We routinely adopted mechanical bowel preparation (MBP) prior to surgery for gastric cancer at our hospital until March 2009, when MBP started to be omitted. Herein, we examined a total of 158 patients with gastric cancer who underwent elective gastrectomy by dividing them into two groups ; 79 patients who underwent gastrectomy with MBP (MBP group) and another 79 patients without MBP (non-MBP group). The incidence of anastomotic leakage, surgical site infection, other complications, days until gas passage, and days until defecation were compared between the two groups. There were no differences in these parameters between the two groups, except for the average number of days until defecation which was shorter in the non-MBP group than in the MBP group (p=0.036). These results suggest that the gastrectomy for gastric cancer patients can be safely performed without MBP.

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Purpose and Method : The original POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) was developed in the United Kingdom in 1991. However, over-prediction of the original POSSUM in the actual situation in Japan has been debated. Hiroshima-POSSUM (H-POSSUM) was accordingly developed in 2007. This time we calculated Shimane-POSSUM (S-POSSUM) by logistic regression analysis based on 622 (in the first half) out of 1246 patients registered in the multi-institutional database of gastrointestinal surgery in Shimane Prefecture from 2002 to 2010. The validity of S-POSSUM was examined in the latter half 624 patients from the database, using the comparison of the observed to expected rates (O/E ratio) and the receiver operating characteristic (ROC) analysis. Results : The O/E ratios of morbidity were 0.52, 0.70, and 0.86, and those of mortality, 0.09, 0.25, 0.46 in original POSSUM, H-POSSUM, and S-POSSUM, respectively. The O/E ratio in the S-POSSUM was the nearest to one. The areas under the curve (AUC) of ROC analysis were almost the same in original POSSUM, H-POSSUM, and S-POSSUM, which were 0.666, 0.672, and 0.672 as for morbidity, and 0.817, 0.829, and 0.836 as for mortality, respectively. Conclusion : S-POSSUM offered the most useful prediction especially in our hospital area.

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Primary small bowel cancer is often asymptomatic and has far progressed at the time of diagnosis. Consecutive 13 cases of primary small bowel cancer, including five cases of jejunal cancer and eight cases of ileal cancer, treated in our hospital were enrolled in this study to investigate how the disease is diagnosed and treated. Double balloon enteroscopy was useful for making the definite diagnosis when the presence of jejunal cancer was suspected, but it did not contribute to detect lesions in an early phase. Many patients with ileal cancer were diagnosed by observing proximal portion of the ileum at colonofiberscopy (CF) as possible as we could. Accordingly observation of the ileum at the time of CF might lead to early detection of ileal cancer. Long-term survival could be gained in some cases in which gross curative resection was done by performing partial resection of small bowel at about 5 to 10 cm apart from both oral and anal sides, including lymph node dissection. We have not experienced any chemotherapies effective for advanced and recurrent cancers.

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TAPP is known to cause less postoperative pain and allow earlier return to work, based on prospective randomized studies comparing TAPP with anterior mesh repair. However, TAPP is technically challenging and it is difficult to perform in some cases. We designed tumescent TAPP employing inguinal preperitoneal infiltration of a large volume of diluted ropivacaine and epinephrine. Twenty-two patients, 58.2 years of age on average, underwent tumescent TAPP in our hospital from May 2010 to March 2011. They comprised of 20 patients with unilateral and two with bilateral hernias. Nineteen lesions were indirect hernias while 5 were direct. Tumescent TAPP caused the inguinal tissue to become tumescent, facilitating dissection of the inguinal peritoneum and connective tissue due to clear anatomy and reduced bleeding. The subjects appeared to have fewer complications, less bleeding and less postoperative pain. We thus conclude that tumescent TAPP facilitates the procedure and is more useful and safer, as a new method for hernia repair.

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A 70-year-old man was referred to our institute for further treatment of an intra-thyroidal thymoma diagnosed by open biopsy. The tumor was located at the lower pole of the left lobe of his thyroid gland, and had originally been suspected to be a malignant lymphoma based on fine needle aspiration cytology. Left lobectomy and lymph node dissection of the central compartment were performed. The tumor showed extrathyroidal invasion to the adjacent adipose tissue, but no further infiltration or metastasis to lymph nodes or distant organs were found. No connection to the mediastinal thymus from the tumor was identified. The final pathological diagnosis was ectopic thymoma of the thyroid (type B2) with invasion to extrathyroidal tissue. He recovered uneventfully, and external beam radiation therapy (50Gy) was added to his treatment regimen. No recurrent disease has been found, to date, 70 months since the operation. Ectopic thymoma in the neck, including that involving the thyroid, is an extremely rare entity, considered to arise from an inappropriately-descended residual thymic tissue in the neck. We report this rare case with discussion focusing on the differential diagnosis and the treatment of ectopic thymoma.

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A 57-year-old female who had received radioactive iodine treatment for advanced thyroid cancer developed a left breast mass. An elastic hard and movable mass, 2.5 centimeters in diameter, was palpable in the inner lower quadrant of the left breast. Mammography showed a high-density mass shadow. Ultrasonography revealed a low echoic mass with an interior cystic pattern, heterogeneity, a clear boundary, and a size of 25 × 24 mm. On core needle biopsy, a diagnosis of invasive ductal carcinoma of the breast was suggested, but was difficult to accept given the discreapancy between the clinical findings and the pathological diagnosis. By comparing this specimen to a past specimen which was resected from a skin metastasis, a similarity was identified, resulting in a diagnosis of mammary metastasis from follicular carcinoma of the thyroid. Thus, a lumpectomy was performed.
Mammary metastases from extramammary malignancies are rare. We report this unusual case of metastasis from thyroid cancer and include a brief review of the literature.

