Intussusception of the jejunum after gastrectomy is rare. Therefore, its clinical characteristics are not well known. We report a case of intussusception of the jejunum that occurred 20 years after gastrectomy and assess the clinical characteristics of 28 cases reported in the Japanese literature, along with our case. A 63-year-old female who had a subtotal gastrectomy using the antecolic Billroth II reconstruction approach with a Braun's anastomosis 20 years prior required emergent laparotomy, due to a preoperative diagnosis of small bowel intussusception. The jejunum, located 10-cm distal from the Braun's anastomosis, was intussuscepted in a retrograde fashion into the afferent loop ; since there was no ischemia a repair was possible. Based on the analysis of all 29 patients, the age at intussusception was not different in the various disease groups. However, in patients with an ulcer, duration from gastrectomy to intussusception was longer than in those with cancer. The preoperative diagnosis could be made on abdominal computed tomography in all 29 patients. In 21 patients who had a subtotal gastrectomy, 12 (57%) were reconstructed using the antecolic Billroth II reconstruction approach with a Braun's anastomosis. Twenty-seven of the 29 patients (93%) had a retrograde intussusception. Even if the intussusception was diagnosed early and the laparotomy could be performed, some patients required a resection of the intussuscepted portion. However, in all patients the postoperative course was uneventful and there were no recurrences.

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We have examined a total of 15,224 women in our hospital aiming at a mass screening of breast cancer with mammography (MMG) during the last 8 years. Subjected women were teachers or staffs of public schools in six prefectures in the Tohoku area. More than 90% of them were under 50 years old and women younger than 49 accounted for about half of them. A recall rate was 3.8%, and breast cancer was found in 55 women (0.36%) and the ratio of cancers diagnosed among recalled women was 9.5%. Twenty-one point eight percent of detected cancers were associated with calcification. The average diameter of the detected tumors in the screening group was 1.6cm, whereas that of outpatients (controls) was 2.5 cm. Stage 0 and I cancer cases in the screening group accounted for 82.0%, whereas those in the outpatient group, 49.6%, indicating a significant increase in detection rate of early breast cancer in the screening compared to the outpatients group. However, detection rate of breast masses was 76.7% of all cases of breas tumor by means of MMG, versus 86.0% by means of physical examination. These results suggest that the mass screening by using physical examination and MMG, as well as ultrasonography, may provide a better clinical application for precise diagnosis, when it is done for working women in the regional public schools who are younger.

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Purpose : We developed a safe and simple technique for open gastrostomy using a replaceable Ideal Button, for a case in which percutaneous endoscopic gastrostomy (PEG) or percutaneous trans-esophageal gastro-tubing (PTEG) was not possible due to recurrence of thyroid cancer in the neck. Procedure : After introducing the guidewire into the hole in the side of the bumper of the button, it was linearized by an obturator and inserted into the stomach. The insertion site in the gastric wall was purse-string-sutured by two stitches of absorbable suture, and the stomach was fixed to the abdominal wall at four points to prevent postoperative buried bunper syndrome and peritonitis. In order to start enteral nutrition in the early postoperative period, a 14Fr sump tube was inserted along the guidewire through the side hole of the bumper. The tube was replaced by inserting the guidewire and using the obturator, and its position in the stomach and absence of leakage into the abdominal cavity were confirmed under fluoroscopy. Conclusion : By devising a method of open gastrostomy using a replaceable Ideal Button for a case in which PEG or PTEG was not possible, enteral nutrition was safely started in an early stage, and the tube was replaced safely and easily.

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The data of 10 patients who underwent emergency operations for colorectal perforation due to colorectal cancer between January 2001 and December 2008 were compared to evaluate their preoperative condition, treatment, and prognosis. Our results suggest that there was no significant difference in the presence of positive or negative lymph node dissections between emergency surgery survivors and nonsurvivors. In patients with colorectal perforation due to colorectal cancer, lymph node metastasis is not rare. In our cases, the rate of lymph node metastasis was 50%. The patient's prognosis was not bad : 6 cases are still alive ; 4 cases died during surgery, due to other diseases, or having stageIV disease.
In general, the death rate related to peritonitis due to colorectal perforation is high. Patients who have a curative operation may expect a long-term convalescence, especially if they also require emergency operation for perforation due to colorectal cancer. Therefore, radical surgery with lymph node dissection should be performed in cases which present with perforated colorectal cancer, if the patient's general condition allows.

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This paper deals with our experience with three cases of laparoscopic-assisted Hartmann's procedure for colorectal cancer.
Patient 1 was a 75-year-old man with Rb rectal cancer who was on hemodialysis and had massive ascites and cardiovalvulitis. Patient 2 was an 82-year-old man with Rb rectal cancer who had cerebral infarction and severe dementia. Patient 3 was an 81-year-old woman with RS rectal cancer who had serious cirrhosis, massive ascites, and diabetes mellitus.
In a series of 463 cases of colorectal cancer resected in our institution since its opening, Hartmann's procedure has been employed in 23 cases (4.9%) and laparoscopic Hrtmann's procedure, in three cases. Patients with rectal cancer of RS : ∼T3 and Ra/Rb : ∼T2 are candidates for this laparoscopic operation in our institution. A mean age of them was 79.3 years old and a mean tumor diameter was 42 mm, There were two cases of tumor depth of invasion of T2 and one case of T3. A mean operating time and a mean operative blood loss were 249 min and 24g, respectively. Postoperative complication (postoperative bleeding) developed in one case in which conservative therapy was successful. The drain indwelling time was 8 days on an average. All three patients were able to start taking meals on the postoperative day 3. A mean duration of postoperative hospital stay was 14.3 days.
It is concluded that laparoscopic-assisted Hartmann's procedure is minimally invasive and can be performed safely for high risk cases of colorectal cancer in which we have to avoid intestinal reconstruction.

