[in Japanese]

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Between October 2004 and December 2007, stereotactic mammotome biopsies were performed for 202 microcalcified lesions on mammography using an up-right stereotactic vacuum-assisted breast biopsy system. We found 39 cases (19.3%) of breast cancer. In these cases, we found 5 cases (12.8%) of invasive ductal carcinoma (IDC) and 34 cases (87.2%) of ductal carcinoma in situ (DCIS). We studied the relationships between the distribution and morphology of the microcalcifications and histopathological incidence of breast cancer. Regarding the distribution of microcalcifications, breast cancer was detected in none of the cases of diffuse calcifications in 21.4% of clustered calcification cases and in 17.6% of fine linear hanching calcification cases. In our hospital, the histopathological incidence of breast cancer was lower in cases of fine linear hanching calcification cases than that in clustered calcification cases. Regarding the morphology of microcalcifications, breast cancer accounted for 2.4%, 7.9%, 57.9%, and 87.5% each of the cases with small round, amorphous, pleomorphic, and fine linear hanching patterns. These results suggest that the morphology rather than the distribution of microcalcifications may be more specific for breast cancers.

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We perform autonomic nerve preserving distal gastrectomy in laparoscopic gastrectomy for early gastric cancer in order to decreas the invasiveness and to preserve functions. In this paper, we particularly describe a technique and results of preserving a celiac branch of the vagus nerve. A total of 150 patients had laparoscopic distal gastrectomy (Billroth-I reconstruction by delta-shaped anastomosis) in our institution between May 2001 to February 2008, and among of them 84 nerve-preserved and 45 nerve-unpreserved patients who could be followed were subjected to a questionnaire survey as well as to an endoscopic evaluation. The results demonstrated that nerve-unpreserved patients were more likely to change bowel habit soft (20.5% vs. 44.4%), and to complain reflux symptoms (17.9% vs. 33.3%, with a significant difference). A significantly frequent occurrence of bile reflux was also noted in the unpreserved patients by gastro-endoscopy (44.1% vs. 62.2%). Although there were some differences in the background factors between both groups, we consider that some postoperative sequel such as diarrhea and bile reflux might be capable of decreasing by this nerve-preserving gastrectomy.

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We experienced two cases of fracture of the subcutaneous implant type central venous catheter (Bard Access Systems) implanted in the right subclavian vein for chemotherapy, which was considered to be caused by compressive crush, which are reported here. Case I was a male in his 60's suffering from liver metastases of sigmoid colon cancer, with a catheterization period of 216 days, and the catheter tip had aberrantly migrated into the peripheral pulmonary artery. Catheter intervention (CI) was attempted, but the catheter could not be removed due to loss of mobility. Case II was a male in his 70's suffering from liver metastases of sigmoid colon cancer, with a catheterization period of 818 days, and the catheter tip had aberrantly migrated into the left pulmonary artery. The catheter was removed with catheter intervention under fluoroscopic guidance. In both Cases I and II, the fracture was determined to have been caused by compressive crush, because the fracture plane of the catheter was crushed. It is considered that the risk of fracture should be kept in mind for patients in whom this same type of catheter is implanted.

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Angiosarcoma of the breast is a rare malignant tumor. To date, several reports described the magnetic resonance imaging (MRI) findings of mammary angiosarcoma. To the best of our knowledge, there are no reports of mammary angiosarcoma with the diffusion-weighted imaging or H MR spectroscopy (MRS) findings. We report a case of a 43-year-old woman with an 8-cm-sized angiosarcoma of the left breast, which was assessed using dynamic contrast-enhanced MRI, diffusion-weighted imaging, and MRS. Dynamic contrast-enhanced MRI showed a heterogeneous enhancing mass and a rapid-washout pattern. Diffusion-weighted images revealed marked signal-intensity loss for the tumor. The high apparent diffusion coefficient (ADC) value of the tumor (1.54 × 10^-3 mm²/s) corresponded to the low pathological tumor cell density. MR spectroscopy revealed no positive choline resonance peak. The presence of a relatively high ADC value and a negative MRS are thought to be useful for diagnosing mammary angiosarcoma.

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We report a case of breast myofibroblastoma in a 53-year-old female hospitalized for further examination of the left breast tumor which she noticed 3 months previously. An elastic hard tumor located in the internal upper quadrant of the left breast was found. Phyllodes tumor was suspected based on imaging and aspiration biopsy cytology results. On excision, the tumor was found to be 2cm in diameter and had a clear surface with a thin capsule.
On histopathology, the tumor had spindle- or oval- shaped nuclei and intercellular collagenous stroma ; it was CD34- and desmin- positive but keratin- negative. Myofibroblastoma was diagnosed based on these results.

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Carcinosarcoma of the breast is rare. A 65-year-old woman developed a right breast mass. A tumor, 3 cm in diameter, was palpated in the C region of the right breast. On mammography and ultrasonography, an invasive ductal carcinoma was suspected ; on aspiration cytology, ductal carcinoma with sarcomatous component was suspected. A modified radical mastectomy was performed. On histology, a tumor consisting of intermingled carcinomatous and sarcomatous areas was found.
Immunohistochemical staining revealed that the carcinomatous component stained positive for AE1/AE3 and epithelial membrane antigen (EMA), the sarcomatous component stained positive for vimentin. The two components were intermingled and there was no transitional area. A carcinosarcoma of the breast was diagnosed. We report this case and review the relevant literature.

