Recently the ratio of women surgeons has been increasing in Japan. Many women surgeons obtaining surgical specialist license are at a stage in their lives in which they want to have a child. In order to manage work as wellas to raise children, these women surgeons must solve many problems. Tokyo Women's Medical University is the only medical university with an all-female student body in Japan. Many support systems for women doctors have already been established in Tokyo Women's Medical University. If similar support systems can facilitate the establishment of the work/life balance in nationwide hospitals, more women surgeons should be able to continue their works after childbirth.

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Triple-negative breast cancer (TNBC) refers to any breast cancer that does not express the genes for ER, PgR, HER2. In this study, we compared for response to neoadjuvant chemotherapy and survival between patients with TNBC and those with non-TNBC. Subjects were consecutive 335 patients who received neoadjuvant chemotherapy for stage I-III breast cancer in our hospital from 2002 to 2010. Clinical and pathological parameters, pathological complete response (pCR) rates, survival rates were compared between those with TNBC and non-TNBC. About 21.1% of the subjects had TNBC.
Compared with non-TNBC patients, TNBC patients showed a high pCR rate (19% vs. 28% ; p=0.09), without significant difference. TNBC and non-TNBC patients who gained pCR with neoadjuvant chemotherapy showed favorable disease-free survival (DFS) and overall survival (OS) rate, without significant fidderences. On the other hand, there was no significant difference in DFS between TNBC and non-TNBC patients who had residual disease (p=0.02), but a significantly low OS rate was noted in TNBC patients compared with non-TNBC patients (p<0.01).
If pCR can be achieved, both patients with TNBC and non-TNBC would have similar survival. In contrast, patients TNBC who have residual disease (RD) are expected to show poor OS compared with such non-TNBC (p=0.01) patients.

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A 69-year-old woman driver wearing a three-point seat belt was involved in a motor vehicle accident, and was transferred to our hospital. She had been prescribed an antiplatelet drug for hypertension and angina. On arrival, she was alert and hemorrhage into the left breast was found. Soon thereafter, her blood pressure was 50-60 mmHg and she became drowsy, but consciousness improved with rapid infusion. US and CT revealed massive hemorrhage into the left breast, but no other injuries were depicted. Immediately after admission, blood pressure was 70-80mmHg and Hb was 7.9g/dl. Two units of red cell concentrate were transfused, and her vital signs stabilized. She recovered without intervention or surgery, and was discharged on the 5th day. With usage of a 3-point seat belt, hemorrhage into the breast should be more readily recongnized as one of the injuries caused by motor vehicle accidents. Subsequent attention to possible late complications including breast cancer is also necessary.

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Phyllodes tumor of the breast is a very rare neoplasm in young women, especially in adolescent girls. A 13-year-old girl presented with a three-month history of an enlarged unilateral palpable mass in her left breast. The diagnosis of benign phyllodes tumor was made on histopathological examination of the resected specimen. Phyllodes tumor in this age group should be treated to maximize breast conservation. Even in adolescent girls phyllodes tumor of the breast should be considered if there is a history of rapid growth.

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Malignant fibrous histiocytoma (MFH) is a rare soft tissue tumor. It typically occurs on the trunk and extremities and rarely in the breast. Only 27 cases of MFH of the breast have previously been reported in Japan. We report a case of MFH of the breast.
A 57-year-old female was admitted to our hospital because of a mass in the right breast. On physical examination, a hard and immobile mass, measuring 40mm in diameter, was palpable in the CD area of the right breast. Mammography showed a circumscribed high density mass. Ultrasonography showed a well-defined hypoechoic mass. Enhanced MRI demonstrated the enhanced tumor in the early phase. Fine needle aspiration cytology revealed Class V. Modified radical mastectomy (Bt+Ax) was performed. Histologically, the tumor was composed of spindle shaped cells with a storiform pattern. On immunohistochemical examination, the tumor cells showed negative staining for actin, S-100, EMA, and Keratin. Thus, the final a diagnosis of MFH of the breast was established. No postoperative adjuvant chemotherapy was given. The patient made an uneventful recovery and has been free from the disease 22 months after the surgery.

