This study included 89 patients with GIST who had a resection between January 1991 and March 2009. The clinicopathological features of the 62 cases with gastric tumors and the 27 cases with small intestinal tumors were compared. The following 11 factors were examined : clinical symptoms, sex, age, tumor size, presence of ulcer, growth pattern, mitotic index, risk classification, tumor metastasis, concomitant neoplasm, and recurrence-free survival. There were no differences between gastric GIST and small intestinal GIST patients in any of the factors except clinical symptoms. During follow up, (median 30.5 months) 20 patients had a recurrence and 19 patients had a concomitant neoplasm. The overall recurrence-free survival was 73.1% at 5 years and 64.3% at 10 years. The 10-year recurrence-free survival for gastric GIST patients was 69.7% and it was 52.1% for small intestine GIST patients. The prognosis of small intestinal GIST patients was not significantly lower compared to gastric GIST patients (p=0.167). Univariate analysis of the clinicopathological factors showed that recurrence-free survival was significantly correlated with tumor size and mitotic index. Multivariate analysis using a Cox proportional hazards model identified tumor size (>50 mm) and mitotic index (>6) as significant independent risk factors for recurrence-free survival.

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Purpose : The aim of the study was to analyse retrospectively short-term outcomes of laparoscopic surgery (LAC) as well as to clarify indications of LAC. Subjects and method : We enrolled a series of 106 patients who underwent LAC for T1 and T2 nonmetastatic colon cancer in the institute from August 1999 to December 2006. The accuracy of the preoperative diagnosis for the indication and clinical outcomes of LAC were evaluated. The median follow-up period was 63 months (range, 1-108 months). Results : Tumor depth of pSS was noted in 15 out of these 106 patients, and thus 91 (about 86%) patients were possible candidates for surgery. Namely the accuracy of the depth of invasion was approximately 86% in T1 and T2 cancers. Lymph nodes were involved in 17 patients and the remaining 89 patients could be indicated surgery. Of the 15 pSS patients, lymph node metastasis was detected in nine patients. Recurrence was noted in two stage I patients, one stage II patient, and two stage III patients, who showed hematogenic metastatic pattern. Positive predictive value of the lymph node metastais was approximately 83%. Three-year disease free survival after surgery was noted in 89.5% of the subjects. There were no serious perioperative complications and in-hospital mortality in our series. Conclusion : Short-term outcomes revealed that LAC could be performed safely and provided good results for T1 and T2 colon cancer patients in our institute.

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Most surgeons conventionally skirt the umbilicus during a midline abdominal incision. But it has been reported that transumbilical incisions are associated with no specific problems and have excellent cosmetic results. Recently, results of transumbilical single incision laparoscopic surgery (SILS) and transumbilical breast augmentation (TUBA) have been reported. We started using the transumbilical incision technique during laparoscopic surgery and midline abdominal incisions since Feb, 2007. Using the technique, the surgeon places absorbed continuous or interrupted sutures just above and just below the bottom of the umbilicus. The skin sutures are not required in the umbilicus. We have not encountered any problems or any specific complications related to this technique. This technique offers excellent cosmetic benefits in straight or shorter incision lines. The linea alba is easily identified in the umbilicus in the cases requiring lower midline incisions. Conclusion : The transumbilical midline abdominal incision should be the incision of choice.

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Background : Recently tension-free repair of abdominal incisional hernia using Composix Kugel Patch^® has spread widely. Some articles about the effectiveness of this surgical technique have been reported, but there have been few about the complications. We report our short term results including postoperative complications of surgical repair of abdominal incisional hernia using Composix Kugel Patch^®.
Subjects and methods : Subjects were consecutive 31 patients with abdominal incisional hernia undergone this procedure in our hospital for over 4 years. We investigated their characteristics, clinical outcomes, postoperative complications, and recurrence of hernia.
Results : Postoperative morbidity rate was 9.7% (3 out of 31 patients). Two patients (6.5%) developed mesh infection that necessitated removal of the prosthesis. The remaining patient (3.2%) developed prolonged subcutaneous seroma that necessitated puncture drainage. These three patients were extremely obese with body mass indexes of more than 30 kg/m². Two patients (6.5%) had recurrence of hernia.
Conclusion : The abdominal incisional hernia repair using Composix Kugel Patch^® is a simple and useful procedure, but we have to be careful about complications such as mesh infection, especially in an obese patient.

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A 63-year-old female complaing of a 4cm-sized mass in the upper outer quadrant of the right mammary gland was referred to our department for close exploration. Mammography showed a distinct mass with spiculation. No definite diagnosis was made by fine-needle aspiration cytology. We chose excisional biopsy at a first step and diagnosed the mass as breast cancer. Finally, we performed modified radical mastectomy with axillary lymph node dissection. Histological examination demonstrated matrix-producing carcinoma (MPC) composed of over carcinoma, a direct transition to cartilaginous matrix without an intervening spindle cell zone or osteoclastic cells. Chemotherapy with AC for 4 courses and tri-weekly PTX were performed. The patient has been doing well without evidence of recurrence. MPC is a rare entity and carries poor prognosis compared to common breast carcinomas. There are many unclear aspects of MPC including its biological behaviors and effective adjuvant chemotherapies, and hence more effective therapeutic methods which might differ from those for common ones should be established. We present clinical characteristics of reported cases and investigate the problems of MPC.

