[in Japanese]

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We analyzed factors that influence the operation outcome of early laparoscopic cholecystectomy (LC) for acute cholecystitis. We enrolled 61 patients with acute cholecystitis performed early LC within 96 hours from the onset of symptoms. Multivariate regression analysis was used to determine whether factors, including sex, age, time from the onset of symptoms, preoperative white blood cell count, preoperative C reactive protein, severity of cholecystitis, presence of cholecystolithiasis and past history of cholecystitis, had a significant association with the operation time, conversion rate to open cholecystectomy and postoperative complications. Operation time, conversion rate to open cholecystectomy, and postoperative complication rate was 124.1 minutes (average), 18.0%, and 13.1%, respectively. Male (p=0.0107), severity of moderate or severe (p=0.0371) and past history of cholecystitis (p=0.0009) were found to be significant risk factors for prolonged operation time of longer than 120 minutes. Acalculous cholecystitis (p=0.0345) was found to be associated with postoperative complications significantly.
Early LC for acute cholecystitis within 96 hours after the onset of symptoms should carefully be performed in the case of a male patient, severity of moderate or severe, acalculous cholecystitis and a patient with past history of cholecystitis.

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Follicular carcinoma is only occasionally diagnosed preoperatively, because of the difficulty to discriminate it from benign adenoma using fine needle aspiration cytology and imaging studies. When follicular carcinoma is diagnosed as “follicular neoplasm” preoperatively, thyroid lobectomy has commonly been selected in Japan. Follicular carcinoma without distant metastasis has a good prognosis, but with distant metastasis it will be life-threatening. It is clinically meaningful to analyse some factors of distant metastasis. In this report, we analysed various factors in patients and their pathological findings. As a result, a post-operation decrease of serum thyroglobulin had significant predictive factors of distant metastasis in follicular carcinoma. Before metastases appeared, serum thyroglobulin increased before clinically detected in this report, so periodic monitoring of serum thyroglobulin is very important. Bone scintigraphy and FDG-PET imaging will be important to find distant metastasis earlier. When distant metastases are found in such examinations, completion thyroidectomy and radioactive iodine therapies will be needed to improve their prognoses.

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«Aim» We investigated the results of second-look operations aimed at achieving intestinal continuity after chemotherapy for obstructive colon cancer initially managed with the Hartmann operation.
«Subjects·Methods» We studied 11 cases with obstructive colon cancer in which a second-look operation was performed with the aim of intestinal continuity. We performed second-look operations in cases without recurrence at the 6 month surveillance after the first operation.
«Results» The colostomy could be closed in all cases, but we selected colo-anal anastomosis in 2 cases and ileo-anal canal anastomosis in 1 case. Diverting ileostomy was performed in 4 cases. Peritoneal dissemination was seen in 4 cases, but all were resectable. Postoperative complications were not serious. All cases remain alive without recurrence since the second-look operation.
«Conclusion» It is important to clarify the aim of surgery and the timing of second-look operations.

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Ten patients who underwent parastomal hernia repair at our hospital between February 1998 and January 2010, were reviewed. There were 7 women and 3 men with an average age of 70 years. All patients underwent laparotomy. The hernia orifice was covered with a manufactured mesh sheet fixed to an abdominal wall and a colon end. The mean operation time and intraoperative blood loss were 167 minutes and 149 ml, respectively. One patient encountered a small intestine fistula due to the polypropylene mesh. Afterwards, we used a bilayer mesh sheet consisting of polypropylene and expanded polytetrafluoroenthylene. Complications were not found in the other 9 patients. No patient developed recurrence of the hernia. Parastomal hernia repair using a prosthetic mesh is a safe and useful method because of its low recurrence rate and less invasiveness.

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A 68-year-old woman who had been pointed out having hypercalcemia but had let it alone for about 6 months was seen at the hospital because of nausea and general fatigue. She was admitted for exploration and treatment. From an elevated level of intact PTH level as well as CT and MIBI scintigraphy findings, primary hyperparathyroidism was diagnosed and right lower parathyroidectomy was performed. Oral ingestion was resumed on the first postoperative day, and just then chyle was drained from a drainage tube. Swelling of the neck and dyspnea also appeared, so that the tissue surrounding the chyle leakage was sutured and ligated, and drainage was performed again. Fasting and total parenteral nutrition for 14 days resulted in a decrease in chyle leakage, and the patient started to take a low fat diet. However, large quantities of chyle leak occurred again after initiation of the oral ingestion. Intermittent subcutaneous administration of octreotide acetate was thus carried out. The chyle leakage started to decrease from the second day after the administration and the 7-day administration provided a cure for the patient.
We present this case of chyle leakage causing swelling of the neck in which octreotide acetate was extremely effective, together with a review of the literature.

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Thyroid hemangioma is very rare, with only 13 cases previously reported in Japan, as retrieved by an on-line search.
The patient was a 79-year-old male who had a soft mass measuring 31 mm in diameter in the right lobe of the thyroid. The ultrasonography showed a mass with irregular-shape, low echogenicity and heterogeneity. Although an aspiration biopsy cytology of the mass revealed no malignancy, the findings of the images made us consider the possibility of follicular neoplasm of the thyroid. Right hemithyroidectomy was performed on suspicion of thyroid cancer. The pathological examination revealed cavernous hemangioma in the thyroid gland.