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A mediastinal germ cell tumor with malignant transformation is rare. We report a 30-year-old man who had an immature teratoma with malignant transformation to an adenocarcinoma. In 1995, the patient was clinically diagnosed as having a malignant germ cell tumor of the mediastinum associated with a marked elevation of serum AFP levels. The AFP level normalized after chemotherapy, which was followed by radiotherapy. In 2006, the patient underwent a left pneumonectomy and mediastinal tumor removal with partial resection of the pericardium, left brachiocephalic vein, and left phrenic nerve, due to the development of anterior chest pain and a slight enlargement of the tumor. On pathology, adenocarcinoma components were noted, neither germ cell tumor nor primary lung cancer components were found. This is compatible with a germ cell tumor associated with a somatic-type malignancy according to the WHO classification. The patient developed distant adenocarcinoma metastases early in the postoperative period. In such patients, persistence or growth of tumor after chemotherapy may suggest the emergence of a somatic-type malignancy.

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Quadricuspid aortic valve (QAV) is a rare congenital heart disease. A 66-year-old man was admitted for investigation of a cardiac murmur. Transthoracic echocardiography (TTE) demonstrated severe aortic regurgitation (AR). QAV was diagnosed on preoperative transesophageal echocardiography (TEE). During the operation, the accessory cusp was found to be located between the left and right coronary cusps. The patient had an aortic valve replacement using a mechanical prosthetic valve, due to difficulty in repairing the valve. The patient's postoperative course was uneventful.

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An 80-year-old woman, who had undergone a graft replacement for an infrarenal abdominal aortic aneurysm, was admitted to the hospital because of episodes of anal bleeding in January and early March 2006. An aortoduodenal fistula was suspected, because an abdominal CT scan showed a parietal thrombus in the proximal anastomotic site and fluid collection around the graft. Further, gastrointestinal fiberscopy showed erosion in the third portion of the duodenum. The patient refused to undergo operation, and the bleeding was managed conservatively. In late March, massive hematemesis and anal bleeding occurred again, and the patient was readmitted. Conservative treatment was successful again, but curative operation was performed for prophylaxis of critical rebleeding on the 14th hospital day. During the operation, a fistula was found between the aorta and the duodenum, and primary closure of the duodenum, in-situ replacement with an artificial blood vessel, and omentopexy to prevent infection and recurrence were performed. No infection has been observed for 3 years after the surgery.

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We report a case of a 34-year-old woman who underwent video-assisted thoracoscopic surgery for pneumothorax with veno-venous extracorporeal lung assist (V-V ECLA). She had previously had a bullectomy of the right lung and right upper lobectomy due to a recurrent right pneumothorax. She developed a left pneumothorax, and a chest drain was immediately inserted. However, she required a bullectomy because of a persistent air leak. After general anesthesia, differential lung ventilation was attempted, but adequate respiratory function was difficult to maintain because of a very low tidal volume (<100ml). Therefore, V-V ECLA was instituted. The right femoral vein and the right internal jugular vein were selected as the cannulation sites. Video-assisted thoracoscopic bullectomy was successfully performed with V-V ECLA. V-V ECLA is useful for supporting patients with severe lung dysfunction.

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A 66-year-old woman was referred to the hospital for the purpose of receiving close exploration of an abnormal shadow in the hilar region of the right lung in a chest X-ray film. A chest CT scan showed a mass with the diameter of 4 cm in S⁶ of the right lung as well as a nodular shadow with the diameter of 5 mm in the S¹⁰. Adenocarcinoma was diagnosed with the bronchoscopic biopsy and cytology from the right B⁶. Meningioma was suspected by preoperative head CT scan, however, we considered that the presence might not disturb surgery for the lung lesions. We performed right lower lobectomy and lymphadenectomy (ND2a). The postoperative pathological diagnosis of the S⁶ lesion was adenocarcinoma, but that of the nodule of the S¹⁰ was meningioma. We judged that the cephalic meningioma did not require surgery. The patient received postoperative adjuvant chemotherapy for lung cancer, but died of cancer one year and two months after the operation.
This case is considered to be extremely rare in that metastasis of meningioma was concomitantly present in the same lobe of the lung from where primary lung cancer had arisen.

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This paper presents a case of right-sided Bochdalek hernia which was shown to progress on repeat computed tomography (CT) in an adult patient with ovarian cancer who was being followed postoperatively. A 21-year-old woman had a left adnexal resection one year prior. Subsequently, she was given chemotherapy. On CT, an enlarging mass suggesting peritoneal dissemination was seen ; surgery was planned. During surgery, a defect in the right diaphragm (Foramen Bochdalek) was noted through which liver had herniated. The foramen was about 3 cm in diameter and had a hernial sac (true hernia). The diaphragmatic defect was closed with interrupted sutures. The patient's postoperative course was uneventful ; there has been no recurrence.

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An 80-year-old man presented to hospital for treatment of primary malignant melanoma of the esophagus. The lesion was initially considered to be melanosis of the esophagus and was found on July, 2005. 20 months later, the lesion was found to be slightly elevated and more densely pigmentated. Given the patient's general condition, a blunt dissection of the esophagus was done. The patient's serum 5-S-cysteinyldopa(5-S-CD) level was high on admission and decreased after surgery ; no increase was seen until Prior to the patient death following a cerebral infarction in December, 2006. Changes in serum 5-S-CD levels in case with primary malignant melanoma of the esophagus are likely useful in following the so patients.