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Mucinous carcinoma of the breast is classified into a special type, and it is a comparatively rare histologic type accounting for 1-6% of all primary breast cancers. In addition, it is extremely rare that primary breast cancer necessitates an emergency surgery due to bleeding.
A 68-year-old woman had noticed a tumor in the right breast C area since 3 months earlier before visiting a local hospital because of a sudden onset of internal massive hemorrhage of the tumor. She was referred to our hospital on the same day and was admitted with the diagnosis of right breast internal hemorrhage. Because of progressing anemia and decreasing blood platelet despite of administration of a styptic, an emergency operation was needed on the next day. The patient received a right mastectomy with axillary lymph node dissection, because the tumor mass was detected in the cut surface of the hematoma. The pathological diagnosis was micropapillary variant of pure mucinous carcinoma with lymph node metastasis. Postoperative radiotherapy, chemotherapy, and endocrine therapy were performed. The patient has survived without recurrence as of six years after the operation.

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We present a case of left breast cancer after breast-enlargement surgery for the right breast in a female patient who was in the first trimester of pregnancy.
A 43-year-old woman had undergone modified radical mastectomy and tissue expander insertion for right breast cancer 4 years earlier. On the 8^th month after the operation, the second stage reconstruction using an implant and an implant breast-enlargement surgery for the contralateral (left) breast were performed at the same time. Endocrine therapy was started postoperatively but was withdrawn after it was maintained for 2 years, because she wanted to have a baby. Further 2 years later when she was on the 5^th week of gestation, a 6mm-sized tumor of the left breast was detected. First, wide excision of the left breast was performed on the 10^th week of gestation under local anesthesia. The pathological diagnosis was invasive ductal carcinoma, ER (+), PgR (+), HER (-), and negative surgical margin. Second, sentinel lymph node biopsy with RI method alone was performed on the 18^th week of gestation, when metastasis was negative. After she was delivered of a baby on the 38^th week of gestation, the endocrine therapy was resumed.
This case poses a variety of problems from the following points of view : it was early breast cancer detected in the first trimester of pregnancy and it was detected after breast-enlargement surgery.

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A 68-year-old woman had been aware of her poor breast development since she had been struck by a hard ball in the right anterior chest at 9 years old. She was seen at the hospital because local tenderness and deformity of the right breast appeared from 1 year earlier. At that time, an irregularly bordered, indurated mass with nipple truction was palpable in the right breast. Mammography and ultrasound findings suggested a category 4 abnormality and a malignant tumor, respectively. No qualitative diagnosis was made by core-needle biopsy. Since the clinical course and imaging findings could not rule out the possibility of breast cancer, we resected the right breast mass. The border between the mass and the pectoralis major muscle was unclear, and the resection of the mass was performed combined with partial muscle resection. The resected mass measured 7×7×3 cm in diameter. Histopathological examination showed immature fibroblasts growing in various directions, leading to the diagnosis of nodular fasciitis. The main location of the tumor suggested that it had arisen from the pectoralis muscle.
Nodular fasciitis commonly arises from the extremities and rarely from the breast or pectoralis muscle. Compared with previously reported cases, her right breast tumor was characterized by following a long-term clinical course and having great diameters. We report this case because of its uncommon appearance and our difficulties in differentiating from breast cancer.

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A 76-year-old man developed hemoptysis. On chest radiographs, slight ground-glass opacities were noted in the left middle-lower lung field. On bronchoscopy, there was continuous bleeding from a left-sided alveolus. After bronchoscopic hemostasis failed, an emergency operation was performed. A left upper lobectomy was performed. After the operation, the patient continued to have evidence of an increased inflammatory response. Laboratory findings, obtained 7 days post-operatively, included an elevated serum myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) level. On histopathology, a diagnosis of microscopic polyangitis was made. The patient responded to treatment with steroid and plasmapheresis. Microscopic polyangitis is rare, but should be included in the differential diagnosis of hemoptysis.

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The patient was an 18-year-old man who was admitted with a diagnosis of left-sided pneumothorax. Chest CT revealed a large number of bullae in the apical portion of the left lung, and surgery was indicated. During resection by video-assisted thoracoscopic surgery, extralobar sequestration was observed in the mediastinum above the diaphragm. After reviewing the preoperative CT and assessing the feeding vessels of the sequestered lung, the sequestered lung was judged as being resectable, and it was resected in a single stage under troracoscopy following resection of the apical portion. Thoracoscopy enabled a favorable field of view during surgery even at a site located in the inferior mediastinum adjacent to the diaphragm.

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A 30-year-old man who had received drainage for bilateral pneumotharax at another hospital developed dyspnea again and was referred to our hospital. Chest X-ray revealed right reexpansion pulmonary edema (RPE). Before drainage, the right lung showed complete collapse. After intravenous administration of methylprednisolone, his symptom improved. A few days later when his general condition became stable, thoracoscopic operation was performed for peumothorax. The patient's postoperative course was uneventful and he was discharged from the hospital on the 4th postoperative day.
We have encountered RPE after drainage for pneumothorax. It is a situation of pulmonary edema due to accelerated permeability of the vessels. The risk factors include complete collapse and radical drainage. Treatments for the situation are artificial respiration and administration of diaretics and methylprednisolone. But such patient's condition sometimes takes downhill course. Particular attention must be paid to the patient who develops RPE after bilateral pneumothorax, because his condition may take a turn for the worse.

