With a recent increase of patients who are pointed out microcalcification on mammography (MMG) but otherwise normal, we have increasingly difficulties in making diagnosis. In this paper we examined magnetic resonance imaging (MRI) findings and diagnosis of microcalcification lesions.
Out of consecutive patients who visited our hospital for close exploration of calcification on MMG from July 2006 to March 2009, 124 patients who were performed MRI were enrolled in this study. The morphology and enhancement kinetics of their lesions visualized by MRI were classified with reference to the BIRADS-MRI and were compared with outcomes of histological diagnoses. As a result, all lesions in which no abnormal enhancement was seen on MRI were benign. Malignant lesions accounted for about 80.0% in mass patterns, and about more than half in non-mass like enhancement. About 30% of the lesions were malignant in the Focus/Foci pattern which designates lesions with the size of less than 5mm.
MRI is capable of predicting whether the microcalcification lesion is malignant or benign in some degree in patients with positive findings, and we can omit ST-MTB in those with negative findings. Accordingly MRI is considered to be an extremely useful modality.

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The usefulness of blood procalcitonin level (PCT) has been winning recognition as a marker of bacterial infections. Consecutive 27 patients with peritonitis demanded emergency operation in the hospital from March 2008 to February 2009 were enrolled in this study to evaluate the usefulness of PCT measurement in DIC risk assessment after operation. To do so, the subjects were divided into two groups by blood PCT values, namely those whose PCT values were less than 3+ (PCT low group) and those whose values were 4+ (PCT high group), and PCT and blood culture results, CRP, and white blood cell count (WBC) were compared between the both groups. As a result, no significant correlation was noted between DIC and CRP or DIC and WBC. In the PCT high group, nine out of 14 patients were diagnosed as having DIC not only immediately but also more than 2 days after the operation. When high value of PCT was designated as a DIC risk factor, the sensitivity was 90% and the specificity was 64%, which were superior to those when blood culture positive was designated as a DIC risk factor.
It is suggested that PCT blood level measurement is useful in DIC risk assessment after operation for peritonitis, and especially for patients whose PCT values are 4+, early application of treatment for DIC might have to be considered.

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The patient in his seventies was admitted to the hospital because of postoperative small bowel obstruction, and his symptoms improved with defecation. However, he developed high fever and respiratory failure, and went into septic shock and multiple organ failure (MOF). Because Citrobacter freundii, a kind of the intestinal bacteria, was detected by blood culture, we diagnosed him as having bacterial translocation (BT) caused by small bowel obstruction. Following systemic administration of antibiotics and early enteral nutrition, his symptoms subsided. Though he needed intensive care with artificial respiration and continuous hemodiafiltration, he was discharged from the hospital very much improved.
It is known that small bowel obstruction can induce BT, but it is rare that small bowel obstruction without strangulation or perforation causes sepsis and MOF. We treated a patient with small bowel obstruction complicated with septic shock and MOF due to BT.

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Papillary thyroid carcinoma easily metastasises into the lymph nodes. The disease has an excellent prognosis, positive surgical treatment is necessary. We treated a patient with papillary thyroid carcinoma who developed a brachiocephalic vein tumor thrombus. A 74-year-old woman presented with an enlarged left cervical tumor. Core needle biopsy of the tumor showed papillary thyroid carcinoma. Preoperative computed tomography revealed a left thyroid tumor metastases to the cervical and the upper mediastinal space lymph nodes as well as a tumor thrombus of brachiocephalic vein.
A total thyroidectomy with modified neck dissection, combined with resection of tumor thrombus from the brachiocephalic vein via an upper sternotomy was done. The patient developed a slight amount of hoarseness after surgery, postoperative course was almost good. We report a rare case of brachiocephalic vein tumor thrombus associated with papillary thyroid carcinoma.

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A 65-year-old man with thoracic esophageal cancer was treated with transthoracic esophagectomy and two-field lymphadenectomy. He was judged to be capable of tolerating the surgery by evaluating his cardiac function before surgery. He received postoperating care with an artificial respirator in the ICU. The postoperative course was satisfactory until postoperative day 2 : his respiratory condition worsened. Electrocardiography showed elevation in ST segment in leads V3∼V6, and ultrasound cardiography showed typical findings of Takotsubo cardiomyopathy, akinesis in the entire left ventricule, apical ballooning, and hyperkinesis in the base of left ventricle. After ruling out the possibility of myocardial infarction on the basis of coronary angiography findings, he was treated for heart failure and followed up strictly. Electrocardiography and ultrasound cardiography performed on postoperative day 7 revealed that the ST segment and systole function, respectively, had normalized. Gastrointestinal surgery is important as the trigger of Takotsubo cardiomyopathy ; few studies have reported Takotsubo cardiomyopathy after esophagectomy. We report a case of Takotsubo cardiomyopathy after esophagectomy.

