We examined prognostic factors of gastric cancer invading the subserosal or deeper layers of the gastric wall with intraperitoneal free cancer cells and no macroscopic peritoneal dissemination (P0cy1 ss or deeper). Among consecutive 987 patients with gastric cancer invading the subserosal or deeper layers of the gastric wall, 86 patients with P0cy1 gastric cancer were enrolled in this study. Their median survival times (MST), one-, 2-, 3-, 4-, and 5-year survival rates were : 1678 days, 83%, 70%, 58%, 51%, and 48% ; 446 days, 56%, 30%, 21%, 14%, and 9.6% ; and 244 days, 36%, 18%, 11%, 3%, and 2% in P0cy0, P0cy1, and P1 gastric cancers, respectively. The prognosis of P0cy1 gastric cancers was proved to be the middle between those of P0cy0 and P1. Prognostic factors of P0cy1 gastric cancer by a univariate analysis were 14 factors including macroscopic type, liver metastasis, extent and number of lymph node metastasis, lymph node dissection, PM, DM, interstitial response, INF, lymphatic permeation, number and size of intraperitoneal free cancer cells, postoperative chemotherapy and chemotherapy. A multivariate analysis selected three prognostic factors including DM, lymph node dissection and postoperative chemotherapy.
Although P0cy1 gastric cancer carries poor prognosis, gastrectomy with D2 or more lymph node dissection, negative surgical margins and postoperative adjuvant chemotherapy would promise better prognosis for the patients with P0cy1 gastric cancer.

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Purposes : This study was designed to clarify risk factors for recurrence in stageII colorectal cancer patients and to determine possible candidates for postoperative adjuvant chemotherapy.
Subjects and Methods : Subjects were consecutive 195 patients with stageII colorectal cancer who were operated on at the hospital from January 1993 to December 2005 and whose operations histologically resulted in a curative one. A univariate analysis was made for the recurrence using clinicopathological factors, risk factors for recurrence were selected by conducting a multivariate analysis, and then the survival rates were analyzed. Results : Factors significantly contributing to the recurrence were gender, age, depth of tumor invasion, ly, and v based on the univariate analysis. According to the multivariate analysis, ly, gender, v, and the depth of tumor invasion were selected as risk factors for recurrence. Patients who had more than two risk factors among of them showed the recurrence rate of 27.9% or more and the cumulative 5-year recurrence-free survival rate of 61.2%, and they were considered to belong to the high risk stageII patient group for recurrence. In the high risk stageII colorectal cancer patients, there was no significant difference in the cumulative 5-year recurrence-free survival rate between those undergone postoperative adjuvant chemotherapy or not (p=0.53). Discussion : We consider that the risk factors for recurrence might be ly, gender, v, and depth of tumor invasion, and that the patients who have more than two factors might be in high risk group for recurrence. A randomized controlled trial would be necessary to evaluate the effect of postoperative adjuvant chemotherapy.

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In order to evaluate the post-operative mid-term results of health related quality of life (HQOL) of laparoscopic surgery for colorectal cancer (LC), we made a case-matched control study comparing with conventional open abdominal operation (OC). The variables were sex, age, ASA score, operated year, tumor location (right, transverse, left, rectosigmoid and rectum), operative procedure and TNM stages (0, I, II, III and IV). The scores of 36-Item Short-Form Health Survey (SF-36, self-filling type questionnaire) and the periods until recovering daily life (recovering period) were compared between the LC and OC patient groups. Except for patients who died or did not agree to be enrolled in this study, subjects were 43 LC patients and 35 OC patients whose operations were done from 2007 to 2008. About 12 to 24 months had elapsed after their operations when they enrolled in this study. The filled questionnaire forms could be recovered from 83.3% of the subjects (83.7% and 82.9% from LC and OC patients, respectively). There were no differences in the patient's background items between both groups. LC patients showed significantly favorable results in the role physical (RP) (52.0 : 45.1), Role emotional (RE) (52.6 : 46.2), and reported health transition (HT) (72.9 : 59.5). There were no significant differences in the other items. The post-operative mid-term HQOL results of RP, RE and HT in the LC patients were more excellent than those in the OC patients under the same condition.

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Prostheses have been commonly used for repair of groin hernia. However, placement of prosthetic material is presumed to increase the risk of infection. The procedure has been contraindicated until recently in the case of the diseas accompanied by intestinal necrosis requiring bowel resection. We therefore examined the Kugel repair in patients with incarcerated groin hernia. Subjects : From January 2006 to December 2008, we performed 67 emergency operations for incarcerated groin hernia, employing the Kugel repair in 45 cases and the conventional repair in the remaining 22 cases. Results : Bowel resection was required in 9 cases (20.0%) of the Kugel repair and 16 cases (72.7%) of the conventional repair. The patients undergone the Kugel repair were free from complications such as wound infection and suture failure, and did not experience recurrence. Conclusion : The Kugel repair seems applicable to selected cases of incarcerated groin hernia.

