The circumstances in which female surgeons are involved are hard for them, and there are few child rearing female surgeons who work at hospitals providing emergency care on a full-time basis. However, the female ratio occupying new graduates from medical schools has been increasing year by year. It is urgently necessary for the surgical field to take some measures. In the Osaka Kosei-Nenkin hospital, a child rearing support system has been introduced in 2004. Thereafter the maternity leave and child-care leave have been established, overtime work for them has been considered, and various supports such as in-hospital day nursery dealing with both healthy and diseased children have been prepared. Since 2005 we have tackled the introduction of the work-life balance and environmental conditions have been improving in the entire workplaces. I started to work as a surgeon in July 2007 when my child became one year old and about one and a half years have elapsed up to now.
From my experience, I think that, in order to make the most of female surgeon's abilities, environmental improvement would be needed in the entire surgery involving male surgeons. And the reformation that answers the needs and backgrounds of the times, such as introduction of medical team system based on the work-life balance, would be mandatory.

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The necessity for additional surgical resection after endoscopic resection of colorectal submucosal invasive cancers is assessed according to the guideline for colorectal cancer treatment (guideline). We enrolled consecutive 101 patients with colorectal submucosal invasive cancer who underwent surgery with regional lymph node dissection in our institution from 1991 to 2008. Based on their clinicopathological results, we comparatively investigated factors which might affect lymph node metastasis, including histological type, vascular invasion (ly factor and v factor), and the depth of sm invasion between lymph node metastasis positive and negative groups. In the positive group, the ly factor positive rate was significantly higher and the depth of sm invasion was significantly larger than those in the negative group. The histological type and v factor were not significantly correlated with lymph node metastasis. One case from the positive group (n=11) failed to satisfy the requirements for additional surgical resection in the guideline. We must utilize the guideline based on the understanding that the guideline has high-sensitivity and low-specificity properties in predicting lymph node metastasis.

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Tetanus is a fatal infection if appropriate treatment is not started immediately. Case 1 involved an 82-year-old man who was referred to the hospital because of cramp and lockjaw. He was treated as having tetanus because he had an infectious injury of the right crura. Artificial ventilation was performed for two weeks and he was discharged very much improved on the 35^th hospital day. Case 2 involved a 78-year-old man who was seen at the hospital because of pharyngeal pain and dysphagia. He was treated as having tetanus for dyspnea and cramp, though he did not have any injuries. Artificial ventilation was performed for five weeks and he was discharged very much improved on the 60^th hospital day.
We must take into consideration the possibility that dysphagia or nuchal stiffness is a symptom of tetanus. The DPT immunization is effective against tetanus, but its efficacy reduces over about 20 years after vaccination if the toxoid booster shot is not performed. It is important to administer not only toxoid but also immune globulin to trauma patients without tetanus immunization and to administer additional two shots of toxoid later.

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Secondary hyperparathyroidism (2^nd HPT) can occur a long time after parathyroidectomy surgery in hemodialysis patients with chronic renal failure (CRF). We recently treated two such cases. The first was a female (56 years old) who had a parathyroidectomy involving 4 glands with autotransplantation 15 years and 8 months prior. Recently, she developed a 2^nd HPT relapse ; mediastinal supranumerary parathyroid swelling was noted. Thus, 2 parathyroid glands located in the mediastinal cavity were resected. The second case was a male (53 years old) who had a parathyroidectomy involving 4 glands with autotransplantation 10 years and 5 months prior. Recently, he developed a 2^nd HPT relapse. One swollen parathyroid gland was resected from the mediastinal cavity. After surgery, serum parathyroid hormone levels became normal in both patients.

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The patient was a 78-year-old woman who had undergone radical mastectomy for left breast cancer, followed by irradiation to the chest wall about 40 years eariler. In the fall of 2006, small purpura appeared around the surgical scar in the left chest. Because it had spread on the chest gradually, she was seen at this hospital on August 28, 2007, when a purple red brownish induration 7.5×3.5 cm in diameter was noted on the left chest. A biopsy gave the histopathological diagnosis of angiosarcoma. According to her clear intention, no therapies have done and thus the tumor has spread over the entire left chest. But she is doing well over two years since she had noticed the purpura without any therapies.
Postirradiation cutaneous angiosarcema is rare, but carries very poor prognosis. In Japan, the number of patients with breast cancer is increasing rapidly, and the number of patients with postirradiation cutaneous angiosarcoma after breast cancer treatment will increase. Surgeons must inform the patients about the possibility that irradiation can cause cutaneous angiosarcoma, and must strictly follow the post-irradiation patients.

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This paper deals with a 57-year-old woman who was found having a right breast tumor during exploration for carcinoma of the uterine body. CT revealed synchronous multiple hepatic metastases as well. The patient was referred to our department and underwent right partial mastectomy. Histopathological studies showed that the tumor cells were large with prominent atypical nuclei, and immunohistochemically neuroendocrine markers were positive. Thus large cell neuroendocrine carcinoma (LCNEC) was diagnosed. The liver metastases were initially considered to be derived from carcinoma of the uterine body, however, total hysterectomy and bilateral adnexectomy for uterine body carcinoma disclosed that the disease was in postoperative clinical stage Ib. Accordingly hepatic metastases were considered to be due to breast LCNEC rather than due to uterine body carcinoma. The patient received chemotherapy at our department, but died about 10 months after the mastectomy.
Few cases of breast LCNEC have been reported in this country, so that we have to accumulate clinical cases to evaluate the therapeutic outcomes and prognosis.