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We report a case with breast pseudoangiomatous stromal hyperplasia (PASH), an uncommon benign breast disease. A 28-year-old woman was seen our hospital because of a large tumor of the left breast. An 8cm firm, well-circumscribed, movable tumor was palpated. Mammography, MRI and ultrasonography could not rule out malignancy. Aspiration biopsy cytology was class III. A preoperative diagnosis of benign phyllodes tumor was made and wide excision was performed. Pathological examination revealed an increased amount of stroma and the presence of anastomosing slit-like spaces lined with spindle stromal cells. Stromal spindle cells were negative for CD34, CD31 and FactorVIII. PASH was diagnosed.

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A 52-year-old woman was presented with headache, dizziness and agnosia. Multiple brain lesions up to 6 cm in diameter were detected by cranial magnetic resonance imaging (MRI) and were suspected to be metastatic brain tumors. Thoracoabdominal computed tomography (CT) scan indicated a tumor 6 cm in diameter accompanied with coarse carcification on the right breast and ipsilateral axillary and supraclavicular lymphadenopathy. This tumor had been followed as an old fibroadenoma for 32 years, and mammography and ultrasonography revealed no malignant finding ; while contrast breast MRI detected it as an enhanced tumor which is a rare finding with an old fibroadenoma. Pathology of the removed brain tumor revealed metastatic adenocarcimona, and subsequent core needle biopsy identified breast cancer. Therefore, the breast tumor was excited, and finally brain metastasis from the invasive ductal adenocarcoma originated in the old FA, both of which were hormone receptor negative, HER2-negative. Breast cancer arising in fibroadenoma is rare and to the best of our knowledge, this is the first case diagnosed from brain metastasis.

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A 45-year-old man with a cough and a stomachache of a few days duration was diagnosed as having bronchitis, for which he was treated, but he did not improve. Thus, computed tomography was done and showed mediastinitis and a left pulmonary abscess. At first, Boerhaave's disease was suspected, but no esophageal perforation was noted during surgery. After surgery, descending necrotizing mediastinitis was diagnosed given the patient's history and the presence of the abscess. Both Boerhaave's disease and descending necrotizing mediastinitis exhibit mediastinitis. Thus, it is difficult to differentiate these two in some cases. It is important to carefully evaluate the patient's history and to evaluate the CT of the area from the neck to the lung.

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We report a case of blunt aortic injury requiring treatment. A 22-year-old man fell down from a height of 1.5 m during work. He sustained an aortic injury and liver injury, as well as fractures of the mandible, lumbar vertebrae, and femur. An emergent operative repair of the aortic injury was performed and liver injury was conservatively treated. There was a massive hematoma around the distal aortic arch, a hemothorax was found, and the intima of the aorta was torn. A prosthetic graft replacement of the thoracic aorta was performed. The post-operative course was uneventful. After the fractures were repaired, the patient was discharged on the 119th day after the initial operation.

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A 59-year-old man was brought into our hospital by ambulance because of hematemesis and melena. Emergency abdominal enhanced CT scan showed an abdominal aortic aneurysm (AAA) 50mm in diameter adhered to the duodenum. Esophago-gastro-duodenoscopy revealed a gastric ulcer in the healing phase alone. The patient was followed conservatively. Three days after admission, he had massive melena and went into circulatory failure. It was strongly suspected that the AAA had penetrated the duodenum. Upon emergency laparotomy, aortoduodenal fistula was diagnosed. We thus performed synthetic graft replacement for the AAA, and partial resection and closure of the penetrated portion of the duodenum. He was discharged on the 23rd postoperative day. But on the 14th day after discharge, an infectious pseud-AAA was formed at the primary graft, and axillofemoral bypass graft and drainage of the abdominal abscess were performed. The patient has had no infectious symptoms as of 5 years after the operation. Primary aortoduodenal fistula is an extremely rare disease, and the lifesaving rate is very low. Prompt surgical resection and careful treatments for postoperative infection are mandatory to save the patients.

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Pulmonary epithelioid hemangioendothelioma is a rare tumor and so far approximately 50 cases have been reported in Japan. We present a case of pulmonary epithelioid hemangioendothelioma with liver metastasis operated on in our hospital. The patient was a 67-year-old woman who was seen at our hospital because a chest abnormal shadow was discovered during observation of other disease at another hospital. Chest x-ray and chest CT scan showed a relatively clearly demarcated nodular shadow in the right lung field. No definite diagnosis was made, and thoracoscopic-assisted partial resection of lung was performed. Histopathological study showed that tumor cells existed so as to fill the alveoli and proliferation of atypical cells with vacuoles was identified. Immunohistochemistry revealed that the tumor cells were positive for vascular endothelial markers CD31 and CD34. Accordingly pulmonary epithelioid hemangioendothelioma was diagnosed. Thereafter liver metastasis occurred in an early time, for which partial hepatectomy was performed.
Effective therapies for the disease have not been established except for surgical resection. Careful observation of the clinical course is mandatory by making the maximum use of imaging procedures including chest and abdominal CT and brain MRI.

