Summary : Laparoscopic surgery for gastric cancer is thought to be less invasive and to offer results comparable to conventional surgery ; the use of this approach has increased remarkably. However in centers with little experience, a lack of technical expertise in laparoscopic lymph node dissection for gastric cancer can potentially affect the patients' cure rate and safety. An understanding of the advantages and disadvantages of laparoscopic surgery can decrease these risks. Therefore a questionnaire survey of institutions where laparoscopic surgery could potentially be used in gastric cancer patients was conducted. In 20 of the 28 institutions who responded such laparoscopic surgery was in fact being done, and 10 of the 20 were considered to be institutions with experience in the procedure, while 10 were considered to lack experience. Factors that affected outcomes were compared between the two groups. In both groups, the advantages of laparoscopy were primarily related to the good visualization offered by laparoscopy due to magnification or being able to view the field from an angle not possible during surgery. However, in the inexperienced institutions, the good visualization was offset by the inability to obtain good surgical fields. This inability might be the result of the surgeons' lack of expertise or the assistants inadequate technical abilities. To correct this situation, it is important to improve the operative teams' skill level.

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Backgrounds : For prolapsing internal hemorrhoids, less invasive treatments such as sclerotherapy using aluminum potassium sulphate/tannic acid (ALTA), and procedure for prolapse and hemorrhoids (PPH) have been introduced recently. We compared the results of ALTA and PPH with those of conventional hemorrhoidectomy. Methods : Between January 2006 and December 2007, we performed conventional hemorrhoidectomy in 331 patients, ALTA in 565 patients, and PPH in 73 patients. Results : Durations of hospital stay were 6.8±2.0 (mean±SD) days in the hemorrhoidectomy group, and 4.2±1.5 days in the PPH group. ALTA could be performed on an outpatient basis without any severe complications. The mean volume of ALTA injected into hemorrhoids was 7.1±2.1mL. The disappearance rates of prolapse were 100% in the hemorrohidectomy, 96.1% in the ALTA, and 98.6% in the PPH group. Conclusions : Conventional hemorrhoidectomy can be indicated for alomost all cases of prolapsing internal hemorrhoids. However, it needs hospitalization, being accompanied with post-operative pain. ALTA is feasible on an outpatient basis without any severe post-operative pain or complications. PPH is a useful alternative treatment be cause it permits of shorter duration of hospital stay and less pain than the conventional hemorrhoidectomy. Less invasive treatments appear to be useful, if we carefully choose candidates for the treatments and pay attention to avoid complications.

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Purpose : To clarify the prognostic factors after resection of liver metastasis in colorectal cancer. Patients and Methods : Fourty-two colorectal cancer cases with liver metastasis were assessed to determine the prognostic factors. Results : The cumulative survival after liver resection was 79.0% at 3 years and 72.9% at 5 years. Recurrences in the resected liver were very frequent in the multiple liver metastases group (p=0.04) ; on the other hand, extrahepatic recurrences after resection were very frequent in both the solitary and the multiple liver metastases groups. Patients' survival after liver resection was related to the presence of bilateral lobar metastases, recurrence in the remnant liver, and extrahepatic recurrences after resection. Multivariate analysis indicated that only extrahepatic recurrence after resection was an independent factor. Conclusions : The prognosis of colorectal cancer patients with a liver resection due to liver metastasis depends on the presence of extrahepatic recurrence after resection. Therefore, after liver resection, extrahepatic recurrences should be curtailed by the use of systemic chemotherapy.

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Objective : Inguinal hernia (hernia) following radical retropubic prostatectomy (RPP) is one of the complications of RPP, and our objective is to clarify its pathology. Methods : Hernia surgery patients and RPP patients were analyzed retrospectively. Results : Among 388 men who had elective surgery for hernia, 9 of the cases were post-RPP hernia, or 2.3%, which was 10.7% of the 84 RPP patients. The frequency of post-RPP hernia occurring bilaterally is high, and bilateral occurrence with 1 year was more common in hernias that did not follow RPP (p<0.01). In surgical findings, all cases were indirect hernias, and detachment of the preperitoneal cavity was often difficult due to a high degree of inflammatory changes. We could not find any clear features that suggested a relation to the cause of hernia in post-RPP patients. Conclusions : It is essential to diagnose post-RPP hernia keeping the possibility of bilateral occurrence in mind, and to select the operative method with consideration of inflammatory changes in the preperitoneal cavity. The next subject to address will be elucidating the cause of occurrence and establishing preventive measures.

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Purpose : To investigate whether recurrent inguinal hernias can be repaired using laparoscopic, transabdominal, preperitoneal mesh repair (TAPP) with acceptable complications. Patients and methods : From 1996 to 2007, conventional / tension-free mesh techniques via an anterior approach or a laparoscopic approach were used in 694 cases. Of these, 27 (4%) patients had recurrent hernias, eleven open mesh repair (OMR) (average age, 62 y) and ten TAPP (average age, 64 y) procedures were performed to repair the recurrent hernia. Results : There was no significant difference in the surgical time between the OMR (108 minutes) and TAPP (96 minutes) groups. Intraoperative bleeding volumes were significantly increased in the OMR group (14 ml) compared to the TAPP group (2 ml). The average length of hospitalization post surgery in the OMR group (8 days) was significantly longer than in the TAPP group (5 days). Three major complications occurred in the early postoperative period ; all were in the OMR group. On the other hand, there were no major complications in the TAPP group. Conclusions : TAPP appears to be better for recurrent inguinal hernia repair since it decreases surgical stress and has a lower complication rate compared to OMR.

