In order to know the mast limited axillary lymph node dissection, we evaluated the lower axillary lymph node dissection (ALND) in the lower part of level I for primary breast cancer patients with no clinical regional lymph node metastasis (N0). In performing the lower ALND, we dissectied axillary lymph nodes below the level of second intercostobrachial nerve of the level I. A total of 1043 patients with N0 breast cancer treated with the lower ALND between Jan. 2001 and Dec. 2008 were enrolled in the analysis. Another 1084 patients with N0 breast cancer treated by lymph node dissection over the level I from 1994 to 2000 were served as control. These two patients groups were comparatively analyzed for pathological axillary lymph node metastasis, survival and relapse-free survival rates, and postoperative complications. The frequency of pathological axillary lymph node metastasis was 21.3% (222/1043) in the lower ALND patient group. The median follow-up time was 72 months and 99.2% of the patients were followed for 5 years. The five-year overall survival and relapse-free survival rates in the lower ALND group were 95.3% and 88.3%, respectively, which were as good as those after the previous standard ALND. Only 6 (0.6%) patients clinically developed axillary lymph node metastasis among 101 (9.7%) recurrent breast cancer cases in the lower ALND group. After the lower ALND, the seroma in the axillary region was remarkably decreased compared with the previous standard ALND, and lymph edema of the ipsilateral upper extremity has not occurred at all. We conclude that the lower ALND in lower part of level I is a useful approach for axillary management of N0 breast cancer patients.

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[Purposes]We made a comparison study of the Mesh Plug method using light weight mesh (Ethicon ULTRA Pro Plug) (the L method) with the conventional Kugel method (the K method) and the Mesh Plug method using heavy weight mesh (the H method). [Subjects and Methods] Subjects were : 32 cases of inguinal hernia in the L method ; 73 cases in the K method ; and 38 cases in the H method. Comparison examinations were performed for ten items among these three groups. [Results]There were few cases which showed significant swelling of the surgical wound in the L method (6.2%) group. Although no significant differences were noted, there was no patient in the L method group who complained of sharp pain after one month or more after surgery or who had prominent induration of the wounds. Incidence of seroma was also less in the L method group. [Conclusion]The use of light weight mesh was considered to reduce the frequencies of swelling of the surgical wound, seroma formation, induration formation and sharp pain which might occur more than one month after surgery, and resultantly to raise the postoperative QOL.

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We experienced a case of gastric carcinoid and rectal cancer in a patient with multiple endocrine neoplasia type 1 (MEN1). The patient was a 66-year-old man who had undergone left hepatic lobectomy for liver metastasis of endocrinoma in March 2007, when the primary disease was not found. Six months after the hepatectomy, he developed abdominal pain and diarrhea, and close exploration disclosed multiple gastric ulcers, gastric carcinoid, rectal cancer and elevated levels of gastrin, parathyroid hormone, and calcium. Abdominal CT scan showed multiple hight-density areas suggestive of neuroendocrine neoplasm in the pancreatic tail. Ultrasonography and parathyroid scintigraphy showed parathyroid tumors. The most likely preoperative diagnosis was MEN1 with gastric carcinoid and rectal cancer. We initially performed distal gastrectomy, and distal pancreatectomy with splenectomy and low anterior resection in November 2007, followed by total parathyroidectomy and autotransplantation in September 2008. Pathological examination revealed that this case was of MEN1 with gastric carcinoid and rectal cancer. The patient is now doing well without any signs of recurrence after the surgery. This is the seventh case of Type IIgastric carcinoid with MEN1 and hypergastrinemia reported in Japan.

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We report a case of an 81-year-old male who developed a malignant fibrous histiocytoma (MFH) in his neck. The patient presented with common cold-like symptoms During the subseguent examination, a tumor was found in his neck. A 50×80 mm, mobile, small tumor was palpable on the right side of the neck. Based on cervical ultrasound, CT scan, and MRI scan results, a well-defined tumor in the area surrounding the right sternocleidomastoid muscle, the infrahyoid muscles, and the fascia colli superficialis was found. Fine-needle aspiration biopsy cytology was classV. The tumor was not continuous with the thyroid gland. Nevertheless, a soft tissue tumor, such as anaplastic thyroid cancer or liposarcoma, was suspected. Thus, to establish a definitive diagnosis a tumorectomy was performed. On histopathology, MFH was diagnosed. On immunohistochemistry, the tumor was positive for vimentin and CD34. Extended resection and postoperative chemotherapy were recommended due to the high-grade of the MFH. However, the patient and his family refused this approach and expressed a strong desire for conservative follow-up. The patient has been free of clinically evident recurrence for 6 years after surgery.

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Paget's disease of the breast is usually localized in the nipple epidermis and the lactiferous duct located near the nipple. However, it is difficult to evaluate the extent of the lesion. Therefore, such patients usually have a mastectomy. We report 4 cases of Paget's disease of the breast without underlying invasive carcinoma or DCIS. Based on CT scan and MRI findings, the patients had cone excisions. CT scan and MRI of the breast were very useful for evaluating the extent of the tumor and deciding on the appropriate surgical procedure in these patients with Paget's disease.

