Laparoscopy-assisted distal gastrectomy has recently spread as a surgical treatment for early gastric cancer. The objective of this study is to inspect the validity of laparoscopy-assisted distal gastrectomy (LADG) for early gastric cancer. Between October 1999 and August 2010, consecutive 100 patients with early gastric cancer undergone LADG and 76 patients undergone open distal gastrectomy (ODG) in our institute were retrospectively compared for therapeutic outcome. To evaluate the impact of obesity, we classified these patients into two groups based on body mass index (BMI). Blood loss was significantly less (P<0.0001) and postoperative ileus was significantly less frequent (P=0.0113) in the LADG group than the ODG group. There was no significant difference between the LADG and the ODG groups in the cancer recurrence (P=0.9999). In the high BMI patients from the LADG group, significantly longer operation time (P=0.0319) and significantly larger amount of blood loss (P=0.0009) were noted than those in the normal BMI patients. LADG for early gastric cancer is a feasible and, minimally invasive procedure compared favorably with ODG and the oncologic safety is similar to ODG. Therefore, LADG should be recommended as a standard surgical treatment for early gastric cancer.

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The aim of this study was to evaluate laparoscopic surgery outcomes in right-sided diverticular disease. A case series of 20 consecutive patients who underwent laparoscopic surgery for right-sided colonic diverticular disease between September 2003 and February 2010 was evaluated. The surgical data and the postoperative complications were primarily reviewed. The operative indication was active bleeding (14 patients) and repeat diverticulitis (7 patients). The median operative time was 143 minutes, and the median blood loss was 25 ml. Operative time and blood loss for right-sided early colonic cancer laparoscopic surgery (n=58) done during the same period were 158 minutes (p=0.28) and 20 ml (p=0.11) respectively. In right-sided diverticular disease laparoscopic surgery patients, the median hospital stay was 7 days ; in all 6 patients (30%) experienced postoperative morbidity. There were no cases of mortality or anastomosis leakage. There were no conversions to open surgery. In right-sided diverticular disease, laparoscopic surgery is safe and feasible.

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[Aim] Recently, although the frequency of surgery in patients with severe acute pancreatitis (SAP) is quite rare, operative intervention is still necessary under specific conditions. In this study, we evaluated the outcomes of SAP patients who were treated with surgery. [Method] Subjects were 7 patients diagnosed with SAP and treated by laparotomy at out hospital from January 2008 to December 2010. [Results] The median age of surgery group was 59 years, gender male (n=6)/female (n=1), etiology alcohol (n=3), idiopathic (n=2), gallstone (n=1), traumatic (n=1). Five of the 7 patients were treated with arterial infusion therapy before surgery. The interval to surgery was more than 100 days in 5 patients and 5 patients unberwent a distal pancreatectomy. One patient died with disseminated intravascular coagulation after surgery, but 6 patients were discharged without any severe events. [Conclusion] Nowadays, surgical intervention for SAP patients has been rare, but surgery could still be necessary for some patients, especially for whom conservative therapy has failed.

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A 45-year-old man was urgently admitted to our hospital because of a several-week history of high fever and back swelling. During examination, the patient's consciousness was clouded, and his skin between the neck and back was red and swollen. A blood examination on admission revealed severe inflammation and abnormal blood coagulation. Computed tomography showed an increased density of the subcutaneous adipose tissue with gas extending from the neck to the back, multiple nodular shadows in both lungs, and bilateral pleural fluid retention. Because acute respiratory failure associated with septic shock was suspected, the patient was transferred to ICU. Incision of the swollen skin revealed necrosis of some fascias with a large amount of light yellow pus discharge. A culture of the pus yielded methicillin-resistant Staphylococcus aureus (MRSA). Early incision, pus drainage, debridement, and antimicrobial treatment were performed, and the patient was discharged from the hospital on the 93rd day of hospitalization.
This is the tenth case of necrotizing fasciitis triggered by MRSA infection in Japan. We report this rare case with some bibliographic considerations.

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The patient was an 82-year-old woman. She complained about an inflammatory wall mass, 10 cm×10 cm in size, on her chest wall. Preoperative percutaneous needle biopsy of this wall mass showed necrotizing granular cells. Complete resection of the tumor including a rib bone was parformed. The resected specimen of the tumor was found to be a tuberculoid granuloma. The postoperative anti-tuberculous treatment course was completed. No recurrence has been seen in 20 months.