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We experienced a case of diffuse enlargement of the thyroid after fine-needle aspiration cytology of an adenomatous goiter. We followed its clinical course and some bibliographic considerations. The patient was a 38-year-old woman. She was diagnosed with a nodular goiter at another hospital, and was referred to our hospital after it increased in size. She had no particular history of internal medication. When fine-needle aspiration cytology was performed on the left lobe of the affected side using a 22G injection needle, she complained of feeling pressure and pain in the neck 2 or 3 minutes later. The right lobe of the unaffected side was observed to have swollen from 1 cm to 4 cm by echo, and internal blood flow was increased. Since there was no improvement after cooling the neck with an ice chip for 1 hour, a steroid was administered and the symptoms rapidly improved. When an echo was conducted after 9 days of decreasing steroid administration, the swelling had improved. We were able to follow-up with periodic echo images. Steroid treatment was conducted before and after surgery, and the patient was discharged after successful surgery without complications. It is conjectured that the diffuse swelling occurred because nerves in the thyroid were accidentally stimulated by the fine-needle aspiration cytology, causing vasodilation and release of vascular permeability factors.

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A 36-year-old man who had schizophrenia developed hypercalcemia and hyper-alkaline-phosphatasemia. He was diagnosed as having hyperparathyroidism, due to the presence of a high serum intact-PTH level (1221 pg/ml). A soft mass (4 cm in diameter) was palpable in the right side of the neck. On US and CT, the mass was found to be a cystic tumor located in the right lobe of the thyroid. MIBI scintigraphy revealed a hot spot in the same area of the right lobe. A diagnosis of intrathyroidal parathyroid cyst was made, and a right hemi-thyroidectomy was performed. The intact-PTH level in the cyst fluid was 317,400 pg/ml. Immediately after surgery, the serum intact-PTH level decreased. Hypocalcaemia was observed on the third post-operative day. On histopathology, the wall of the cyst was found to consist of a chief cell adenoma. A functional parathyroid cyst is rare, and an intrathyroidal functional parathyroid cyst is even rarer. This report presents the case and reviews the relevant literature.

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A 35-year-old woman presented to our hospital with a painful lump in her left breast. Clinical findings, mammography, ultrasonography, computeriged tomography(CT) and magnetic resonance imaging(MRI) strongly suggested malignancy. Excisional biopsy was performed for definitive diagnosis and granulomatous mastitis was demonstrated histopathologically. A month later, erythma nodosum appeared on bilateral legs. Both lesions were healed without any drugs.
Granulomatous mastitis is a rare benign breast disease. Since its clinical manifestations are similar to those of mammary carcinoma, this condition was misdiagnosed as carcinoma. We report a rare case of granulomatous mastitis with erythema nodosum, together with a review of the literatures.

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A 46-year-old woman developed a large right breast tumor. A phyllodes tumor was diagnosed based on needle core biopsy results. A CT scan showed right axial lymph node swelling and invasion of the pectoralis major muscle. The tumor and the axial lymph nodes were removed. The resected specimen weighed 3,927 g, and on histology, a diagnosis of malignant phyllodes was made. This paper presents our case and reviews the 26 cases of giant malignant phyllodes tumor of breast reported in the Japanese literature to date.

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A 19-year-old woman underwent an ovarian cyst operation. She was then diagnosed as ileus and as the case progressed, she was next diagnosed as spontaneous pneumomediastinum.
In our hospital, she underwent an adenexectomy and omentectomy. In the pathologic diagnosis, she was diagnosed as yolk sac tumor.
On postoperative day 13, she was given chemotherapy.
On the 9th day after her chemotherapy was started, she had abdominal distention and frequent vomiting. She was then diagnosed with mechanical ileus. At same time, she had subcutaneous emphysema over the right region of the buccalis and neck, and the region of the neck was palpable.
CT scan examination of neck and chest showed pneumatosis in the mediastinum.
A long intestinal tube was inserted, and her condition and pneumatosis in the mediastinum were improved.
Our case suggests that pneumatosis in the mediastinum was caused by pleural pressure increased by severe vomiting with postoperative ileus. We report the case with reference to the literature.

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A 75-year-old man had anterior chest pain even at rest since April, 2008. Preoperative coronary angiography revealed severe stenosis of segment 5, 6, and 11. His chest X-ray and computed tomography (CT) showed an abnormal shadow with an indentation in the right upper lobe. The diagnosis of lung cancer was made by transbronchial lung biopsy.
As angina pectoris and lung cancer were diagnosed, the patient was scheduled to undergo surgery of both the heart and lung in a one-stage operation. We performed concomitant off-pump coronary artery bypass (OPCAB) and right upper lobectomy with ND2a lymph nodes resection for lung cancer trough median sternotomy.
The postoperative course was uneventful. He was discharged after confirming the patent bypass grafting on the 15th postoperative day. Histopathological diagnosis was squamous cell carcinoma without lymph node metastasis. Lung cancer and ischemic heart disease can be surgically treated simultaneously, benefitting selected patients.

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A 63-year-old diabetic man complaining of high-grade fever, low back pain and both legs swelling was admitted to another hospital. Although he had undergone an antibiotic therapy under the diagnosis of urinary tract infection, his symptoms gradually worsened. He was transferred to our hospital. Abdominal CT scan revealed gas surrounding the saccular infrarenal abdominal aortic aneurysm. Inferior vena cava (IVC) was compressed by the aneurysm and had thrombosis. Blood culture samplings from peripheral artery yielded salmonella species, confirming the diagnosis of infected abdominal aortic aneurysm associated with IVC thrombosis. A temporary vena caval filter was placed above the renal veins for prevention of pulumonary thromboembolism prior to the operation. In-situ aortic reconstruction was performed using a EPTFE bifurcated graft. The patient remains alive without further evidence of infection as of 40 months after the operation.

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In January 2008, a 79-year-old woman was seen due to difficulty breathing. On chest CT, thyroid cancer and a tracheal stenosis about 3-cm long located approximately 5 cm below the vocal cords were noted. Thyroid cancer surgery was not indicated. Nevertheless, tracheal stent placement was done. Midazolam was given, and a laryngeal mask was inserted with the patient breathing spontaneously. Subsequently, a flexible bronchoscope was inserted into the laryngeal mask. A guide wire was inserted once the tracheal narrowing was identified, the metallic stent was inserted intratracheally along the guide wire and then deployed. Tracheal stent placement using flexible bronchoscopy and a laryngeal mask is useful in patients whose general condition is poor and in whom the stenosis is located near the vocal cords.