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A 55-year-old woman visited our breast clinic with complains of discomfort of the left breast and discharge from the left nipple. On physical examination, there was a mass of about 6.0×5.5 cm in size in the lower outer quadrant of the left breast with bloody nipple discharge. Mammography showed slightly high-density mass which had a lobulated shape measuring approximately 6.0×5.5 cm, of which the border was partly obscured. Ultrasonography demonstrated a well-defined and lobulated complex mass. Histopathological findings of a core needle biopsy indicated ductal adenoma. Microdochectomy was performed. On histopathological examination, there were some nodular lesions and the microscopic findings revealed compact proliferations of atypical tubular structures without a benign double epithelial cell layer which consisted of monotonous cells in the ductal adenoma. A diagnosis of ductal carcinoma in situ arising in the ductal adenoma was made, and irradiation therapy was ordered. The ductal adenoma contained the whole benign lesion. It is considered that ductal adenoma is not usually associated with a predisposition to carcinoma. This case seems to be extremely rare and valuable.

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A 61-year-old female had a right breast cancer. Since uterine cancer was also found on imaging, the patient underwent a right mastectomy and a hysterectomy. About 1 year later, a left thyroid lobectomy was performed since thyroid cancer (papillary carcinoma) was detected in the left lobe. Three years after the first operation, the patient noticed a tumor in the left breast. Left breast cancer was diagnosed, and a left mastectomy was done. She had macrocephaly nodules in her face, tongue, hands, and feet. Esophageal acanthosis, gastric polyposis, and colon polyps were diagnosed based on endoscopic studies. The patient was diagnosed as having Cowden disease according to the diagnostic criteria. On genetic testing mutations in the PTEN gene were found.

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A 27-year-old woman was suspected of having a mediastinal tumor on screening. Thoracic computed tomography and magnetic resonance imaging showed a 22-mm, multilocular, cystic mass adjacent to the right of the trachea and back side of the superior vena cava ; there was no pulmonary lesion. We diagnosed the patient as having a mediastinal tumor and performed video-assisted thoracic surgery. On histopathology, caseous necrosis and an epitheloid granuloma with Langhans' giant cells were noted. Tuberculosis DNA was detected in the resected specimen by PCR. Finally, the patient was diagnosed with mediastinal tuberculous lymphadenitis.
Mediastinal tuberculous lymphadenitis with no pulmonary lesions is difficult to distinguish from other mediastinal tumors.

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A 73-year-old woman was admitted to our hospital with a left axillary mass. A painless mass was located on the left lateral chest, but was recently enlarged. Chest computed tomography (CT) and magnetic resonance imaging (MRI) showed the hourglass shaped mass penetrating her left fourth intercostal muscle, and growing into the intra-and extra-thoracic areas, with a size of 65×50×40 mm. Her laboratory findings were almost within normal ranges. We performed a resection of the tumor and partial resection of the 4th and 5th ribs with the help of thoracoscopy. Pathological diagnosis was “intramuscular lipoma-infiltrating type, with no malignancy”. Assistance of the thoracoscopic approach was found to be useful for complete resection of the hourglass tumor found in the intra-and extra-thoracic areas.

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A 78-year-old woman was referred to our hospital because of an abnormal shadow on a chest radiograph obtained during a routine medical check-up. Chest CT revealed an inflammatory lesion located in the left upper lobe. A year and seven months later, the lesion was found to have grown and was a mass about 3 cm in diameter. On bronchoscopy, a definitive diagnosis could not be made. FDG-PET confirmed abnormal accumulation in the lesion. These findings suggested a lung tumor. The patient had a left upper lobectomy and a lymph node dissection using video-assisted thoracoscopic surgery. Microscopically, the lumen of the cysts contained a mucous secretion and was covered with ciliated epithelia. The surrounding lung tissue included epithelioid granuloma composed of a lymphocyte and plasmacyte infiltration. The final diagnosis on pathology was that of a bronchial cyst. A bronchial cyst with uptake on FDG-PET is rare, and it should be considered in the differential diagnosis of lung cancer.

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A 72-year-old man first noticed a bulge in his left chest wall in 2003. He was hospitalized due to a syncopal attack in May, 2009, and the left chest wall tumor was investigated. The tumor in the left anterior chest wall was bone hard over 10 cm in diameter. Chest CT showed that the tumor was connected to the left 7th rib, and that the interior had diffuse calcification. Hot spots corresponding to the tumor were seen on bone scintigraphy. In June, 2009 an operation was performed under a diagnosis of a bone tumor of the left chest wall. The tumor arose from the ventral part of the left 7th rib, and it had a very clear margin and expansive growth into the surrounding tissue. On pathology, a conventional chondrosarcoma (grade II) was diagnosed. Additional treatment was not administered. On medical follow-up, there is no evidence of recurrence 2 years after the operation.

