The CT guided lung biopsy is considered to be a useful examination, but the frequency of complications including serious pneumothorax and pulmonary hemorrhage is high. In this study, a series of 72 CT guided biopsy cases in the center were investigated. The results were the sensitivity of 86.2%, the specificity of 57.1%, and the accuracy of 83.3%. Pneumothorax and pulmonary hemorrhage occurred in 11 (15.2%) cases and 21 (29.1%) cases, respectively. Conservative therapy was successful in all cases. There were no cases in which air embolism or dissemination of tumor was complicated. In patients who developed these complications, the lesions were small and were present in the deep place where was far from the pleura. Hence the normal lung was apt to be injured by the biopsy that might contribute to cause complications. In addition small lesions might decrease the correct diagnosing rate. Other methods including partial resection of the lung should be considered for small lesions less than 2cm in diameter.

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We reviewed 318 outpatients with internal hemorrhoids who had suction ligation therapy using our modified McGowne ligator ; relief of initial symptoms was studied. Anal bleeding was the most common symptom (222 cases), prolapse was the second (89 cases) while the third was related to anal discomfort or pain (77 cases). Suction ligation for anal bleeding has a 99.0% success rate. Anal discomfort or pain after three or four suction ligation sessions has an 84.0% success rate. If the results are unsatisfactory, surgery should be considered in these two types of patients. Anal prolapse is less effectively treated (36.0%) using this method ; thus, surgery should be considered the first option in these patients. Using Goligher's grading, first and second degree patients whose main complaint is anal bleeding, such patients account for 90% of all internal hemorrhoid patients, 92.2% obtain symptom relief with this method. Only 46.9% of third degree patients can be expected to obtain symptom relief using this method ; fourth degree patients require surgery.
Suction ligation therapy is safe, easy, and painless It requires no hospitalization and can be done without assistance.

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Case 1 : A 50-year-old female was found to have advanced transverse colon cancer with simultaneous multiple liver metastases (SE N2 H2 P1 M1). She was started on treatment with mFOLFOX6 (oxaliplatin 75mg/m², a bolus of 5-FU 400mg and 46-hour continuous intravenous infusion 2,000mg/m²). She was admitted for the 16th course of chemotherapy. Seven hours after the beginning of chemotherapy, she developed purpura and gingivorrhagia. A blood test revealed the platelet count to be 0.5 × 10⁴/μl. She was treated with platelet transfusions and steroids. After 4 days, blood tests had normalized and she was discharged. Platelet associated IgG (PAIgG) was high(272 ng/10⁷ cells) and, on the drug lymphocyte stimulation test(DLST), oxaliplatin was positive. We diagnosed drug-induced thrombocytopenia resulting from sensitivity to oxaliplatin. Case 2 : A 48-year-old male was found to have advanced rectal cancer with multiple liver and lung metastases (A N2 H3 PX M1). He was started on treatment with mFOLFOX6, as in case 1. He was admitted for the 21st course of chemotherapy. Seven hours after the beginning of chemotherapy, he developed purpura. A blood test revealed a platelet count of 0.1 × 10⁴/μl. He was treated with platelet transfusions and steroids. After 6 days, blood tests had normalized and he was discharged.

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Carcinoid tumor of the breast is rare and carries good prognosis in most cases, however, there are some death cases due to recurrence of the fulminant type that poses problems in clinical treatment of the disease which have not been resolved as yet. Authors have experienced a patient with the disease who has been alive without recurrence for 9 years. In this paper the authors present a clinical study of the patient together with 26 patients reported in the Japanese literature whose prognoses were clearly reported.
A 63-year-old woman was seen at the hospital because of a palpable, elastic-hard, and well-movable tumor at the left breast. Ultrasonography and MRI visualized a 26×24mm well-defined tumor which was composed of cystic and solid parts concomitantly. Fine needle biopsy cytology offered a diagnosis of breast cancer and breast-conserving surgery was performed. HE staining showed palisade and rosette-like arrangement of small nucleolus and small tumor cells rich in chromatin. The tumor showed positive reactions to chromogranin A, synaptophysin, and NSE staining, and it was rated T2, N0, Stage IIA, and estrogen receptor (+). Postoperative irradiation was added, but no adjuvant chemotherapy was done.
The clinical study of a total of 27 cases revealed that the mortality rate was about 15%, the important prognostic factor was the presence of metastasis at the operation, more limited operation might be possible, and chemotherapy was meaningful in patients who had lymph node metastasis.