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The patient was a 67-year-old female who had no significant medical history. She was admitted to our hospital because of an abnormal opacity in the right lung. A 35mm nodule was found in the right middle lung field on chest X-ray in June 2007. Although thoracic CT scan, FDG-PET and bronchoscopy revealed no obvious malignant findings, the lung nodule was suspected to be a malignant tumor such as undifferentiated carcinoma or sarcoma. We performed right middle lobectomy under video-assisted thoracoscopy. Histologically, the tumor was composed of densely proliferating spindle-shaped to oval cells in fascicles. These cells stained positively for vimentin. RT-PCR demonstrated SYT-SSX1 fusion gene transcripts. These findings confirmed a diagnosis of primary synovial sarcoma of the lung, monophasic fibrous type. During 3 years and 6 months of follow up, to date, the patient has remained recurrence free. Preoperative diagnosis of spindle-cell tumors is difficult. We have described herein a rare case of primary synovial sarcoma of the lung. The definitive diagnosis was achieved using postoperative molecular studies.

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We report a case of a diaphragmatic hernia that developed after coronary artery bypass surgery without a GEA graft. An 81-year-old man underwent coronary artery bypass surgery 8 months prior to being admitted with a low grade fever and abdominal pain. Chest X-ray revealed a niveau above the diaphragm. Abdominal CT scan showed that the transverse colon was herniated into the pericardium. A hernial orifice was right behind the sternum ; diaphragmatic hernia was diagnosed. Emergency surgery was performed to release the ileus and repair the diaphragmatic hernia with a bioabsorbable omega-3 oil-coated mesh. Cardiovascular and gastroenterological surgeons should be aware that a diaphragmatic hernia may well be a complication of CABG without a GEA graft. Bioabsorbable mesh is thought to be useful for repairing such diaphragmatic hernias.

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The patient was a 60-year-old male with a 30-year history of esophageal achalasia which had only been treated irregularly. As his dysphagia worsened in 2005, he visited our hospital. Esophageal achalasia of Sigmoid type and grade II was diagnosed by upper gastrointestinal tract radiography, and the patient underwent laparoscopic Heller-Dor surgery the same year. After this surgery, he was followed up as an outpatient annually by upper gastrointestinal endoscopy. In 2008, early esophageal cancer detected by upper gastrointestinal endoscopy was treated by endoscopic submucosal dissection. Pathologically, the tumor was a moderately differentiated squamous cell carcinoma (0-IIc, m2, INFb, ly0, v0, pHM0, pVM0) and there was no subsequent evidence of recurrence. Esophageal cancer occurrence following surgery for esophageal achalasia is relatively rare. We herein report such a patient with a review of the relevant literature.

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A man in his seventies was diagnosed as having two gastric submucosal tumors three years prior, but refused follow-up gastroscopy. He was admitted to our hospital because of anal bleeding and dizziness. Gastroscopy showed submucosal tumor bleeding.
A partial resection of the stomach was planned given the risk of multiple gastrointestinal stromal tumors ; two more tumors were found during the operation. Therefore, a pylorus-preserving distal gastrectomy was performed. The tumors were diagnosed as inflammatory fibroid polyps on postoperative pathology. Multiple gastric inflammatory fibroid polyps are very rare based on our literature review. Therefore, we report this case.

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The patient was a 54-year-old man with advanced gastric cancer and multiple para-aortic lymph node metastases. Neoadjuvant chemotherapy was started using TS-1 (120 mg/body/day, day 1-14). Next, TS-1 + CDDP. TS-1 (120 mg/body/day) was administered orally for 3 weeks followed by a 2-week rest period ; CDDP (80 mg/m²) was administered intravenously on day 8. After two courses of TS-1 + CDDP, the para-aortic lymph node metastases had disappeared on abdominal CT scan. We performed a total gastrectomy with lymph node dissection (D2 + No.16 sumpling). On histology, no cancer cells were noted in the dissected lymph nodes. The patient was given TS-1 orally for 8 months after the operation. Five years after the surgery, the patient is still alive without a recurrence. In this patient, neoadjuvant chemotherapy was useful for advanced gastric cancer with multiple para-aortic lymph node metastases.

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The patient was found to have early gastric cancer of the angle on endoscopic examination for epigastralgia in August 2001. The biopsy specimen were classified as Group V (por). The patient refused surgery and did not visit our hospital again for about seven years. In December 2008, he underwent medical examination for epigastralgia at our hospital. This time he wanted to be treated against the cancer and a distal gastrectomy was performed. The final diagnosis was early gastric cancer (0-IIa+III, por) and the depth of invasion was pT1(m). Cases of early gastric cancer are rarely followed for such a long time. We describe herein this type of early gastric cancer and review the relevant literature.

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A 58-year-old man was admitted to our hospital because of abdominal pain and vomiting. He had undergone enterotomy for an intestinal obstruction caused by a bezoar 9 months previously. We diagnosed the intestinal obstruction as being due to a similar bezoar based on further examination and previous history. At laparotomy, two foreign bodies were seen in the stomach and another was impacted at the ileum about 90 cm from the Bauhin valve. All three were removed, via gastrotomy and enterotomy. Sizes were 5.5×4.5cm, 5.5×4cm and 4.5×4cm and their components were not specified. Intestinal obstruction caused by a recurrent phytobezoar is very rare. The patient consumed large amounts of a cocktail containing beer and tomato juice, which contained a gelatinous agent. The combination of pectin and prolonged gastric emptying was concluded to have resulted in phytobezoar formations.