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We report a case of chest wall fibrosarcoma as a second malignancy after radiation therapy for breast cancer. The female patient had received radiation therapy to the chest wall and the regional lymph nodes after mastectomy at the age of 44 and had been suffered from severe radiation dermatitis. She noticed a subclavicular chest wall tumor 3cm in diameter at the age of 55. Although the tumor was resected with the diagnosis of local recurrence of breast cancer, the pathologic diagnosis was fibrosarcoma arising from the soft tissue. Two years later, an another chest wall tumor occurred. Chest wall resection and reconstruction with GORE-TEX^® sheet and a rectoabdominal myocutaneous flap was performed. Histologic findings were the same as the first tumor, fibrosarcoma. Multifocal tumor arising from the chest wall with severe radiation dermatitis convinced that the tumor was induced by the radiation therapy.

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A 66-year-old male noticed a left breast tumor. Mammography and ultrasonography revealed a 20-mm-diameter mass in the left mammary gland (area C). Fine needle aspiration cytology and core needle biopsy results suggested the possibility of malignancy. Based on immunohistochemical staining the tumor was diagnosed as a carcinoid tumor or a neuroendocrine carcinoma. Estrogen and HER2 receptors were positive, PgR receptor testing was negative. A modified radical mastectomy with axillary lymph node dissection was performed. On histology a large cell neuroendocrine carcinoma (LCNEC) was diagnosed. Lymph node metastases were not found. Subseguently, the patient received adjuvant chemotherapy (EC) ; Letrozole administration is ongoing. To date the patient is without recurrence for one year and eleven months. Male breast cancer and LCNEC are rare. In particular only six cases including our case of LCNEC have been reported in Japan. The 6 cases were reviewed to evaluate their therapeutic outcomes so as to establish a prognosis for this disease entity.

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Occult breast cancer is rarely presents with the symptoms of distant metastases, but is usually detected due to axillary LN swelling.
We report a rare case of an occult breast cancer patient whose first symptoms were from multiple brain metastases.
The patient was a 59-year-old female whose first symptoms of the disease were progressively worsening headaches and disorientation. Brain CT and MRI showed multiple metastatic tumors. Several examinations were performed, including MMG, US, CT, and GIF to detect the primary lesion ; only a right axillary lymph node swelling was identitied. Fine needle aspiration cytology of the lymph node revealed metastastatic adenocarcinoma. IHC staining of brain tumor specimens showed ER(-), PgR(-), Herceptest(3+), Mammaglobin(+), CK7(+), CK20(-), GCDFP-15(+), and E-Cadherin(-). Based on these findings diagnosed and given the characteristics of the primary lesion, multiple brain metastases without a significant primary lesion, or an occult breast cancer were.
When brain metastases with no known primary lesion are detected, especially in females, occult breast cancer should be considered as the likely origin.

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An 80-year-old man was admitted to our hospital for close exploration of dyspnea. A cardiac echogram confirmed the presence of advanced stage of aortic stenosis with low ejection fraction (42%) and low pressure gradient (12mmHg). Dobutamine stress echocardiography was carried out to evaluate the indication of the aortic valve replacement. We resultanty performed the aortic valve replacement with an bioprosthesis. The patient's postoperative course was uneventful and he was discharged from the hospital after the operation.
We believe Dobutamine stress echocardiography should be recommended for almost patients with aortic stenosis with low ejection fraction and low pressure gradient, whose surgical outcomes are often poor.

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We report the case of a 50-year-old man with an organizing pneumonia in whom a mass was detected on X-ray. Chest computed tomography revealed a mass (3 cm in diameter) at the right S10 segment. CYFRA21-1, CEA, CA19-9, SCC, NSE, and Pro-GRP were all within normal limits. Sputum cytologic results were negative for malignancy. Bacteriological cultures and polymerase chain reaction for Mycobacterium species of the bronchoscopic bronchial aspirate were all negative. On transbronchial lung biopsy, there were epithelioid granulomas, but no malignancy was found. However, FDG-PET/CT showed high FDG uptake in the mass, and the maxSUV was 3.753. Therefore, lung cancer could not be ruled out, and the lesion was resected via VATS. On pathology, an organizing pneumonia was diagnosed.