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We report the case of a 27-year-old man treated for ectopic mediastinal parathyroid adenoma with ^99mTc-MIBI and radioguided thoracoscopic surgery. The patient had elevated serum calcium levels, normal parathyroid hormone levels, decreased serum phosphate levels and a history of recurrent urinary stone colic annually. Therefore, thoracoscopic removal of the mediastinal tumors was suggested. Prior to surgery, he was given 600 MBq of ^99mTc-MIBI by injection, and tumor identification was checked. Thus thoracoscopy was performed under gamma probe guidance. Radioguided thoracoscopic surgery with ^99mTc-MIBI is a safe and effective method for treating ectopic mediastinal parathyroid adenomas.

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Medullary thyroid carcinoma is a relatively rare phenomenon. We report a case of medullary thyroid carcinoma detected by FDG-PET examination during a medical checkup for an elevated serum CEA value. A 67-year-old female was identified with an elevated serum CEA value by a general practitioner. GI tract and lung CT examinations showed no abnormal findings. However, FDG-PET examination identified an intensive signal mass in the left thyroid lobe. For further examinations, she was referred to our hospital.
Aspiration biopsy cytology showed a malignant tumor of the thyroid gland. In addition, medullary thyroid carcinoma was highly suspected from high serum CEA and calcitonin values. Therefore, a left lobectomy, isthmectomy and left modified neck dissection were performed.
Pathological and immunohistochemical findings led to a diagnosis of medullary thyroid carcinoma.

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An 84-year-old woman received a cross incision on her left breast for a suspected diagnosis of inflammatory breast cancer, because there was no pus discharge. She had a 3cm tumor at the ACE area in her left breast with invasion to the skin. Ultrasonography revealed a low echoic mass in her left breast. A core needle biopsy was performed for confirmation of breast cancer and lymphomatoid papulosis was diagnosed based on atypical CD30 (+) lymphocytes in the tumor.
The 5 year survival rate with this disease is more than 90% because of natural remission. The tumor tended to climinish gradually without treatment. Ultimately, the mass had completely disappeared on visual inspection, CT, US and MMG at 5 months after biopsy.

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We report a case with two concurrent fibroadenomas arising from the right axillary accessory mammary gland and the mammary gland. A 42-year-old woman noticed an elastic hard mass in the right axillary region. A right breast cancer with regional lymph node metastasis was suspected, but aspiration biopsy cytology was not diagnostic. On excisional biopsy both the axillary accessory mammary gland lesio and the mammary lesion were diagnosed as fibroadenoma. This case cautions against doing an excessive resection for an axillary accessory gland tumor since it can be difficult to distinguish from breast cancer lymph node metastasis.

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Angiosarcama of the breast is rare. The correct diagnosis of this disease requires a precise histopathological approach. We present a case of intermediate-grade angiosarcoma of the breast. A 27-year-old woman had a lump and pain in the right breast. She was followed under a diagnosis of benign tumor at another hospital. Since the lump gradually increased in size, the patient was seen in our university teaching hospital. Mammotome^® biopsy resulted in a diagnosis of vascular tumor. Mastectomy and immediate reconstruction with a breast implant were performed. The final diagnosis was angiosarcoma. Following surgery, she underwent adjuvant chemotherapy (weekly paclitaxel). She has been followed closely ; no recurrence has been noted.

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In 2002, A 60-year-old woman with right breast cancer was treated with preoperative chemotherapy, followed by right breast mastectomy (Bt+Ax). In 2005, a central venous port was implanted via the left subclavian vein for treatment of bone metastasis. However the port had to be removed due to a port-related infection.
In June 2008, a second device was implanted in the left upper arm. In May 2009, the patient complained of neck pain and swelling. CT scan and color doppler ultrasound revealed a left internal jugular vein thrombus. The patient was treated with continuous intravenous infusion of heparin for 4 days to prevent pulmonary embolism before removal of the port. Then, oral anticoagulation was begun.
In our 276 cases managed between January 2007 and June 2009, central venous port-related venous thrombosis occurred in 6 (2.1%). Venous thrombosis should be considered, after implantation of a central venous port, especially in cancer patients receiving systemic chemotherapy. CT scan and ultrasonography are useful examinations for detecting central venous port-related venous thrombosis.

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Bronchiolitis obliterans organizing pneumonia (BOOP) is a rare complication during/after irradiation following breast-conserving surgery. Similar interstitial pneumonias caused by endocrine therapy have also been reported. Herein, we present two breast cancer patients who developed BOOP during/after radiotherapy that was diagnosed as drug-induced pneumonia by the drug lymphocyte stimulation test (DLST). Case 1 was a 42 year-old female (T1cN0M0 StageI) who underwent breast-conserving surgery and radiotherapy. She developed fever and dyspnea while receiving hormonal therapy (tamoxifen). We diagnosed BOOP caused by irradiation, though DLST for tamoxifen was positive. We finally diagnosed drug-induced pneumonia. Case 2 was a 60 year-old female (T1cN0M0 StageI) who underwent breast-conserving surgery and then developed a fever, caugh and dyspnea. Twelve days after receiving radiotherapy and hormonal therapy (anastrozole) she was diagnosed with drug-induced pneumonia based on a positive DLST for anastrozole. Predonisolone was very effective in both cases. In conclusion, DLST facilitates examination for the differential diagnosis of drug-induced pneumonia in breast cancer patients with BOOP during adjuvant therapy.