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The patient was a 78-year-old male who had noticed a tumor at his left breast, but had let it alone for 18 months without any treatments. The tumor had rapidly grown during 3 months before the first visit to us. We suspected a phyllodes tumor and then performed left modified radical mastectomy. The histopathological diagnosis was mucinous carcinoma. One week later, we performed additional left axillary lymph node dissection together with radical operation for right inguinal hernia. Pathological examination revealed no lymph node metastasis. Male breast cancer, especially rapidly growing mucinous cancer, is rare. The rapid growth seems to be related to mucin production by tumor cells. One and a half years had passed since he awared of the tumor. The prognosis is considered to be relatively good, because mucinous carcinoma is well-demarcated and has less vascular invasion. However, careful follow-up observation as well as appropriate adjuvant therapy should be considered.

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We report a rare case of male Pagetoid carcinoma presenting with redness and erosion of the right nipple. A 78-year-old man was admitted due to redness and erosion of the right nipple. A 20 × 17 mm, hard tumor was felt in the EC area of the right breast. The possibility of malignancy could not be ruled out based on ultrasonography and aspiration biopsy cytology results. On histology of a core needle biopsy, invasive ductal carcinoma was diagnosed. Therefore, the patient had a mastectomy with lymph node dissection of the axillary region. A final histopathological diagnosis of a solid-tubular carcinoma infiltrating into the subcutaneous tissue at the nipple was made. Lymph node metastases were not found ; estrogen and progesterone receptors were positive. Therefore, the patient received adjuvant endocrine treatment. Pagetoid carcinoma of the breast presents with redness and erosion of the nipple due to the presence of invasive ductal carcinoma.

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The patient was a 71-year-old woman who had undergone core needle biopsy (CNB) followed by breast conservative surgery and sentinel lymph node biopsy for her right breast cancer in March 2008. Six months later, during the hormone therapy, a hard mass of 29mm in diameter was noticed in the skin close to the surgical scar. It was considered to be solitary and local recurrence caused by needle tract seeding following CNB (16G needle). The recurrent lesion was resected under general anesthesia in November 2008. The lesion histopathologically resembled the primary tumor without ductal component nor vascular infiltration. Some large phagocytic cells which suggested the needle tract were seen near the recurrent lesion.

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We report a case of a 62-year-old woman who had undergone standard radical mastectomy followed by adjuvant chemotherapy for left breast cancer with invasion into the skin and pectoral muscle and atillary lymph node metasis at the age of 35. She was seen at the hospital because of a 6-month history of productive cough. Chest CT scan revealed a mass 5 cm in diameter in the anterior mediastinum. FDG-PET showed accumulation of FDG in this mass and the sternum. Needle biopsy guided by CT for both areas gave pathological findings showing recurrence of breast cancer. ER was 1+, PR was-, and Her2 was1+. We performed radiation therapy for the both lesions at a dose of 60 Gy. The sizes of these lesions decreased even on a follow-up chest CT scan taken 12 months after the radiation therapy. But at that time bone metastases in the left scapula and the right rib newly appeared. Chemotherapy was thus started.

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The patient was a 31-year-old man with a 130×65 mm mass located in the anterior mediastinum. Preoperative percutaneous needle biopsy of this mass under computed tomography revealed mediastinal seminoma ; chemotheraphy was given. After chemotherapy, the mass was smaller ; the residual mass was 30×15 mm. F-¹⁸fluorodeoxyglucose positron emission tomography (FDG-PET) showed accumulation in the mass. Therefore, the mass was resected. The resected lesion's microscopic findings included many macrophages but no tumor cells.

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We report on the surgical management of radiation-induced intractable pericardial effusion. A 74-year-old man received chemoradiotherapy for esophageal carcinoma located in the middle thorax. After treatment, a complete response was noted. Seven months later, he developed a pericardial effusion, which required repeated percutaneous drainage. Due to the presence of adhesions, percutaneous drainage was difficult. Therefore, the patient had pericardial fenestration and greater omentum insertion into the pericardium. On pathology fibrosis and inflammatory cell infiltration but no malignant cells were found in the resected pericardium. The patient has been followed for 2 years and 6 months ; there has been no esophageal cancer or pericardial effusion recurrence. Pericardial fenestration and greater omentum insertion are effective for treating intractable pericardial effusion.

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We report a case of solitary fibrous tumor of the pleura accidentally discovered during rectal cancer pre-operative examinations. A 41-year-old woman was admitted due to rectal cancer and a solid mass in the right thoracic cavity. CT scan and MR imaging revealed a solid mass on the diaphragm. She was diagnosed as having SFT based on needle biopsy results. First she had surgery for SFT and then surgery for rectal cancer. She has been followed up for 6 years and 7 months and there is no evidence of recurrence. We treated this rare case of SFT of the pleura in a patient with advanced rectal cancer by doing two operations. The sequence of Surgery in such patients should be carefully chosen.

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We report a case of an esophageal hiatus hernia complicated by a gastric volvulus, which was successfully treated during laparoscopic surgery. A 79-year-old woman developed epigastralgia. Esophagogastrography and the barium enema revealed an organoaxial volvulus of the stomach and an incarcerated transverse colon. The patient's abdominal pain was so severe that she could not eat or work. Thus, a radical laparoscopic operation was done. The operation involved repair of the hiatus hernia using a polytetrafluoroethylene mesh and a Toupet fundoplication. One year after surgery the patient's condition is good, and the has been no recurrence of the hiatus hernia. This approach can be considered to be safe and effective for preventing the recurrence of a large hiatus hernia.