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We report a case of pyothorax caused by the swallowing of a press-through package (PTP) by mistake. A 79-year-old man developed fever and epigastralgia. He was examined but no cause was found for the symptoms. Although antibiotic therapy was started, not only did his symptoms not improve but he developed dyspnea and subcutaneous emphysema. At this point, the patient was admitted to hospital. The chest CT showed a left pyothorax and mediastinal emphysema. After chest drainage, esophageal endoscopy was done to identify the cause of the pyothorax ; esophageal injury was suspected given the presence of mediastinal emphysema. A PTP was found in the thoracic esophagus 35 cm distal to the dentition ; an ulcer was present. An esophageal perforation caused the PTP injury was likely the cause of the pyothorax. The PTP was endoscopically removed. The pyothorax and esophageal perforation could be successfully treated by thoracic drainage and lavage. The diagnosis of esophageal injury caused by PTP is difficult to make if the patient does not report swallowing a PTP. PTP swallowing should be considered in patients with fever and epigastralgia because delay of the diagnosis and therefore of treatment might result in serious complications.

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The Barrett's ulcer is found in 24% cases of Barrett's esophagus as a precancerous lesion of the esophageal adenocarcinoma. We report a case of Barrett's ulcer with complete occlusion due to reflux esophagitis. An 82-year-old woman had a chief complaint of vomiting. An obstructing lesion was detected in UGI in the lower esophagus and injection of contrast media did not reveal debouchement to the anal side. GIF revealed an occulusion at 30 cm from the incisor line. Chest CT revealed thickening of the well of the lower esophagus, and no high-intensity signal was observed on the MRI diffusion emphasis image. Because stenting was difficult, we performed esophagectomy. Histopathological image of the narrow segment revealed ulceration, and the anal mucosal surface of the occlusion site was covered by specialized columnar epithelium.

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We report the case of a patient with nutritional deficiency who developed infective endocarditis after esophagogastrectomy. A 55-year-old man who had undergone esophagectomy at the age of 54, was subsequently administered oral anticancer drug treatment ; however he abandoned the treatment due to adverse effects (diarrhea, dysgeusia) 2 months later. He was admitted with chronic undernutrition and persistent dysgeusia after 6 months. He was administered empirical antimicrobial therapy because of increasing high fever 1 month after admission. He was less responsive to appropriate anti-MRSA therapy for beating MRSA bacteremia and infective endocarditis. Then, septic shock and DIC occurred with progressive infective endocarditis. In spite of intensive care, he died due to multiple brain hemorrhage. Antimicrobial therapy was unsuccessful in curing severe infective endocarditis due to MRSA in a post-surgical patient with esophageal cancer. A fast and more accurate diagnosis method as well as treatment are required for treating infective endocarditis.

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A 71-year-old woman who was seen at the hospital because of abdominal pain, vomiting and bloody stool was diagnosed as having superior mesenteric arterial occlusion without associating with intestinal necrosis based on close exploration. Anticoagulation therapy was started and symptomatic remission was noted, however, hypoalbuminemia was exacerbated that necessitated frequent administration of albumin preparations. From examinations including small bowel endoscopy and protein-losing scintigraphy, protein-losing gastroenteropathy from the small intestine was diagnosed. An about 200-cm long portion of the intestine involving from the central portion of the small intestine to the ascending colon was removed. Defluxion of the normal mucosa was observed over a wide area of the removed intestine, at where fur adhered and multiple circular ulcers were observed as well. After the operation serum albumin level was normalized.
Superior mesenteric arterial occlusion is associated with serious intestinal necrosis that may be fatal in not a few cases, but it can be cured conservatively. It is rare that protein-losing gastroenteropathy occurs after the conservative therapy, and our case is the third report in Japan. In our case emergent massive resection of the intestines could be avoided because the cause was etiologically considered to be due to necrosis of mucosa alone, however, associated protein-losing gastroenteropathy demanded intestinal resection.

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A 35-year-old woman was been followed up for recurrent abdominal pain of unknown origin. In July 2008, she was admitted to our hospital with high-grade fever and epigastralgia. Abdominal computed tomography (CT) revealed thickened gastric wall with low-density area in the pyloric part. Gastroscopy revealed submucosal prominence. Conservative therapy with antibiotics was performed because gastric wall abscess formation was suspected, which relieved her symptoms. Follow-up CT after 3 months revealed disappearance of the previous findings. However, same pain was recurrent after 14 months. CT showed the similar findings as before and the submucosal lesion, ulceration, and purulent discharge were detected on gastroscopy. Surgical resection was performed on clinical diagnosis of gastric wall abscess formation. Microscopic findings revealed ectopic pancreas consisting of acinar cells and pancreatic ducts, inflammatory cell infiltration, and increase in interstitial connective tissue. Pathological diagnosis was ectopic pancreas concomitant to abscess formation. Since ectopic pancreas with any symptoms is relatively rare, we report this case with the review of literature.