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A 48-year-old woman with osteogenesis imperfecta was found to have aortic regurgitation on screening done when she was 40-years-old. The patient was 143cm tall. Since childhood the patient had suffered from several bone fractures. On physical examination, bone deformities blue sclera, and her stature were the clinically manifestations of osteogenesis imperfecta. An aortic valve replacement with a 25-mm. On-X prosthetic valve was successfully performed for aortic valve insufficiency and slight annulo-aortic ectasia. She had a history of open-heart surgery for an atrial septal defect in childfood ; her soft tissues and sternum were fragile. Thus, the surgery required the utmost care. On pathology, the aortic valve and media layer of the aorta had mucoid deposition. The patient recovered from surgery and was discharged. Osteogenesis imperfecta is one of the collagen diseases caused by a gene abnormality, which results in fragile bones that are easily fractured. Cardiovascular disease is rarely associated with osteogenesis imperfecta, and the surgical mortality rate is high.

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A 63-year-old man was admitted with fever, lumbago and right leg edema. Abdominal computed tomographic (CT) scan done on admission showed a hematoma around the right iliac artery without leakage of contrast media. A CT scan conducted 4 days after admission showed a 3 × 4 cm area pooled with contrast media within the hematoma ; this finding indicated leakage of the contrast through the internal iliac artery into the hematoma. An emergent surgical repair consisting of arterial reconstruction with an extra-anatomical bypass and extensive retroperitoneal debridement was performed. The pseudoaneurysm originated from the right internal artery. No pus was observed. Salmonella infection was diagnosed on the basis of aneurysmal sac and hematoma specimen cultures. Early diagnosis of infected pseudoaneurysm is often difficult because the clinical features are nonspecific, i.e., unknown fever and lumbago. Our case demonstrates the importance of serial CT examinations in suspected cases ; these should be obtained even if the initial CT findings are negative.

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Case 1 : A 61-year-old man with diabetes mellitus developed chest pain and fever ten days prior to being seen. Computed tomography (CT) revealed a right multilocular pleural effusion. A chest tube was placed to drain a small turbid pleural effusion. Acute fibrinopurulent empyema was diagnosed. Intracavitary instillation of urokinase at a dose of 120,000 U/day was started on day 12. Nine days later, the pleural effusion had almost resolved so that the chest tube could be removed.
Case 2 : A 60-year-old man who had diabetes mellitus underwent tracheostomy for repeated pneumonia ; he developed fever four days prior to being seen. CT revealed a right multilocular pleural effusion. A chest tube was placed to drain a small turbid pleural diffusion. Acute fibrinopurulent empyema was diagnosed. Intracavitary instillation of urokinase at a dose of 6,000 U/day was started on day 15 ; 12 days later, the pleural effusion had almost resolved so that the chest tube could be removed. In both cases the postoperative course was uneventful. The intracavitary instillation of urokinase for acute empyema is minimally invasive and is readily available. Thus, this therapy should be considered prior to instituting surgical treatment.

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A 67-year-old woman was admitted to our hospital for the surgical removal of a nodular lesion located in the left upper lobe. She had undergone a left modified radical mastectomy for breast cancer 17 years previously. Preoperative chest CT revealed a nodule, 1.1 cm in diameter, in S⁵ of the left lung and micro-nodular changes on the interlobar fissure. A bronchoscopy was performed, and pulmonary adenocarcinoma was diagnosed on cytology. A thoracoscopic approach was chosen, as there were multiple small nodules on the visceral and parietal pleura. On intraoperative pathology, a primary lung cancer (adenocarcinoma) and pleural metastasis from the breast cancer were diagnosed. A wide partial resection of S⁵ was performed, and the patient had an uneventful postoperative course. She is currently receiving endocrine therapy, and is doing well without any evidence of recurrence 26 months after surgery. In this paper the relevant literature and the case are presented.

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A 57-year-old man was referred to our hospital because of a lung tumor that was pointed out at the right upper lobe at a medical checkup. The tumor rapidly enlarged from 2cm to 3cm in diameter within a month on CT. We suspected the tumor might be primary lung cancer, and performed surgery. Because of the intraoperative pathological examination indicating lung cancer, we eventually performed right upper lobectomy. The cut surface of the specimen which was 32×40mm in diameter, well-defined, grayish white in color, and solid included hemorrhagic necrosis inside. Microscopically, the tumor revealed the epithelial component mimicking fetal lung tissue and the proliferative mesenchymal component consisting of immature and heteromorphic nuclear cells as well. According to these findings, the tumor was finally diagnosed as pulmonary blastoma (IB : pT2N0M0). He received adjuvant chemotherapy (Paclitaxel+Carboplatin). He has been free from recurrence as of 1.5 years after the operation.
Preoperative diagnosis of pulmonary blastoma is not easy to be made. Eary diagnosis with surgical resection is only curative way of treatment. When we encounter a lung tumor that shows a rapid growth, we should suspect this disease and extirpate it surgically as soon as possible.