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Gastrointestinal stromal tumor (GIST) of the esophagus is a rare entity and accounts for less than 2% of all gastrointestinal GISTs. We present four cases of esophageal GIST.
Patient 1 was a 69-year-old man who underwent resection of the middle and lower esophagus with reconstruction using a stomach tube via posterior mediastinal route for a submucosal tumor of the esophagus which had been detected 3 years before admission and increased to 7cm in diameter. Hepatic metastasis occurred 3 years 3 months after the operation and then oral administration of imanitinib mesylate was started. The patient has been alive without recurrence.
Patient 2 was a 76-year-old woman who underwent subtotal excision of thoracic esophagus with esophageal reconstruction using a stomach tube via retro-sternal route for a submucosal tumor 5cm in diameter at the lower esophagus and swollen superior mediastinal lymph node. The patient has been doing well as of 27 months after the operation.
Patient 3 was a 52-year-old man who underwent thoracoscopic-assisted enucleation of a submucosal tumor of the esophagus 3cm in diameter which was detected by a medical check-up. The patient has been doing well as of 23 months after the operation.
Patient 4 was a 53-year-old man who underwent resection of the middle and lower esophagus with reconstruction using a stomach tube via posterior mediastinal route for a submucosal tumor 7cm in diameter at the lower esophagus. The patient has been doing well as of 8 months after the operation.
In all four patients, the tumors showed CD34(+), c-Kit(+), α-SMA(-) and S100(-). They were thus diagnosed as GIST in the narrow sense and were classified into the high risk group.

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An 81-year-old man had a distal gastrectomy for gastric cancer. He developed food passage problems after the operation and received conservative treatment. Fifty-two days after surgery, unusual bleeding-a subcutaneous hemorrhage-was noted. Further examinations revealed a marked prolongation of APTT, very low factor VIII activity, and a high factor VIII inhibitor level. He was diagnosed as having acquired hemophilia. The patient was first treated with activated prothrombin complex concentrate and then prednisolone ; subsequently cyclophosphamide therapy was started. With treatment, the patient's condition improved gradually. However, he died due to sudden hematemesis and aspiration. Acquired hemophilia is a rare disease, which is sometimes associated with the presence of a malignancy. When unusual bleeding occurs after surgery for a malignant disease, acquired hemophilia should be considered.

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The patient was a 79-year-old woman who underwent surgery for bilateral invasive lobular carcinoma. Preoperatively, gastric wall thickening and mild enhancement were observed on abdominal CT, but no abnormalities were found on gastroscopy. After surgery, tumor marker levels increased and gastric wall thickening became more severe on abdominal CT. Based on the third gastroscopy, the patient was diagnosed with gastroduodenal metastasis of breast cancer and was given chemotherapy using paclitaxel. However, due to onset of symptoms of pyloric stenosis, gastrojejunostomy was performed. At 11 months after the procedure, the patient's general status has shown a tendency to exacerbate, with onset of peritoneal metastasis as well as obstructive jaundice.
We herein report out experience with a case of gastroduodenal metastasis of breast cancer that was difficult to diagnose on gastroscopy.

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A 51-year-old man was admitted due to general fatigue, melena, body weight loss, and jaundice. Abdominal imaging revealed dilatation of the bile duct, and, on endoscopic examination, an ulcerative tumor of the duodenal papilla was found. Pylorus-preserving pancreatoduodenectomy was performed. A 68-year-old man with situs inversus totalis developed epigastralgia. Bile duct dilatation was noted, and a tumor of the duodenal papilla was diagnosed. Pancreatoduodenectomy was performed. The first case had squamous cell carcinoma, and the second case had adenosquamous carcinoma. Both cases died of liver metastasis and peritonitis carcinomatosa ; the first case died eight months after surgery, and the second case died ten months after surgery.

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A 66-year-old man suddenly developed lower abdominal pain. His body temperature was 35.4°C. The abdominal pain was intermittent and he had mild abdominal tenderness. Slight rebound tenderness was detected in the lower abdominal area. On history, it was found that he had let his 2-year-old grandchild jump up and down on his abdomen two hours before the onset of symptoms. The next day, his body temperature was 38.7°C, and rebound tenderness was detected throughout the abdomen. On CT, no obvious free air was identified, but ascites was confirmed in Douglas's pouch. An emergent operation under a diagnosis of generalized peritonitis due to bowel perforation was performed. During surgery, muddy ascites and a 3-mm perforation of the ileum were found. The patient had a partial resection of ileum and peritoneal lavage. His postoperative course was good, and he left the hospital on the twelfth post-operative day. The patient's traumatic bowel perforation was the result of his 2-year-old grandson jumping on his abdomen.

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Idiopathic intussusception is very common in children. However, it is very rare in adults, even in young adults. We report a 15-year-old boy who had acute right lower quadrant pain. Computed tomography showed the pseudokidney sign. Therefore intussusception was diagnosed. Laparoscopic surgery was done. An ileo-colic type of intussusceptions was seen, and the laparoscopic reduction was successful. The patient's clinical course was fine, and he was discharged on the sixth day after surgery. Three months after the operation, on colonoscopy no lesions or malignancy was found. Thus, idiopathic intussusception was diagnosed. Successful laparoscopic reduction of adult idiopathic intussusceptions cases is very rare. In the paper we examine the relevant literature and report our case.