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A 54-year-old man was seen at the hospital because of abdominal discomfort and upper abdominal pain. On abdominal physical examination, there were distention and mild degree of tenderness in the upper middle portion of abdomen. An abdominal CT scan revealed a 19×14×8cm multilobular cyst compressing the left lobe of liver and the stomach. Abdominal MRI showed a cystic lesion with septum in its center which was visualized as low signal intensity on T1-weighted images and as high signal intensity on T2-weighted images. Laparotomy was thus performed with a suspected diagnosis of an outgrowing type multiple liver cyst. As a result, we identified a huge multilobular cyst with a thin capsule arisen from the lesser curvature of the upper body of the stomach. Since its adhesions with the surrounding tissues were negligible, the cyst was removed with a part of the gastric wall. The cystic fluid was faintly yellowish and slightly clouded lymph which amounted to about 1200ml. The pathohistological diagnosis was lymphangioma composed of dilated lumen showing a lymphatic vessel like structure. Huge multilobular cystic lymphangioma of the stomach is a rare entity, and hence its clinical characteristics together with our case are reported here.

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A 66-year-old man was found to have a gastric submucosal tumor in March, 2007. On CT scan and EUS, a diagnosis of gastric lipoma was made. Therefore, the patient was followed. He developed tarry stools in July, 2008. On emergent endoscopy, hemorrhagic ulcers were seen on top of the gastric submucosal tumor. The hemorrhagic points were successfully clipped. To deal with the risk of re-bleeding, a wedge resection of the stomach was subsequently performed. The resected specimen included a smooth, solid, semispherical tumor covered with gastric mucosa (50×50 mm in size). Furthermore, multiple ulcers were located on the overlying mucosa. Histological examination confirmed the diagnosis of gastric lipoma, with no evidence of tumor necrosis or bleeding. The development of hemorrhagic ulcer formation in a gastric lipoma is rare. We report a case of gastric lipoma which during follow-up.

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We experienced a case of early small cell carcinoma of the remnant stomach. A man in his later half of eighties was seen at the hospital because of upper abdominal discomfort and was found to have a type 0-IIa+IIc lesion like a submucosal tumor in the posterior wall of the lesser curvature of the remnant stomach reconstructed by Billroth-II method by an upper gastrointestinal endoscopy. The lesion was bulging in a gradual slope, and was covered with normal mucosa except the concave center. Immunohistochemically the biopsied tissue was strongly positive for CD56 and slightly positive for Chromogranin A and Synaptophysin, and then small cell carcinoma of the remnant stomach was diagnosed. Total removal of the remnant stomach, D1+βlymph node dissection and R-Y reconstruction were thus performed. The tumor showed sheet-like, honeycomb and trabecular arrangement of atypical cells which were oval-shaped and lacked in cytoplasm, and had infiltrated into the submucosal layer. Metastasis to lymph nodes of the group I was noted.
Small cell carcinoma of the stomach is a relatively rare histological type. It metastasizes to the lymph nodes and the liver in an early stage, showing a potent malignant potential. In this case, an endoscopic study performed 10 months earlier had already revealed a submucosal tumor like lesion in an early stage that might be an evidence of rapid enlargement of small cell carcinoma of the stomach.

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A 59-year-old male had a giant mass located in the upper right abdomen. On abdominal CT large lesion with a largest diameter of 20 cm was detected, ; a lesion with a diameter of 20 mm and a marginal contrast effect was also detected in the hepatic posterior segment. On upper gastrointestinal endoscopy, a submucosal neoplastic lesion was detected in the descending part of the duodenum ; forceps biopsy specimens were found to be c-kit-positive and CD34-positive on immunostaining. A gastrointestinal stromal tumor was diagnosed. Imatinib mesylate (400 mg per day) was administered for 309 days. A cytoreductive effect was obtained, and therefore a pancreaticoduodenectomy, a right hemicolectomy, and a partial hepatectomy could be done. Imatinib was not given after surgery. Currently, 15 months after surgery, the patient is relapse-free.

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In general, Meckel's diverticulum causes no symptoms. However, it can sometimes result in abdominal pain, which can require treatment. We report a case with a perforated Meckel's diverticulum caused by a fish bone. A 67-year-old man had a total gastrectomy 3 years previously. He developed lower abdominal pain. Acute peritonitis of unknown cause was suspected, and a laparotomy was done. It was found that a fish bone, about 4.3 cm long, had perforated the Meckel's diverticulum and then had entered the abdominal cavity. The diverticulum was located in the small intestine about 50 cm proximal from the ileocecal junction. A partial resection of the diverticulum was done.
The present case of Meckel's diverticulum perforated by a fish bone is the seventeenth to have been reported in Japan. None of the previous patients had had a total gastrectomy. Total gastrectomy is a high-risk factor for perforation of the alimentary tract because the absence of gastric acid allows for the easier passage of foreign bodies into the small intestine. Meckel's diverticulum perforation due to a fish bone in a gastrectomized patient is rare.

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A 55-year-old man was admitted due to lower abdominal pain. Abdominal CT scan showed a tumor about 3.5 cm in diameter which involved the small intestine. The patient refused treatment. However, three months later, he was admitted again due to severe lower abdominal pain. The patient had spontanous pain, tenderness and guarding in the lower abdomen. At this time the abdominal CT showed a tumor about 5 cm in diameter which involved the small intestine ; fluid was noted. Emergency surgery was carried out given the diagnosis of an abdominal abscess related to the tumor ; a partial resection of the intestine was done. The tumor, about 5 cm in diameter, was found on the antimesenteric side of the small intestine. On histopathology, the tumor was found to be composed of spindle cells. On immunochemistry, the tumor cells were positive for c-kit and CD34. Thus the tumor was diagnosed as a small intestinal GIST. GIST of the small intestine with abdominal abscess is rare ; no previous cases have, to the best of our knowledge, been reported in Japan.