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A 73-year-old man underwent preoperative chemotherapy, followed by subtotal esophageal resection, 2-field lymph node dissection, posteriormediastinal reconstruction with the stomach tube with a diagnosis of cancer of the lower thoracic esophagus. On the next day after the operation, redness appeared on the surgical wound at the midline of abdomen. The wound was thus kept open and a culture was carried out. The redness on the abdominal midline gradually enlarged and black-colored necrosis became apparent. Acute circulatory failure and worsening respiratory condition were noted, and an abdominal CT scan and upper gastrointestinal endoscopy were performed. The CT scan showed a remarkable increase in density of fatty tissue surrounding the midline wound. Upper gastrointestinal endoscopy revealed the mucosal surface of the stomach tube to be of an abnormal hue. Necrosis of the stomach tube was likely. Emergency surgery on the same day was performed to identify and to remove the necrotic stomach tube, including removal of the stomach tube, esophagostomy, and debridment of the midline wound. The causative microorganism of the wound was identified to be Aeromonas hydrophila, and infectious shock caused by A. hydrophila was diagnosed. The patient demanded intensive care after the operation, but eventually recovered. Closure of the esophagostomy, reconstruction of the right colon and skin grafting for the wound were conducted on the 62nd hospital day, and the patient was discharged very much improved on the 143rd hospital day after the initial operation.
Reports on Aeromonas hydrophila infection presented with surgery are few, but it often follows a rapidly progressive downhill course and might be a postoperative complication to be cautioned.

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Chyloperitoneum is a rare postoperative complication after gastrectomy. We report two cases of chyoperitoneum with paraaortic lymph node metastasis-positive gastric cancer who received neoadjuvant chemotherapy.
Case 1 : A 66-year-old male gastric cancer patient with multiple paraaortic lymph nodes and right supraclavicular lymph node metastases had undergone two cycles of S-1 + CDDP neoadjuvant chemotherapy and had a distal gastrectomy with D2 lymph node dissection as well as paraaortic lymph node sampling for chemotherapy evaluation. Chyloperitoneum occurred one month after the operation. Chyloperitoneum was not cured after three months of consevative treatment (total parenteral nutrition). Thus surgery was undertaken but the lymphatic fistula could not be found ; therefore, definitive surgical treatment was not possible. After the operation, two more weeks of conservative treatment reduced the chyloperitoneum.
Case 2 : A 64-year-old male gastric cancer patient with multiple paraaortic lymph node metastases underwent three cycles of S-1 + CDDP neoadjuvant chemotherapy and had the same operation as described in case 1. Chyloperitoneum occurred one month after the operation. Two months of consevative treatment involving total parenteral nutrition were required to achieve a cure.
Neoadjuvant chemotherapy for multiple paraaortic lymph node metastases could be a risk factor for postgastrectomy chyloperitoneum.

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We report a case of a woman in her 70's who was suspected of having sarcoidosis 2 years prior. She was referred to our hospital for further evaluation of a gastric cancer. Barium enema study and endoscopic examination showed a type 3 tumor located at the corpus ; biopsy revealed a poorly differentiated adenocarcinoma. Computed tomography (CT) showed extensively enlarged lymph nodes and multiple low-density areas related to the spleen ; 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed abnormal FDG uptake at these sites. These lesions had been noted on the CT scan obtained 2 years prior and had been considered to be sarcoidosis. The patient underwent a distal gastrectomy with D2 lymph node dissection and needle biopsy of the spleen. Histological examination of the spleen revealed inflammation with granuloma formation ; thus, a definite diagnosis of splenic sarcoidosis was made based on the patient's medical history. We report a rare case of splenic sarcoidosis that required differentiation from gastric cancer metastasis ; the treatment is also discussed.

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A 46-year-old woman admitted for upper abdominal pain was found to have an elevated tumor located in the papilla of Vater. Based on a biopsy, a neuroendocrine tumor of the papilla of Vater was diagnosed. We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node dissection. The histological findings showed adenoendocrine cell carcinoma in the papilla of Vater. The patient has had no signs of recurrence in the 39 months since the surgery. Adenoendocrine cell carcinoma arising in the papilla of Vater is extremely rare, and only 14 cases, including our case, have been reported. Although the prognosis of endocrine cell carcinoma is ordinarily dismal, our patient has remained disease-free for 39 months since her surgery, presumably thanks to adjuvant chemotherapy, oral S-1.

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A 90-year-old woman was referred to the hospital because of the abrupt onset of upper abdominal pain occurred about 2 weeks after she ate a slice of salmon, so-called “harasu (fish meat over the viscus)”. An abdominal CT scan showed abscess formation in the upper abdomen, and an about 2 cm-long high density linear shadow was identified within the abscess. Intraperitoneal abscess due to a fish bone was diagnosed and the patient was urgently admitted for observation of her clinical course. On the next day, peritonitis was exacervated and emergency operation was performed. Laparotomy disclosed an abscess at an area surrounded by the proximal jejunum, its small bowel mesentery, and the greater omentum, and a fish bone which had passed into the abscess. However, no perforated site was detected at the jejunal wall and only abscess drainage was performed. The postoperative course was uneventful. She was discharged from the hospital on the 15th postoperative day.
We present this case of perforation of the jejunum due to an ingested fish bone which was cured by drainage without any invasive surgical therapies, because no perforated site was identified during surgery though the fish bone was found in the intraperitoneal abscess. Some bibliographical comments are presented as well.