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A 54-year-old man developed abdominal pain and vomiting. Abdominal X-rays showed that the greater part of the large intestine was on the right side of the abdomen. Abdominal CT revealed that the superior mesenteric vein was located to the left of the superior mesenteric artery, and a whirl-like pattern was noted. An emergency laparotomy was done. The proximal portion of the jejunum was twisted clockwise 540° ; the volvulus was removed. After releasing the rotation, we formed the ligament of Treitz and performed the Ladd operation, and then fixed the cecum and the ascending colon to the posterior abdominal wall. In most cases, intestinal malrotation is diagnosed in the neonatal period within a week after birth. Never the less, it is indispensable, even after the neonatal period, to suspect malrotation and to perform appropriate examinations in patients with persistent abdominal pain and vomiting.

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We report two cases of intractable entero-cutaneous fistulas successfully treated by the local cutaneous flap method. As for operative procedures in these cases, skin incision was made around the fistula under general anesthesia. Debridement of the scarred tissues was done. The fistula was closed tightly with the cutaneous tissues around the fistula by 3-0 absorbable interrupted sutures. This skin defect was covered with a cutaneous flap. Patient 1 had undergone chemotherapy and radiation therapy at 40Gy after an operation for seminoma of the testis 10 years before admission. Recently, an entero-cutaneous fistula induced by radiation therapy appeared at the surgical scar. The local cutaneous flap method was performed. Oral intake was started 3 weeks after this method. Patient 2 had undergone subtotal colectomy with ileostomy for toxic amebic colitis. An intractable entero-cutaneous fistula was formed after the second operation done for peritonitis due to small intestinal perforation 9 days after the first operation. The fistula could not be cured with conservative therapy for 11 months. The local cutaneous flap method was thus performed. Although leakage of intestinal juice occurred 3 weeks after the method, the fistula was cured 3 months after this method. It is considered that the method should be tried for intractable entero-cutaneous fistula.

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A 58-year-old male patient visited our hospital with a chief complaint of lower right abdominal pain. Abdominal multidetector-row computed tomography (MDCT) revealed multiple diverticula in the appendix, an enlargement of the distal portion of the appendix, and an increase in the surrounding fat concentration. The patient was diagnosed with appendiceal diverticulits based on the findings, including an enlargement of the peridiverticular area at the distal portion of the appendix and an increase in fat concentration. A laparoscopic appendicectomy was performed. Appendiceal diverticulitis was also determined histopathologically. Appendiceal diverticulitis is reported to be associated with a high perforation rate, and to be extremely difficult to preoperatively diagnose. Since we experienced a case with appendiceal diverticulitis, which was diagnosed preoperatively by MDCT examination and treated via laparoscopic appendicectomy, we report on this case together with a review of the literature.

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We report two cases of acute appendicitis associated with adult intestinal malrotation. Case 1 : A 54-year-old woman was admitted because of lower abdominal pain. An intra-abdominal abscess due to perforation of the digestive tract was diagnosed based on abdominal computed tomography results. An emergency laparotomy was done. Acute appendicitis with intestinal malrotation was diagnosed since the ascending colon ran from the median to the left upper quadrant. Case 2 : A 24-year-old man was admitted due to right lower quadrant pain. Acute appendicitis associated with adult intestinal malrotation was diagnosed based on abdominal computed tomography results and upper gastrointestinal radiographic contrast studies. The patient underwent an emergency laparoscopic appendectomy. Cases of intestinal malrotation are usually diagnosed during the neonatal period due to the onset of duodenal obstruction ; surgery is done at that time. Thus, there are few adult cases. Almost all adult cases are found during laparotomy done for other reasons, and few are identified preoperatively. Diagnosing acute appendicitis associated with intestinal malrotation is often difficult due to the various locations of the appendix. Thus, it may become necessary to expand the operative incision in many cases.

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We report a case of a perianal abscess due to a fish bone in an aged patient with a previous history of gastrectomy.
An 84-year-old man was seen at the hospital because of an about one-month history of anal pain which became worse gradually. An abdominal CT scan showed a linear shadow on the left side of the periphery of the anal canal. The patient was thus diagnosed as having an abscess caused by an aberrant fish bone, and was admitted to the hospital for the purpose of localizing the inflammation and removing the foreign body. Incision of the perianal reddened skin failed to remove the fish bone, and then drainage and administration of antibiotics were started. Thereafter the fish bone moved backward and it was barely removed on the 20^th hospital day, with a resultant cure of the abscess.
The decreased acidity of gastric juice is considered as one of factors that are apt to induce gastrointestinal perforation due to a fish bone, so that its possibility should be emphasized in daily lives, especially for patients after gastrectomy.

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We present a case of multiple, laterally spreading tumors (LST) of the colon, including 3 cancers with invasion to the submucosa (sm) and 6 mucosal cancers treated by laparoscopic-assisted subtotal colectomy. A 54-year-old female was referred for multiple colon polyps. Colonoscopy showed 7 granular type LSTs (LST-G) and 8 pedunculated or polypoid-shaped polyps which consisted of numerous nodules and were similar to LST-G ; their diameters varied between 10 and 40 mm, and they were located from between the ascending colon to the sigmoid colon. Histologically, two of the eight polyps removed by endoscopic mucosal resection proved to have submucosal invasion. The remaining LSTs could have been invasive cancers. Therefore, a laparoscopic-assisted subtotal colectomy was performed. The specimen showed 3 lesions invading the submucosa and 6 lesions limited to the mucosa. The patient had an uneventful postoperative course. Two years after the operation the patient is currently well with no evidence of recurrence ; she has 1-2 normal bowel movements per day.