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A 76-year-old man was treated with methotrexate and prednisolone due to joint pain. Due to the presence of colon cancers in June, 2003, he had a laparoscopy assisted deccnding colonectomy (pSMN0M0 stageI), and in August, 2004, he had a sigmoidectomy (pSMN0M0 stageI). In August, 2007, chest CT showed an abnormal 3-cm shadow in the right lung (S3). At that time, his symptoms included hemoptysis, chest pain, and cough. Chronic necrotizing pulmonary aspergillosis (CNPA) was diagnosed. The patient was treated with voriconazole ; the extent of the CNPA decreased, and his symptoms improved. The patient had a right upper lobe resection, and the edge of the right upper bronchus was covered by a flap of latissmus dorsi muscle. On pathology, no findings of aspergillus were found. It is likely that voriconazole treatment caused the aspergillus to become necrotic. In this case, voriconazole was very effective in treating CNPA.

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The patient was a 12-year-old girl who visited the pediatric department of our hospital with chief complaints of abdominal pain and vomiting. Tenderness was observed in the entire upper abdomen, and plain thoracoabdominal X-ray and thoracoabdominal CT confirmed a large amount of gastrointestinal gas in the left pleural cavity. The patient was diagnosed with intestinal obstruction caused by diaphragmatic hernia and underwent emergency laparotomy on the day of admission. Findings included a Bochdalek hernia in which parts of the transverse colon,descending colon, jejunum and greater omentum had prolapsed into the pleural cavity through a hernial orifice measuring approximately 5×3 cm in the lateral posterior region of the left side of the diaphragm. Surgery was completed by closing the hernia orifice using an interrupted suture. The patient followed a favorable postoperative course and was discharged on day 7.
The patient indicated in an interview that she had engaged in vigorous abdominal exercise from the day before admission, and this was thought to have caused an increase in abdominal pressure that led to herniation.

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A 42-year-old woman was seen at our hospital because of abdominal pain in September 2007 (the 2nd day of menstrual period) and was admitted with a diagnosis of small bowel obstruction after CT scanning. The CT also showed a tumor lesion in the abdominal cavity. The bowel obstruction was conservatively treated. Follow up CT scan at seventh day ravealed disappearance of dilatation of the small intestine as well as the tumor like lesion. In January 2008 (the 2nd day of the period), she was readmitted to the hospital because of ileus. Ectopic endometriosis was suspected based on the tumor like lesion on CT and recurrent ileus at menstrual periods. Ectopic endometriosis was also suspected by MRI. On March 2008 (the 3rd day of the period), she was readmitted because of ileus. An emergency operation was performed for this recurrent ileus. Laparotomy disclosed inflammatory adhesion at the terminal ileum and it was considered the obstructive part. Partial resection of the small intestine was performed. Moreover, some white nodes 5mm in diameter were scattered on the surface of the proximal intestine. The histopathological diagnosis was endometriosis. We conclude that clinical findings and diagnostic imagings are useful for making the diagnosis of ectopic endometriosis.

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A 14-year-old boy presented with abdominal pain and vomiting. On physical examination, his abdomen was tender around the umbilicus. Ultrasonography (US) and computed tomography (CT) showed a whirlpool sign and an SMV rotation sign. A midgut volvulus with malrotation was diagnosed ; emergency surgery was done. During surgery, a midgut volvulus was identified ; there was no intestinal necrosis. The intestine was repositioned, Ladd's ligament was cut, and an appendectomy was done. The patient was discharged six days postop. A whirlpool sign and an SMV rotation sign on either US or CT are characteristic findings in these types of patients. US is considered to be useful for diagnosing midgut volvulus, since it is associated with less injury and easily can be repeated at the bedside. Therefore, we would recommend the use of US for patients presenting with vomiting.

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A 71-year-old man was admitted to our hospital with the chief complaint of abdominal pain. Examination of his abdomen revealed localized tenderness with muscular defense. Distal ileum was not enhanced by intravenous contrast material in the early phase of Dynamic CT. Vasospasms of mesenteric arteries were not detected by angiography. Laparotomy showed ischemic change of the distal ileum. After 36-hour countinuous intrarterial administration of papaverine, second look operation proved that ischemia of the distal ileum was improved. In many cases, NOMI was diagnosed by angiography, but in our case, ischemic change of intestine was revealed by dynamic CT scan.

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We analyzed clinicopathological features of ten patients with primary appendiceal carcinoma experienced during 1986 to 2007, which accounted for 0.79% of all resected colorectal carcinomas in our hospital. The mean age was 59.7 years, and the male to female ratio 7 : 3. The diagnosis of appendiceal carcinoma could be made preoperatively in only one case. We performed ileocecal resection in 5 cases, right hemicolectomy in one, and appendectomy in three. Ileocecal resection was performed in one case as an additional surgery after appendectomy. Regarding the histologic type, the tumor was mucinous cystadenocarcinoma in five cases, and adenocarcinoma in five cases. The tumor depth was classified as ‘ss' or deeper in all cases. Regarding clinicopathological staging, 7 cases were in StageII, and 3 cases StageIV. The StageIV cases included lymph node metastasis in one case (10%), liver metastasis in one (10%), and peritoneal dissemination in three (30%). Eight cases remained alive, five of them without recurrence, but two cases died from peritoneal dissemination. The type of recurrence in all cases was peritoneal dissemination. Primary appendiceal carcinoma is very difficult to diagnose preoperatively, most cases are diagnosed as advanced carcinoma, especially with peritoneal dissemination. Multidisciplinary treatment is required for improvement of the outcome of appendiceal carcinoma.