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Isolated dissection of the superior mesenteric artery (SMA) is rare. There is no consensus about medical treatment for this disease. We studied nine cases with isolated SMA dissection diagnosed at our hospital between 1995 and 2008.
All were male. The average age was 56.8 years. Eight patients were diagnosed by CT, and one by MRI. Eight patients were smokers, and five had hypertension. Four cases had SMA dissection with a thrombotic false lumen, while the other five had a persistent false lumen. All cases were well managed with conservative therapy including antihypertensive, anticoagulant and antiplatelet drugs.
Conservative therapy is generally useful for this disease. Thus, the prognosis may be relatively good. More meticulous and longer observation is needed in cases of SMA dissection with persistent false lumen than in cases with a thrombotic false lumen.

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A 73-year-old man complained of a sense of chest constriction. Esophageal carcinoma was diagnosed by esophagoscopy. Preoperative 3D-CT revealed an aberrant right subclavian artery (ARSA) and suggested the presence of a nonrecurrent inferior laryngeal nerve (NRILN). We performed prone thoracoscopic esophagectomy and identified the ARSA as arising from the aortic arch and ascending through the right side of the esophagus. The right recurrent nerve was not identified around the right vague nerve during mediastinal lymphadenectomy. Then during cervical lymphadenectomy, we identified the NRILN, arising from the right vagus nerve and innervating the larynx directly. Though NRILN is a relatively rare congenital anomaly caused by ARSA, we must take into consideration these anatomical anomalies and perform lymph node dissection carefully when a NRILN is suspected preoperatively. This is the first report of prone thoracoscopic esophagectomy for esophageal carcinoma with NRILN.

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It has been reported that about 60-80% of intussusceptions of large bowel in adults are caused by cancer. So far almost 60 adult cases of intussusception due to cecal cancer have been reported in the Japanese literature. We report 6 adult patients with intussusception due to cecal cancer. The average age was 59.2 years old (range 36-77), with the male-to-female ratio of 3 : 3. Two patients were performed emergency operation, one, elected operation without reduction, and three elected operation with preoperative reduction. Except for the last three patients, intussusception had naturally been reducted at laparotomy in one, it was reducted with Hutchinson maneuver before resection in one, and it was resected without reduction in one patient. As for the Stage of cecal cancers, one was in fStage I, three were in fStage II and two in fStage IIIa, and all patients have been doing well without cancer recurrence. Adult patients with intussusception of large bowel with cecal cancer had variable symptoms and it was not always necessary to perform emergency operation. And even if elected operation was chosen, reduction before operation was not always necessary.

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A 67-year-old woman visited our hospital complaining of both an elastic hard tumor, 2.0 cm in size, of the right breast, C region, and an elastic hard tumor, 1.5 cm in size, of the left breast, C region. Mammography showed an irregular tumor shadow with spicula and microcalcifications in the right breast, C region, and a focal asymmetric density (FAD) in the left breast, C region. Ultrasonography showed a low echoic lesion, 22×10 mm in size, in the right breast, C region, and a low echoic lesion, 15×8 mm in size, in the left breast, C region. Histological examination of core needle and excisional biopsy specimens revealed invasive carcinoma, apocrine carcinoma of the left breast and apocrine ductal carcinoma in situ of the right breast. Synchronous bilateral breast cancer was diagnosed. Bilateral mastectomy with disection of the axillary lymph nodes was performed. Postoperative histology revealed bilateral apocrine ductal carcinomas in situ without lymphatic metastasis. Estorogen receptor positivity was borderline, progesterone receptors were negative and HER2 was negative (1+).

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A 60-year-old woman developed an infective endocarditis (IE) which involved the mitral valve. Treatment with antibiotics was effective. However, one month later, the patient presented with pain in the epigastric area. A superior mesenteric artery (SMA) aneurysm was diagnosed based on ultrasound and CT images. Since the patient had an excellent collateral circulation, direct suture of the SMA and a resection of the aneurysm were performed. The patient had no major complications postoperatively. Aneurysm of the SMA associated with infection is rarely seen. Patients with IE require careful follow-up.

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A 75-year-old man was hit by a car and taken by ambulance to hospital. He had quadriparesis on arrival. The chest CT and MRI revealed a right hemothorax, mediastinal hematoma, cervical cord compression, cervical fracture, and a third thoracic vertebral burst fracture. He developed dyspnea on the 4^th day and required artificial venitilation. A right bloody pleural effusion was observed on the same day, and a purulent effusion was noted the next day. The chest CT showed a right pneumothorax and mediastinal emphysema. Esophageal perforation was confirmed by endoscopy on the 6th day. Therefore, a traumatic esophageal rupture was diagnosed. The patient had a partial esophagectomy and esophagostomy with a cervical incision, a gastrostomy, and a jejunostomy. The esophageal rupture was thought to have been caused by a thoracic vertebral fracture segment. Traumatic esophageal rupture is rare. This is the first case of esophageal rupture following thoracic vertebral fracture seems to reported in Japan. It is important to diagnose and treat such cases. Therefore, esophageal rupture should ruled out in patients with thoraco-abdominal trauma.

