non-small cell carcinoma and peritonitis carcinomatosa was clarified. Following close exploration, Stage IV non-small cell carcinoma of the left lung was diagnosed. One course of chemotherapy with carboplatin and paclitaxel yielded a decrease of the primary lesion in size. However, abdominal pain developed on the 11^th day after the regimen and an abdominal x-ray film showed free air. General peritonitis due to perforation of the digestive tract was suggested and laparotomy was performed on the same day. A 3 × 2cm metastatic lesion was confirmed in the upper portion of the jejunum, of which center part became necrotic and perforated. Three other metastatic lesions were present in the small intestine. Partial resection of the small intestine including all lesions was performed. The chemotherapy was scheduled to resume after the operation, however, the pulmonary lesion progressed, the patient's general condition deteriorated, and the patient died on the 18^th hospital day.
Cases of lung cancer metastasized to the small intestine are often encountered, but such cases causing perforation are rare. Careful observation of clinical course would be mandatory during treatment of lung cancer associated with intra-abdominal metastasis by keeping a possibility of gastrointestinal perforation in mind.

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A 46-year-old woman presented with a foreign body by way of, a needle-shaped metallic image detected in the left diaphragma on her chest x-ray during a health examination. Computed tomography showed two metallic images at the left diaphragma and the left chest wall. The surgical removal of the foreign body (sewing needle) was performed under the X-ray image. The postoperative course was uneventful, and she was discharged on the 4^th postoperative day.

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A man in his twenties who was diagnosed as schizophrenic drank a few gulps of hydrochloric acid (toilet-bowl cleaner) and surface acting agent in a suicide attempt, then rushed to a nearby hospital. On admission, he vomited and showed hoarseness. An endoscopic examination revealed Grade IIb laryngitis, esophagitis and gastritis : circumferential erosions and liner ulcerations in these areas. He was transferred to the intensive care unit and got through the acute period with a conservative treatment. After improvement of his psychiatric manifestation and an enterostomy, he was referred to the Department of Surgery in our hospital. Fortunately, stenosis of the thoracic esophagus was mild and improved gradually, adequate nutrition was provided from the tube feeding and oral intake, and neither endoscopic dilatation nor surgery were required. The patient was discharged 153 days after the prolonged treatment of mental disorder. The enterostomy tube was removed at 122 days after the incident. The patient did not have any digestive symptoms at 15 months after the incident. Enterostomy is a minimally invasive surgery and is very useful in these patients with corrosive esophagitis/gastritis made in early period after ingestion.

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A 76-year-old female patient was referred to our hospital with diagnosis of suspicious acute cholecystitis. CT study revealed retroperitoneal emphysema and possible duodenal perforation or retroperitoneal abscess was suspected and an emergent operation was performed. A necrotic cystic mass of 2cm in diameter was found in the descending part of the duodenum and the wall of the cystic mass was incised and a drainage was performed. Possible perforation of the duodenal diverticulum was considered but the definite diagnosis was not established without proof in the intraopretive image findings. Postoperative image study through the drain visualized duodenum and the presence of a duodenal diverticulum. We report a case of perforation of paraduodenalpapillary diverticulum managed with a drainage.

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A 59-year-old female with von Recklinghausen's disease (VRD) was found to have elevated serum hepatobiliary enzymess. On abdominal CT scan, dilatation of the biliary tract and a tumor at the second portion of the duodenum were noted. On endoscopy, an irregularly shaped tumor was seen on the papilla of Vater ; based on the pathology of the biopsy specimen, the lesion was diagnosed as a carcinoid tumor. The patient had a pylorus-preserving pancreatoduodenectomy. In addition to the ampullary tumor, duodenal submucosal tumors were seen in the resected specimen ; based on the histopathology, a somatostatin-producing carcinoid tumor of the papilla of Vater and gastrointestinal stromal tumors of the duodenum were diagnosed. It has been reported that various gastrointestinal lesions are occasionally found in VRD patients. This paper reports the case and reviews the related literature.

