Conservative treatment followed by interval appendectomy has been advocated for appendicitis with abscess formation against urgent appendectomy performed during the acute stage in children. Appendectomy in the presence of an appendiceal abscess is a technically challenging procedure with a high frequency of complications. We have performed interval laparoscopic appendectomy following conservative treatment for appendiceal abscess in 27 children during 11 years since 1999 to 2009. The mean age of the patients was 9.0 ± 3.1 years and their WBC and CRP were 16766 ± 6502/mm³ and 13.1 ± 7.2 mg/dl, respectively. All patients responded to initial conservative treatment and no patients required drainage or appendectomy. The length of initial hospitalization was 15.4 ± 5.3 days. Interval appendectomy could be performed as late as 86.1 ± 40.3 days after symptomatic remission. However, five patients had recurrence before appendectomy. Their symptoms improved by antibiotic therapy. Most of the removed specimens revealed gross structural transformation and chronic inflammation from the histological aspect. There were no significant postoperative complications. Laparoscopic elective appendectomy is a safe and effective method of treatment following conservative treatment for appendicitis with abscess formation in children.

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Although treatment for appendiceal abscess is primarily surgery, the operative procedures are difficult and we often have great difficulties in dealing with postoperative complications. Recently clinical reports on interval appendectomy for appendiceal abscess are encountered, which comprises conservative therapy followed by elective appendectomy. In our institution, 13 cases of appendiceal abscess were treated by conservative treatment since 2007, in order to decrease postoperative complications. In doing so, these patients were given antibiotics after complete fasting and percutaneous drainage was done if it was necessary. Improvement of the abscess was gained in 11 patients by antibiotics alone, but one patient needed drainage, and one patient experienced intestinal obstruction associated with a decrease in size of the abscess. A mean hospital stay was 8 days. In eight patients of them, interval appendectomy was performed under laparoscopy, and all eight patients were discharged from the hospital within 4 days after the operation, without having postoperative complications. No patients needed ileocecal excision. The nonsurgical treatment for appendiceal abscess is a safe and effective therapy and interval appendectomy can be done safely.

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Objectives : This study was made to elucidate risk factors for recurrence and predictive factors for prognosis of Stage II colorectal cancer and to evaluate effects of postoperative adjuvant chemotherapy. Subjects and methods : Consecutive 216 patients who underwent radicality A or B operation for Stage II colorectal cancer were enrolled in this study, and their clinicopathological findings were examined. Results : A multivariate analysis selected three risk factors for recurrence, namely location of the tumor (Ra, Rb), depth of tumor invasion (SE, SI), and venous invasion of the tumor (V2, 3) : and three predictive factors for prognosis, namely location of the tumor (Ra, Rb), depth of tumor invasion (SE, SI), and lymphatic invasion (ly2, 3). A study evaluating effects of postoperative adjuvant chemotherapy on prognosis resulted in that the overall surviving rate tended to be higher in the patients group with postoperative adjuvant chemotherapy than other patients group without it (P=0.08). Another study of effects on recurrence in patients who had risk factors for recurrence revealed that a higher tendency in relapse-free survival rate was noted in the patients group with postoperative adjuvant chemotherapy than the other group without it (P=0.08). Considerations : This study suggests that we may be able to expect favorable effects on recurrence and prognosis of Stage II colorectal cancer patients by performing postoperative adjuvant chemotherapy.

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Purpose : In order to clarify the usefulness and problems of laparoscopic cholecystectomy (LC) for acute cholecystitis by severities of the disease, we examined patients who underwent LC for acute cholecystitis. Subjects and methods : Consecutive 122 patients undergone LC for acute cholecystitis in our institution from June 2004 to November 2009 were classified by the severities of inflammation and operation timing (early operation, EO ; and delayed operation, DO), and examined for the patient's background, operative outcome, postoperative hospital stay, complications, and pathohistological results. Results : There were 64 severe cases (43 EO cases and 21 DO cases), 40 intermediate cases (34 EO cases and six DO cases), and 18 mild cases (14 EO cases and four DO cases). In two cases of severe and DO cases, LC was converted to open surgery. Statistically significant increases in severe inflammation group were noted about patient's age, preoperative WBC count, preoperative CRP level, operation time, and operative bleeding. No significant difference an postoperative hospital was noted among three groups. Operation time and operative bleeding loss in DO cases were significantly increased compared with EO cases in severe cases ; and operation time in DO cases was significantly increased compared with EO cases in the intermediate cases. No serious intraoperative complications were seen. Postoperative complications were noted in six (9.3%) of severe cases and one (2.5%) of intermediate cases, which were relieved conservatively. Five cases of advanced gallbladder cancer were identified in the severe cases by pathohistological examinations. Conclusions : Surgical outcomes of LC for mild to intermediate degree of acute cholecystitis are very favorable and useful. In treating severe cases, early LC as possible as we can might contribute to decrease operation time, operative bleeding loss and the number of conversion cases, but it might entail great difficulties in operation itself as well as a problem of gallbladder cancer which is difficult to be diagnosed before surgery. Accordingly we must deal with such severe cases carefully.

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Since February, 2008, in Japan, breast cancer patients that overexpress HER2 protein were able to receive trastuzumab as a postoperative adjuvant treatment. Although in Japan the clinical benefits and safety data related to trastuzumab (2 mg/kg weekly) used in relapse therapy have been examined the acceptability of trastuzumab given in a dose of 6 mg/kg triweekly for postoperative adjuvant treatment is still unclear. Therefore, we examined the presence of cardiotoxicity, which is the most noteworthy side effect of trastuzumab, in 26 patients treated with trastuzumab as postoperative adjuvant therapy for 1 year. Twenty-four patients (92.4%) previously received anthracycline-containing regimens which is one of the known cardiotoxic risk factors. No patient developed heart failure, but two patients had asymptomatic cardiotoxicity during the dosing period. In these two patients, cardiac function was restored after trastuzumab administration was terminated ; thus, the cardiotoxicity was reversible. In summary, trastuzumab can be safely given as adjuvant treatment to patients who were previously treated with anthracycline, if their cardiac function is carefully evaluated.

