Introduction : We examined the safety and appropriateness of sentinel lymph node biopsy (SLNB) performed by surgical residents and here report our findings. Methods : Retrospective comparison was made of 50 patients on whom SLNB with breast cancer was performed by a surgical resident using combined blue dye and radioisotope method (study group) and a control group of 60 patients on whom the procedure was performed by the supervising surgeon. Results : The identification rates in the study group and control group were 98.0% and 100%, respectively, which was satisfactory in both groups. There was no difference in the rate of complications between the two groups, and the only complication related to SLNB was seroma, which had an incidence of 4 cases (8.0%) in the study group and 3 cases (5.0%) in the control group. Discussion : It was confirmed that SLNB could be performed safely and with a high rate of identification by residents using combined blue dye and radioisotope method.

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In this paper, we describe a treatment strategy for perforated gastric cancer based on a clinicopathological study. Out of 2120 petients wih gastric cancer operated on from January 1988 to March 2005, 20 patients had perforated gastric cancer. These 20 patients were subjected to the study. There were 13 men and 7 women, with a mean age of 70 years (39-87). We could successfully diagnosed as perforated cancer in 12 cases, and successfully perfomed gastrectomies in 18 cases (90%). Perforation occurred in the region L (11 cases), M (7 cases) and, U (2 cases). Macroscopically Borrmann type 2 and 3 cancers accounted for 80% (16 cases) and histologically there were 11 cases of poorly differentiated adenocarcinoma, 4 cases of moderately differentated adenocarcinoma, and 3 cases of signet ring cell carcinoma. As for the short-term outcomes, 19 patients could be discharged from the hospital, but there was one post-operative death. Concerning the long-term outcomes, the 5-year survival rate was 36% in curative A and B patients, but all curative C patients died within one year after the operation. The operative outcome was poor, but some of curative A and B patients were able to have favorable prognosis. Thus we consider that radical operation should be carried out if the patient's general condition permits it.

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40 cases of perforation of the small intestine who were operated at our hospital from January 1999 to September 2006 were studied retrospectively regarding to their age, sex, cause, clinical symptom, diagnostic imaging, preoperative diagnosis, interval from the onset to operation, technique of operation, the site of perforation, postoperative complications and prognosis. There were 20 cases of traumatic and 20 cases of non-traumatic perforation of the small intestine. The average age of traumatic was 53.3 years and that of non-traumatic was 69.9 years, and in either case the number of men were more than woman. The ratio of cases that showed signs of peritoneal irritation was 55.0% in traumatic cases and 60.0% in non-traumatic cases. Chest-abdominal plain radiograph or abdominal computed tomography revealed intra-abdominal free air in 70.0% of traumatic cases and 52.6% of non-traumatic cases. None were diagnosed exactly before the operations. In non-traumatic cases, it took a longer time from the onset to operation as compared to traumatic cases and we couldn't save two patients who fell into septic shock. In traumatic cases, we could save all patients. We consider that careful observation, repeated examinations and prompt surgical procedure are important for the treatment of perforation of the small intestine in cases with abdominal pain.

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Patients with liver metastasis from gastric cancer are rarely candidates for local therapy, and the criteria for hepatic resection has not been clarified. The purpose of this study was to assess our outcome of hepatic resection for hepatic metastases of gastric cancer and to identify suitable candidates for hepatectomy. Twelve patients who underwent hepatectomy for hepatic metastases of gastric cancer between 1990 and 2006 were assessed for survival rate and clinicopathological factors of prognostic value. The overall 5-year survival rate after hepatectomy was 27.8% and two patients survived for more than 10 years without recurrence. The number of metastases, less than 3, was the only significant factor for the favorable prognosis. Age, gender and factors associated with primary lesion : depth of invasion, differentiation and lymph node metastasis were not significant. In conclusion, hepatectomy for hepatic metastases is beneficial for the patients properly selected. Less than 3 metastases is a good indication for hepatectomy.

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(Background) Cases requiring ventilation were assessed based on the presence of ventilator-associated pneumonia (VAP).
(Patients & Methods) 69 cases required ventilation post surgery of a total 1393 cases that had surgery under general anesthesia from November 2004 to July 2007. The 69 cases were divided into an elective surgery group and an emergency surgery group. The groups were compared with respect to : factors affecting the need for ventilation rate, the hospital mortality rate, tracheostomy rate, rate of weaning from artificial ventilator, ventilator reattachment rate, the duration of artificial ventilation, and the incidence of VAP.
(Results) The overall ventilation rate was 5% ; the duration of ventilation was 10 days. The duration of ventilation was prolonged in patients 70 years of age and older as well as in those with a PaO₂/FiO₂ ratio of less than 300 immediately after surgery. The incidence of VAP was 4.3 cases per 1000 days spent on a ventilator.
(Conclusion) The VAP incidence was higher among cases requiring ventilation following emergency surgery. The duration of ventilation was prolonged in elderly patients and in those in whom oxygenation was depressed immediately after surgery.

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A 77-year-old man was diagnosed as a recurrence of thyroid cancer, and was referred to the department concerned. The presence of a tumor 10 cm in greatest dimension was confirmed in cervical CT. In PET·CT, FDG accumulated markedly in the mediastinal space from the right cervix, and multiple pulmonary metastasis was suspected in the lungs. Although abscission was not expected to provide a cure, we decided to do internal radiotherapy after having extracted the left lobe of the thyroid gland, tumor reducing abscission, and tracheotomy. The reason was that the results of needle biopsy revealed differentiated-type papillary cancer, and that we needed to avoid airway obstruction. After the operation, we performed two Radioiodine I-131 treatments for a neck tumor remnant and mediastinal lymph node which spread to the lung lesion. The contraction rate of the neck tumor was 75% by CT 11 months after the second radiotherapy, the tumor reduced, and the QOL was markedly improved. We Considered that prognostic amelioration was obtained by the tumor reducing operation and Radioiodine I-131 treatments, for local recurrence of unresectable giant papillary adenocarcinoma of thyroid.