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A 53-year-old man with a past history of diverticulitis and diverticular bleeding visited our hospital because of fever and right lower abdominal pain.
Abdominal CT scan revealed air-bubbles at the ileocecal region. Emergent surgery was performed with a preoperative diagnosis of penetrating diverticulum of the terminal ileum based on a past abdominal CT scan comparison. Ileocecal resection and intraabdominal drainage were performed. The resected specimen revealed an ileal diverticulum penetrating the mesentery at the point 3cm proximal to Bauhin's valve. Pathological examination demonstrated a mesenteric abscess caused by penetration of the terminal ileal diverticulum. The postoperative course was uneventful and he was discharged 14 days after the operation.

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The patient was a 79-year-old man who had received endoscopic retrograde biliary drainage (ERBD) subsequent to endoscopic stone extraction for acute cholangitis caused by common bile duct stones at another hospital. A pigtail ERBD tube had been indwelt in the common bile duct. He was admitted to our hospital six months later because of lower abdominal pain. An abdominal CT scan revealed an ERBD tube migrated to the small intestine and intra-abdominal free air, so an emergency surgery was done. Intra-operative findings included multiple diverticula mainly in the ileum, and perforation of a diverticulum caused by the ERBD tube. Partial resection of the small intestine was performed. Histopathological findings showed the perforated diverticulum with inflammation and ulceration. Diverticulitis or long-term contact with the ERBD tube had presumably formed ulcer at the wall of a diverticulum, and ERBD tube had perforated the thinning wall of the diverticulm due to mechanical tress including peristalsis. We present this rare case of ileal perforation with multiple small bowel diverticulosis caused by a migrated biliary pigtail stent.

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An 80-year-old man, who had been diagnosed with chronic myelomonocytic leukemia (CMML) was admitted due to bloody stools. Endoscopic study, CT scan and angiography failed to detect the origin of the bleeding. However scintigraphy revealed the small bowel to be the origin. Surgery was performed with intraoperative endoscopy, and several ulcers were observed in the small bowel, followed by resection from the ileum to the cecum, including the ulcers. Pathologically, infiltrations of myelocytic and monocytic cells in the submucosal layer of the ulcers were observed, such that the bleeding was concluded to be from the ulcers which had resulted from necrosis of the mucosa due to infiltration. CMML is a preleukemic disease and infiltration of proliferating monocytic cells is on occasion seen in various organs, but is relatively rare in the intestine. Attention is necessary during the operative course in patients with hematologic diseases, as in this case. Also, we emphasize the effectiveness of intraoperative endoscopy to detect the origin of the bleeding and to determine the range of resection.

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A 65-year-old man was admitted to our hospital for abdominal pain and anemia. Laboratory data showed severe anemia, marked inflammatory response and elevation of tumor marker. Abdominal CT scan and MRI examination showed a small intestinal tumor with a thickened wall and bilateral adrenal tumors, which was possibly metastasis. An emergency operation was performed for possible intestinal bleeding. On opening the abdomen, a small intestinal tumor was located 20 cm from the Treitz' ligament and invading the descending colon. Partial excision of the small intestine was performed with combined resection of the descending colon. Histopathologically, the tumor was undifferentiated carcinoma of the small intestine. Immunohistochemical examination showed the lesion to be positive for CAM5.2, AE1/AE3 and vimentin. Undifferentiated carcinoma of the small intestine has been rarely reported. We describe the clinical experience of the present case and review the relevant medical literature.

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A 76-year-old woman complained of right lower abdominal discomfort. Barium enema and colonoscopy showed a submucosal clevated lesion in the cecum. Abdominal computed tomography revealed a 4.0×1.5 cm mucocele of the appendix. A preoperative diagnosis of an appendiceal benign mucinous cyst was made. A laparoscopic partial excision of the cecum was done. The diagnosis of an appendiceal mucinous cystadenoma was confirmed, and the surgical stumps were negative on intraoperative histopathology. The postoperative course was uneventful, and the patient was discharged on the 7th hospital day.
Laparoscopic surgery and partial excision of the cecum are appropriate for a cystic lesion of the appendix when the preoperative diagnosis is benign.

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The patient was a 60-year-old woman receiving chemotherapy for malignant lymphoma of the left neck region. She visited our facility, with chief complaints of abdominal pain and vomiting. Slight swelling and tenderness were noted in the hypogastric region, but the hematological tests revealed no elevation of inflammatory reactions. CT scans disclosed dilatation of the small bowel through the transverse colon. Because abdominal symptoms were mild, the patient was followed without active treatment, while avoiding oral ingestion. On the 14^th hospital day, she developed right hypogastric pain and fever. CT scans revealed thickening of the appendix. However, since severe inflammation was noted around the ileum, we considered this to be the primary site of inflammation and adopted conservative treatment. CT scans on the 25^th day disclosed further thickening of the appendix, accompanied by thickening of the surrounding ileal wall. She was thus suspected of having appendicitis and terminal ileitis associated with an appendiceal tumor, and open abdominal surgery was carried out. The appendix, white, hard and degenerative, was resected. Histopathological examination of the resected tissue allowed a diagnosis of recurrent diffuse large B cell lymphoma. The postoperative course was uneventful, allowing resumption of chemotherapy on the 25^th postoperative day. Our experience with this case suggests that when dealing with a patient complaining of abdominal symptoms during treatment of malignant lymphoma, we must keep in mind the possibility of intraperitoneal lesions.