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A 79-year-old woman was complained of anorexia and weight loss. A mass was found in the right lower abdomen. On pathology a diagnosis of malignant diffuse large B cell lymphoma was made. Given the size of the mass, extensive surgery was required. Therefore, chemotherapy (THP-COP) was given first. After 1 course of chemotherapy, the tumor was no longer detected on computed tomography. However, the patient developed a small bowel obstruction. A localized ileocecal resection with lymph node dissection was performed. The macroscopic findings included a severely narrowed segment of the terminal ileum. On microscopy, fibrosis in the submucosa and the upper muscularis layers was noted ; but no evidence of lymphoma cell infiltration was found. Thus, the patient had a pathological complete response (pCR). This type of course is quite rare. Whether to proceed with surgical resection or chemotherapy should be determined on a case by case basis.

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A male in his 50's was diagnosed with Crohn's disease (ileocolitis) 11 years prior to admission for an intra-abdominal abscess. He improved on conservative therapy, but 2 months later developed sudden abdominal pain and a high fever. Given a diagnosis of pan-peritonitis, an emergency operation was done, and a perforated ileum without tumor-related changes was found. The stenotic and perforated part of the ileum was resected. On histopathology of the resected ileum, a moderately differentiated tubular adenocarcinoma, which invaded the subserosa around the perforation was found. The patient died 21 months after operation due to recurrence.
In Japan, only 28 cases of Crohn's disease complicated by carcinoma of the ileum have been reported up to 2008. However, with the increasing number of patients with Crohn's disease, there is a possibility of an increase in the number of Crohn's cases with carcinoma of the ileum.

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Recently, we experienced a case of acute appendicitis with mesenterium commune. A 25-year-old man, who had mental retardation, was emergently operated on under a diagnosis of acute abdomen of unknown origin. The intra-operative diagnosis was acute panperitonitis due to gangrenous appendicitis with mesenterium commune. Appendectomy and irrigation drainage were performed. The postoperative course was uneventful, and the patient was discharged on the postoperative day 15. In the circumstances of acute abdomen, it might be useful to take the coexistence of intestinal malrotation like mesenterium commune into consideration.

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Primary appendiceal carcinoma is a relatively rare disease, for which it is very difficult to obtain a definitive diagnosis pre-operatively, because it lacks specific clinical symptoms. We report a case of early carcinoma of the vermiform appendix in a young man. A 15-years-old man was referred to our hospital with the suspected diagnosis of appendicitis. On admission, a tumor was palpable with tendeness at the right lower abdomen. Abdominal US, and CT revealed appendix swelling with inflammatory reaction. We performed appendectomy based on the diagnosis of appendicitis. Histopathological examinations of the resected samples revealed well differentiated adenocarcinoma. Because of the suspicion of positive margin of resection, ileocecal resection with D3 dissection was performed after 20 days of the first operation. The resected specimen had no residual tumor nor lymph nodes metastases.

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We report a case of food-induced ileus due to the ingestion of “mochi” rice cakes treated conservatively. A 39-year-old woman complained of increasing abdominal pain and distension for 3 days. Abdominal plain CT showed 4 areas of high density in the stomach, and 1 area of high density in the ileal end of the intestine ; impaction to the ileum-end and extension of the oral side of the small intestinal cavity were noted. Based on these results and a detailed history a food-induced ileus related to “mochi” rice cakes was diagnosed. Since there were no signs of peritoneal irritation or inflammatory findings on laboratory tests, the patient was treated conservatively ; scopolamine butylbromide (Buscopan^®) and digestive enzyme preparation (Beritym^®) were used. The abdominal pain gradually decreased and disappeared ; 2 days after starting of the conservative therapy the abdominal CT showed that the high density areas located in the stomach and the ileal end of the intestine had disappeared ; ileal findings diminished, and expansion of the small intestine had decreased.
It was not difficult to establish the diagnosis of the food-induced ileus due to “mochi” rice cakes on admission. Conservative therapy involving scopolamine butylbromide and a digestive enzyme preparation was successful in treating food-induced ileus due to “mochi” rice cakes.

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An 89-year-old man was seen at the hospital because of gradually intensifying lower abdominal pain. An abdominal CT scan revealed a localized dilatation of the ileum with the maximum diameter of about 13cm associated with gross calcification in its inner portion. Meckel's diverticulum was initially suspected and the patient was operated on. Upon laparotomy, we saw a cystic dilatation of the intestine distal to the anastomosis due to the previous partial resection of the small intestine for intestinal obstruction caused by a parasite done in 1961. In addition three enteroliths 4cm in diameter were present in the lumen of the dilated intestine. An analysis of components of the enteroliths disclosed that they were true enteroliths mainly consisted of calcium oxalate.
True enterolith is a relatively rare entity and so far only 46 cases of true enterolith have been reported in Japan. This case is also discussed in terms of its peculiar morphology of cystic dilatation of the ileum distal to the anastomosis.

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A 73-year-old woman, who had undergone laparoscopic-assisted sigmoidectomy for sigmoid colon cancer, presented with a sudden onset of lower abdominal pain and vomiting one year and nine months after the surgery. She was admitted to the hospital for conservative treatment but the symptoms progressed. Abdominal contrast-enhanced CT scan showed a strangulated ileus at the lower left quadrant of abdomen causing marked obstruction of the jejunum, and collection of ascites. Emergency surgery was thus performed with a diagnosis of postoperative strangulated ileus. Laparotomy revealed a strangulated ileus through a mesenteric defect which had not been closed in the previous operation. A necrotic ileum loop, ranging from 150 to 220cm distal to the Treitz's ligament, was resected.
Many surgeons including us tend to leave the mesenteric defect open in LAC. Repair of the defect after LAC is a matter of controversial opinion. Our experience as well as nine case reports of strangulated ileus after LAC might suggest that closure of the mesenteric defect could help preventing occurrence of post-operative strangulated ileus.

