[in Japanese]

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Purpose : The purpose of this study was to compare tumescent local anesthesia with spinal anesthesia in inguinal hernia repair.
Subjects and methods : Subjects were 27 lesions of 25 patients with inguinal hernia who underwent hernia repair under local anesthesia using tumescent local anesthesia (the local anesthesia group) in our hospital in an 18-month period from May 2008 to November 2009, and they were compared with 50 lesions of 46 patients who underwent hernia repair under spinal anesthesia in the same period (the spinal anesthesia group).
Results : In the local anesthesia group, the male-to-female ratio was 22 : 3, with an average age of 64.4 years. There were 23 cases of unilateral hernia and two cases of bilateral hernias. As for the types of hernias, there were 22 indirect and five direct inguinal hernias. The Mesh-plug method was employed for 26 lesions and the Marcy method for one lesion. When compared with the spinal anesthesia group, the local anesthesia group showed no statistically significant differences in the patient's background factors, operating time, and postoperative pain control. However, a significantly shorter staying time at the operating room was noted in the local anesthesia group, and the local anesthesia significantly contributes to shorten the duration of hospital stay as well.
Conclusions : It is suggested that inguinal hernia repair under tumescent local anesthesia that may make early ambulation and early discharge possible and can offer an economic benefit in medical cost is superior to that under spinal anesthesia.

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A 78-year-old woman was referred to our hospital in May 2009 with swelling and subcutaneous hemorrhage of the neck that developed following neck discomfort and pharyngeal pain. Tests performed on admission revealed Hashimoto's disease and anemia. Serum calcium levels were normal. The patient complained of tenderness in the neck, and although CT showed a hematoma in the lower pole of the left lobe of the thyroid gland and contrast-enhanced CT revealed a mass with blood flow inside, no aneurysms were observed. Upper gastrointestinal endoscopy showed extramural compression and internal bleeding in the laryngopharynx. Since gallium scanning revealed no areas of increased uptake, the patient was diagnosed not with a tumor but with bleeding in a thyroid cyst. Following admission, the patient fasted, had her neck cooled, and was given hemostatic drugs. Surgery was performed one week after admission. Based on the findings of subcutaneous internal hemorrhage and a 40-mm cyst with internal bleeding that was not continuous with the lower pole of the thyroid gland, the patient was diagnosed as having bleeding in a cyst in the left inferior parathyroid gland, and the cyst was resected. Although the serum intact PTH was only slightly elevated preoperatively, intact PTH in the luminal aspirate was high (59,110 pg/ml). The histopathological diagnosis was parathyroid cyst with Hashimoto's disease. A patient who developed subcutaneous hemorrhage of the neck due to spontaneous bleeding in a parathyroid cyst is reported.

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This paper deals with a patient presented with hypoglycemia associated with a giant breast tumor.
A 69-year-old woman was brought into the hospital because of a giant mass in the left breast in July, 2008. She had noticed the mass since about 2 years earlier, and malodorous secretion from the mass for about these six months. The mass which was movable freely was about soccer-ball sized, and had a sarcomatous appearance, with ulceration through the skin. A breast CT scan revealed a high-density bulky mass in the left breast without axillary lymph node swelling and it was suspected to have expanded to the left pectoral muscles and skin. On biopsy examination, the mass was diagnosed as phyllodes tumor. During hospital stay, she suddenly had an attack of consciousness loss (JCS III-300) 20 days after admission, when the serum blood sugar level was 34 mg/dl. She was successfully treated with injection of glucose. We suspected that hypoglycemia might be related to the giant mass in the left breast, and performed left mastectomy with resection of the left major and minor pectoral muscles on August 24 days after admission. The resected tumor weighed 3900 g, measured 27×22×14 cm. The resected specimen had leaf-like papillary protrusions of stromal connective tissue lined with epithelium and duct-like element, and was diagnosed as borderline type of phyllodes tumor. After removal of the tumor, the blood sugar level was gradually normalized, and she was in a healthy condition. These events suggested that the patient's hypoglycemia was associated with the giant phyllodes tumor that consumed glucose, generally named non-islet cell tumor hypoglycemia (NICTH).

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A 54-year-old woman who had shown no abnormal findings at an examination for breast cancer performed one year before was seen at the hospital because of a right breast mass which had been felt since 1.5 months earlier. A mass 1.5cm in diameter was felt in the C area of the right breast and on the inside of it, an about 4 cm-sized induration like mastopathy was also felt in the CA area. Fine needle aspiration biopsy cytology (FNABC) of the former tumor resulted in classIII and core needle biopsy (CNB) proved no malignant cells. FNABC of the latter tumor resulted in class I. We decided to follow the patient's clinical course. Four months later the tumor in the C area enlarged to be 2cm in diameter and axillary lymph node swelling was confirmed. Another CNB of the tumor showed malignant findings and FNABC of the axillary lymph node resulted in class V. The tumor was diagnosed as T1N2aM0 and stageIIIA, and so preoperative chemotherapy was started. The tumor in the C area showed shrinkage but the induration in the A area showed no change in size, when the axillary lymph node could not be felt. The patient was operated on. Histologically the induration in the CA area was cystic hypersecretory carcinoma, non-invasive, ly0, v0, NG1, n0 (0/13), ER(-), PgR(-) and HER2=0.
We present this case of cystic hypersecretory carcinoma because this malignancy is non-invasive carcinoma and shows characteristic histopathological features.