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An 82-year-old woman developed constipation and abdominal pain. Computed tomography (CT) showed a diaphragmatic hernia prolapsing into the right pleural cavity, an incarcerated transverse colon, and incarcerated soft tissue. Laparoscopic emergency surgery was performed. The herniation occurred via the foramen of Larrey. The transverse colon was already reduced because of the pneumoperitoneum. The size of the hernia orifice was 4 × 3 cm. A primary closure was done, and the patient was discharged after an uneventfull recovery. There was no evidence of recurrence on CT done 1 month after the operation. A laparoscopic repair should be considered as the first choise for treatment of a Morgagni or Larrey hernia.

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An 87-year-old man with a history of thoracoabdominal trauma five years prior was admitted to our hospital because of chest and abdominal pain. Chest X-ray showed bowel gas in the left lower thorax. Chest CT scan revealed herniation of the stomach and the colon into the left thoracic cavity, left atelectasis, and displacement of the heart to the right. Upper gastrointestinal series revealed that the stomach prolapsed into the mediastinum and gastrographin was not flowing to the duodenum. Based on these findings, the patient was diagnosed as having diaphragmatic hernia. The herniation was irreducible endoscopically, and thus laparotomy was performed. A fist-sized defect of the diaphragm was observed, through which the stomach, the spleen, and the colon had herniated into the thoracic cavity. The herniated organs were reduced into the abdominal cavity by hands and the diaphragmatic rupture was repaired with thoracoscopic assistance. The patient is currently alive and shows no signs of recurrence.
Careful post-traumatic observation is necessary because the traumatic diaphragmatic hernia can recur later like in this case.

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We report 4 cases of spontaneous esophageal rupture treated with primary transhiatal sutures. The subjects were 3 men and 1 woman aged from 64 to 89 years who were hospitalized with chest and abdominal pain after vomiting and were preoperatively diagnosed with lower esophageal wall rupture. The lower esophageal rupture was treated with a primary suture through an upper median incision and a thoracostomy tube was placed in the left thoracic cavity. An omental pedicle flap was applied over the sutured site, and jejunostomy was conducted in 3 subjects. All patients were discharged with 31-53 postoperative days. We could observe the lower esophagus completely under a good field of view. Transhiatal approach is thought to be useful for the treatment of lower esophageal wall rupture.

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We report a case of undifferentiated carcinoma (non-small cell type) with lymphoid stroma of the esophagus. A 67-year-old man was admitted to our hospital for esophageal tumor. Esophagoscopy revealed a protruding lesion with a central ulcer, and endoscopic biopsy showed it to be an adenocarcinoma. Thus, the patient was preoperatively diagnosed with adenocarcinoma of the esophagus, and was treated with subtotal esophagectomy. A diagnois of undifferentiated carcinoma with lymphoid stroma of the esophagus (non-small cell type) was made on the basis of the findings of pathologic tests of specimens. Postoperative chemoradiotherapy was not performed ; mediastinal lymph node and lung metastases were confirmed at 2 years after the operation. The patient responded to chemo radiotherapy but died at 53 months sfter the operation. We retrospectively reviewed and analyzed 21 cases of undifferentiated carcinoma of the esophagus (non-small cell type) and 3 cases of lymphoid stroma in the Japanese literature.

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Secondary solid tumors (SST) that develop after bone marrow transplantation (BMT) are acquring increasing interest with a recent improvement of outcomes of BMT. SSTs commonly generate from the squamous epithelium in the skin and the mouth, but rarely present with esophageal carcinoma. We have experienced three cases of esophageal carcinoma after BMT. These three cases showed many common features to those of SSTs after BMT other than esophageal carcinoma in the onset period of the disease after BMT, risk factors, and treatment methods. It is known that SSTs develop from 10 to 20 years after BMT and the risk factors include associated graft versus host disease and the use of immunosuppressive agents. Clinical reports concerning the treatments of SSTs have been few, but similar treatments to those of primary carcinoma have been done in many cases.

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A 68-year-old man was admitted to our hospital for vomiting and abdominal fullness. Computed tomography (CT) of the abdomen showed dilatation of the stomach.
Despite nasogastric decompression, he complained of severe acute abdominal pain with muscular defence. Repeat CT of the abdomen showed large amount of free air and ascites. Emergency operation was performed since the incidence of perforative gastric ulcer was suspected. Laparotomy showed tear in the gastric wall and extensive food leakage. Partial gastrectomy was performed and the abdomen was drained and lavaged. After the operation, he developed shock, and required intensive care. Since the patient underwent laparotomy without delay, he survived, despite developing shock and severe peritonitis.

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A 74-year-old woman underwent modified radical mastectomy in 2005. Follow-up chest CT scan revealed a linear high-density structure in the stomach. However, we did not detect the foreign body at the initial examination. The patient did not show any symptoms or signs of inflammatory reaction and could walk normally. Therefore, she was discharged. At 10 days after discharge, when she visited our hospital, we derecred the foreign body. Abdominal CT scan revealed a linear high-density structure at the same position. Gastrointestinal endoscopic examination revealed only a granulation on the posterior wall of the lower gastric body. We assumed that the penetration of the stomach was caused by a foreign body. An emergency operation was performed. We found a 50 mm fish bone covered by granulation. The fish bone that had penetrated the lower gastric body had pierced through the antrum. We present a very rare case of gastric penetration and a review of the literature.