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A 73-year-old man was found to have an elevated lesion suggestive of a submucosal tumor in the orifice of the appendix on colonoscopy. Following endoscopic biopsy and histopathologic examination, a tubular adenoma with moderate atypia was diagnosed. To confirm the diagnosis of this pre-malignant lesion, a laparoscopic appendectomy was done in November, 2005. A 40-mm tumour with a granular surface, completely contained in the resected appendix, was sent to pathology. A diagnosis of colonic-type well-differentiated adenocarcinoma confined to the mucosa was made. After 5 years of follow-up, the patient remains well without any evidence of recurrence. In contrast to the previous studies favouring more aggressive operations for appendiceal cancer, the present study suggests that a simple appendectomy can be safely used in patients with a colonic-type appendiceal mucosal cancer. Laparoscopic appendectomy, including a single-incision approach, is a feasible altemative to open appendectomy for early appendiceal cancer.

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Pneumatosis cystoides intestinalis (PCI) is a comparatively rare disease characterized by the inclusion of numerous small gas-containing cysts within the submucosal or subserosal layer of the intestinal tract wall. PCI is a symptom contributing to damage in the intestine including necrosis, and when intestinal necrosis is suspected, emergency surgery might be required. We report four cases of PCI cured by conservative therapy. The mean age was 77.5 years (57-90 years). One case was male, 3 were female. Though PCI was present in all cases, abdominal manifestations were slight and there was no peritoneal irritation symptom. Intraperitoneal free air was present in 3 cases, and 2 cases also had ascites. Portal venous gas was demonstrated in 2 cases one case also had retroperitoneal emphysema. All cases resolved with conservative therapy.
PCI is not an indication for surgery by itself and treatment policy must be decided based on general status, abdominal symptoms and various laboratory findings.

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A 60-year-old man was seen at the hospital because of left lower quadrant pain. An abdominal ultrasonic study and an abdominal CT scan showed a tumor shadow 4 cm in diameter just under the left lower quadrant of the abdomen and adjacent to the sigmoid colon. From these findings, epiploic appendagitis was the most likey diagnosis. The patient's clinical course was observed conservatively, but the abdominal pain persisted. The patient was thus admitted to the hospital to remove the epiploic appendage, and underwent laparoscopic-assisted resection of the epiploic appendage of the sigmoid colon. During surgery, we confirmed that the epiploic appendage of the sigmoid colon was adherent to the abdominal wall with inflammatory changes. The adhesions were dissected under laparoscopy and the appendage was pulled out from the small incision to outside of the body, when we saw the swollen appendage 2 cm in diameter with inflammatory changes. The appendage was ligated, transected, and removed. The histopathological findings included congestion, infiltration of inflammatory cells, and fat necrosis, and epiploic appendagitis was finally diagnosed.
Epiploic appendagitis is a rare entity and the differentiation from diverticulitis of the large intestine is important. As recent imagine diagnostic methods including CT and ultrasonography increasingly make progress, we are likely to gain imaging findings characteristic of epiploic appendagitis more often. This paper presents a case of epiploic appendagitis diagnosed preoperatively and treated by laparoscopic-assisted resection.

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We experienced two patients with ulcerative colitis showing exacerbation after pregnancy or delivery. A postpartum 29-year-old woman experienced massive anal bleeding due to ulcerative colitis exacerbation. She underwent emergent subtotal colectomy. The next day, massive anal bleeding recurred, necessitating emergent residual rectal resection.
A 27-year-old woman was admitted to our hospital for repeated melena due to ulcerative colitis exacerbation. After admission, she was found to be 6 weeks pregnant. She underwent laparoscopic subtotal colectomy with abortion, because the bleeding could not be stopped with internal medical therapy. There are few reports focusing on exacerbation of ulcerative colitis during pregnancy or after delivery. We report two cases with a review of the relevant literature.

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A 43-year-old female with type 1 diabetes was referred to our hospital with a suspected perforation of the gastrointestinal tract. The patient presented with fecal incontinence and abdominal pain. A CT scan showed severe colon dilation and peri-sigmoidal inflammation. Defecation was not induced despite the administration of laxatives and enemas for 5 days. A gastrographin enema X-ray showed obstruction in the rectosigmoid colon. Colonoscopy showed fecal impaction and a geographic ulcer. Emergent laparotomy was performed because of the appearance of dyspnea due to abdominal swelling and the possibility of colon perforation due to the wide-spread ulcer. Operative findings included severe dilation of the colon with massive feces and inflammatory change around the sigmoid colon. Under observation of the site of the ulcer formation during colonoscopy, the sigmoid colon containing the ulcer was resected, and a Hartmann operation was performed. The resected specimen showed a geographic ulcer involving the whole circumference with the typical finding of a stercoral ulcer. The colostomy was closed 4 months after the operation.