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A 40-year-old man was admitted to our hospital for the treatment of acute aortic dissection. After admission, he developed epigastric pain and rebound tenderness. Abdominal enhanced CT showed intraperitoneal hemorrhage and a hepatic artery aneurysm. Since he was hemodynamically stable without anemia, we closely followed the patient overnight. The next day, he developed shock, and therefore, we decided to perform laparotomy instead of transcatheter embolization, which was contraindicated due to aortic dissection. Intraoperative findings revealed a ruptured left hepatic artery aneurysm, for which we performed aneurysmectomy and ligation of the left hepatic artery. The patient was discharged on postoperative day 39 after the mild liver dysfunction improved. The aortic dissection was the thrombotic type, which has been stable.

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The management of patients with concomitant abdominal aortic aneurysm (AAA) and colorectal cancer is controversial. We report a case who underwent surgery for AAA and advanced sigmoid colon cancer (SCC). The 80-year-old man had a past history of chronic pyothorax. He developed conspitation and was diagnosed as having SCC. On pre-operative CT a thoraco-abdominal aortic aneurysm (TAAA), 57 mm in diameter, and an AAA, 65 mm in diameter, were noted ; no distant metastases of SCC were identified. We decided to observe the TAAA given the patient's age and the presence of chronic pyothorax. However, the AAA had a risk of rupture because of its cystic shape and size. Thus, the AAA and the SCC needed to be treated. We planed the operations so as to reduce the risk of graft infection and colostomy. First, the AAA was resected and grafted ; 1.5 months later, a sigmoidectomy was performed. The post-operative course was an eventful. Twenty-two months after the sigmoidectomy the patient is alive with no recurrence.

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The patient was a woman in her seventies undergone pylorus preserving pancreaticoduodenectomy for cancer of the papilla of Vater. The histological diagnosis was tubular adenocarcinoma, moderately differentiated, AbpBi, H0, pPanc0, pDu2, P0, PN1(+)(only 13b), M(-), St(-), pT3, and stage III. While she had been followed in the clinic, a chest CT scan taken 2 years after the operation showed a 2cm-sized solitary abnormal shadow in the right lung S2. Bronchoscopic cytodiagnosis resulted in class II, but FDG-PET showed a significantly abnormal accumulation of FDG. Abdominal and head CT scans as well as bone scintigram showed no abnormal findings. From these findings, upper lobectomy of the right lung was performed with the most likely diagnosis of primary lung cancer. Finally lung metastasis from cancer of the papilla of Vater was diagnosed based on epithelial proliferation into the alveolar cavity on the resected specimen, histopathological findings including secondary formation of tubular glands, and results of immunostaining.
Cancer of the papilla of Vater can metastasize locally or can do to the lymph nodes, the liver and the lung after the operation, which are considered to be usual metastatic patterns. However, postoperative solitary metastasis to the lung which is treated by lung resection is rare, so that this case is reported here, together with a review of the literature.

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A delayed traumatic incarcerated diaphragmatic hernia is rare ; only 23 cases have been reported in Japan to date. A 31-year-old man complained of severe epigastralgia following an episode of vomiting. He had a history of multiple trauma caused by a traffic accident 5 years ago. Since there were no signs of peritonitis, NPO was instituted, and he was given an H2-blocker. Upper GI series and endoscopy showed an abnormally shaped stomach and poor flow of contrast media. Exploratory laparoscopy revealed a prolapse of the stomach into the thoracic cavity via the left diaphragm. The diagnosis of traumatic diaphragmatic hernia was confirmed, and the operation was converted to a laparotomy. The stomach was pulled back into the abdominal cavity, and the abnormal hiatus was closed. In retrospect, the patient noted that since the traffic accident he often had postprandial epigastralgia. In this patient, the stomach might have prolapsed slightly to the left diaphragm due to the accident. An elevation of intra-abdominal pressure caused by vomiting likely worsened the prolapse of the stomach.

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The patient, a 52-year-old man, underwent endoscopic subtotal esophagectomy, retrosternal gastric tube reconstruction, and 3-field lymph node dissection for stageII thoracic esophageal cancer in September 2006. After CRT for right neck lymph node recurrence, the patient had been followed until April 2008, when the patient suddenly developed upper abdominal pain and visited the hospital's emergency room. CT confirmed the patient having ileus due to a diaphragmatic hernia, and emergency surgery was performed. Intraoperative findings included : the esophageal hiatus that had enlarged during the previous surgery served as a hernia orifice ; and the transverse colon and the small intestine prolapsed into the left thoracic cavity. No clear signs of necrosis were seen with them, they were not dissected, and the esophageal hiatus was ligated. Although a diaphragmatic hernia following esophageal cancer surgery is rare, it is a grave complication. In the present patient, the diaphragmatic hernia occurred because the esophageal hiatus had enlarged during surgery, and endoscopic surgery resulted in minimal adhesion to the abdominal cavity.