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We report a case of CA19-9-producing gastric cancer. An 81-year-old man had tarry stools and high serum CA19-9 values Gastro-intestinal endoscopy showed a type3 lesion in the lower third of the anterior wall of the gastric body. Blopsy examination suggested moderately differentiated adenocarcinoma. Distal gastrectomy was performed. A gastric tumor had invaded the serosa and two liver metastases were observed. On immunohistochemistry, cancer cells stained positive for CA19-9. The serum CA19-9 level deceased to normal range in the first postoperative month. He rejected adjuvant chemotherapy. At three months after the operation, the serum CA19-9 level had risen and multiple skin metastases of the head, abdominal wall and Achilles tendon were detected. Chest CT showed multiple lung metastases. The patient died 6months after the operation.

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A 58-year-old man was admitted to our hospital because of an abnormal shadow of the stomach on barium meal at a medical check-up. Upper gastrointestinal endoscopy showed an ulcerated tumor at the greater curvature of the gastric antrum. It was diagnosed as gastric cancer (poorly differentiated adenocarcinoma) and distal gastrectomy was performed. Histopathological examination of the resected specimen showed tumor cells proliferating to the submucosal layer and the tumor was immunohistochemically positive for synaptophysin. Accordingly the tumor was diagnosed as early small cell carcinoma of the stomach. In addition, two lymph nodes with micrometastasis were revealed in the infrapyloric lymph node.
Gastric small cell carcinoma is rare and carries extremely poor prognosis due to the presence of vascular invasion or metastasis at an early stage. This case was of early gastric small cell carcinoma but micrometastasis of lymph node had already occurred. We need to recognize that even early gastric small cell carcinoma can already have micrometastasis.

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A 64-year-old female who had undergone splenectomy combined with total gastrectomy for advanced gastric cancer in 2005 followed by adjuvant S-1 chemotherapy was admitted to our hospital because of high fever, diarrhea and mental confusion in January 2008. On the second day following admission, neck stiffness developed, and examination of cerebrospinal fluid (CSF) showed pleocytosis up to 17,400 cells/mm³ and elevated protein level of 572mg/dl. Haemophilus Influenzae was isolated from CSF and blood. We diagnosed the case as overwhelming postsplenectomy infection (OPSI) syndrome due to Haemophilus Influenzae meningitis. After administration of dexamethasone (8mg/day) and cefmetazole (2g/day) followed by meropenem (2g/day) and then ceftriaxone (4g/day), she survived without any sequelae. She was discharged from the hospital on the 50th hospital day.
Although Haemophilus Influenzae is a common cause of meningitis in children, adult case of OPSI caused by Haemophilus Influenzae is rarely reported. Splenectomized patients have been recognized as immunocompromized hosts, for whom fluminant bacterial infection can be associated with high morbidity and mortality. Therefore, early diagnosis and urgent treatments are important to reduce the mortality of such infections. To prevent OPSI, adequate vaccination and prophylactic administration of antibiotics seem to be effective. Moreover, physicians should always be aware of the onset of OPSI and educate the splenectomized patients and their families about OPSI so as to seek medical attention at the earliest signs of the infection.

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Case : A 53-year-old man was referred to our hospital. His chief complaint was a 3-day history of epigastralgia. Emergency laparotomy revealed a perforated duodenal ulcer, also seen on CT. There was a 3.5cm perforation at the 1^st portion of the duodenum. It was too large to close with omentum, and the jejunum could not be mobilized due to prolonged inflammation. Therefore, we used a gallbladder serosal patch to close the perforation. The patient was discharged without complications. A gallbladder serosal patch is a useful method of closing a perforated duodenal ulcer when the omentum or jejunum is not feasible.

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A 68-year-old man complaining of pain of the whole body was diagnosed as having polymyalgia rheumatica at the department of orthopedics and steroid therapy was started. After a temporary remission, general pain recurred. Close exploration revealed a tumor of the left lower lobe of the lung and left lower lobectomy was performed. The histopathological diagnosis was carcinosarcoma involving squamous cell carcinoma and angiosarcoma. His pain and inflammatory reaction dramatically improved after the operation, however, 9 months later, general pain became worse again and inflammatory reaction was also increased. As a result of close exploration, a solitary metastatic lesion of pulmonary carcinosarcoma was identified at the duodenum. Pancreaticoduodenectomy was thus performed. His pain and inflammatory reaction subsided after the operation, and no recurrence has occurred up to now.
This case is of lung carcinosarcoma involving rare angiosarcoma component and its recurrence to a rare site of the duodenum was resected. Clinically pain of the whole body was noted in this patient, and disappearance of the tumor and pain was well correlated with increase and decrease in CRP and IL-6 levels. We rarely encounter patients with symptoms which are similar to those of polymyalgia rheumatica due to malignant neoplasm, but no patients presenting such symptoms due to carcinosarcoma like in this case have been reported so far and this is the first reported case.

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We report a case of neuroendocrine carcinoma of the papilla Vater of the duodenum which is a rare entity. A 78-year-old woman was admitted to the hospital for close exprolation of liver dysfunction. Abdominal CT scan showed a contrast enhanced lesion, 1.5cm in diameter, in the pancreas head and intrahepatic bile duct dilatation. Immunohistological examination of endoscopic biopsy of the papilla Vater revealed CD56, synaptophysin and chromogranin A positive. Neuroendocrine tumor was thus diagnosed and we performed pyrolus preserved pancreaticoduodenectomy (PPPD) with lymph node dissection. The pathological diagnosis was well differentiated neuroendocrine carcinoma of the papilla Vater of the duodenum because the Ki67/MIB1 index was low and lymph node metastasis was found. She has been well and free from recurrence as of 16 months after the operation.