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We report two cases of delayed hemothorax which occurred after blunt chest trauma. In both cases, the hemothorax was caused by a fractured rib edge lacerating the diaphragm. Case 1, A 34-year-old man, who had fallen from a height of 2 m ; a left rib fracture were noted on CT. The patient was admitted for pain control. On the 3rd hospital day, the left hemothorax suddenly deteriorated after the patient defecated ; immediate chest tube drainage was performed. Emergency surgery was required due to continuous bleeding from the chest tube. Case 2, A 66-year-old woman received blunt chest trauma during a traffic accident. She was transported to the critical care medical center and diagnosed as having bilateral multiple rib fractures, pulmonary contusion, hemopneumothorax, and an aortic rupture. Emergency surgery was required due to thoracic aortic rupture that occurred on the same day. On the 4th hospital day, the right chest tube discharge suddenly became bloody ; the hemorrhage continued after the patient's position was changed. Emergency surgery was performed. Active bleeding from a lacerated diaphragm was found. In both cases a fractured rib edge was responsible for the laceration that led to bleeding.

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A woman in her seventies, who had received a total of two dilatations for diagnosis of achalasia, was referred to our surgical department in August 2008 because of recurrence of dysphagia after a temporary symptomatic remission. Esophagoscopic study revealed that her achalasia was of Flask type, Grade II. An abdominal CT scan demonstrated a cystic tumor at the pancreas body and tail. From these findings, achalasia and intraductal papillary mucinous tumor were diagnosed and surgery was scheduled for the patient. However, the patient developed declined myodynamics and dyspnea before surgery, and she was transferred to the department of neurological medicine for the purpose of exploration and treatment. In November 2008, she had the abrupt onset of abdominal pain when an abdominal CT scan showed intra-abdominal free air. Because she presented symptoms of general peritonitis, an emergency operation was performed. During surgery, we confirmed small quantities of ascites, but there was no perforation. Laparotomic drainage and jejunal colostomy were performed. The patient's postoperative course was uneventful and she returned to the department of neurological medicine to resume the exploration for causes of her symptoms. No definite diagnosis has been made up to now and her rehabilitation has been kept at another hospital.
As far as we could review, no case of achalasia associated with spontaneous pneumoperitoneum has been reported, so that this case which is considered very rare is presented with a review of the literature.

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We report a case of gastric MALT (mucosa associated lymphoid tissue) type lymphoma that mimiced a submucosal tumor (SMT) without the presence of definite mucosal lesions. A 28-year-old woman had a gradually enlarging SMT located in the greater curvature side at the corpus of the stomach. Given a clinical diagnosis of gastrointestinal stromal tumor (GIST), a laparoscopic partial gastrectomy was done. On pathology, a MALT type lymphoma was diagnosed ; many lymphoid aggregates composed mainly of medium sized lymphocytes with mild nuclear irregularity were scattered in the gastric wall but not in the mucosa. In the present case, the endoscopic and imaging findings were not suggestive of a MALT type lymphoma. It is important to make the correct diagnosis preoperatively to differentiate GIST from other SMTs, especially atypical MALT type lymphoma since they have different treatment strategies.

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We report a case of gastrointestinal stromal tumor (GIST) of the gastric fornix presented ball valve syndrome.
A 75-year-old man was admitted to our hospital because of bouts of vomiting. Abdominal CT scan revealed a well defined tumor 5 cm in diameter in the duodenal bulb. Upper gastrointestinal endoscopy revealed that a well-defined tumor 5 cm in diameter in the duodenal bulb upper. Gastrointestinal endoscopy revealed that a sessile polypoid lesion was incarcerated into the duodenal bulb from the fornix of stomach, and endoscopic reduction of the impaction was unsuccessful. Surgical resection was thus performed. At surgery, we reduced the impacted tumor into the stomach by hands and comfirmed that the tumor was a sessile submucosal tumor. Partial gastrectomy was performed. Pathologically, the tumor, which measured 5 cm in diameter, was GIST originated from the proper musucular layer and was positive for c-kit and CD34, and negative for smooth muscle action and S-100 protein on immunostainings. The postoperative course was uneventful. He has shown no signs of recurrence up to now.

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A 67-year-old man was followed for diabetes mellitus and angina pectoris. Hypoalbuminemia was found ; March 2007. He was admitted due to the presence of nephrotic syndrome. Abdominal CT showed gastric wall thickening and swelling of multiple lymph nodes. Upper gastrointestinal endoscopy showed two type 2 tumors : one located in the angle and the other in the upper area of the body of the stomach. The pathology of the biopsy specimens showed that one tumor was poorly differentiated / non-differentiated, while the other tumor was well / moderately differentiated. Radiographic examination showed that the tumor, which was about 80 mm, was a type 2 lesion ; it was located at angle. The other tumor located in the upper area of the body was a type 3 lesion. Total gastrectomy and cholecystectomy were performed in August. On histopathology, both tumors were found to be poorly differentiated adenocarcinoma, but the tumor located at the angle contained cells that had differentiated into endocrine cell carcinoma. This tumor was diagnosed as an endocrine cell carcinoma due to positive chromogranin A and CD56 results.

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A 57-year-old woman undergoing extended left hepatectomy was found to have two cystic hepatic tumors ; postoperatively a pathological diagnosis of hepatic metastasis of neuroendocrine carcinoma (NEC) was made. In the preoperative diagnostic workup, no primary lesion was detected ; only three small submucosal gastric tumors (SMTs) were found. The SMTs were less than 20 mm in size and had no ulcerations or mucosal changes. Several biopsies did not yield a pathological diagnosis. An open biopsy of the SMTs showed one to be a primary lesion. Thus, a distal gastrectomy and lymph node dissection were done. The common appearance of NEC is type 2 or 3 which is similar to advanced cancer ; the average size exceeds 60 mm. In this case, the primary lesion was so small that it could not be detected prior to the first operation. Gastric NEC even though small and benign in appearance should be suspected as a primary lesion when encountered in a patient with atypical liver metastasis.