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The number of cases of bezoar have increased recently with advances in upper gastrointestinal endoscopy. Some patients require surgical treatment due to intestinal obstruction, while treatment by endoscopy has been reported in many cases. We experienced a case of small bowel obstruction due to the fragments of a crushed bezoar. A 93-year-old woman was admitted to our hospital with upper abdominal discomfort. Computed tomography and upper gastrointestinal endoscopy revealed a 5-cm bezoar in the second part of the duodenum. The bezoar was endoscopically crushed into fragments using a grasping forceps and snare ; however, the bezoar fragments caused small bowel obstruction after 27 days. Despite conservative treatment, small bowel obstruction did not improve ; therefore, we performed an operation. The fragments of bezoar were impacted in the ileum, and we resected this segment of the ileum, including bezoars. We report that careful examination is important after crushing bezoars, because the bezoar fragments cause small bowel obstruction.

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Liver is the most common site of recurrence of gastric gastrointestinal stromal tumor (GIST). In most cases, the recurrence occurs within 2 years of the resection of the primary lesion. However, in our patient, liver metastasis occurred 11 years after initial surgery.
A 60-year-old man underwent proximal gastrectomy in 1997 for a submucosal tumor of the stomach. Gastric leiomyosarcoma was diagnosed on the basis of immunohistochemical examination performed at that time. In 2008, a liver tumor was detected during an abdominal ultrasound in a voluntary health screening. After close inspection, we suspected metastasis of the GIST to the liver and partial hepatectomy was performed in December, 2008. Immunohistochemical examination revealed that this liver tumor was caused by metastasis of the GIST.

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We treated a case of carcinoma arising in the reconstructed gastric tube after radical surgery for esophageal cancer. A 64-year-old man with esophageal cancer had undergone subtotal thoracic esophagectomy and retro-sternal reconstruction using a gastric tube 5 years and 6 months earlier he developed an anemia. A Borrmann type 3 advanced cancer was discovered in the lower part of the gastric tube. Total resection of the gastric tube and an ante-thoracic reconstruction using the right half of the colon and ileum were performed in July 2005. On pathology, a well differentiated adenocarcinoma, intermediate type, INFβ, ly0, v0, mp, N0, H0, P0, M0, StageIB was found. Currently, the patient is healthy without any signs of recurrence. We reviewed 118 reported cases of gastric cancer occurring after esophagectomy. To ensure the early detection of gastric cancer after esophagectomy, periodic follow-up endoscopy should be done.

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A-72-year-old woman with an umbilical tumor was admitted to our hospital for resection of the tumor and to establish a definitive diagnosis. During the operation, we found an elastic mass near the pylorus. Pathological examination revealed the tumor as signet ring cell carcinoma, and endscopic examination and findings from biopsy of the stomach revealed that the tumor was caused by metastasis of the gastric cancer. Umbilical metastasis of the intraabdominal malignant neoplasm is known as “Sister Mary Joseph's nodule.” Early pathological examination should be performed to treat a patient with an umbilical tumor of unknown origin.

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A 64-year-old man examined for epigastralgia was found to have type 2 tumor at the lesser curvature of the gastric corpus on gastric endoscopy. Although biopsy specimens were negative for malignancy, total gastrectomy and D3 lymph node dissection were performed for advanced gastric cancer with multiple lymph node metastasis. Gastric small cell carcinoma was diagnosed on the basis of the pathological findings after operation. Despite adjuvant TS-1 chemotherapy, liver metastasis appeared 1 year after operation, and partial hepatectomy was performed. Hepatic arterial infusion (HAI) of low-dose 5-fluorouracil/cisplatin (FP) was administered once every 2 weeks after partial hepatectomy. Computed tomography (CT) performed during the course of HAI chemotherapy showed the recurrence of liver tumor twice. The chemotherapeutic regimen was continued for, few months later ; however, CT performed during this period did not reveal liver tumors. Recurrence was not observed, and the patient is alive for 5 years after first surgery.
Gastric small cell carcinoma is associated with a poor prognosis, and there is no established therapy to date. However, long-term survival has recently been reported in some cases. We suggest curative gastrectomy with extensive lymphadenectomy and long-term local control with hepatectomy and HAI for liver metastasis as a effective treatment of choice for gastric small cell carcinoma.

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A 49-year-old man with mental retardation admitted to our hospital because of abdominal pain. Physical examination showed high-grade fever tenderness of the abdomen. An abdominal radiograph showed a foreign body in the left side. Abdominal computed tomography showed a foreign body in the small intestine and free air and fluid collection in the retroperitoneal space around the duodenum. We asked his caretakers detailed questions about the foreign body and diagnosed duodenal perforation due to a partial denture. We performed an emergent operation for the removal of the partial denture and closure of the duodenal perforation. The presence of a foreign body should be specified before deciding the therapeutic plan. However, it is difficult to ask detailed symptoms to patients with mental retardation. Therefore, careful physical examination and effective communication to with the family and caretakers of these patients is important.