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The patient was a 74-year-old man with complaints of abdominal pain and melena. At first, an abdominal CT showed a completely encircled wall thickness from the descending colon up to the rectum. The patient was admitted to our hospital with the diagnosis of ischemic colitis. Then shock suddenly occurred. A repeated CT showed hematoma in the abdominal cavity. We preoperatively diagnosed him as a case of ruptured aneurysm in the abdominal artery. An emergency operation was done. The origin of the bleeding was the aneurysm in the middle colic artery, and hemostasis was done by ligation. No colon resection was done because his condition was good. The patient was discharged from the hospital on the 13th postoperative day. This was a case of a ruptured aneurysm in the middle colic artery presenting with symptoms of ischemic colitis and hemorrhagic shock. But the hemostasis was done promptly, and lifesaving was possible after laparotomy.

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An 80-year-old man was seen at the hospital because of appetite loss 5 days after he had fallen down and got a bruise on the abdomen in his garden. Abdominal plain CT scan showed a soft-part shadow including air in an area outside the intestine and on the ventral aspect of the Morrison's pouch and the transverse colon. The patient was admitted to the hospital with a suspicion of intra-abdominal abscess formation secondary to minute perforation of the lower digestive tract. His clinical course was conservatively observed. Enema study disclosed transudation of contrast material from the intestine in the vicinity of the hepatic flexura of the colon and at the center part of the transverse colon. Thereafter oral ingestion was started after we confirmed that there was no transudation of contrast material from the intestine by barium enema. The patient was discharged very much improved on the 44^th day after the trauma. He has been followed in the clinic, without signs of recurrence.
It is believed that lower gastrointestinal perforation can follow a fatal course in a high possibility and the patient is a candidate for emergency operation as a rule. However, there are some cases in which surgical intervention can be avoided by conservative therapy, and hence we must keep the fact in mind in the diagnosis of acute abdomen.

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An 80-year-old woman was admitted due to abdominal distension, abdominal pain, and vomiting. On abdominal CT scan, there was marked dilatation of the colon. However, no organic disease was noted on colonoscopy and contrast enema. The patient did not improve on conservative medical treatment, and she went into shock. Emergency surgery was done, and an artificial anus was created in the dilated transverse colon. During surgery, no abnormalities were found in the colon. The patient's postoperative course was uneventful, and she was discharged 19 days after surgery. On histopathology, the nerve plexus of the transverse colon was normal. One should consider acute colonic pseudo-obstruction as a cause of colonic ileus. It is rapidly progressive and emergency surgery is required in seriously ill patients.

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We experienced a family in which both the mother and daughter underwent surgery for ulcerative colitis (UC). The mother developed UC with the onset of melena at the age of 51, and was diagnosed with pancolitis. Although she was given steroids in addition to 5-ASA and followed, her symptoms waxed and waned. Despite increased steroid dose and granulocyte apheresis (GCAP), the symptoms exacerbated and the patient was admitted to our department on an emergency basis. Total colectomy, rectal mucosectomy, ileal pouch-anal anastomosis (IPAA), and ileostomy were immediately performed. The patient had an unremarkable course thereafter. The daughter developed UC with the onset of melena at the age of 18, and was given GCAP, steroids, immunomodulators, and other treatments for pancolitis and followed. However, the patient's symptoms waxed and waned and became a hindrance to her social life. The patient was diagnosed with refractory UC and underwent the same surgeries as her mother. Her postoperative course was favorable. Both mother and daughter underwent ileostomy closure and are currently being followed. No other members of this family had developed inflammatory bowel disease. The frequency of familial occurrence of UC has been reported as 1.8%. However, our literature search revealed no other cases of a mother-child pair undergoing IPAA.

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We report a case of metachronous anal metastasis from sigmoid colon cancer.
A 68-year-old man who underwent sigmoidectomy for sigmoid colon cancer in January 2006 was found to have a metastatic liver tumor located in the S7 by a follow-up abdominal CT scan 12 months after the operation. He underwent partial hepatectomy. Twenty-one months after his initial surgery, he complained of anal pain. Imaging studies revealed an anal tumor. On digital examination, a tumor 2 cm in diameter was felt in the subcutaneous structure on the dorsal aspect of the anus. This tumor was suspected of metastasis from sigmoid colon cancer, and abdominoperineal resection of rectum was performed. Histologically the tumor was classified into moderately differentiated adenocarcinoma and was considered to be metastasis from the primary sigmoid colon cancer. We have reported this case because it appears to be an interesting and uncommon disease.

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With careful preoperative preparation and inventive surgical and anesthesia methods, we performed splenectomy and open sigmoidectomy with lymph node dissection by HALS at one time for advanced sigmoid colon cancer complicated by severe COPD and ITP, and here report the satisfactory results obtained. The patient was a 72-year-old woman. She had consulted a nearby doctor with chief complaint of melena and was referred to our hospital when sigmoid colon cancer was diagnosed by lower gastrointestinal endoscopy. She also had COPD due to a long history of smoking and a high degree of obstructive impairment was observed in respiratory function test. From her first outpatient visit she started cessation of smoking, respiratory function training and use of an inhaled bronchodilator.
She also had ITP, with a low platelet count of 10000/μL on the first examination at the department of surgery, and gamma-globulin massive dose therapy was conducted immediately before surgery. The operation was an open sigmoidectomy plus D2 dissection performed with splenectomy by HALS and elongation of the HALS wound, from the perspective of minimally invasive surgery and avoiding prolonged pneumoperitoneum. Anesthesia was general without the use of muscle relaxant, using epidural anesthesia combined with continuous probofol infusion for spontaneous ventilation. The post operative course was satisfactory and the patient was discharged 11 days after surgery.

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An 84-year-old man showed positive fecal occult blood. Colonoscopy indicated an early-stage looked rectal cancer, and a low anterior resection was conducted. Histologically, the tumor was composed of moderately-differentiated adenocarcinoma with a micropapillary component in the mucosa. The tumor reached the subserosal layer, and lymph node metastasis was seen. It is suggested that colorectal cancer with a micropapillary pattern may represent a high biological grade and poor prognosis, like other organs.