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A rare case of breast cancer is described. A 50-year-old woman presented with a left axillary mass, which she had noted one year earlier. The lesion was excised given a preoperative diagnosis of atheroma. On histology, an invasive ductal carcinoma with a ductal component was diagnosed. On immunohistochemistry, the tumor cells were positive for both estrogen and progesterone receptors ; staining for HER2 was negative. These findings were compatible with accessory breast cancer. The surgical margin was suspected as being positive. The patient had additional excision and axillary lymph node dissection ; the skin defect was filled using a local flap in order to preserve shoulder joint movement. The patient has had no recurrence for one year since surgery.

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A 34-year-old man complained of throat pain and stated that he had swallowed a chopstick. His chest X-ray was normal, and upper gastrointestinal endoscopy revealed only a laceration at the lower pharynx. Two days later, he developed a high grade fever, cervical swelling, and throat pain. Chest computed tomography (CT) showed mediastinal emphysema and a foreign body. Surgery was done immediately to remove the foreign body and to institute mediastinal drainage. Using a rigid esophagoscope a laceration located at the lower pharynx, was identified ; the laceration was sutured. On the 19^th day after surgery, he was discharged from hospital. The mediastinal infection has not recurred.
It is difficult to detect a wooden foreign body on plain X-ray. Several authors have reported that CT is the most effective imaging modality in such circumstances. It is important to use appropriate CT window settings and to reconstruct the images using three dimensional CT.

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A 33-year-old male patient was transferred to our hospital for persisting fever of unknown origin. Multiple blood cultures demonstrated Staphylococcus aureus and echocardiography revealed a huge vegetation on the anterior leaflet of the tricuspid valve. Despite internal treatment with several antibiotics, no improvement in inflammation was gained. The patient was thus operated on. About half of the anterior leaflet was resected to remove the vegitation attached there and then the tricuspid valve repair using autologous pericardium and artificial chordae was performed. The postoperative course was uneventful and he was discharged on the 30th day after the operation. There has been no recurrence of inflammation for 1 year of follow-up period.
The technique of leaflet repair with autologous pericardium and artificial chordae might be a valuable choice for patients with infective endocarditis of the tricuspid valve which can cause leaflet destruction.

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A 61-year-old woman who suddenly developed back pain was noticed to have left paralysis by her family and was brought into a hospital by ambulance. She was then transferred to our hospital after diagnosed as having acute type A aortic dissection with cerebral infarction. Her Japan Coma Scale was 10. Her arm systolic blood pressure was in the 70mmHg range on the right while in the 110 mmHg range on the left. CT scan showed an aortic dissection started from the ascending aorta to bilateral iliac arteries, and the brachiocephalic artery (BA) and the right common carotid artery (RCCA) were occluded by thrombosed false lumen. We started emergency operation. Operative procedures included cardiopulmonary bypass with arterial cannulation from the left axillary and femoral arteries, and venous cannulation from the right atrium. We found the dissection entry at the ascending aorta. We inserted a Fogarty catheter to the RCCA from the BA, scraped thrombus, and then replaced the ascending aorta. Her left extremities started moving on POD 3, and she was able to walk by herself. She was discharged on POD 33.
We report a case of acute aortic dissection with left hemiplegia treated without sequela.

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Over the past 8 years, 9 cases with ruptured abdominal visceral aneurysms were treated. The lesions involved the following locations : 3 cases involved the middle colic artery, 2 cases the right colic artery, and 1 case each for the pancreaticoduodenal artery, the first jejunal artery, the left gastric artery, and splenic artery. Angiography was done in all cases. TAE was attempted in 8 cases. Hemostasis was achieved using TAE in 3 cases ; 4 cases required emergency surgery. We performed 1 resection of the aneurysm, 2 ligations and 2 intestinal resections which included the aneurysm. Seven cases are still alive and 2 have died. One aneurysm recurred and rebled during the perioperative period. In this case, TAE was performed successfully. On pathology of the 3 cases, in whom a pathology report was available a diagnosis of segmental arterial mediolysis (SAM) was made. When a ruptured abdominal visceral aneurysm is suspected, angiography should be done first and TAE should be attempted as first-line therapy. We would recommend MDCT for follow-up of ruptured abdominal visceral artery aneurysms.

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Pulmonary Langerhans' cell granulomatosis (PLCG) is a rare lung interstitial disease. We report two cases of PLCG diagnosed on lung biopsy obtained during video-assisted thoracic surgery (VATS). Case 1 was an asymptomatic 25-year-old man who had an abnormal shadow on routine chest X-ray. His chest computed tomography (CT) showed multiple nodular shadows that were present bilaterally. A lung biopsy was obtained during VATS. The pathological diagnosis was PLCG. The patient had quit smoking prior to surgery. Three months after smoking cessation, the nodules were not present on chest CT. Case 2 was a 30-year-old man who had a fever and chest pain. His chest X-ray showed a left-sided pneumothorax ; chest CT showed nodules of varying sizes present bilaterally. He was diagnosed as having PLCG based on the biopsy obtained during VATS. The patient had quit smoking prior to surgery. On chest CT scan done eleven months after smoking cessation, the nodular lesions found to have decreased in size ; his pneumothorax has not recurred.

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A 22-year-old woman presented with an asymptomatic pulmonary nodule detected on routine chest X ray. The chest CT showed an approximately 1.5-cm, solitary, well-circumscribed nodule located in the S6 segment of the right lung. A pulmonary S6 segmentectomy was performed. The tumor histopathologically showed spindle cell proliferation with infiltration of various inflammatory cells ; a pulmonary inflammatory myofibroblastic tumor was diagnosed. The patient is still alive 46 months after surgery ; no recurrence has been noted. Inflammatory myofibroblastic tumor is a rare disease that most often occurs in the lung. We report this case and review the literature.