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An 83-year-old man was found to have severe anemia during hemodialysis for chronic renal failure. An upper gastrointestinal endoscopic study showed a whole-circumferentially growing adenocarcinoma at the duodeal bulb. An abdominal CT scan showed multiple hepatic metastases and unresectable duodenal adenocarcinoma was diagnosed. However, it was difficult for the patient to be a candidate for chemotherapy due to his great age and his renal failure requiring hemodialysis. We thus performed gastrectomy with the resection of the duodenal bulb (palliative surgery). The histopathological diagnosis was adenosquamous carcinoma, in which squamous cell carcinoma had dominated the main foci. As for the patient's postoperative course, he developed jaundice due to hepatic metastasis followed by hepatic failure in an early time and died on the 23rd postoperative day.
Adenosquamous carcinoma arisen in the duodenum in the narrow sense is extremely rare and carries poor prognosis. We present here a case of adenosquamous carcinoma of the duodenal bulb in an aged hemodialysis patient whose lesion was resected, together with a review of the literature.

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An 85-year-old woman who had felt intermittent periumbilical pain since July 2007 and experienced body weight loss of 10kg during 6 months was seen at our emergency clinic because of severe periumbilical pain and vomiting in May 2008. There were strongest tenderness in the periumbilical area and left upper quadrant of abdomen. She was diagnosed as having intestinal obstruction by an abdominal X-ray film. Furthermore, an abdominal CT scan showed whirl sign. We diagnosed the case as volvulus of the small intestine and performed emergency operation to reduce axis rotations. At laparotomy, the small intestine was twisted counterclockwise by 360 degree around the superior mesenteric artery. We considered it primary volvulus, as there was no organic lesion and anatomical disorder causing volvulus of the small intestine. Some elderly people may show few clinical symptoms and minimal changes in laboratory data even if they have volvulus of the small intestine, and they may experience acute aggravation after following the chronic clinical course, like in this case. Accordingly the possibility must be kept in mind in making diagnosis.

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An 86-year-old man who had an about 8 month-history of lower abdominal pain, pollakiurea, and urinary contamination was seen at the department of urology in our hospital, after unsuccessful treatments for his symptoms in two another hospitals. Cystoscopic study disclosed a stoma in the wall of the urinary bladder, from which fecal juice flew out. A CT scan showed multiple diverticula in the sigmoid colon. Colovesical fistula caused by diverticulitis of the sigmoid colon was diagnosed, and the patient was referred to our department of surgery. The patient's general condition was poor resulted from long-lasting inflammation and malnutrition. Upon laparotomy, a perforated site about 1cm in diameter was present at the sigmoid colon and abscess formation was confirmed around the perforated site, at where a 0.7cm-long fish bone was identified in the lumen. In the deep part of the abscess cavity, a hypertrophied and hardened wall of the urinary bladder existed and the fistula was identified. The perforated sites in the sigmoid colon and the urinary bladder were closed by sutures, and in the oral side, covering colostomy was performed.
We rarely encounter colorectal perforation due to a fish bone, but our case is the second report on colovesical fistula caused by a fish bone in Japan.

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A 62-year-old woman was referred to our hospital for anal pain and constipation. Digital examination revealed an unmovable round and elastic hard tumor with a smooth surface in the anterior wall of the lower rectum. MRI showed that the tumor was 12 cm in diameter and was present in the lesser pelvic cavity. Colonoscopy revealed submucosal tumor with central ulceration. On the basis of findings from biopsy specimens, the tumor was diagnosed as a high-risk rectal gastrointestinal stromal tumor (GIST) with c-kit mutation of exon 11. We decided to administer neoadjuvant therapy with imatinib mesylate because the operative procedure had the risk of tumor cell dissemination due to rupture of tumor capsule and because the tumor had a c-kit mutation of exon 11. After 6 months of treatment, the tumor volume reduced to 40%. Abdominal-peritoneal resection with partial resection of the vaginal wall was performed without tumor perforation. Histological examination of the resected specimen revealed massive hyalinization and Ki-67 labeling index was significantly decreased. She was alive without recurrence after 14 months of operation followed by treatment with imatinib mesylate as adjuvant therapy.

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A 74-year-old woman was admitted to the hospital because of an abdominal reddish mass under the umbilicus and fever which developed after abdominal pain lasting for 14 days. An abdominal CT showed an abscess which was adjacent to the transverse colon and extended from the peritoneal cavity to the abdominal wall. We tried a conservative therapy using antibiotics, but the abdominal wall abscess still enlarged. Drainage of the abscess was performed. Oral intake was started, but she had the onset of ileus. An ileus tube device was dffective, but a gastrographin enema revealed stenosis of the transverse colon. We diagnosed the case as transverse colon cancer with an abdominal wall abscess and ileus. On the 33rd hospital day, transverse colectomy with the omentum and lymph node dissection was carried out. The pathological diagnosis was type 2, well-differentiated adenocarcinoma of the transverse colon. The carcinoma had invaded the omentum without lymph node metastasis. Adjuvant chemotherapy was performed and the patient was discharged on the 76th hospital day. She has remained in good health without recurrence 18 months after the surgery. We reviewed a total of 22 domestic cases of transverse colon cancer with an abdominal wall abscess, including our case.