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A 72-year-old man who had been treated with methotrexate (MTX) for rheumatoid arthritis (RA) presented with the abrupt onset of emesis and was diagnosed as having gastric malignant lymphoma by upper gastrointestinal fiberscopy (GIF) and biopsy at another hospital. He was admitted to our hospital to receive chemotherapy. After admission, he vomited blood again, and endoscopic hemostasis was unsuccessful. Emergency total gastrectomy was thus performed. Finally, we diagnosed the case as primary gastric T-cell lymphoma (PGTL) by histopathological and immunohistochemical findings.
Gastric lymphoma is usually derived from B cells, and PGTL is extremely rare. As PGTL is believed to carry poor prognosis compared to B cell lymphoma, it should be treated by multimodal therapy as well as surgical resection. However, no standard treatment for PGTL has been as tablished as yet because of a small number of cases accumulated. Recently it has been pointed out that there is some relation between MTX for treatment of RA and the onset of malignant lymphoma, and we report this case which is interesting from the standpoint of the onset of malignant lymphoma.

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A 61-year-old man who had been treated for myotonic dystrophy (MD), was found on screening endoscopy to have a type IIb early gastric cancer in the posterior wall of the middle stomach. Respiratory function tests showed restrictive ventilatory impairment, and electrocardiography showed first-degree atrioventrioular block. Distal gastrectomy was performed. Anesthesia was maintained with intravenous anesthetic, and a muscular relaxant was used only during the induction of anesthesia. After the operation, the patient's progress was complicated by the development of pulmonary atelectasis ; the patient required a ventilator. The patient was weaned from ventilatory support on postoperative day 5 and was discharged on postoperative day 17. We present a rare case with MD and concomitant gastric cancer requiring surgery under general anesthesia.

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A 61-year-old woman was admitted to our hospital for treatment of a left lower abdominal wall tumor. She had undergone total gastrectomy for stage IB gastric cancer 11 years earlier. Abdominal CT scan and ultrasonography showed a mass more than 30mm in size in the left abdominal wall. On aspiration cytology, metastasis to the abdominal wall from gastric cancer was suspected. Since no other metastatic site was revealed, she underwent tumorectomy. Pathologically, the resected specimen was a poorly differentiated adenocarcinoma similar to her primary gastric cancer, suggesting that this tumor was a metastatic lesion from the gastric cancer. Solitary metastasis of gastric cancer to skeletal muscle is rare, especially the presentation of a relapse after more than 10 years. Therefore, we describe this case together with a review of the literature.

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A 50-year-old woman underwent distal gastrectomy for gastric cancer in June 2003 (stageII). UFT adjuvant chemotherapy was continued for five months. Thereafter, she developed otitis media and liver dysfunction. UFT administration was stopped and 5FU tablet administration was started two months later. Two months thereafter in May 2004, echo showed a 13mm in diameter tumor on the surface of the pancreatic head. 5FU tablet administration was continued. The tumor became undetectable on echo. 5FU tablet administration was stopped in June 2005. The pancreatic tumor was detected again on echo in February 2006. PET showed abnormal uptake only in the pancreatic mass. We removed the tumor locally. The histopathologic diagnosis of the pancreatic tumor was the same type as the previous gastric cancer. About 70% of the tumor was surrounded by pancreatic tissue and no lymph node structure was seen in the tumor. The tumor was compatible with pancreatic metastasis from gastric cancer. Post-operative S-1 adjuvant chemotherapy was performed for four years after the second operation, and the patient has survived without recurrence. Pancreatic metastasis of gastric cancer manifests no operative indications in many cases. However, we should evaluate the indications for surgical treatment when no other organic metastases are recognized.

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A 72-year-old woman was admitted to our hospital because of abdominal fullness, nausea and vomiting lasting for three months. Upper gastrointestinal fiberscopy suggested pyloric stenosis and no mucosal irregularity. Abdominal computed tomographic scan showed that a tumor had displaced the gastric wall into the stomach cavity. On the blood examination, the carbohydrate antigen 19-9 (CA19-9) level was markedly elevated to 1,333 U/ml. Preoperative histopathological examination failed to provide definitive diagnosis, and then distal gastrectomy was performed. After the gastric tumor was diagnosed as well differentiated adenocarcinoma by the intraoperative rapid diagnosis, D2 lymph node dissection was additionally performed. Postoperative histopathological findings showed that the main location of the tumor was in the submucosa of the stomach wall and the tumor was unexposed to the mucosal surface. Adenocarcinoma was present adjacent to an ectopic pancreas with pancreatic ducts in the muscularis propria of the stomach (Heinrich type III). Immunohistochemical study for CA19-9 revealed aberrant pancreas transformed to adenocarcinoma and was helpful for making diagnosis of adenocarcinoma arising from an ectopic pancreas of the stomach. It is rarely seen that an ectopic pancreas of the stomach gives rise to cancer. We report a case of adenocarcinoma arising from an ectopic pancreas with a remarkably high CA19-9 level before surgery.