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A 75-year-old female was admitted for upper abdominal pain. Abdominal computed tomography and MRI showed a mass lesion in posterior segment of the liver measuring 5 cm, where no mass had existed 2 months before. On DWI, the intensity of the mass lesion was high and homogenous. Angiography revealed portal flow absence in the mass lesion. Malignancy, such as intrahepatic cholangiocarcinoma or cystadenocarcinoma of the liver could not be ruled out based on the radiologic examination. The patient's general status became worse due to continuing high fever and the rapid growth of the mass, so we decided to remove the tumor surgically. S6 hepatectomy was performed. Histopathological examination revealed that the tumorous lesion consisted of collagenous stroma in which severe fibrosis had occurred. Infiltration of inflammatory cells, mainly by plasma cells and lymphocytes, were observed. This tissue was diagnosed as an inflammatory pseudotumor (IPT) of the liver. The postoperative course was uneventful, and the patient was discharged 15 days after operation. Similar to the many reported cases of hepatic IPT, this case presented difficulty in excluding malignancy. But to our knowledge, this is the first reported hepatic IPT case which presented high intensity of the mass lesion on DWI-MRI.

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The patient was a 71-year-old woman who underwent laparoscopic cholecystectomy for cholecystolithiasis and a gallbladder polyp in 2006. On that occasion, there were hepatic tumors 1cm in diameter in S2 and S5 of the liver, which had been followed at another hospital. Since the tumor suddenly enlarged to 5.2 × 4.2cm in diameter and a new hepatic tumor was detected, the patient was referred to the hospital in September 2007. These tumors which were located in S3, S5, and S8 were not enhanced in arterial, portal and delayed phase by CT scan. Gastrointestinal endoscopy, colonoscopy and positoron emission tomography (PET) did not reveal other malignancies. Tumor markers such as α-fetoprotein (AFP), protein induced by vitamin K absence or antagonist-II (PIVKA-II), carcinoembryonic antigen (CEA), and CA19-9 were negative. As a result of liver biopsy, immunohistochemical staining of chromogranin A was positive and that of synaptophysin was slightly positive. Therefore, these liver tumors were diagnosed as primary hepatic carcinoid tumor. Left lobectomy and partial hepatic resections of S5 and S8 were performed. She has been followed in the clinic, without evidences of recurrence.
It has been reported that 74% of all primary carcinoid tumors originate from the gastrointestinal tract. Primary hepatic carcinoid tumor is rare, and so we report this case which appears to be of primary hepatic carcinoid tumor.

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A 67-year-old male without a virus-related hepatitis was diagnosed as having hepatocellular carcinoma (HCC), 3.5 cm in diameter. Prior to admission for curative surgery, he developed dermatomyositis. Since it is well known that dermatomyositis often occurs in patients with a malignant tumor and that a curative resection is the first choice of therapy a lateral segmentectomy of the liver was done to remove the HCC. At present, 10 months after surgery the patient is doing well ; there has been no recurrence of the tumor or of the dermatomyositis.

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A 62-year-old woman complained of right hypochondralgia. A diagnosis of hepatocellular carcinoma (HCC) was made and transarterial chemoembolization was performed. She was referred to our hospital for surgical resection. We performed an extended right lobectomy for the huge HCC in the anterior segment of the right lobe (t3n0m0, StageIII). The pathological diagnosis was poorly-differentiated hepatocellular carcinoma. The serum AFP level started to increase three months after the operation, and a solitary mediastinal lymph node metastasis was demonstrated by chest CT scan and FDG-PET. Lymphadenectomy was performed following systemic chemotherapy. A pathological examination demonstrated the tumor cells were AFP-positive and compatible with relapse of HCC. Although the serum AFP level decreased from 5425 ng/ml to 24.4 ng/ml postoperatively, it started to increase again three months after lymphadenectomy, and multiple lung and mediastinal metastases appeared subsequently. Systemic chemotherapy was ineffective, and she died 25 months after the first operation. We report a rare case of hepatocellular carcinoma relapsing with solitary metastasis to a mediastinal lymph node.

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A 68-year-old female with chronic renal failure and type 2 diabetes melitus presented unconscious. She was diagnosed as being uremic and recovered consciousness with hemodialysis. However, she vomited blood several times, and tarry stool was observed. On initial gastroendoscopy, no abnormalities were found. However, the hematemesis and melena continued. The third gastroendoscopy revealed blood spurting from the papilla of Vater ; a diagnosis of hemobilia was made. Enhanced abdominal CT showed an enlarged gallbladder (GB) and a high density area, 3 cm in diameter, located in the GB. A diagnosis of ruptured pseudoaneurysm of the cystic artery was made, and an open cholecystectomy was performed. On pathology, cholecystitis and a hematoma were diagnosed. GB hemorrhage is rare but should be considered in the differential diagnosis of patients with hematemesis and melena.

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Patient 1, an 86-year-old woman was admitted to our hospital for right hypochondrical pain. A computed tomography (CT) of the abdomen showed shrunken gallbladder and fluid collection around the gallbladder. Emergent cholecystectomy and abdominal drainage was performed. Resected specimen showed necrotic change from the body to fundus of the gallbladder and a perforation with acute ulcer. Patient 2, an 82-year-old woman was admitted to our hospital because of epigastralgia. CT showed shrunken gallbladder and fluid collection around the gallbladder. Emergent cholecystectomy and abdominal drainage was performed. Resected specimen showed necrotic change of the fundus. These 2 cases showed no gallstones and no inflammatory signs of these gallbladders, and the cultures of the ascites were negative. We diagnosed them as idiopathic perforation of the gallbladder.
Perforation of the gallbladder is usually caused by gallstone or acute inflammation. Idiopathic perforation is caused without these causes and is a rare disease. We present our two cases of idiopathic perforation of the gallbladders with bibliographical reviews.