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Descending necrotizing mediastinitis (DNM) is known to be a fatal illness resulting from oropharyngeall infections and which rapidly progresses to sepsis and multiple organ failure. Because of its virulence, delayed diagnosis and therapy are directly linked with high mortality. We must keep DNM in mind when treating a case with progressive oropharyngeal infectious disease. We report successful treatment of a DNM case. The patient recovered with thoracoscopic mediastinal drainage surgery. This patient had undergone cervical drainage surgery for a cervical abscess resulting from pharyngitis at another institution. However, his clinical condition deteriorated and DNM was diagnosed by computed tomography on postoperative day (POD) 7, followed by referral to our institution. The DNM extended into the posterior mediatinum below the carina. We performed thoracoscopic mediastinal drainage surgery, resulting in a good outcome. It is our experience that thoracoscopic mediastinal drainage is a good choice for DNM management because it is minimally invasive and efficacy is assured.

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This case deals with a 75-year-old man had recurrent pyrexia during a six-months period of time.
Echocardiography revealed vegetation on the aortic valve and thickening of the anterior leaflet of the mitral valve. Enterococcus faecium was isolated on blood culture. The patient was diagnosed with infective endocarditis and underwent surgery after receiving antimicrobial therapy. Preoperative transesophageal echocardiography showed a mass echo indicative of abscess formation extending from the aortomitral continuity to the left ventricular side of the anterior mitral leaflet. On examination of this site after resection of the aortic valve, 10-mm ulceration, which was thought to be a spontaneous rupture of the abscess, was found on the left ventricular side of the anterior mitral leaflet. The abscess was closed via the transaortic approach using an autologous pericardial patch, and the aortic valve was replaced was. Postoperative transesophageal echocardiography showed that the ulcer on the left ventricular side of the mitral valve was fully repaired.

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There are relatively few reports about heart surgery in patients with a history of retrosternal gastric tube reconstruction for esophageal cancer. In these cases, the gastric tube reconstructed retrosternally may preclude the usual procedure of doing a median sternotomy. This makes it difficult for the surgeon to devise an appropriate approach. Our a 56-year-old male patient had a history of retrosternal gastric tube reconstruction for esophageal cancer at the age of 51 years. He required heart surgery under a diagnosis of aortic incompetence associated with infectious endocarditis due to Enterococcus faecalis. After identifying the gastric tube reconstructed during an upper abdominal mini laparotomy a median incision was made by carefully removing the retrosternal surface from below the xiphoid process, followed by the upward dissection of the sternum in a segmental manner. The gastric tube was opened toward the left side with the dissected left half of the sternum. This procedure allowed adequate visualization of the surgical field, as is available with during standard aortic valve replacement cases.

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A 58-year-old man underwent left lower lobectomy for primary lung cancer (T1aN0M0, stageIA) which was detected by a medical check up. Preoperative contrast enhanced CT scan of the lung demonstrated abnormal branching of the left A⁸ from the left main pulmonary artery, adjacent to the left lower bronchus. This is the fifth case report of abnormal branching of the basal pulmonary artery from the left main pulmonary artery diagnosed preoperatively in this country.

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The patient was an 81-year-old male who had a right hemicolectomy for an ascending colon carcinoma (stage IIIA) in May 2002. In March 2007, computed tomography showed a 40-mm mass in S⁴ of the right lung with a calcified area. A right middle lobectomy was done. On histology, on ossified was diagnosed metastasis of colon cancer. Cases with ossification only in the metastatic lesion but not in the primary lesion are rare.

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A 69-year-old woman visited a neighbor doctor complaining of tightness of the chest and respiratory discomfort. Abdominal ultrasonography and CT scan showed a 10cm-sized liver mass and chest X-ray revealed cardiac tamponade. Pericardial puncture was emergently performed and 800ml bloody effusion (cytology indicated classI) was drained. Then she was referred to our department. MRI and angiography disclosed a blood rich masses in the left lateral segment of the liver, diaphragm and pericardium. Angiosarcoma of the liver was suspected and trans-catheter arterial chemo-embolization (TACE) was performed, followed by lateral segmentectomy of the liver with resecting a part of the left diaphragm and the pericardium. The histopathological diagnosis was malignant mesothelioma. The core of the tumor was located in the diaphragm and the direct invasion up to the pericardium and down to the liver was found. She received 6 cycles of postoperative adjuvant chemotherapy consisting of pemetrexed and cisplatin (CDDP). She has been recurrence-free for more than 16 months.

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A 50-year-old man who had fallen from a high place to the ground and broken the cervical vertebra underwent anterior cervical internal fixation using a metal plate. Eight years after the operation, the plate had displaced and the screw had fallen. An endoscopic examination disclosed exposure of the plate at the cervical esophagus, and esophageal perforation was diagnosed. The plate was removed and repair of the esophagus was carried out. Via oblique incision of the left anterior neck, the plate was removed from the lumen of the esophagus, though it was difficult by firm adhesions surrounding the esophagus. A T-tube was indwelt at the incision site and drainage was performed. The patient's postoperative course was uneventful, and he was discharged on the 34th hospital day without having stenosis or fistula.
Esophageal perforation can sometimes become intractable due to associated mediastinitis or fistulation so that a variety of treatment methods have been reported so far. Further inapparent and delayed esophageal perforation like in this case is an extremely rare complication and we thus present this case together with some bibliographical comments.