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A 79-year-old woman consulted her doctor due to cough and sputum in March 2005. A chest X-ray showed a tumor shadow 6 cm in size. Chest CT revealed a tumor 6×5 cm in size and air in the bronchi located in S⁹ of the left lower lung lobe. A transbronchial lung biopsy (TBLB)was done, but a tumor was not diagnosed. Two months later, the tumor was found to have slightly decreased in size. Therefore, pneumonia was diagnosed ; the patient was treated and followed. However, in July, 2007, the tumor was found to have enlarged in size. A bronchioloalveolar adenocarcinoma was diagnosed on TBLB. A left lower lobectomy was done. The tumor was 9×8 cm in size soft and solid on histopathology, a mucinous type bronchioloalveolar carcinoma was diagnosed. Due to the difficultly in making a diagnosis surgery was delayed by 2 years 8 months.

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In May 2009 an 83-year-old woman with fatigue, anorexia, and anemia was diagnosed as having type 1 gastric cancer based on gastrointestinal fiberscopy, X-ray examination of the upper gastrointestinal tract, and abdominal CT-scan ; the gastric cancer was located in the anterior wall of the antrum. The patient underwent a curative distal gastrectomy with a D2 lymph node dissection. Surgical findings were T2, N1, P0, H0, M0, stage II. The final pathological diagnosis was an early small cell carcinoma of the stomach with lymph node metastases (sm, n1 (+)). The tumor was immunohistochemically positive for synaptophysin and CD56. Among 67 gastric cancer cases reported in the Japanese literature, only 6 patients had early gastric cancer. Five of the 6 patients with early gastric cancer had lymph node metastases. Primary early gastric small cell carcinoma is rare and has a poor prognosis due to the presence of lymph node and liver metastases in the early stage.

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Although duodenal diverticula are often found in asymptomatic patients, perforation of a duodenal diverticulum is rare. We experienced a case of perforation of a duodenal diverticulum is rare. We experienced a case of perforation of a duodenal diverticulum caused by incarcerated enterolith.
An 86-year-old woman was admitted to our hospital because of right lower abdominal pain. On the basis of abdominal CT findings we diagnosed the case as perforation of a duodenal diverticulum and performed an emergency operation. During surgery, we found enterolith incarcerated in a diverticulum and its resultant perforation of the diverticulum at the posterior wall of the descending part of the duodenum. Removal of the diverticulum and closure of the defect were performed. The patient was discharged from the hospital on the 33rd postoperative day without serious complications. So far nine other cases of perforation of a duodenal diverticulum caused by enterolith have been reported in Japan, and surgical therapy was employed in them.

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We report a rare case of primary carcinoma originating from the first portion of the duodenum. A 63-year-old man, who complained of epigastric discomfort, was found to have an obstruction of the duodenum by upper gastrointestinal endoscopy and was referred to our hospital. Because no malignancy was ever confirmed, we chose conservative treatment. However, endoscopic examination showed no improvement. Thus, we decided to perform surgery. A specimen taken from nodules of the duodenal wall indicated malignancy, necessitating pancreaticoduodenectomy. We subsequently added adjuvant chemotherapy with oral S-1 administration, and he has survived without evidence of recurrence or metastasis for more than a year.
There is no doubt that the first line treatment for primary carcinoma of the duodenum should be curative surgery. However, the role of adjuvant chemotherapy is controversial and the guidelines for unresectable cases are unclear. The management of duodenal malignancy therefore needs to be further investigated in a multicenter trial.

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A 28-year-old woman who had not previously undergone abdominal surgery was hospitalized due to schizophrenia. She developed ileus and abdominal CT showed an object 4×6×3.5cm with internal heterogeneity in the small intestine. A detailed case history revealed reiterate pica. Ileus with foreign body ingestion was diagnosed and conservative therapy was started because her abdominal symptoms disappeared. However, her symptoms showed exacerbation and emergency surgery was done. The object was in the terminal ileum, which was cut open to extract the object. It was a medical glove, denatured and hard. The postoperative course was uneventful and the patient was discharged on postoperative day 26. In the case of ileus with psychiatric disease, it is necessary to keep intestinal obstruction due to a foreign body in mind. In this case, MDCT was useful for diagnosing foreign body ingestion.