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We report a rare case of poorly differentiated adenocarcinoma of the duodenum in a 53-year-old man. The patient was admitted to our hospital because of 15kg weight loss in half a year. Barium meal study and gastric endoscopy examination revealed a Borrmann 2 type tumor in the duodenal bulb. Histological diagnosis of the biopsy specimen was adenocarcinoma. After the preoperative examination showed a tumor confined to the duodenal wall but no lymph node metastasis, we performed distal gastrectomy and partial duodenectomy with D2 lymph node dissection. The resected specimen contained a 60×35mm ulcerated tumor, and the pathologic examination revealed a poorly differentiated adenocarcinoma invading to the serosa with lymph nodes metastases.
We reviewed the case of 21 Japanese patients with poorly differentiated adenocarcinoma of the duodenum and analyzed the clinicopathologic features.

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The gastrointestinal tract is a siteprone to amyloid deposition, but this has rarely been reported to cause perforation of the gastrointestinal wall. We report a case of small bowel perforation due to dialysis amyloidosis. A 68-year-old woman who had been under hemodialysis for 30 years visited our hospital with a chief complaint of fever. She was diagnosed as having peritonitis due to a gastrointestinal perforation and underwent surgery. A segment of the ileum at 20cm proximal to the ileocecal junction was necrotic and ileostomy was performed. Histopathological examination led to a diagnosis of ileal necrosis due to dialysis amyloidosis. Following surgery, the patient received intensive care and her general condition improved. This case highlights the need for renewed awareness regarding long-term dialysis as a risk factor for gastrointestinal perforation.

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A 64-year-old man consulted a clinic in his neighborhood because of nausea and a gradually aggravating abdominal pain. He was diagnosed strangulated ileus and was referred to our hospital. Upon arrival, his level of consciousness was normal but the whole abdomen was swollen and pressure pain was recognized in the left flank. Abdominal CT revealed a large amount of ascites from the periphery of the liver to the vesicorectal fossa. Furthermore, there was about 180 degree torsion of the mesentery with the superior mesenteric artery as the axis, which led to the diagnosis of strangulated ileus. Accordingly, an emergency operation was performed on the same day. When we opened the abdomen we found a large volume (ca. 1000mL) of chyle-like ascites, and about 180 degree torsion of the mesentery in the clockwise direction with the superior mesenteric artery as the axis. The small intestine was pale purple and chyle-like fluid retention was observed in the small intestine mesentery. After the torsion was freed, the color of small intestine rapidly improved and the retention of chyle-like fluid in the mesentery tended to decrease. The post-operative course was favorable and the patient was discharged 10 days after the onset of symptoms.

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An 88-year-old man undergoing chemotherapy for hepatocellular carcinoma, without a history of abdominal surgery, presented with sudden vomiting on December 31, 2006. Conservative medical treatment did not reduce the amount of discharge from naso-gastric tube, and thus strangulation ileus by internal hernia others was doubted as a result of close inspection. Thus, we performed a laparoscopic operation. Upon laparoscopy, the great omentum adhered to the abdominal cavity and the small intestine was strangulated by a loop that formed, making the great omentum adhere to the posterior leaf of the transverse mesocolon. When the loop was opened, blood flow of the small intestine was recovered, so we did not resect the small intestine. All maneuvers were done laparoscopically. Laparoscopic operation has high diagnostic value, and it is useful in determination of the dimensions and point of abdominal operation in the case of shifting. Laparoscopic operation is indicated for strangulation ileus in patients in good general condition, as in our case. To our knowledge, this is the first reported case of ileus due to great omentum and posterior leaf of transverse mesocolon reported in Japan.

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We report a case of multiple primary nonspecific ulcers of the small intestine. An 81-year-old woman visited our hospital because of pain and distension at the upper abdomen. She had no remarkable medical history. The laboratory data showed severe inflammation and anemia. The computed tomography revealed free air and elevation of the fat density surrounding the small intestine. These findings led to a diagnosis of perforative peritonitis. An emergency operation was therefore performed. At laparotomy, a punched-out perforation was observed in the small intestine at a point 180 cm on the distal side from Treitz' ligament. Furthermore, deformities due to ulcer of the small intestine were observed at 250 cm and 320 cm distal from the Treitz' ligament. Those were located on the opposite side of the attachment of the mesentery. Partial resections of the respective small intestine were performed. These lesions were diagnosed as primary nonspecific ulcers of the small intestine by the clinical features and the histopathological findings.