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A 79-year-old woman visited the hospital because of abdominal distention and vomiting was admitted with a diagnosis of ileus. On physical examination, swelling of an umbilical hernia was noted but abdominal findings were absent. Several examinations revealed no causes of ileus. Then, we repaired the umbilical hernia, but abdominal distention persisted after the operation. Gastrografin enema examination after depressurization of the small intestine by an ileus tube revealed a tumor at the ascending colon. We thus performed right hemicolectomy with lymph node dissection and the pathological diagnosis was well differentiated adenocarcinoma. The patient's postoperative course was satisfactory, but one year after the operation, she visited the hospital complaining of a palpable tumor in the lower abdomen with pain. An abdominal CT scan revealed a tumor on the rectus abdominis muscle and a tumor of the transverse mesocolon. We suspected metastasis to the rectus abdominis muscle and peritoneal dissemination from colon cancer, and performed the resection of both muscle and mesocolon tumors and abdominal wall repair. Pathologically both tumors were proved to be metastasis from adenocarcinoma of the colon. Despite postoperative chemotherapy, multiple metastases appeared. She has been receiving palliative treatment.

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A 64-year-old man complaining of left hypochondralgia was diagnosed as having cancer of the transverse colon with an abdominal wall abscess and a jejunocolic fistula following close examinations. Abscess drainage was performed, followed by laparotomy after inflammatory findings subsided. Upon laparotomy there were no ascites, peritoneal dissemination and hepatic metastases, and then transverse colectomy with associated resection of the abdominal wall and the jejunum was performed. The resected specimen involved a 60×50 mm type 2 tumor in the transverse colon and a fistula with the jejunum. The histopathological diagnosis was moderately differentiated adenocarcinoma with direct invasion into the jejunum. The pathologic staging was SI (jejunum), N0, H0, P0,M0 and Stage II. The patient's postoperative course was uneventful. No recurrence has occurred as of 3 years after the operation.
Although it is extremely uncommon that colon cancer appears with an abdominal wall abscess and a jejunocolic fistula, favorable prognosis can be expected by aggressive associated resection.

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A 63-year-old woman with colon cancer had a colon resection in 2000 and subsequently had three pulmonary metastasis resections. She was followed at our hospital and her tumor marker level was elevated abnormally, 8 years after colon resection. After examination for recurrence, she was diagnosed with pancreatic metastasis from the original colon cancer. A distal pancreatectomy was performed in March 2008. The resected lesion had a microscopic appearance that was similar to the primary tumor, not only morphologically, but also immunohistochemically. Resectable pancreatic metastasis from colon cancer is so rare that our search of the literature revealed only 36 cases reported in Japan, including this case, which we report with a review of the literature.

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A 29-year-old woman was seen at our hospital because of a 6-month history of abdominal pain. The pain gradually increased in intensity for these months. Abdominal ultrasonography and contrast-enhanced computed tomography showed intussusception caused by a cecal tumor. Colonoscopy revealed type 1 cecal cancer encircling the bowel and we could not pass the scope through the lumen. Gastrograffin enema showed a mass like a crab claw from the cecum to the ascending colon. Pathological examination of the biopsied specimen revealed well differentiated adenocarcinoma. We made the diagnosis of intussusception caused by the cecal carcinoma and conducted right hemicolectomy with D3 dissection. At laparotomy, we saw that the cecal tumor had prolapsed into the lumen of the ascending colon. The resected specimen involved an 85×60mm tumor in the cecum. The final histological diagnosis was well differentiated adenocarcinoma, se, n2, StageIIIb (Japanese Classification of Colorectal Carcinoma, the 7^th Edition). The patient has been free from recurrence as of one year after the operation. We reviewed 21 cases of colorectal cancer presented with intussusception in younger people reported in the Japanese literature, including the present case.

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The patient was a 56-year-old woman who had been diagnosed as having left-sided chronic ulcerative colitis at the age of 40 and her disease was currently in a chronically sustained condition after the course of repeated exacerbation and relief. Colonoscopy performed during yearly cancer surveillance showed stenosis at the sigmoid colon through which the fiber could not pass. A biopsy of the same area resulted in Group 5. Magnifying endoscopy showed the pit pattern to be of VI-VN. EUS revealed the tumor invading the forth layer or deeper in the sigmoid colon. Barium enema showed disappearance of hustra and manifestation of lead pipe figure from the rectum to the splenic flexure, and a stenotic lesion in the sigmoid colon. Colitis cancer was thus diagnosed and ileal pouch anal anastomosis with covering ileostomy was performed. The histological diagnosis was advanced colon cancer with the size of 45×38mm, muc>tub2, se, and n (-) ; dysplasia was also seen around the cancer lesion.
In chronic ulcerative colitis, destruction and repair of the pit may be repeated on the background mucosa due to persistent inflammation so that non-cancerous areas can show an abnormal pit pattern that makes early diagnosis of the disease difficult.