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We report a rare case of intestinal duplication with perforation. A 6-year-old boy, admitted for right lower quadrant pain and fever, underwent emergency laparotomy after being diagnosed with acute appendicitis with perforation. The appendix showed no signs of inflammation, but we found a cystic tumor with perforation at the end of the ileum on the mesenteric side, necessitating ileocecal resection. Macroscopically, the perforated 1 cm cystic tumor communicated with the ileum, in the mesentery of the terminal ileum 1.5 cm from the oral side of Bauhin's valve. Histopathologically, the cyst had the proper muscular layer and mucosal lining. The find diagnosis was a duplication cyst. This is, to our knowledge, only the 17th case of duplication cyst with peforation reported in Japan.

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We report a case of Peutz-Jeghers syndrome with repeated small intestinal intussusceptions. A 22-year-old woman with small intestinal intussusception underwent surgery and was diagnosed with Peutz-Jeghers syndrome based on family history, oral pigmentation and pathological findings, in 2001. Because of small intestinal intussusception, she underwent small intestinal endoscopy for polypectomy of all but the largest polyp near Treitz's ligament in 2007. However, she was admitted for surgery because of repeated small intestinal intussusceptions in May 2008. Repair of the five small intestinal intussusceptions and endoscopic polypectomy were performed without resection of the small intestine. The postoperative course was uneventful and no further small intestinal intussusceptions occurred. In the case of early detection of recurrences, periodic endoscopic examination is required.

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The patient was a 51-year-old male who presented with abdominal pain. Plain abdominal X-ray revealed free air, and a perforated peritonitis was diagnosed. Free air, marked dilatation of the small intestine and the colon, and a large amount of ascites were observed on abdominal computed tomography (CT). The vital signs taken on arrival indicated the presence of systemic inflammatory response syndrome (SIRS) (a heart rate of 180/min, respiratory rate of 36/min, and body temperature of 38.3°C). Therefore, emergency surgery was performed. During the operation, a pinhole perforation was observed in the duodenal bulb. Purulent ascites (1,500ml) was present, the cecum was distended and twisted 360 degrees clockwise. A cecal volvulus was diagnosed. Omental transposition, correction of the volvulus, and cecopexy were performed. The patient developed acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) postoperatively. Intensive treatment was successful, and he was discharged on postoperative day (POD) 40.
A case of cecal volvulus complicated by perforated peritonitis is extremely rare. Multi-detector computed tomography is useful for making a preoperative diagnosis.

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Appendiceal diverticulitis is a relatively rare disorder that is difficult to diagnose preoperatively. We herein report a patient who underwent surgery after being diagnosed preoperatively on abdominal CT with appendicitis complicated by appendiceal diverticulitis and then discuss the literature. The patient was a 54-year-old man with a chief complaint of right lower quadrant pain. On palpation, tenderness, rebound tenderness, and abdominal quarding were observed around McBurney's point. Body temperature was 37.7°C, the leukocyte count was 15,900/μl, and the CRP was 3.1mg/dl. CT showed multiple diverticula of the cecum, an enlarged appendix with multiple diverticula, and opacity of fat tissue. Based on these findings, the patient was diagnosed as having appendicitis complicated by appendiceal diverticulitis and underwent surgery. Part of the appendiceal diverticula had perforated, and the patient had localized peritonitis due to acute phlegmonous appendicitis complicated by appendiceal diverticulitis. The perforation rate in appendiceal diverticulitis has been reported to be high (27-66%), over four times the rate in acute appendicitis. Due to the high rate of peritonitis and the high susceptibility to abscess formation and perforation, symptomatic patients diagnosed with appendiceal diverticultis associated with acute appendicitis on CT or by other means should be treated with surgery rather than conservative therapy, regardless of the degree of inflammation.

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A 20-year-old man admitted to our hospital because of melena had a palpable tumor with the size of an infant's head in the right lower quadrant of abdomen. Radiological examinations and histological study of the biopsy specimen taken by colonoscopy revealed that he had primary malignant lymphoma of the appendix, and right hemicolectomy with regional lymph node excision was performed. The histological diagnosis was non-Hodgkin lymphoma, diffuse large B cell type. Postoperative FDG-PET showed abnormal accumulation in the lymph nodes of the retroperitoneum and the mediastinum. Adjuvant chemotherapy (R-CHOP) was thus conducted, which induced complete response. He is doing well 2 years and 10 months after the operation without recurrence. We also review 39 cases reported in the Japanese literature.

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A case experiencing two idiopathic perforations of the colon is reported. A 78-year-old woman who had undergone Hartmann's procedure for idiopathic perforation of the rectum on 26 March 2006, presented with sudden left lower abdominal pain on 1 February 2009. She was admitted to the hospital for conservative treatment but her symptoms worsened. Colonoscopy showed partial necrosis of the sigmoid colon mucosa and a round recess in proximity (5cm) to a colostomy. Computerized tomography revealed the formation of an abscess cavity and penetration to the mesentery. An operation was thus performed. At laparotomy, a perforation 3cm in diameter was observed on the oral side 5cm from the colostomy. The pathological diagnosis was idiopathic perforation. Only four cases with repeated idiopathic perforation of the colon have been reported in the Japanese literature. Idiopathic colon perforation is associated with many unexplained factors, and can occur repeatedly. Careful observation, including a complete history of bowel habits, is required in the outpatient clinic.