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An 82-year-old man was admitted to our hospital because of melena, whose grandchildren had been diagnosed as having von Willebrand disease. Colonoscopy revealed a type 2 tumor in the sigmoid colon. He was operated on with the diagnosis of sigmoid colon cancer that was well differentiated adenocarcinoma histopathologically. Preoperative blood examination revealed a low level of ristocetin cofactor activity of von Willebrand factor, and we diagnosed him as having von Willebrand disease (Type 2). We thus administered blood clotting factor VIII/von Willebrand factor concentrate for 5 days just before and after the operation, and successfully maintained the ristocetin cofactor activity of von Willebrand factor at above 80%. Postoperative course was uneventful.
Because von Willebrand disease causes dysfunction of platelet and destabilization of blood clotting factor VIII, von Willebrand factor should be administered in the perioperative period for the management of hemostasis.

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A 54-year-old woman consulted our hospital for a chief complaint of abdominal distension. Colonoscopic examination revealed advanced sigmoid colon cancer without intestinal obstruction. A few days later, the patient was urgently hospitalized in the emergency department because the symptoms worsened. An abdominal CT scan showed a multilocular cystic tumor, of 10 cm in diameter and abundant ascites. The cytodiagnosis of ascites was class II and further examination was scheduled for the suspicion of left ovarian cancer. However, emergency surgery was performed due to sudden abdominal pain and severe ascites. Laparotomy showed thick hemorrhagic ascitic fluid and bleeding from the rupture of the left ovarian mass. Because quick cytological examination of ascitic fluid showed adenocarcinoma cells, we diagnosed rupture of metastatic ovarian tumor from sigmoid colon cancer. High anterior resection and left oophorectomy were performed. Postoperative pathological examination and immunohistochemistry findings confirmed that the ovarian tumor had metastasized from sigmoid colon cancer. The patient received postoperative adjuvant chemotherapy. To date, no sign of recurrence has been observed 4 years after surgery.

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An 81-year-old man was seen at the hospital because of anal bleeding. Colonoscopy revealed an elevated tumor which had grown circumpherentially and encircled halfway around the lower rectum mainly in the left wall. The surface of the tumor showed redness and a strong tendency to bleed. Signet-ring cell carcinoma was identified by a biopsied specimen from the same site. Chest-abdominal CT scan showed no findings suggestive of distant metastasis, and no abnormal findings were noted in the surrounding organs including the prostate. Abdominoperineal resection of the rectum was performed with a diagnosis of primary rectal carcinoma. The resected specimen revealed an ill-defined, irregular, and concave lesion, 6cm in maximum diameter, in the left wall of the lower rectum, and at the oral side, another concave lesion which showed relatively strong redness in color. Histopathological findings of the both lesions revealed that small adenocarcinoma where tubular formation was obscure had invaded from the mucosa to outer membrane. The cytoplasm was pale and light, and positive for PSA. Accordingly rectal metastasis of prostatic cancer was diagnosed.

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Xanthogranulomatous cholecystitis (XGC) is a subgroup of cholecystitis characterized by the presence of granulomatous nodules in the gallbladder wall. It is often difficult to differentiate XGC from severe inflammation and gallbladder carcinoma (GBC). Extended surgeries have been performed for the treatment of XGC mimicking GBC. However, GBC has also been reported in XGC. Therefore, such associated conditions should be carefully ruled out before selecting the surgical procedure. We faced difficulty in selecting the correct surgical procedure in two cases diagnosed as XGC with probable GBC. Both cases were men in their fifties with a chief complaint of pain in the right upper quadrant. A definitive diagnosis was not possible because CT and PET images showed the possible presence of GBC in the XGC with inflammation extending to the surrounding organs. Since the intraoperative findings revealed no adhesions attributable to GBC, extended resections of the gallbladder were performed. The excised specimens were diagnosed as XGC on histology.

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The patient was a 69-year-old woman, who, in 2001, had a laparoscopic cholecystectomy due to the presence of choleliths. In 2008, a submucosal tumor was found on gastrointestinal fiberscopy ; the patient was asymptomatic. After further examinations, this tumor was thought to be either a primary or a matastatic duodenal cancer. The patient underwent surgery. On pathology, carcinoma of the remnant cystic duct was diagnosed. Carcinoma of a remnant cystic duct is extremely rare. In this paper, we review of cystic duct carcinoma cases and discuss the relevant literature.