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The patient was a 72-year-old man who underwent hernia repair using an intraperitoneal composite mesh for abdominal incisional hernia at the age of 69. Two years and eight months later, the patient was seen at the hospital because of abdominal pain and pus discharge from the surgical wound. Fistula formation at the surgical wound was identified and fistulography visualized the small intestine. Enterocutaneous fistula was thus diagnosed and the patient was operated on. After an en-block resection of the small intestine adherent to the fistula and the abdominal wall including the mesh, hernia repair by suturing the abdominal wall in two layers using 1-VICRYL was done again. The postoperative course was uneventful and the patient was discharged from the hospital on the ninth postoperative day. He has been free from relapse of the hernia or infection after the operation.
We report a case of enterocutaneous fistula caused by an intraperitoneal composite mesh used for abdominal incisional hernia, together with a review of the literature.

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An 84-year-old woman underwent mesh repair for obturator hernia 2 years prior. She was admitted with abdominal pain and vomiting. Abdominal X-ray and CT scan revealed a small bowel obstruction. Since long tube insertion was not effective, surgery was required. The terminal ileum had adhered to a mesh near the obturator canal, and this caused the bowel obstruction. The mesh was removed from the abdominal wall and the ileum.
Adhesive bowel obstruction due to a mesh should be suspected in cases with bowel obstruction after hernia repair. In this paper, the relevant literature and the case are presented.

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A 60-year-old man with chronic renal failure visited a hospital because of abdominal pain and chill. There were tenderness and rebound tenderness in the left lower quadrant of abdomen, and an abdominal plain CT scan showed dilatation and wall thickening of the small intestine localized in the left abdomen. The patient was referred to our hospital with a diagnosis of localized peritonitis. An abdominal CT scan on admission revealed an increase of ascites and intraperitoneal micro air bubbles. Perforation of the digestive tract was diagnosed, and emergency operation was performed. A site of perforation and a localized abscess were identified in the mesentery of the ileum 30 cm distal to the ligament of Treitz. We resected the jejunum containing the abscess. The histopathological diagnosis was perforation of a jejunal diverticulum. The clinical features of this rare case are briefly reviewed.

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A 40-year-old woman was sent to our department, because of acute abdomen. She had abdominal pain for 3 days with a fever and peritonitis was diagnosed by physical examination. Computed tomography showed ileus, ascites, an abscess in the pelvis and a small high intensity structure inside the intestine. We diagnosed perforation and performed an emergency operation. We found a perforation of Meckel's diverticulum (MD). There was an enterolith inside MD. We performed local enterectomy including the perforated MD and intraperitoneal drainage. MD showed heterotopic gastric mucosa. The enterolith was made of bile. Perforations caused by Meckel's enteroliths are very rare. The diagnosis is not usually made before surgery. We describe this rare case with a discussion of the literature.

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We performed appendectomies for two cases with appendicolithiasis. Patient 1, a 21-year-old man, was seen at our hospital because of pain in the right lower quadrant of the abdomen. Plain abdominal radiography, computed tomography and doppler echography revealed an appendiceal calculus. A stone (18×7mm) was detected in the resected appendix. The appendiceal calculus was composed of 30% calcium phosphate, 21% calcium carbonate, and 49% calcium salts of fatty acids. Patient 2, a 24-year-old man, was seen at our hospital because of pain in the right lower quadrant of the abdomen. Plain abdominal radiography, computed tomography and doppler echography revealed an appendiceal calculus and acute appendicitis. A stone (10×10mm) was detected in the resected appendix. The appendiceal calculus was composed of 45% calcium phosphate and 55% calcium carbonate.
The stones were composed of calcium phosphate, calcium carbonate and calcium salts of fatty acids. Several reports have also shown appendiceal calculi to mainly be composed of these three components. We believe these features to possibly be related to the causes of the diseases in our two cases.

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Case 1 : An 87-year-old woman who had a history of diabetes mellitus was seen at the hospital because of abdominal pain and vomiting. There was tenderness in the lower abdomen with mild degree of rebound tenderness. An abdominal CT scan revealed hepatic portal venous gas and dilatation as well as wall thickening from the ileum to the ascending colon. Emergency colonoscopy revealed whole-circumferentially spread shedding and erosion of mucosa from the ileum to the ascending colon, but no apparent findings of bowel necrosis were seen. Conservative therapy was employed. Symptomatic remission was gained from the next day, and the patient was discharged very much improved.
Case 2 : An 85-year-old woman, who had been on oral prednisolone regimen at a dose of 15 mg/day for 15 years for dermatomyositis, underwent prosthesis replacement for necrosis of the right femoral neck. From the ninth hospital day, diarrhea and abdominal pain occurred, and an abdominal CT scan performed on the 14th hospital day disclosed hepatic portal venous gas and wall thickening in the entire colon. Emergency colonoscopy showed sporadic presence of mucosal erosion and edema, but apparent findings of bowel necrosis was absent. Consequently conservative therapy was employed. The patient was discharged very much improved.
This paper deals with these two cases of enteritis associated with hepatic portal venous gas, in which conservative therapy selected based on colonoscopic findings was successful.

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A 65-year-old man underwent an aortic valve replacement at 45 years of age. He suddenly developed abdominal pain after having lunch in the fall of 2009 ; emergency medical treatment was required. Contrast-enhanced CT of the abdomen reveled intravascular gas extending from the superior mesenteric vein to the main trunk of the portal vein and the intrahepatic portal vein. In addition, a part of the small intestinal wall was poorly visualized ; intestinal necrosis was suspected. Intraoperative findings showed distention of the entire intestine with no obvious necrosis. However, two months after discharge, the patient was again hospitalized. CT again revealed portal venous gas. The cause was suspected to be anticholinergic-induced intestinal gas retention, and the drug was discontinued. After the discontinuation of the drug, the patient's abdominal fullness disappeared, and there has been no recurrence of any symptoms. We report a very rare case with two episodes of portal venous gas occurring within two months of each other. To the best of our knowledge, there are previously reported cases in the literature.