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A 78-year-old man was injured in a traffic accident and was admitted to our hospital. Thoraco-abdominal CT showed the stomach and the transverse colon in the left thoracic cavity. Under a diagnosis of diaphragmatic hernia, an emergency operation was performed. A thoracotomy was made at the 7^th intercostasl space with the patient in a right semi lateral position. A torn left diaphragm was found along with the herniated stomach and the transverse colon. After the abdominal organs were reduced back into the abdominal cavity, the diaphragmatic fissure was found to reach the pericardium. The torn pericardium was repaired with a PTFE patch from the abdominal side. Patients with a traumatic diaphragmatic hernia must be positioned for surgery in such a manner that allows an abdominal approach and thoracic approach.

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The patient was a 54-year-old man who received a pacemaker in 2007. The patient was informed of the risk of developing sarcoidosis at the time of surgery. In May 2008, he was admitted to our hospital because of profuse hematemesis. Diagnoses of gastric gastrointestinal stromal tumor (GIST), multiple liver metastases, and multiple lymph node swelling were made, and the patient was administered imatinib therapy. After imanitib treatment, FDG uptake was not observed in the stomach and liver whereas that in multiple lymph nodes, which was thought to be caused by sarcoidosis, increased. PET/CT suggested that the lesion in the stomach had became imatinib resistant, and total gastrectomy was pertomned for this GIST. After the operation, we observed FDG uptake in the liver metastases. The patient received sunitinib therapy for the lesion in the liver. Sarcoidosis is known to be associated with malignant tumors, but a combination of GIST and sarcoidosis is extremely rare.

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A 78-year-old woman was admitted to our hospital because of epigastralgia. Upper gastrointestinal endoscopy revealed a type 1 tumor on the posterior wall of the gastric antrum and a type 0-IIc tumor at the posterior wall of the gastric lower body. Abdominal CT scan revealed no hepatobiliary or pancreatic diseases, but the serum CA19-9 levels were high, 245 U/ml on the first medical examination, 849 U/ml on admission, and 1,036 U/ml before operation. A laparoscopy-assisted distal gastrectomy including the two tumors was performed. The serum CA19-9 level decreased to 73.7 U/ml immediately after the operation and normalized on the postoperative 3 months. Both tumors were well differentiated tubular adenocarcinoma. While the tumor in the antrum gave positive reaction to CA19-9 staining, the tumor in the lower body gave negative reaction to CA19-9 staining. It is the first case in which CA19-9 producing and non-producing gastric cancers occur synchronously. This case is presented together with a review of the literature.

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The patient was a 67-year-old woman who had a total gastrectomy for gastric cancer in June 2008. On pathology, a poorly differentiated adenocarcinoma that reached the muscularis propria layer with no lymph node metastasis was diagnosed.
In January 2010, her tumor marker level increased. An abdominal CT was done in February. On CT, a tumor, about 7 cm in size, close to the left kidney, spleen, and pancreas was found. She had surgery in March. On pathology, metastasis of the left adrenal gland was diagnosed.
An isolated adrenal metastasis after gastric cancer surgery is very rare.

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We report a case of duodenal hemangioma resection that recurred after endoscopic resection enforcement this time.
A 72-year-old woman who had undergone endoscopic treatment (ethanol local injection and demucosation) for duodenal neoplasm was seen in June 2008 for difficulty in breathing. After examining the upper gastrointestinal tract by endoscope, CT, MRI, and duodenography in our hospital, a bleeding tumor was found in the duodenal 2nd portion, but the tumor was large and we judged that endoscopic resection was difficult. We performed a partial resection of the duodenal second portion, after confirming the position of a papillary protruded lesion using intraoperative endoscopy. The surrounding tissue of the duodenum showed extensive scarring from the last ethanol local injection. The pathologic finding of the duodenal neoplasm after the resection was an angiomatous diagnosis. Duodenal hemangioma is a disease with few reports, and is quite rare. A therapy in one report showed excision using an endoscope, but there were no reported cases of duodenum hemangioma that recurred after endoscopic resection enforcement. In this case we experienced a rare resection, so we added discussion from the literature and reported on it here.