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A 76-year-old male developed diarrhea, hematochezia, and nausea. On the second hospital day, he developed a marked change in his abdominal pain. On CT scan, free intraperitoneal air and massive ascites was noted. The patient had a laparotomy. Perforations were visualized at the cecum and the transverse colon. A right hemicolectomy and an ileostomy were done. The cause of the perforation could not be determined. On day 4, the patient developed intense abdominal pain. On CT, re-perforation of the colon was found ; perforations were visualized at the transverse colon and the lower rectum. The patient had a total colectomy with a subtotal proctectomy. On day 10 after the first operation, amoebic trophozoites were identified in the colonic mucosa specimen. Metronidazole was administered. The patient's general condition improved, and he was discharged. The number of cases of Entamoeba histolytica is increasing in Japan. Early diagnosis followed by early chemotherapy is the key to successfully treating this disease.

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A 64-year-old female with a history of chronic rheumatoid arthritis complained of epigastralgia and diarrhea. She was found to be anemic. On barium enema images, stenosis of the transverse colon was found. Her symptoms did not improve despite the administration of TPN ; her transverse colon stenosis progressed. The transverse colon and the descending colon were excised. Mucosal edema and a widespread, large, longitudinal ulcer were found in the resected specimen. On histopathology, a diagnosis of intestinal amyloidosis was made. Amyloidosis is a relatively rare disease. However, in recent years it is becoming increasingly more frequent. There is a good association between amyloid depositions and digestive system symptoms. However, to date, very few specific symptoms or findings have been identified that are uniquely associated with large intestine involvement.

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A 68-year-old man with a 16 year history of ulcerative colitis underwent surveillance colonoscopy in September, 2005 ; neither cancer nor dysplasia was detected. In a colonoscopy study in July, 2006, rectal cancers were found. Abdominal CT showed multiple swollen lymph nodes, considered to be metastases. Pathological study revealed poorly and moderately differentiated adenocarcinoma with multiple metastases in the submucosal layer of the rectum and in lymph nodes. There was no dysplasia near the cancer. Therefore, we concluded that the rectal tumor was colonic cancer.
We present herein a rare case of colitic cancer with extraordinarily rapid progression, less thar ten months.

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We report a case of rectal stenosis, possibly caused by penetration of the rectum. An 84-year-old man seen for constipation and abdominal distension had on abdominal X-ray showing subileus findings. Neither physical nor laboratory examinations revealed any inflammatory findings. Digital examination of the rectum revealed a hard rectal tumor. Abdominal CT showed a tumor-like lesion in the Ra-rectum, and, moreover, barium enema examination revealed complete rectal obstruction. The patient could pass gas and defecate softly. Colonoscopy showed rectal stenosis, and suspicion of a submucosal tumor, without rectal cancer. The colonoscope barely passed through the stricture portion. During surgery, we identified a hard inflammatory lesion within the mesenterium of the Ra-rectum, which, after resection, histologically showed no malignant tissue. Complete penetration of the proper muscular layer of the rectal wall with severe inflammatory infiltration, and disappearance of epithelial cells, possibly caused by diverticulitis, were demonstrated.

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In August, 2007 a 63-year-old woman was found on X-ray images to have a left cervical tumor and an abnormal right lung shadow ; metastatic thyroid and lung cancer was diagnosed. Histological findings and immunological staining suggested that the primary lesion was a colonic cancer. On colonoscopy, a stage IV ascending colon cancer was diagnosed. Due to severe stenosis, a right hemicolectomy was done in October 2007 followed by 4 courses of mFOLFOX6 chemotherapy in November 2007. A left thyroid lobectomy and an upper right lung lobectomy were done in February 2008. On histopathology, a mucinous moderately differentiated adenocarcinoma (SS N1 H0 M1 stage IV) was diagnosed. The patient's postoperative course was good. A adjuvant chemotherapy using a single TS-1 agent was given. There has been no recurrence during one year and three months of follow-up.

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Patient 1, a 78-year-old man, was seen at the hospital because of epigastralgia. There was muscular defense in the right lower quadrant of abdomen. On blood analysis CEA level was high. An abdominal x-ray film and an abdominal CT scan did not show intra-abdominal free air but abnormal gaseous image in the mesentery. Emergency operation was performed with a diagnosis of peritonitis associated with cancer, and we found ascending colon cancer and feces in the mesentery. Right hemicolectomy was thus performed. The removed material revealed a type I tumor and penetration proximal to it on the mesentery side of the ascending colon. An ischemic change was identified on the mucosa.
Patient 2, a 73-year-old man, was brought into our hospital by ambulance because of abdominal pain. An abdominal CT scan showed abnormal gaseous image in the mesentery. Emergency operation was performed with a diagnosis of penetration of the mesentery of the ascending colon. Upon laparotomy, massive fecal masses in the mesentery and ascending colon cancer were disclosed. Right hemicolectomy was thus performed. On the removed material, there were a type 3 tumor and a penetrated portion proximal to it on the mesentery side of the ascending colon. Pathological studies showed circulatory impairment at the penetrated portion. Their postoperative courses were comparatively uneventful and they were discharged from the hospital.
Ascending colon cancer associated with intramesenteric penetration is a rare entity. In our cases, abdominal CT scanning is useful for making diagnosis of the disease and simultaneous anastomosis during emergency operation was performed with saving their lives.