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In this report, we present the case of a preoperatively diagnosed gastric schwannoma. A 52-year-old man presented with a submucosal tumor, measuring approximately 40 mm in diameter, located in the middle portion of the stomach ; the tumor was identified after the patient underwent an upper gastrointestinal series and gastrointestinal fiberscopy in July 2009. Endoscopic ultrasonography revealed a hypoechoic tumor in the 4^th layer. A bowring biopsy of the submucosal tumor revealed a palisade of spindle cells, and the tumor was pathologically diagnosed to be a schwannoma of the stomach. Immunohistochemical staining for S-100 protein(+), c-kit(-), and α-SMA(-) was performed. A partial gastrectomy was performed. The postoperative pathological findings were same as the biopsy findings. In addition, postoperative immunohistochemical staining results were positive for vimentin and negative for CD34 and CD68. The biopsy and immunohistochemical staining results were valuable for establishing the preoperative diagnosis of the schwannoma of the stomach.

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A 59-year-old man underwent distal gastrectomy with D2 dissection for advanced cancer of the antrum in February 2010. From the day of the operation, slightly clouded discharge, which amounted to about 500 ml/day, from a drain was noted. On the second postoperative day (POD) the discharge temporarily decreased. However, when oral ingestion was started from the 5th POD, the clouded discharge from the drain became to increase on the 6th POD. It was diagnosed as chylous ascites based on properties of the discharge. We considered that he had chylous leakage after gastric resection for gastric cancer, and started subcutaneous injection of octreotide at a dose of 300μg/day on the 10th POD lasting for 7 days. Chylous leakage temporarily subsided. Resuming of oral ingestion resulted in appearance of chylous leakage again. For that, additional subcutaneous injection of octreotide was done for 5 days. On the 28th POD, oral ingestion resumed, but chylous leakage was kept improved and the drain was able to be removed. He was discharged from the hospital on the 31st POD.
We often have great difficulties in treatment of chylous leakage after surgery for gastric cancer, and in that case, subcutaneous administration of octreotide might be helpful.

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We report a case of type 1 advanced gastric cancer which caused ball valve syndrome. An 88-year-old man was admitted because of vomiting after eating. Endoscopic examination revealed a transpyloric prolapse caused by a type 1 gastric cancer. Using the intrabulbar retroflexion method, the whole course of the prolapsed gastric cancer into the duodenal bulb could be easily observed, and an accurate diagnosis could be easily made. The cancer was pushed back into the stomach ; endoscopic submucosal dissection was performed. However, the cancer had infiltrated the muscle layer of the stomach. Therefore, a distal gastrectomy was performed. The tumor was a type 1 tumor 50×45 mm in diameter located in the antrum of the stomach. Histological examination showed moderately differentiated adenocarcinoma infiltrating into the muscle layer of the stomach wall. We report this case along with an analysis of 35 cases of gastric cancer prolapsing into the duodenum reported from 1983 to 2010 in Japan.

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We report a case of small bowel perforation due to Metagonimiasis yokogawai infection. A 47-year-old man with diabetes and chronic renal failure who had vomiting and abdominal pain was found on abdominal CT to have an ileus caused by an intraperitoneal abscess. Emergency surgery was done. Intraoperative findings included an abdominal abscess in the ileocecal area and the pouch of Douglas caused by a small bowel perforation. Microscopic findings included many erosions and an eosinophilic gastroenteritis surrounding Metagonimiasis yokogawai. Therefore it is likely that the perforation was due to Metagonimiasis yokogawai. Patients with a Metagonimiasis yokogawai infection rarely have symptoms such as abdominal pain and diarrhea. There have been no previous reports of gastrointestinal perforation due to Metagorimiasis yokogawai in Japan.

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An 86-year-old man was seen at the hospital because of a right inguinal mass on January 23, 2009, when he had no incarceration and symptoms suggestive of intestinal obstruction. Thus elective surgery was scheduled, but the patient was seen at the hospital again because of upper abdominal pain on January 27, 2009. Abdominal plain X-ray film showed niveau formation. An abdominal pelvic CT scan revealed an incarcerated intestine in the right inguinal region and whirl sign in the upper abdomen. Secondary small intestinal volvulus due to right incarcerated inguinal hernia was suspected, and emergent laparoscopic-assisted surgery was performed on the same day. At surgery, we confirmed the wholly dilated small intestine in the abdominal cavity, and Richter type right incarcerated inguinal hernia of the terminal ileum. The incarcerated intestine was repositioned into the abdominal cavity by using forceps. There were no ischemic changes in the incarcerated intestine. Further exploration disclosed volvulus twisted counterclockwise by about 720 degree around the superior mesenteric vein as the axis, and repositioning of the intestine was done. No ischemic changes were seen in the involved small intestine and thus intestinal resection was not demanded. Radical repair for the right inguinal hernia was made by using the Mesh plug method and the operation was finished. The patient's postoperative course was uneventful and he was discharged from the hospital on the 17th postoperative day.