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A 73-year-old man, with a history of an abdominoperineal resection of the rectum and colostomy for rectal cancer in 1996, as well as a middle bile duct resection for bile duct cancer in 2007, was found to have bleeding stomal varices 2 months after the bile duct resection. He was admitted due to the presence of repeat bleeding episodes which occurred despite the use of pressure and ligation. The patient's abdomenal was distended and was in shock. Enhanced abdominal CT showed pooling of contrast medium around the colostomy stoma and ascites. The stomal varices involved an afferent from the inferior mesenteric vein and drained into the left inferior epigastric vein. The stomal varices were treated with an inferior mesenteric vein ligation and left inferior epigastric vein obliteration using N-butyl-2-cyanoacrylate (Histoacryl^®) under local anesthesia. The patient's postoperative course was uneventful ; his bleeding stomal varices have not recurred. Variceal obliteration is effective in controlling bleeding stomal varices.

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We report a rare case of gastrointestinal stromal tumor (GIST) of the rectum with lymph node metastasis and review the relevant literature.
A 57-year-old man developed constipation. An ulcerative tumor was found in the rectum. On histology of the biopsy specimen, a stromal tumor was diagnosed. A laparoscopy-assisted abdomino-perineal resection was performed. The resected specimen's tumor cells were immunohistochemically positive for CD34 and c-kit ; one of the dissected lymph nodes had metastasis. Twenty-five months later, multiple liver metastases and lung metastases were noted. Imatinib mesylate was given, but the patient's general condition gradually deteriorated. The patient died 29 months after surgery.

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A case of sigmoid colon carcinoma presented with a strangulated inguinal hernia is reported.
An 89-year-old man, seen at the hospital because of right inguinal swelling and diagnosed as having a right inguinal hernia, was found to have a strangulated inguinal hernia by enhanced CT scan 4 days after the diagnosis. Radical operation to repair the hernia was immediately performed. A hard omental mass was found inside the hernia sac, which was histologically proven to be metastasis. Colon fiberscopy showed a type 2 colon cancer tumor encircling the entire lumen of the sigmoid colon. Partial sigmoidectomy showed ascites and peritoneal seeding metastasis.
Colon carcinoma presented with inguinal hernia is rare and so far five cases, including ours, have been reported in the Japanese literature.

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We report a case of lymph node metastasis to the paraaortic lymph nodes from a sigmoid colon tumor with submucosal invasion. A 46-year-old woman was found on colonoscopy to have a 10-mm Is tumor of the sigmoid colon. A sigmoidectomy was done based on the diagnosis of a cancer with more than 1000μm submucosal invasion. On pathology, a moderately differentiated adenocarcinoma, pSM (5.2mm), ly1, v0, pN1(+), fStageIIIa was found. Six months after surgery, a swollen lymph node was detected in the paraaortic region on CT. On FDG/PET, a high accumulation was found in this lymph node. Colon cancer recurrence was suspected, and lymph nodes 216, 252, and 253 were resected. On pathology, metastasis from the sigmoid colon tumor was found in nodes 216 and 253, but not node 252 ; these findings were consistent with a previously missed lymph node metastasis. Missed lymph node metastasis is seen in 10% of all colon cancer cases. The frequency of paraaortic lymph node metastasis from sigmoid colon tumors with submucosal invasion is 0.2%. Our case is thus rare.

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Crohn's disease can be associated with a variety of extraintestinal complications, but it is rare that this disease is complicated by liver abscess. Here we report a case of Crohn's disease complicated by a mesenteric abscess and a liver abscess during anti-TNF-alpha therapy (infliximab).
A 49-year-old man, who had undergone partial resection of the small intestine for Crohn's disease two months prior and was receiving scheduled maintenance infusion of infliximab, presented with fever, abdominal pain, and abdominal fullness. Surgical drainage was performed on the 15th hospital day because an abdominal CT scan showed a mesenteric abscess. However, his fever and abdominal pain persisted, and a further abdominal CT scan 10 days after the drainage showed an enlargement of a liver abscess. Therefore, percutaneous transhepatic abscess drainage was performed along with ultrasonography, and this treatment was effective.
In this case, the liver abscess which is an extraintestinal complication of Crohn's disease might be aggravated because he was easily affected by infection due to receiving infliximab.

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A 69-year-old man developed fever and jaundice. Endoscopic retrograde cholangiopancreatography revealed a radiolucent mass in the hilar bile duct and the intrahepatic bile duct in the left hepatic lobe. Abdominal computed tomography showed HCC in segment 5 (S5). He had radiofrequency ablation (RFA) for the HCC, and an extended left hepatic lobectomy combined with extrahepatic bile duct resection and biliary reconstruction for suspected hilar bile duct cancer. Based on the resected specimens, hepatolithiasis was diagnosed ; there was no evidence of hilar cancer. On the 12th postoperative day, the patient developed a 39-40°C fever and septic shock. Abdominal ultrasonography confirmed a solitary liver abscess at the ablation site. Percutaneous transhepatic abscess drainage was performed promptly. RFA has been widely adopted as a local treatment for HCC because it has a good therapeutic effect and low invasiveness. However, a liver abscess can develop in the ablated site due to ascending cholangitis in patients with biliary reconstruction. Such patients should be closely monitored for liver abscess formation and the possible development of septic shock.