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An 11-year-old boy was seen at the hospital because of lower abdominal pain. On physical examination, there was tenderness mainly in the lower abdomen and muscle defense and rebound tenderness were present as well. An abdominal CT scan showed a swollen appendix, calcification in the lumen of the appendix, and encapsulated fluid collection with internal gas images in the pelvic cavity. Perforation of acute appendicitis was suggested and emergency operation was performed. Operative findings included a 6.2×3.6cm Meckel's diverticulum in the ileum about 30cm proximal to the terminal ileum, which had become necrotic due to its torsion. Partial resection of the small intestine including the diverticulum was thus done. The histological diagnosis was true Meckel's diverticulum of the small intestine.
Meckel's diverticulum is yolk sac remnant and almost all patients with the disease have been asymptomatic, but sometimes it can cause bleeding, perforation, and diverticulitis. Torsion is rarely associated with the disease in a far lower frequency than those of other complications. It is etiologically inferred that the Meckel's diverticulum which had become necrotic due to its torsion presented with peritoneal signs in this patient.

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About 2.7% of diverticula in the digestive tract are found in the small intestine. It is uncommon that diverticulum of the small intestine causes penetration or perforation, but once it occurs, delayed diagnosis can be fatal. We report a case of local peritonitis caused by a penetrated diverticulum in the terminal ileum.
A 67-year-old man was seen at our hospital because of fever and right lower quadrant abdominal pain. Physical examination revealed tenderness and muscle guarding localized in the right lower quadrant of abdomen, suggestive of local peritonitis caused by acute appendicitis or diverticulitis of the ascending colon. An abdominal plain CT scan showed more severe inflammatory changes in the terminal ileum than in the ileocecal region, surrounded by free air. Abnormally high level of CRP was also noted. Emergency laparotomy revealed an inflammatory mass in the ileocecal region, so we resected the terminal ileum and cecum containing the inflammatory mass. The mass was disclosed as mesenteric abscess secondary to perforation of the terminal ileum, 13 cm proximal to the ileocecal valve. The pathological diagnosis was mesenteric abscess caused by a penetrated diverticulum in the terminal ileum.

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A 61-year-old woman complaining of vomiting was diagnosed as having intestinal obstruction at a nearby gastroenterological clinic and underwent i. v. drip infusion therapy in the out-patient clinic. However, no remission was noted so that she was admitted to the hospital and was managed under placement of a long intestinal tube. Thereafter a blood examination revealed BUN of 90.1 mg/dl and Cr of 2.9mg/dl, showing severe dehydration and then she was referred to our emergency clinic. Fluoroscopy through the ileus tube and an abdominal CT scan showed intussusception and emergency operation was performed on that day. Upon laparotomy, a portion of the jejunum about 25cm distant from the Treitz ligament was invaginated which was caused by a tumor. The invagination was repositioned manually, when two tumors were identified in the jejunum, 25cm and 35cm distant from the Treitz ligament, respectively. The portion of the jejunum involving the tumors was removed. These were well-defined, elastic-soft submucosal tumors with the diameter of about 2cm, each. The histopathological diagnosis was neurofibroma for each tumor. It is etiologically considered that the patient had von Recklinghausen's disease as an underlying disease and her neurofibromas might be secondary to the disease.

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A 46-year-old male patient visited a doctor in his neighborhood with chief complaints of abdominal pain and tar-like stools. Since upper and lower endoscopy did not reveal any significant abnormalities, he was referred to our institution. A CT scan showed a fat-density tumor, which was suspected to have induced ileal intussusception. Double-contrast radiography of the small intestine also revealed translucency indicating a mass lesion in the ileum. Since differentiation between benign and malignant lesions was difficult in this case with symptoms, laparoscopically-assisted resection was performed. Wall thickening of 20 cm length in the ileum, 20 cm in length, at the ileocecal junction, and ileal intussusception were confirmed. The right side of the umbilicus was elevated and a 5-cm incision was made. The ileum was brought out extracorporeally and resected. By using the specimen of resected tissue, the patient was disgnosed as having had non-neoplastic lesions associated with diverticular disease as a lead point for ileal intussusception. Histopathologically, it was diagnosed as intussuception due to an inverted Meckels diverticulum with lipohyperplasia in the leading head.

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A 73-year-old man was admitted to our hospital due to 2-week weight loss. Abdominal computed tomography showed findings indicative of intussusception of the ileum, and enteroscopy showed an ileal lipoma producing intussusception. We performed laparoscopy-assisted partial resection under a diagnosis of intussusception due to an ileal lipoma. Histopathological examination revealed proliferating fat cells in the submucosal layer. These characteristics confirmed the diagnosis of an ileal lipoma. Laparoscopic surgery is recommended for benigh tumors of the small intestine because it is minimally invasive. Our experience supports enteroscopy as an effective tool in the preoperative diagnosis of bowel lipoma.