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We herein report two cases of laparoscopy-assisted resection of intestinal lipoma associated with invagination.
Case 1 : An 87-year-old woman was admitted to our hospital because of severe abdominal pain. Physical examination revealed a fist-sized tumor in her right lower quadrant of abdomen. Abdomino-pelvic CT scan showed a large tumor with fat density within it and ring-enhanced intestinal wall resembling a “target sign”. Colonoscopy revealed a yellowish, submucosal tumor with a smooth surface in the ascending colon. Lipoma of the ascending colon associated with invagination was diagnosed and, laparoscopy-assisted ileocecal resection was performed. Case 2 : A 58-year-old woman, with a history of breast cancer, was found to have an intra-abdominal tumor with target sign by a follow-up CT scan. Colonoscopy revealed an egg-shaped tumor in the terminal ileum which moved easily into the ascending colon. Ileal lipoma with asymptomatic invagination was diagnosed and, laparoscopy-assisted ileocecal resection was performed. Their post-operative courses were uneventful and the patients were discharged at 10th and 8th day after the operation, respectively. Laparoscopic surgery is minimally invasive, offers cosmetic benefits, and can be used in the treatment of benign as well as malignant diseases.

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A 61-year-old man was admitted due to intermittent abdominal pain of two months duration which became continuous the day before admission. Abdominal CT scan showed circumferential wall thickening of the transverse colon, distention of the colon oral from the thickened site, and the cecum in the center of the lower abdomen. Transverse colon cancer, bowel obstruction, and intestinal malrotation were diagnosed. We conducted a right hemicolectomy with a lymph node dissection. Ladd's ligament and a normal Treitz's ligament were found ; the patient's cecum was in the center of his abdomen. Therefore, he had a malrotation type of intestinal rotation. In Japan, 51 cases of colon cancer with intestinal malrotation have been reported to date ; we review these cases and report our case with transverse colon cancer as well as intestinal malrotation.

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There is no standard laparoscopic operation for synchronous, multiple, colorectal cancers. This report describes the use of laparoscopic surgery in a case of synchronous transverse colon and rectal cancers. A man in his 60's had hematochezia. Investigations revealed transverse colon (T1N0M0, c-stage I) and rectal (T2N0M0, c-stage II) cancers. A mini-laparotomy was initially done for lymph node dissection and vessel ligation. Then, the large intestine was mobilized during laparoscopy. An 8-centimeter-long midline incision was made about the level of the umbilicus. The left branch of the middle colic vessels was tied, and the middle colic lymph nodes were dissected. The transverse colon cancer was removed during the mini-laparotomy. Subsequently, the inferior mesenteric lymph nodes were dissected while preserving the left colic artery, then, the superior rectal artery was tied. Next, the rectum was mobilized via the hand-assisted laparoscopic surgery (HALS) procedure. The rectum was excised using a conventional stapling device (ACCESS 55^TM) during the mini-laparotmy. Anastomosis with a circular stapler was performed under pneumoperitoneum using the HALS procedure. Curative, combined, laparoscopic-assisted colorectal surgery and laparotomy can be performed for synchronous colorectal cancer. This approuch may decrease complications.

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We report a case of rectal cancer presented with liver abscess.
A 66-year-old man was seen at the hospital because of high fever and vomiting. Hematological studies showed a high degree of inflammation, increases in hepatobiliary enzymes and anemia. An abdominal ultrasonography and an abdominal CT scan revealed multiple low density areas principally in the lateral segment of the liver. Multiple liver abscesses were diagnosed and administration of antibiotics and percutaneous transhepatic drainage were performed. Lower gastrointestinal exploration to identify the origin disclosed a type 1 tumor in the rectum. A biopsy resulted in moderately differentiated adenocarcinoma. Low anterior resection of the rectum and lateral segmentectomy of the liver were carried out. The histopathological diagnosis of the primary lesion was tub2, ss, ly1, v0 and stage II. No metastatic lesions were found in the liver. It was etiologically inferred that infection from rectal cancer through the portal vein might cause the hepatic abscesses.
We thus consider that, in the diagnosis and treatment of hepatic abscess, lower gastrointestinal exploration would be required by keeping a possibility of colorectal malignancy in mind as a causative disease.

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A 64-year-old woman was seen at the hospital because of skin itching and general fatigue. The T. bilirubin level was as high as 15.1, showing severe jaundice. An abdominal CT scan revealed dilatation of the intrahepatic bile duct and an 8cm-sized cyst in the liver S4. ERCP and enhanced PTCD showed gradually oppressing pressure and narrowing from the bilateral hepatic ducts to the common hepatic duct. The serum CA19-9 level was remarkably elevated to 20,600U/ml, but benign simple hepatic cyst was diagnosed based on imaging findings. Puncture of the cyst with drainage followed by infusion therapy with minocycline hydrochloride resulted in shrinkage of the cyst and remission of jaundice. No particular complications and adverse side effects were noted. The patient was discharged from the hospital and has been followed in the clinic. It is extremely rare that obstructive jaundice is induced by a benign parasitic huge hepatic cyst. We present a case of obstructive jaundice due to a huge hepatic cyst for which infusion of minocycline hydrochloride was successful.

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We report a case of a gallbladder polyp and gallstone complicated by a communicating accessory bile duct. A 59-year-old woman, who had been diagnosed as having a gallbladder polyp and a gallstone a few years previously, was referred for surgical treatment. 3D-DIC-CT revealed a low-union hepatic duct and an extra bile duct connected to the left and right hepatic ducts, forming a circuit at the hepatic hilum ; the cystic duct joined the right hepatic duct. Laparoscopic cholecystectomy was performed, and the biliary anomaly was confirmed on intraoperative cholangiography. The patient's postoperative course was uneventful, and she was discharged on the 5th postoperative day. This case had a communicating accessory bile duct, based on the paper by Goor et al. Preoperative 3D-DIC-CT is very useful for visualizing the anatomy of the biliary system so as to prevent intraoperative bile duct injury during laparoscopic cholecystectomy.