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The duodenal anatomic location adjacent to the pancreas and colon makes it difficult to resect gastrointestinal stromal tumors (GIST) of the duodenum. A 64-year-old male, was incidentally found to have a growing gastrointestinal stromal tumor (GIST) at the inferior duodenal flexure during treatment and follow up of duodenal cancer. The patient was so obese (BMI : 31.7) that a large abdominal incision seemed to be necessary to access to the duodenum and resect the tumor. Therefore, we applied a laparoscopic approach for right colonic mobilization and exposure of the duodenum. Then, we made a minilaparotomy just above the duodenum, and the tumor was resected under direct vision. Operative time was 286 minutes and blood loss was minimal. The pathological findings were consistent with c-kit positive GIST with intermediate to high risk. The postoperative course was favorable, and he left the hospital on postoperative day 12. We consider this approach to be a useful option for the treatment of duodenal tumor in the 2nd or 3rd portion, especially in obese patients.

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A 62-year-old female was incidentally found to have a tumor in her pelvic cavity on ultrasonography and was thus referred to our hospital. MRI and PET-CT showed an egg-shaped, homogeneous tumor with high FDG accumulation. On laparotomy with a small incision, a tumor 6cm in diameter, arising from the ileum at 80 cm from the ileocaecal valve, was resected. Histopathological examination showed the tumor to have arisen from the proper muscle of an ileal diverticulum and to be KIT positive. Therefore, the tumor was diagnosed as a gastrointestinal stromal tumor (GIST) arising from a Meckel's diverticulum (MD). GIST arising from MD, though very rare and difficult to diagnose preoperatively, should be included among pelvic tumors. Diagnosis with multi-modal imaging and complete resection of the tumor are considered to be essential for appropriate management of this tumor.

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A 78-year-old man visited our hospital due to fresh blood in his stool that had been present since the previous morning. The following day, because melena occurred once and loss of consciousness 3 times, he visited another hospital-where low hemoglobin (8.1 g/dl) was revealed. He was then transferred to the Emergency and Critical Care Center of our hospital. Despite conservative management with fluid after admission, melena recurred. There was also a decrease in blood pressure. Because angiography was difficult due to a history of conservative treatment for abdominal dissecting aneurysm, emergency laparotomy was performed. The surgical findings revealed a hemorrhagic site at a diverticulum in the distal ileum and hemorrhage of the mesentery in the same region, possibly an effect of the ileal hemorrhage. Thus, ileocecal resection was performed for the hemorrhagic site causing melena. No blood accumulation was observed in other parts of the intestinal tract. After surgery, no new gastrointestinal hemorrhages were observed, and the patient was discharged with an uneventful course. The ileum is a rare source of gastrointestinal hemorrhage. We experienced a case in which ileocecal resection was performed for a hemorrhagic diverticulum of the ileum. We herein report this case with a review of the literature.

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We report a case undergoing resection of ileum and colon assisted by laparoscopy for recurrent Crohn's disease complicated by ileo-colic fistula with a history of ileocecal resection. Though the distal segment of the ileum had a complex disease status with some stenoses and fistulae, multi-detector row CT and 3D-gastrointestinalgraphy evaluated the extent of this disease and clarified the position and distance between stenotic lesions and fistulae in three dimensions. With this radiological examination, we were able to obtain a detailed surgical simulation prior to surgery and conducted perioperative navigation. We could thus perform laparoscopic reoperation safely. 3D-gastrointestinalgraphy can support laparoscopic surgery for Crohn's disease as a useful diagnostic modality which facilitates understanding disease status and devising surgical strategies.

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The patient was a 68-year-old woman who had been diagnosed with malignant lymphoma eight years earlier and was in a remission state with long-term oral prednisolone regimen for recurrence after chemotherapy and peripheral stem cell transplantation. Recently she was seen at the hospital because of a two-week history of poor appetite. An abdominal CT scan demonstrated extra-intestinal free air in the vicinity of the rectum in the minor pelvis. Emergency operation was performed with a diagnosis of rectal perforation. Pathological study disclosed that the perforation was caused by cytomegalovirus (CMV) enteritis. Because the patient had already been given ganciclovir, the dose of the drug was increased but the patient still exhibited positive CMV antigenemia. Symptoms recurred about two months later, when we selected conservative therapy because her general condition was poor and were able to avoid surgical intervention. Thereafter oral ganciclovir regimen has been maintained to preserve further recurrence and the patient is now on home nursing.
In the treatment of intestinal perforation in the immunosuppressive patient, we actively suspect the presence of cytomegalovirus enteritis and early administration of antiviral agent is desirable.