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We report a case with both an esophageal squamous cell carcinoma and a gastric adenocarcinoma located at the esophagogastric junction. An 81-year-old male complained of heartburn. On endoscopy and pathology, a squamous cell carcinoma was diagnosed in the lower esophagus that infiltrated the cardiac part of the stomach. He had a lower esophagectomy with a regional lymph node dissection and reconstruction using a gastric roll via a right thoracotomy and laparotomy. On postoperative pathology, two different carcinomas were identified an esophageal squamous cell carcinoma and a gastric adenocarcinoma, which had originated independently of each other. The two tumors met at the esophagogastric junction ; there was no intermingling.

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A 60-year-old man had a tumor shadow in the right upper lung field on enhanced computed tomography (CT) ; on histology of the biopsy specimen, a lung adenocarcinoma was found. Nine months after a curative resection an elevated CEA level was noted and multiple brain metastases were found on enhanced magnetic resonance imaging (MRI). After gamma knife therapy the brain metastases disappeared and the CEA level returned to normal. In July 2003, the CEA level increased again ; on enhanced CT, ultrasonography, and 16F-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET), a tumor located close to the gall bladder, transverse colon, and stomach was found. A distal gastrectomy and cholecystectomy was required. On histopathological examination and immunohistochemical staining with a monoclonal antibody to TTF-1, gastric metastases were identified. The patient has remained disease-free during 4 years of follow-up.

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We report a case of a gastric wall abscess with choledocholithiasis and cholangitis. A 74-year-old woman developed jaundice and epigastralgia. Her WBC count, CRP levels and direct bilirubin levels were remarkably elevated. A submucosal tumor, 5 cm in size, was seen in the fundus of the stomach during the insertion of endoscopic nasobiliary drainage. Contrast enhanced CT showed choledocholithiasis and thickening of the gastric wall with irregular enhancement. The patient had a cholecystectomy, choledocholithotomy, and partial gastrectomy. On pathology, a gastric wall abscess with the formation of inflammatory granulation tissue and neutrophil infiltration was noted.

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The patient was a 75-year-old female who had hematemesis. On gastroscopy, an arterial hemorrhage from a submucosal tumor located in the anterior wall of the superior gastric body was found. Since endoscopic hemostasis was difficult to achieve, angiography-guided arterial embolization with a microcoil was performed. Then, contrast-enhanced radiography of the upper digestive tract and abdominal computed tomography (CT) were done ; they showed an extramural gastric lesion, measuring 5.5 cm in diameter, with marked calcification. Under a tentative diagnosis of a gastrointestinal tumor (GIST), a partial gastrectomy was performed via laparotomy. The resected specimen measured 5.3×4.6×4.3 cm and was hard. On the cut surface, marked calcification and hyaline degeneration were noted. Immunohistologically, the patient was positive for c-kit and CD34, and negative for αSMA, desmin, and S-100 ; these results suggested GIST. The number of nuclear divisions was 1 or less per 50 highly magnified visual fields, suggesting a low-level malignancy. There has been no relapse during the 17-month postoperative follow-up period. In Japan, only 6 such GIST cases have been reported to date. In this paper, we report our patient and review the literature.

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The patient was a 60-year-old woman who had visited the hospital because of edema and had been detected to have iron deficiency anemia and hypoproteinemia in 1996. At that time, gastric endoscopy showed gastric polyposis with giant folds in the whole stomach as well as a huge polyp prolapsing from the stomach into the duodenum. Hyperplastic polyp was diagnosed and her clinical course had been followed until December 2005, when she had tarry stool and vomiting. Antral stenosis due to the giant polyp at the pyloric antrum was diagnosed. Surgical therapy was considered necessary because the polyp resisted conservative therapy. Laparotomy was thus performed. During surgery, extraserosal invasion and peritoneal dissemination were identified. Total gastrectomy was performed with the diagnosis of peritonitis cancinomatosa due to gastric cancer. The histopathological diagnosis was juvenile polyposis localized in the stomach with gastric cancer.
Generally juvenile polyposis is believed to be non-tumorous hyperplastic lesion and to show a malignant change in few cases. However, the disease can be associated with cancer in a high incidence and hence total gastrectomy would be required as a radical therapy for protein-losing gastroenteropathy and anemia.

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Gastric small cell carcinoma is an extremely rare entity which rapidly grows and progresses to carry poor prognosis. We report two patients with the disease who survived for a comparatively long time.
Patient 1, an 80-year-old woman, was found to have a type 2 tumor at the posterior wall of the lesser curvature of the gastric antrum by upper gastrointestinal endoscopy while she had been followed her clinical course after surgery for ovarian cancer. A biopsy provided a diagnosis of gastric small cell carcinoma. Distal gastrectomy + D1β dissection was thus performed. The histopathological findings were pT2(SS), ly2, v2, pm(-), dm(-), pN1(2/32 : #4d, 6), and fStageII.
Patient 2, a 57-year-old man, was detected to have a submucosal tumor like lesion with ulcer at the cardiac part of the stomach at a medical check-up. A biopsy provided a diagnosis of gastric small cell carcinoma, and total gastrectomy + D2 dissection and associated resection of the spleen and gallbladder were performed. The histopathological findings were pT2(MP), ly2, v1, pm(-), dm(-), pN1(1/17 : #3), and fStageII.
In a series of 2566 cases of gastric resection in our institution, two cases were of gastric small cell carcinoma, accounting for 0.08%. These two patients who were detected having this neoplasm in Stage II have been free from recurrence, as of 3 years 2 months and 2 years 7 months, respectively, without adjuvant chemotherapy. There two cases are reported, together with some bibliographical comments.