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We conducted two types of phase I clinical studies using 1) tailor-made type of cancer vaccines (TM-type), namely peptides showing higher immune responses (a maximum of four peptides), or 2) peptides derived from colorectal cancer (CR-type) by using cDNA microarray profiling in combination with oral chemotherapy of UFT and LV for patients with metastatic colorectal cancer who had failed to respond to the standard therapy. Fourteen patients with TM-type and 20 patients with CR-type were enrolled. All adverse events were grade 1 or 2, and both protocols were well tolerated in all patients enrolled. Although no patients showed either complete of partial response in both protocols, stable disease (SD) was observed in 46-83% of them. Interestingly, overall survival was well correlated with increased levels of peptide-specific responses in both protocols. The longest survivor survived more than 1,000 days in both protocols. The cancer vaccine therapy with oral chemotherapy demonstrated satisfactory safety and good immunogenicity as well as promising disease control rate, and therefore warrants further clinical studies.

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(Introduction) With the exception of advanced age, the most common cause of groin hernia in adults is patent processus vaginalis (PPV). The surgical methods used commonly at present to repair groin hernia in adult patients, such as the mesh-plug method, require the use of artificial materials that remain permanently within the body after surgery. Laparoscopic percutaneous extraperitoneal closure (LPEC) is a surgical technique that is commonly performed to repair groin hernias in infants. In this study, we evaluated the utility of the LPEC technique to repair groin hernia in adults, and compared the procedure and results with other commonly used hernial repair methods at present.
(Method) Between 2007 and 2008 we operated on 20 patients aged between 17 years and 30 years who were diagnosed with inguinal hernia. We used the LPEC method to treat 5 patients and the mesh-plug method to treat 15 patients. (Result) There were many advantages of using the LPEC surgery technique repaining groin hernia in adults, such as comparatively shorter duration and the less invasive nature of the surgery as compared to the mesh-plug method.
(Conclusion) LPEC is safely applicable to the adult patients with inguinal hernia as a repairing method. Further, the patients' reproductive system remains intact, and the incision sites become indiscernible after nealing.

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The case reported herein involves a 45-year-old man who had been suffering from pharyngitis for 2 weeks before visiting the internal medicine section of the hospital. Oral administration of medicines was not effective, and laboratory tests indicated hepatic dysfunction. Therefore, the patient was admitted to the hospital. He complained of upper abdominal pain and developed circulatory collapse on the morning of the 7^th day of hospitalization. Intra-abdominal hemorrhage caused by splenic rupture was diagnosed by ultrasonography and CT. Shortly after embolization with complementary angiography, the patient suffered cardiopulmonary arrest. Although was resuscitated, he suffered cardiopulmonary arrest again. Immediately after the second resuscitation, emergency laparotomy was performed and the spleen was resected because there was continuous bleeding from the damaged and extremely frail tissue. Infectious mononucleosis caused by an initial infection of EB virus was diagnosed by antibody tests. The patient developed thrombocytopenia, coagulation disorder, and finally, disseminated intravascular coagulation. His life was saved by intensive care ; however, he did not regain consciousness. This case is a rare example of infectious mononucleosis complicated with splenic rupture, and is the 9^th such case reported in Japan since 1983.

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A 68-year-old man who underwent sigmoidectomy for sigmoid colon cancer developed anastomotic leakage after the operation. However, it was cured by drainage without re-operation and he was discharged from the hospital. Six days after the discharge, the leakage recurred and he was readmitted to our hospital. Central venous catheter was inserted into his right internal jugular vein, and an intravenous hyper-alimentation was performed. Eight days after the insertion of the catheter, he had high fever and complained of neck pain. The most likely diagnosis was catheter infection, and we removed the catheter. But high fever and neck pain persisted, and MRSA was detected in cultures from the catheter and blood. MRI showed pyogenic spondylitis, for which intravenous administration of was very effective linezolid (LZD). Inflammatory reaction and spondilitis subsided without surgical treatments. In this case, the intravenous LZD administration was very effective for MRSA pyogenic spondylitis, though it often demands surgical therapies.

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The patient was an 82-year-old woman who developed a right axillary mass. A first-sized, friable mass with an irregular surface was seen in the right axilla. CT revealed a swollen lymph node (20 mm in diameter) located in the right axilla. No signs of metastasis were found in the liver or lungs. The patient was diagnosed as having a malignant tumor with metastasis to the right axillary lymph node. Both the tumor and the metastatic lymph node were resected. On histopathology, the epithelial tumor cells were found to consist of arrangements of cords and sheets ; the tumor cells had large round nuclei. Immunostaining of the cells was strongly positive for S-100 protein ; melanosome was not identified. A diagnosis of an epithelioid malignant peripheral nerve sheath tumor was made. Further resection was not performed, partly due to the patient's advanced age and left arm hemiplegia caused by a cerebral infarction. However, 9 months after surgery, a local subcutaneous recurrence was noted. It was resected.

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An 87-year-old woman was referred to our hospital because of right chest pain. Physical examination on admission disclosed an about 7-mm sized redness in the right thoracic region. Plain x-ray film showed a linear shadow in the same region. Chest and abdominal CT scans revealed an aberrant needle perforating through the chest wall and the liver with right pneumothorax and subcutaneous emphysema. As she had sewn her nightclothes by herself and slept with them on the previous night, it was probable that the needle which might be left in the nightclothes stuck into the chest wall. Because an attempt to remove the needle under X-ray was unsuccessful we performed vide-assisted thoracoscopic surgery (VATS) to remove the aberrant needle. We found the needle which had stuck in the diaphragm and reached to the liver. The postoperative course was uneventful and she was discharged on the postoperative day 7. Thoracoscopic removal may be the treatment of choice for an intrathoracic needle because it is minimally invasive with minimal pain.

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An asymptomatic 75-year-old man presented at our hospital with an abnormal shadow on a routine chest radiograph. Chest CT revealed an expansile tumor, 6.2×3.7 cm, containing delicate bony trabeculae, in the posterior portion of the right third rib. FDG-PET examination suggested malignancy, but postoperative pathology examination of the resected tumor confirmed the cavernous hemangioma. In cavernous hemangioma, according to the existing literature, an internal hemorrhage accomperied by inflammation occurs frequently. Therefore, there is a possibility that high FDG uptake is observed in FDG-PET in cavernous hemangioma.