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The patient was a 79-year-old female with complaints of exertional palpitation and chest pain. Upper gastrointestinal endoscopic study, blood pool scintigraphy and CT study did not reveal any abnormal findings. Endoscopic study of the small intestine revealed a mobile, easily bleeding pedunculated protruding tumor of about 20mm in size in the jejunum at about 270cm from the mouth. Cytology study of the tumor revealed granulating tissue and inflammatory cells. Segmental resection of the jejunum was performed for diagnosis and treatment. Pathohistological study revealed superficial erosions, proliferation of vessels of different sizes in the edematous interstitial space and partial leaflet like proliferations were observed. Accordingly the diagnosis of pyogenic granuloma was made. Pyogenic granuloma which arises in the intestinal tract other than in oral mucosa is extremely rare and only 29 cases are reported in Japan until now. The ones that arose in the jejunum are only 3 cases including ours. Massive melena and recurrences are reported and so a complete resection and careful follow-up are important. In case of intestinal bleeding of unknown origin, the possibility of this pathology should be included in the differential diagnosis.

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The patient was a 64-year-old man who had visited another hospital because of tarry stool in 2004. Abdominal CT revealed an intra-abdominal 10-cm-sized tumor in December 2006. In January 2007, he complained of nausea and abdominal fullness and was diagnosed as having ileus by abdominal x-ray film. At laparotomy, we found a 180° small intestinal volvulus. The tumor was located in the ileum 240 cm from the end of Bauhin's valve and 270 cm from the Treitz'ligament. The tumor and partial ileum were removed and an ileoileostomy was performed. Post operative pathological diagnosis was intermediate-grade GIST of the small intestine. GIST of the small intestine associated with small bowel volvulus is a very rare disease.

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We report a very rare case of multifocal early carcinomas arising from the vermiform appendix. A 32-year-old woman was referred to our hospital with a suspected diagnosis of appendicitis. On admission, a tumor of about 5cm was palpable with tenderness at the right lower abdomen and severe anemia was revealed by the hematological study. Abdominal CT, MRI and Ba enema disclosed a tumor in the cecum that was apparently prolapsing from the orifice of the vermiform appendix on colonoscopy. Histopathologically the tumor was diagnosed as tubular adenoma with atypia. Moreover, abdominal sonography strongly suggested the presence of another tumor in the distal appendix. We performed right hemicolectomy with D3 dissection. The resected specimen showed a polypoid tumor prolapsing into the cecum from the proximal appendix and another subpolypoid tumor in the distal appendix. These tumors were histopathologically diagnosed as multifocal early carcinomas.

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A 44-year-old man was admitted to the hospital because of an abscess of the left inguinal region. An incision of the abscess yielded elimination of feces and a fistula was formed at this place. Fistulography revealed a colocutaneous fistula due to diverticulitis of the descending colon. Transverse colostomy reduced the colocutaneous fistula, but the fistula did not close. Partial colectomy was performed and the resected colon revealed fistula formation, wall thickening and stenosis of the cavity. Pathological findings were consistent with those of diverticulitis of the colon, and had no evidence of specific inflammation or inflammatory bowel disease.
We report a case of a colocutaneous fistula due to diverticulitis of the colon that is a rare entity.

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An 80-year-old male complained of lower abdominal pain and tarry stool, in January, 2004 on colonoscopy, a type 2 tumor was noted in the transverse colon. A diagnosis of adenocarcinoma (Group V) was made based on the histopathology. On computed tomography (CT) images, in addition to liver metastasis and lymph node metastasis, left renal hydronephrosis was found. The patient was seen by the urological service and renal cell cancer was diagnosed. Thus, the patient presented with two independent cancers. The patient refused surgical treatment and was not seen for 5 months. He received neither anticancer treatment nor any medications. In august, 2004, repeat colonoscopy was done, and the IIc lesion was no longer visible, a biopsy was done at the site where the lesion had been located, and on pathology, no cancer cells were noted. In August, 2004 the patient also had a right nephrectomy. Since that time, the colonic lesion was followed at regular intervals. In January, 2007, 30months after the disappear once of the lesion on colonoscopy and the right nephrectomy, the patient was alive with no signs of recurrence. This finding suggests that spontaneous regression can occur in patients with colonic.