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The patient was a 62-year-old man who had been diagnosed as having ankylosing spondylitis and been controlled well by prednisolone (10mg/day) from November 2006. He was urgently admitted to the hospital because of severe anemia in March 2007. Upper gastrointestinal endoscopy showed a tumor with ulceration beyond the Treitz's ligament. Abdominal enhanced CT scan showed an irregular wall thickening and the density of the tumor with heterogeneous enhancement effect. Emergency operation was performed under a diagnosis of a bleeding tumor of the jejunum. On intraoperative findings, the tumor, developed extramurally on the mesentery side with an abscess formation, was found at the jejunum about 10cm distal from the Treitz's ligament. We performed partial resection of the duodenum and jejunum including the tumor with regional lymph node dissection followed by reconstruction with side to side duodeno-jejunostomy (Over lap method). The histological diagnosis was primary jejunal adenocarcinoma with lymph node metastasis. His postoperative course was good and he could be taken off prednisolone. He has been doing well without signs of recurrence, and having no prednisolone as of 2 years after the surgery.

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The case involves a male in his 20s, who was hit by a truck while he was riding his bicycle along a major road. A nearby hospital diagnosed multiple traffic accident injuries along with a pelvic fracture ; the patient was immediately transferred to our hospital. His consciousness level was 30 on the Japan Coma Scale (JCS) and 13 on the Glasgow Coma Scale (GCS). On examination, the patient was found to have multiple injuries including an acute subdural hematoma, a pulmonary contusion and a pelvic fracture. Since free air was observed in the abdominal cavity on CT, it was surgically dealt with orthopedic surgery for his pelvic fracture and his left thighbone fracture. The patient was found to have a retroperitoneal hematoma and hematoma in his ascending colon, but no obvious gastrointestinal perforation nor abdominal organ injury. Therefore nonsurgical pneumoperitoneaum was diagnosed and the abdominal wall was closed. As for the pathogenic mechanism explaining the presence of free air, it is possible that a pulmonary contusion caused pneumomediastinum to leak air into the abdominal cavity. A literature review was also performed.

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An 86-year-old woman had repeat episodes of choledocholithiasis. A straight endoscopic retrograde biliary drainage (ERBD) tube was inserted into the bile duct. Twenty-nine days later, she developed abdominal pain and peritonitis. The findings on CT included intra-abdominal free air, ascites, and evidence that the ERBD tube had migrated to the sigmoid colon that had a diverticulum. Emergency surgery was done. Intra-operative findings included a diverticular perforation of the sigmoid colon by an ERBD tube ; Hartmann's operation was performed. The patient's postoperative course was uneventful, and the patient was discharged 31 days after surgery. Although the majority of migrated biliary endoprostheses pass through the intestine without causing any problems, intestinal perforation can occur in patients with a diverticulum. Careful diagnosis is required to identify migrating biliary endoprostheses.

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We report a case of sigmoid-vaginal fistula, due to diverticulitis of the sigmod colon, treated with laparoscopy assisted surgery. A 77-year-old female who had undergone total hysterectomy at the age of 37 and laparoscopic assisted distal gastrectomy at the age of 76 was admitted because of stool-like discharge from the vagina. Endoscopic and radiological examinations showed multiple diverticulae of the sigmoid colon with the formation of a fistula communicating with the vagina.
Laparoscopy-assisted sigmoidectomy was done. Dissection of the mesentery was done by the medial approach and the stump of the vagina was not closed because the fistula adhered to the bladder. Her postoperative clinical course was uneventful except for wound infection. The stool-like discharge from the vagina disappeared. Two cases of laparoscopy-assisted surgery for sigmoid-vaginal fistula have been reported in Japan. Laparoscopic surgery was thought to be an option for fistula due to diverticulitis.

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We present a case of gastrointestinal stromal tumor (GIST) arising in the perianal region. A 78-year-old Japanese man who had suffered from an asymptomatic buttock tumor from April 2006 was seen at our hospital because of anal discomfort and dyschezia in December 2006. He had undergone treatments for a perianal abscess and an anal fistula. The buttock tumor had grown gradually and a possibility of malignancy could not be ruled out, so the tumor was surgically excised on March 16th 2006. The excised tumor was 6.0cm in diameter and was composed of spindle-shaped atypical cells. In histopathological examinations, both c-kit and CD34 antigens were positive and the tumor was diagnosed as GIST. The patient has been well without any recurrent signs in these 26 months.