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A 59-year-old man was admitted to our hospital because of abdominal pain and nausea. Abdominal CT scan showed wall thickening and stenosis of the sigmoid colon and left hydronephrosis. Gastrographin examination showed stenosis of the sigmoid colon, approximately 5 cm long. Sigmoid colon cancer invading the retroperitoneum and the ureter was diagnosed. Thus, a low anterior resection was performed, preserving the left ureter. The resected specimen showed stenosis and wall thickening for approximately 5 cm long, covered with normal mucosa. On pathology, normal mucosa, thickening of the muscular layer, and infiltration of inflammatory cells were noted. No malignancy was seen. The hydronephrosis and the stenosis were likely caused by the diverticulitis. We report a case of sigmoid colon diverticulitis with hydronephrosis and intestinal obstruction requiring surgical resection.

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An 80-year-old woman with anorenia was admitted to our hospital for pyrexia, abdominal distention, and vomiting. Physical examination revealed muscular defense and rebound tenderness. Abdominal CT scan and MRI suggested the presence of a mature ovarian cystic teratoma penetrating the sigmoid colon. The patient underwent an elective surgery in which the tumor in the left ovary, which was closely adhered to the sigmoid colon, was removed. Macroscopic examination of the resected specimen revealed evident communication between the ovarian tumor and the sigmoid colon. The tumor was diagnosed as a dermoid cyst with malignant transformation to squamous cell carcinoma. The patient was alive without recurrence at 15 months after the surgery. Herein, we present a case of an ovarian dermoid cyst with malignant transformation penetrating the sigmoid colon and our literature review.

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A 61-year-old man was admitted to our department for the treatment of a sigmoid colon tumor diagnosed by a colonoscopy performed on account of positive fecal occult blood test in April 2009. Histological examination of the endoscopic mucosal resection specimens revealed that the tumor was a mucosa associated lymphoid tissue (MALT) lymphoma. His stomach was positive for H. pylori infection. H. pylori eradication therapy was started in June and the eradication was proved successful in August. However, no remarkable regression of the tumor was recognized by colonoscopy in October. Then we started local radiotherapy for the MALT lymphoma in November 2009. Colonoscopic studies performed after January 2010 revealed regression of the MALT lymphoma. No exacerbation of the MALT lymphoma has occurred as of March 2011.
Although H. pylori eradication is the first choice therapy for MALT lymphoma of the stomach, no therapeutic guideline has been established as yet for MALT lymphomas of the large intestine. In this case, the eradication was ineffective and local radiotherapy was effective. There is still a possibility that local exacerbation or appearance of multiple intestinal lesions can occur, and thus we must carefully follow the patient's clinical course.

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A man in his 68 underwent low anterior resection for Ra rectal cancer with multiple hepatic metastases. His postoperative course was uneventful, and modified fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) treatment for the hepatic metastases was initiated in the first month after the operation. Abdominal computed tomography for the evaluation of the treatment effect at the end of 3 courses of chemotherapy revealed air bubbles produced in succession from the anastomotic site within a soft-tissue shadow in the presacral region. Fluoroscopic and endoscopic examinations of the lower gastrointestinal tract revealed fistula formation on the anastomotic suture line of the rectum, which led to a diagnosis of late suture failure. Because the patient abstained from food and received central venous nutrition therapy for a week, the fistula closed, and the air bubbles disappeared. Chemotherapy was restarted after a one-month washout period.