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An internal malignancy metastasizing to the umbilicus is called Sister Mary Joseph's nodule (SMJN), and is a relatively rare prognostic sign. Herein, we report a case of umbilical metastasis of gastric cancer with a literature view.
The present patient was a 76-year-old man who underwent distal gastrectomy following a diagnosis of gastric cancer in April 2007. Although the patient received adjuvant chemotherapy, tumor markers, CEA and CA19-9 increased. Tumor markers then decreased temporarily, but CA19-9 again increased from August 2008. As umbilical metastasis was observed in August 2008 in October 2008 the lesion was resected due to odiferous discharge. Furthermore no other tumors were detected by CT and PET scan. SMJN very rarely occus after resection of early gastric cancer.

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A 37-year-old man developed sudden epigastric pain and vomiting. An abdominal CT scan showed a 6 cm in diameter, homogenous tumor located in the second part of the duodenum. On endoscopy, the gastric folds were found to converge through the pyloric ring. The patient was diagnosed as having a gastroduodenal intussusception caused by a tumor of the stomach ; emergency surgery was done. During surgery, the presence of a gastroduodenal intussusception was confirmed, ; the tumor was repositioned using Hutchinson's maneuver. The submucosal tumor arising from anterior upper gastric wall was removed during the partial gastrectomy. On pathology, the tumor consisted of spindle-shaped cells ; a gastrointestinal stromal tumor CD117- and CD34-positive was diagnosed.

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We report a case of delayed duodenal stenosis after blunt trauma. A 64-year-old man was driving a tractor, when the tractor overturned and he was pinned between the ground and the steering wheel. The patient complained of a slight pain in the upper abdomen. His vital signs were stable. Computed tomography showed a hematoma around the inferior vena cava and the superior mesenteric vein. The patient's clinical course was uneventful until the 8th hospitalization day when he vomited several times ; the radiological examination revealed a duodenal stenosis located in the distal 2^nd and 3^rd portion of the duodenum. Conservative therapy did not improve the stenosis, and a duodenojejunostomy was done on the 30^th hospitalization day. Operative findings included severe stenosis of the duodenum. The disturbed venous return caused by the hematoma located close to the duodenum likely resulted in the duodenal stenosis given the patient's clinical course and operative findings. He was discharged on the 15^th postoperative day. A delayed duodenal stenosis related to blunt trauma usually does not improve with conservative therapy. Thus, early surgical intervention should be considered in such cases.

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Familial adenomatous polyposis (FAP) patients have a tendency to develop multiple neoplasms, such as colon cancer, gastric cancer, duodenal cancer, and desmoid tumor. Some patients require multiple operations. We report a FAP patient with duodenal cancer who previously had had four operations. The 47-year-old man had a prophylactic total colectomy for FAP, a distal gastrectomy for gastric ulcer, and an adhesiotomy and a colostomy due to an ileus. On followup abdominal CT and FDP-PET, a duodenal tumor that was strongly suspected of being malignant was found. On upper gastrointestinal endoscopy, the duodenum could not be reached due to the presence of adhesions and several anastomoses. However, by using Single Ballon Enteroscopy (SBE), the duodenal cancer could be diagnosed. SBE also showed the position of the anastomosis and helped us to perform a radical resection and reconstruction.
Pancreatoduodenectomy was successfully performed using the information obtained using SBE.

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A 76-year-old man with abdominal pain was admitted three months after a right hemi-colectomy for cecal cancer. Radiography of the abdomen revealed a metallic foreign body in the abdominal cavity whose presence was confirmed on computed tomography and abdomenal ultrasonography. Surgical removal of the metallic fragment (total length of 7 cm), which perforated the small intesitinal wall, was performed under the X-ray imaging. It was identified to be a tip of a broken metal stylet. In a previous operation the endotracheal tube had been intubated into the esophagus by mistake during the induction of general anesthesia. The tip broke due to metal fatigue and then slipped into the esophagus. The patient's postoperative course was uneventful, and he was discharged on the 10th postoperative day. The patient has been followed for three and half years since the operation and his condition is good.

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A 26-year-old woman was admitted with severe right lower abdominal pain, muscular guarding, and a high fever. On history, it was not clear whether she had eaten raw fish prior to admission. An emergency operation was done. The operative findings included serous ascites. The ileum adjacent to the terminal ileum was inflamed. The length of the lesion was about 20cm. The ileum containing the lesion was excised. On macroscopic examination, a deep longitudinal ulcer was located at the mesenteric side of the ileum ; the lesion resembled Crohn's disease. On microscopy, evidence of an infestation Anisakis was present ; there were worms in the tunica muscularis propria and mesentery which were surrounded by eosinophilic granulomas and abscess formations. No epithelioid cell granulomas were seen.

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A 67-year-old man, who had a history of adhesiotomy for ileus after cholecystectomy for gallbladder stone and acute cholecystitis, was hospitalized due to the presence of pyrexia and jaundice. Abdominal CT scan and endoscopic retrograde cholangiography showed acute obstructive suppurative cholangitis due to choledocholithiasis. Adhesiotomy, choledocholithotomy, and T-tube drainage were performed via the same surgical incision used in the previous operation. On postoperative day (POD) 5, there was an intestinal fluid discharge from the drain and the surgical wound ; surgery was performed. The small intestine was resected, since a perforation in the injured small intestine was found. On POD 7 after repeat surgery, there was an intestinal fluid discharge from the surgical incision which resulted in refractory enterocutaneous fistula formation. Conservative treatment was ineffective. After direct drainage of the proximal small intestine using a 27Fr urethral balloon catheter was performed the enterocutaneous fistula was successfully closed by primary suturing. If at all possible percutaneous intestinal drainage should be attempted for refractory enterocutaneous fistula.