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We herein report a case of intracystic carcinoma with neuroendocrine features. A 91-year-old woman was referred to our hospital with a chief complaint of right breast tumor. The tumor with smooth surface and clear margin located in the CD area of the right breast was 2.5 cm in size and quite movable. A cystic tumor with septa and mural nodules was demonstrated by echogram. Wide excision of the tumor was performed with a diagnosis of intracystic tumor. Macroscopically, the tumor consisted of a large cyst 2.0 cm in diameter, and two small cysts 0.5 cm in diameter. There was a solid part showing papillary proliferation in the small cysts. Microscopically, the papillary lesion contained hyalinized stroma and vascular tissue. Neither invasion nor intraductal spread was observed. Tumor cells were rich in cytoplasm containing eosinophilic granules, and were ER-positive, PgR-positive, and HER-2-negative. Most of the tumor cells were positive by synaptophysin and chromogranine staining. The tumor was considered to be a neuroendocrine ductal carcinoma in situ (NE-DCIS) in the form of an intracystic papillary carcinoma.

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The patient was a 52-year-old woman who had undergone tumor resection at 26 and 38 years of age following diagnosis of benign phyllodes tumor of the right breast. She noticed a mass in the right breast around 1995, and visited our hospital following rapid enlargement of the mass from January 2007. A mass 20 cm in size was observed in the right breast, and the patient was diagnosed with recurrence of phyllodes tumor and underwent right partial mastectomy. Pathological diagnosis was borderline lesion. Redness and swelling were observed around the wound approximately three weeks postoperatively, and the patient was diagnosed with early postoperative recurrence. Modified radical mastectomy of the right breast, right axillary lymph node dissection, and right skin graft were performed. Postoperative histopathological diagnosis was malignant phyllodes tumor, and metastasis to the right axillary lymph node was also observed. Although chemotherapy was strongly recommended to the patient due to detection of multiple lung metastases and enlargement of the right axillary lymph node on chest CT at discharge, it was refused by the patient, and follow-up observations were made on an outpatient basis. A local recurrence was observed at the site of skin graft two weeks after discharge, and the lesion showed a tendency toward further enlargement. The patient's general condition gradually deteriorated further, and she died in July of the same year.

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A woman in her sixties found a rapidly growing lump in her left breast. Physical examination disclosed a lump 10 cm in size under thin and purple-red colored skin in the upper-outer quadrant area of the left breast. The mammography showed a round and high-density mass without calcification that occupied most of the left breast. Ultrasonography revealed the presence of two papillary isoechoic lesions in a round, well-circumscribed, large, and hypoechoic lesion. Contrast-enhanced CT imaging, and gadolinium-enhanced MRI demonstrated an enhanced papillary lesion in the cyst with a diameter of 10 cm. Fine-needle aspiration cytology was performed twice, but atypical cells were not found. Although it suspected the tumor to be an intracystic papilloma, we decided to perform tumor extirpation to obtain a definitive diagnosis. The pathological examination revealed an intracystic solid-papillary carcinoma with limited cyst wall invasion. She received irradiation and endocrine therapy after surgery. Patients who receive early treatment for intracystic papillary carcinoma are known to have a good prognosis. However, the pre-operative diagnosis and the appropriate treatment of the patient remain controversial. We reported a case with some review of the literature.

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A 50-year-old female had noticed a lump in her right breast by a physical checkup. On physical examination, a firm irregular mass measuring approximately 6 cm in its greater dimension in the upper outer quadrant of the right breast was palpable. Ultrasonography showed a hypoechoic nodule with irregular margin. Mammography revealed a poorly demarcated mass without microcalcification. The tumor was diagnosed as acinic cell carcinoma by a core needle biopsy. The patient underwent a modified radical mastectomy with axillary lymph node dissection, adjuvant chemotherapy and radiation therapy. Histopathologically, the tumor was very similar to a case of acinic cell carcinoma of the parotid gland or the pancreas (t3, f (+), ly0, v0, n0, stageIIB). Immunohistochemically, EMA, cytokeratin (AE1/AE3), S-100, α1-antichymotrypsin, lactalbumin, lysozyme, GCDFP-15 and amylase were positive, and ER, PgR and HER-2 were negative. To our knowledge, this is the thirteenth report of a case of acinic cell carcinoma worldwide.

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A 73-year-old woman with a rib fracture was hospitalized in February, 2006. In hospital, she developed epigastralgia. There were no remarkable findings on gastroendoscopy. After discharge, the patient developed diarrhea and was hospitalized in March. She complained of oppressive pain diffusely located in the abdomen. Laboratory data revealed an advanced inflammatory reaction. Four days after admission, she vomited a large amount of blood and went into shock. An emergency endoscopy was done ; multiple ulcers were seen in her stomach. A bleeding point could not be identified. The patient did not recover from shock despite massive blood transfusion. Emergency surgery was performed. At laparotomy, the stomach was found to be swollen ; massive clots were present. However, the serosa of the stomach was unremarkable. A total gastrectomy was performed. On gross examination, shallow ulcers were seen throughout the stomach lining. On pathology, multiple small granulations scattered in the lamina propria mucosae were noted, and the stomach was found to be infected with H. pylori. The pathological findings were not compatible with sarcoidosis, Crohn's disease, tuberculosis, syphilis, or tumor. The diagnosis was idiopathic granulomatous gastritis. The patient's postoperative course was uneventful.

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A 58-year-old Japanese man was admitted to our hospital for the treatment of type 2 advanced cancer of the upper part of the stomach. He had a past history of diabetes and angina ; both of them had been well controlled by medication for 5 years. The preoperative value of tumor marker, CEA, was within the normal limit. He underwent total gastrectomy with distal pancreatosplenectomy, and pathology of the resected specimen demonstrated poorly-differentiated adenocarcinoma, T2N2H0P0M0 Stage IIIB, and curability B. Two months after operation, CEA and fasting blood sugar levels began to increase. Radiological examinations demonstrated neither any sign of recurrence nor newly developed neoplasm in the other organs. He had been followed with no treatment except for medication for diabetes, and the CEA level began to decrease after 6 months postoperatively. The diabetic status also improved, and there seemed to be a correlation between the glucose tolerance and the CEA level. He has been doing well without any sign of recurrence for 51 months to date.