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A 52-year-old male had a laparoscopic cholecystectomy for cholecystolithiasis ten years previously ; the postoperative course was good. The patient developed right hypochondrial pain two months prior to being seen, and he visited the Department of Gastroenterology at our hospital. On abdominal CT, a high-intensity lesion was observed in the cystic duct. He was diagnosed as having a cystic duct stone. A laparoscopic excision of the cystic duct was done. Inside the cystic duct, two clips and two small stones were found, the clips had been used to ligate the cystic artery. There is an increasing number of reports of bile duct stones related to the migration of surgical clips, which become nuclei. A further increase in such cases is expected. The present case high light, the mechanisms of the migration. Clip migration is a complication that should be taken into consideration in patients with a laparoscopic cholecystectomy. In the future, ligation techniques and surgical instrumentation that do not involve the use of clips should be developed.

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A 42-year-old woman was admitted with melena and right hypochondralgia. On admission, her laboratory data showed mild liver dysfunction and anemia. Emergency panendoscopy revealed no sign of bleeding from the papilla of Vater. Abdominal ultrasonography, plain CT, and MRI showed evidence of cholecystitis with a hematoma in the enlarged gallbladder. Hemorrhagic cholecystitis was diagnosed. After one week of conservative therapy, a laparoscopic cholecystectomy was performed. The examination of the resected specimen showed that the wall of the gallbladder was mildly thickened, and that a hemorrhagic ulcer was present in the neck ; no gallstones were present. On pathology, submucosal hemorrhage and fibrosis in the area of ulceration, with no evidence of neoplastic or arteriosclerotic changes were noted. The final diagnosis was hemorrhage due to acute non-calculous cholecystitis. The patient has been well without any recurrence of bleeding for the last 5 months. Gallbladder hemorrhage should be considered in cases with unexplained bleeding from the gastrointestinal tract.

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Cholangiocarcinoma presents with jaundice and is often in an advanced stage when it is detected. We report two cases of extrahepatic cholangiocarcinoma without jaundice.
Case 1 : A 70-year-old woman was admitted to our hospital because of fever. Blood analysis revealed the normal level of serum total bilirubin, but elevated hepatobiliary enzymes. Multidetector CT (MDCT) scan revealed a tumor at the lower bile duct. The pathological diagnosis on endoscopic biopsy was papillary adenocarcinoma. Superficially mucosal spreading of carcinoma toward the upper bile duct was not found on peroral cholangioscopy. The patient had pylorus-preserving pancreatoduodenectomy. The depth of cancer invasion was fibromuscular layer on pathological study. Case 2 : A 63-year-old woman was admitted to our hospital because of body weight loss. Blood analysis revealed the serum total bilirubin level of 1.5mg/dl and elevated hepatobiliary enzymes. Abdominal ultrasonography revealed intrahepatic biliary dilatation. MDCT scan revealed a tumor at the hepatic hilus of the bile duct. The cut-line of the bile duct was planned by endoscopic retrograde cholangiography. The patient had extended left hepatectomy, caudate lobectomy and extrahepatic bile duct resection. The pathological diagnosis was moderately differentiated tubular adenocarcinoma with invasion to subserosal layer.
These date suggest that extrahepatic cholangiocarcinoma without jaundice might not be early cancer. A new system is required for early diagnosis of extrahepatic cholangiocarcinoma to improve the prognosis.

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A-72-year-old female was referred to our hospital in January 2008 for a suspected lung tumor. She had undergone abdominoperineal resection for rectal carcinoma 2 years previously followed by adjuvant chemotherapy. FDG-PET and MRI revealed a pancreatic mass with moderate FDG uptake as well as a pulmonary tumor. These imaging modalities yielded a diagnosis of concurrent metastases of rectal carcinoma. Distal pancreatectomy and splenectomy in this month and subsequently thoracoscopy-assisted partial lobectomy in April were performed for these lesions. The pulmonary lesion was histopathologically proven as metastasis of rectal carcinoma, however, the pancreatic mass showed IgG4-positive plasmacyte infiltration and fibrosis, with no metastatic cancer cells, suggesting autoimmune pancreatitis. The differential diagnosis of focal autoimmune pancreatitis is very difficult, especially in patients with previous/concurrent malignancy as ours.

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A 76-year-old man with sigmoid colon cancer had a sigmoidectomy in 1997. Subsequently, he had two pulmonary metastasis resections. In February 2006, abdominal CT scan showed a tumor located in the pancreatic body ; endoscopic retrograde pancreatography showed stenosis of the main pancreatic duct in the pancreatic body. With a diagnosis of primary pancreatic cancer or metastatic pancreatic tumor, a distal pancreatectomy was done in April 2006. On pathology, a metastatic colon cancer was diagnosed. The patient is alive with no signs of recurrence 3 years after the distal pancreatectomy. In colorectal cancer patients, resectable pancreatic metastasis is very rare. In fact, only 32 cases, including this case, have been reported in Japan.

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The patient, a 79-year-old woman who had a total right nephrectomy for a right renal cell carcinoma in June 1994, was found to have a 20-mm tumor in the pancreatic head on ultrasound in May 2007. Given the tumor's volume the patient was admitted for surgery in June 2008. The patient had a poor surgical risk due to her advanced age, as well as the presence of an old myocardial infarction, chronic renal failure, diabetes mellitus, and cataract-induced decreased vision. Preoperative diagnostic investigations identified a 44-mm tumor in the pancreatic head and 22- and 16-mm tumors in the pancreatic body and tail, separated slightly from the gastroduodenal artery and pancreatic head arcade. Thus, later that same month, extended distal pancreatectomy and splenectomy were performed. Postoperatively, there was persistent pancreatic fluid leakage. When the patient was discharged in October, she no longer required treatment for diabetes. Surgery is generally recommended in patients with pancreatic metastases of renal cancer to improve their prognosis. The preoperative examination can guide surgery so that QOL can be maintained.