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A 73-year-old woman was admitted to our hospital for further evaluation because she had tested positive for fecal occult blood. A protruding lesion was detected in the ascending colon by colonoscopy and examination of the tumor biopsy specimen showed the tumor corresponded to an undifferentiated carcinoma. Laparoscopic assisted right hemicolectomy was performed under the diagnosis of ascending colon cancer. The tumor was polypoid with a slight central depression and 10×10mm in size. Pathological findings showed the tumor consisted of abnormal cells without gland formation and mucin production. Immunohistochemically, the tumor was positive for EMA and keratin but negative for chromogranin A and synaptophysin. The tumor invaded the colon well up to the submucosa. Therefore we diagnosed for patient as warring had an undifferentiated carcinoma. We report this rare case of early undifferentiated carcinoma of the colon with a review of the literature.

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We report 2 cases of AFP-producing colon cancer that we encountered. Case 1 involved a 40-year-old male who was seen by the Department of Cardiovascular Medicine of our hospital because of chest discomfort. A screening blood test revealed anemia and stool test was positive for occult blood. Serum AFP level was high at 168 ng/ml, and further investigation led to a diagnosis of ascending colon cancer, for which right hemicolectomy was performed. Case 2 involved a 51-year-old female who was seen at this hospital because of abdominal discomfort and a palpable lower abdominal mass. Serum AFP level was high at 3,920 ng/ml. Further investigation led to a diagnosis of sigmoid colon cancer with multiple liver and lung metastases, for which left hemicolectomy was performed. Histopathology led to a diagnosis of poorly differentiated adenocarcinoma in case 1 and moderately-differentiated adenocarcinoma in case 2 and in both cases, AFP immunostaining was positive. Both patients underwent systemic chemotherapy postoperatively, the patient in case 1 is 8 years and 7 months postoperatively, and currently surviving without recurrence, and the patient in case 2 experienced exacerbation of multiple liver metastases and passed away due to liver failure 4 months postoperatively.

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In April, 2004, a 71-year-old male was found to have rectal carcinoma on colonoscopy. Based on the pathology of the biopsy specimen a small cell carcinoma was diagnosed. An abdominoperineal resection was done ; adjacent lymph node metastasis was suspected, but no lesions were detected in other organs. On histopathology, the resected specimen showed small cell carcinoma, Stage IIIb (according to General Rules for Clinical and Pathological Studies on Cancer of The Colon. Rectum and Anus, The 7th Edition). Postoperative chemotherapy included 6 cycles of CDDP and VP-16. On follow-up 45 months post-surgery, the patient was disease-free. Small cell carcinoma of the rectum is very rare and usually has a very poor prognosis. Thus, we are reporting this case of small cell carcinoma of the rectum that was resectable and that has had long-term survival.

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This paper deals with a case of granulocyte-colony stimulating facor (G-CSF)-producing undifferentiated carcinoma of the rectum in which the disease rapidly progressed to its termination after resection of the primary lesion. A 63-year-old man was admitted to our hospital for thorough examination of a large tumor of the rectum, for which undifferentiated carcinoma was suggested. Because of bleeding from the tumor and no evident metastasizing lesions demonstrated by PET-CT, we performed abdominoperineal rectum resection. However, it became apparent by the 11^th postoperative day that the disease had relapsed in the pelvic cavity with multiple metastasizing lesions in the liver and lungs. Also noted were a high-grade fever with marked leukocytosis (>110000/μl) and an elevated serum G-CSF level (115pg/ml) during this period. Afterwards, the patient's condition rapidly deteriorated and he died 26 days after the surgery. Microscopic examination including immunohistochemical staining gave a diagnosis of undifferentiated carcinoma. Furthermore, tumor cells positively stained for anti-G-CSF antibody.
Reports of undifferentiated carcinoma arising in the large bowel are extremely rare and, to the best of our knowledge, no G-CSF-producing undifferentiated carcinoma of the rectum has not been documented to date. Thus, the significance of G-CSF in the clinical course and therapeutic strategies for such patients remain unresolved. Nevertheless, a review of the literature suggests that early detection followed by complete resection of such tumors would be the best possible therapeutic modality at this point.