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A 52-year-old man developed a high fever and abdominal pain. On abdominal CT, an abscess was found. Percutaneous abscess drainage was performed. Water-soluble contrast medium infusion through the catheter showed a small intestine with a cavity. On small intestinal tract examination, a jejunal diverticulum was found. The cavity decreased in size with drainage. However, the patient's high fever and abdominal pain recurred after the patient ate a meal. The patient had surgery. A small intestinal mass located about 10 cm from the Treitz ligament was resected ; a cavity leading to the jejunum was found.

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A 37-year-old female was admitted due to abdominal pain. Abdominal X-rays showed obstruction of the intestinal tract. After decompression of the intestine with a long intestinal tube, enterography showed a mass located at the end of the small intestine. An ileocecal resection was performed. A hard lesion was palpated. On histopathology, intestinal endometriosis was diagnosed. It is difficult to diagnose intestinal endometriosis prior to surgery due to the limitations of endoscopic biopsies and the rarity of this disorder, especially when it affects the small intestine compared to the rectum or the colon. In young women with intestinal obstruction, intestinal endometriosis should be considered in the differential diagnosis.

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The patient was a 58-year-old man who was hospitalized at another institution to treat schizophrenia and had been treated for water intoxication and hyponatremia in our hospital. A chest x-ray film taken at another institution as a periodic examination revealed intra-abdominal free air in the bilateral subdiaphragmatic spaces. The blood pressure was 80/60mmHg and the pulse was 116/min, showing tachycardia. Although he did not complain of spontaneous pain, he was referred to our hospital with a suspicion of gastrointestinal perforation. An abdominal CT scan showed intra-abdominal free air and retention of gas in the entire small intestinal wall. Physical findings indicating peritonitis were absent but a possibility of intestinal perforation could not be ruled out, so that a diagnostic laparotomy was performed. During surgery, intramural emphysema was noted in the entire small intestine, but there was no intestinal perforation. Following irrigation of the peritoneal cavity, the operation was completed. Based on findings of various examinations as well as operation, pneumatosis cystoides intestinalis (PCI) associated with intra-abdominal free air was diagnosed. After the operation he temporarily developed aspiration pneumonia but recovered from it with respiratory management and administration of antibiotics. He was discharged very much improved on the 56^th postoperative day.
PCI associated with intra-abdominal free air in a schizophrenia patient is relatively rare and so far seven such cases, including our case, have been reported in Japan.

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We present a case with a resecTable giant gastrointestinal stromal tumor (GIST) of the jejunum that was hypervascular ; it was fed by three different arteries. A 78-year-old female developed hematochezia. Abdominal computed tomography (CT) showed a large, well-defined mass with a heterogeneous internal density measuring 9 cm in diameter in the pelvic cavity without evidence of other lesions. Double balloon intestinal endoscopy and contrast enema images showed stenosis of the jejunum at the site of the tumor. Angiography revealed tumor staining, fed by three different arteries, including the superior mesenteric artery, the internal pubic artery, and the superior rectal artery. A GIST of the jejunum was suspected, and the tumor was resected. On histopathology, the tumor was found to consist of spindle cells. On immunohistochemistry, the tumor stained positive for KIT protein ; the positivity rate for MIB-1 staining was greater than 10%. Based on these findings, the tumor was diagnosed as a high-grade GIST. The surgical approach to a giant GIST that receives its blood supply from several arteries must take into consideration the anatomy of the feeding vessels.

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A 65-year-old woman who had abdominal pain, appetite loss, and anemia was found to have a large lower abdominal mass and a 1-cm liver mass on imaging. An ileal tumor with hepatic metastasis was suspected. Thus, ileocecal resection, liver biopsy, and RFA for the liver metastasis were performed. The resected tumor was 16 cm in diameter, and multiple hepatic metastases were noted during the operation. On histology, an endocrine cell carcinoma component that showed undifferentiated alveolar cells and a funicular pattern was noted ; immunohistochemical staining confirmed the diagnosis. Furthermore, in some areas, an adenocarcinoma component was observed side by side of the endocrine cell carcinoma ; thus, an adenoendocrine cell carcinoma was also diagnosed. An analysis of 16 cases reported in the Japanese literature showed that an endocrine cell carcinoma of the small bowel has an extremely high malignancy potential. The accumulation of further cases is necessary to establish effective therapy for this disease.

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A 61-year-old woman presented to our department because PET/CT showed an accumulation with a standardized uptake value (SUV) in the ileocecum. Abdominal enhanced CT and colonoscopy showed a tumor measuring 4 cm in the ileocecum. Biopsy revealed it to be staged as group 2. The laparoscopic ileocecal resection was performed under the suspect of a neoplastic lesion including primary carcinoma of the appendix. The tumor site of the cecum was reddish and regional lymph nodes were swollen. Acute appendicitis was histopathologically diagnosed. Although PET/CT is useful in diagnosing colorectal tumors, inflammatory diseases should be considered in the differentiation from tumor lesions of the ileocecal region.