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A 54-year-old man developed epigastric discomfort. Based on preoperative gastroendoscopic findings and an upper gastrointestinal series, type 3 gastric cancer infiltrating into the esophagus was diagnosed. On abdominal computed tomography, gallstones were noted, and the gallbladder wall could not be evaluated due to the presence of the gallstones. The operative findings included evidence of advanced gastric cancer invading the liver, with multiple lymph node metastases. Thus, the patient had a total gastrectomy with a hepatic resection, pancreaticosplenectomy as part of an extended lymph node dissection for gastric cancer, and a cholecystectomy. On histopathology, the gastric cancer was found to be a type 3 poorly differentiated adenocarcinoma tumor with serosal penetration into the liver, and lymph node metastases. The resected gallbladder wall was slightly thickened in the fundus, and gastric metastatic cancer was diagnosed, since the adenocarcinoma had proliferated into the stroma and had the same histological features as the gastric adenocarcinoma. The definitive diagnosis was T4 (SI ; liver), N3, H0, P0, CY0, M1 (OTH), Stage IV. Gallbladder metastasis from gastric cancer is very rare. Overall, the patient's treatment included radical gastric cancer surgery, and postoperative chemotherapy (TS-1).
The patient has survived without recurrence for 3.0 years post surgery. Although the survival rate is extremely low in gastric cancer patients with gallbladder metastases, curative surgery, which includes extendsive lymph node dissection, could be considered in order to improve patient survival.

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A 52-year-old man who had alcoholic liver cirrhosis and diabetes mellitus was seen for abdominal pain in April, 2007. Chest X-ray film showed free air under the left diaphragm. Perforation of digestive tract was suspected and an emergency laparotomy was done. Perforation of a bulbar ulcer was found and closure of the hole with omentopexy was done. In spite of continuous postoperative antibiotic treatment, infection signs and symptoms continued. Abdominal computed tomography on postoperative days 8 showed an abscess formation around the pancreas and the left kidney and in the retroperitoneal space along the left iliopsoas muscle. Percutaneous drainage of the retroperitoneal abscess was done through a catheter put in the left anterior pararenal extraperitoneal space. The drainage from the catheter was good, but infection marker did not improved. Then an open drainage and drain tube placement around the kidney over the left iliopsoas muscle for the retroperitoneal abscess was done through left retroperitoneal approach on 16 days after surgery. The second drainage therapy worked well and he was discharged on postoperative days 32.

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An 80-year-old-man who underwent a screening gastrointestinal fiberscopy was found to have duodenal carcinoma. A pancreaticoduodenectomy with a regional lymph node dissection was done since the cancer had invaded the papilla of Vater. On pathology a highly differentiated adenocarcinoma, which extended into the lower bile duct via the papilla of Vater, was found. However, the depth of invasion was ‘m'. This is a very rare case of early duodenal carcinoma that extended into the lower bile duct.

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A 49-year-old man was admitted to our hospital because of sudden epigastric pain and vomiting. He had a previous history of undergoing a gastrectomy for duodenal ulcer 30 years before admission. A tumor was palpable in the upper abdomen. An abdominal X-ray film showed a gas image in the small intestine and the target-like sign was seen in the CT scan. We diagnosed intestinal obstruction caused by intussusception and a laparotomy was performed. The finding showed that antecolic Billroth-II method (B-II) with Braun's anastomosis had been done and the efferent jejunal loop was found to be intussuscepted retrogradely through the Braun's anastomosis 40 cm from the anal side. After manual reduction, a part of the jejunal intussusceptum was resected.
In the past 20 years, intussusception after gastrectomy had been reported in 58 cases including our case in our country. The most common type was seen in after the reconstruction of gastric resection with B-II (35 cases), and the following was in Roux-en-Y method (14 cases), Billroth-I method (1 cases) and others (8 cases). Among them, 17 cases were in B-II with Braun's anastomosis after distal gastrectomy. A case of retrograde jejunojejunal intussusception that occurred after gastrojejunostomy is described.

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A 91-year-old woman developed lower abdominal pain. On abdominal CT, a small amount of little ascites, free air, and a high density object located in the small intestine were noted. Given the provisional diagnosis of perforative peritonitis, emergency surgery was required. However, her family refused surgery due to of the patient's age. Therefore, only the ascites was drained. The patient gradually recovered, and additional examinations were done. On multidetector-low CT, a press through package (PTP) was clearly seen in the small intestine. Therefore, elective surgery was performed. During the surgery, the PTP was removed from the small intestine. The patient's postoperative course was uneventful. This patient had had an intestinal perforation caused by a PTP 14 years prior to the present episode.

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A 72-year-old woman was referred to our hospital complaining of abdominal pain with ileus. She had undergone irradiation therapy for uterine cancer 25 years earlier. A long tube was inserted, which caused the clinical manifestation to improve. An abdominal computed tomography scan showed a foreign body in the terminal ileum. We thought that there might be stenosis in the gastrointestinal tract due to post-radiation therapy. Upon operation, radiation-induced enterocolitis was observed around the terminal ileum. A foreign body, a seed the size of a plum (2.5 cm×1.5 cm), was impacted 5 cm from the terminal ileum. This case illustrates the problems that can arise when an object such as a plum seed becomes lodged in a narrow segment of the intestine. In cases of radiologic enteritis with intestinal stenosis, it is advisable to consider the patient's dietary habits, as a foreign body of comparatively small size, such as a plum seed, can cause ileus.