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A 69-year-old female developed meningitis. She was given antibiotic therapy for 2 weeks. At that time, her cerebrospinal fluid cultures were negative but her blood cultures were positive for Streptococcus bovis. A colonoscopy revealed advanced carcinoma of the sigmoid colon and she underwent a sigmoidectomy, (ss, n1, H0, P0, M(-) ; Stage IIIa). It is important to remember that there is an association between Streptococcus bovis bacteremia and colorectal cancer. Therefore, patients with this type of bacteremia should be appropriately investigated.

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A 60-year-old woman complained of constipation. Contrast enema and colonoscopy indicated a sigmoid colon tumor (type2). On pathology, a well differentiated adenocarcinoma was diagnosed. Abdominal CT scans and MRI revealed liver and adrenal tumors. She was diagnosed as having sigmoid colon cancer with synchronous liver and adrenal metastases. Sigmoidectomy, posterior segmentectomy, and right adrenalectomy were performed. The operative findings included pSE, pN2, sH1, sM1 (adrenal gland) fStage IV. The histological diagnosis of the sigmoid colon, liver, and adrenal tumors was that of a well differentiated adenocarcinoma. There have been no signs of recurrence for 6 years since the operation ; the patient was not given chemotherapy. The resection of an adrenal metastasis in patients with colon and rectal carcinoma is a rare event. It is possible that the resection of the primary and metastatic lesion contributes to an improved prognosis.

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A 57-year-old male patient visited a doctor in his neighborhood complaining of generalized arthralgia and diarrhea. After he received treatment as an outpatient, the symptoms became less severe. He had a fever of 38-40°C and a blood test revealed that he developed a severe inflammatory response. 2 days later, he was referred to our hospital. Based on the results of an abdominal CT scan and ultrasonography, he was diagnosed with liver abscess and immediately hospitalized. He received meropenem but his fever stayed high. Percutaneous transhepatic abscess drainage (PTAD) was then performed. While yellow purulent fluid was aspirated, it was negative both for microbiological tests and cytology. Since the day following PTAD, the fever went down to 38°C or lower while the symptoms improved and the inflammatory response also abated. In parallel, therefore, we investigated the cause of the liver abscess. A barium enema examination revealed a 4-cm ulcerated lesion on the anterior wall of the rectum below the peritoneal reflection (Rb), which was diagnosed as rectal cancer. Abdominoperineal resection (Miles procedure) was performed and the histopathology of the surgical specimens revealed moderately differentiated adenocarcinoma. The depth of invasion was ‘A'. It was stage II rectal cancer without lymph node metastasis, peritoneal dissemination or distant metastasis. In the effort to identify the cause of hepatic abscess, gastrointestinal examinations should be performed at the earliest possible stage.

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A 48-year-old man had a low anterior resection of a rectal cancer in April 2006. On histopathology, a primary well-differentiated adenocarcinoma (T2N0M0 Stage I) was diagnosed. Although the serum CEA (carcinoembryonic antigen) level was found to be elevated in January 2008, abdominal computed tomography, CT gastroscopy, and colonoscopy did not reveal a recurrence. However, a positron emission tomography (PET)/CT scan showed an accumulation spot in the rectus abdominis muscle. A definitive diagnosis was made based on a CT-guided percutaneous biopsy. Neither lymph node metastases nor peritoneal dissemination were found in the abdominal cavity ; therefore an en-bloc excision of the rectus abdominis muscle was performed. The abdominal wall was reconstructed using prolene mesh (inlay mesh repair). Histopathological findings of the rectus abdominis muscle included those of a metastatic adenocarcinoma, which was consistent with the previously resected rectal cancer. Currently, after 1 year and 5 months of follow-up the patient has no signs of recurrence.

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A 36-year-old woman with a tumor in the right lobe of the liver was referred to our hospital because of right flank discomfort. Abdominal computed tomography revealed a 7-cm mass located in segments 6, 7, and 8. After being explained the possibility of malignancy and the risk of rupture, the patient expressed the desire to undergo hepatectomy. Using a three-dimensional (3D) virtual hepatectomy program based on hepatic circulation, lapascopy-assisted resection of the right lateral sector and dorsal part of the right paramedian sector was performed. The histological diagnosis was focal nodular hyperplasia with proliferating bile ductules in fibrous septa. The patient recovered uneventfully and was discharged on the 16th postoperative day, and is currently alive and well, 20 months after the operation. Despite increasing experience with laparoscopic liver surgery, there have been only 13 English-Language reports of hepatectomy using the minimally invasive laparoscopic approach for lesions located in the upper right segments of the liver. Lararoscopy-assisted liver resection may also be applicable to cranially located hepatic tumors, based on our experience using 3D virtual hepatectomy for preoperative planning.