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A 52-year-old female complaining lower abdominal pain and fever was admitted to the hospital. Adrenal cortex steroids had been orally administered when the patient developed SLE at 21 years of age. She was diagnosed to have a perforation in the digestive tract when free air in the abdomen was detected by abdominal computed tomography (CT), and underwent emergency laparotomy. Retention of pyoascites was observed in the mesotransverse colon. Hartmann's operation was performed because a perforation measuring 3 cm in diameter was detected in the transverse colon. Idiopathic perforation of the colon was diagnosed because microscopic examination showed there were no changes indicating vasculitis or thrombogenesis. However, the patient was readmitted to the hospital complaining of abdominal pain on postoperative day 135. Abdominal CT revealed an air-containing pyoascites in the peritoneal cavity near the colostomy. Perforation in the digestive tract was diagnosed, and emergency laparotomy was performed. Retention of numerous pyoascites was observed in the mesotransverse colon. The patient underwent right hemicolectomy and ileostomy because a perforation measuring 2 cm in diameter was detected in the transverse colon on the oral side, 5 cm from the colostomy. A microscopic examination again indicated a diagnosis of idiopathic perforation of the colon.

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We report herein a case of sigmoid colon diverticulosis causing a high serum carbohydrate antigen (CA) 19-9 level. A 66-year-old man complained of abdominal fullness and diarrhea. These symptoms were found to originate from a sigmoid colon stenosis due to diverticulosis. He was admitted for surgical treatment. Laboratory examinations showed elevation of the serum CA19-9 (1894.0 U/ml) level. Colonoscopy and computed tomography demonstrated diverticulosis with sigmoid colon stenosis. No images revealed the presence of malignant disease. Laparoscopy-assisted sigmoidectomy was performed under the diagnosis of diverticulosis and the possibility of latent cancer in the sigmoid colon. On pathology, diverticulosis with sigmoid colon stenosis was diagnosed ; there was no evidence of malignancy in the resected specimen. On immunohistochemical examination, the brush border and the cytoplasm of the epithelium at the diverticula was stained by CA19-9 antibody. The serum CA19-9 level decreased rapidly and reached to the normal range about 4 months after surgery. Therefore, it is likely that CA19-9 was released by the diverticula.

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This paper deals with a case or ischiorectal fistula with the secondary opening at the abdominal wall, which is extremely rare. The patient was an 82-year-old man complaining of high fever who noticed purulent discharge from the abdominal wall. Based on preoperative examinations including MRI, we diagnosed the case as ischiorectal fistula which originated from the ischiorectal fossa, passed through the peritoneal subcutaneous structure, and then formed the secondary opening at the abdominal wall. Abdominal MRI was very helpful to diagnose the course of the anal fistula. Even in such a case of ischiorectal fistula as it follows uncommon run like ours, MRI appears to be helpful to select the most appropriate therapy.

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We report a case of adenocarcinoma of the transverse colon during pregnancy. The patient was a 41-year-old woman with abdominal pain at the 28th week of gestation. An ultrasound examination and abdominal magnetic resonance imaging (MRI) showed a thickening of the wall in the middle portion of the transverse colon. Colonoscopy showed a typeII tumor on the middle portion of the transverse colon.
She was diagnosed with adenocarcinoma of the transverse colon during pregnancy. At the 29th week of gestation, cesarean delivery was performed followed by a transeverse colectomy with D3 lymph node dissection. A 1,280 g female was delivered with an apgar score of 8/9. The pathological diagnosis was tub2, ss, n2, ly0, v1, H0, P0, M0, Stage IIIb. Colorectal cancer during pregnancy is very rare. Only about 55 cases of colorectal cancer during pregnancy have been reported in Japan. It is said that one or two in 100,000 pregnant woman may have the disease. We examine the clinical characteristics of the disease.

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Gastrocolic fistula complicating colon cancer is rare, with only 24 cases reported, to our knowledge in Japan. A 68-year-old man was admitted to the hospital for further examination of diarrhea and foul eructation. Abdominal CT scan showed a huge tumor from the splenic flexure to the descending colon. Colonofiberscopy showed a type 5 tumor of the descending colon and gastrocolic fistula leading into the stomach. Biopsy specimens showed well differentiated adenocarcinoma. He was diagnosed with advanced descending colon cancer with gastrocolic fistula, and a curative operation performed. Pathologically, the tumor was a mucinous adenocarcinoma and invaded the mucosal layer of the stomach.

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Segmental arterial mediolysis (SAM) has increasingly been reported in recent years as a primary disease involving rupture of the abdominal splanchnic arteries. The present case was a 48-year-old man in whom SAM occurred with sudden abdominal pain. Computed tomography (CT) revealed an extensive high density area in the retroperitoneum, suggesting a retroperitoneal hematoma. However, CT did not identify an obvious source of bleeding. Although relief of symptoms and redction of the retroperitoneal lesion were initially seen in response to conservative treatment, duodenal edema caused obstruction and acute cholecystitis. When angiography was performed to identify the source of bleeding, an aneurysm was identified in the anterior inferior pancreaticoduodenal artery. On the basis of clinical and imaging findings, aneurysmal rupture due to SAM was diagnosed, and coil embolization was performed for the aneurysm. Aneurysmal rupture can be life-threatening and diagnosis of an aneurysm is often difficult because it can occur in any of the splanchnic arteries, causing a variety of symptoms. However, prompt diagnosis with an appropriate imaging study and determination of optimal treatment strategies may be important.