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An 85-year-old woman, who underwent lower gastrointestinal endoscopy because her stools were positive for occult blood, was found to have an elevated lesion in the sigmoid colon. The histopathological diagnosis of a biopsied specimen was poorly differentiated adenocarcinoma. An abdominal CT scan performed in November 2007 when she was first seen showed no recognizable metastases to the liver, lung and lymph nodes. On November 15, 2007, sigmoidectomy + D2 dissection was performed with a diagnosis of cancer of the sigmoid colon. The final histopathological diagnosis was endocrine cell carcinoma, localized in the submucosal layer, N0 and StageI. Another CT scan performed on the 7th month after the operation revealed multiple hepatic metastases and pulmonary metastasis. Thereafter these metastatic lesions rapidly enlarged and eventually the patient died 9 months after the operation.
It has been reported that endocrine cell carcinoma of the large intestine is rare and carries poor prognosis. Although the disease in our patient was in StageI when she was operated on, multiple hepatic as well as pulmonary metastases occurred early after the operation and it progressed rapidly to its termination. This paper presents our case together with a review of the literature.

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An 88-year-old woman emergently hospitalized for lower abdominal pain was found on physical examination to have a flat, soft, unirritated abdomen. Hematological and biochemical tests showed no white-blood-count (WBC) or C-reactive protein (CRP) elevation. Abdominal radiography showed marked intestinal-tract gas and contrast computed tomography (CT) showed branched portal vein gas in both hepatic lobes. An antibiotic was administered via the central vein. Emergency surgery for intestinal tract necrosis was scheduled, but symptoms and the gas had disappeared by hospitalization day 3. This condition can be caused by gas-producing bacteria due to infection associated with intestinal tract necrosis. Definitive diagnosis, however, requires clear systemic abdominal findings. WBC and CRP results were useful references in determining surgical indications.

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A female in her 60's had undergone a cholecystectomy for cholecystolithiasis at the age of 26. She was diagnosed as having hereditary spherocytosis at the age of 33 years ; splenectomy was not recommended due to the presence of only minimal symptoms. The patient developed right hypochondralgia in Feburuary 2007 ; a severe hemolytic anemia and jaundice, as well as hepato and choledocholithiasis, were noted. Due to the persistent and severe anemia as well as jaundice, a laparoscopic splenectomy was performed. Subsequently, a left hepatic lobectomy with hepaticojejunostomy was performed. She was discharged without any complications. In patients with hereditary spherocytosis pigmented gallstones are common, but the development of hepatolithiasis is rarely reported. The presented patient had a cholecystectomy without a splenectomy ; this was thought to have resulted in hepatolithiasis. In the present case, the splenectomy was done before the liver resection ; this allowed the hepatic resection to be done electively in the absence of severe anemia or jaundice.

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A 98-year-old woman complaining of abdominal pain and vomiting was referred to our hospital with a diagnosis of ileus. The patient's abdomen was tender, and the CRP value was elevated to 26 mg/dl. The WBC count was 10500/ul. Hepatic and renal cysts and a dilated bowel were observed on abdominal CT scans, but there was no evidence of strangulation. Because the patient was a PS4, a person of advanced age, for whom surgery entailed great risk, she was treated conservatively and her clinical course was monitored. However, she went into shock on the next day and, emergency surgery was performed after consultation with her family. The intraoperative findings showed torsion of a necrotic gallbladder which had displaced to the lateral side of the right kidney. The necrotic gallbladder was excised, and the patient was discharged on the hospital day 9. What appeared to be a dilated bowel on the preoperative CT scans was clarified to be a twisted gallbladder. Careful differential diagnosis is necessary for patients who have hepatic cysts as well as paralytic ileus.

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An 82-year-old man with epigastralgia was admitted. Computed tomography (CT) showed a mass in the pancreatic head, a dilated extrahepatic bile duct, and a dilated pancreatic duct ; as well a common hepatic artery originating from the superior mesenteric artery and travelling along the ventral side of the head of the pancreas was noted on visceral angiography. Endoscopy showed a carcinoma of the ampulla of Vater. The patient had a pancreaticoduodenectomy with preservation of the replaced common hepatic artery and accessory hepatic artery. On pathology, an extrahepatic dile duct cancer with neither lymph node metastasis nor invasion to the pancreas was diagnosed. There were no postoperative complications.