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The patient was a 70-year-old woman who was being followed-up for hypertension.
Echocardiography, which was performed for screening purposes, showed a mobile and high-intensity tumor-like echo measuring 10.5×9.5 mm in the right atrium.
Contrast-enhanced computed tomography (CT) showed the presence of a filling defect of 28 mm in diameter in the right atrium. The filling defect, containing a high-density region, was found to compress the inferior vena cava.
Emergency surgery was performed because of the risk of embolism and occlusion of the inferior vena cava by the tumor.
The tumor in the right atrium was removed surgically by using a cardiopulmonary bypass.
The postoperative course was good, and the patient was discharged on the 15^th day after the emergency surgery.
The analysis of the resected specimen revealed that the tumor was a blood cyst calcified in the center.

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A 56-year-old woman complained of abdominal pain and went into shock. Abdominal computed tomography revealed the presence of a large, low-density mass located in front of the pancreas. IIematologic examination revealed an anemia ; abdominal paracentesis demonstrated the presence of blood. A clinical diagnosis of hemorrhage due to the rupture of a tumor or an aneurysm of an abdominal visceral artery was made. The patient's severe anemia persisted ; on the next day, angiography revealed an aneurysm in the middle colic artery. Therefore, emergency surgery was done. A hematoma located in the transverse colonic mesentery was noted during surgery ; the patient was subsequently diagnosed as having a hemorrhage from a ruptured 2 × 1 cm aneurysm which was located near the first branch of the middle colic artery. The aneurysm was removed after it was confirmed that the blood flow to her intestine was preserved by marginal arteries. The pathological findings were consistent with those of segmental arterial mediolysis (SAM). Computed tomography scans taken postoperatively showed that the patient did not have only other visceral aneurysms.

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We experienced a case of sevoflurane induced malignant hyperthermia developed during elective graft replacement for an abdominal aortic aneurysm. A 79-year-old woman who had a juxtrarenal abdominal aortic aneurysm was scheduled for graft replacement for the abdominal aorta under general anesthesia with sevoflurane. When three hours had elapsed after the initiation of surgery, the level of end-tidal CO2 was elevated, and about 30 min later, the body temperature rose to 39°C. A rise more than 0.5°C in less than 15 min was noticed, and thus malignant hyperthermia was supected. Dantrolene sodium was administered intravenously. Soon after the administration of dantrolene sodium, the PCO2 level and body temperature declined within normal ranges. The patient's subsequent postoperative course was uneventful.
Malignant hyperthermia is rare, and its mortality rate is still high nowadays. We report our experience with this rare case, together with a review of other four cases reported in the Japanese literature.

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We report a resected case of primary lung cancer with a micropapillary pattern (MPP) in a 60-year-old male. Chest CT scan showed an abnormal shadow located at S6a of the right lung. The tumor was 18 mm in diameter, and hilar lymph node swelling was present. Primary lung cancer with lymph node metastasis was suspected ; the intraoperative needle biopsy confirmed the suspicion. Subsequently, a right lower lobectomy with a mediastinal lymph node dissection was performed during video-assisted thoracic surgery (VATS). On histology, an MPP and 23/45 lymph nodes metastasis were diagnosed. On pathology, a pT1N2M0 StageIIIA was diagnosed. It is possible that lung cancer with an MPP has a higher potential for extensive lymph node metastases.

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During treatment for another disease a 68-year-old man was found to have an abnormal mass shadow on chest X-ray. Chest CT showed a mass shadow, 10 mm in diameter, at S6 of the right lung. The tumor was found to have rapidly enlarged to 15 mm in diameter three weeks later. PET scan revealed FDG accumulation at S6 of the right lung. The lesion was suspected as being an adenocarcinoma based on transbronchial lung biopsy results. Subsequently, surgery was performed. Based on frozen section examination, a diagnosis of large cell carcinoma was made. Therefore, a left lower lobectomy and a lymph node dissection (ND2a) were done. On postoperative pathology, a diagnosis of pleomorphic carcinoma, pT1N0M0 stage IA, of the lung was made. Pleomorphic carcinoma is a rare lung cancer which has rapid growth. In the present case, the tumor at presentation was small ; nevertheless careful observation is required because this lesion exhibits high-grade malignancy.

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A 65-year-old female presented with a month long history of dry cough. Chest X-ray showed a large mass in the right middle lung filed ; she was admitted for further examination. Chest computed tomography scans indicated a large tumor, with a diameter of 8 cm in the S5 lung segment ; contrast enhancement was present in some areas of the tumor. A needle biopsy through the anterior chest wall under ultrasonographic guidance revealed poorly differentiated carcinoma. During surgery, the tumor was found to invade the pericardium. A right middle lobectomy with a combined resection of the pericardium was done. The histological diagnosis was lymphoepithelioma-like carcinoma (LELC) T3N0M0 (stage IIB). The presence of Epstein-Barr virus was confirmed on EBER in situ hybridization testing. The patient was given combined carboplatin/paclitaxel chemotherapy as postoperative adjuvant therapy. We report a rare case of pulmonary LELC, and review the relevant literature.