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A 68-year-old male was found to have a gastric cancer located in the middle one-third of the stomach. Computed tomography revealed swelling of the lymph nodes adjacent to the lesser wall of the stomach. The patient had a Billroth I gastrectomy with a D2 lymph-node dissection. On pathology, signet-ring cell carcinoma with submucosal invasion of the stomach was diagnosed. However, the metastatic lymph nodes contained small cell carcinoma that stained positive for chromogranin A. No other malignancy in other organs such as the lung was found to account for the lymph node metastasis S-1 adjuvant chemotherapy was given. The patient is alive 3.6 years after surgery.

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A 66-year-old woman developed gastrointestinal bleeding and progressively worsening anemia. Abdominal contrast-enhanced CT scanning and upper gastrointestinal endoscopy showed gastrointestinal bleeding from a submucosal tumor, located at the lower duodenum curve which grew extraluminally. Endoscopic hemostasis was not successful. Three days after admission, the patient developed massive hematemesis, which resulted in hypovolemic shock. She had emergency surgery to resect the tumor and the bleeding site. A laparoscopic partial duodenectomy was also done. After insufflation, her arterial blood pressure increased and vital signs became sTable allowing laparoscopic surgery.
She was discharged on the 16^th postoperative day. On histopathology, a gastrointestinal stromal tumor was found.
It is well known that elevated intraabdominal pressure lead to increased arterial blood pressure. In cases complicated by hemorrhagic shock, the establishment of a pneumoperitoneum during laparoscopic surgery has a large effect on the circulation. This effect and its uses should be studied further.

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The patient was a 30-year-old woman with von Recklinghausen's disease who had undergone pylorus-preserving pancreaticoduodenectomy (PpPD) for carcinoid tumor of the papilla of vater in 1998, when lymph nodes #13b, 17a and 17b were positive for cancer. Eight years after this operation, sizing up of para-aortic lymph nodes (#16b) was pointed out by an abdominal CT scan and the size of the lymph nodes got bigger year after year. And FDG-PET imaging revealed FDG uptake in the same place, and we performed resection of the swollen lymph nodes for diagnosis and treatment. Histopathologic diagnosis of the resected specimen was metastasis of carcinoid tumor of the papilla of vater. The patient remains alive as of 10 months after the operation without reccurence and metastasis.

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A 38-year-old man came to the emergency room in our hospital because of abdominal pain. On admission, there was tenderness in the entire abdomen and the abdomen was board-like. He was diagnosed as having generalized peritonitis. Blood tests showed a high level of the serum amylase and high-degree of metabolic acidosis. An abdominal contrast CT scan revealed swollen pancreas, narrowed superior mesenteric artery, portal venous gas, and poorly-enhanced intestinal walls. Emergency operation was performed under a diagnosis of intestinal necrosis with acute pancreatitis. Upon laparotomy, the blood flow in an area from the lower part of the small intestine to the right side of the colon was obstructed. Therefore, resection of these intestines was performed. The postoperative pathohistological diagnosis was nonocclusive mesenteric ischemia (NOMI). To the best of our knowledge, there have been only 5 reported cases of NOMI or intestinal gangrene following acute pancreatitis in Japan. We present our case with a review of the literature.

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A 31-year-old unmarried woman developed abdominal pain and vomiting in July 2006. Given a diagnosis of ileus the patient had an intestinal tract decompression using a Denis tube. Despite symptomatic relief, enterography showed a stenotic lesion in the terminal ileum. During laparoscopic surgery, a kinking stenosis of the ileum and adhesions between the lesion and the uterus were noted. The adhesions were dissected and the stenosis was released without resecting the bowel. On histopathology, endometriosis was found in the adhesive tissue. An LH-RH analogue was given as adjuvant therapy. The patient has had no recurrence in the two years and six months since surgery. Our case is the first reported in Japan of ileal endometriosis presenting with intestinal obstruction that was not treated by bowel resection. In this paper, we also reviewed the 49 cases of endometriosis causing ileal obstruction reported in the Japanese literature.

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Meckel's diverticulum is a rare entity and it can occasionally cause perforation and hemorrhage. In this paper we present a case of Meckel's diverticulum causing ulcerative perforation in a juvenile patient, together with a review of the literature.
A 13-year-old boy, who had visited a hospital because of lower abdominal pain in the evening, was brought into our hospital by ambulance for aggravated abdominal pain on the next day. When he was first seen, the abdominal wall was hard and there was strong peritoneal sign. Inflammatory reaction showed a high value on blood examination. Abdominal CT scan demonstrated findings of peritonitis due to intestinal perforation. Emergency laparotomy was thus performed when a Meckel's diverticulum with a large perforation in its center was identified in the ileum at about 50cm proximal to the ileocecal region. A wedge resection of the ileum including the diverticulum was performed. The histopathological studies showed the greater cul-de-sac line near the bottom of the ulcer, and it was etiologically considered that the ulcer had been formed in the ectopic gastric mucosa, causing perforation.
Meckel's diverticulum is rare but it can sometimes cause gastrointestinal perforation or hemorrhage of unknown cause. Accordingly the diseases must be kept in mind as a possible cause of acute abdomen in juvenile patients.

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The solitary metastasis of colon cancer to the small intestine is rare. Case 1 : A 64-year-old female had a right hemicolectomy for ascending colon cancer (fStageIIIa) in September 2004. She developed an ileus and elevated serum CEA levels Subsequently, a small intestinal tumor was detected on colonoscopy. In October 2005 a partial resection of the small intestine was done ; chemotherapy was given. However, the patient died due to lung, liver, and bone metastasis of the colon cancer. Case 2 : A 56-year-old female had a right hemicolectomy for cecum cancer (fStageII) in November 2007. She had repeat episodes of ileus after surgery. Thus, the patient had a repeat laparotomy. A tumor of the small intestine was detected, and a partial resection of the small intestine was performed in February 2008. A metastatic splenic tumor was found in November 2008. After chemotherapy, laparoscopic assisted splenectomy was performed in March 2009. In both patients, the typeIItumor had infiltrated to the serosal surface of the ileum, and on pathology, a solitary metastasis of colon cancer to the small intestine was diagnosed. Clinically, no peritoneal dissemination was present. Metastases to the small intestine in such cases is thought to have either a hematogenous or a lymphogenous route.