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A 61-year-old man who visited a hospital because of eruption was found to have impaired hepatic function and dilatation of the intrahepatic bile ducts by ultrasonography, and was referred to our hospital. Abdominal MRI showed stenosis of the middle portion of the extrahepatic bile duct. Carcinoma of the bile duct was suggested and the patient was operated on. During surgery, the gallbladder was felt hard and the induration was present like it had invaded the middle portion of the extrahepatic bile duct. Accordingly we etiologically inferred that the primary lesion was gallbladder carcinoma which invaded the middle portion of the extrahepatic bile duct, and performed cholecystectomy, resection of the extrahepatic bile duct, and resection of segments 4a and 5 of the liver. Histological studies of the resected specimen revealed that gallbladder lesion, the primary foci, was histologically adenocarcinoma, where as the metastatic foci in the resected liver showed different histological type of adenosquamous cell carcinoma.
It has been viewed that adenosquamous carcinoma and squamous cell carcinoma of the gallbladder originate from squamous cell metaplasia of adenocarcinoma. We present this case here because it is interesting in terms of substantiating the view.

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A 45-year-old female presented with a chief complaint of epigastralgia. She had been treated at a regional hospital for pulmonary tuberculosis. On examination, she was found to have a mass located at the hepatic hilum on abdominal ultrasound. A computed tomography scan of the abdomen showed a pancreatic head cystic tumor. Positron emission tomography with 18F-fluorodeoxyglucose (FDG-PET) revealed a hot spot only in the pancreatic head. Under a presumptive diagnosis of malignancy, a laparotomy was performed. During the operation, a caseating necrotic mass and posterior pancreatic head lymph nodes were identified. Peripancreatic tuberculous lymphadenopathy was suspected. The diagnosis was confirmed on polymerase chain reaction (PCR) examination. Cases of peripancreatic tuberculous lymphadenopathy are rare. We reported a case of peripancreatic tuberculous lymphadenopathy mimicking pancreatic head cystic tumor that was difficult to diagnose preoperatively.

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A 71-year-old woman was referred to our hospital for further examination and treatment after a tumor, approximately 5 cm in diameter, was detected in the right upper quadrant on abdominal ultrasound as part of a medical check-up. Gastrointestinal stromal tumor (GIST) of the duodenum with extramural spread was suspected based on MRI, CT, and other tests, and surgery was performed. A solid mass, 5 cm in size, was observed on the ventral side of the head of the pancreas, and it was detached from the duodenum. Because the mass adhered to the pancreas, the tumor was resected by excising part of the head of the pancreas. Based on the histopathological findings (CD34-positive, c-kit-negative, etc.), the mass was diagnosed as a solitary fibrous tumor (SFT). The patient's postoperative course was favorable. SFT is known to occur in the pleura and soft tissue, and it rarely occurs in the abdominal cavity. It is a lesion that is difficult to evaluate for malignancy. In addition, it has been reported that local recurrence is very likely if the tumor is not completely resected in the present patient, although malignancy may be unlikely based on tumor size and the absence of high degrees of atypia and pleomorphism, further careful follow-up is considered necessary.

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A 60-year-old female patient, in whom the levels of some tumor markers were found elevated, was referred to our institution. She had a carcinoembryonic antigen (CEA) level of 8.7 ng/ml and a CA 19-9 level of 51 U/ml and a 30-mm multilocular cystic neoplasm was detected in the pancreatic tail. Since the neoplasm involved the main pancreatic duct which was dilated, the patient was diagnosed with mixed-type intraductal papillary mucinous neoplasm (IPMN). A 70-mm cystic neoplasm was also found extended from the umbilicus into the abdominal cavity. While metastasis from IPMN was also considered, but since IPMN could not be considered to be invasive carcinoma, the patient was therefore diagnosed as having simultaneous double cancer and underwent resections of the pancreatic tail and the neoplasm in the umbilicus. Histopathologically, both were cystic neoplasms covered with a simple columnar epithelium and diagnosed as IPMN/IPMC with urachal carcinoma, which, so far as we know, has not yet been recorded. Both were similar morphologically as well as histopathologically defining the case as interesting.