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An 82-year-old woman was seen at the hospital because of left lower abdominal pain. An abdominal CT scan showed a high density foreign body in the sigmoid colon, free air, and retention of ascites. Perforation of the sigmoid colon due to a foreign body was diagnosed and emergency laparotomy was performed because she presented peritoneal sign. A 5mm-sized perforation was identified in the sigmoid colon and a foreign body was felt just under the perforated site. The removal of the foreign body was performed, followed by partial excision of sigmoid colon and colostomy. The removed material disclosed the presence of diverticulum at a portion where continued to the perforated site. And a patient interview conducted after the operation clarified that she had eaten a persimmon including seeds. Perforation of the diverticulum of the sigmoid colon due to an ingested seed of persimmon was finally diagnosed.
So far only two cases of gastrointestinal perforation due to an ingested seed of persimmon have been reported in Japan. This extremely rare case is presented here, together with a review of the literature.

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We present a case of perforation of the sigmoid colon following transanal insertion of foreign bodies.
The patient was a 59-year-old man with previous histories of undergoing transanal removal of a rectal foreign body and two open surgeries to remove foreign bodies. This time he inserted balls into the anus but he could not evacuate them by himself. When he was seen at the hospital, he complained of a abdominal fullness but did not of abdominal pain. Abdominal simple x-ray examination revealed free air and thus emergency operation was performed. Upon laparotomy, two round foreign bodies with the diameter of 10cm and 20cm respectively were impacted in the sigmoid colon, and a perforation 4cm in diameter was identified. The perforated site was covered with a 10-cm vinyl ball so that no defluxion of feces was confirmed. We removed three foreign bodies by expanding the perforated site and the perforated site was treated by simple closure. He was discharged alive 8 days after the operation. To our knowledge this is the 8th reported case of sigmoid perforation following transanal insertion of foreign body in Japan.

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A 75-year-old woman, who had undergone total hysterectomy for a uterine leiomyoma 33 years earlier, visited a hospital because of dull pain of the vulva and incontinence of feces through the vagina. The patient was referred to our hospital for exploration and treatment. Endoscopic study revealed multiple diverticula in the sigmoid colon, and barium enema examination demonstrated a fistula from the sigmoid colon to the vagina. From these findings, sigmoidovaginal fistula secondary to diverticulitis of the sigmoid colon was diagnosed, and fistulectomy and partial sigmoidectomy were performed. There have been no signs of recurrence, as of one year after the operation.
Although vesicovaginal fistula is sometimes reported as a complication of colonic diverticulosis, sigmoidovaginal fistula has rarely been reported. Accordingly this case is presented here, together with a review of the literature.

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A 75-year-old man had an ileo-cecal resection due to cecal cancer. A C type2 43×38mm fT2(SS)N0M0H0P0 fStageII Well-Moderately differentiated adenocarcinoma was diagnosed. One and a half years later, he developed bloody stool and anemia ; on colonoscopy, a tumor was located at the anastomotic site between the ileum and colon. During surgery, anastomosis resection and FEEA were performed. On pathology, a moderately differentiated adenocarcinoma was diagnosed ; the final diagnosis was T2(SS)N0M0H0P0 fStageII. Thirteen months later, a recurrence located at the anastomotic site was detected on colonoscopy. Surgery was performed. At this time, the anastomosis was hand sutured. Papillary adenocarcinoma was diagnosed at the anastomotic site between the ileum and the colon. On pathology, the three cancers were similar and had the same origin. It is possible that on two separate occasions viable floating cancer cells located in the lumen were implanted in the FEEA site. This is the first report of two recurrences after FEEA was performed for colon cancer.

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A 69-year-old male was admitted to our hospital complaining of abdominal distension. CT showed severe dilatation of the gastrointestinal tract and thickening of the sigmoid colon wall. Conservative treatment did not resolve his symptoms. He, thus, underwent surgical resection. Laparotomy revealed a tumor measuring 4 cm at the sigmoid colon, and he was therefore diagnosed as having colon cancer. Sigmoid colectomy with lymph node dissection was carried out. The resected specimen showed circumferential wall thickening, but there were no other remarkable findings except for multiple diverticuli on the mucosal surface. Histological examination demonstrated the cancer to have arisen from the mucosa of a diverticulum and expanded to the serosa. UICC TNM classification showed T3N2M0. We describe a rare case of colon cancer arising in the diverticulum with a review of the literature.

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Colon cancer complicated with a fistula in other intestine is a rare pathologic condition. Case1 : A 61-year-old woman was diagnosed as having sigmoid colon cancer with a sigmoido-intestinal fistula and liver metastasis, and was performed resection of the sigmoid colon combined with the small intestine and the liver. Peritoneal metastasis was found during the operation and was resected as well. Liver metastasis and peritoneal recurrence were diagnosed 3 years and 9 months after the surgical resection. Case2 : A 78-year-old woman, diagnosed as having sigmoid colon cancer, was suspected to have jejunal invasion of cancer intraoperatively. Therefore, resection of the sigmoid colon combined with the jejunum was performed. The resected specimen showed sigmoid colon cancer with a jejunocolic fistula. Liver and lung metastases occurred 11 months after the surgical resection. Case 3 : A 71-year-old woman was diagnosed as having sigmoid colon cancer with a duodenocolic fistula, and was performed resection of the sigmoid colon combined with a part of duodenum. Liver metastasis was diagnosed 3 months after the surgical resection. Many case reports have indicated that colon cancer with fistula in other intestine shows rather low incidences of hepatic and lymph node metastases as well as peritoneal recurrence and its prognosis can improve by radical surgery. But we have recognized early recurrence in all our three cases. It is important to follow up them carefully according to the evolving state of the disease.