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A 76-year-old man was admitted to our hospital with a liver tumor. Abdominal CT showed the liver tumor was located in the Spiegel lobe with a vena cava tumor thrombus. Cavagraphy showed that the thrombus did not reach to the conflunence of the vena cava and the hepatic vein. At the time of operation, we placed a temporary IVC filter to prevent pulmonary embolism from dislodgement of the tumor thrombus, followed by a caudate lobectomy with thrombectomy. Blood pressure was maintained by clamping the IVC below the hepatic vein. THVE (Total hepatic vascular exclusion) was not necessary. The patient survived 16 months after the operation but died of intrahepatic reccurence and pulmonary metastases. The prognosis of hepatocellular carcinoma with IVC thrombus is dismal, but a possibility of long term survival may be altained by resection, if the operation can be safely performed. Administration of effective adjuvant chemotherapy and chemotherapy for intra, and extrahepatic recurrence is required to improve the long term survival.

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Hepatocellular adenoma (HA) is a benign tumor and extremely rare. We report an 80-year-old man with hepatocellular carcinoma (HCC) mimicking a hepatocellular adenoma. The patient was admitted to the hospital because of a hepatic tumor detected by abdominal ultrasonography. HBs antigen and HCV antibody were negative and liver function test and the serum level of alpha-fetoprotein were within normal ranges. Abdominal ultrasonography showed a hyperechoic, well-defined nodule 4cm in diameter in the segment 2 of the liver. Abdominal magnetic resonance imaging scan showed low signal intensity on T1- and high signal intensity on T2-weighted images. Because a possibility of HCC could not be ruled out from these imaging findings which suggested benign hepatic tumor, lateral segmentectomy was performed. Grossly the tumor had a capsule and histopathological examination showed thin-trabecular pattern. There were no portal tracts. It was difficult to diagnose the tumor as HCC because of the morphology which was similar to HA. However, infiltration of the tumor into the peritumoral capsule was seen in the restricted area. The tumor was thus diagnosed as well to moderately differentiated HCC. Histologically, well differentiated HCC may be difficult to distinguish from HA.

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A 51-year-old man was initially seen at another institution for right upper quadrant pain. An abdominal computed tomographic scan revealed a hepatic mass in the left lateral segment and tumor thrombi invading continuously from the mass to the common hepatic duct. He was admitted to our hospital and diagnosed as hepatocellular carcinoma invading the biliary tract. He was given hepatic arterial injection chemotherapy using CDDP powder (100 mg monthly) due to the obstructive jaundice (T-Bil. 7.4). After the second course, the tumor thrombi underwent involution and the jaundice disappeared. Extended left hepatectomy with partial resection of caudal lobe and plasty of hepatic bile duct were performed. We report a case of successfully resected hepatocellular carcinoma with bile duct thrombi after neoadjuvant hepatic artery injection chemotherapy.

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A 69-year-old man who had undergone pancreaticoduodenectomy for adenosquamous carcinoma of the intrapancreatic remnant bile duct in June 2006 was admitted to the hospital because of fever about six months after the surgery. Severe inflammatory findings were noted and serum CEA level was elevated. Abdominal US and CT scan revealed a liver tumor in the S7 of the liver. It was difficult to differentiate between metastasis and an abscess. No symptomatic remission was gained by conservative therapy and an increasing tendency of the tumor was observed. Then needle puncture was performed after all. The histopathological examination revealed liver metastasis of adenosquamous carcinoma of the bile duct. Hepatic arterial infusion therapy with 5-FU+CDDP was performed. The liver tumor subsequently shrank, uncontrollable inflammation improved, and the serum CEA level fell to normal range.
Adenosquamous carcinoma of the bile duct carries extremely poor prognosis and is prone to recur or metastasize in an early phase. No effective multimodal therapy for the disease has been established as yet. We suggest that the hepatic arterial infusion therapy with 5-FU+CDDP is a useful therapy for liver metastasis of adenosquamous carcinoma of the bile duct.