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The patient was a 35-year-old woman who underwent myomectomy on May 12, 2008 after being diagnosed as having uterine myoma. During laparotomy, a spherical neoplastic lesion approximately 2 cm in diameter was found protruding from the ileal wall about 80 cm from the terminal ileum. Partial resection of the small intestine was consequently performed. Histopathological analysis showed that the lesion was a mixed tumor composed of well-differentiated adenocarcinoma with a papillary structure and carcinoid tumor with circular-shaped cells forming alveolar, luminal, or ribbon-like structures. We experienced a case of mixed carcinoid-adenocarcinoma of the small intestine that was incidentally found during myomectomy. We report the present case with reference to literature as we consider it an interesting case from the perspective of histogenesis.

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A 51-year-old man, who had undergone right upper lobectomy for adenocarcinoma of the lung in 2002 (p-T1 N2 M0 pStageIIIA), had been prescribed UFT-E and followed on an ambulant basis for 3 years. In July 2007, tumor recurrence was suspected in the upper mediastinal lymph nodes on a surveillance CT scan, which was then confirmed by FDG-PET. The patient received radiation therapy at a dose of 60Gy. In May 2008, the serum CEA level increased to 16.1ng/ml, but there was no evidence of tumor recurrence in the thoracic cavity by FDG-PET. FDG-PET showed high FDG accumulation in the appendix and mesenteric lymph nodes. There were no recognizable abnormalities by colon endoscopy. We suspected a malignant tumor of the appendix and performed laparoscopic ileocecal resection and D2 lymphadenectomy. The histopathological diagnosis was poorly to moderately differentiated adenocarcinoma. The tumor was immunostained for TTF-1(+), CK(+), and CK20(-) and diagnosed as appendiceal metastasis from lung cancer. Here we report this case of appendiceal metastasis from lung cancer with a review of the literature.

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A 61-year-old man who had been followed as an outpatient after treatment of cardiac infarction became to have right lateroabdominal pain and a slight fever from February 2007. He was admitted to our hospital because internal medication was unsuccessful. A fist-sized mass was palpable in the right flank, and abdominal CT scan showed the mass with an abdominal abscess in the ileocecum. We diagnosed the case as colon cancer with an abdominal abscess and performed surgery after inflammatory reaction was improved by conservative therapy. Operative findings revealed ileocecal cancer with abscess formation at the abdominal wall. Right hemi-colectomy and abdominal wall resection including the abdominal abscess were performed. The postoperative course was uneventful and he was discharged on the post-operative day 20. He is doing well as of one year and a half after the surgery without relapse. To our knowledge, colon cancer with an abdominal wall abscess is comparatively rare and we discuss it in light of the literature.

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A 67-year-old man suddenly developed severe abdominal pain. On abdominal CT, rotation of the small intestinal mesentery and gas in the small intestine wall were found. Under a diagnosis of strangulated ileus of the small intestine emergency surgery was conducted. On laparotomy, an oval defect, 3 cm in diameter, was found in the sigmoid mesocolon. Approximately 180 cm of the small intestine had herniated through the defect from the outside of the sigmoid colon and had become strangulated. Under a diagnosis of transmesosigmoid hernia-related strangulation ileus, the necrotic intestine was resected and the oval defect was closed. Transmesosigmoid hernia is rare. In this paper, the relevant Japanese literature is also reviewed.

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A 51-year-old man who was diagnosed as having acute appendicitis at another hospital and was transferred to our hospital for the purpose of operation was performed an emergency operation. Operative findings included marked inflammatory change in the right-lateral colon and perforation at the ileocecal region. In addition a tumor lesion of the transverse colon was suggested on palpation. Right hemicolectomy with massive irrigation drainage was thus performed. On the resected material multiple ulcers with rand wall were seen in the entire right half of the colon. Pathologically amebae (trophozoite) were identified, and amebic colitis was definitely diagnosed. Metronidazole was orally administered at a dose of 1500mg/day for 10 days, starting at the 13^th hospital day. Colonoscopy performed on the 30^th hospital day showed multiple ulcers in the anal side colon from the anastomosed site, and hence oral administration of metronidazole 1000mg/day was added for 10 days. The patient was discharged from our hospital on the 49^th hospital day.
From 1970 to 2008, a total of 72 cases, including our case, of fulminant amebic colitis with colon perforation have been reported in Japan. We present our case, together with some bibliographical comments.

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The patient was a 69-year-old woman who had been diagnosed as having systemic sclerosis 24 years prior. One year prior, she developed proctopsia, which became exacerbated rapidly. The patient was 149 cm tall and weighed 34 kg. She had brown, shiny spots of sclerema on the face and fingers. About 10 cm of rectum had prolapsed. The prolapsed rectum was edematous and engorged ; it was the size of a softball. The CT examination on exertion showed that gas was retained in the wall of the prolapsing rectum, and that the rectum was invaginated by the small intestine. The proctopsia was treated by perineal proctosigmoidectomy (Altemeier technique) combined with levator muscle suturing. The postoperative course was uneventful Systemic sclerosis accompanied by fibrous sclerosis of connective tissue can cause proctopsia. The Altemeier technique is considered effective for proctopsia caused by systemic sclerosis. It is not invasive and allows levator muscle suturing.