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Only 13.0% of patients with pancreatic cancer who have had a radical resection are expected to have a 5-year-survival. We report a case in which lung metastasis occurred 6 years after pancreaticoduodenectomy and had a curative resection of the lesion. The patient was a 79-year-old woman who developed abdominal discomfort and was diagnosed as having pancreatic cancer in 2002.
A pancreaticoduodenectomy was done. After the resection, she had chemotherapy with gemcitabine and UFT. In 2008, a lung tumor was detected on follow-up CT. A transbronchial lung biopsy was done, and a lung metastasis of pancreas cancer was diagnosed. Since she had no other metastasis, video-assisted lung surgery was performed to remove the tumor ; In the 1 year of follow-up since the lung metastasis resection the patient has had no other recurrences. If lung metastasis of pancreas cancer is found, and there is no other metastasis, tumor removal is indicated.

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A 77-year-old man who had had a drinking habit had the sudden onset of epigastralgia. He was diagnosed as having splenic rupture and underwent emergency operation. During surgery, a ruptured spleen and a pseudocyst were identified, and splenectomy was performed. Histopathological studies suggested that a splenic aneurysm might rupture due to pancreatitis. We had great difficulties in treating fistula of the pancreas after the operation, but eventually we were able to manage the fistula. The patient has been followed in the clinic.
Non-traumatic splenic rupture is a rare entity, and it is known that the disease may be caused by alcoholic chronic pancreatitis, hematological / metabolic disorders, infections, and malignant neoplasms. This paper deals with our experience with a patient who could be saved by splenectomy for splenic rupture which might be caused by rupture of a splenic aneurysm secondary to alcoholic chronic pancreatitis.

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A 15-year-old male was diagnosed as having a splenic cyst in December, 2004. He presented to the hospital because of severe abdominal pain after suffering a bruise in September 2008. The serum CA19-9 level was high at 1044U/ml. Computed tomography revealed a collapsed splenic cyst surrounded by ascites. Peritonitis due to splenic cyst rupture was suspected, and a dome resection with coagulation was thus performed via a laparotomy. The CA19-9 level in the cystic fluid was high at 4.19×10⁶U/ml, but there was no cytological evidence of malignancy. The histological diagnosis was benign true cyst. Immunostaining showed positive responses for CA19-9 in the intra-cystic epithelium. After surgery, the serum CA19-9 level returned to the normal range. The patient has since been free of recurrence but is being followed closely, since there are few long-term follow-up studies on such cysts.

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A 38-year-old woman was seen at our hospital because of right lower quadrant abdominal pain in January 2007. Oral analgesic did not relieve the symptom and she was admitted to our hospital two days later when marked leukocytosis of 10,930 cells/mm³ and C-reactive protein of 5.9 mg/dl were noted. We conducted emergency surgery with a diagnosis of acute appendicitis with an ovarian cyst determined by computed tomography (CT). Intraoperative exploration revealed a normal appendix and a cyst 60 mm in longer diameter which was continuous to the uterine tube and adjacent to the right ovary. The cyst was twisted counter-clockwise by 540 degree. The diagnosis of torsion of hydrosalpinx was made.
Torsion of hydrosalpinx is rare and is often misdiagnosed as torsion of an ovarian cyst, but torsion of hydrosalpinx should be considered in female patients with lower abdominal pain after tubal sterilization.

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An 83-year-old woman visited a hospital because of lower abdominal pain. She had no past abdominal operations other than an appendectomy. Inflammation was severe. Thus, we administered antibiotics and an infusion. CAT scan showed an urachal abscess and dilatation of the ascending colon. We operated on her four days after admission. The urachal abscess was about 10cm in diameter. The large omentum was adherent to the abscess wall, such that patency of the transverse colon was lost. We partially resected the abscess wall. There was no communication among the abscess cavity, bladder, and umbilicus. Her post-operative course was good.

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We report a case of lymphangioma of the mesoleum. A 71-year-old woman developed abdominal discomfort. Abdominal ultrasonography and MRI showed a multilocular cystic lesion adjacent to the ileum ; the PET-CT examination showed a high radiotracer concentration on FDG-PET. A mesenteric tumor was diagnosed, and surgery was performed. On laparotomy, a 4.5×3.5 cm tumor located 125 cm proximal from the ileum end was found in the mesoileum. The tumor along with part of the ileum was resected. The resected tumor was a multilocular cystic lesion that contained coagulated blood. On histopathology, the cyst was found to be lined with flat endothelial epithelium, which was positive for D2-40 on immunohistochemistry. Lymphangioma of the mesoileum is extremely rare in adults. The case is reviewed in context with other such cases presented in the Japanese literature.