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A 28-year-old man was referred to our hospital because of epigastralgia in the end of June, 2010. We found out a tumor about 5 cm in diameter at the epigastric region on an abdominal CT scan and fully examined the tumor in the abdominal cavity. Esophagogastroduodenoscopy revealsd a submucosal tumor-like bulge at the duodenal bulb. FDG-PET study showed a high FDG uptake mass in the epigastric region. On endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB), the mass was found to be composed of spindle-shaped cell bundles. The mass was positive for S-100 protein and negative for CD34, c-kit and α-SMA. A possibility of malignant peripheral nerve sheath tumor could not be ruled out because it had extensive necrosis. We performed tumor resection. On histopathology, the tumor was composed of spindle-shaped cell bundles ; it had little atypia, and the MIB-1 index was about 1% in the tumor. Therefore the tumor was diagnosed as schwannoma. Although the schwannoma arising in the hepatic portal region is very rare, it is an important lesion to be remembered as a differential diagnosis of tumors occurred in the hepatic portal region.

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A sclerosed hemangioma of the liver is an extremely rare type of benign hepatic tumor. A 72-year-old female was referred to our hospital because of a liver mass, which was detected incidentally on computed tomography (CT). The tumor, 3 cm in size and located in segment 2-3 of the liver, was depicted as a low-density tumor with ring enhancement by CT. Magnetic resonance imaging showed it to be a tumor with a low signal on T1-weighted and a slightly high signal on T2-weighted images. She underwent a left hepatectomy for possible malignant liver tumors, including intrahepatic cholangiocarcinoma. The histological examination of the surgical specimen revealed the tumor to be a hepatic sclerosed hemangioma with characteristic dense collagenous tissues. We report here on the case of this unusual tumor and review the relevant literature.

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The patient was a 73-year-old man who had been on therapies including transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) for liver arterial chemoembolization (TACE) and radiofrequency ablation (RFA) for liver cirrhosis type C and hepatocellular carcinoma since the age of 70. Recently he was admitted to the hospital because of high fever and pain extending from the lumbar region to the right thigh. Following CT examination, right iliopsoas abscess was diagnosed. Since the patient exhibited hepatic function of Child-Pugh classification C, surgical intervention under general anesthesia was considered to entail a high risk for him. We selected abscess drainage through retroperitoneal approach under local anesthesia. Cultivation of the abscess yielded E. coli and postoperative barium enema study revealed right hemicolonic diverticula and cecal fistula. The final diagnosis was thus iliopsoas abscess secondary to retroperitoneal penetration of cecal diverticulitis.
Iliopsoas abscess associated with liver cirrhosis is so rare that only nine cases have been reported in Japan. For the patient with the disease in poor general condition, our selection of less invasive therapy might contribute not only to maintain but also to improve the patient's QOL.

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This report presents a case of pneumatosis cystoides intesitinalis accompanied by pneumoperitoneum that presented with acute cholecystitis. The patient was a 76-year-old male, whose present history revealed the oral use of drugs (alpha-glucosidase inhibitor) prescribed for diabetes mellitus. He was admitted to our hospital because of colicky upper abdominal pain in January 2011. We noted an excessive inflammatory reaction (WBC 19,900/μl, CRP 28mg/dl) in his laboratory data and the presence of small bowel emphysema, pneumoperitoneum, and acute cholecystitis by an abdominal computed tomography scan. Emergency surgery was performed under a diagnosis of acute cholecystitis. No recognizable perforation which might cause pneumoperitoneum was observed in the gut. There were blocks of foamy gas bubbles on the transverse colon. These were fragile and easily ruptured, so we concluded that the pneumoperitoneum was caused by the gas bubbles. After discontinuation of the alpha-glucosidase inhibitor, the pneumatosis cystoides intesitinalis rapidly subsided. The patient has since been free from recurrence and is currently being strictly followed.

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We report a rare case of synchronous double cancer of the common bile duct and papilla of Vater. A 74-year-old woman was referred to our hospital because of dilatation of the common bile duct. After admission, upper gastrointestinal fiberscopy showed an enlarged papilla of Vater with an irregularly shaped concave lesion. Abdominal CT showed a slightly enhanced tumor at the papilla of Vater and this tumor spread to the lower bile duct. Under a diagnosis of cancer of the papilla of Vater invading the bile duct, pancreatoduodenectomy was performed. Histopathologically, the tumor of the papilla of Vater and that of the lower bile duct were completely separate from each other and both tumors were moderately differentiated tubular adenocarcinoma. Immunohistochemical staining for CEA differed between these two tumors. We thus diagnosed double cancer of the common bile duct and papilla of Vater. Cases of double cancer have increasingly been reported, but such tumors in the biliary tract are rare. To our knowledge, only 2 cases of double cancer involving the common bile duct and papilla of Vater have been reported in the Japanese literature.