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“Double cystic duct” is a rare anomaly of the biliary duct system. Two cases of cholecystolithiasis with double cystic duct were encounted. The first patient was a 60-year-old woman in whom cholecystolithiasis was detected by abdominal ultrasonography at a medical check up. Laparoscopic cholecystectomy was performed in June 2004. Intraoperative cholangiography from the main cystic duct showed another cystic duct, which had diverged from the right hepatic duct. The second patient was a 46-year-old man who had recurrent bouts of right upper abdominal pain presumably due to cholecystolithiasis. Laparoscopic cholecystectomy was done in May 2006. Intraoperative cholangiography through the main cystic duct showed another cystic duct from the right hepatic duct. Double cystic duct was diagnosed. At surgery the gallbladder was removed after the both cystic ducts were transected.
“Double cystic duct” is a rare unnatural run of the biliary duct system, and it can be a cause of intraoperative injury. It is difficult to detect this anomaly by conventional preoperative examinations. These cases suggest the importance of intraoperative cholangiography to avoid unexpected injury of the cystic duct during laparoscopic cholecystectomy. Clinical reports of double cystic duct have been accumulating, and we present the case, together with some bibliographical comments.

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We report two resected cases of intrahepatic bile duct cystadenoma which produced mucin and communicated with the bile duct. Case 1 : A 79-year-old man was found by CT to have a cystic lesion and dilated intrahepatic bile ducts in the left lateral segment (S₂) of the liver. Percutaneous transhepatic cholangiography showed filling defects in the bile duct from B₂ to CBD, and partial resection of the liver was performed. Case 2 : A 73-year-old man was admitted for epigastric pain and fever. Laboratory studies showed liver dysfunction, and abdominal CT revealed a cystic lesion measuring 2.2 cm in diameter and slight dilatation of the left intrahepatic bile duct. We resected the left hepatic lobe. The pathological diagnoses of both resected tumors were intrahepatic bile duct cystadenoma. No mesenchymal stroma was observed in either case.

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A 25-year-old woman was referred to our hospital under a diagnosis of a large hepatic tumor detected by abdominal ultrasonography at a previous clinic. Laboratory examinations revealed HBs-Ag and HCV-Ab negative, mild liver dysfunction, mild inflammatory finding and tumor markers in normal ranges. Abdominal CT scan showed a large hepatic tumor in the right lobe of the liver which had two components of solid and cystic parts. The solid part of the tumor was enhanced in the early phase and the enhancement effect disappeared in the late phase, which was similar to hepato cellular carcinoma (HCC). The peripheral region of the cystic part was slightly enhanced, but its central region was not enhanced at all. Angiography showed irregular tumor stain. Therefore we diagnosed the tumor as malignant hepatic tumor, and performed right lobectomy of the liver. Macroscopically cut surface of the resected specimen included solid and cystic components, in which cholangiole cell-like tumor cells formed small glandular lumens histologically. Immunohistochemical staining of cytokeratin 7 was positive and hepatocyte negative. Consequently the tumor was diagnosed as cholangiolocellular carcinoma. The patient was discharged from the hospital on the 17th day after the operation. There have been no recurrence as of four years after the operation without any adjuvant therapy.

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A woman in her fourties was referred for a examination because it was pointed out that she had a tumor of pancreas in the physical check-up. The abdominal CT showed a 2cm circular tumor that had a strong contrast effect on the superior margin of the pancreatic body. We suspected a nonfunctioning pancreatic endocrine tumor and operated. We performed only tumor enucleation, because the perioperative frozen section showed the histology of Castleman's disease. This disease is the hyperplasia of the lymph nodes characteristicaly develop in the mediastinal space and cervix. It is comparatively rare that Castleman's disease develops intraperitoneally. According to a few reports, it can develop in the lymph nodes of mesenterium and retroperitoneum. It is benign disease basically, and good prognosis is obtained by simple tumor enucleation. In this case, it was important to consider the possibility of pancreatic endocrine tumor as a differential diagnosis. We mode diagnosis by perioperative frozen section, and could avoid an enlarged operation.