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We report a case of metastasis to the small intestine from esophageal squamons cell carcinoma presented with small bowel obstruction.
An 85-year-old man complaining of abdominal pain and abdominal distension presented with small bowel obstruction. Adhesive intestinal obstruction resulting from gastric resection was the most likely diagnosis, and conservative therapy was attempted. No remission was attained and so laparotomy was carried out. During surgery, no particular adhesions were seen, but a tumor was identified in the ileum that was determined to be the causative lesion for intestinal obstruction. Intraoperative biopsy was done for a tumor in the right lateral chest wall which had been noted before the operation, and the resection of the small intestine was performed for the small bowel tumor. Pathologically both lesions were diagnosed as well differentiated squamous cell carcinoma. Because primary lesions were demonstrated by imaging procedures, the tumor of the right lateral thoracic region was diagnosed as rib metastasis and the small bowel tumor as small bowel metastasis from the esophageal squamous cell carcinoma, respectively.
When we encounter the patient manifesting gastrointestinal symptoms such as intestinal obstruction who had a previous history of esophageal cancer, small bowel metastasis must be kept in mind as a probable course of the disease.

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We report on a patient with esophageal hiatus hernia after laparoscopy-assisted total gastrectomy.
The patient was an 80-year-old man who underwent laparoscopy-assisted total gastrectomy and Roux-en-Y reconstruction for cardiac gastric cancer. On the 2^nd postoperative day, he complained of dyspnea, which became progressively worse. The computed tomography scan showed that the dilated intestine was transmitted to the left thoracic space, with which we made the diagnosis of esophageal hiatus hernia after the laparoscopy-assisted total gastrectomy. On the same day, the repair of the esophageal hiatus hernia was performed by laparoscopy. The examination inside the abdominal cavity with a laparoscope showed that the small intestine and transverse colon were incarcerated in the thoracic cavity through the esophageal hiatus.
The protrusion of intestines was reduced into the abdominal cavity, and the hernia orifice was occluded by suturing the anterior and posterior walls of the diaphragm crus.
Esophageal hiatus hernia after surgery is a rare entity and our laparoscope-assisted repair was the first case.

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A 54-year-old man had a left adrenal gland abnormality and underwent surgery with a preoperative diagnosis of left adrenal tumor based on an imaging study. The pathological examination revealed the tumor to be a gastrointestinal stromal tumor (GIST) growing out of the gastric wall.
He was diagnosed with multiple metastatic liver tumors 2 years and 2 months after the first surgery and underwent a partial hepatectomy. Due to the frequent recurrence of multiple liver metastases, he also underwent three radiofrequency ablations. As the period from treatment to recurrence became shorter, we started oral imatinib therapy, and he remained recurrence free for 6 years and 7 months after the first recurrence. Although imatinib administration is the first-choice therapy for recurrent GIST, one must consider active surgical treatment for resectable lesions, in particular for patients with a long period between their first treatment and recurrence.

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We report two cases of gastric cancer associated with protein-losing gastropathy.
Case 1 : A 69-year-old man was admitted to our hospital because of loss of weight. He had a huge type 1 tumor at the gastric body and hypoproteinemia (TP 5.8g/dl, Alb 2.9g/dl). ^99mTc-HSA scintigraphy showed the leakage of HSA from the tumor. He was diagnosed as having gastric cancer with protein-losing gastropathy, and distal gastrectomy was performed. His hypoproteinemia improved soon after the operation. Case 2 : A-57-year-old man was admitted to the hospital because of difficulty in swallowing. Just like the case 1, he had hypoproteinemia (TP 5.9g/dl, Alb 2.9g/dl) and a type 1 gastric tumor. Gastric cancer with protein-losing gastropathy was diagnosed by ^99mTc-HAS scintigraphy. He underwent distal gastrectomy, pancreatoduodenectomy and enterostomy, because the tumor had invaded the pancreas head. The operation relieved hypoproteinemia, and no postoperative complications occurred.
Hypoproteinemia induced by this disease is intractable, and most conservative treatments are ineffective, so that early operation is important. However, we must be well-informed about that the patients with this disease invariably suffer from malnutrition and belong to a high-risk group for operation.

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A 61-year old female with ulcerative colitis (UC), who had received medical treatment for 2 years, was admitted due to an aggravation of the disease. Although extensive medical treatments with high doses of prednisolone (up to 60 mg per day), cyclosporine, and granulocytapheresis, were carried out, the symptoms did not improve. In an examination for upper-abdominal discomfort, a gastroendoscopy was performed, which revealed gastric cancer at an advanced stage (type 3, c T2 (MP) N0 M0 stage Ib). A simultaneous laparoscopic subtotal colectomy with ileostomy and a distal gastrectomy reconstructed by Roux-en-Y was performed successfully. The postoperative course was uneventful, and she was discharged on 24 POD. To the best of our knowledge, this paper is the first to report a simultaneous laparoscopic surgery in the treatment of UC accompanied by gastric cancer.

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A 67-year-old man had previously undergone distal gastrectomy reconstructed by the BillrothII method. He was referred to our hospital complaining of upper abdominal pain. Computed tomography showed emphesyma and an abscess in the retroperitoneal space aroud the pancreatic head and duodenum. Emergency surgery was performed under a diagnosis of duodenal perforation. An abscess was found in the retroperitoneal space around the pancreatic head and duodenum. Perforated duodenal diverticlum at the second portion was revealed via of an incision of the fascia. Diverticulectomy, C-tube drainage and tube duodenostomy were performed. During the postoperative course, minor leakage from the suture line occured but was managed conservatively. We report this case of perforated paraduodenal papillary diverticulum after distal gastrectomy by the BillrothIIreconstruction method.