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A 54-year-old woman, who had previous histories of undergoing appendectomy and cholecystectomy, was seen at the hospital because of recurrent symptoms of bowel obstruction for these several years. We performed laparotomy with a diagnosis of adhesional ileus. Operative findings showed multiple intestinal diverticula but there were no other abnormalities which might have caused bowel obstruction. She also had a history of juvenile-onset uterine and vaginal prolapse. Pelvic organ prolapse and acquired diverticula might be associated with fragility of connective tissues. She was clinically diagnosed as having Ehlers-Danlos syndrome (EDS) because of her family histories and physical findings.
EDS is a rare hereditary disease caused by genetic disorder of connective tissues. Patients with EDS show various manifestations, which are dependent on its clinical type or each patient. The cause of bowel obstruction in this case was considered to be decreased peristalsis due to EDS. There have been no specific therapies for EDS but EDS sometimes causes life-threatening complications such as spontaneous hemorrhage or intestinal perforation. Based on features of this disease, adequate follow-up is needed.

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A 60-year-old man was admitted as an emergency case for severe abdominal pain and melena following continuous and mild abdominal pain for a week. He showed rebound tenderness of the abdomen, and enhanced CT of the abdomen showed superior mesenteric and portal vein thromboses as well as edema of the small intestine with ascites, thereby suggesting jejunal necrosis. He underwent emergency operation in which a 65-cm segment of the jejunum at a distance of 15 cm from Treitz's ligament showed necrosis with bloody ascites. The necrotic small intestine was resected and anastomosed. Postoperative, anticoagulation therapy was administered using heparin followed by warfarin. A diagnosis of superior mesenteric and portal vein thromboses caused by antithrombin III deficiency was made, because a decreased level of serum antithrombin III was confirmed after surgery.

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This study reports a case of solitary metastasis of ascending colon cancer to the small intestine. The patient was a 92-year-old woman who had undergone right hemicolectomy for ascending colon cancer in September 2008. Pathological examination showed poorly differentiated adenocarcinoma (pSI, ly1, v2, pPM0, pDM0, n0). She was admitted to our hospital because of colicky abdominal pain in March 2009. She underwent partial resection of the small intestine since adhesion ileus was diagnosed. A solid tumor (measuring about 2.0 cm in size, elastic hard, Bor2 type) was detected mainly in the submucosal layer in the excised sample. No evidence of any malignancy was observed in the abdominal cavity. Histological findings revealed poorly differentiated adenocarcinoma, these findings were similar to those obtained for ascending colon cancer. Immunostaining revealed that the tumor cells were positive for cytokeratin-7 and -20. The patient has been free from recurrence since surgery, and is being followed up strictly.

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A 75-year-old man presented at another hospital with breathlessness. He was admitted to our hospital for the examination of anemia and hepatic tumors. Upper gastrointestinal endoscopy and colonofiberscopy revealed no abnormal findings. Double-balloon endoscopy revealed a type 3 tumor in the upper jejunum. A jejunal tumor with hepatic and lymph node metastasis was suspected. We interpreted that radical operation was impossible because of the associated para-aortic lymph node metastasis, and performed a partial resection of the jejunum. Histological examination revealed a sheet arrangement of atypical cells. The immunohistochemical staining (CD56) results were positive. Therefore, the tumor was diagnosed as neuroendocrine cell carcinoma of the jejunum. After the operation, the patient received chemotherapy with CDDP and CPT-11. However, he died 5 months after the operation in spite of anticancer therapy. Since neuroendocrine cell carcinoma of the small bowel is rare, we report this case with some bibliographical comments.

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Diverticulitis of the appendix (DA) is relatively rare, and few studies have reported the use of laparoscopic surgery for DA. We analyzed 6 patients with DA who underwent laparoscopic appendectomy at our hospital. The mean age of the patients was 48.8 years. The patients included 4 men and 2 women. One patient was preoperatively diagnosed with DA, and the preoperative diagnosis in the remaining 5 cases was acute appendicitis, and not DA. All patients were treated with laparoscopic appendectomy, and no patient was converted to laparotomy. Perforation of the diverticulum was observed in 3 cases (50%). All patients were discharged from the hospital without postoperative complications.
DA has been reported to be associated with a high perforation rate, which was observed in all the 6 patients. Laparoscopic appendectomy is considered to be a useful technique for the management of DA.