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A 65-year-old woman presented with right hypochondralgia of three days duration. There were no signs of peritonitis. Ultrasound and CT scans showed gallbladder enlargement and thickening of the gallbladder wall, suggesting acute cholecystits. Soon after emergent percutaneous transhepatic gallbladder drainage (PTGBD), the patient's laboratory tests and symptoms improved. Laparoscopy was performed electively on the 8th day after admission. Once the adhesion had been dissected, the gallbladder was found to be twisted clock/wise 180 degrees around the cystic duct. After the torsion had been corrected the gallbladder was resected laparoscopically. The gallbladder was found to be minimally attached to the liver and was thought to be a Gross type II “floating gallladder”. Torsion of the gallbladder is rare in patients with an acute abdomen. Emergent cholecystectomy for torsion of the gallbladder is recommended since the gallbladder can easily necrotize or become perforated due to ischemic change. In our case, emergent surgery was avoided by the use of PTGBD. Elective laparoscopic cholecystectomy was then successfully performed.

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A 45-year-old male patient received cholecystectomy by his private doctor for cholelithiasis and chronic cholecystitis in Feb., 2002. The bile duct was injured during the procedure and it was repaired by simple suturing. The patient had been doing uneventfully until Aug., 2007, when he started to notice general malaise and jaundice and came to the medical department of our hospital. CT study revealed dilatation of the intrahepatic bile duct, stenosis of the mid bile duct and a mass of 10mm in size with enhanced image in the common bile duct. With suspicion of cancer of the bile duct, excision of the bile duct and choledochojejunostomy was performed. An extramural tumor of approximately 10mm in size was found and its pathohistological study revealed a neuroma arising from excised edge of the bile duct. The patient was discharged on the 13^th postoperative day without any complication. He is presently doing well. Neuroma arising from edge of the bile duct causing stenosis is difficult to differentiate from carcinoma of the bile duct. In case of ductal stenosis after a biliary surgery, a possibility of this type of pathology should be kept in mind.

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A 44-year-old female patient came to our hospital with the chief complaint of epigastric pain. After detailed studies, a diagnosis of choledocholithiasis was made and the patient was referred to our gastroenterology department and an endoscopic sphincterotomy of the papilla of Vater was performed. Intraoperative choledochography revealed a 3mm in size pathological elevation of the wall with smooth surface. The patient was followed in the out patient clinic without particular problems, but was referred to our department to rule out possible malignancy. Cholecystectomy was performed with an intraoperative endoscopic study of the common bile duct through the cystic duct. The tumor was a submucosal one and only a wedge resection was performed as it was believed to be benign. Intraoperative pathological diagnosis was a cyst without atypical cells and a T-tube was inserted through the incision. Seepage of bile was observed postoperatively, but this was successfully managed conservatively. The patient was discharged 27 days after the surgery. The final pathological diagnosis was a simple intramural cyst of the common bile duct. We report this case with some review of the literatures.

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A 77-year-old woman was admitted with the complaint of epigastralgia and was diagnosed as cholangitis as a result of stones in the common bile duct. Abdominal ultrasonography and computed tomography revealed an irregular tumor in the gallbladder. We diagnosed this as carcinoma of the gallbladder and performed cholecystectomy. Macroscopic examination of the resected specimen showed a papillary tumor growing from the fundus and body of the gallbladder.
Histologically, the resected specimen consisted of an adenocarcinoma and a sarcomatous tumor of spindle-shaped cells and we diagnosed this case as carcinosarcoma of the gallbladder. Carcinosarcoma of the gallbladder is very rare, so we report this case with a review of the literature.

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We report a case of non-functional pancreatic endocrine tumor growing into the main pancreatic duct (MPD) which is rare.
A 46-year-old woman was admitted to our hospital because of epigastralgia. On admission, an egg-sized tumor was palpable at the epigastrium and hematological studies showed that the values of tumor markers and gastrointestinal hormones were in normal ranges. Abdominal echography, CT, MRI, angiography, PET and ERCP revealed two hypervascular lesions which were adjacent each other but one in the pancreatic parenchyma and the other in the MPD. We performed pancreaticoduodenectomy. Because the resected specimen showed that the tumor was growing into the MPD from the parenchyma and a histopathological study proved each and every lesion to be the same endocrine tumor. Consequently the final diagnosis was non-functional pancreatic endocrine tumor growing into the MPD.

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Case 1 involved a 37-year-old man who was seen at the hospital because of abnormalities pointed out at a medical checkup. Abdominal CT scan showed disruption of the pancreatic duct in the pancreas body, dilatation of the caudal pancreatic duct, and contraction of the pancreas tail. MRCP visualized disruption of the main pancreatic duct and dilatation of the caudal pancreatic duct. Invasive duct cell carcinoma of pancreas was diagnosed and the resection of the pancreas body and tail was performed. On the resected material, a 1.4-cm tumor with invasion into the main pancreatic duct was identified.
Case 2 involved a 48-year-old man who was referred to the hospital because of suspected acute pancreatitis. Abdominal CT scan showed an about 1.5-cm tumor at the pancreas tail and dilatation of the pancreatic duct caudal from the tumor. Endoscopic retrograde pancreatography (ERP) revealed disruption of the main pancreatic duct. The resection of the pancreas body and tail was performed with a diagnosis of invasive duct cell carcinoma of pancreas. The resected material disclosed a 1.3-cm tumor with invasion into the main pancreatic duct.
Histopathological findings in both cases included monotonous proliferation of eosinophilic cells with small nucleus, positive response to chromogranin A staining, and negative responses to various hormone stainings. From these findings, non-functioning endocrine cell tumor of pancreas was diagnosed.
In the treatment of endocrine cell tumors of pancreas, it may be appropriate to interpret the involvement of the main pancreatic duct as a malignant finding.