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A 37-year-old woman was admitted to our hospital with a 2 day history of severe gradually worsening, upper abdominal pain. Abdominal CT scan showed thickening of the intestinal wall in the ileum and ascites. Emergency surgery was performed given the diagnosis of acute abdomen. Laparoscopic findings showed hemorrhagic ascites and edematous thickness of the ileum and mesentery. A segmentectomy of the ileum was performed. Three days after the operation, purpura appeared on both lower extremities and the back. Histopathological examination of the ileum and skin findings showed leukocytoclastic vasculitis. Thus, Schönlein-Henoch purpura was diagnosed and the patient was treated with 30 mg/day of prednisolone ; her symptoms improved.

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We report a case of primary volvulus of the small intestine. A 74-year-old man with no history of abdominal surgery was admitted for acute abdominal pain. Abdominal ultrasonography revealed torsion of the superior mesenteric vessels. Abdominal CT revealed a “whirl-like sign”. We suspected volvulus of the small intestine. An emergency operation revealed that the small intestine had rotated 360° in a counterclockwise manner because of mesenteroaxic torsion. The patient's postoperative course was uneventful. In this case, abdominal ultrasonography was useful in the preoperative diagnosis of volvulus of the small intestine.

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A 59-year-old man consulted our hospital with a chief complaint of intermittent abdominal pain. Abdominal CT revealed an ileo-ileal intussusception caused by a tumor in the small intestine, and double-balloon enteroscopy revealed an ileal tumor 70-cm from the ileocecal valve. We diagnosed the patient as having ileo-ileal intussusception due to tumor of the small intestine, and performed laparoscopy-assisted partial resection of the small intestine including the tumor site. Histopathological findings suggested that the tumor was composed of inverted true diverticulum containing ectopic gastric mucosa ; hence, we finally diagnosed this patient with inverted Meckel's diverticulum. The occurrence of intussusception caused by inversion of Meckel's diverticulum in adults is relatively rare, and hence preoperative diagnosis of the disease is difficult. Herein, we reviewed the Japanese literature on intussusception caused by inverted Meckel's diverticulum and discussed the origin, diagnosis, and optimal therapeutics of this condition.

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A 27-year-old women had a history of repeat episodes of acute appendicitis ; she had had for 3 episodes of appendicitis within 6 months after her first delivery. After the fourth episode of appendicitis, she consented at last to surgery. However, prior to surgery, she was found to be pregnant, and the operation was delayed. At 6 weeks of gestation, a fifth episode of appendicitis occurred. As she hoped to continue with her pregnancy, an elective appendectomy was scheduled for the second trimester of pregnancy. In the meantime, conservative therapy was implemented ; fortunately, the patient responded favourably. At 14 weeks of gestation, a laparoscopic appendectomy was performed under general and epidural anesthesia with pneumoperitoneum. The patient was discharged 4 days after the operation, and at 40 weeks of gestation, she delivered her baby with no complications. Laparoscopic appendectomy for pregnant woman is not often done in Japan. Here, we report on the details of this rare case requiring surgery during pregnancy.

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The case involved an 84-year-old man who had been transferred to our hospital for the purpose of undergoing gastrostomy after cerebral infarction. When he was examined, he had already developed MRSA enteritis and it was the third day after initiation of transluminal administration of VCM at another hospital. An abdominal plain X-P and ultrasonic study revealed intestinal emphysema from the ascending to transverse colons, intra-abdominal free air, and hepatic portal venous gas. There was no ascites, and perforation and necrosis of the intestines were unlikely from physical and blood biochemical findings. The most likely diagnosis was a pathologic condition associated with MRSA enteritis. Accordingly conservative therapy under management with TPN was started and symptoms were improved. Thereafter the patient developed bacteremia due to MRSA and CV catheter infection, but he recovered from them. PEG was performed after free air and intestinal emphysema had disappeared, and then he was transferred to another hospital.
Recently clinical cases of pneumatosis cystoides intestinalitis with intra-abdominal free air and hepatic portal venous gas have been increasingly reported, however, no cases of these diseases associated with MRSA enteritis have been reported as far as we could review. This case is thus reported here, together with a review of the literature.

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An 80-year-old woman, who had the abrupt onset of lower abdominal pain while she was working at her farm around 4 : 30 pm late in June 2009, was at the hospital at about 7 pm when she had no fever and abdominal tenderness was slight. There were no rebound tenderness and muscle guarding. Blood biochemical date at that time were WBC of 6900μl and CRP of 0.1mg/dl which were within checked normal ranges. Abdominal contrast enhanced MDCT scan revealed portal venous gas (PVG) and diverticuli of the sigmoid colon. On the same day, she was referred to a general hospital for surgical treatment, and complete fasting, infusion therapy, and administration of antibiotics (IPM. CS) at the hospital resulted in symptomatic remission. An abdominal CT scan performed on the first hospital day showed disappearance of PVG. Thereafter her clinical course was uneventful, and she was discharged from the hospital on the 13th hospital day. No recurrence has occurred thereafter and she is followed in our hospital as of July 2010.
We present a case of sigmoid colon diverticulitis associated with PVG successfully treated by conservative therapy, together with a review of the literature.