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The patient was a 78-year-old man. He underwent a health checkup in March 2008, which revealed an abnormal chest shadow. Lung carcinoma was diagnosed on the basis of sputum cyology. Diagnostic imaging strongly suggested tumor invasion of the aortic arch, and the tumor was rated as clinical stage IIIB non-small cell lung cancer. Because the patient's renal function was compromised, platinum-based chemotherpy was avoided, and radiotherapy was started in September 2008. During this therapy (after 44 Gy irradiation), diarrhea and melena developed. Lower gastrointestinal endoscopy was performed to determine the cause of these symptoms. Endoscopy revealed an elevated lesion (forming clots) at the end of the ileum. This lesion was judged to be the source of bleeding, and biopsy of the lesion was performed. However, definite dianosis could not be established. Early in November 2008, the patient was referred to our department for detailed examination of the gastrointestinal lesion. We repeated biopsy under lower gastrointestinal endoscope guidance, but could not arrive at a definite diagnosis. Subsequently, the patient suddenly developed symptoms of ileus, which were accompanied by the exacerbation of anemia due to bleeding from the lesion. We therefore decided to resect the lesion to alleviate the symptoms. Because the patient's respiratory function was poor, celiotomy was performed under lumbar + epidural anesthesia. Oral ingestion was resumed immediately after surgery, and it was accompanied by the alleviation of anemia. The resected specimen was examined histopathlogically, and a definite diagnosis of the metastasis of poorly differentiated lung adenocarcinoma to the small bowel was made. Metastasis of lung cancer to small bowel is generally rare, and it is more likely to be observed in cases with poorly differentiated lung adenocarcinoma or cases with large cell lung cancer. Patients with small bowel metastasis of lung cancer have a poor prognosis and are considered as being at the terminal stage. However, resection of the lesions in some cases may lead to palliation of the symptoms. The indications of surgical treatment for patients with bowel metastases of lung carcinoma need to be discussed adequately among the doctors concerned involved in such cases.

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Herein, we report the case of a metastatic appendiceal tumor derived from small cell carcinoma of the lung treated by laparoscopic appendectomy. A 72-year-old man was referred to our hospital with a small cell lung cancer. Positoron emission tomography revealed a high uptake of 18F-fluorodeoxyglucose in the left hilum of the lung, medeastinal lymph node, and vermiform appendix. We diagnosed primary appendiceal carcinoma or metastatic appendiceal carcinoma originating from lung cell cancer, and performed laparoscopic appendectomy. Histopathological examination confirmed the latter. The postoperative treatment course was uneventful, and chemotherapy is now underway. We report a rare case of metastatic appendiceal tumor derived from small cell carcinoma of the lung, wherein the tumor was diagnosed preoperatively and resected preventively.

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A 71-year-old woman presented with acute dyspnea caused by a right massive pleural effusion. She had been treated for liver cirrhosis and hepatocarcinoma related to type C hepatitis. A transdiaphragmatic communication from the abdominal cavity to the right pleural cavity was confirmed by radio nucleotide study using 99mTc-macro aggregated (MAA) albumin, and by computed tomography scan after the injection of a contrast medium into the peritoneum revealed some blebs on the diaphragm. Several pleurodesis attempts using OK-432 failed to reduce the effusion. Therefore, video-assisted thoracoscopic surgery (VATS) was performed. Some blebs were found lying on the diaphragm, and a small pore was detected continuously leaking air bubbles after insufflation of carbon dioxide gas into the peritoneal cavity using a peritoneal catheter. The diaphragm including the pore and the nearby blebs was resected and sutured using auto-suturing instruments. OK-432 was injected into the pleural cavity on postoperative day 2, and the chest drain tube was removed on postoperative day 3. There was no reccurence of the pleural effusion. Insufflation of carbon dioxide gas into peritoneum during VATS is less invasive than surgery and is useful for reliably identifying a diaphragmatic pore.

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A 73-year-old, bed-ridden woman with strictures of both upper and lower limbs had been living in an old age home ; she could barely communicate with the staff when admitted to hospital with a simple intestinal obstruction. Her family doctor discussed her condition with her family ; it was decided that surgery would only be done for urgent conditions which could be treated easily. She was managed with an intestinal decompression long tube, which dislocated in the peritoneal cavity. Her family was informed that she had an esophageal perforation by her family physician since an urgent operation was required, she was transferred to our center and underwent the surgery. During the operation a strangulated intestinal obstruction and esophageal perforation caused by the decompression long tube were found. The necrotic intestinal loop was resected, and a simple closure of the esophagus was done. She was transferred to the referring hospital on the 13th hospital day. Informed concent for the urgent operation could be easily obtained and the patient could be quickly transfered to the referring hospital because the patient's family doctor had maintained a good relationship with the patient's family.

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We report a rare case of esophageal hiatal hernia with incarceration of the gastric antrum and duodenal bulb, which were reduced spontaneously. An 85-year-old woman vomited during the preparation for colonoscopy, and she was admitted to our hospital. She had a history of lumbar spondylosis and neurogenic bladder. During the initial gastrointestinal endoscopy examination, the endoscope was not advanced into the gastric antrum because of deformity of the stomach. Upper gastrointestinal series showed that the gastric fundus, antrum, and duodenal bulb were incarcerated within an esophageal hiatal hernia. The patient was diagnosed with mixed esophageal hiatal hernia with incarceration of the gastric antrum and duodenal bulb. Because she and her family did not consent to an operation and there were no symptoms of the total occlusion and strangulation of the incarcerated bowel, she was administered conservative treatment. Approximately 3 weeks after admission, her appetite improved gradually. Upper gastrointestinal series revealed that the gastric antrum and duodenal bulb were reduced. At the subsequent gastrointestinal endoscopy examination, we were able to advance the endoscope into the second portion of the duodenum ; the endoscopy results revealed that the gastric and duodenal mucosa were normal. The patient was discharged after being treated for neurogenic bladder.

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A 69-year-old man with bezoar, which was previously treated unsuccessfully with endoscopy-guided Cola lavage at another hospital, was admitted to our hospital for surgical treatment. We fragmented the bezoar into 3 large pieces using gravel ; however, the bezoar was fragmented into only 2 pieces at the previous hospital. The bezoar could not be divided by our endoscopic treatment. During laparoscopic surgery, the bezoar collapsed easily when grasped by forceps ; subsequently, the incised wall of the stomach was lifted extracorporeally to remove the bezoar without spilling it into the abdominal cavity. During the surgical removal of the bezoar by Cola lavage and endoscopic treatment, it is necessary to consider its fragility ; mini-laparotomy might be needed in some cases.