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We report a case of sigmoid colon cancer and abdominal aortic aneurysm (AAA) treated with endovascular aneurysm repair (EVAR) followed by laparoscopy-assisted colon resection. A 74-year-old male was treated by EVAR for on AAA that was increasing in size. Gastrointestinal screening done after the aneurysm repair revealed the presence of sigmoid colon cancer. Laparoscopy-assisted sigmoidectomy was done 3 months after AAA treatment. The laparoscopic surgery was not hampered by the presence of the repaired aneurysm. The combination of EVAR and laparoscopy-assisted colectomy is a less invasive approach to treatment than the standard approach.

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A 66-year-old woman with hepatitis C was found to have a heterogeneous low echoic lesion, 4 cm in diameter, with a high echoic margin in segments VII and VIII of the liver on abdominal sonography. No flow was noted in the lesion on Doppler sonography. CT and MRI showed a cystic lesion with an enhanced papillary projection. Laparotomy was performed because the lesion could not be differentiated from biliary cystadenocarcinoma. Laparotomy showed a tumor projecting from the liver, which adhered to the diaphragm. Hepatic right upper segmentectomy was performed. The resected specimen showed that the cystic lesion contained debris and a thick irregular wall. On microscopy with HE staining, the lesion was found to contain a small amount of viable cells within an area of massive necrosis located in the wall above a thick peripheral fibrotic border. Ag staining showed the remains of reticulin fiber, suggesting that a neoplasm had existed in the cystic lesion. It is likely that the patient had a neoplasm which underwent spontaneous necrosis. Such cystic hepatic lesions should be considered in patients with lesions which are difficult to differentiate form malignancy.

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A 66-year-old man with a past history of diabetes mellitus and fatty liver was referred for further examination of a hepatic tumor detected on screening US. The tumor measured 4 cm in diameter and had an irregular surfaces it was located in segments 5 and 6. All serological markers for HBV and HCV infections were negative. Tumor markers were within normal range. His BMI was 29.7 kg/m². Under the Provisional diagnosis of intrahepatic cholangiocellular carcinoma, a resection of segments 5 and 6 of the liver was done. His postoperative course was uneventful and he was discharged on the 8^th post operative day. On pathology a diagnosis of a well to moderately differentiated hepatocellular carcinoma was made. However, the noncancerous areas of the resected specimen showed moderate steatohepatitis and mild fibrosis. Given the patient's history, nonalcoholic steatohepatitis was the likely cause of HCC without cirrhosis. The patient has been followed-up for 13 months without recurrence.
To the best of our knowledge, only a few cases of HCC without cirrhosis caused by NASH have been described in the literature ; we therefore report this rare case.

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A 39-year-old man with situs inversus totalis was found to have gallbladder polyps found on mass screening ultrasonography. The chest X-ray revealed dextrocardia. Abdominal CT showed complete transposition of the abdominal viscera. There was no anomaly in the cystic duct or common bile duct seen on MRCP. The polyps were asymptomatic, but the patient requested surgery. A laparoscopic cholecystectomy using the single-handed technique was performed. The operation was completed using three trocars and no drain. Recently, the number of reports dealing with laparoscopic cholecystectomy in situs inversus totalis patients has been increased. If patients with situs inversus are properly diagnosed prior to laparoscopic cholecystectomy, surgery can be safely performed by appropriately using various devices.

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A 75-year-old woman with an abnormal abdominal US was admitted for investigation. A tumor, 70mm in size located at the serosal site of the body of the gallbladder and stones located at the neck of the gallbladder were found on CT and MRCP. She had a cholecystectomy with lymph node dissection since gallbladder carcinoma was suspected. On pathology of the resected specimen, papillary growth of atypical high-columnar epithelium, which was positive for HGM and negative for alcian blue, CD10, Villin, and cdx2 by immunostain was noted. The tumor had a mitotic index that was under 1%, a MIB-1 labeling index of 2.5% and was locally positive for p53. Mucin gene expression was MUC5AC positive, MUC6 positive, MUC1 weak positive, and MUC2 negative. The patient was diagnosed as having a pyloric gland-type adenoma with carcinoma located in the gallbladder. Immunostaining is useful for differentiating between the different types of gallbladder adenomas. Almost all pedunculated type adenomas have an area of carcinoma but are not invasive despite their large size ; our patient's tumor was 70mm in size. It is important to diagnose this type of adenoma accurately to avoid excessive sugery.

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We report a very rare case of recurrent pyogenic cholangitis. A 60-year-old woman was admitted for right upper quadrant pain. Based on percutaneous transhepatic cholangiodrainage results, a diagnosis of cholangitis with intrahepatic stones was made. Drainage was not effective, and her clinical symptoms of cholangitis did not improve. The diagnosis of recurrent pyogenic cholangitis was made given the ultrasound and CT results. Choledochotomy, left hepatectomy, and partial resection of the caudal lobe were performed. The minor intraoperative pancreatic injury and the biliary fistula that developed were treated conservatively. On pathology, there was evidence of cholangiocarcinoma.