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A woman in her fifties who had been pointed out an abnormal finding by gastric x-ray examination at a medical checkup underwent gastric endoscopy which detected a IIc lesion at the pyloric antrum. Early gastric cancer was diagnosed and distal gastrectomy with Roux-Y reconstruction using a stapling device was performed. The patient vomited in the night of the 4th hospital day. Abdominal x-ray examination on the next morning revealed remarkable dilatation of the remnant stomach, so that a gastric tube was placed. Fluoroscopic study performed on the 6th hospital day showed that contrast materials stayed in the remnant stomach and could not pass through the anastomosis site. Anastomosis stenosis was diagnosed and her clinical course had been observed while the gastric tube was placed, however, large quantities of discharge persisted. Another fluoroscopic study on the 12th hospital day revealed findings suggestive of intussusception at the anastomosis site. Re-operation was performed on the 14th hospital day when we saw that the stump of the jejunum had impacted into the remnant stomach. The surrounding gastric and small bowel walls hardened with inflammation and the intussusception could not be reduced entirely. Subsequently the whole anastomosis site was removed and reconstruction was made again.
Intussusception after gastrectomy is rare and we present this case, together with cases reported so far in Japan.

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A 40-year-old woman was admitted to our hospital with complaints of vomiting and right lower abdominal pain. Since the abdominal CT scan did not show remarked swelling of the appendix, we started administration of antibiotic drugs. The next day, we found muscle defence on the right lower part of the abdomen. As an abdominal enhanced CT revealed acites and abscess formation ; we performed an emergency operation. In the intra-operative findigs, the cecum colon was not fixed to the retroperitoneum. The size of appendix was normal. Small intestine was sifted to the right side of the abdomen. Meckel's diverticulum was located in the ileum, 60 cm from the ileocecal valve ; showed abscess formation, and adhered to the right parietal peritoneum. We diagnosed the case as Meckel's diverticulitis with intestinal malrotation, and performed a small intestine resection and appendectomy. Histology revealed small ectopic gastric mucosa in the mucosal layer of the Meckel's diverticulum. The post operative course was uneventful, and she was discharged from our hospital 18 days after operation.

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Small bowel diverticula are rare. Except for Meckel's diverticula, most diverticula of the small intestine arise in the mesentery side. Once they have penetrated the small intestine, mesenteric abscess is formed in many cases. Recently we have experienced two cases of mesenteric abscess due to penetration of an ileal deverticulum, which were diagnosed by preoperative CT scanning and were operated on.
Case 1 involved a 79-year-old man who was referred to our hospital because of right lower quadrant pain. An abdominal CT scan revealed an abscess on the mesentery side of the ileocecal region and a diverticulum of the ascending colon. Accordingly mesenteric abscess due to penetration of ascending colon diverticulitis was diagnosed and ileocecal excision was performed.
Case 2 involved a 63-year-old man who was admitted to our hospital because he developed fever and abdominal distension following colonoscopy at another hospital. An abdominal CT scan revealed abscess formation within the mesentery of the small intestine. Mesenteric abscess formation caused by penetration of an ileal diverticulum was diagnosed, and the resection of the small intestine was done. In both cases, the histopathological diagnosis was mesenteric abscess due to penetration of an ileal diverticulum.
Although it is difficult to diagnose the presence of an ileal diverticulum preoperatively, the disease must be kept in mind as a possible diagnosis when a mesenteric abscess is demonstrated on CT.

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A 75-year-old man with adult T-cell leukemia (ATL) was admitted to the hospital because of abdominal pain. His abdomen was distended with muscular rigidity. Abdominal CT scan demonstrated the presence of free air. An emergency laparotomy was performed with a diagnosis of visceral perforation. At surgery, a perforation 5 mm in diameter was recognized at the jejunum, 100 cm distal from the ligament of Treitz. We also found multiple small soft nodules along the entire small intestine. Partial resection of the jejunum was performed. Microscopic findings disclosed a small intestinal perforation due to CMV infection. Ganciclovir was started on post-operative day 7 based on the pathological diagnosis. Eight days after the operation, wound dehiscence occured and abdominal closure was performed immediately. However the patient died from sepsis and multiple organ failure on post-operative day 9. Although gastrointestinal perforation caused by CMV infection is very rare, CMV infection should be included in the differential diagnosis in an immuno-compromised host, such as the patients with ATL.

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A 75-year-old woman was brought into our ER by ambulance complaining of the sudden onset of lower abdominal pain. Physical examination showed abdominal muscle guarding with rebound tenderness. An abdominal CT scan revealed an infant's head-sized tumor with irregular wall thickening at the proximal jejunum, associated with free air and ascites around the liver. She was diagnosed as having a perforated jejunal tumor, and underwent emergency operation. Laparotomy showed an infant's head-sized tumor with huge perforation at the proximal jejunum, which involved SMA and the distal duodenum. The tumor was removed by resecting the proximal jejunum using Echelon 60 and intestinal continuity was maintained by side-to-side duodenojejunostomy. The histological diagnosis was primary T-cell malignant lymphoma of the small intestine. The residual tumor showed rapid growth after the operation, and she died 56 days after the operation. Not only early detection of intestinal symptoms but also early diagnosis with PET or small bowel endoscopy before perforation is likely to improve clinical course of primary T-cell malignant lymphoma of the small intestine.