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A 47-year-old woman was admitted to our hospital because of the sudden onset of abdominal pain, vomiting and diarrhea which were intractable. Abdominal enhanced CT scan revealed a whirl sign and a tubular structure with the blind end that had the wall edema and a decreased imaging effect. So we suspected strangulated ileus caused by a Meckel's diverticulum and performed an emergency operation. At surgery, we found a Meckel's diverticulum located in the ileum 70 cm proximal to the end of the Bauhin's valve. A rope thing generated from the top of the Meckel's diverticulum adhered to the mesentery of the small intestine 10 cm proximal to the end of the Bauhin's valve. The Meckel's diverticulum had been twisted by 720 degrees in the base. Partial resection of the small intestine including the Meckel's diverticulum was carried out. The rope thing was clarified to be mesodiverticular vascular band by postoperative pathological studies.
We report a case of strangulated ileus caused by a mesodiverticular vascular band of Meckel's diverticulum in which preoperative CT scanning was useful for diagnosis, together with some bibliographical comments.

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A 75-year-old man was found to have primary lung cancer (stageIV). After a radiotherapy for vertebral metastasis (30Gy), he was treated with gefitinib oral intake. Then, he was admitted in the hospital for ileus. Because his condition did not improve with a conservative therapy, he underwent a long tube insertion. Then, a laparotomy was performed under the suspicion of complete intestinal obstruction. Obvious metastatic findings were not seen in the abdominal space and only jejunal stenosis at 100cm from Treitz ligament was found, and we performed a partial excision of the intenstine. There was no evidence of malignancy in the excisional spacimen pathologically.
We report this rare case.

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A 29-year-old man developed right lower abdominal pain and fever. On abdominal multi-detector computed tomography (MDCT), a cystic lesion, which included a high-density area, was seen in the pelvic cavity. The sagittal image showed that the cystic lesion communicated with the adjacent small bowel on the antimesenteric side. With a provisional diagnosis of peritonitis due to Meckel's diverticulitis complicated by a tumor, emergency surgery was performed.
An egg-sized cystic mass was found on the antimesenteric side of the ileum, 150 cm oral from Bauhin's valve. During a minilaparotomy, partial resection of the ileum, with entire resection of the cystic mass, was done. On pathology, the cystic mass was found to have features identical to a genuine diverticulum, involving ectopic gastric tissue. Macroscopic examination of the specimen revealed that the solid tumor, 3×2.8 cm in size, had arisen from the tip of the cystic (diverticulum). Immunohistochemical studies showed that the solid tumor cells were positive for α-smooth muscle actin and desmin, but negative for c-kit. A diagnosis of leiomyoma was made. The patient was discharged 8 days after surgery.
This case highlights the fact that MDCT is very helpful for diagnosing Meckel's diverticulitis and leiomyoma arising in Meckel's diverticulum.

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A 90-year-old man who developed nausea and vomiting in the morning was brought into the emergency center in our hospital by ambulance because of aggravation of these symptoms. Lower abdominal pain was noted on abdominal examinations. Abdominal CT scan visualized intussusception at a distal portion of the small intestine. Small intestinal ischemia was suggested and thus an emergency operation was performed. Exploration of the abdominal cavity under laparotomy disclosed reduced intussusception and an about 2cm-sized submucosal tumor at a portion where was about 200cm proximal to the ileocecal valve. A mild degree of small intestinal thickening in the vicinity of the tumor was seen where was considered to be the intussuscepted portion. Except the intussusception, no other abnormal findings including Meckel's diverticulum were seen. A wedge resection of the small intestine involving the tumor was performed. Pathological studies showed that the tumor was surrounded by smooth muscle and had no extra-hepatic and endocrine glands. Thus ectopic pancreas of Heinrich classification type III was the most likely diagnosis. No postoperative complications occurred and the patient was discharged from the hospital on the 14^th hospital day.

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The patient was a 74-year-old woman in whom a tumor and intussusception were suspected in the right lower quadrant on abdominal ultrasound examination during a health checkup. As the patient did not have distension of the upper intestine or any symptoms, she was admitted for further examination. Colonoscopy revealed a tumor that was exposed from the Bauhin valve along with small intestinal mucosa, but no definitive diagnosis could be made. The patient was indicated for surgery due to the need to qualitatively diagnose the tumor as well as the risks of intestinal obstruction and strangulation, and laparoscopically-assissted surgery was selected due to its minimal invasiveness. Intussusception was confirmed on laparoscopy and reduced by making a small incision and pulling the affected site outside the body, and the ileal tumor was resected. Histopathological diagnosis was inflammatory fibroid polyp (IFP). Gastrointestinal IFP commonly occurs in the stomach and rarely occurs in the small intestine. Cases occurring in the small intestine often manifest with intussusception and requie emergency surgery. In our patient, minimally invasive elective surgery assisted by laparoscopy was possible due to the absence of symptoms. No relapse has occurred after three years of postoperative follow-up. We report our patient with reference to literature.

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The patient was a 66-year-old male who visited our hospital with the chief complaint of hematochezia. No source of bleeding was observed in the upper and lower intestinal endoscopic examinations. The abdominal CT scanning with contrast medium revealed a tumor of 4cm diameter in the prximal jejunum. The abdominal angiography showed a pachychromatic image of a tumor in the upper jejunum, suggesting a small intestinal GIST. As hematochezia occurred repeatedly during the said tests and blood pressure dropped, and as hemorrhage from the small intestinal tumor was discovered an emergency operation was performed. Laparotomy revealed a tumor of 5cm diameter growing extramurally at 10cm from the Treitz's ligament contralaterally to the mesenterium. A 10cm portion of the small intestine was excised. Histopathological examination revealed a growth of spindle-shaped cells with small blood vessels and increased cell density. Immunostaining confirmed GIST. It is often difficult to detect small intestinal GIST in patients who present with hematochezia. We present a list of cases reported in the past and discuss the differential diagnosis based on imaging and locality.