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Splenic abscess is a rare complication in patients with infective endocarditis. We successfully treated an extremely rare case of active infective endocarditis with splenic abscess using percutaneous drainage under echo guidance.
The patient was a 79-year-old man with high fever and sepsis.
Echocardiogram showed vegetations attached to the mitral valve and moderate mitral regurgitation. Computed tomography and ultrasonography demonstrated a huge cystic mass located in the left subphrenic space. After making the diagnosis of splenic abscess based on echo-guided needle aspiration, a drainage tube was introduced into the abscess cavity. The patient recovered 37 days later. Given our patient's results percutaneous drainage under echo guidance appears to be a safe and effective treatment for splenic abscess.

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The patient was a 79-year-old woman who was transferred to our hospital for emergency treatment due to onset and exacerbation of left lower back pain from approximately 10 days earlier in addition to lower abdominal pain and vomiting from two days earlier. The patient had undergone abdominoperineal resection for rectal cancer 16 years ago. Muscular defense was observed in the left lower quadrant of the abdomen, and blood tests indicated marked inflammation. Abdominal CT revealed peritonitis, a giant kidney stone in the left kidney, and enlargement of the left iliopsoas muscle. Emergency surgery was performed on the day of admission. Laparotomy showed milky purulent ascites as well as lifbuse peritonitis, but no strangulation or perforation was seen in the intestinal tract. Based on these findings, the patient was diagnosed with acute panperitonitis associated with pyelonephritis, and only lavage and drainage were performed. On the following day, a percutaneous nephrostomy tube was inserted into the left kidney pelvis. During imaging, the contrast material filled Douglas'pouch from the left ureter, and shortly later the colon was directly filled from the kidney. Perforation of the ureter and renocolic fistula were suspected. Repeat surgery revealed occlusion near the intersection of the left ureter and the common iliac artery, as well as perforation at the center of the ureter. Pathological examination suggested that the renocolic fistula had occurred due to colonic diverticulum.

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We report a resected case of a retroperitoneal ganglioneuroma. A 61-year-old male was found to have an abnormality on his chest X-ray in July 2008. He was admitted in September 2008. CT showed a hypovascular tumor that had a dumb-bell shape ; it surrounded the aorta and did not appear to invade surrounding tissues. The tumor had low/signal intensity on T1 MRI images and high/signal intensity on T2 MRI images. A retroperitoneal tumor was diagnosed ; surgery was done. On histopathology, spindle cell bundles similar to Schwann cells and ganglion cell abnormalities were present. The immunohistopathological examination revealed that the tumor cells were S-100(+) positive ; they were α-SMA(-), CD34(-), c-kit(-), cdk(-), MDM2(-), and MIB-1 negative. Therefore a retroperitoneal ganglioneuroma was diagnosed definitirely.

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Paraduodenal hernia is one form of internal hernias which accounts for approximately 1% of all small bowel obstructions. We present a case of a 57-year-old male who was admitted to our emergency department because of progressive abdominal pain and vomiting. He had no past modical history. Abdominal CT scan revealed a sac-like appearance of small bowel loops to the right upper guadrant of the abdomen. The CT findings were consistent with the diagnosis of strangulated ileus for right paraduodenal hernia. Contrast-enhanced CT scan showed superior mesenteric vein (SMV) rotated to the left side of SMA (SMV rotation sign). An urgent laparotomy revealed the presence of a gangreous bowel herniated through a right side paraduodenal hernia, and missing of the Treiz ligament. Accordingly right paraduodenal hernia with malrotation was diagnosed. The compromised small bowel was resected. The patient was discharged from the hospital after an uneventful recovery. Conclusion : Paraduodenal hernias are rare but can be lethal. Especially, paraduodenal hernia with malrotation is not well known. Therefore, prompt diagnosis is essential for favorable outcomes. We should be aware of possible variables of abnormal anatomies to avoid a delay in decision of surgery.

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A 50-year-old woman was seen at the hospital because of an upper abdominal tumor with pain. Although she had undergone cesarean section, the painful site difleved from the previous surgical scar. She had no other histories of trauma. We identified two tumors, one tumor with the size of tip of the thumb between the xiphoid process and the umbilicus and another tumor with the size of tip of the small finger above the umbilicus. An abdominal CT scan identified the tumor below the xiphoid process as a 20mm-sized low density area, but did not done the tumor above the umbilicus. From these findings, multiple linea alba hernia was diagnosed and the patient was operated on. A skin incision made on the midline of the upper abdomen disclosed two hernia sacs. Both hernia openings were small, and then the operation was completed following closures of the peritoneum and fascia. The patient's postoperative course was uneventful and no recurrence has occurred up to now.
Because linea alba hernia is a rare entity in Japan and few cases of multiple occurrence of this disease have been reported, this case is presented here, together with a review of the literature.

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A 71-year-old woman was admitted in January 2008 with on upper thoracic esophageal squamous cell carcinoma and a right chest wall skin tumor. When she was 32 years old, she had a radical mastectomy for right breast cancer and received postoperative radiation. Due to the presence of lung adhesions, trans-thoracic esophagectomy could not be done ; thus, a blunt dissection was performed. She was discharged on the 19^th postoperative day. On pathology, a pT2N0M0 (pStage II) esophageal tumor was diagnosed. A resection of her skin tumor underwent 79 days after the esophageal surgery ; on pathology, the skin tumor was diagnosed as a basal cell carcinoma. Since the esophageal tumor and the skin tumor occurred in the same area that had received radiation therapy, these tumors were diagnosed as being radiation-induced secondary tumors. In the English language medical literature, several reports of radiation-induced esophageal cancer occurring as a second cancer after radiotherapy for breast cancer have been published. Radiation-induced esophageal cancer rates may increase in Japan given the number of women who previously received radiotherapy for breast cancer.

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