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An 88-year-old woman was admitted to our hospital because of worsening lower abdominal pain. The laboratory findings indicated a severe inflammatory response and abdominal CT scan showed a large amount of gas in the lower anterior abdominal wall. She was immediately given a broad spectrum antibiotic and underwent drainage. Because her condition did not improve, debridement under spinal anesthesia was performed. Extensive necrosis, affecting both fascial planes and subcutaneous tissue, was observed. There was a depression in the right lower abdominal wall. Many weeks later, a CT fistulogram showed fistula formation between the intestinal tract and the right lower abdominal wall. Laparotomy was performed. The fistula had formed between the appendix and right lower abdominal wall. An appendectomy was performed and the fistula was sutured. There have been 6 reported cases of necrotizing fasciitis (NF) caused by acute appendicitis in Japan. We thus report our experience with this rare case with NF caused by acute appendicitis.

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The patient was a woman in her sixties who had had recurrent bouts of right lower quadrant pain every about 6 months since the summer of 2007 and had been treated with conservative therapy with a diagnosis of appendicitis at another hospital. In July 2009, she developed right lower quadrant pain and visited the previous hospital. On hematological examinations, inflammatory findings were of minor degree as the WBC count was 7700/μl and CRP was 1.5 mg/dl, but an abdominal CT scan showed an enlarged appendix. The patient was thus referred to our hospital, when her clinical symptoms had subsided. Considering that she had had recurrent bouts of right lower quadrant pain for these years, we electively performed appendectomy with a diagnosis of appendicitis. The appendix was swollen and showed dark red in color, but grossly no elevated lesion was seen on the surface of mucosa. Histopathologically signet ring cell carcinoma of the appendix was diagnosed, and the surgical margin was reported to be positive. Accordingly ileocecal excision (D2) under laparotomy was performed 22 days after the initial operation. The histopathological diagnosis was signet ring cell carcinoma, mp, n0, and stage I. The patient has been followed in the clinic.
This case of signet ring cell carcinoma of the appendix is presented here, together with a review of the literature.

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Fluminant amebic colitis can develop in an amebic carrier patient triggered by immune suppression. This disease sometimes becomes fatal in a short term resulting from perforation of the digestive tract. We have experienced a case of fluminant amebic colitis presented with a huge rectal ulcer that was induced by systemic chemotherapy for lung cancer. The ulcer worsened to form a refractory vesicorectal fistula and severe inflammatory reaction due to the associated multiple hepatic abscesses was noted. After immediate anti-amebic therapy, we performed a colostomy followed by closure of the colostomy after an interval of 10 months when the cure of the fistula was confirmed. Soon after that, we re-started chemotherapy for lung cacer.
It is rare that fluminant amebic colitis develops by systemic chemotherapy for malignancy. Immediate definitive diagnosis and early initiation of anti-amebic therapy might determine the recovery of such patients.

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We report two cases of colon canser recurrence at the anastomosis site after colectomy, most likely due to implantation of exfoliated cancer cells. Both cases had advanced cancer at the primary surgery and we performed the operations with a hand-sewn anastomosis under laparotomy. The ratio of colon cancer recurrence at the anastomosis site in our department, and we usually perform a hand-sewn anastomosis, was 0.92% (2/217cases) between 2000 and 2009. We did not perform bowel cleaning prior to anastomosis or use povidone-iodine pledgets at the primary operations. Local recurrence probably originated from implantaion. Effective means must be developed to prevent recurrence at the anastomosis site.

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[Introduction] Colovesical fistulas are mostly caused by diverticulitis and sometimes colon or bladder cancer, and so treatment should be carefully selected. [Case] A 77-year-old male visited our hospital because of pollakiuria was diagnosed as to have intractable cystitis. An abdominal CT scan demonstrated a tumor mass which protruded downward from the sigmoid colon and displaced the bladder, and pneumatization in the bladder. With enteroclysis, whole-circumferential stenosis of the sigmoid colon and multiple diverticula and a sigmoidovesical fistula in its oral side were observed. It was difficult to observe the lesion by lower gastrointestinal endoscopy and cystoscopy, and no definitive diagnosis of cancer could be made before surgery. [Treatment and Diagnosis] We performed sigmoidectomy and partial cystectomy. The pathological diagnosis was colovesical fistula due to extramurally growing colon cancer. [Discussion] Internal fistula-forming colon cancer is a locally advanced cancer, but the lymph node metastasis positive rate is comparatively low. It is considered that the malignancy might behave in a different biological manner from cancers involving other organs. We herein report a case of extramurally growing colon cancer forming fistulas within the bladder with some bibliographical considerations.

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A 30-year-old woman with Down's syndrome visited a physician because of bloody stool, diarrhea and abdominal pain. She was diagnosed as enteritis and medicated. However, she had a checkup at another hospital because her symptoms did not improve. Barium enema examination demonstrated a sigmoid colon cancer. So she was admitted to our hospital and underwent sigmoidectomy with lymphnode dissection (D3). She has survived without recurrence as of thirty months after the operation. Patients with Down's syndrome have greater risk of leukemia than the general population, but lower risk of other malignancy, so we report this rare case.