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We report a rare case of intussusception caused by multiple cystic lymphangioma of the ascending colon. A 17-year-old woman visited our hospital with abdominal pain. We diagnosed an intussusception at the ascending colon with abdominal ultrasonography and computed tomography. After reducing the intussusception, we diagnosed multiple cystic submucosal tumors at the ascending colon by colonofiberscopy. When the patient was questioned in detail about her symptoms, she reported the same symptom that was observed a few months ago. The patient subsequently underwent right hemicolectomy. The final diagnosis was an intussusception with multiple cystic lymphangioma of the ascending colon, which was confirmed by histopathology.

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With an increase in the incidence of colorectal cancer in recent years, there have been occasional reports on liver abscess occurring with colon cancer. It is difficult to differentiate this condition from from liver metastasis. One of the causes of liver abscess is secondary infection of liver metastasis, which was caused by colorectal cancer. We report the case of a 76-year-old man who had concurrently undergone resection of colorectal cancer and hepatectomy for a liver abscess in which liver metastasis could not be ruled out in the preoperative diagnosis. Since different surgeons have used different treatment strategies for liver abscess which occurred with colon cancer we have also included some literature review in our report.

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A 60-year-old man consulted our hospital because of upper abdominal pain, anorexia, weight reduction, and diarrhea ; gastrointestinal fibroscopy revealed type 4 advanced gastric cancer with signet-ring cell carcinoma. Abdominal computed tomography (CT) revealed diffuse wall thicknening from the ascending colon to the descending colon. Extended narrowing of the bowel canal and cobblestone appearance were revealed by barium enema radiography and colonoscopy. Under the diagnosis of gastric cancer with Crohn's disease, total gastrectomy and subtotal colectomy from the ileum end to the descending colon were performed.
Histological findings revealed poorly differentiated adenocarcinoma with signet-ring cell carcinoma in the specimens of both the stomach and the colon.
We reported a rare case of metastatic colon cancer from gastric cancer which was difficult to differentiate from Crohn's disease because the unique radiograph.

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The patient was a 72-year-old man. He was referred to our hospital with complaints of obstipation and anemia. Four tumor lesions were detected in his descending colon and sigmoid colon. We performed extended left hemicolectomy with dissection of regional lymph nodes. Pathological examination revealed 1 carcinoma in the sigmoid colon, 5 carcinomas in the descending colon, 3 carcinomas in the transverse colon, and lymph node metastasis. All tumors were tubular adenocarcinomas, and 4 carcinomas were adenomas. These findings indicate that this case may be associated with adenoma-carcinoma sequence.

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The patient was a 79-year-old woman who presented with abnormal bowel movements as the chief complaint. Her medical history included radiation therapy (details including dose unclear) for uterine cancer at 46 years of age. At 64 years of age, she had undergone regular endoscopic examination of the lower digestive tract because of abnormal bowel movements. In the first biopsy of the rectal ulcer region, rectal cancer was diagnosed as a well-differentiated adenoma, and an abdominoperineal resection of the rectum was performed. The pathological findings indicated mucinous carcinoma (mp, ly1, v0). We report the case of radiation-induced rectal cancer. In the course of observations after radiation therapy, it is necessary to take secondary cancer into consideration and record the observations accordingly.

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A 75-year-old-woman was referred to our hospital because of hepatic encephalopathy and hyperammonemia (258μg/dl) due to an intrahepatic portosystemic venous shunt (PSVS). Enhanced abdominal computed tomography, 3-dimensional reconstructed images, and arterial portography revealed two PSVSs in the hepatic anterior segment, as well as an extrahepatic PSVS between the veins originating from the ascending colon and inferior vena cava. During the preoperative examination, the patient developed septicemia due to urinary tract infection caused by Klebsiella species. After treatment with endotoxin-absorption and continuous hemodialysis-filtration, a hepatic anterior segmentectomy and ligation of the extrahepatic PSVS were performed. The liver parenchyma was normal on histology. The postoperative course was uneventful and the patient's consciousness level normalized, although her serum ammonia level fluctuated between 60 and 120 μg/dl. In the patients with intrahepatic PSVS, the presence of extrahepatic PSVS should be considered.

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A 59-year-old man diagnosed as having a hemorrhagic hepatic cyst ruptured three times was seen at the hospital for suspected hepatocellular carcinoma. An abdominal enhanced computed tomographic (CT) scan showed a low-density mass 8 cm in diameter in the right hepatic segment 8. An abdominal dynamic CT scan showed a low-density mass in both artery and portal-dominant phases, with contrast medium extravasation at the segments 5 and 6. Magnetic resonance imaging (MRI) of the abdomen showed a mass with heterogeneous low signal intensity in T1-weighted imaging and heterogeneous high signal intensity in T2-weighted imaging. No tumor staining or vessel compression was seen in selective hepatic arteriography and no portal vein compression in portography. Serum PIVKA-EC was elevated to be 11,206 mAU/ml. The most likely diagnosis was hypovascular hepatocellular carcinoma, and we conducted right hepatic lobectomy. Pathological findings showed moderately differentiated hepatocellular carcinoma and immunochemical findings positive for CD34 showed many microvessels in the tumor. Because there was no difference between hyper and hypovascular hepatocellular carcinoma in microvessels positive for CD34, we inferred that the tumor staining was not related to microvessel density in the tumor.