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A 72-year-old man complaining of fever and abdominal pain was performed emergency endoscopic transnasal biliary drainage (ENBD) with a diagnosis of obstructive cholangitis at another hospital. As a result, no findings of stones or stricture in the common bile duct were seen, but the cystic duct was not visualized. The patient was thus referred to our hospital for further close exploration and treatment. An abdominal multi-detector row CT (MDCT) scan showed a tumorous lesion with faint enhancement effect only in the cystic duct, but no stones and tumor lesions were proved in the gallbladder. Endoscopic retrograde cholangiography (ERC) showed a filling defect at the joint portion, and abrasive cytology of the same site offered a diagnosis of adenocarcinoma. Intra-ductal ultrasonography showed a tumorous lesion which looked like to fill the cystic duct, and a part of the lesion had protruded into the common bile duct but no progression to the bile duct was demonstrated. Cholecystectomy, resection of the extrahepatic bile duct and lymph node dissection (D2) were performed with the preoperative diagnosis of cystic duct carcinoma. The pathological diagnosis was papillary adenocarcinoma, depth of fm patCGnBm, INFβ, ly0, v0, pn0, pHinf0, pBinf0, pPV0, pA0, pN0, pHM0, pBM0, and EM0. It was early cystic duct carcinoma. The patient has been doing well as of 17 months after the opration.

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A 75-year-old man was seen due to right upper abdominal pain and fever. A diagnosis of cholecystitis and cholangitis was made. Abdominal ultrasonography showed a thick gallbladder wall with an irregular elevated lesion. Computed tomography showed stones in the common bile duct. PTCD was performed ; laparoscopic cholecystectomy and choledochotomy were performed after resolution of the inflammation. The tumor was located in the fundus of the gallbladder. On pathology, an adenoendocrine cell carcinoma was diagnosed. A diagnosis of gallbladder cancer was made, and a S4a, 5 bisegmentectomy of the liver with a regional lymph node resection (D2) was performed. The patient developed multiple metastases to the liver and lymph nodes 22 months after the operation and died 24 months after the operation. Since adenoendocrine cell carcinoma of the gallbladder is rare, we report this case along with the relevant literature.

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A 66-year-old woman underwent pylorus-preserving pancreaticoduodenectomy (PPPD) and Child reconstruction with Braun anastomosis for carcinoma of the ampulla of Vater in March 2007 ; final findings were non invasive tubular adenocarcinoma pTis pN0 H0 P0 M(-) Stage0 Resection A, according to general rules specified in Japanese Classification of cancer of the bile duct. She reported rectal bleeding on postoperative day (POD) 26 and POD 28. Scintigram for gastrointestinal hemorrhage showed accumulation of radioisotope in the small intestine and superior mesenteric artery (SMA) angiography showed that the contrast agent leaked from the jejunal artery. Emergency endoscopic examination was performed and bleeding from the afferent loop was arrested using an endoscopic clip. The patient recovered well and was discharged on POD 44. In the Child method with Braun anastomosis, the jejunal loop anastomosed to the duodenal bulb was directly exposed to the gastric juice without neutralization by pancreatic juice from the oral jejunal limb. The gastrointestinal reconstruction method without a mixture of gastric juice and pancreatic juice may be a causal factor for the marginal ulceration that occurs after PPPD.

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The patient, a 67-year-old man, had epigastric pain from April 2009. In June, he was found to have high pancreatic enzyme levels ; a cyst in the pancreatic tail that was 30 mm in diameter was also found. By August, the diameter of the cyst had increased to 160 mm. An enhanced abdominal CT examination showed marginal staining of the pseudocyst, that was 16×5×9 cm in size. The localized swelling in the pancreatic body had poor contrast on imaging taken during the pancreatic parenchymal phase ; the late-phase state showed pale staining. Cancer was diagnosed based on EUS-FNA results. At the end of September, the pseudocyst had disappeared ; there was no ascites or distant metastasis. A distal pancreatectomy with splenectomy was performed. A pseudocyst present in a patient with pancreatic cancer is thought to develop and then subseguently rupture due to obstruction of the pancreatic duct by the cancer.

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A 68-year-old female consulted the department of internal medicine in our hospital with the chief complaint of fever up. She was admitted with a diagnosis of pneumonia, but a tumor-like mass with a cystic lesion was detected in the pancreatic tail by an abdominal CT scan for close investigation. After discharge, various examinations were performed and the most likely diagnosis was solid-papillary tumor or cystic tumor of the intrapancreatic accessory spleen. According to wishes of the patient, pancreatic tail resection and splenectomy were performed. On pathologic examination, the mass was a cyst connecting to the pancreatic tail and a portion of the outer surface of the cyst was covered with the accessory spleen. Then the pathologic diagnosis was epithelial cyst of the intrapancreatic accessory spleen.
Cystic tumor of the intrapancreatic accessory spleen is rare and it has been reported in less than fifty cases in the world. In addition, it is a benign tumor, but surgical resection was performed because a possibility of malignancy could not be ruled out. This case is reported together with some bibliographical comments here.