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Osler-Weber-Rendu disease is a hereditary disease characterized by angiotelectasia of the skin, mucosal membrane, and internal organs and recurrent bleeding from the dilated capillary vessels. We report the case of a patient with Osler-Weber-Rendu disease who underwent total gastrectomy and splenectomy for refractory recurrent gastric bleeding and aneurysms of the splenic artery. A 74-year-old woman who was diagnosed with Osler-Weber-Rendu disease, had been experiencing repeated episodes of gastric bleeding. She had undergone 10 rounds of endoscopic argon plasma coagulation in the past. Then, she visited our hospital due to hemorrhagic shock caused by gastric bleeding, and we found that she had become unresponsive to medical treatment. Endoscopic examination revealed pathological changes similar to angioectasia in the entire stomach and bleeding from the angiectatic part in the upper portion of the stomach body. Computed tomography revealed aneurysms of the splenic artery. Therefore, we performed total gastrectomy and splenectomy.

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The patient 1, a 13-year-old boy who had got a bruise on the right lateral abdominal region above the navel by the handlebar of his bicycle, was seen at the emergency clinic in our hospital. When he was first seen, his vital signs were stable but abdominal pain with peritoneal sign was noted. A contrast-enhanced abdominal CT scan suggested traumatic duodenal injury or pancreatic injury, and emergency operation was performed 4 hours after injury. Intraoperative findings disclosed rupture (30×20 mm in diameter) of the horizontal portion of the duodenum, and then simple closure of the ruptured site, gastrostomy and enterostomy were performed.
The patient 2, a 7-year-old boy who had fallen from a swing when he had got a strong bruise on the abdomen with a fence in front of the swing, was seen at the emergency clinic in our hospital. An abdominal CT scan revealed retroperitoneal emphysema. Emergency operation was thus performed with a diagnosis of traumatic duodenal injury 3 hours after admission. Intraoperative findings disclosed rupture (25×20 mm in diameter) of the descending portion of the duodenum. Following simple suture and closure, gastrostomy, duodenostomy and cholecystostomy were established.
It is difficult to diagnose traumatic duodenal injuries and to select operative procedures for them in children, and we sometimes have great difficulties in dealing with postoperative complications. In this paper we present our experiences with two cases of traumatic duodenal rupture in children, together with a review of the literature.

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A 25-year-old man with von Recklinghausen's disease was admitted because of abdominal pain. Abdominal CT scan revealed colitis and a tumor 60 mm in diameter, adjacent to the duodenum and the upper jejunum. Small intestinal fiberscopy revealed a submucosal tumor in the fourth portion of the duodenum. CT during angiography showed no other tumors. The patient had a laparotomy under the diagnosis of gastrointestinal stromal tumor (GIST) of the duodenum. The operative findings showed that the tumor in the fourth portion of the duodenum had grown into the transverse mesocolon. A partial resection of the duodenum was performed. The tumor which was immunohistochemically positive for c-kit and CD34 was diagnosed as GIST. We report a case of GIST of the duodenum in a patient with von Recklinghausen's disease.

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The occurence of an adenoendocrine cell carcinoma of the duodenal ampulla of Vater is rare. A 77-year-old woman was referred to us for further examination of liver dysfunction. Endoscopic retrograde cholangiopancreatography revealed an ulcerated mass lesion in the duodenal ampulla of Vater and severe stenosis of the lower common bile duct. We performed pylorus-preserving pancreaticoduodenectomy on the basis of the diagnosis of carcinoma of the duodenal ampulla of Vater with no metastases. The resected specimen showed an ulcerative mass 30 mm in diameter in the duodenal ampulla of Vater. Postoperative pathological examination revealed adenoendocrine cell carcinoma with pT4 (pDu3, pPanc2), pN1, P0, H0, M(-), and stage IV a. Although early postoperative course was uneventful, the patient died 51 days after surgery due to rapid progression of multiple liver metastases. Therefore, it is important that patients with adenoendocrine cell carcinoma should be observed closely and early chemotherapy should be administered to improve prognosis.

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We report a rare case of adult intussusception caused by ectopic gastric mucosa on the jejunum. A 22-year-old woman who suffered from repeated intermittent abdominal pain since the age of 12 was admitted to our hospital with the complaints of long-lasting abdominal pain, vomiting, and bloody excrement. Abdominal CT revealed the presence of intussusception of small intestines. We performed an emergency operation. During the operation, we observed that the jejunum and the mesentry had invaginated into the distal jejunum over a distance of 60 cm. After reducing the intussusception by the Hutchinson's method, we found a 6-cm diameter tumor on the jejunum, where it is in 15 cm anal side from the Treitz's ligament ; this tumor was the starting point of the intussusception. Pathological examination revealed that the tumor was an ectopic gastric mucosa on the jejunum.
Intussusception usually occurs in children with no specific causes. However, in the case of adults, it is associated with some causes. In this case, we suspect that our patient had had the ectopic gastric mucosa since she was a child, which was the cause of the repeated intussusception. We must be careful while examining a patient with repeated abdominal pain, and consider intussusception as one of the cause during diagnosis.

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We report a patient with a strangulated obstruction due to Meckel's diverticulum torsion. A 14-year-old male developed abdominal pain and vomiting. He had no previous history of abdominal surgery or trauma. Laboratory results included an elevated white blood cell count and elevated LDH levels. The blood gas analysis showed that his base excess had decreased to -0.4 mEq/L. Abdominal CT scan showed the whirl sign, and a loop which suggested strangulated intestine. An emergency operation was performed given a presumptive diagnosis of a strangulated obstruction. Laparoscopic fingings showed a twisted Meckel's diverticulum ; the Meckel's diverticulum was resected. The patient was discharged 7 days after surgery. Given this patient's history laparoscopy appears to be useful for making a diagnosis ; it is also less invasive than conventional surgery.

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The patient was a woman in her 70s. In 1995, she underwent a partial resection of the small intestine because of a small intestine GIST. In February 2008, an abdominal ultrasonography performed during a health check-up detected an abdominal tumor ; therefore, the patient underwent detailed examination. Abdominal MRI and DWIBS were performed, and a mass with an abnormal signal intensity, measuring 2.6×3.4 cm, was detected on the left side of the abdominal aorta. In May of the same year, the mass was diagnosed as a retroperitoneal metastasis of the GIST, and the patient was administered imatinib, but she was later found to have rhabdomyolysis, and the treatment was discontinued. Subsequently, the tumor was resected, and operative findings and pathological findings led to the diagnosis of para-aortic lymph node metastasis of GIST. In February 2009, an MRI DWIBS revealed residual para-aortic lymph node involvement ; therefore, an extensive para-aortic lymphadenectomy was performed. Pathological examinations revealed metastasis to 2 lymph nodes. Currently, more than 1 year after surgery, follow-up shows no recurrence. In this communication, we report our experience with a surgical case of GIST, which showed recurrent metastases exclusively in the para-aortic lymph nodes 13 years after the initial surgery. The report also includes a discussion based on our literature review.