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Caroli's disease is a rare congenital hepatobiliary disorder characterized by multifocal segmental dilatation of intrahepatic bile ducts affecting all or parts of the liver. Two forms of Caroli's disease have been described ; the pure form and that associated with periportal fibrosis. This disease may diffusely affect the liver or be localized to one lobe or segment. About 20% of all reported Caroli's disease cases are of the monolobar type. We report a case of simple type Caroli's disease confined to the left lateral segment of the liver in a 45-year-old man. He was initially admitted due to slightly elevated transaminase 1. Computed tomography (CT) scanning, magnetic resonance imaging (MRI) and positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) findings indicated a diagnosis of biliary cystadenoma. The diagnosis of Caroli's disease was ultimately confirmed by pathological findings. He underwent left hepatic lateral segmentectomy and recovered completely.

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A 40-year-old man with a history of acute pancreatitis was admitted for right-sided chest pain. Chest X-ray showed a massive right pleural effusion. A pancreatic pleural effusion due to rupture of a pancreatic pseudocyst was diagnosed based on thoracentesis and a computed tomography (CT) scan. The patient was successfully treated with drainage of the right-sided thoracic cavity. Three months later he was readmitted for left-sided chest pain. Chest X-ray showed a massive left pleural effusion. Coronal CT reconstruction revealed a pancreaticopleural fistula between the left-sided thoracic cavity and the dilated main pancreatic duct. We diagnosed a pancreatic pleural effusion due to a pancreaticopleural fistula with exacerbation of acute pancreatitis. Therefore, the patient underwent distal pancreatectomy to remove the disrupted main pancreatic duct. The patient had a good postoperative course and has remained well during 13 months of follow-up.

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A 59-year-old man presented with a chief complaint of epigastric pain. He was admitted to our hospital with high fever and severe inflammatory signs (CT) scan revealed inflammatory changes in the gastrosplenic ligament and multiple low-density areas containing air in the spleen and intrahepatic portal vein ; however, abdominal examination did not reveal any remarkable findings. There were no findings suggesting intestinal ischemic change. On the second hospital day, disseminated intravascular coagulation occurred. After conservative therapy, his condition improved temporarily, but high fever developed again. Computed tomography CT scan showed a splenic abscess, and emergency splenectomy was therefore performed. Intraoperative findings suggested that the splenic abscess had developed from colonic disease, and partial colectomy of the splenic flexure was therefore performed. The pathological findings revealed that the splenic abscess had developed from colon penetration associated with colon cancer. Owing to the postoperative failure of sutures, colostomy was performed. The postoperative course was uneventful, and chemotherapy was started. Eleven months have passed without relapse. Splenic abscess caused by colon penetration associated with colon cancer is a rare condition, which can suddenly deteriorate and result in serious complications. To the best of our knowledge, there have been only 9 reports similar to those of the present case.

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A 59-year-old woman with liver cirrhosis fell down the stairs and was found to have a bruise in her lumber area. She was checked in a hospital, and admitted since her blood pressure was low ; her laboratory data were normal. Next morning, she became unconscious and became progressively more anemic Enhanced abdominal CT demonstrated intra-abdominal bleeding in the left lower side of the abdomen. She was transferred to our hospital. On arrival, she was in hemorrhagic shock ; an urgent laparotomy was performed. There were 2500 ml of bloody ascites ; the bleeding source was found to be ruptured left ovarian varices. Hemostasis was achieved by ligating the varicose veins. Ectopic varices are often seen in patients with liver cirrhosis. This is the first case of traumatic rupture of ovarian varices reported in Japan ; an overview of the disease is also provided.

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Fournier's gangrene is a specific type of necrotic fasciitis. Fournier's gangrene is a life-threatening disease and still has a high mortality rate. We report 3 cases of Fournier's gangrene. Cases 1 and 3 were 55-year-old men, and case 2 was a 40-year-old man. Two patients had underlying disease : case 1 had rectal carcinoma, while case 3 had rheumatoid arthritis. In all patients CT scans revealed a lesion with gas. WBC and CRP were elevated in all patients. A wide variety of causative organisms was found. All patients had drainage operations and were given antibiotics. In case 1 and case 3, covering stomas were constructed to rest the wound. All 3 patients survived.