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A 75-year-old woman was transferred to our hospital in shock having complained of right upper quadrant (RUQ) pain. On admission, the physical examination showed tenderness and muscle guarding in the RUQ. The white-cell count and C-reactive protein level were 13,480 /μl and 11.9 mg/dl, respectively. Liver function tests were almost in the normal range. On contrast-enhanced multidetector row computed tomography (MDCT), poor enhancement of the thickened gallbladder wall and a twisted pedicle of the gallbladder mesentery, showing a whirl sign, were noted. With a diagnosis of gallbladder torsion, an emergency operation was performed. The gallbladder was found to have rotated around its pedicle 360 degrees in a clockwise direction. Histopathological findings showed transmural necrosis consistent with torsion. MDCT imaging can be useful in making a definitive diagnosis of gallbladder torsion.

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The patient was a 59-year-old man admitted due to cholecystolithiasis. After admission, he developed right hypochondrial pain and was diagnosed as having cholecystitis. The patient was given nothing orally ; antibiotics (cefoperazone/sulbactam) were given for 7 days. After 7 days of this conservative therapy, a diagnosis of abnormal prothrombinemia caused by a vitamin K deficiency was made based on the patient's prothrombin time (PT), activated partial thromboplastin time (APTT), and hepaplastin time (HPT). The patient was treated with menatetrenone (K₂) intravenously. Within 1 day, the coagulation disorder improved rapidly and a cholecystectomy could be done. Postoperative PT, APTT, and HPT levels were normal. Hypocoagulability should be considered in patients given who are kept NPO for a long time.

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Xanthogranulomatous cholecystitis (XGC) is a destructive inflammatory disease of the gallbladder, which can rarely involve adjacent organs and mimic advanced gallbladder carcinoma. A 71-year-old man was admitted due to right upper abdominal discomfort and the recent development of jaundice. Ultrasonography and computed tomography showed thickening of the gallbladder wall and a heterogeneous mass with low density areas located in the liver. Endoscopic retrograde cholangiography (ERC) showed normal findings in the common bile duct and cystic duct, but cytology of the bile juice revealed atypical epithelial cells with high-grade dysplasia. Moreover, ¹⁸F-FDG PET imaging showed definite uptake at the gallbladder lesion. Clinical, serological, cytological, and imaging data were highly indicative of gallbladder cancer with invasion of the liver. A central bisegmentectomy of the liver en-bloc with the gallbladder and extrahepatic bile duct resection was performed. Histological examination revealed an XGC with inflammatory tissue invading the liver, with no evidence of malignancy.

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The patient was a 60-year-old man who had been undergoing hemodialysis due to chronic renal failure since 1994 (age at the time, 52 years). In October 2002 (age at the time, 59 years) a gallbladder polyp 8×4 mm in size was detected. As the polyp rapidly increased in size a year later, gallbladder cancer was suspected and laparoscopic cholecystectomy was performed in November 2003 (age at the time, 60 years). The pathological diagnosis of gallbladder cancer was confirmed postoperatively. In February 2004 a metastatic lesion 30×22 mm in size was detected in segment 4a of the liver, and partial hepatectomy was therefore performed. We report our experience with the present patient, who has since been free of relapse for five years and continues to undergo outpatient hemodialysis our hospital.

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We report a case of intrahepatic cholangiocellular carcinoma complicated by a right-sided round ligament. A 67-year-old woman was found to have high CEA and CA19-9 levels. On abdominal CT, a solitary mass, 4.5×3.0 cm, was noted in the left lobe. The umbilical portion was not located in the usual position ; the gallbladder was located beneath a rightward-deviated umbilical portion. CT images obtained during an arterial portogram (CTAP) showed that the portal trunk first gave rise to a branch of the right posterior segment ; the portal trunk ran cranially and gave rise to two branches to the lateral segment. The portal vein formed the umbilical portion and gave rise to branches to the right anterior segment. CT images obtained during drip infusion cholangiography (DIC-CT) revealed marked stenosis of the left hepatic duct. An extended left hepatectomy with a caudate lobe resection was performed. The patient's postoperative course was uneventful, and she was discharged 38 days after the operation. Although right-sided round ligaments are rare, they are often accompanied by portal system anomalies. A detailed preoperative and intraoperative evaluation using diagnostic modalities such as MDCT, angiography, CT, and ultrasonography is important so as to minimize the incidence of postoperative complications.

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An asymptomatic 70-year-old man was found having a tumor in the liver S5 on an abdominal US at a thorough medical checkup. Laboratory tests showed high levels of AFP (2305.2ng/ml) and PIVKA-II (99mAU/ml), but HBV Ag and HCV Ab were negative. Abdominal enhanced CT scan demonstrated a tumor in the liver S5 approximately 6cm in size. The border was contrasted heterogeneously in early phase, and the contrasting effect was protracted in the delayed phase. Cholangiocellular carcinoma was considered as a differential diagnosis based on image evidence, but hepatocellular carcinoma was diagnosed because AFP and PIVKA-II showed high levels. We performed liver S5 subsegmental resection. Histopathological study showed cholangiolocellular carcinoma (CoCC), and the AFP and Hepar-I were positive partly in immunostaining.
CoCC is an extremely rare disease, and there are few cases in which AFP shows hight level preoperatively. Because so far no such an immunohistochemistrical feature as this case showed has been reported, we present it with some bibliographical discussion.