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We report a case of recurrent mucinous cystic tumor of the pancreas 3 years after the operation. A 44-year-old Japanese female was found on a CT to have a low density tumor in the epigastrium during a screening CT for the follow-up of an ovarian cyst. All the laboratory investigations including the liver function tests, carbohydrate antigen 19-9 and carcinoembryonic antigen were within normal limits. CT showed a giant bulbiform cyst in the body and the tail of the pancreas. We could not identify the possible presence of a communication between the cyst and the pancreatic duct because we could not insert a tube in the pancreatic duct by an endoscope. We suspected a mucinous cystic tumor of the pancreas from the sex, age of the patient and the image before the operation. The patient underwent distal pancreatectomy with splenectomy. The pancreatic cyst was not connected with the pancreatic duct in the image study of the resected specimen. The mucinous cystic tumor of the pancreas have ovarian like stroma. The histology revealed a pancreatic cystic tumor with features consistent with a mucinous cyst adenoma. Mucinous cystadenoma or non-infiltrative cancer of the pancreas rarely have recurrence after the operation. However, she had recurrence in the retroperitoneum 3years after the operation and we report the case here.

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A 72-year-old man was admitted due to vomiting. Hematological studies revealed only mild anemia. The serum CEA and CA19-9 levels were normal. Abdominal ultrasonography showed a large tumor with several cystic areas in the spleen and swollen lymph nodes along the splenic artery. The tumor occupied most of the spleen. An abdominal CT scan showed enhancement of the tumor bordered by the tail of the pancreas. Angiography showed a hypervascular tumor. Endoscopic examination revealed a submucosal tumor of the stomach and colonic polyps. Given a diagnosis of angiosarcoma arising in the spleen the patient had a distal pancreatectomy, splenectomy, and partial gastrectomy. The histological diagnosis was acinar cell carcinoma of the pancreas with splenic invasion and gastric metastasis. The patient is alive without recurrence 1 year after surgery.

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A 63-year-old man developed tarry stools. On upper gastrointestinal endoscopy, a reddish lesion was found in the middle body of the stomach. Based on the pathology of the biopsy specimen, a diagnosis of adenocarcinoma was made. On laboratory testing, a slight anemia and a high serum alpha-fetoprotein (AFP) level (871.1 ng/ml) were noted. On abdominal computed tomography, a large mass, 10 cm in diameter, was seen in the left upper abdomen ; there was invasion of the stomach, pancreatic tail, and spleen. Though the tumor was heterogeneously enhanced by iopamidol, the central part of the tumor showed no enhancement. An adenocarcinoma originating from the stomach or pancreas was diagnosed. The patient had a left upper abdominal exenteration. On gross examination, the tumor had a lobulated pattern and was not encapsulated. On histology, tumor cells with acinar and tubular structures were found ; the whole layer of the stomach was replaced by the infiltrating tumor cells. The tumor cells were positive on anti-trypsin mAbs immunohistochemical staining. The final histological diagnosis was acinar cell carcinoma of the pancreas. Postoperatively, the patient's AFP level normalized, and no signs of recurrence have been seen on follow-up.

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A 45-year-old man was admitted to our hospital, complaining of severe abdominal pain twice, followed by lasting upper abdominal dull pain. Abdominal CT and MRI images revealed a left adrenal cyst. Blood analysis revealed a non-functioning lesion. For ruling out of malignancy and reliefing from its symptom, complete resection of the adrenal cyst was performed. The resected specimen was diagnosed as benign adrenal pseudocyst. Improvement of recent diagnostic modalities serves in detection of non-functioning and non-symptomatic smaller adrenal cyst as adrenal incidentaloma or giant adrenal cyst. However these reports are rare in Japan. Our case is the 8th largest adrenal cyst that have been reported in Japan according to the review of literatures.

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A 57-year-old woman was referred to our hospital with a suspicion of hepatocellular carcinoma. An abdominal CT scan revealed a 30 mm-sized hypervascular tumor beside the liver caudate lobe. Further examinations could not determine whether this was a hepatic tumor or a neurogenic tumor. A urinary analysis showed no elevations of catecholamines. During laparotomy, incision of the lesser omentum disclosed a hypervascular tumor outside the liver on the inferior vena cava. Palpation of the tumor caused a sudden increase in the systolic blood pressure to 250-300 mmHg. We diagnosed the tumor as an extra-adrenal pheochromocytoma. We performed tumorectomy after administration of a hypotensive drug (i.v. nicardipine). The postoperative course was uneventful. She has had no signs of recurrence for 18 months after the operation. Preoperative diagnosis could not be made in this case, because it was difficult to differentiate from a hepatic tumor and the urinary analysis showed no abnormal levels of catecholamines. When we encounter a para-aortic neoplasm of unknown origin, extra-adrenal pheochromocytoma should be kept in mind as a possible differential diagnosis.

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Solitary fibrous tumors (SFTS) are mesenchymal tumors of the mesothelium and are generally thought to be benign pleural tumors. We report a rare case of SFT that was located in the retroperitoneum. An 83-year-old woman was found to have a left lower abdominal tumor in July 2005. A 10-cm-diameter tumor that was elastic hard and had poor mobility was seen in her left lower abdomen. Abdominal computed tomography showed an encapsulated mass with the same density as muscle ; angiography showed a hypervascular tumor fed by the circumflex iliac artery. The tumor was considered to be a retroperitoneal tumor which originated in the muscles or nerves ; a tumorectomy was performed. On pathology an SFT was diagnosed since spindle-cells with slight dysplasia that grew close to each other and were positive for CD34, vimentin, and Bcl-2 on immunohistochemical staining were found. SFT is often reported to recur and metastasize despite its low-grade malignancy potential. Therefore, careful follow-up is warranted in this patient.