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A 53-year-old woman who underwent laparoscopic cholecystectomy for acute cholecystitis was discharged from the hospital after an uneventful postoperative course. However, she developed upper abdominal pain on the 6th postoperative day and was admitted to the hospital again with a suspicion of panperitonitis. Abdominal trial top found collection of biliary ascites. Postoperative biliary injury was likely. Endoscopic retrograde cholangiography disclosed leakage of contrast material from a communicating accessory bile duct which communicated between the cystic duct and the right hepatic duct. Bile leakage due to injury of the communicating accessory bile duct after cholecystectomy was diagnosed. Endoscopic nasobiliary drainage tube was placed and the conservative therapy was successful.
The communicating accessory bile duct is an anomalous biliary structure which communicates between the major bile ducts and forms a circuit with the normal bile duct. In case the cystic duct is involved in a circuit, its cutting point must be determined after branching variation of the biliary tract is confirmed by preoperative examinations including DIC-CT.

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A 78-year-old woman was admitted to our hospital because of the sudden onset of abdominal pain. A computed tomography (CT) of the abdomen showed fluid coloection around the gallbladder. Twelve hours later, another abdominal CT scan showed an increase of ascites and signs of peritoneal irritation increased. Upon emergency laparotomy, massive biliary ascites and perforation of the gallbladder were revealed and cholecystectomy and abdominal drainage were performed. The resected specimen showed a localized transmural necrotic change in the body of the gallbladder. This case showed no gallstones and no inflammatory signs of the gallbladder, and the cultures of the biliary ascites yielded no bacterial growth. We diagnosed the case as idiopathic perforation of the gallbladder.
Perforation of the gallbladder is usually cased by gallstone or acute inflammation. Idiopathic perforation which occurs without these causes is a comparatively rare disease and only 36 cases have been reponted in Japan. We present a case of idiopathic perforation of the gallbladder, together with some bibliographical comments.

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A 66-year-old woman presented to a physician with chief complaints of ash gray stool and epigastralgia. She was diagnosed with bile duct carcinoma and admitted to our hospital. Laboratory data showed abnormally high values for total bilirubin, serum hepatic transaminase and the tumor markers CA19-9 and DUPAN-2. Abdominal contrast computed tomography (CT) demonstrated an enhancing tumor in the middle portion of the common bile duct. Under a diagnosis of middle bile duct carcinoma, the patient underwent subtotal stomach preserving pancreatoduodenectomy and was discharged 30 days after the surgery without major complications. Immunohistochemically, neuroendocrine markers such as chromogranin A and synaptophysin were positive in the tumor cells. The tumor was diagnosed as primary endocrine cell carcinoma of the bile duct. The patient has not had a recurrence for nine months after the surgery, without adjuvant chemotherapy.
We present this rare case of primary endocrine cell carcinoma of the bile duct with a review of 12 cases reported in the Japanese literature.

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A 74-year-old man who had undergone right nephrectomy for renal cell carcinoma (RCC) 9 years earlier, was found to have a pedunculated tumor of the gallbladder.
Abdominal CT demonstrated a pedunculated tumor which was strongly enhanced and had a maximum diameter of 11mm. Abdominal ultrasonography showed the mass to occupy a region with low echoic solidity, and there was a high echoic layer on the surface. He also had controlled metastasis of the left lung which had been treated with chemotherapy for a period of 4 years. Therefore, the tumor was suspected to be metastasis from the original RCC.
Laparoscopic cholecystectomy was performed. The tumor was histologically diagnosed as clear cell carcinoma. Moreover, immunostainings for CEA, EMA and CK7 expressions were all negative, while Vimentin staining was positive. These findings indicated the tumor to be gallbladder metastasis from RCC. Gallbladder metastasis from RCC is rare. Only 17 cases have been reported to date in Japan.

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A 50-year old woman had cancer in the gallbladder neck and massive lymph node metastases that invaded the pancreas head, extending toward the common hepatic artery, the portal vein which was resected partially, the superior mesenteric artery, the inferior vena cava and the right renal artery (#8ap, #9, #14a and #16a2). Extended cholecystectomy was performed and the massive lymph node metastases were removed altogether through pylorus-preserving pancreaticoduodenectomy. A metastatic nodule in the left lobe of the liver (S2) was also resected. Histologically they were poorly differentiated tubular adenocarcinoma (Hinf1, Binf2, N3, H1, StageIVb). Four years later, a para-aortic recurrent lymph node (#16b1) was detected by a follow-up CT scan and was removed surgically. Each operation was followed by chemotherapy with cisplatin and 5Fu. She is still alive as of 15 years after the first operation. Her well-being for 15 years after the first operation is a rare success of thoroughgoing surgical management against far advanced gallbladder cancer.

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A 22-year-old woman was transferred to our hospital after being involved in a traffic accident. Physical examination revealed diffuse abdominal tenderness without peritoneal irritation. Abdominal computed tomography (CT) showed pancreatic head injury, liver injury and intra-abdominal bleeding. Conservative therapy was instituted. Abdominal CT of the next day revealed retroperitoneal fluid collection around the right kidney and increased ascites. Emergency surgery was performed 38 hours after the accident. During surgery, we discovered retroperitoneal biliary fluid collection and transection of the pancreatic head involving the pancreatic duct and the intrapancreatic common bile duct. We also discovered a parenchymal laceration 4 cm in depth in the lateral segment of the liver and contusion of the descending portion of the duodenum. Her general condition was stable. We performed a subtotal stomach preserving pancreaticoduodenectomy. Postoperatively, there was no pancreatic fistula. She was discharged on the 46th postoperative day.