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A 61-year-old male was admitted to our hospital because of an asymptomatic liver tumor and common kileduct stone which were detected during treatment of chronic heart failure. Abdominal CT scan showed a liver mass occupying S4, 5, and 8 of the liver. The rim surface of the tumor was focally enhanced by contrast media and the internal area was revealed as a homogeneous low density area without contrast enhancement, suggesting non-typical hepatocellular carcinoma. Blood examinations showed moderately impaired liver function without any hepatitis virus infection. Upon laparotomy, the liver mass had ruptured and directly invaded the subphrenic membrane with extensive peritoneal dissemination. We determined that curative surgery was impossible. Biopsies of the tumor and normal liver tissue and choledochotomy were performed. Pathological findings revealed that the tumor cells had large atypical nuclei, and its growth pattern was not arranged in hepatic cords. Immunohistochemical studies showed marked positivities for vimentin, cytokeratin AE1/AE3, and CD10. Sarcomatoid hepatoma was thus diagnosed. Despite TAE, the tumor grew rapidly and he eventually died 4 months after the initial diagnosis. Hepatocellular carcinoma with sarcomatous features such as central necrosis has a higher malignant potential than usual HCC. Radical resection seems to be the curative treatment of choice, although its therapeutic effect is limited.

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A 75-year-old man with distal bile duct carcinoma underwent pancreatoduodenectomy after percutaneous transhepatic biliary drainage (PTBD) punctured from S3 for obstructive jaundice and diagnosis, because canulation via the ampulla of Vater was unsuccessful. Thirty-two months after the operation, an enhanced abdominal CT scan detected a 10mm low density lesion in the liver surface (S3). As it was diagnosed as isolated recurrence of bile duct carcinoma, we resected the liver (S3) and the abdominal wall where were included in the route of PTBD catheter after 6 courses of gemcitabine therapy. Pathological findings showed the same moderately differentiated adenocarcinoma cells as former bile duct carcinoma. We report herein the case of distal bile duct carcinoma with metastatic seeding to the PTBD tract after curative resection.

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A 46-year-old woman was found on ultrasonography (US) and computed tomography (CT) to have a cystic mass containing a crescent-shaped solid portion in the head of the pancreas, measuring 5 cm in diameter. Endoscopic retrograde cholangiopancreatography (ERCP) showed a normal main pancreatic duct, and genetic analysis of the pancreatic juice revealed a point mutation of the K-ras gene. During surgery we found a cystic mass with a well-defined capsule in the head of the pancreas, and extirpated the tumor. A pathological study during the surgery revealed no malignant regions in the solid component of the tumor. The resected specimen revealed a cystic portion containing a mucous, hyaline like liquid and a yellow-colored solid mass. Microscopic examination showed an S-100-positive schwannoma with Antoi A-type cells. The patient's post operative course was uneventful and no evidence of recurrence has been found until 8 years after the surgery.

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An 81-year-old woman was brought into the emergency clinic in our hospital by ambulance because of clouding of consciousness late in October 2006. When she was first seen, she regained consciousness and had no abnormal neurological findings. However, a fist-sized tumor was palpable in the left lower quadrant of abdomen. Digital examination revealed a tumor and tenderness in the left direction of the anterior wall of the rectum. An abdominal CT scan showed thickening of the intestinal wall at the recto-sigmoid portion, and obscure border between the affected intestine and the uterine and the left adnexa. Air fluid level was noted in the lumen of the uterus. Barium enema showed an irregular stricture at the recto-sigmoid portion. From these findings, the most likely diagnosis was rectal carcinoma with pyometra and then we performed low anterior resection of rectum with hysterectomy and left salpingooophorectomy. The rectal tumor had invaded the uterus to form a fistula and it was pathologically confirmed to have invaded the lumen of the uterus.
It is etiologically considered that uterus invasion of rectal carcinoma formed the rectouterine fistula, with resultant pyometra.

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A 70-year-old male visited our hospital because of abdominal pain and a high fever. Since abdominal CT examination revealed an intra-peritoneal abscess, antibiotics were administered. The abscess decreased, his symptoms improved, and he was discharged from the hospital. However, two months later, his symptoms had returned and the abscess was larger, As a result, he underwent surgery Numerous white nodules were found in the peritoneum with tight adhesion between the omentum and the peritoneum. We resected a granuloma in the omentum and the mesenterium. The pathological diagnosis was a granulomatous inflammation with a great number of parasitic eggs of Paragonimus westermanii. By listening again to his detailed past history, we learned that he had eaten raw boar meat which is known to be an intermediate host of Paragonimus westermanii. Praziquantel, one of the antihelmintic drugs effective against flatworms, was orally administered. In cases with abdominal abscess of unknown cause, ectopic paragonimiasis should be considered in the differential diagnoses.