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We report a case of a schwannoma of the greater omentum.
A 59-year-old woman was admitted to the hospital because of epigastric distress. An abdominal CT scan showed a well-defined cystic tumor 10cm in diameter with calcification located in the right upper abdominal cavity. This tumor was filled with liquid component containing low signal on T1-weighted and high signal on T2-weighted images in MRI. An operation was carried out, though no definite diagnosis was made. Upon laparotomy, the tumor was found to continue to the greater omentum partly and to be fed by a vessel branching from the right gastroomental artery. The tumor with part of the greater omentum was removed. The removed tumor was a multilocular tumor containing an orange transparent serous component with a part of solid tissue. Histopathologically the tumor was composed of numerous spindle-shaped cells with round nuclei which were positive for S-100 protein and negative for KIT. It was thus diagnosed as Antoni B type benign schwannoma.
Schwannoma of the greater omentum is so extremely rare that only 8 cases have been reported in Japan. It is difficult to diagnose this disease preoperatively for lack of subjective symptoms and specific imaging findings. We should consider a schwannoma as a probable differential diagnosis of the tumor in the greater omentum.

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A 51-year-old man complained of upper abdominal pain. There was no rebound tenderness or abdominal muscle guarding. Bloody ascites was seen on plain abdominal CT scan. Enhanced multidetector CT (MDCT) showed an aneurysm, 9 mm in diameter involving the left gastroepiploic artery (LGEA). An intra-abdominal hemmorage caused by rupture of the LGEA aneurysm was diagnosed. Angiography to make a definite diagnosis and for transcatheter arterial embolization (TAE) was performed. We successfully embolized the artery proximally and distally to the aneurysm. After embolization, the patient had no abdominal symptoms ; his anemia did not progress. The aneurysm was no longer detected on enhanced CT. Two months later, enhanced CT showed the aneurysm filled with organized thrombus.
There are only a few reports of a ruptured aneurysm diagnosed on MDCT and treated using transcatheter arterial embolization (TAE) without resorting to surgery. We report this case and review the relevant literature.

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A 39-year-old Japanese male presented with right lower abdominal pain and fever. Appendicitis was diagnosed, and antibiotics were immediately given intravenously. The patient's symptoms did not improve after 3 days, and the patient had an appendectomy. The appendix was located retrocecally, and there was no perforation or abscess formation. Postoperatively, the patient continued to have a low-grade fever. On follow up abdominal CT scan done on the 4^th postoperative day (POD), an abscess located adjacent to the ileocecal region was noted ; superior mesenteric vein (SMV) thrombosis was also found. The abscess resolved with intravenous antibiotic treatment, and the patient was discharged home on POD 15. However, on POD 19, the patient developed a fever over 38°C. The emergency abdominal CT scan showed that the thrombus, which had initially been located solely in the SMV, had extended into the intrahepatic portal vein. The thrombus resolved completely on oral antibiotics, aspirin, and warfarin treatment. SMV thrombosis is a rare complication of acute appendicitis. The current case is only the 5^th case reported in Japan to date.

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A 58-year-old man with atrial fibrillation and liver cirrhosis was admitted due to abdominal pain. The patient had a total gastrectomy for gastric cancer 1 year prior. Under the diagnosis of a strangulated ileus, an urgent laparotomy was performed 29 hours after the onset of abdominal pain. The operative diagnosis was necrosis of a large portion of the small intestine due to occlusion of the superior mesenteric artery. Though the jejunum which had been reconstructed at the Y arm of the total gastrectomy and the right part of the colon had undergone ischemic change making their resection was judged hazardous. Therefore only a 550-cm length of the necrotic small intestine was excised and the patient had a jejunostomy, an ileal mucous fistula created, and a tube duodenostomy. The preserved small intestine was 50 cm long. Five months after surgery, ischemic stenosis in the lower part of the Y arm had progressed, so that a severe dilatation of the Y arm was present above the stenotic site resulting in repeat episodes of aspiration pneumonia. Therefore, a percutaneous jejunostomy was created endoscopically at the site of the dilated Y arm ; subsequently the patients aspiration pneumonia was well controlled. However, he developed short bowel syndrome and required home intermittent total parenteral nutrition. The patient died 13 months after surgery due to liver failure.

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We report a case of spontaneous mesenteric hematoma in a hemodialysis patient.
A 40-year-old woman, who had been on hemodialysis since the age of 30, was admitted to the hospital because of the sudden onset of lower abdominal pain. Abdominal CT scan showd a low density area suggestive of hematoma in the mesenterium of the sigmoid colon. Three hours later, abdominal enhanced CT scan showd enlargement of the hematoma and extravasation of contrast material to the sigmoid colon mesenterium. Angiography showed no extravasation of contrast material. But she showed advanced anemia, and then an emergency operation was performed. Laparotomy showed a massive hematoma in the sigmoid colon mesenterium, and sigmoidectomy including the hematoma was performed. Histopathological examination showed no vascular lesions. Therefore spontaneous mesenteric hematoma was definitely diagnosed. She was discharged from the hospital on the 28th day after the surgery. No recurrence has been seen.
Spontaneous mesenteric hematoma is so rare that only 44 cases, including our case, have been reported in the Japanese literature. This case is presented here, together with some bibliographical comments.

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