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A 25-year-old woman with epigastric pain was seen in May 2007. No abnormalities were found on gastro/intestinal/fiberscopic examination. However, on ultra-sound, a cystic lesion was noted in the body of the pancreas. The lesion's diameter was 4 cm. The cystic lesion had a multilocular appearance on CT and MRI. A cystic tumor located in the pancreas was diagnosed. Surgery was done in July 2007. During surgery, a lymphangioma of the pancreas without a fibrous capsule was found. Thus, a partial resection of the pancreatic body including the cystic lesion was performed. The patient was discharged from the hospital without any complications on the 12th postoperative day ; she had no abdominal pain after surgery. On pathology, a cavernous lymphangioma of the pancreas was diagnosed ; no malignancy was found. This report deals with the clinical and pathological feature of this case of primary cavernous lymphangioma of the pancreas.

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A patient 79-year-old male was regularly coming to his family physician for the treatment of diabetes since 12 years prior, when he had acute pancreatitis. Since Feb. of 2006 his diabetes got worse and then a tumor was found in the tail of pancreas by a CT study and was referred to our hospital. Tumor markers were all within normal range. Abdominal echo, CT and MRI studies revealed a tumor of 20mm in size in the tail of pancreas and dilatation of the distal main pancreatic duct. Possible malignancy could not be ruled out by image studies, and therefore a surgical intervention was performed. Laparotomy revealed an induration of 20mm in diameter with depression of the surface, tightly adhering to the transverse colon and mesocolon. Remaining part of the pancreas looked almost normal. Resection of the tail of the pancreas, splenectomy and partial resection of the transverse colon were performed. Postoperative pathohistological study revealed cholesterin crystals and foreign body giant cells surrounding cholesterin crystals at the center of the tumor and the diagnosis of cholesterin granuloma was made. Cholesterin granuloma is occasionally reported to arise in the liver, but the one confined in the pancreas is rare, and we could not find any other reported case in Japan.

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A 25-year-old man suffered from epigastralgia and was referred to our gastroenterological department in July, 2007. He had anemia. Gastrofiberscopy showed atrophic gastritis. In September, he was admitted for acute abdominal pain. CT showed hemorrhagic ascites due to splenic rupture. Conservative treatment was selected, because of his steady vital signs and no anemia. But the next morning, his abdominal pain became worse accompanied by shock, so an emergency operation was carried out. About 3000 ml fresh blood and coagula in the peritoneum was aspirated, and the germinal pole of the spleen was the hemorrhage point. Splenectomy was performed. Pathological examination diagnosed splenic bleeding from the rupture without any cause. He had no history of trauma, or any underlying causative diseases. His postoperative course was uneventful.

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A 45-year-old woman was detected to have a cystic lesion at the tail of the pancreas by abomominal ultrasonography in a routine physical examination. She consulted a general physician who, diagnosised it as benign lesion, and recommended to follow the clinical course. Six months later, the tumor increased in size and she was admitted to our hospital for close exprolation. Computed tomography (CT) showed a cystic lesion 2.0cm in diameter in the pancreas tail, and the well enhanced cystic wall. On T1-weighted magnetic resonance imaging (MRI), the cystic lesion showed a low intensity shadow, and T2-weighted MRI showed an iso-intensity shadow. Since a possibility of malignant disease could not be ruled out, operation was performed. The cystic lesion was 2.0cm in diameter and unilocular, and contained a brown serous fluid. Histopathologic study of the frozen section during the operation confirmed it to be an epidermoid cyst in an accessory spleen at the pancreatic tail. Ectopic splenic tissue in the abdominal cavity is a common entity. However, intrapancreatic accessory spleen is rare, especially cyst formation in it. It could be misdiagnosed as cystic tomor or pseudocyst of the pancreatic tail, thus differential diagnosis would be required. We report this rare case of cyst formation in an intrapancreatic accessory spleen.

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A 74-year-old man who had had recurrent bouts of eruption of the whole body which started in August 2006 was referred to the department of dermatology in our hospital for the purpose of exploration of the cause in June 2007. His eruption was diagnosed as erythema multiforme, and possibilities of infection and drug-related allergy could be ruled out from the causative disorders. Abdominal CT scan for further exploration disclosed a tumorous lesion in the spleen, and then the patient was referred to our surgical department. Ga-scintigraphy and positron emission tomography (PET) showed abnormal accumulation of contrast materials at the same lesion. Blood biochemical studies provided positive reactions to both soluble IL-2 receptor antibody and thymidine kinase. From these findings, malignant lymphoma arisen in the spleen was diagnosed, and laparoscopy-assisted splenectomy was performed in September of the year. Relief of eruption was observed on the postoperative day 1, itching sensation disappeared on the pod 3, and thereafter erythema multiforme disappeared. The pathological diagnosis of the splenic lesion was diffuse large B cell lymphoma. Postoperative adjuvant chemotherapy was conducted, and the patient has been free from recurrence as of 10 months after the operation.
In this case the causal relationship between erythema multiforme and primary malignant lymphoma of the spleen has been suggested and the splenectomy has come to an extremely effective therapy for erythema multiforme.

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Splenic metastasis is uncommon and usually occurs in patients with widespread visceral metastases. We report a case with cancer of the sigmoid colon who had a synchronous solitary splenic metastasis. An 85-year-old woman developed constipation. On barium-enema, an apple core sign was seen in the sigmoid colon. On abdominal CT scan, a low density area in the spleen was noted ; her serum CEA was elevated. An isolated intrasplenic metastasis from sigmoid colon cancer was suspected. The patient had a sigmoidectomy and splenectomy. Based on the histopathology, a diagnosis of sigmoid colon cancer and a splenic metastasis of the colonic cancer was made. The woman's postoperative course was uneventful, and her serum CEA normalized. However, 4 months postop, her serum CEA increased. Multiple metastasis in the kidneys and lungs were found 8 months postop. The patient died 25 months postop.