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We present a case of transverse colon cancer with portal and peri-aortic lymph node metastases, in which curative lymph node dissection provided recurrence-free survival for one year and 5 months which was done one year after operation for the primary colon cancer.
A 79-year-old woman underwent right hemi-colectomy with dissection of regional lymph nodes and sampling dissection of porta hepatis lymph node in July 2006. The specimen was histologically proved to be poorly differentiated adenocarcinoma, mp, n3, H0, P0, M1 (portal lymph node), StageIV, and curability C. After the operation, we began chemotherapy with oral S-1 for the residual portal and peri-aortic lymph nodes and attained PR. But 1 year later, the residual lymph nodes swelled again. We enforced curative dissection of metastatic lymph nodes at the porta hepatis and peri-aortic area in July 2007. We dissected a total of 17 lymph nodes, and six of them were histologically proved to contain poorly differentiated adenocarcinoma cells. The six positive lymph nodes were of no.8, 12a, 13, or 16a lymph nodes. No adjuvant chemotherapy was employed and she is alive without recurrence as of 1 year and 5 months after the second operation.
In the treatment of colon cancer with advanced lymph nodes metastasis, we consider that surgical treatment with curative dissection of lymph nodes is recommended if the metastasis is localized, and no other organs are involved.

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A 43-year-old female presented with abdominal pain, diarrhea, and fever. Abdominal CT scan revealed an abdominal wall abscess, 7cm in diameter, and a thickened descending colon encircling the lumen which continued to the abscess. Perforation of the descending colon by colon cancer with abscess formation was suspected. Despite administration of an antibiotic for 2 days, her condition deteriorated and left hemicolectomy and simultaneous abscess drainage were performed. Histopathologically, the tumor was undifferentiated carcinoma without neuroendocrine features on immunohistochemical examination. The postoperative course was uneventful and adjuvant chemotherapy was started. However, liver metastases occurred quite early, and the patient died 7 months after the operation.
Undifferentiated carcinoma of the colon is quite rare, accounting for less than 1% of all cases of colon cancer. Its prognosis is very poor. Colon cancer with an abdominal wall abscess is also rare. Most such cases reported so far are of well-differentiated adenocarcinoma or mucinous carcinoma, and this is the first report of undifferentiated colon carcinoma associated with an abdominal wall abscess.

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A 14-year-old boy was diagnosed as having an acute appendicitis. An urgent laparotomy was done on the day of admission. On laparotomy, a markedly swollen appendix and a thickened cecum were found ; an ileocecal resection was performed. On histopathology, mucinous adenocarcinoma-signet ring carcinoma without lymph node involvement was diagnosed. Therefore, the patient had a right hemicolectomy with lymph node dissection, which is the standard radical operation for advanced colonic cancer. After the operation, he received adjuvant chemotherapy. However, peritoneal metastasis developed 3 years after the operation. He died of peritonitis carcinomatosa 56 months after the first operation. Signet ring cell carcinoma of the colon in children is very rare. To date, only 16 cases have been reported in Japan.

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A 76-year-old female had a proctocolectomy due to familial adenomatous polyposis 40 years earlier ; she developed general malaise with severe hyponatremia and hyperkalemia. A large tuberous tumor was found at the ileostomy site. The tumor had been noted five years prior ; on biopsy, a well differentiated adenocarcinoma had been diagnosed at that time. The patient had a wide resection and a reconstruction of the abdominal wall using an inguinal muscle cutaneous flap. Primary adenocarcinoma rarely develops at the ileostomy site, and its pathogenesis is still unclear. However, the literature indicates that long-term ileostomy is by itself risk factor for developing cancer, regardless of the underlying disease.

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We report an adult case of capillary hemangioma of the liver. A hepatic tumor was detected during pre-operative screening for breast cancer in a 41-year-old woman. The lesion increased in size during one-year of follow-up. She was otherwise well, and blood laboratory tests were normal. The lesion was about 2 cm in size ; on ultrasonography, a circumscribed hypoechoic tumor was seen in Segment 3. On plain computed tomography, the tumor was found to be a low density lesion, which was strongly and homogeneously enhanced in the early phase and slightly enhanced in the late phase on dynamic studies. Since the tumor size had increased and the patient requested confirmation of the lesion's pathology, a laparoscopic partial hepatectomy was conducted to rule out malignancy. Histologically, the tumor was diagnosed as a capillary hemangioma. It is difficult to diagnose capillary hemangioma. However it is important to consider this disease in patient's with a liver tumor showing particular CT findings.

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A 68-year-old male had hepatocellular carcinoma (HCC) associated with primary biliary cirrhosis (PBC). The PBC was not accompanied by clinical symptoms such as jaundice and Pruritus. A liver tumor was detected on follow-up ultrasonography. Since the tumor's size gradually increased, further tests were done.
Dynamic computed tomography showed a 2.5-cm-diameter tumor located in segment 7. The tumor had a high-density area in the arterial phase and a low-density area in the portal and the capillary phases. Therefore, the tumor was diagnosed as an HCC with PBC. Given that the ICGR15 was 17.6% and the liver function reserve was reasonable, an extended posterior segmentectomy was performed. On histopathology, the tumor was found to be a moderately to poorly differentiated HCC, and the non-cancerous liver tissue was diagnosed as Scheuer stageIVPBC. It has been reported that the 5-year-survival rates of PBC cases have increased. Therefore, resectable HCC with PBC cases with an adequate liver function reserve should have a hepatectomy.

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A 74-year-old female developed fever and epigastralgia. Laboratory data showed inflammation and elevated hepato-biliary enzyme levels. The common and intrahepatic bile ducts were dilated. She was diagnosed as having an acute obstructive cholangitis ; percutaneous transhepatic biliary drainage was performed. Cholangiography revealed an irregular stenosis at the lower portion of common bile duct. Therefore, cholangiocarcinoma was diagnosed, and a pylorus-preserving pancreatoduodenectomy was done. On surgery granular mucosa, 13×12 mm in size, was seen at the lower bile duct ; the wall was thickened and stenotic in one area. On histopathology, the bile duct epithelium was structurally papillary ; mild reproductive atypia was seen, but carcinoma was not seen in the mucosa. The patient was diagnosed as having an adenomatous hyperplasia of the lower bile duct. Hyperplasia of bile duct epithelium is generally thought to be a precancerous lesion since it often accompanies carcinoma. In fact, case with only local stenosis of bile duct are rare. In such cases it is difficult to differentiate the lesion from a malignant leision.