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A 34-year-old male was referred to out hospital for surgical treatment of liver tumor, which was pointed out during the treatment of a left adrenal gland tumor. In the laboratory data on admission, normal liver function was noted and the markers for hepatitis virus were negative. Preoperative diagnostic imaging such as abdominal ultrasonography, CT and MRI revealed a well-defined and dumbbell-shaped tumor, 6 cm in size in the lateral segment. The ventral part of the dumbbell-shaped tumor containing a central scar was diagnosed as FNH preoperatively ; but the other part of the tumor had neither a central scar nor a typical contrast-enhanced pattern of FNH, so that we were not able to reach at definite clinical diagnosis. Then a lateral segmentectomy of the liver was performed. Postoperative histopathological examination showed a well-defined tumor consisting of two compartments ; one was on the ventral side which was diagnosed as FNH, and the other one was on the dorsal side which was telangiectatic FNH. Both lesions were connected to each other resulting in a single tumor. We report a rare case of a benign liver tumor with two different components, FNH and telangiectatic FNH, treated by surgical resection.

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A 46-year-old man was seen at the department of gastroenterology in our hospital because of upper abdominal pain. Imaging methods revealed a 4 cm-sized hypovascular tumor with the heterogeneous center at the pancreas head and several nodular lesions in the liver. The pancreas tumor and the multiple nodules in the liver gradually increased in size, and on the 10th hospital day, the tumor at the pancreas head ruptured and was bleeding. Emergency hemostatic drainage was thus performed. The multiple nodules in the liver increased in size on the sixth postoperative day, and a nodule in the S3 ruptured and was bleeding. TAE was performed aiming at establishing temporal hemostasis and saving his life. He died of hepatic failure on the 10th postoperative day or on the 22nd hospital day. Based on autopsied findings, hepatic angiosarcoma was finally diagnosed.
We present this rare case of hepatic angiosarcoma presented with a tumor of the pancreas head and was diagnosed with difficulties. Some bibliographic comments are presented as well.

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We report a case of abdominal pain associated with the intrapancreatic residual bile duct (BD) after an operation of anomalous arrangement of the pancreaticobiliary duct (AAPBD). A 36-year-old man, who had undergone a cholecystectomy and partial resection of the extrahepatic BD with hepaticojejunostomy for AAPBD with dilated BD, had occasional abdominal pain after the operation. We conducted a total resection of the intrapancreatic residual BD under a diagnosis of intrapancreatic residual cholangitis. We exfoliated the intrapancreatic residual BD to the confluence of the pancreatic and BD in the pancreas, which was completely resected after ligation of the BD terminal. There have been many reports referring to malignant changes of intrahepatic residual BD after an initial operation for AAPBD. Therefore, complete resection of the extrahepatic BD, including the intrapancreatic region is essential in the operation for AAPBD. Moreover, when the residual BD in the pancreas is found, reoperation for complete resection of the BD should be considered.

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We report a case of pancreatoduodenal injury successfully treated with second-stage pancreatojejunostomy. A 60-year-old man sustained a blunt injury to the upper abdomen due to falling from a height of 4 m. Emergency laparotomy revealed complete disruption of the head of the pancreas and transection of the first portion of the duodenum. The distal end of the transected portion of the duodenum was closed, and distal gastrectomy with Billroth II reconstruction was performed. Pancreatic injury was managed by external drainage of pancreatic juice through the pancreatic tube and intra-abdominal drains. Postoperative percutaneous biliary drainage was required because of delayed common bile duct obstruction. Three months after the injury, the patient underwent delayed reconstruction by the modified Child's method and recovered uneventfully. In the case of proximal pancreatic injuries with disruption of the main pancreatic duct, procedures to preserve the distal pancreas are required. However, these procedures may be hazardous in unstable patients. Hence, a delayed second-stage reconstruction following an abbreviated emergency laparotomy is a reasonable option.

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Lymphangioma of the pancreas is a very rare benign tumor, and it is thought to be caused by obstruction of the lymphatic tract. Most lymphangiomas of the pancreas reported previously were polycystic tumors, so their differential diagnosis were mostly cystic tumors of the pancreas. We experienced a case of primary cavernous lymphangioma of the pancreas, which was resected under the diagnosis of a solid pancreas tumor by the preoperative findigs.
A 66-year-old man with diabetes mellitus was admitted to our hospital because of right upper abdominal pain. Computed tomography revealed a 2.5 cm diameter tumor in the pancreatic body. Distal pancreatectomy was performed under the diagnosis of a non-functioning pancreatic endocrine tumor. The resected tumor was dark brown with a fibrous capsule and was diagnosed as cavernous lymphangioma on pathology.
This report deals with the primary cavernous lymphangioma of the pancreas which seemed to be a solid pancreas tumor.