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A 60-year-old woman was referred to the hospital because of abdominal pain and vomiting. Abdominal CT findings of the abdomen at the time of admission indicated enlargement of the small intestine within the pelvis and deviation of the uterus to the right. Symptomatic remission was attained by placing a long tube, but a complete obstruction was detected in the lower part of the small intestine. Thus she was operated on at the department 7 days after admission when laparoscopic operation was done for making the definite diagnosis and treatment. At laparotomy, we found that the ileum approximately 1m proximal to the ileocecal region was heriated into an about 3cm-sized defect of the left broad ligament of the uterus. Since intestinal necrosis had not developed, we extricated the intestine and sutured the defect without resecting the intestine. The patient had an uneventful postoperative course and was discharged from our hospital on 9^th postoperative day.
Internal hernia through a defect of the broad ligament of uterus is very rare. We report on our experience with a case of this entity. We analyzed all cases of internal hernia through the broad ligament of uterus reported in Japan to elucidate the clinical characteristics of this disease.

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The patient was a 68-year-old woman. She had an emergency admission to our hospital with chief complaints of sudden right abdominal pain and vomiting. A surgical scar was observed on the lower right abdomen and midline of the lower abdomen. There were high degrees of spontaneous pain and tenderness, and plain abdominal X-ray showed extensive dilatation and gas in the small intestine. An abdominal CT scan also showed marked dilatation of the small intestine lateral to the ascending colon, and the ascending colon was displaced toward the median. It was difficult to alleviate the pain with analgesics or sedatives. Thinking that it was either postoperative adhesive ileus or incarcerated internal hernia, we performed exploratory laparotomy. The laparotomy findings revealed no intraperitoneal adhesion, but the small intestine was impacted in the paracolic gutter of the ascending colon paracolic gutter. The hernia orifice was opened and the small intestine was reduced. The small intestine was not resected since the impacted small intestine was not necrotic. The hernia orifice was closed with sutures to finish the operation. The postoperative course was uneventful and she was discharged in remission after 18 days. An internal hernia occurring in the paracolic gutter of the ascending colon is a very rare disorder, and since the imaging findings were also distinctive, we report them together with some bibliographic consideration.

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A 62-year-old man presented with right lower abdominal pain. On physical examination, tenderness was noted in the right upper guadrant, thus, acute appendicitis was suspected. Abdominal CT scan showed a lesion in the ileocecal region, a diagnosis of an abscess secondary to appendicitis or a cecal tumor was discounted. The possibility of neoplasm was considered since the inflammatory reaction was negligible, and colon endoscopy was done, but neither a tumor nor a diverticulum was noted in the colon. During surgery, a normal appendix was found, there was an inflammatory mass in the ileocecal region. An ileocecal resection was carried out. There was a divertivculum on the ileum located 5 cm from the ileocecal valve, where the mesenteric abscess had formed. On pathology, a diagnosis of a mesenteric abscess due to a perforated duplication cyst of the ileum was made. The patient was discharged from the hospital on the 13^th postoperative day.

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The patient was a 79-year-old woman who had been receiving calcium polystyrene sulfonate (Argamate jelly) for hyperkalemia associated with chronic renal failure. She visited a local doctor following sudden onset of lower abdominal pain on April 3, 2008. After being diagnosed with perforative peritonitis, she was immediately transferred to our hospital and underwent emergency surgery on the same day. Laparotomy revealed an extremely hard fecal mass in the sigmoid colon that was impacting the sigmoid colon. Approximately 10 cm of the serosa in the upper intestinal tract was ruptured, and a perforation (1.5 cm) was observed in the ruptured area. The sigmoid colon, including the lesion site, was resected, and peritoneal drainage and Hartmann's procedure were performed. Multimodality therapy was given postoperatively, and the patient survived. Pathological findings included a crystalline material at the lesion site as well as in the fecal mass, suggesting that the administration of Argamate jelly played a major role in the onset of sigmoid colon perforation. The present case indicates the importance of control of bowel movement during administration of this drug.

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A 68-year-old woman was seen at the hospital, due to a 9-cm-diameter, right lower abdominal mass. The mass was palpable in the right lower abdomen, when the mass was pressed the patient felt pain radiating into the front of the right thigh. Abdominal ultrasonography, CT scan, and MRI showed the well-defined tumor in the pelvis. A preoperative diagnosis of retroperitoneal neurilemmoma arising from the femoral nerve was made. At laparotomy, the tumor was found to be adjacent to the iliopsoas muscle, it partially adhered to and ventrally displaced the femoral nerve. The tumor was carefully removed from the femoral nerve. After surgery, the patient complained of a slight sensory disturbance in the front of the right thigh ; this symptom disappeared after several days. On pathology, a benign neurilemmoma was diagnosed. Excision of a neurilemmoma arising from the femoral nerve can result in severe damage. Therefore, if there are no pre- and intraoperative malignant findings, the nerve should be preserved.

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Abstract : Here we report a case of a retroperitoneal mucinous cystic epithelial tumor, whose serum CEA level elevated one year after extirpation of the tumor.
A 67-year-old woman was admitted to the hospital because of abdominal distension. Abdominal CT scan showed a huge multilocular cystic mass, which seemed to occupy nearly whole pelvis, lower and mid-abdominal cavities. At the time of en bloc removal, the tumor was found to arise from the retroperitoneum, strongly oppressing the abdominal organs. The resected tumor consisted of multilocular cysts. The cyst walls and septa showed inhomogeneous thickening and each chamber contained a little whitish, almost transparent mucinous fluid. Histopathologically, the inner surface of the cyst was lined with monolayer of tall columnar epithelium with a fraction of atypical cells. Based on these findings and immunohistological analyses, the tumor was diagnosed as mucinous cystadenoma of borderline malignancy originated from the retroperitoneum. One year later, this patient's serum CEA level temporarily elevated for the first time because of unknown origin.
So far there have been no Japanese reports of retroperitoneal mucinous cystadenoma which showed postoperative elevation of serum CEA level.

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