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During laparoscopic cholecystectomy, it is important to check for remnant calculus by palpating the cystic duct with a clamp. We report a case with carcinoma of the cystic duct that was diagnosed using this technique. A 76-year-old male developed right hypochondralgia. The preoperative examination revealed that there was no tumor in the biliary tract except for a calculus measuring approximately 15 mm in diameter that was located in the gallbladder. A laparoscopic cholecystectomy was performed. A mass was found on palpation with the clamp when searching for any remnant calculi before treatment of the cystic duct. The intraoperative pathological diagnosis of the cystic duct with the mass dissected from the bile duct side indicated papillary adenocarcinoma. Therefore, the bile duct was resected, and a hepatocholangiojejunostomy was performed. During laparoscopic surgery, it is important to obtain information via palpation.

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A 54-year-old male was admitted to our hospital because of upper abdominal discomfort after meals and mild fever. Laboratory findings showed that the values of CRP, serum amylase, urine amylase, and elastase 1 were positively high. Abdominal CT scan revealed that a calcified substance of 1.5 cm in diameter was in the body of the pancreas, the density of the fat tissue around the pancreas was elevated, and fluid collected in the abdominal cavity. MRI image showed the dilatation of the duct of the body and the tail of the pancreas. Accordingly, obstructive pancreatitis due to incarceration of the pancreatic stone was strongly suggested. A couple of weeks after the conservative therapy, the disease flared up. Therefore the surgical treatments were performed, including distal pancreatectomy, removal of the fragments of the stone through the cut of the pancreatic duct, and abdominal irrigation and drainage. There was not any considerable morbidity after the operation.
Recently extracorporeal shock wave lithotripsy (ESWL) and endoscopic intervention for obstructing pancreatic duct calculi have been performed and might be considered first in such cases. But when the disease becomes worse after the conservative therapy or if the size of the calculus is inadequate for the endoscopic therapy, surgical treatments should be taken promptly.

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There are several reports of internal drainage for pancreatic fistula done using interventional techniques. We report a case of pancreatic fistula after pancreaticoduodenectomy treated successfully with non-invasive internal drainage via a percutaneous endoscopic gastrectomy (PEG). A 54-year-old man had a pancreaticoduodenectomy reconstruction which included choledoco-jejuno and gastro-pancreatico anastmosis. The patient required surgery due to postoperative bleeding from pancreatic anastomosis leakage ; the patient required hemostasis and pancreatic juice drainage using a sprint tube inserted into the main pancreatic duct. Given the patient's malnutrition, open surgery for internal drainage was not advisable. Therefore, PEG was done first, and a pancreatic tube was inserted into the residual stomach via the PEG to improve the patient's nutritional status. After the patient's malnutrition was corrected, with the patient under local anesthesia, the pancreatic tube was buried in the subcutaneous space for internal drainage. In the three years since internal drainage was instituted, no untoward effects such as tube obstruction, have been noted. In a patient with malnutrition secondary to a pancreatic fistula, internal drainage can be safely achieved after the patient has improved their nutritional status by directing the pancreatic juices into the digestive tract via a PEG.

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This paper presents a case of recurrent bouts of pancreatitis after pancreaticoduodenectomy treated by using a double balloon endoscope, with resultant symptomatic remission due to the improved defluxion of pancreatic juice.
The patient was a 76-year-old man who had undergone pancreaticoduodenectomy (PDIIA-1) for pancreas head cancer in March 1997, and had been detected no recurrence by periodic examinations until recently. During this time he had been admitted to our hospital because of acute abdominal pain caused by pancreatitis six times. On April 18, 2008, he was seen at our hospital because of left hypochondriac pain. Abdominal CT scan and magnetic resonance cholangiopancreatography (MRCP) showed acute inflammation in the remaining pancreas. After emergency admission, he was treated by a fast cure and received anti-inflammatory drugs intravenously. The abdominal pain improved gradually by those treatments. However, abdominal pain recurred with an increase in meals and he had had repeated episodes of pancreatitis before admission so that we concluded it was necessary to observe the anastomosis of the pancreaticojejunostomy directly. Since it was difficult to reach the attollens jejunum by using a usual scope, we employed a double balloon endoscope to observe the anastomosis. With this approach, a stone formed by a suture thread was observed at the anastomosis and we etiologically considered that frequently-occurred pancreatitis might be caused by the stone. We removed the stone and the thread endoscopically. After the treatment, symptomatic remission was attained.
Double balloon endoscopy is useful for observation, diagnosis, and treatment of postoperative reconstructed gastrointestinal tract, as well as for diagnosis of small intestinal diseases.

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A 73-year-old man initially noted stomach bloating, anorexia, and abdominal pain. His abdominal pain got worse and he was admitted. On admission, the abdominal CT showed a 13cm-sized cyst that was located in the pancreatic tail. Two hours after admission, the patient developed severe abdominal pain. The abdominal CT was done again, and a reduction of the pancreatic pseudocyst was found ; ascites lateral to the liver and the spleen was also noted. On emergency laparotomy, it was found that the pancreatic pseudocyst had ruptured. The pancreatic tail, along with the cyst and the spleen, was removed. A pancreatic fistula developed after surgery, transpancreatic stenting was required.