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A 68-year-old woman with cancer of the cecum and the sigmoid colon had a laparoscopic ileocectomy and a sigmoidectomy. Fever and right flank pain occurred 6 days after the operation ; abdominal enhanced CT showed thrombosis of the superior and inferior mesenteric vein and the right branch of the portal vein without an intestinal congestion sign. After fasting and heparinization for 5 days, the findings resolved. The second abdominal CT done 14 days after the operation showed thrombus expansion ; she had no symptoms and was discharged after conversion from heparin to warfarin. The thrombus had disappeared on sonography and D-dimer levels decreased 78 days after the operation. The third CT done 99 days after the operation showed collapse of the superior mesenteric vein distal to the branch of the first jejunal vein, which had compensatory hypertrophy as well as collapse of the inferior mesenteric vein. Although the etiology of the thrombus was unknown, it is likely that sufficient collateral blood flow in the marginal vein avoided intestinal congestion and liver dysfunction.

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An 81-year-old woman, who had previous histories of appendicitis at the age of 20 and of undergoing surgery for intestinal obstruction at the same age, had noticed a left abdominal tumor since several years earlier but left it as it was. She was admitted to the hospital for close exploration because of recently developed constipation, nausea, and abdominal pain. Following close exploration, the abdominal tumor was clarified to be fecalith which existed in a blind loop formed by side-to-side anastomosis between the transverse and sigmoid colons. Because endoscopic therapy was difficult for the fecalith, open surgery was selected.
Pathologic conditions caused by blind loop are defined as blind loop syndrome (BLS) and induce a variety of gastrointestinal symptoms, however, no reports on fecalith occurred in a blind loop have been described as yet. This case is thus considered rare. A possibility of malignancy could be ruled out by preoperative examinations in this case, but carcinogenesis in the blind loop has been reported in the literature. In the treatment of abnormal bowel movement in aged people, we must keep in mind whether they have a blind loop or not.

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A 32-year-old pregnant woman was admitted to a hospital because of the sudden onset of abdominal pain. She was treated for threatened abortion. Seven days later she was brought into our hospital by ambulance, because the therapy was unsuccessful and ileus was suspected by abdominal X ray, abdominal US and MRI. Physical examinations showed peritoneal signs. As an abdominal CT scan revealed intraabdominal free air and ascites, we suspected perforation of the rectum and performed an emergency operation. We could not recognize any perforation site at the rectum because of the huge uterus, and so we performed drainage and setting of trasverse colostomy. After the operation, her pregnancy was terminated spontaneously. She was discharged from our hospital 46 days after the operation.
It is difficult to diagnose acute abdmen in pregnant women because imaging examinations are limitted. CT was useful for diagnosis in our case. To treat perforation of the colon during pregnancy as well as to rescue the fetus is very difficult. We need to pay much attention for constipation in pregnancy.

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A 68-year-old female was admitted in July, 2004, due to the long standing presence of diarrhea, abdominal pain, and malnutrition. On colonoscopy, multiple reddish polyps with white caps were found from the rectum to the sigmoid colon, and sigmoidectomy was performed. On pathology inflammatory polyps were diagnosed ; Cap polyposis (CP) ; at this time was not diagnosed. In 2007 and 2008, the same symptoms and the recurrence of the same multiple polyps in the anastomotic site of the sigmoid colon were noted. Steroid enemas, mesalazine, and salazosulfapyridine were given under a diagnosis of inflammatory bowel disease, but they were not effective. The clinical, endoscopic, and pathological features suggested CP. The etiology of this disease is still unknown. However, Helicobacter pylori (HP) eradication therapy was tried because the patient had HP in her stomach, and there were some case reports about its effectiveness in CP. After this treatment, the patients symptoms completely disappeared, and the polypoid lesion in the colon resolved. The treatment of CP is not established, but HP eradication therapy was very effective in this case.

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A 79-year-old man was admitted to a hospital because of high fever and somnolence. Computed tomography of the abdomen and ultrasonography revealed a solitary liver abscess (diameter, 5 cm) in the left abdominal lobe. The patient responded well to the administration on antibiotics and percutaneous transhepatic abscess drainage (PTAD). Several gastrointestinal examinations were performed to determine the cause of the liver abscess. Colonoscopy revealed a type 2 tumor in the rectum that resulted in well-differentiated adenocarcinoma. Cytologic test of the abscess revealed no malignant cells, and no causative oraganisms could be isolated by culture. After the abscess diminished, abscess we performed high anterior resection with D2 lymph node dissection. Histopathological findings of the resected tumor specimen were as follows : tub1, ss, n0, ly1, v0, and stage II. The patient was free from liver metastasis and liver abscess 3 years after the operation. In conclusion, pyogenic liver abscess without hepatobilliary origin requires a complete gastrointestinal evaluation.

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An 85-year-old woman was hospitalized for lower abdominal and perianal pain. There was no evidence of intestinal obstruction ; a type I tumor was observed in the rectum on endoscopy. Computed tomography showed a mass with a multiple concentric ring sign in the rectum. A diagnosis of rectal intussusception due to rectal carcinoma was established, and an operation was performed. Manual reduction was tried at first, but was not successful. Therafore, Hartmann's operation was performed. In adults rectal carcinoma presenting as intussusception is extremely rare. Thus, we present this case and discuss the relevant literature.