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A 76-year-old woman complaining of appetite loss and vomiting visited a hospital in January 2010. She was found to have a mass at the second portion of the duodenum and referred to our hospital.
An upper GI examination revealed severe stenosis in the second portion, whereas esophgogastroduodenoscopy showed an almost normal mucosa. Biopsy showed no malignancy. Abdominal CT showed a umorous leision at the head of the pancreas. Groove pancreatic carcinoma was suspected. Pancreaticoduodenectomy was performed and the pathological diagnosis was adenocarcinoma of the groove involving the duodenal wall. The main pancreatic duct was normal. We describe our case of pancreatic groove carcinoma and discuss the relevant literature.

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The patient was a 75-year-old woman with hypertension and diabetic mellitus who regularly visited our hospital. In May 2010, she consulted a plastic surgeon at our hospital with a 2-month history of a tumor of the umbilicus. Abdominal computed tomography (CT) showed a low-density mass of about 5 cm in diameter in the pancreatic body and an enhanced mass of about 2 cm in diameter in the umbilicus. Although we could not make a definite diagnosis by biopsy, we diagnosed the tumor as pancreatic cancer with umbilical metastasis. There was no evidence of metastasis except in the umbilicus. We performed a distal pancreatectomy and umbilical tumor resection in July. Umbilical metastasis from an internal malignancy is known as Sister Mary Joseph's nodule and has a very poor prognosis. Here, we report a rare case of umbilical metastasis from pancreatic cancer.

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A-59-year-old man found to have a pancreatic tumor on CT underwent distal pancreatectomy (DP) in May, 2003. The pathologic diagnosis was T2N1M0 StageIII. After the operation, chemotherapy with Fluorouracil from the hepatic artery and the portal vein was dministered. In May 2006, his CA19-9 level was increased. Although CT and MRI revealed no lesions, PET-CT only showed a pancreatic head tumor indicating recurrent pancreatic cancer. We performed a total pancreatectomy and the pathologic diagnosis was T4N1M0 StageIVa. In January, 2008, metastases to mediastinal lymph nodes and the lung were seen on CT. Therefore, systemic chemotherapy (TS-1) and radiotherapy were administered. In August, 2008, metastasis appeared in Douglus' pouch on CT performed to identify the cause of constipation. He thus underwent radiotherapy in September, and chemotherapy (TS-1/GEM). In January, 2009, he died. We report this patient who survived nearly 5 years and 7 months after DP, and 2 years and 11 months after total pancreatectomy.

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A 49-year-old male who had complained of epigastralgia for a month and had noted dark urine for approximately 2 weeks, came to our hospital for evaluation. His abdominal CT scan showed an irregular enhanced tumor at the head of the pancreas, and cystic lesions on the cranial side of the tumor. MRCP revealed that the common bile duct and main pancreatic duct were compressed by the cysts and tumor, and both showed peripheral dilatation. Abdominal angiography showed no vessel invasion by the tumor, and demonstrated heterogeneous staining of the tumor. He was diagnosed as having adenocarcinoma at the pancreas head, and underwent a pancreatico-duodenectomy. The tumor, measuring 4.3 cm×4.2 cm in size, occupied the pancreatic head, and the pathological diagnosis was non-functioning well-differentiated endocrine carcinoma of the pancreas. The main pancreatic duct was completely destroyed by the tumor. Retention cysts were observed on the cranial side of the tumor, and the common bile duct near the papilla of Vater was obliterated by the tumor. The patient had no complications after the surgery, and was discharged from our hospital after one month.

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An 84-year-old man complained of epigastralgia. Abdominal CT showed a low-density tumor about 30 mm in diameter in the body of the pancreas close to a pancreatic cyst. Endoscopic retrograde pancreatography revealed a stenotic lesion of the main pancreatic duct in the body of the pancreas with a dilated distal pancreatic duct. Endoscopic ultrasonography revealed a mural nodule in the pancreatic cyst ; this nodule extended to the irregular pancreatic body tumor. The patient was diagnosed with invasive ductal carcinoma derived from an intraductal papillary mucinous neoplasm (IPMN), a distal pancreatectomy was done. The histopathological diagnosis was adenosquamous carcinoma derived from IPMN. The patient is doing well without recurrence 23 months after the operation. We report a case of adenosquamous carcinoma of the pancreas derived from IPMN and review the literature.

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A 62-year-old woman undergoing surgery to remove ovarian cancer and postoperative chemotherapy in March 2003 had been followed in the clinic until March 2010, when the serum level of CA125 started to increase. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed abnormal uptake of FDG in the spleen. An abdominal CT scan showed a tumor in the spleen. Solitary metastasis to the spleen from ovarian cancer or primary splenic tumor was likely and we conducted laparoscopic splenectomy in April 2010. The pathological diagnosis of the tumor was adenocarcinoma compatible with metastasis from ovarian cancer. The patient's postoperative course was uneventful. She was discharged on 6th postoperative days and underwent adjuvant chemotherapy as an outpatient. There have been no recurrence as of 4 months after the surgery.
Since solitary splenic metastasis from ovarian cancer is rare, we report on this case with some bibliographical comments.