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A 54-year-old woman was diagnosed as having an endocrine tumor in the pancreatic body due to an incidental finding on abdominal CT. Further evaluation revealed hepatic metastases ; caudal to the pancreatic body tumor, the parenchyma and the main pancreatic duct were absent. She was diagnosed as having an endocrine tumor and agenesis of the body and tail of the pancreas. The planned treatment included resection of the pancreatic tumor and hepatic infusion of chemotherapy for the liver metastases.
At surgery, a palpable indurated mass in the pancreatic body was noted. Caudally, thick adipose replacement tissue was found without the presence of pancreatic parenchyma or a main pancreatic duct. The mid-portion of the pancreas was resected ; a pancreatic-enteric reconstruction was not performed. The histopathological diagnosis was a well-differentiated neuroendocrine carcinoma. The caudal aspect of the lesion was almost completely replaced with fatty tissue. Some islets of Langerhans were present, but there were no pancreatic exocrine cells.
Postoperatively, the patient had good pancreatic exocrine function, without glucose intolerance. We present this rare case of a pancreatic endocrine tumor with fatty replacement in the pancreatic body and tail, in which a middle pancreatectomy without a distal pancreatic-enteric reconstruction was performed.

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We report a case of multiple renal cell carcinoma metastases treated via a total pancreatectomy. A 59-year-old woman had a right nephrectomy for renal cell carcinoma 14 years prior. There was no recurrence postoperatively. In April 2008, abdominal CT-scan showed multiple pancreatic tumors with enhancement. These were diagnosed as multiple metastases to the pancreas from the renal cell carcinoma A total pancreatectomy, with lymph node discection (D1) and splenectomy, was performed. After the operation, the patient's blood sugar levels were controled by insulin injections ; she is doing well 10 months after the operation. The surgical treatment of metastatic renal cell carcinoma pancreatic lesions should improve the patient's prognosis.

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In middle-aged women mucinous cystic neoplasm (MCN) of the pancreas can occur in the body or tail of the pancreas. We report a rare case of mucinous cystadenocarcinoma (MCC) located in the head of the pancreas identified in a 77-year-old woman. The patient was admitted due to right subcostal pain and fever. MCN was strongly suspected due to the presence of an encapsulated, multilocular, cystic tumor with a diameter of 11 cm located in the head of the pancreas on CT. Multiple mural nodules were seen on MRI. Thus, MCC was strongly suspected. A subtotal stomach-preserving pancreaticoduodenectomy (D2 lymphadenectomy) was performed. Ovarian-type stroma and non-invasive adenocarcinoma were evident in the resected specimen on pathology. Thus, the final diagnosis was MCC. It is accepted that complete resection of the tumor is necessary to achieve a cure in non-invasive MCC patients. However, what constitutes an adequate lymphadenectomy is still controversial.

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A 54-year-old man, who complained of chest discomfort and was scheduled to undergo surgery with a diagnosis of cancer of the pancreas tail at another hospital, was seen at the hospital for his own request. We recommended surgery with the same diagnosis but he refused it. One month later the patient was seen at the hospital again because of the onset of abdominal pain and desired to receive surgery. His surgery resulted in exploratory laparotomy because he had hepatic metastasis and peritoneal dissemination as well. After discharge, one course of chemotherapy with gemcitabin hydrochloride was completed on an ambulant basis when he developed upper abdominal pain with chill and shiver. An abdominal CT scan showed that most of the tumor became necrotic to form a cavity. Intra-abdominal free air was also noted. It was etiologically considered that a portion of the transverse colon involved in the tumor had come to tumor necrosis resulting from the efficacy of chemotherapy, and then had perforated. In the clinical course, he developed gastrointestinal bleeding and required transverse colectomy and colostomy.
Colorectal perforation developed during chemotherapy with single use of gemcitabin hydrochloride is so rare that only two cases, including our case, have been reported in Japan. Bibliographical comments are also presented here.

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A 34-year-old woman developed pain in the left upper abdomen and flank. On physical examination, a tender 10-cm abdominal mass was found in the left upper quadrant. An abdominal CT scan and ultrasonography revealed a well-defined, solid tumor. Magnetic resonance imaging of the tumor revealed a light hyperintense area on T1-weighted images and a strong hypointense area on T2-weighed images, which suggested the presence of an internal hemorrhage. A contrast-enhanced MD-CT scan revealed hypodensity with only thin peripheral rim enhancement, cyst-shaped findings, and that flow in an artery derived from the splenic artery had suddenly stopped, suggesting torsion of a feeding artery. Explorative laparotomy revealed a bluish congested mass with a 360° twisted pedicle connected to the splenic artery and vein. Torsion of an accessory spleen was diagnosed. An accessory splenectomy was done. The histological findings were consistent with splenic congestion. This condition is difficult to identify preoperatively. However, it can be diagnosed if the relationship between the vessels and circumferential organs can be determined on MD-CT. Accessory spleen infarction with pedicle torsion is very rare, but it should be considered in the differential diagnosis of acute abdomen.

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We report a case of omental torsion secondary to an inguinal hernia. A 53-year-old man was admitted due to right inguinal and lower abdominal pain. He had an incarcerated right inguinal hernia which could not be released.
Abdominal CT scan showed a concentric whorl-like structure which was edematous distally towards the right inguinal hernia. Under a diagnosis of secondary omental torsion associated with an incarcerated right inguinal hernia, emergency surgery was performed. An indirect inguinal hernia was found ; the greater omentum adhered to the hernia sac and was twisted clockwise four times at this location. The distal side of the omentum was necrotic, but the proximal side was not necrotic. The distal side of the necrotic omentum was resected, and a radical repair of the inguinal hernia using a mesh-plug was performed. The patient was discharged from the hospital on the 8th postoperative day. Right abdominal pain possibly due to edema of the residual omentum persisted for three weeks after the operation ; it resolved with conservative therapy.