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A 69-year-old man was seen for hematochezia, and found to have a large type 2 tumor of the rectum (Rasb) invading into the urinary bladder and the seminal vesicle. Metastatic pararectal and right lateral lymph nodes were suspected on pelvic CT and MRI scan. A detailed history revealed changes in his bowel habits. The bowel obstruction was treated with a transverse colostomy. Four cycles of mFOLFOX6 chemotherapy were administered. Bevacizumab was given in addition to the mFOLFOX6 for two cycles. Repeat imaging showed remarkable shrinkage of the tumor, and elective surgery with curative intent was performed. Pelvic exenteration was carried out because the tumor grossly invaded the urinary bladder, the seminal vesicle, and the prostate. Pathological findings of resected specimen showed no residual adenocarcinoma consistent with a complete response.

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A 70-year-old man with a complaint of bleeding at defecation and anal pain was admitted to our hospital. A type 2 tumor was detected in the anal canal. Biopsy examination under unbar anesthesia revealed small-cell carcinoma, which was removed by abdominoperineal resection. Histopathological examination revealed a well-differentiated villous adenocarcinoma and solid nest-like cancer cells. A round cell that proliferated to solid alveolar form was positive for CD56, chromogranin A, and synaptophysin, and was diagnosed as neuroendocrine cell carcinoma. We administered 6 rounds of FOLFOX4 therapy as adjuvant chemotherapy. At 12 months after surgery, lung and liver metastases were observed on CT, and mFOLFOX6 therapy was started. Neuroendocrine cell carcinoma of the anal canal is extremely rare and its prognosis is poor. Surgery alone is not enough for radical cure and combined treatment is required.

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The authors report a case of traumatic rupture of a liver hemangioma treated by hepatectomy following Transcatheter Arterial Embolization (TAE). A 64-year-old female fell and bruised her lumbar area ; she became hypotensive. After fluid resuscitation her cardiovascular status normalized. Computed tomography of the abdomen demonstrated intra-abdominal bleeding, a 4-cm hemangioma in the left lobe of the liver, and extravasation of contrast from the hemangioma. A traumatic rupture of a liver hemangioma was diagnosed, and TAE was performed. In order to avoid the risk of re-bleeding, a hepatectomy was performed 26/days after TAE.
Ruptured hemangioma is associated with a high mortality rate. The TAE procedure is effective, but there is a risk of re-bleeding and uncertainty about it's long-term effectiveness. In ruptured hemangioma cases, TAE should be considered before hepatectomy, to stabilize the patient hemodynamically.

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The patient was a 60-year-old man who was urgently hospitalized with a chief complaint of upper abdominal pain. Examination revealed an approximately 20-cm tumor mass with poor contrast enhancement adjacent to the lateral segment of the liver as well as a 3-cm tumor mass in liver segment 6, gallstones, and choledocholithiasis. Due to marked tumor adhesion, the tumor of the left lateral segment was resected along with the transverse colon. This was followed by resection of the tumor in S6, cholecystectomy, and choledocholithectomy. The postoperative pathologic examination revealed the giant tumor to be a foreign-body granuloma containing a suture, and the tumor of liver segment 6 was diagnosed to be a hepatocellular carcinoma. It was later revealed that a liver biopsy had been performed for gastric cancer surgery 14 years ago. We assuned that a suture used in liver biopsy 14 years ago was the cause of the granuloma.

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A 70-year-old man with chronic hepatitis C developed single hepatocellular carcinoma (HCC). He underwent enucleation of the tumor. Seven months later, he also underwent removal of tumor due to localized peritoneal dissemination. Five months after the second operation, a recurrent single disseminated nodule was found between the right liver dome and the diaphragm. This tumor was associated with a tumor thrombus into the inferior vena cava (IVC) via a diaphragmatic vein. Since the patient had no other metastasis at that time, he underwent combined removal of the nodule and the tumor thrombus via a longitudinal sterno-abdominal incision. He was uneventfully discharged from hospital on the 14th postoperative day. 8 months after this operation, he died of liver failure due to portal thrombus of bilateral hepatic lobes. His quality of life had been so good that the death was unexpected. Although the surgical treatment of HCC complicated by peritoneal dissemination and IVC tumor thrombus is still controversial based on the literature surgery may change the prognosis depending on the particular case.

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A 78-year-old male patient presented with intermittent episodes of high fever and jaundice over the course of 4 years and was admitted. He had had a cholecystectomy 10 years prior to admission. Under a diagnosis of cholangitis due to benign biliary stricture, endoscopic retrograde biliary drainage was introduced to control the infection. It was difficult to control the infection, and the patient was referred to our department. Cholangiography revealed a stricture of the upper bile duct and hepatolithiasis. The patient underwent a bile duct resection, lithotomy, and a Roux-en Y hepaticojejunostomy. Histological examinations of the stricture revealed thick fibrous tissue with prominent proliferation of nerve fibers. As a result, the lesion was diagnosed as an amputation neuroma. Although it is a rare type of lesion, amputation neuroma should be considered in the differential diagnosis of bile duct stricture in patients with previous biliary surgery. Surgical intervention is strongly recommended, when a biliary stricture caused by an amputation neuroma is implicated in repeat episodes of cholangitis.