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A 66-year-old female was admitted for abdominal pain. The patient had undergone a radical hysterectomy and had received postoperative irradiation for carcinoma of the uterus at 43 years of age, and a neurogenic bladder was diagnosed at 64 years of age. After admission, her symptoms improved with conservative treatment. One week after admission, she complained of severe acute abdominal pain. Abdominal CT showed a large amount of free fluid in the peritoneal cavity. The punctured ascitic fluid was slightly muddy. Peritonitis due to spontaneous rupture of the urinary bladder was suspected. The patient received nonsurgical treatment including intra-abdominal drainage and a urinary catheter. Cystography showed leakage of the contrast medium into the peritoneal cavity. After treatment, she did not have any symptoms, and she was discharged with an indwelling urinary catheter.
Perforation of the urinary bladder should be considered in patients presenting with acute abdomen, particularly in those with previous histories of pelvic irradiation or neurogenic bladder.

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A 49-year-old woman had a third recurrence of peritoneal dissemination related to an abdominal malignant soft tissue tumor. She had an ileocecal resection, partial sigmoidectomy, and extirpation of 9 disseminated lesions ; the remnant ileum was 70 cm long. Histological finding included undifferentiated pleomorphic sarcoma (pleomorphic malignant fibrous histiocytoma). Immunohistochemistry showed non-specific differentiation with negative CD34, S-100, desmin, and positive SMA. Seven months later, the patient had recurrent tumor related to dissemination. Since she already had short-bowel syndrome, surgery was not an option ; thus, chemotherapy was given She achieved complete remission (CR) after 4 courses of combined chemotherapy with IFO/VP16 and CDDP/DXR. After 14 months of CR, she had a recurrent disseminated tumor. She was given chemotherapies in reduced dosages due to renal dysfunction, but this was not effective, and she died 6 years after the initial operation. Abdominal malignant soft tissue tumors are rare, and complete resection combined with chemotherapy is necessary. Surgeons must not hesitate to consult a chemotherapy specialist.

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An 88-year-old woman had under gone excision of an abdominal wall tumor in the lower abdomen, 27 years prior to the current presentation, She noticed a mass in the abdominal wall 5 years previously and was admitted to our hospital because of rapid tumor growth for six months. Computed tomography showed a large tumor mass adjacent to the abdominal wall muscles. A part of the tumor was adherent to the abdominal wall muscle, but we found no apparent invasion of abdominal organs. It was resectable based on these images. We thus preformed tumor resection. The excised specimen was a solid tumor with a maximum diameter of 23cm, weighing 1,300g. It was diagnosed as a synovial sarcoma by histopathological examination. We describe this extremely rare case, a synovial sarcoma arising from the abdominal wall in an elderly individual, with a relevant discussion of synovial sarcomas.

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We present the case of a 69-year-old man with von Recklinghausen disease accompanied with gastric carcinoid, jejunal gastrointestinal stromal tumor (GIST) and lung cancer. He was diagnosed with gastric carcinoid by upper gastrointestinal fiber screening, then admitted to our hospital for detailed examination. He was diagnosed with gastric carcinoid with A-type gastritis due to hypergastrinemia. Computed tomography showed small indurations on the jejunum and a lung tumor. Although he underwent endoscopic submucosal dissection for gastric carcinoid, the pathological examination revealed invasion of small vessels. Then he underwent subtotal gastrectomy and partial resection of the duodenum and the upper jejunum with Roux-en-Y reconstruction. Pathological examination revealed lymph node metastasis of the carcinoid and jejunal GIST without gastric carcinoid. Eleven months later, he underwent a partial upper lobectomy of the left lung. We reported a rare case of von Recklinghausen disease accompanied with gastric carcinoid, jejunal GIST and lund cancer.

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An 76-year-old man with right lower abdominal pain underwent abdominal contrast-enhanced computed tomography, which detected a cecal tumor and severe right hydronephrosis.
Preoperative total colonoscopy revealed cecal carcinoma and a rectal polyp measuring 25 mm in size for which an endoscopic mucosal resection (EMR) was done. Rectal polyp was diagnosed as a well differenciated adenocarcinoma in adenoma histologically. Early gastric cancer was incidentally found by gastroscopy during a regular physical examination. Considering the patient's age and Alzheimer's dementia, a right hemicolectomy, right nephrectomy and total gastrectomy were done in a two-stage operation. Since the histological examination showed no metastasis of lymph nodes in those aseas, adjuvant chemotherapy has not been used. And no sign of recurrence or metastasis has been seen since the surgery. As synchronous triple gastrointestinal cancers are relatively rare, we report this case and review the literature.

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