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A 59-year-old man had undergone a low anterior resection and partial resection of the bladder for a rectal cancer (tub2, pSI (bladder), pN0, ly0, v0, pStageII) two years previously. Adjuvant chemotherapy with UFT had been done, however, an abdominal CT scan examination for the follow-up study revealed a tumor in the tail of the pancreas. The size of the tumor was 5 cm in diameter and there was no enhancement at the CT scan. The surrounding tissues were invaded by the tumor and the splenic vein was occluded, which is a typical pattern seen in cases of primary pancreatic cancers. Laboratory findings showed elevated levels of hemoglobin A1c (HbA1c) and carcinoembryonic antigen (CEA). With a diagnosis of cancer of the pancreatic tail (cT4 (PV(+)), cN1, cM0, cStageIVa), a distal pancreatectomy was performed. The histological diagnosis was a metastatic pancreatic tumor from the previous rectal cancer, because tumor cells were negative for CK7 and positive for CK20 and cdx-2 immunohistochemically. Chemotherapy was initiated and is still being given.
Only a small number of cases of metastatic pancreatic tumor have been reported and they were rarely resectable. Only 34 resectable cases have been reported in Japan.

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A 54-year-old woman visited a nearby hospital upon becoming aware of pain in the upper abdomen and after passing yellow urine. Because liver dysfunction was noted, she was referred to our hospital for exploration and treatment. Based on imaging tests, she was diagnosed as having obstructive jaundice due to limy bile which flowed into the common bile duct. Following endoscopic sphincterotomy (EST), calcifications of the gallbladder and the common bile duct disappeared, and the jaundice improved. Subsequently, the patient was followed in the clinic. Ten months after EST, calcifications relapsed in the gallbladder, and hence laparoscopic cholecystectomy was performed. A calculus analysis of cream-colored paste substances observed inside the gallbladder disclosed that 98% or more of these were calcium carbonate. This case is considered valuable, because we could observe the relapsing limy bile within the gallbladder with time after calcifications in the gallbladder and the common bile duct had once disappeared following EST.

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We report a rare case of gallbladder amyloidosis which developed during the treatment of multiple myeloma. A 66-year-old woman was diagnosed with multiple myeloma and renal amyloidosis. She suffered right hypochondrial pain and fever during chemotherapy. Acalculous cholecystitis was diagnosed, and she given antibiotics and subcutaneous gallbladder drainage. However, cholecystectomy became necessary because the cholecystitis recurred. After the operation, the gallbladder was diagnosed pathologically as showing amyloidosis. Renal insufficiency suddenly worsened after the operation, progressing to renal, cardiac and respiratory failure. She died on the 28th day after the operation. Therefore, we concluded that the condition of multiple myeloma plus the existence of amyloidosis in other organs is important in judging the treatment priority for gallbladder amyloidosis.

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We report a case of adenosquamous cell carcinoma of the gallbladder which had a good prognosis after radical resection. A 69-year-old man was admitted with high fever and was initially diagnosed as having an acute cholecystitis and a liver abscess. Finally, the patient was diagnosed as having cancer of the gallbladder, based on CT scan and ultrasonography. The lumen of the gallbladder was filled with a tumor, and liver invasion was present. On blood tests, a high serum SCC level and inflammation was noted. Adenosquamous cell carcinoma was suspected. A radical resection involving cholecystectomy, hepatectomy of S4a + S5 subsegments and common bile duct resection were performed. On histopathology, an adenosquamous cell carcinoma of the gallbladder with massive liver invasion and regional lymphatic metastasis was diagnosed. The final residual tumor status was R0. The patient has survived recurrence-free for 69 months after radical resection without adjuvant therapy.

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A 68-year-old man was admitted to the hospital because of jaundice. Serum total bilirubin level was elevated to 13.6mg/dl. An abdominal CT scan showed the dilatation of the intrahepatic bile duct and the common bile duct (CBD). Cholangiography of percutaneous transhepatic biliary drainage (PTBD) showed a complete obstruction of the distal part of the CBD. Cytology of bile juice from PTBD tube was class I, and serum CEA, CA19-9, and DUPAN-II levels were within normal limits. However, malignancy of the distal bile duct was strongly indicated and pylorus-preserving pancreatoduodenectomy (PpPD) was performed. After the operation, histological examination revealed that the tumor was composed of both a part of cancerous tubular structure and a part showing transition to sarcomatous spindle cells. On immunohistochemical stainings, both epithelial and non-epithelial portions were positive for keratin and cytokeratin, and positive stain to vimentin was also observed in non-epithelial portion, showing so-called carcinosarcoma. Pathological TNM grading (UICC) was pT3 (pancreas) pN2 (peripancreatic) M0, stage IVA. During follow-up period, an abdominal CT scan revealed multiple liver metastases 4 months after the operation. The patient died 8 months after the operation.
Carcinosarcoma of the CBD is so rare that only 19 cases have been reported in the Japanese literature as far as we could review.

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A 68-year-old man developed seen in our hospital abdominal pain. Abdominal echography revealed a multilocular, cystic tumor in the pancreatic body to the tail. Enhanced CT revealed a 7-cm tumor with an irregularly thickened septum. On pancreatography the guide wire reached into this tumor from the main pancreatic duct. PET-CT revealed a concentration in the thickened septal wall. A distal pancreatectomy was done. On pathology a giant cell osteoclastoid type carcinoma was diagnosed. This tumor is rare. We discuss our case and review the relevant literature.