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A 75-year-old male with diffuse mucinous ascites underwent cytoreductive surgery including appendectomy. At laparotomy, cystadenocarcinoma was detected from the ascites and pathology revealed cystadenocarcinoma of the appendix with perforation. Pseudomyxoma peritonei caused by carcinoma of the appendix was diagnosed. The patient received a modified FOLFOX6 regimen postoperatively until the side-effect of peripheral neuropathy (Grade3) appeared after completion of 10 cycles. Despite this finding, a computed tomography (CT) scan revealed complete disappearance of ascites and no recurrence 6 months after discontinuation of chemotherapy. To date, the patient has been free of recurrence.

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We report a case of a pelvic schwannoma.
A 72-year-old man was admitted because of melena. Ultrasonography revealed a well-defined cystic tumor located in the pelvis. CT scan showed a well-defined tumor, 6 cm in diameter, which had calcifications and was located in the presacral space. The tumor showed mixed intensity on T1 and T2-weighted MRI images. An operation was done. The tumor was removed. The tumor was found to be very adherent to the anterior surface of the sacral bone, it was nevertheless removed. The resected tumor measured 6 × 5.5 × 5 cm and had multiple cysts filled with serous fluid. On histopathology, the tumor was found to be composed of spindle-shaped cells without nuclear-atypia that were positive for S-100 protein. Thus, a benign ancient schwannoma was diagnosed.
Pelvic schwannoma is relatively rare and difficult to diagnose preoperatively due to a lack of specific subjective symptoms and specific imaging findings. Since excision of the tumor can result in a neurological disorder patients must be informed of this risk prior to surgery.

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We report a case of metachronous bilateral obturator hernia obstruction with contralateral onset occurring nine days after initial surgery. An 81-year-old woman was re-admitted due to a small intestinal obstruction related to a left obturator hernia which occurred nine days after a hernioplasty for a right obturator hernia. It was thought that she might have already had the contralateral obturator hernia at the time of the initial operation. Retrospectively, it was noted that the abdominal pelvic CT done at the time of the first operation showed a left soft tissue density area with a space of more than 10 mm between the pectineus and the obturator muscles, thus providing evidence of left obturator hernia. In patients with a unilateral obturator hernia, we a contralateral hernia should be ruled out. Pelvic CT may be helpful in such cases in order to help plan the operative procedure.

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We present a case of obturator hernia treated by the modified Kugel method via an inguinal approach. A 91-year-old female was referred to our hospital because of vomiting and left femoral pain. Pelvic CT scan revealed a left obturator hernia and an emergency operation was performed. Aiming at less surgical stress, we employed an inguinal approach. After releasing the incarcerated hernia, we closed the hernia opening by the modified Kugel method. This method seems to be a beneficial and reasonable procedure which ensures clourse of not only the obuturator hernia canal but other hernias as well.

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In a 46-year-old woman with bloody stools colonoscopy revealed rectal cancer 10cm from the anal verge. Laparoscopy-assisted low anterior resection was performed and the patient was set in the 20°head down and 20°right side down position during the operation. Both arms were 70-80°abducted and shoulder braces were placed over both acromioclavicular joints. The operation time was 6h25m and the patient moved four times during the operation, such that anesthetic depth needed to be adjusted. Right after the operation, the patient began to complain of left arm palsy. Several examinations revealed a diagnosis of left brachial plexus palsy due to improper positioning during the operation and the patient was treated conservatively with physiotherapy and rehabilitation. For laparoscopy-assisted surgery, patients sometimes must be placed differently from the positioning for laparotomy. Several reports mention neuropathy due to improper positioning during laparoscopy-assisted surgery. To avoid nerve injuries due to malpositioning, a better understanding of positioning during surgery should be kept in mind by surgeone.

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The patient, an 87-year-old woman, complained of abdominal pain ; an obstructive ileus due to ascending colon cancer was diagnosed, and a right hemicolectomy was done. One year later, a metastatic lesion was found in the left lower lung on computed tomography. FDG-PET study showed a high FDG uptake tumor in the right upper extremity ; on pathology of the excisional biopsy, a schwannoma was diagnosed. Currently FDG-PET is often performed to identify colon cancer recurrence. Schwannoma is an important lesion to remember in the differential diagnosis of metastatic cancer.

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