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The patient was a 73-year-old man who had been treated for chronic pancreatitis in the department of internal medicine in our hospital on an ambulant basis since 3 years 2 months earlier. When he was first seen, a cystic mass on the dorsal aspect of the pancreas was found by abdominal CT scan and thereafter the clinical course had been followed with a suspicion of a pancreatic pseudocyst. The cyst had started to enlarge gradually since one year earlier and the serum CA19-9 increased to an abnormally high level (5240U/ml) as well. Due to the difficulty in differentiation from a malignant tumor, the patient was referred to our department for the purpose of operation. Upon laparotomy, the tumor on the dorsal aspect of the pancreas was about 4cm in diameter and there were not so many inflammatory findings in the surrounding tissues. Considering a possibility of a tumorous lesion, resection of the pancreatic body and tail with splenectomy, cholecystectomy, and anastomosis of the pancreatic duct to the stomach were performed. Histopathologically the lesion was composed of a large and a small cyst and the cystic wall was covered with stratified squamous epithelium with lymphatic follicle in places. Lymphoepithelial cyst was thus diagnosed. The patient's postoperative course was uneventful and the CA19-9 level was normalized to 11.4U/ml 2 months after the operation.
This time we experienced a case of a lymphoepithelial cyst which was incidentally found in the course of chronic pancreatitis and then was operated on with a suspicion of a pancreatic pseudocyst. This case is considered to be suggestive in inferring the etiology of the cyst because the lesion enlarged with time and was associated with chronic pancreatitis.

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A 70-year-old man visited a doctor with the main complaints of fever and right abdominal pain. A blood test revealed an inflammation reaction and abdominal enhanced CT showed a thrombus continued to the portal vein from the superior mesenteric vein (SMV), along with ascending colon diverticulitis. He was admitted and diagnosed with superior mesenteric vein thrombosis secondary to diverticulitis of the ascending colon, because blood coagulation and another disease were negative. Because the abdominal symptoms were slight, we preferred conservative therapy and improvement of the inflammation. For thrombosis, we considered anticoagulant therapy immediately, but we canceled because of a hemorrhagic gastric ulcer. Abdominal enhanced CT on day 10 showed improvement of the diverticulitis and the reduction of the thrombus. We confirmed the improvement of the gastric ulcer, and continuous infusion of heparin was performed intravenously from the same day. Heparin was converted to warfarin on day 30, and he was discharged on day 46. But three months later, he was readmitted for recurrence of the diverticulitis. Abdominal enhanced CT on the same day showed a normal SMV.

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Superior mesenteric artery embolism remains a challenge to those involved in its diagnosis and treatment. We performed transcatheter thromboaspiration for acute superior mesenteric artery embolism and avoided unnecessary laparotomy. To the best of our knowledge, there have been only 15 cases of SMA thrombosis treated with per-catheteric thrombus aspiration procedure in Japan.
A 69-year-old man was brought into the hospital by ambulance because of severe epigastralgia. Abdominal enhanced CT scan revealed a complete obstruction of the SMA. Five hours after the onset of this complaint, abdominal angiography was performed to dissolve and aspirate embolism through a catheter. After the treatment, abdominal pain was resolved. The patient recovered without laparotomy and was discharged on the 13^th day after the treatment. In this case, percutaneous transcatheter thromboaspiration was useful for acute superior mesenteric artery embolism.

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We report a case of mesenteric panniculitis with necrosis of the sigmoid colostomy that occurred after abdominoperineal resection (APR). A 41-year-old man with lower rectal cancer underwent APR after preoperative chemoradiation. He had persistenth high fever associated with slams and symptoms of severe inflammation after the operation. Thirteen days after the operation, necrosis and perforation of the sigmoid colostomy occurred. Hence, we operated on him again to repair the colostomy. Intraoperatived the mesenterium of the sigmoid colon was found to have become markedly thick and sclerous. We resected the thick portion of the sigmoid colon and made a descending colostomy. Furthermore, part of the small intestine was resected because it had adhesred to the retroperitoneum. The pathological diagnosis of the resected specimen was mesenteric panniculitis. In patients with ever of an unknown cause and inflammation soon after surgery, it is important to keep this disease in mind.

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