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A 47-year-old man who had been treated for diabetes mellitus, chronic hepatitis B, and hepatic cirrhosis was seen at another hospital because of upper abdominal pain. Bleeding in a pancreatic cyst was diagnosed and conservative therapy was started, but the bleeding could not be controlled. The patient was thus brought into our hospital. When he arrived at our hospital, he was in a pre-shock state and an abdominal CT scan showed large quantities of ascites and a monolocular cyst about 4 cm in diameter at the pancreas head. Intraabdominal penetration of bleeding in the pancreatic cyst was diagnosed. His general condition was extremely poor. We determined that conservative therapy could not save his life and performed emergency operation. The operation was very difficult due to severe adhesions caused by inflammation around the pancreas head, but eventually pylorus-preserving pancreatoduodenectomy (PPPD) was done. The patient's postoperative course was uneventful and he was discharged from our hospital on his feet on the 40th hospital day. The histopathological diagnosis was pancreatic retention cyst.
Few cases of pancreatic retention cyst have been reported so far. We often hesitate to employ surgical therapy for the patients in poor general condition, but it is the only option for saving their lives if conservative therapies are ineffective. We have to consider the surgical therapy aggressively in such cases.

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A 74-year-old man was admitted to our hospital with hypochondriac pain. Enhanced abdominal CT revealed a tumor 7 cm in diameter in the tail of the pancreas. MRCP revealed a filling defect in the tail of the pancreatic duct. A distal pancreatectomy was performed. The tumor invaded the stomach, spleen, transverse colon and left renal fascia. Resections were thus performed. Pathological examination demonstrated an undifferentiated carcinoma of the pancreas. Tumor cells stained positive for CEA, CA19-9, Cytokeratin19 and Vimentin. Gemcitabine+S-1 combination therapy was administered for 1 year after surgery. The patient has been followed up for 5 years and 11 months, to date, without evidence of recurrence.

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We report a patient who had pancreatic head cancer complicated by celiac axis compression. A 54-year-old man was found to have an increased PSA. Screening abdominal ultrasonography revealed dilatation of the main pancreatic duct and a solid mass in the pancreatic head. Angiography demonstrated compression of the proximal celiac axis and collateral blood flow to the hepatic artery via the dilated pancreatic arcade through the inferior pancreatico duodenal artery. Abdominal CT also revealed compression of the origin of the celiac axis. The patient was diagnosed as having a pancreatic head cancer with celiac axis compression by the median arcuate ligament. A pancreaticoduodenectomy was performed after division of the median arcuate ligament. During surgery, it was useful to monitor the hepatic artery flow using Doppler ultrasonography.

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We report three cases which survived superior mesenteric artery embolism, when we performed an embolectomy with laparotomy. In these cases, there was no intestinal necrosis but thrombolysis and interventional radiology was ineffective. We observed persistent embolisms in Case 1, hemorrhage of the suture point in Case 2, and good flow in the superior mesenteric artery in Case 3, by immediate postoperative angiography. Accurate intraoperative evaluation of superior mesenteric artery flow is difficult only by palpation or a doppler flow meter. Immediate postoperative evaluation of superior mesenteric artery flow is effective in the cases of embolectomy with laparotomy.

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We have experienced two cases of idiopathic superior mesenteric artery dissection treated by combination of anti-coagulant and thrombolytic therapies.
Patient 1, a 55-year-old man, presented with periumbilical pain. An abdominal contrast-enhanced CT scan and abdominal angiography demonstrated a dissection of the superior mesenteric artery at about 1 cm distal from the ostium. Continuous intraarterial infusion of urokinase through a catheter placed in the artery and systemic administration of heparin were started. Angiography performed again on the 6th hospital day revealed disappearance of thrombus in the false lumen. The patient has been followed in our clinic and no recurrence of symptoms has occurred up to now.
Patient 2, a 49-year-old man, presented with epigastralgia. An abdominal contrast-enhanced CT scan demonstrated a dissection of the superior mesenteric artery from the ostium and thrombus which filled the false lumen. After aspiration of the thrombus under angiography, continuous intraarterial urokinase infusion therapy was started. The patient was discharged with marked improvement on the 14th hospital day.
Recent progression of imaging diagnosis has enabled us to make early diagnosis as well as to start early treatment of idiopathic superior mesenteric artery dissection. Combined use of anti-coagulant and thrombolytic therapies can be a beneficial therapy for the disease in a slight degree.