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A 51-year-old man was seen at our hospital in the morning because of the abdominal pain started night before. At the time of consultation, the abdominal symptom was improved. His blood test showed only mild inflammatory reaction. Abdominal CT showed a mass in the ascending colon and ileocecal intususception was suspected. At first we tried endoscopic reduction by colonoscopy, but it was not successful. We performed an emergency surgery. At laparotomy, ileocecum was found invaginated into the ascending colon, so we tried manual reduction by Hutchinson maneuver. There was a mass at the appendiceal root. We performed ileocecal resection (D3 dissection) because of possible malignancy. The histopathological examination after the surgery revealed that the mass at the appendiceal root was consisted of turning over of the appendiceal lumen. So we diagnosed as appendiceal intussusception. There were no malignant lesions in the mass. Appendiceal intussusception is rare comparatively and there is sometimes idiopathic one like this case. We report in detail this case of idiopathic appendiceal intussusception with a review of literatures.

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We report a rare case of early ileocecal valve cancer probably originated from cecal mucosa. A 76-year-old man underwent colonoscopic examination for the follow up of colon polyp. A tubular adenoma on ileocecal valve was found. Because of ileal invasion, endoscopic resection was not possible. So, laparoscopy-assisted ileocecal resection was performed. Pathological examination of the surgical specimen revealed that the tumor contained intramucosal adenocarcinoma stained by both alcian blue stain pH1.0 and pH2.5 on the ileocecal valve. Accordingly, we considered that this tumor originated from the cecal mucosa.

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Stercoral perforation of the sigmoid colon can occur in elderly patients who are on prolonged bed rest or in patients with a history of mental disorders. However, it is rarely noted in young individuals. We report a case of sigmoid colon perforation in a teenaged patient who was otherwise healthy.

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A 83-year-old woman was admitted for general fatigue and loss of appetite. She complained of severe diarrhea. On laboratory deta, dehydration and hypokalmia were found. A colonofiberscopy and computed tomography reavealed a huge villous tumor in the lower rectum. We diagnosed her as electrolyte depletion syndrome (EDS), and perfomed an abdominoperineal rectal resection.
The size of the tumor was 185×100×45mm. The histlogical finding was villous adenoma with severe atypia. After one year, there have been no recurrences of EDS.

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The patient was a 61-year-old man who had received total gastrectomy for type 3 advanced gastric cancer about 2 year earlier, which was poorly differentiated adenocarcinoma including signet ring cell carcinoma, pT2(ss), pN0, H0, P0, M0, and Stage IB. This time, colonoscopy revealed IIc like lesions in the ascending, descending, and sigmoid colons. The histological diagnosis was poorly differentiated adenocarcinoma including signet ring cell carcinoma in all lesions biopsied. The patient was thus operated on with the diagnosis of primary or metastatic colonic carcinomas. The postoperative pathological diagnosis for all lesions was poorly differentiated adenocarcinoma including signet ring cell carcinoma. Immunohistopathologically the tumors were positive for AE1/AE3 and cytokeratin 7(CK7) and negative for CK20, which are characteristic findings of carcinoma arisen in the stomach. The colon carcinomas resected this time showed the same histological as well as immunohistological findings as the gastric cancer resected before. Thus metastatic carcinoma of the colon from gastric carcinoma was diagnosed.

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The patient was a 61-year-old woman who had undergone right hemicolectomy for carcinoma of the ascending colon in 1996, definitively diagnosed pathologically as well-differentiated adenocarcinoma, invasion to the subserosa, and no metastasis to lymph nodes. No recurrence had been detected for 6 years after the surgery, but 10 years after the surgery, she was found to have anemia and a fist-sized abdominal mass. Abdominal CT scan showed a 6-cm mass near the third portion of the duodenum involving the surrounding organs. GIF showed an ulcerative lesion in the third portion of the duodenum. Suspecting lymph node metastasis from carcinoma of the ascending colon invading the duodenum, we conducted pancreatoduodenectomy in January 2006. The 7-cm tumor was surrounded by the duodenum, pancreas and colon and invaded the duodenal lumen. The pathological diagnosis was moderately differentiated adenocarcinoma, the main lesion was located in the duodenum and invaded the surrounding organs. We considered that the lesion did not originate in the duodenum but metastasized from the cancer of the ascending colon 10 years earlier. Such a case of colon carcinoma recurred and resected 10 years after the first operation is rare.

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We experienced a case of colon cancer with ossification. The patient was a 77-year-old female, with constipation and hematochezia for three months. Barium enema and colonoscopy revealed an advanced cancer of the sigmoid colon. The pathological diagnosis of the biopsy specimen was moderately differentiated adenocarcinoma. Computed tomography revealed multiple lung metastases and para-aortic lymph node metastases. Sigmoidectomy with D3 lymph node dissection was followed by a systemic chemotherapy using a combination of 5-FU, CPT-11, and l-LV. On histological examination of the surgical specimen, ossification was detected in the tumor. We reviewed 18 cases of bone forming colon cancer in the Japanese literature and speculated that the clinical features of this type of colon cancer are relatively malignant compared with those of other common types, whereas in 1963 Dukes had reported low malignancy of this type of colon cancer with no tendency to spread by veins and lymphatics, resulting in a slow-growing tumor with better prognosis.

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We have reported on a case of colonic carcinoma presented with intussusception in a young man, together with a review of the literature.
A 29-year-old man, seen at the hospital because of abdominal pain and mucous and bloody stool, was found to have intussusception of the descending colon by an abdominal CT scan. Hydrostatic pressure reduction of the intussuception revealed that it was caused by a mass. Colonoscopy showed type 1 colonic cancer encircling about two-third of the lumen, when we passed the scope through the lumen of the colon with difficulty but recognized narrowing of the lumen. A biopsy yielded the diagnosis of moderately differentiated adenocarcinoma, and laparoscopy-assisted left colectomy was performed. Histological study of the removed material resulted in SS INFβ, ly1, v0 NO. Although the patient had no familial history of colorectal cancer, a possibility of HNPCC could not be ruled out due to its juvenile onset. Thus microsatellite instability (MSI) analysis was done that gave negative outcome.
This case has suggested that the possible presence of colorectal malignancy must be kept in mind even in a young patient, if he or she has intussusception.