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With development of diagnostic imaging in recent years, pancreaticoduodenal artery (PDA) aneurysms are found incidentally. We report a case of PDA aneurysm treated laparoscopically. A 67-year-old man was admitted with an asymptomatic abdominal visceral aneurysm detected on a screening abdominal CT scan. 3D-CT showed a PDA aneurysm 30 mm in diameter located in the PDA. To effectively treat the patient and given the advantages of minimally invasive surgery, we resected the aneurysm laparoscopically. There were no intraoperative or postoperative complications. The patient has been doing well for 2.5 years after surgery. Laparoscopic surgery is a safe therapeutic option for the patient with a non-ruptured true PDA aneurysm.

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Pancreatic fistula after pancreaticoduodenectomy is an intractable complication. In this paper we present a case of complete external pancreatic fistula after pancreaticoduodenctomy successfully treated by interventional internal drainage.
The patient was a 73-year-old man who underwent pancreaticoduodenectomy for an adenoma of the duodenal papilla. The postoperative course was uneventful and he was discharged from the hospital on the 17th postoperative day. A pancreatic tube for complete external pancreatic fistula was scheduled to be removed in the clinic. Thereafter the discharge from the pancreatic tube halted because the tube was bent, but it had been left as it was. On the 30th postoperative day, suture failure at the pancreatojejunostomy with abscess formation was confirmed, so that percutaneous drainage was done. There was no communication between the abscess cavity and the jejunum, and discharge of pure pancreatic juice persisted after the drainage. Complete external fistula was thus diagnosed. On the 115th day after the drainage, an endoscope inserted through the fistula demonstrated a suture used for transpancreatic and jejunal seromuscular stitch, with which we safely punctured the jejunum in the vicinity of the anastomosis and placed a tube for internal drainage. The tube was clamped on the eighth day and was removed on the 78th day after the placement. Except mild dilatation of the main pancreatic duct, the patient has no symptoms of pancreatitis and impaired glucose tolerance, and is doing well, as of 4 years after the internal drainage.

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We experienced two cases with pancreatic head carcinomas with annular pancreas presenting as acute pancreatitis. Patient 1 was a 71-year-old man admitted to our hospital because of acute pancreatitis with epigastralgia. 3D-CT showed the pancreatic parenchyma encircling the duodenum and stenosis located in the descending part of the duodenum. A cystic tumor with a mural nodule was also seen in the head of the pancreas. Annular pancreas with IPMC was diagnosed.
SSPPD was performed. Pathological examination indicated annular pancreas and intraductal papillary-mucinous carcinoma, minimally invasive. Patient 2 was a 72-year-old woman admitted to our hospital because of acute pancreatitis with upper abdominal pain. 3D-CT showed stenosis located in the descending part of the duodenum, and a low density tumor in the head of the pancreas. Annular pancreas with invasive ductal carcinoma was diagnosed. SSPPD with SMV resection was performed. Pathological examination confirmed annular pancreas with invasive ductal carcinoma.

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A 45-year-old man visited a hospital because of jaundice and fever. On admission, severe leukocytosis, severe anemia and obstructive jaundice were found. On abdominal computed tomography, an unevenly enhanced large mass was found in the pancreatic head and second portion of the duodenum. Based on the clinical and imaging findings, a preoperative diagnosis of an aggressive pancreatic or duodenal neoplasm was made. The differential diagnosis included a granulocytic sarcoma with blast crisis in chronic myelocytic leukemia (CML). Following sub-stomach preserving pancreaticoduodenectomy, the histopathological diagnosis of the tumor was the pleomorphic type of anaplastic carninoma of the pancreas. Immunohistochemical staining showed pancreatic cancer cells to be positive for G-CSF, leading to a diagnosis of G-CSF-producing tumor associated with marked leukocytosis. Multiple hepatic metastases and paraaortic lymph node metastases developed only two months after surgery, and the patient died nine months after surgery despite intensive therapy.

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The patient was a 65-year-old man performed right upper lobectomy for small cell lung carcinoma at the age of 63. His serum ProGRP level started to rise gradually in the 15th month after the surgical treatment for lung cancer, and whole-body PDG-PET was performed to explore possible local or distant metastasis. It showed two areas with abnormal FDG-uptake in the body of the pancreas without findings suggestive of another metastasis and local recurrence. Abdominal contrast enhanced CT scan showed two poorly enhanced masses in the body of the pancreas, 2 cm and 1.5 cm in diameter, respectively. We diagnosed then as pancreatic metastases from the small cell lung carcinoma and performed distal pancreatectomy. The resected specimen included two ash-gray solid tumors, 1.0 cm and 0.6 cm in diameter, respectively. Histopathological findings were compatible with metastasis from small cell lung carcinoma. He had brain metastasis 21 months and died 42 months after the pancreatic resection. It is well accepted that pancreatic metastasis carries poor prognosis to the patient and is not a candidate for surgical resection in most cases except for pancreatic metastasis from renal cancer. However, several reports suggest that surgical resection of the metastatic lesion can improve the patient's prognosis. Surgical treatment should be considered even in patients with pancreatic metastasis from small cell lung carcinoma, if the disease is localized in the pancreas.