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A 40-year-old woman was referred to the department of gynecology in our hospital with a suspicion of swelling of the right ovary that was revealed by transvaginal ultrasound at another hospital following her abortion on the 5th-week gestation. Abdominal magnetic resonance imaging showed a cystic tumor 6cm in diameter in the vicinity of the right ovary. Surgery was started to perform laparoscopic-assisted right ovariectomy with a preoperative diagnosis of a right ovarian cyst, but the both ovaries were found to be normal during the surgery. The cystic tumor was adjacent to the dorsal aspect of the appendix. Because a possibility of a malignant tumor could not be ruled out, ileocecal resection was performed. The histopathological diagnosis was mucinous cystadenoma arisen in the mesoappendix (of borderline malignancy).
In general mucinous cystadenomas in the abdominal cavity most commonly arise in the ovary and the pancreas, but rarely in the mesenteries including the mesoappendix. So far few cases of mucinous cystadenoma arisen in the mesentery have been reported and then we present this case together with a review of the literature.

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A foreign body in the intestinal tract, such as a fish hone, rarely causes perforation of the intestinal tract, abscess or inflammatory granuloma, since it usually passes through without difficulty. We report 2 cases with retroperitoneal abscesses caused by fish bone penetration. Both were treated by retroperitoneal drainage. A 73-year-old man and an 83-year-old man with retroperitoneal abscesses including a fish bone were admitted to our hospital. One had the abscess in the retroperitoneal space of the right kidney and the other in the dorsal space of the descending colon. Retroperitoneal space drainage was performed without celiotomy. We found fish bones, removed them and placed drains in the space. Preoperative correct diagnosis and removal of fish bones are important in this disease, and the most appropricte operation should be selected for each case.

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Though the incidence of ileus due to internal hernia is not low, an internal hernia caused by the sigmoid colon epiploic appendix is extremely rare.
We report the clinical features of an internal hernia with a sigmoid colon epiploic appendix.
A 73-year-old woman was diagnosed as ileus from her clinical features. We performed an emergent operation under laparoscopic assisted surgery on the day after admission. Operative findings revealed that the epiploic appendix of the sigmoid colon formed a hernia orifice with the shape of a loop, and 40 cm of the small intestine was incarcerated into the hernia orifice.
Only 24 cases of ileus due to an internal hernia caused by the epiploic appendix were reported in Japan according to our investigation. The earlier operations showed patients had better results without resection of the small intestine. We need to keep this in mind for this disease when we face patients with ileus due to unknown origin and left lower abdominal pain. Early treatment is required to get a good prognosis.

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A 24-year-old female was seen at the hospital because of low abdominal pain for two days. Abdominal computed tomography scan showed the small intestinal expanded and incarceration of the ileum accepted views to the pelvic floor. An internal hernia was suspected and confirmed by laparoscopic surgery.
From the operative findings, we accepted the views that the ileum became incarcerated in the peritoneum defect of the Douglas pouch. We performed a hernia repair without intestinal resection because there was no necrosis of the intestinal tract.
We experienced a rare case of pouch Douglas pelvic hernia.

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A 62-year-old man underwent abdominoperineal resection (APR) with curative intent for anal canal cancer. The tumor was finally classified as stage II (T2N0M0) according to the UICC classification. He was discharged on the day 19 following his operation with no complications. About 2 months after the APR, he complained of a perineal lump which made prolonged walking or sitting difficult. Abdominal CT scan showed the small intestine protruding through the pelvic floor into the perineal area ; a secondary perineal hernia was diagnosed. A pelvic floor reconstruction with a DUALMESH^® was performed transabdominally. There have been no signs of recurrence in 1 year of follow-up. Secondary perineal hernia is a rare complication of APR or pelvic exenteration and we found 21 cases reported in Japan including conference proceedings. We herein report a case of secondary perineal hernia following APR successfully repaired with DUALMESH^®. Furthermore, aggregating the cases reported in Japan in addition to our case, we review the literature to discuss the clinical features of this complication.

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