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A 64-year-old man with rectal cancer had a rectal resection in 2002 and subsequently had three pulmonary metastasis resections. In February 2008, on abdominal CT, an ill-defined mass 2cm in diameter was noted in the pancreatic head. Based on diagnostic imaging, the differential diagnosis included pancreatic cancer or pancreatic metastasis from the rectal cancer. A pancreaticoduodenectomy was performed in March 2008. The resected lesion had a microscopic appearance that was similar to the primary tumor, not only morphoplogically, but also immunohistochemically. The patient's postoperative course was uneventful, and he was given adjuvant therapy. In colorectal cancer patients resectable pancreatic metastasis is very rare. In fact, only 25 cases including this case have been reported in Japan.

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This paper deals with a 62-year-old male patient with postoperative hepatic recurrence of carcinoma of the gallbladder whose radiation therapy associated with chemotherapy using S-1 and cisplatin yielded normalization of elevated levels of tumor markers and a complete response (CR) on imaging 3 months after the surgery. There have been no signs of recurrence, as of 5 years 4 months after the surgery.
We describe the successful treatment with irradiation associated with chemotherapy using S-1 and cisplatin for a case of recurrence of the liver developed after radical operation for StageIVa advanced carcinoma of the gallbladder invading the duodenum, which resulted in the patient's long-term survival. Bibliographical comments are also presented here.

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A 71-year-old male patient came to our hospital with the chief complaint of upper abdominal pain. Abdominal CT study indicated a possible presence of gallbladder torsion but without definite diagnosis and PTGBD (percutaneous transhepatic gallbladder drainage) was performed. The drained fluid from the gallbladder was dark sanguinous and the presence of gallbladder torsion was strongly suspected. Following the procedure the symptom disappeared and the blood study also showed improvement of inflammation, therefore an operation was performed on the 17^th day of admission. Gallbladder torsion is difficult to differentiated from acute cholecystitis and PTGBD was formerly performed frequently for diagnosis, but since the improvement in the diagnosis of the disease it has been thought rather contraindicated on the base of anatomical reason. PTGBD has been used less frequently now. Our case reported here was Gross II complete type and the improvement of symptoms was obtained by PTGBD and an elective operation was followed. There are cases in which PTGBD was useful in diagnosis and conservative management was effective. In case of an elderly patient with high risk, PTGBD can be performed first, followed with surgical treatment after the improvement of the general condition of the patient.

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Xanthogranulomatous cholecystits (XC) is an inflammatory disease of the gallbladder which occasionally infiltrates into the surrounding tissues, for that it clinically mimics advanced gallbladder cancer and is often treated by extended surgery. We report a case of XC which infiltrated into the liver, transeverse colon and bile duct.
An 80-year-old man was admitted to the hospital because of general fatigue and body weight loss. Computed tomography (CT), magnetic resonance cholangiography (MRC) and radiographic examination of the colon suggested locally advanced gallbladder cancer. Tumor marker, CA19-9 was elevated. Extended surgical resection of the gallbladder tumor including the liver, transverse colon and bile duct was thus performed. Histological findings did not reveal any tumor cells, but chronic inflammatory cells including foamy and giant cells infiltrating into the liver and colon. Despite hyperbilirubinemia observed for 2 weeks after the operation, he was discharged in a good condition. Although preoperative diagnosis of XC is difficult, XC should be kept in mind as a differential diagnosis of gallbladder tumors.

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A 64-year-old man was admitted to our hospital because of appetite loss. The laboratory examination showed elevated biliary enzymes. Abdominal computed tomography (CT) showed a mass in the pancreas head. Endoscopic ultrasonography (EUS) showed a mass in the inferior bile duct. Perctaneous transhepatic cholangiopraphy (PTC) and magnetic resonance cholangio-pancreatography (MRCP) showed complete obstruction of the inferior bile duct. We performed pylorus-preserving pancreaticoduodenectomy with diagnosis of carcinoma of the common bile duct (T2N0M0 StageII). Macrospically, the tumor was nodular protruded type, 2cm in diameter and invaded to the pancreas in part. Histolopathologically, HE staining showed the tumor cells arranged in solid or trabecular structure. They were small and round shaped and their nuclei were severely atypical with hyperchromatism. Partly, well differentiated adenocarcinoma cells were mixed, and the transition between these two types of carcinoma was observed. Immunohistochemical staining of the tumor cells showed positive reaction for N-CAM (CD56) and for synaptophysin. Based on these findings, a definite diagnosis of adenoendocrine cell carcinoma of the inferior bile duct was made (pT3pN0pM0, fStageIII). Six months after the operation, multiple liver metastases were recognized on the follow-up CT examination. Endocrine carcinomas of the bile duct were reported in 25 cases in the Japanese literature including our report.

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A 79-year-old female patient developed jaundice after the treatment for acute cholecystitis and was finally diagnosed as obstructive jaundice due to upper biliary duct cancer with vascular infiltration. Since the patient was in elderly age of 79 and had senile dementia without understanding of her disease, surgical resection of the cancer was thought to be impossible. Recently internal fistulizations with stenting for inoperable malignant biliary obstructions have been performed, but occasionally there are cases not suitable for stenting. In our case percutaneous transhepatic internal fistulization was not successful and endoscopic biliary drainage was not performed as the cooperation of the patient was difficult to obtain. After discussing the situation with the family of the patient, an intrahepatic biliary-jejunostomy (Longmire method) was performed to improve the QOL of the patient. The patient died of hepatic failure 1 year and 4 months after the procedure, but lived at her home maintaining fair QOL. Open internal biliary fistulization accompanies some surgical invasion, but often can contribute for the improvement of the QOL of the patient without troubles seen in stenting.