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A 54-year-old man was being treated with hormone therapy for prostate cancer with bone metastasis. On abdominal CT done to ascertain the effectiveness of treatment, a mesenteric tumor of the small intestine was found incidentally. Since the a tumor was not detected prior to treatment, lymph node metastasis of the prostate cancer was suspected ; the hormone therapy was continued. On CT done 3 months later, an enlarged mesenteric tumor and no bone metastasis changes were noted. It was thought that the tumor was not a lymph node metastasis but unrelated mesenteric tumor. Gastrointestinal fiberscopy did not identify any malignant tumors. Though the origin was unknown, surgery was performed under a presumptive diagnosis of intra-abdominal tumor such as a mesenchymal tumor. On pathology, a desmoid tumor was diagnosed. The patient had no family history of familial adenomatous polyposis or previous abdominal surgery. A hormonal imbalance resulting from the hormone therapy given for prostate cancer was suspected of having contributed to the occurrence and growing of the mesenteric tumor.

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A 58-year-old woman was seen at the hospital because of epigastric pain and vomiting. An abdominal CT scan revealed free air which looked like abscess in the inner part of the second portion of the duodenum and the posterior aspect of the spleen, and an increased density which seemed an inflammatory change from the pancreas head to the posterolateral aspect of the second portion of the duodenum and further to the right anterior paranephric cavity. The most likely diagnosis was retroperitoneal abscess associated with perforation of the second portion of the duodenum, and an emergency operation was done. Laparotomy through upper abdominal midline incision followed by repositioning of the duodenum demonstrated an edematous retroperitoneal cavity from the anterior aspect of the inferior vena cava to the right lower pole of the kidney. Furthermore, a necrotized diverticulum was present in the inner part of the second portion of the duodenum, and a 2.5-cm sized enterolith was seen in the inner part of the diverticulum. Duodenal perforation caused by the diverticular enterolith was diagnosed. After dissection of the diverticulum followed by transection of it with a stapling device, abdominal drainage was performed. The postoperative course was uneventful, and the patient was discharged from the hospital on the 27th postoperative day.
Although perforation of a duodenal diverticulum is a very rare entity, it often reveals characteristic CT findings. We must keep a possible association of the disease in mind in making appropriate therapeutic decisions.

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A 49-year-old woman underwent radical excision of dermatofibrosarcoma protuberans (DFSP) in May 2002. Seven years later, a follow-up abdominal CT scan showed retroperitoneal recurrence of DFSP. Before laparotomy, the left iliolumbar artery and the left deep circumflex iliac artery, which were feeding arteries, were embolized. Total excision of the tumor was performed in January 2009. Intraoperative blood loss was 95mL. The resected tumor measured 13×9×9 cm and weighed 450g. Pathological examination revealed CD34(+), vimentin (+), bc1-2(-) and desmin (-), showing the similar pattern to that of the primary tumor. Recurrent DFSP was thus diagnosed. No recurrence has been observed for 20 months after the operation.
DFSP is a relatively uncommon soft tissue neoplasm with intermediate-to low-grade malignancy. Long-term recurrence of DFSP would be likely and so careful follow-up is reguired.

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A 52-year-old man complained of anorexia. Enhanced abdominal CT revealed a well-defined soft tissue tumor with calcification, 51×48mm in diameter, on the left side of the pelvic cavity. MR images revealed enlarged lymph nodes around the tumor. Tumor resection was performed, although we could not make a definite diagnosis preoperatively. The tumor had been present behind the left external iliac artery and vein. Extensive adhesion was demonstrated between the tumor and the left external iliac vein. The tumor could be separated, and was thus resected. The pathological diagnosis was plasma cell type Castleman disease. Castleman disease is a disorder of unknown cause characterized by a huge tumor involving lymph nodes. Castleman disease localized in the pelvic cavity is very rare. Only 11 such cases, including our present patient have been reported in Japan. We describe this case and review the relevant literature.

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An 84-year-old woman was seen at the hospital because of radiating pain from the left inguinal region to the left thigh. A pelvic CT scan showed an oval-shaped intestine between the left pectineal muscle and the external obturator muscle, and left obturator hernia was diagnosed. Because the hernia was spontaneously reduced, elective surgery by extraperitoneal approach through an inguinal region was performed. A skin incision was made similar to the approach for inguinal hernia and a hernia sac impacted into the left obturator foramen was seen. There was no hernia content so that the hernia sac was reduced by hands. The hernia orfice was 1 cm in diameter. A 4 × 3 cm oblong inlay graft of Marlex mesh was sutured with the superior ramus of pubis and internal obturator muscle so as to cover the obturator foramen, in the meantime careful attention was paid for the obturator nerve, artery and vein. The hernia orfice was thus covered. The patient's postoperative course was uneventful and she was discharged from the hospital on the 8th postoperative day.
This repair using an inlay graft of Marlex mesh is a safe and reliable repair for obturator hernia, because it is minimally invasive, it does not give any tension to the surrounding organs, and it does not compress the obturator nerve, artery and vein. The approach is considered to be very useful for cases of obturator hernia which are candidates for elective surgery and have no risk of intestinal necrosis.

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