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A 76-year-old woman was admitted to the department of orthopedic surgery of our hospital, and she underwent an operation for cervical spondylosis. She frequently used nonsteroidal anti inflammatory drugs after the operation. She was prescribed prednisolone for rheumatoid arthritis. After 6 weeks of the orthopedic surgery, she had fever. The fever persisted inspite of treatment with antibiotics. Three weeks later, she had severe lower abdominal pain of sudden onset. Laboratory studies showed a white blood cell count of 25,600/mm³ and c-reactive protein level (CRP) of 8.1 mg/dl. Abdominal CT scan revealed the presence of free air and fluid in the abdominal cavity. We suspected gastrointestinal perforation and performed emergency laparotomy. A large amount of watery and foul-smelling pus was found in the abdominal cavity. The gastrointestinal tract appeared normal. The pus exuded from a 5-mm perforation in the fundus of the uterus. We performed peritoneal lavage and drainage to remove the pus. In addition the uterine pus was removed by transperitoneal drainage, thereby eliminating the need for hysterectomy. The patient recovered and was moved to the department of orthopedic surgery for rehabilitation.
Peritoneal lavage and drainage with transperitoneal drainage of the uterine pus are effective, when the general status of patient is extremely poor or the patient has complications.

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A 64-year-old man was admitted to hospital due to left lower abdominal pain. Endoscopy and double contrast fluoroscopy, as well as CT, revealed sigmoid colon cancer with lymph node involvement. Sigmoidectomy with lymph node dissection was performed. During surgery, the tumor was found to infiltrate to the left spermatic artery, vein, and duct. The tumor was removed en bloc with lymph nodes, spermatic vessels, and duct. Two days after surgery, the patient became febrile (37.8°C) ; his left testis was swollen and painful. No blood flow signal was detected on Doppler ultrasonogram. Ischemic necrosis was confirmed clinically and removal of the left testis was performed on 4^th postoperative day.
In general, the concomitant resection of the spermatic artery during sigmoidectomy does not result in necrosis of the testis due to the presence of many collaterals. Nevertheless, our patient developed left testicular necrosis after sigmoidectomy. We report this case since this is a rare occurrence.

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An 18-year-old woman developed vomiting and abdominal pain. On contrast enhanced MDCT, horizontal sections in the area between the inferior vena cava and the portal vein showed a dilated small intestine. Coronal sections of MDCT more clearly visualized the mesentery of the small intestine strangulated through the foramen of Winslow and the incarceration of the small intestine in the omental bursa. A foramen of Winslow hernia was diagnosed ; an emergent operation was performed. After the manual reduction, it was found that the small intestine which had become incarcerated in the omental bursa via the foramen of Winslow already had ischemic change. Therefore, about 100 cm of the ischemic intestine was resected. No abnormal opening of the foramen of Winslow was noted. In a young person with an ileus and no history of laparotomy, we should consider the possibility of an internal hernia including a foramen of Winslow hernia. As for diagnosis, MDCT is very useful since it can produce multidirectional, fine, and accurate images.

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An 84-year-old woman was admitted for vomiting and hematemesis. She had no previous history of laparotomy. A soft mass was derected on palpation of the abdomen. Upper gastrointestinal endoscopic examination showed a stricture of the gastric body and a stenosis of the antrum of the stomach. Abdominal computed tomography showed significant dilation of the stomach and stricture of the gastric body. Thickening of the wall of the gastric antrum was observed replace with ; however, no tumors were found in the surroundings of the stomach. An operation was performed for gastric cancer. Laparotomy revealed hernia hiatus about 7-cm in length in the omental bursa ; the hernia hiatus was located between the mesentery of the transverse colon and the pancreas. The stomach was incarcerated in the retroperitoneal space. The stomach was reverted by manipulation and the hernia hiatus was repaired by suture. The postoperative course was uneventful.

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Omental torsion is a relatively rare disease and resection of the infarcted omentum was performed for almost all cases. We conservatively treated 3 cases of this disease diagnosed by computed tomography (CT).
A 41-year-old man had right abdominal pain with tenderness and peritoneal signs. Abdominal CT showed a high density mass with concentric strands. We diagnosed the condition as omental torsion and treated it conservatively. On the next day, he had no fever and his abdominal pain subsided. We could also treat the other 2 patients conservatively. Operation is not required for all cases of omental torsion.

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A 52-year-old man was admitted with abdominal pain. Abdominal enhanced CT scan revealed a mechanical ileus due to a band near the end of the ileum. An emergency operation was performed, because a strangulated ileus was suspected. During the surgery, the small intestine was found to be covered by a thin film, and the band was found to be located in the ileum, 10 cm proximal to the end of Bauhin's valve. The film was identified as the left mesocolon, and the band was identified as the inferior mesenteric artery, which had diverged from the superior mesenteric artery. A partial resection of the small intestine and an anastomosis in the front of the inferior mesenteric artery were performed. The patient's postoperative course was good, and the patient left the hospital on the 14th day. We report an extremely rare case of ileus caused by the abnormal divergence of the inferior mesenteric artery. This is the first such reported case.