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A 40-year-old man was found to have a mass in the abdominal cavity on ultrasound. Abdominal CT scan showed a mass with a solid and a cystic compartment located in the right upper epigastrium. He was observed for three months. At this point in time he developed gastromegaly ; the mass had moved to the left upper epigastrium and had increased in size based on abdominal CT scan images. Surgery was scheduled. Prior to surgery the gastromegaly disappeared, and the patient became anemic. A rupture of a tumor was since on abdominal CT scan the tumor had decreased in size, and hemoperitoneum was present. Intraoperative findings included hemorrhagic ascites and a pedunculated cystic mass which arose from the lesser omentum ; the tumor was removed. On pathology, a gastrointestinal stromal tumor (GIST) of the lesser omentum that was positive for KIT and CD34 was diagnosed. Adjuvant therapy was not given despite the diagnosis of malignant GIST due to the presence of hemoperitoneum preoperatively. Pedunculated GIST of the lesser omentum is very rare. It requires careful follow-up.

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A 77-year-old woman complaining of high fever and vomiting was admitted to the hospital with a suspicion of gastroenteritis. On the next morning, lower abdominal pain appeared which gradually intensified, and the patient went into shock in that evening. An abdominal x-ray film showed calcification along the wall of the right colon. An abdominal CT scan revealed thickening of the wall and calcification from the ascending to transverse colon. Ascites and free air were also identified. Accordingly emergency laparotomy was performed with a suspected diagnosis of general peritonitis due to intestinal perforation. During surgery purulent ascites was noticed and the intestinal wall from the cecum to the descending colon was deep purple in color and was felt hard. A perforated portion about 1cm in size was present at the ascending colon, and colon perforation due to ischemic enteritis was diagnosed. The portion from the terminal ileum to the descending colon where changed in color was resected, and ileostomy was established. Pathological studies revealed fibrous hypertrophy of the venous wall, calcification around the veins, and submucosal fibrosis, so that mesenteric phlebosclerosis was diagnosed.

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A 30-year-old woman was admitted to our hospital because of lower abdominal pain and vomiting. Abdominal plain X-ray film and abdominal CT scan revealed a small-intestinal gas image and an air-fluid level. There was an extended intestine like a loop, of which wall was poorly enhanced. An emergency operation was performed with a suspected diagnosis of strangulated ileus due to internal hernia. Laparotomy revealed an abnormal defect 1cm in diameter in the sigmoid mesocolon. Approximately 10cm portion of the small intestine, at a point 140cm proximal to the terminal ileum, had herniated through the defect and had been strangulated. The invaginated intestine was reduced by manupulation, when no necrosis was seen. The defect was repaired by sutures. The post-operative course was uneventful and the patient was discharged on the 10th post-operative day. Transmesosigmoid hernia in the mesentery of the sigmoid colon is very rare. This paper also present a review of the Japanese literature.

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A 66-year-old man visited another hospital complaining of abdominal distention. Close examination revealed ileus, and he was referred to our hospital for detailed examination and treatment. Abdominal CT revealed thickening of the peritoneum and mesenterium, and ascites. Gastrografin enema revealed stenosis of the jejunum. We suspected intestinal tumor, possibly malignant. Therefore, a diagnostic laparoscopy was performed. Laparoscopy revealed multiple white nodules on the peritoneum and wall of the intestine, and mucous ascites with slightly muddy yellow fluid. Laparoscopic biopsy of the lesions was performed for pathological diagnosis and selection of the appropriate treatment protocol. The pathological diagnosis was peritoneal malignant mesothelioma. Thus diagnostic laparoscopy was useful for detecting peritoneal malignant mesothelioma.

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A 35-year-old woman presented with epigastralgia and back pain. She was found to have a right suprarenal tumor, 6 cm in diameter, that occupied the dorsum of the inferior vena cava based on ultrasongraphy, CT, and MRI images, and accumulation of fluorodeoxyglucose in the tumor was seen on positron emission tomography ; the pattern of the uptake mimicked that of a malignant tumor. Under the diagnosis of a non-functioning right adrenal malignant tumor, a laparotomy was done, and the tumor along with the right adrenal gland was removed. On histopathology, a retroperitoneal benign schwannoma was diagnosed. The patient's postoperative course was good, and she has not had a recurrence during 11 months of follow up. This case and the available literature on retroperitoneal schwannomas are discussed in this paper.

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We report a rare case of internal hernia after gastrectomy. A 64-year-old man, who had undergone total gastrectomy (Roux-en-Y reconstruction) for gastric cancer 9 months earlier, was admitted to our hospital ten days after the onset of abdominal pain and constipation. He had mild tenderness in the upper abdominal region, but no peritoneal irritation. Abdominal X-ray revealed intestinal gas only on the right side of the abdomen, and abdominal CT scan showed dilation of the right colon and the whirl sign. We diagnosed an internal hernia and performed surgery. The ileum was strangulated through the space between the mesentery of the Roux-limb and transverse mesocolon (Petersen's defect). We reversed the ileal strangulation and closed the hernia orifice.

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We report two cases with elastofibroma dorsi, a 58-year-old man and a 60-year-old man. Both had a tumor of the subscapular region and severe back pain. Chest CT showed masses with a low density area. Chest MRI revealed masses with low signal intensity and interspersed areas of high signal intensity on T1 and T2 weighted spin echo sequences. They were diagnosed as elastofibromas and the masses were excised. Histological examinations revealed increased collagenous and elastic fibers with elastic van Giesson staining. An elastofibroma was thus diagnosed in both cases. There have been no symptoms or signs of recurrence since surgery.

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