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We report a case with a supravesical hernia showing both external and internal type features. A 59-year-old man who had felt inguinal bulging for 10 years was admitted because of abdominal pain and vomiting. He was found by abdominal computed tomography to have a dilated small intestine pressing the bladder and thereby causing a caliber change in the small intestine. Internal hernia was suspected and emergency surgery was conducted, establishing a diagnosis of strangulated ileus due to incarceration of the ileum in the supravesical hernia. We partially resected the ischemic ileum and closed the hernia orifice. His postoperative course was uneventful. External supravesical hernia and internal supravesical hernia are both very rare. To our Knowledge this is the first report of a supravesical hernia with both external and internal type features.

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A 68-year-old woman who had histories of diabetes and chronic dysuria was hospitalized at the department of orthopedics in our hospital for lumber spinal canal stenosis and syringomyelia in August 2010. In the same month, she developed epigastralgia during hospitalization. Close exploration was performed and an abdominal CT scan disclosed ascites and free air in the abdominal cavity. Moreover bubbles of gas in the wall of the bladder and emphysematous cystitis were identified. Laparotomy was performed with a suspected diagnosis of emphysematous cystitis and perforated peritonitis. However, no perforation was found in the urinary bladder, though crackling sensation was slightly felt. No perforated sites were also seen in the abdominal cavity including gastrointestinal tracts. Intraperitoneal lavage and drainage were carried out and the operation was terminated. The patient's postoperative course was uneventful and another abdominal CT scan confirmed improved findings compared with preoperative ones.
A total of 60 cases of emphysematous cystitis have been reported in Japan, and the disease causing peritonitis has been reported in only three cases. However, no cases of the disease with peritonitis without being associated with perforation or rupture of the urinary bladder, like our case, have been reported so far. It is considered to be an extremely rare pathologic condition so that this case is presented here, together with some bibliographical comments.

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Immediate closure of the abdominal wound is required in the case of an infected open abdomen after abdominal surgery. However, direct closure is usually difficult to accomplish due to edema in the abdominal wall and increased abdominal pressure. We treated a 35-year-old man with an MRSA-infected open abdomen accompanied by an ileus that occurred after a left nephrectomy. Emergent operation was performed, and temporary abdominal wound closure was done using a Silicon Disk^® (Hakko Co., Ltd., Nagano, Japan) as a hernia prosthesis, because direct closure was impossible. Primary closure was successfully performed 21 days later, after sufficient damage control was obtained. The Silicon Disk^® is a disposable device designed for organ retraction during laparoscopic surgery. It is composed of a thin silicon rubber membrane with a flexible metal rim around it. The wound repaired with the Silicon Disk^® held up well against abdominal pressure without the need for any muscle relaxant. Therefore, the patient needed bed-rest for a few days, and an oral diet could be started on the 12th postoperative-day. This device is made of silicon rubber ; therefore, no adhesion to the surrounded tissue was observed at the second operation. The retrieval of the device was quite easy, and primary closure could be done without any difficulty.

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We report a case of mesenteric bleeding following blunt abdominal trauma that was successfully treated with transcatheter arterial embolization (TAE). A 73-year-old man presented with blunt abdominal trauma while reportedly in a state of shock. The first systolic blood pressure reading was 175 mmHg, but then decreased to 80 mmHg. We performed rapid fluid resuscitation, and systolic blood pressure rose to 100 mmHg. Computed tomography revealed contrast media extravasation from a branch of the ileocolic artery with no evidence of bowel perforation. Thereafter, systolic blood pressure again decreased to 80 mmHg. We performed another blood transfusion, and systolic blood pressure rose to 100 mmHg. A diagnosis of transient responder state of shock was made. We successfully performed TAE at the bleeding site, after which the patient recovered from shock. Laparotomy was not required and the patient left our hospital 14 days later. Thus, TAE can be regarded a suitable treatment for patients with mesenteric bleeding in a transient responder state of shock.

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A 44-year-old man complained of abdominal pain and was initially diagnosed as having an acute abdomen. Finally, SMVT was diagnosed, and a small intestinal resection was done during emergency surgery. After the operation, heparin was given as anticoagulant therapy. Suddenly on the 11th day, the patient's platelet count decreased. HIT was diagnosed since there were no symptoms of DIC. Heparin was discontinued at once, and argatroban was administered. The anti-PF4/heparin complex antibody was detected. Warfarin anticoagulant therapy was initiated after the platelet count recovered. The patient was discharged from hospital on the 30th day.

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A male patient in his 60s who initially presented with a 2-month history of abdominal bloating and reduced appetite is reported. Although abdominal bloating was seen on initial examination, the patient had no abdominal pain or fever, and he had only a mildly elevated CRP. CT showed massive ascites, pleural effusion, and inflammation extending from near the pancreatic body to the mesentery, as well as an irregular mass in the lower part of the pancreas that surrounded the superior mesenteric artery (SMA). Abdominal paracentesis showed that the ascitic fluid was chylous, Sudan-positive, and bacterial culture-negative, and cytology showed no malignant findings. The ascitic fluid had abnormally high CA125 levels. Since diagnosis was difficult, excision biopsy of the mesenteric mass was performed under general anesthesia to confirm the diagnosis and determine whether the mass was benign or malignant. The ascitic fluid was chylous, adhesive, and hemorrhagic. Pathologically, fibrous connective tissue with lymphocytic infiltration, granulation, and panniculitis were observed, but no malignant findings were seen. The patient was diagnosed as having mesenteric panniculitis accompanied by massive chylous ascites. Steroid treatment resulted in marked effects, including reductions in ascites and the size of the inflammatory mass.

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