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An 81-year-old woman who had right lower abdominal pain for 7 days was referred to our hospital. She had rebound tenderness in her right lower abdomen. Laboratory findings revealed a high level of CRP (10.47 mg/dl), and abdominal CT scan revealed a swollen appendix and abscess of the ileocecal area. She was diagnosed with perforated appendicitis and ileocecal abscess, and an emergency operation was performed. A fish bone was found in the abscess adjacent to the perforated appendix, and the patient was diagnosed with perforation of the appendix by a fish bone. After the operation, we could find a linear high-density lesion by re-interpretation of preoperative CT scan.
Cases with perforations of the appendix by a fish bone have been rarely reported, and the preoperative diagnosis in such cases is very difficult. In order to diagnose these patients accurately, it is important to carefully study the patient's clinical records. We must assume the presence of a fish bone if a linear high-density lesion is detected on CT scan.

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A 46-year-old woman accidentally swallowed a denture during a meal. She presented at our hospital with abdominal pain, tenderness, and peritoneal signs in the right lower-quadrant the nest day. Plain abdominal radiography revealed a metallic foreign body in the right lower abdomen, and abdominal computed tomography showed a foreign body in the appendix and inflammatory changes around the appendix. An emergency operation was performed after the diagnosis of acute appendicitis caused by the migration of the denture into the appendix. We found that the appendix was swollen and inflamed but not perforated. Therefore, appendectomy was performed. A denture was found in the resected specimen, according to the preoperative diagnosis. The histological diagnosis was gangrenous appendicitis. Appendicitis due to migration of a foreign body into the appendix is rare. We report this case and a review of previously reported cases in the literature.

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The patient was a 66-year-old male who had undergone partial sigmoidectomy associated with transverse colostomy for perforation of the sigmoid colon in July 2008. Histopathologically, amyloid deposition was found in the resected colon. He visited our hospital because of abdominal pain in October 2009. We performed emergency laparotomy with a diagnosis of diffuse peritonitis due to perforation of the sigmoid colon stump. During surgery we recognized perforation at the stump of the sigmoid colon, and the sigmoid colon and lower part of the descending colon scattered with dark-red ischemic changes. So we performed left hemicolectomy. Histopathologically, amyloid deposition was also found in the resected colon. The component of amyloid fibers was identified as AL type by immunohistochemical staining. Perforation of the sigmoid colon caused by amyloidosis was thus diagnosed.
Gastrointestinal amyloidosis is often asymptomatic and it presents with intestinal perforation in comparatively few cases. Our case demonstrates that association of amyloid deposit can lead to repeated perforation of the intestine.

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Skin metastasis from visceral cancer is relatively rare, and skin metastasis from colorectal cancer does not occur often. We present a case of colorectal cancer which had multiple cutaneous and subcutaneous metastases and also review the literature. The patient was a 44-year-old male who had cancer of the ascending colon with hepatic metastasis and peritoneal dissemination. After an operation for the cancer, a total of four tumors (multiple cutaneous and subcutaneous metastases) were resected during two operations, to achieve symptomatic amelioration. Skin metastasis of visceral cancer appears to be a part of the systemic metastasis that occurs in advanced cancer. Notwithstanding that the prognosis is generally poor, long-term survival cases have been reported. In consideration of patients' QOL and symptomatic amelioration, tumors of skin metastasis should not be left untreated and should be resected actively, even though most patients have a poor prognosis. Local control via surgical resection and systemic treatment via chemotherapy will hopefully improve the prognosis.

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We report a case of a rectal carcinoid tumor, 12 mm in diameter, with metastasis to the right internal iliac lymph nodes. A 46-year-old man was found to have fecal occult blood. Colonoscopic examination revealed a small tumor, 12 mm in diameter, in the lower rectum. On histopathology of a biopsied specimen, a rectal carcinoid tumor was diagnosed. Abdominal computed tomography demonstrated two swollen lymph nodes in the right internal iliac region. A super low anterior resection, with regional lymph node dissection was done. On histopathology, a rectal carcinoid in the lower rectum and metastasis to the right internal iliac lymph nodes without metastasis to the pararectal lymph nodes were diagnosed. No evidence of local recurrence or metastasis has been found during 4 years of follow-up. Regional lymph node involvement has to be evaluated even for small rectal carcinoid lesions prior to surgery. In cases of rectal carcinoid with possible lymph node metastasis, surgical resection and regional lymph node dissection are required.

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We report a case of liver injury caused by cardiopulmonary resuscitation (CPR). A 31-year-old pregnant woman developed convulsions just after delivery and went into respiratory arrest and shock. She was emergently transported under cardiopulmonary resuscitation by bag-mask respiration and closed-chest cardiac massage. Her respiration recovered, and her shock improved with CPR and intensive care. She was diagnosed as having an amniotic fluid embolism, and developed a serious coagulopathy related to obstetrical DIC. Subsequently, abdominal distention and hypovolemic shock were noted and gradually progressed. Abdominal CT showed massive bleeding from the left lateral segment of the liver. Emergency laparotomy revealed massive intraperitoneal hemorrhage from hepatic capsule rupture caused by widespread subcapsular hematoma originating in a parenchymal laceration located at the lateral segment. She recovered after hemostatic surgery and was discharged on the twelfth postoperative day. The liver of a pregnant woman is soft and vulnerable to trauma ; furthermore, obstetrical DIC accelerates hemorrhage. In addition, CPR, which is lifesaving, has nevertheless the unintended potential to result in liver injury in patients with these pre-conditions.