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An 82-year-old woman with a two-day history of left back pain of unknown cause, had an abdominal ultrasound study which revealed no particular abnormalities. However, she developed nausea and appetite loss ; repeat abdominal CT scan suggested rupture of the spleen. She was referred for emergency surgery. During laparotomy, about 1,000 ml of bloody ascites was found, as well as an enlarged spleen (20×11×5 cm), a ruptured capsule, and a hematoma undex the capsule. Intraabdominal hemorrhage due to splenic rupture was diagnosed, and a splenectomy was done. Based on the hematology results a coexistent hematological disorder was suspected. On bone marrow biopsy, chronic myeloproliferative disorder (CMPD) was diagnosed (Philadelphia chromosome negative).
There are occassional reports of spontaneous splenic rupture. However, spontaneous splenic rupture with CMPD is rare ; this case is only the fifth reported in the Japanese literature. Our paper presents this extremely rare case along with a review of the literature.

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Inflammatory pseudotumor of the spleen is a rare entity. It lacks characteristic imaging features and so its preoperative diagnosis is difficult. Splenectomy is often performed for diagnosis and therapy of this disease. We experienced a case of an inflammatory pseudotumor of the spleen which was incidentally found and diagnosed by laparoscopic splenectomy.
A 48-year-old man who had been followed by an urologist for left urethral stenosis and stones was incidentally found to have a splenic tumor 2cm in diameter by an abdominal enhanced CT scan. He was referred to our department for operation. We performed laparoscopic splenectomy carefully so as not to destroy the capsule of the spleen, because a possibility of malignancy could not be ruled out. The postoperative histological findings showed an inflammatory pseudotumor of the spleen. His postoperative course was quite uneventful, and he was discharged on the 6^th postoperative day. There have been 19 reported cases of inflammatory pseudotumors of the spleen resected by laparoscopic surgery in Japan.

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The patient is a 66-year-old man who had undergone an emergency operation for abdominal injury at the age of 40 years. He was admitted to our hospital with a giant mass in the left upper abdomen. We performed detailed examination to identify the mass. Abdominal ultrasonography revealed irregular high-amplitude echoes in a hypoechoic mass. Abdominal CT scan revealed a cystic mass in the left upper abdomen, which pressed the stomach and transverse colon extrinsically. Abdominal T2-weighted MR images revealed a folded fabric appearance of the tumor. On the basis of these findings, he was diagnosed with a gauzeoma with abscess as a secondary infection, and an operation was performed. We could not resect the tumor because it was firmly attached to the surrounding tissues, so we only drained the pus from the tumor. No complication, such as infection, occurred after the operation. The partially resected wall of the tumor was identified as an inflammatory granuloma with gauze fibers, and infiltration of inflammatory cells and a foreign body composed of giant cells were observed on histopathological examination. In this case, US and MRI were very useful for establishing the preoperative diagnosis of gauzeoma. Herein,report this case with some bibliographical comments about the diagnosis of gauzeoma.

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This paper deals with two cases of desmoid tumor in which PET/CT contributed to diagnosis.
Patient 1, a 64-year-old man, was referred to the hospital because he noticed an abdominal mass. An abdominal CT scan showed a total of three tumors with clear margin in the abdominal cavity. PET/CT showed slight uptake of 18F-FDG, and MRI showed that the tumors had fibrous component. Partial resection of the small intestine was performed with the most likely diagnosis of desmoid tumor. The histopathological diagnosis was desmoid tumor.
Patient 2, a 71-year-old man, was referred to the hospital because of an abdominal tumor which was found during follow-up period after pancreaticoduodenectomy. An abdominal CT scan showed a tumor with clear margin involving an 8 cm-sized right ureter. Since PET/CT findings showed slight uptake of 18F-FDG and metastasis or recurrence was considered to be unlikely, fine needle biopsy cytology was done. The histopathological diagnosis was desmoid tumor.
In the treatment of intra-abdominal tumors which have a variety of differential diagnoses, PET/CT scanning contributes to differentiation between benign and malignant lesions so that it can be a useful tool.

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A 90-year-old man was diagnosed as having a congenital antithrombin III deficiency and a pulmonary thromboembolism 4 years prior. Warfarin potassium was prescribed subsequently, he developed anemia. Upper and lower endoscopy showed gastric cancer and ascending colon cancer. His AT-III activity was only 42%. AT-III was administered from four days before the operation to four days after the operation. Heparin was administered from three days before the operation to the day of the operation. Distal gastrectomy and right hemicolectomy were performed. From three days after the operation, heparin was administered for four days, and then from seven days after the operation. Warfarin potassium was administered. No complications occurred during the intraoperative and postoperative time periods. We report this, along with a review of the relevant literature.

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