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A 72-year-old woman complaing of abdominal full sensation after meal was referred to our department of gastroenterology on suspicion of a cystic tumor of the pancreas head. The main pancreatic duct was displaced by the cyst but had no connection to it by ERCP. The cystic mass 12×8cm in size in the pancreas head was unilocular, its capsule was uniform, its fluid content was homogeneous, and no septum was seen by abdominal ultra sonography and abdominal CT scanning. Abdominal angiography revealed right lateral displacement of GDA. Therefore it had little findings of malignancy. However, laparotomy was performed because of an enlarging tendency of the cyst and her subjective symptoms. The cyst had a thin capsule and displaced the duodenum and CBD. Its content was a colorless, transparent, and serous fluid and showed a low level of amylase. Because the normal pancreas tissue at the head was elongated thin and the MPD was considered to be displaced as well, duodenum-preserving pancreas head resection was performed. The histopathological diagnosis was true cyst of the pancreas. She was discharged on the POD 29 after temporary duodenal obstruction.

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Lymphoepithelial cyst of the pancreas is comparatively rare diseases. We report a case that was difficult to differentiate from a submucosal tumor of the stomach. A 65-year-old man consulted our department for the tumor between the stomach and pancreas. He had no symptoms and no abnormality was found by a physical examination. Blood examination showed no abnormality in particular. Imaging studies revealed an approximately 5cm cystic, internally heterogeneous mass between the stomach and pancreas. The mass was considered a submucosal tumor of the stomach by an upper endoscopy study. We suspected the mass to be a GIST of the stomach or cystic lesion of the pancreas. Because of a possibility of malignancy, we performed resection of the pancreatic body and tail with splenectomy and partial gastrectomy. Grossly, the unilocular cyst was filled with gray-whitish pasty material. Histologically, the cyst was lined by mature keratinizing squamous epithelium, and the wall contained lymphoid tissue with germinal centers.

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A 47-year-old man, admitted to the hospital because of epigastric pain, was suspected to have obstructive jaundice from chemical laboratory data. An abdominal CT scan disclosed a solid tumor, 8cm in diameter, with a distinct border in the body and tail of the pancreas. ERP showed a filling defect in the main pancreatic duct, suggestive of an intraductal tumor growth, and endoscopic biopsy of the duodenal papilla revealed moderately differentiated tubular adenocarcinoma. A total pancreatectomy was performed. Macroscopically the tumor showed an intraductal solid growth throughout the pancreas with pancreatic atrophy extended to the duodenal papilla. Histologically the tumor showed an acinar growth pattern which consisted of acidophilic tumor cells with fine granular PAS positive cytoplasm. Immnohistochemically the tumor cells were positive for amylase and α-1-antitrypsin. Accordingly intraductal and papillary variant of acinar cell carcinoma of the pancreas was diagnosed. We report this case as the 11th case in Japan.

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A reported 20% of patients with Behçet's syndrome develop vascular diseases such as aneurysms, arterial occlusion, and venous thrombosis/occlusion. Aneurysms complicating Behçet's syndrome have been frequently reported to involve thoracic and abdominal aortas. We report an extremely rare case of splenic artery aneurysm in a patient with Behçet's syndrome. A 33-year-old man diagnosed with incomplete Behçet's syndrome was taking oral prednisolone at 10 mg a day. He visited the emergency room with a chief complaint of left flank pain. His blood pressure was 90 mmHg, and Hb 8.8 g/dl. CT revealed marked dilatation of the splenic artery and perisplenic fluid accumulation, leading to the diagnosis of splenic artery aneurysm rupture with hemorrhagic shock. He underwent emergency surgery, which revealed an aneurysm, approximately 6 cm in diameter, continuous with a 2 cm splenic laceration. Distal pancreaticosplenectomy was performed. The postoperative course was uneventful, and he was discharged on the 14th postoperative day. Examination of the resected specimen resulted in the diagnosis of splenic rupture due to the perforation of the spleen by the splenic artery aneurysm. While regularly visiting the outpatient clinic, he developed a left brachial artery aneurysm, for which he has been followed.

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We report a case of a 32-year-old man with Crohn's disease complicated by a 10-year history of an enterovesical fistula which was surgically resected.
The patient presented with lower abdominal pain underwent sigmoidectomy and resection of the ileovesical fistula under a preoperative diagnosis of retroperitoneal tumor in February 1996. The clinical diagnosis was Crohn's disease and he underwent medical treatment. In April 1997, bacteriuria suggested relapse of the fistula, but he elected to avoid reoperation. When severe abdominal pain and appetite loss developed in August 2004, he chose infliximab treatment. One year later, no symptomatic remission was attained and so he elected to receive total parenteral nutrition at home. In April 2006, he was readmitted to the hospital because of severe abdominal pain and fever. A barium enema showed a severe stenotic lesion at the rectum with a rectovesical fistula. Cystography showed a small cavity in the urinary bladder leading to an intestine. Abdominal pain was so severe that he required large doses of narcotics. In May 2006, he underwent low anterior resection of the rectum, ilectomy, resection of the vesicoenteric fistula, and cutaneous ureterostomy. He has had no recurrence postoperatively. We believe that surgical intervention for Crohn's disease complicated by an enterovesical fistula should be indicated before the shape and function of the urinary bladder are impaired.

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We report a case of rectal involvement secondary to prostatic cancer which needed to distinguish from rectal cancer.
An 82-year-old man admitted to a clinic because of a 3-week history of dyschezia was diagnosed as having a rectal tumor by digital examination and was referred to our hospital on July 8. Rectoromanoscopy showed high degree of stricture at a lower portion of the rectum, which was suggestive of rectal carcinoma. But rectal biopsy yielded no conclusive findings. Abdominal CT scan showed diffused thickening of the rectal wall adjacent to the enlarged prostate. High level of serum PSA (118ng/ml) offered a suspicion of rectal involvement of prostatic cancer. Transrectal biopsy specimen of the prostate showed poorly differentiated adenocarcinoma and was positive for PSA immunohistochemical staining. The final diagnosis was established as primary cancer arising in the prostate which infiltrated into the rectum wall. Hormonal therapy was started on August 3. It effectively resolved the rectal stricture, and serum PSA level significantly decreased to be 5.19 ng/ml on September 4. No recurrence of stricture has occurred in the rectum and the serum PSA level has been kept within the normal range for a year after the treatment.