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The patient was an 85-year-old man who had undergone surgeries for descending colon cancer in 2004, transverse colon cancer in 2005 and rectal cancer in 2006. In June 2007, a CT scan of the abdomen showed a heterogeneous tumor in the lateral segment of the liver, accompanied by biliary dilatation. Cholangiocellular carcinoma was suspected. In November 2007, left hepatic lobectomy was performed because the biliary dilatation had extended to near the umbilical portion of the portal vein. Histopathological examination showed that moderately differentiated adenocarcinoma proliferated along the epithelium of the bile duct. On immunohistochemical studies, the tumor was negative for cytokeratin 7 and positive for cytokeratin 20 which were similar to those of the transverse colon cancer that had been resected in 2006. Metastasis from transverse colon cancer was thus diagnosed. It is rare to detect biliary invasion on diagnostic imaging studies in a patient with liver metastases from colorectal cancer, and so far only 11 such cases have been reported in Japan.

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A 61-year-old man, was febrile for a week ; a hepatic mass was found on chest computed tomography (CT). A liver abscess was suspected and antibiotic therapy was begun. On abdominal hepatic CT and magnetic resonance imaging (MRI), the mass was found to be a primary hepatic tumor. Hepatic sarcoma was suspected based on percutaneous liver biopsy results S7 subsegmentectomy was performed ; On histopathology, an undifferentiated hepatocellular carcinoma was diagnosed. The fever resolved on postoperative day 6 ; necrotic tumor tissue was suspected as being the cause of the fover. Undifferentiated hepatocellular, carcinoma is extremely rare, and there is no precise definition for the diagnosis. Although curative resection was achieved in this case, careful follow-up is required.

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The first case was a 53-year-old female with hepatocellular carcinoma (HCC) who underwent hepatectomy at another hospital in 1996. In 2001, radiofrequency ablation (RFA) was performed for HCC recurrence. In October 2006, an increase in her α-fetoprotein (AFP) level was noted. CT and MRI showed a mass in the chest wall and tumor recurrence at S5 of the liver along the RFA needle tract. Consequently, she was referred to our department. Two months later, an S5 partial hepatectomy and excision of the chest wall mass were performed. On histopathology, a moderately differentiated hepatocellular carcinoma and needle-tract implantation on the thoracic wall were noted. Three months later, tumor recurrence appeared in the chest wall. The chest wall mass was excised.
The second case was a 65-year-old male, who, in February 2006, was referred to our department because of persistent hepatocellular carcinoma (HCC). He had previously, in 2003, undergone RFA for S5 HCC three times at the referring hospital. A right hepatectomy was immediately performed upon referral. In November 2006, CT revealed a tumor at the RFA tract in the ninth intercostal space of the thoracic wall. The following month, a tumorectomy was performed via a thoracotomy. On histopathology examination, a moderately differentiated hepatocellular carcinoma was diagnosed. We report these two cases of needle-tract implantation of hepatocellular carcinoma after percutaneous RFA and review the relevant literature.

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A 65-year-old woman complained of left upper abdominal pain. No abnormality was found on ultrasonography or gastroscopy done at the primary care hospital. The pain continued for a month, and she developed a high fever. US, CT, and MRI done at our hospital revealed a splenic mass lesion which was in close contact with the pancreatic tail. The differential diagnosis included : cancer of the pancreatic tail, pancreatitis, or malignant lymphoma, raising from the spleen. At laparotomy, a pancreatic tail cancer invading the spleen, left kidney, and mesocolon was found ; a distal pancreatectomy and an en-bloc resection of the left kidney and adrenal body were performed. On histopathology, a pancreatic tail carcinoma invading the spleen was diagnosed ; the splenic parenchyma showed basophilic degeneration based on pancreatic enzyme testing.
The pancreatic tail carcinoma was an invasive ductal carcinoma ; T3N1M0 StageIIB. Basophilic degeneration of a part of the splenic parenchyma resulting from invasion of a pancreatic tail carcinoma is very rare. We report this case of pancreatic tail carcinoma with basophilic degeneration of a part of the spleen.

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A 76-year-old man was seen at the department of internal medicine in our hospital because of malaise at the lower abdomen, and was pointed out having bilateral inguinal bulges. He was referred to our surgical department for the treatment with the diagnosis of bilateral inguinal hernias. Abdominal ultrasonic studies suggested bilateral bladder hernias, and standing cytography confirmed prolapsed bladders. We diagnosed the case as bilateral bladder hernias and performed radical operation using the Direct Kugel method. The bilateral hernia hila were identified at the cranial side of the pubic tubercle, which were of type II-1. No circulatory impairment was noted at the bladder wall and the herniated bladders were easily reduced. After sufficient dissection of the posterior aspect of the pubic tubercle from the bilateral bladders, the hernia repair was completed by inserting Direct Kugel Patches^® between the pubic bone and the bladders. Postoperative cytography revealed disappearance of the prolapsed organs.
In order to prevent intraoperative injury to the bladder, preoperative diagnosis is important. From this point of view, abdominal ultrasonography and cys'tography are helpful for diagnosis. The Direct Kugel Patch method is considered to be useful for the disease, because it hardly causes injuries to the bladder due to its morphology, it can be extended between the pubic bone and the bladder, it does not slip out of place, and it can reinforce the floor of the inguinal canal widely.

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We experienced a case of mucinous borderline tumor of urachal origin. An 80-year-old man had a large lower abdominal mass. Preoperative examinations failed to lead a presumptive diagnosis, and a laparotomy was done. The huge mass was present in the preperitoneall cavity. Because the tumor was strongly attached to the apex of bladder, we resected the tumor with a part of the bladder. We diagnosed a mucinous borderline tumor of urachal origin on the basis of the immunohistochemistry results.