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A 60-year-old male who had fallen down on the road was brought into a hospital by ambulance and was diagnosed as having fracture of the femoral neck of the right leg in February 2008. He was then transferred to the department of orthopedic surgery in our hospital. On arrival at our hospital, he had severe abdominal distention and a giant retroperitoneal tumor was suspected from abdominal CT findings. He was admitted to our surgical department for further examination and treatment of the tumor. He was found to have deep vein thrombosis of the left leg and a giant retroperitoneal tumor with the direct invasion into the left kidney. An inferior vena cava filter was placed in March 2008, and then surgery was performed. The abdomen was dominated by the retroperitoneal tumor and the left kidney was also encased within it. The tumor as well as the left kidney needed to be removed. The tumor weight was 14kg. The histopathological diagnosis was dedifferentiated liposarcoma.
A retroperitoneal liposarcoma heavier than 10kg is rare in Japan. No complications occurred during the perioperative period fortunately in this patient, despite deep vein thrombosis of the left leg and the left kidney being encased within the tumor.

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An 84-year-old woman was admitted due to pyrexia, cough, and a lumbar backache. She was treated with vancomycin (VCM) under the diagnosis of methicillin-resistant staphylococcus aureus (MRSA) pneumonia. Despite the fact that her pneumonia resolved, her inflammatory marker levels remained high. Abdominal CT and spinal MRI demonstrated a first and second lumbar vertebral osteomyelitis, as well as an extradural abscess communicating with an iliopsoas muscle abscess. MRSA vertebral osteomyelitis was definitively diagnosed on examination of fluid obtained from the iliopsoas muscle abscess. Systemic VCM was changed to systemic linezolid (LZD) due to LZD's excellent penetration into osteo-articular tissues. Inflammatory markers gradually decreased during LZD treatment ; LZD was given for 28 days. 8 months after LZD treatment, reactivation of the MRSA vertebral osteomyelitis has not occured ; additional LZD other antibiotic treatment did not need to be given.

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A 75-year-old man was seen at the hospital because of a left inguinal bulging and left inguinal pain, when his scrotum had enlarged to be the adult's head size and the penis had been buried. Following an abdominal CT scanning, left inguinal hernia containing the sigmoid colon was diagnosed. Our attempt at repositioning the sigmoid colon by hands was unsuccessful and then emergency operation was performed. When the left inguinal region was incised to release the inguinal canal, the prolapsed sigmoid colon was confirmed, however, it was difficult to reduce the herniated colon by the inguinal method. The herniated sigmoid colon was able to be reduced by operations through an additionally made midline incision. Using a Direct Kugel Patch (size M), the hernia orifice was repaired. The patient's respiratory condition became worse due to an increased intra-abdominal pressure postoperatively, and we had to manage him under artificial respiration but could extubate on the 3rd postoperative day. Thereafter his clinical course was uneventful, and he was discharged from the hospital on the 9th postoperative day. No recurrence of hernia has occurred up to now.

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Case 1 : A 53-year-old man who had undergone renal transplantation (RT) at 30 years of age presented with a gradually increasing right inguinal swelling in 2004. Lichtenstein operation was performed in June 2006. The hernia was diagnosed as a supravesical hernia, class II-1. The internal hernia ring was destroyed, with considerable internal deviation of the spermatic cord. Case 2 : A 44-year-old man who had undergone RT at the age of 25 years presented with a gradually increasing right inguinal swelling in 2005, and Lichtenstein operation was performed in June 2008. The hernia was diagnosed as an internal hernia, class I-2. In these inguinal hernia operations after RT, it was very difficult to confirm the position of the spermatic cord and peel the inguinal canal floor because of firm adhesions of the inguinal canal and/or retroperitoneal space. To avoid inadvertent injury to the transplanted kidney, in case of patients with a transplanted kidney, the retroperitoneal tissue should be carefully dissected unlike that in inguinal hernia operations in patients without transplanted kidney. From this point of view, Lichtenstein operation is a suitable procedure for transplant-side inguinal hernias.

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Mohs' paste is a histopathological fixative based on zinc chloride which is applled to perform chemosurgery of malignant tumors of the skin. We report our experience using this paste. Patient 1 was a female in her 60's who was emergently admitted with syncope due to a hemorrhage from her left breast cancer. Her breast cancer (11×6×11 cm) was diagnosed as stage IV (T4N3M1) and was unresectable. Therefore, chemotherapies and hormonal therapies were given. The hemorrhage from her cancer continued. Therefore, we used Mohs' paste, and hemostasis was achieved 24 hours later. The patient developed total necrosis of the cancer in one week, and the lesion fell off spontaneously about two weeks later. Patient 2 was a male in his 60's who had advanced lung cancer (squamous cell carcinoma, T2N2M1 stage IV). He developed an abdominal skin metastasis with a markedly pungent odor, and massive exudates that was painful ; this reduced his quality of life. After using Mohs' paste, the pungent odor and the exudates disappeared five days later ; the lesion was planarized about 4 weeks later, and the pain decreased.

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