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A 34-year-old woman felt lumbago in October, 2004. A retroperitoneal-mass was pointed out in US study. Abdominal CT scan showed a 27×26mm cystic mass with fat density in abdominal side of the aortic bifurcation. Abdominal angiography showed an avascular mass. Abdominal MRI revealed a 34×28mm demarcated tumor in the mesenterium. This tumor has a surrounding cupsule, which was filled with fat componenent containing high signal of both T1 and T2 in MRI. It was diagnosed as a mesentric teratoma in the pre-operative image. Laparotomic excision of the tumor was performad. Pathological Diagnosis was benign mesenteric cystic teratoma.
Teratoma occurs from the digestive tract including the mesentery is very rare. Preoperative differential diagnosis between benign and malignant is very difficult. Total-excision of the tumor produces good prognosis. Surgical exision should be the first treatment option for the mesenteric teratoma.

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A 63-year-old woman with abdominal distention lasting for about 2 months was referred to our hospital. Abdominal CT scan showed massive ascites and tumors around the greater omentum. Aspiration cytology of ascites showed agglomeration of atypical cells but no primary tumors. Abnormal findings were not seen in the gastrointestinal tract, ovaries, and uterus. Serum CA125 level was elevated. Omentectomy was performed, when normal bilateral ovaries were seen. Pathological examination showed papillary serous adenocarcinoma with infiltrative growth, and we diagnosed the case as peritoneal papillary serous adenocarcinoma. Chemotherapy with paclitaxel+carboplatin (TJ regimen) was conducted for ovarian cancer postoperatively. Because of tumor growth, resection of the tumor with splenectomy and local resection of the stomach was performed 11 months after the first operation. She died of intestinal obstruction and perforation of the ileum 3 years and one month after the first operation.

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An 80-year-old woman was found to have a palpable abdominal mass at a periodic medical checkup. Computed tomography and magnetic resonance imaging of the abdomen showed a 60-mm soft density mass with irregular surface on the lateral aspect of the hepatic flexure of the colon. Accumulation of fluorodeoxyglucose to this tumor was seen in positron emission tomography. We performed laparotomy and found a tumor adjacent to the serosa of the colon and disseminated nodules in the omentum majus. The intraoperative frozen section diagnosis of this tumor was analogous to serous papillary adenocarcinoma. Thus we conducted right hemicolectomy and omentectomy removing the disseminated nodules. Although the right adnexa seemed macroscopically normal, it was resected because we could not rule out a possibility that it might be the primary focus. Observation of the left adnexa was impossible due to firm adhesion to the sigmoid colon. Macroscopically the tumor was 70 mm × 65 mm in size, whitish, solid and lobulated. Histopathologically the tumor was serous papillary adenocarcinoma, the focus of which was in the adipose tissue of the peritoneum, invading the muscularis propria of the colon. A 5-mm cancer nest was present in the vicinity of the fimbria of fallopian tube of the right adnexa, however, we diagnosed the case as serous papillary adenocarcinoma of the peritoneum considering its size and contiguity.

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A 37-year-old woman was found to have an 18×18×10cm huge monolocular cyst with calcification on the subhepatic space. No definite diagnosis was made preoperatively and retroperitoneal bronchogenic cyst was diagnosed by histological studies of the resected material.
Bronchogenic cyst is a congenital disorder generating from aberration of bronchial primodium to ectopic tissues during embryonal development. It is rare that the disorder occurs in the retroperitoneum, and so the case is reported here, together with some bibliographical comments.

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The patient was a 65-year-old male. An upper abdominal mass has been noted at a health check. A tumor of approximately 19 cm was observed in the left upper abdomen by CT and MRI. Internally it mostly showed the density of adipose tissue, with some parts having calcified components or soft tissue. The stomach was displaced caudally and to the left by the mass, and the pancreas was displaced caudally and dorsally, but no clear invasive findings were observed. A mature teratoma that developed retroperitoneally from the superior border of the pancreas was diagnosed, and surgery was performed. The mass strongly adhered to the pancreatic body mainly at the superior border of the pancreas in the retroperitoneum, and excision of the caudal portion of the pancreatic body was also considered necessary. Pathological findings showed a mature teratoma without malignant findings. There were no clear invasive findings in the pancreas. The development of a retroperitoneal teratoma in an adult male is very rare. Looking at past reports, cases with difficulty in detachment are not rare in the mature type, and there has also been difficulty in differentiating benign and malignant masses, so preoperative preparations should be done with consideration of the incision of nearby organs as well.

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A 45-year-old man developed scrotal swelling and pain. On abdominal CT, a 20-cm-diameter tumor located in the left lateral region was found. A provisional diagnosis of gastrointestinal stromal tumor or retroperitoneal tumor was made, and the patient had surgery. During surgery, an agglomeration tumor, 22×14 cm in size, involving the sigmoid colon, and a number of white nodes suspected of being peritoneal dissemination were found. The tumor in volving the sigmoid colon was extirpated. On cross-section, the tumor was pale yellow in color, septate, and lobulated. On pathology, a final diagnosis of retroperitoneal myxofibrosarcoma with necrosis infiltrating the sigmoid colon was made. The patients scrotal pain went into remission, and he was discharged from our hospital on post operative 8 day. The patient had two courses of palliative chemotherapy consisting of ifosfamid and doxorubicin, but died as a result of local recurrence and peritonitis carcinomatosa 19 months after surgery. The majority of myxofibrosarcomas arise in the limbs and trunk. We report a rare case of myxofibrosarcoma that originated in the retroperitoneum.

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