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We have performed duodenojejunostomy for two cases of superior mesenteric artery syndrome of different etiologies.
The patient 1, a 66-year-old man, was seen at the hospital because of recurrent bouts of vomiting, abdominal pain, and weight loss since about 3 years earlier. An upper gastrointestinal series and an abdominal contrast enhanced CT scan showed severe gastric dilatation and narrowing at the third portion of the duodenum, and superior mesenteric artery syndrome was diagnosed. The patient was considered to be a candidate for operation because his ailing time was long, and was performed duodenojejunostomy. The patient's postoperative course was uneventful.
The patient 2 was a 77-year-old man who had undergone anterior resection of the rectum for rectal cancer about 30 years before admission. This time left colectomy was performed for transverse colon cancer. Vomiting occurred on the postoperative day 9. An upper gastrointestinal series and an abdominal CT scan provided the diagnosis of superior mesenteric artery syndrome. After unsuccessful conservative therapy, duonenojejunostomy was performed on the 21st postoperative day. The clinical course after the second operation was uneventful.
Etiologies of the disease in these patients appear to be different. In the patient 1, a decrease in periduodenal fatty tissues due to weight loss might cause the disease. In the patient 2, overextension of the superior mesenteric root due to left colectomy following anterior resection of the rectum might result in deviation of the superior mesenteric artery (SMA) toward the caudal direction.

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We report a case of nonocclusive mesenteric ischemia due to hypotensor drug abuse. This is the first case in Japan. A 52-year-old man who abused hypotensor drugs was admitted to our hospital with vomiting. He subsequently developed severe hypotension, aspiration pneumonia, and acute renal failure, but these symptoms resolved gradually after intensive treatment. On day 8, abdominal pain suddenly occurred. Computed tomography revealed ascites and ischemic changes in the small intestine and ascending colon. Emergency operation was performed to determine whether intestinal necrosis had occurred. Intraoperative examination revealed segmental, discrete necrosis from the lower part of the ileum to the right side of transverse colon ; however, the superior mesenteric artery was patent. The involved parts of the intestine were resected. The postoperative diagnosis was nonocclusive mesenteric ischemia, and the patient recovered uneventfully.

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A 39-year-old woman was admitted due to the presence of a left lower abdominal mass. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a well-defined and irregular tumor with internal heterogeneity, which was 9×7cm in size. Barium enema examination revealed that the middle descending colon was displaced ventrally. A tumor of the retroperitoneum or the descending mesocolon was diagnosed, and a laparotomy was performed. Although the tumor adhered to the descending colon, the descending mesocolon, and the retroperitoneum, it was possible to decorticate it from the fascia of the retroperitoneum. Therefore, the tumor was diagnosed as arising the descending mesocolon. The tumor was resected along with a part of the descending colon. On pathology, dense fusiform cells with nuclear atypicality were noted ; on immunohistochemistry, α-SMA and vimentin were positive, but CD-34, c-kit, and S-100 were negative. Therefore, a leiomyosarcoma was diagnosed. The patient's course has been uneventful during 10 months of follow-up after surgery. This case is the first report of a mesenteric leiomyosarcoma arising in the descending mesocolon. Although mesenteric leiomyosarcomas have a poor prognosis, curative resections should performed if it in possible.

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A 73-year-old male patient who underwent previous gastrectomy was admitted for left upper quadrant abdominal pain. MD (Multidetector) CT on admission showed a mesenteric abscess 7.5 cm in size with a 20 mm linear high-density area in the center suggesting a fish bone ; otherwise, neither free air nor ascites were noted. Thus, we diagnosed localized peritonitis due to fish bone perforation of jejunum wall. The abdominal pain was light and localized, and the inflammatory response was mild with stable vital signs ; these findings were in the lower of conservative treatment rather than surgery. The patient was treated with antibiotics and was on fasting diet after providing informed consent. After decrease of abscess size and symptomatic recovery with antibiotics, the patient resumed eating without any difficulty. Herein, we report a rare case of a mesenteric abscess caused by an ingested fish bone, which was successfully treated with conservative therapy, and review of similar case in the literature.

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A woman in her 40s presented with an upper abdominal tumor that was detected on abdominal ultrasound during a complete medical checkup. On abdominal ultrasound, a 5-cm-diameter tumor was observed between the lesser curvature of the stomach and the lateral segment of the liver ; it was slightly hypoechoic relative to the spleen. On abdominal contrast-enhanced CT and plain MRI, the tumor had an almost uniform density and intensity, with similar enhancement to the spleen. An accessory spleen was suspected, but because the possibility of malignant lymphoma, gastrointestinal stromal tumor (GIST), and other conditions could not be ruled out, the tumor was surgically resected. The tumor, which was hard and 5 cm in diameter, was surrounded by an enlarged lymph node, with which it formed a single mass. Histopathological tests revealed a follicular dendritic cell tumor accompanied by Castleman's disease. We report the present case with reference to the literature because this condition is extremely rare.

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A 79-year-old woman was being followed for an adenomatous goiter of the thyroid ; cervical lymph node swelling was detected. A lymph node biopsy was performed. A metastatic adenocarcinoma of unknown origin was diagnosed. Despite extensive testing, no evidence of a primary lesion was found. The patient died due to disease progression. On postmortem examination the tumor was found to have grown along the retroperitoneum under the diaphragm from the hypogastrium ; remarkable swelling of the lymph nodes near the aorta was seen. On histology, a retroperitoneal serous adenocarcinoma with a micropapillary structure was diagnosed ; extensive lymph vessel invasion was noted. Immunohistochemistry yielded CA125 positive findings ; the ovaries were negative. Therefore, peritoneal serous papillary adenocarcinoma (micropapillary carcinoma) was diagnosed. Micropapillary carcinoma is primarily related to breast cancer. Micropapillary carcinoma related to peritoneal serous adenocarcinoma has not been previously reported. In this paper our rare case is discussed, and the relevant literature is considered.

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A 34-year-old man with right inguinal swelling and pain was diagnosed as having an incarcerated right external inguinal hernia. The preoperative CT scan clearly showed that the hernia sac contained a vermiform appendix. This extremely rare condition is known as Amyand's hernia. Since the patient's inflammatory indices were not elevated to high levels, and there was no bowel obstruction an operation was scheduled for the next day. Intraoperatively, the swollen vermiform appendix was located in the hernia sac as had been determined preoperatively. An appendectomy and a hernioplasty using the iliopubic tract repair procedure were done. The postoperative course was uneventful. Although Amyand's hernia is extremely rare, it could be easily diagnosed on CT scan preoperatively, which helped avoid a risky emergency operation. Since emergency surgery is not necessary in patients with an incarcerated right inguinal hernia, it is important that the possibility of this entity is taken into account preoperatively.

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