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(Case 1) A 61-year-old woman developed vomiting and abdominal pain. Abdominal plain radiography and CT scan revealed linear calcification of the right colonic wall ; the barium enema showed absent haustra from the cecum to the transverse colon, at which point the lumen narrowed, and a thumb-printing appearance was observed. A diagnosis of idiopathic mesenteric phlebosclerosis was made. Laparoscope-assisted surgery was performed. She is doing well without recurrence 1 year after surgery. (Case 2) A 72-year-old man with a positive fecal occult blood test had colonoscopy, which demonstrated purple-blue, edematous mucosa from the cecam to the transverse colon ; ulcers were also present. On pathology, fibrotic sclerosis which stained negatively with Congo red was observed in the intramural venous wall. Abdominal multidetector computed tomography revealed a thickened colonic wall and linear calcification along the colonic wall and in the mesenterium. These findings are consistent with idiopathic mesenteric phlebosclerosis. Thus, the patient required no treatment. The patient is being followed and is well.

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We report a case of superior mesenteric vein thrombosis treated with interventional radiology. The patient had abdominal pain and was diagnosed as having superior mesenteric vein thrombosis on enhanced abdominal CT. No signs of peritonitis were noted on physical examination ; on enhanced CT no bowel infarction was noted. Therefore, conservative interventional radiology therapy with the continuous infusion of urokinase, heparin, and PGE1 into the SMA was used. Immediately after the start of therapy the patients clinical manifestations improved. Post treatment enhanced abdominal CT demonstrated that the thrombus that had been located in the superior mesenteric vein was no longer present. The last branch of the ileal vein was well visualized during venous phase angiography. No underlying disease was identified. Therefore, idiopathic superior mesenteric vein thrombosis was diagnosed. The patient has been disease-free for 8 years.

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A case of abdominal actinomycosis is described herein. A 50-year-old man was admitted due to abdominal distension and appetite loss. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a vaguely-delineated mass located in the upper abdominal cavity, which invaded the gall bladder, the anterior surface of the pancreas, and the hepato-duodenal ligament. A tissue biopsy was obtained from the abdominal wall.
A histopathological diagnosis of an inflammatory granuloma caused by Actinomyces israelii was made. The patient was given penicillin for six months.
It is acknowledged that it is difficult to distinguish an abdominal actinomycosis from abdominal invading malignant tumor. Thus, it is important to obtain an adequate biopsy specimen in patients with an abdominal mass impinging on other organs in order to rule out abdominal actinomycosis.

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We present a case of internal herniation of the small bowel through a defect in the broad ligament diagnosed preoperatively and treated under laparoscopy.
A 46-year-old woman was seen at the hospital because of the sudden onset of left lower abdominal pain. An abdominal multi-detector CT scan showed a dilated intestine in the floor of the pelvis, displacement of the uterus slightly toward the right, and a finding suggestive of impaction of the ileum into the left broad ligament. Thus hiatal hernia of the left broad ligament of the uterus was suspected. Laparoscopic-assisted surgery disclosed that an about 15cm portion of the ileum was impacted into an abnormal defect which had developed in the left broad ligament of the uterus. The impacted intestine was pulled out carefully and the abnormal defect was closed by sutures under laparoscopy. No ischemic change was seen in the impacted intestine and the operation was completed without performing intestinal resection. The patient's postoperative course was uneventful and she was discharged from the hospital on the 5^th postoperative day. No recurrence has occurred as of 7 months after the operation.
Internal hernia of the small intestine through a defect in the broad ligament of uterus can be diagnosed preoperatively based on typical imaging findings. The disease should be kept in mind as a possible diagnosis in female patients with ileus of unknown origin.

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The patient was a 69-year-old woman who had sustained injuries to the transverse colon, mesentery of the transverse colon, and the pancreas, rib fracture, and pulmonary contusion at a traffic accident in July 2008. She was servived by partial resection of the transverse colon, irrigation and drainage. In 6 months later following the injuries, she was checked at the hospital because she noticed a bulging in the left lateral abdomen. An abdominal CT scan revealed rupture of the lateral abdominal muscle and herniation of the intestine into subcutaneous space. Accordingly traumatic abdominal wall hernia was diagnosed.
Traumatic abdominal wall hernia is a hernia resulting from muscular injuries due to direct or indirect force to the abdominal wall. Although the disease is believed to occur immediately after injury, our study on our case as well as domestic cases has disclosed that there are many delayed cases. When we encounter patients with an abdominal bulging with a previous history of trauma, the disease must be kept in mind as a probable differential diagnosis.

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A 64-year-old woman, who had been diagnosed as having Ehlers-Danlos syndrome half a year prior, developed vomiting. She was found to have a hernia orifice, 5×7 cm in size, located at the lower end of a midline upper abdominal incision. She was diagnosed as having an incisional abdominal hernia containing contents of the small intestine. A hernioplasty using Composix Mesh^® was dune because the tissue around the hernia was too fragile to suture directly ; the clinical outcome was successful. Ehlers-Danlos syndrome is rare. The surgical management of Ehlers-Danlos syndrome is difficult because of tissue fragility. Composix Mesh^® is useful when doing a hernioplasty for an incisional abdominal hernia in patients with Ehlers-Danlos syndrome.

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