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A 72-year-old man, had a right hemicolectomy for an ascending colon cancer (tub1, a2, n0, ly0, v0, stage II) done in January, 2005. However, 2 years 10 months of postoperatively on CT a pulmonary mass and a 1-cm pancreatic tail lesion with were noted. The pulmonary mass was surgically removed ; on histopathology, a diagnosis of ascending colon carcinoma that had spread to the lungs was made. The mass in the pancreatic tail was followed ; 3 years 3 months after initial surgery the mass was found to be 3-cm large on CT. At that point the body of the pancreas cauda was excised. On histopathology, a diagnosis of colon cancer metastases to the pancreas was made. The patients postoperative course was good, and he left hospital on the 18^th postoperative day. Three months later there was evidence of new spread to the lungs. Chemotherapy was started and is still being given. Metastases to the pancreas of large bowel cancer are relatively rare ; to date, only 21 cases have been reported in Japan. This metastatic pattern to lungs and pancreas is caused by hematogenous metastasis.

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The patient was a 58-year-old woman. On routine abdominal ultrasound, a splenic tumor, 5.5 cm in diameter was found ; her serum soluble IL-2 receptor level was high (1730 U/mL). Abdominal ultrasound showed a hypoechoic lesion. Contrast-enhanced abdominal CT showed a well-defined low density area that became enhanced over time from the margin to the center. MRI showed a slight high signal intensity on T1-weighted images and a low signal intensity on T2-weighted images. Abdominal angiography showed a hypovascular mass, 5.5 cm in diameter. FDG-PET showed a ring-shaped form corresponding to the site of the tumor, which contained a nonuniform accumulation. Since it was difficult to rule out a primary malignant splenic tumor an open splenectomy was performed. On pathology, noncaseating granulomas with multinucleated giant cells were noted ; splenic sarcoidosis was diagnosed. We report this case of splenic sarcoidosis that was difficul to differentiate from other diseases on imaging.

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A 75-year-old female patient developed a high fever. She had no symptoms of gastroenteritis. She had had surgery related to her angina pectoris and had a mediastinal infection as a complication 3 months prior. Computed tomography and ultrasonography showed a large abscess in the spleen. An echo-guided needle aspiration was performed, and Salmonella Enteritidis was found. No abscesses were detected in any other organs, thus, a solitary splenic abscess caused by Salmonella was diagnosed. The patient received drainage with antibiotic coverage for the first 4 days. However, a splenectomy was required due to a persistent fever ; the patient's fever disappeared 14 days later.
The source of Salmonella infections is generally thought to be food. However, no food source could be identified in this patient. Solitary splenic abscess is rare. Only 9 cases of isolated splenic abscess caused by Salmonella have been reported in the Japanese literature since 1948.

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A 68-year-old woman was seen at the hospital because of abdominal pain. Close exploration for suspected acute peritonitis revealed free air. Emergency operation was performed with a suspicion of perforation of the upper digestive organs. At surgery no perforation was identified in the digestive organs, but formation of an abscess and perforation were seen in the spleen. Splenectomy was thus performed. The patient's postoperative course was uneventful. It was etiologically considered that the splenic abscess formation might be caused by poor control of her diabetes mellitus.
Splenic abscess is a comparatively rare entity. In this paper we present our case, together with a review of a total of 82 cases reported in Japan.

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The patient was a 74-year-old man who was receiving hemodialysis (with normal urinatin) at a local clinic for chronic renal failure due to diabetes mellitus. In mid-April he developed fever and general malaise, and was referred to our hospital from the clinic. Strong inflammatory reaction and fecaluria were observed. Pelvic CT showed abscess formation in the area of the prostate and air in the bladder. Rectovesical fistula due to advanced prostatitis was diagnosed, and a transverse loop colostomy for fecal diversion was performed. The postoperative course was good, and he was discharged with no more inflammatory reaction. We report our experience of a rare case of rectovesical fistula caused by prostatitis together with bibliographic discussion.

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The patient was a 34-year-old man. He had visited a hospital because of abdominal pain and had been found to have an intra-abdominal multilocular cyst occupying from the upper abdomen to the pelvic cavity. Percutaneous drainage with a diagnosis of pseudocyst of the pancreas resulted in symptomatic remission. Four years later, he had recurred abdominal pain. Percutaneous drainage was performed again, but no symptomatic remission was attained. The patient was referred to our hospital. Abdominal CT and MRI scans showed a multilocular huge tumor adjacent to the lesser curvature of the stomach which was considered to be an extrahepatic lesion. The patient was operated on with the diagnosis of a lymphangioma of the lesser omentum. When the abdomen was opened, a huge multilocular cystic tumor was present mainly in the lesser omentum. The tumor was adherent to the pancreas and stomach, but did not invade other neighboring organs. The tumor was removed. On the resected material the tumor was 16×12×9cm in size and 800g in weight. The histopathological diagnosis was cystic lymphangioma. The patient's postoperative course was uneventful, and was discharged in very much improved condition on the 14^th postoperative day.

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A 50-year-old man complaing of abdominal fullness and pain was found to have an abdominal mass. Abdominal CT scan showed a solid mass about 14 cm in diameter consisting of heterogeneous contents. The tumor made extensive contact with the lesser curvature of the stomach. Abdominal angiography showed that the tumor was fed by the righ and left gastric arteries, the dorsal pancreatic artery, the great pancreatic artery and the right epigastric artery. We performed operation under a diagnosis of gastrointestinal stromal tumor (GIST) of the stomach. Laparotomy showed that a mass from the lesser omentum did not invade, but was in direct contact with the lesser curvature of the stomach. Simple resection of the tumor was performed without difficulty. Histopathological study showed that the tumor was composed of proliferated spindle-shaped cells with high cellularity and partly with clotted blood and necrosis. Immunohistochemically, the tumor was positive for c-kit, CD34 and vimentin, but negative for desmin, S-100 protein and alpha-smooth muscle actin. From these findings GIST of the lesser omentum was diagnosed. The patient remains free of recurrence when 29 months have elapsed after the operation.

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