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A 66-year-old male had experienced swelling of his left scrotum beginning in March 2010. Thereafter it became progressively larger, thus making it difficult to urinate while standing. He consulted a hospital in May of 2010. He was suspected to have an inguinal hernia, and was referred to our hospital. On palpation, a painless left scrotal swelling was noted that was difficult to reduce. Computed tomography (CT) and magnetic resonance imaging (MRI), showed a giant tumor localized in the scrotum, composed mainly of fat, which was not continuous with the retroperitoneum. The tumor was suspected to be an intrascrotal liposarcoma based on the clinical course and rapid growth.
In addition to performing a left high orchiectomy, the left intrascrotal tumor was also removed. The tumor measured about 30 × 17 ×12 cm in size, and weighed 1,300 g. It was diagnosed as a well-differentiated liposarcoma based on the histological examination. Over a ten-month period after surgery, the patient has been free from any recurrence.

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We report two rare cases of Ewing sarcoma with peripheral primitive neuroectodermal tumor (ES/pPNET) arising from the abdominal cavity in a 78-year-old female patient and a 38-year-old female patient. In Japan, ES/pPNET arising from the abdominal cavity is a very rare disease. We could only find 10 reports in Japan. We experienced two such cases, and put these dates in order and suggest that perfect surgical resection is very important together with postoperative chemotherapy.

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We report a case of omental torsion that we diagnosed preoperatively and resected by laparoscopic operation. A 45-year-old woman was admitted because of right lower abdominal pain. On physical examination, a hand-sized hard mass was palpated with severe tenderness in the right lower abdomen. Using abdominal computed tomography (CT), omental torsion was diagnosed preoperatively, and we performed an emergent laparoscopic operation on the same day. Laparoscopic examination revealed a necrotic omental mass twisted counter-clockwise by four turns, and bloody ascites were also observed. We resected the necrotic part of the omentum. The postoperative course was uneventful and the patient was discharged from our hospital on the 6th postoperative day. Omental torsion is a relatively rare disease, and it is generally difficult to diagnose preoperatively. Abdominal CT was useful for preoperative diagnosis, and laparoscopic operation was useful for treatment of this case.

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A 49-year-old woman who had no previous history of undergoing abdominal surgery or noteworthy family history was seen at the hospital because of an intraabdominal tumor on abdominal ultrasonography at a medical checkup. Colonofiberscopy showed extramural pressure at the hepatic flexure of the colon with a dimpling on mucosa. Abdominal CT scan revealed a 6-cm diameter tumor in the mesocolon. Mesenteric GIST was likely and partial excision of colon was performed. Pathologically the tumor cells were negative for α-SMA, CD34, S-100 protein and c-kit, but positive for β-catenin. From these findings, desmoid tumor arisen in the mesocolon was diagnosed.
Desmoid tumor is a fibrous soft tissue tumor and occurs most often in young women. Furthermore desmoid tumors often affect patients with familial adenomatous coli and Gardner syndrome, or those who have a history of undergoing laparotomy. It rarely occurs in patients without these diseases or histories. In this paper, we report a case of a removed desmoid tumor in the mesocolon in a patient who was not associated with either familial adenomatous coli or Gardner syndrome, and who had no previous history of undergoing abdominal surgery, together with some bibliographical comments.

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A 70-year-old man, with a history of occupational asbestos exposure for more than 50 years, complained of abdominal distension and came to our hospital in May 2008. No original malignancy which could have caused the massive ascites was detected, so we performed diagnostic laparoscopy after the paracentesis to evacuate ascites. All around the peritoneum we found numerous white nodules, specimens of which were diagnosed as malignant mesothelioma pathologically. We chose a combination of chemotherapy with CDDP and Pemetrexed as the first line of treatment. He showed temporary improvement initially, but after the 5^th cycle he became worse and ascites increased again. Although we tried some other chemotherapy, his condition deteriorated and he died about 15 months after the diagnosis. Peritoneal mesothelioma is such a rare entity that there is no standard management. But the disease is expected to increase in number in the near future, so management techniques need to be investigated further.

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A 79-year-old man, was examined for bilateral leg edema in a local clinic, and subsequently admitted to our institution for treatment of a huge abdominal tumor. A giant tumor with a clear margin was detected as a mosaic pattern image in an abdominal ultrasound (US) examination. An enhanced computed tomography (CT) scan revealed a huge low-density tumor in the retroperitoneal space, and the superior and inferior mesenteric arteries were compressed and shifted by the tumor. We diagnosed this as a retroperitoneal tumor from the preoperative examinations, and performed a surgical resection of the tumor. The size of the tumor was 27×27 cm and weighed 6,900 g. Pathological diagnosis of the tumor was a sclerosing-type of well differentiated liposarcoma. The patient was discharged at postoperative day ten with no surgical complications. We have managed the care of his postoperative course without the use of chemotherapy, and there has been no sign of recurrence of the tumor for three years.

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A 78-year-old woman, was referred to our hospital for further examination of early gastric cancer, and underwent a laparoscopic-assisted distal gastrectomy (LADG). She started to complain of nausea, vomiting and a left lower abdominal pain appeared on the fourth postoperative day. Abdominal computed tomography (CT) scan revealed ileus due to incarceration of the small intestine at the site of the 12 mm port incision. An urgent operation was performed and a peritoneal defect was observed at the port site of the 12 mm trocar which was inserted from the left middle abdomen, and a part of the ileum was incarcerated into the muscle through the peritoneal defect. We pushed it back into the abdominal cavity, rendering intestinal resection unnecessary. Abdominal CT scan is useful for diagnosis and allows precise diagnosis even when the abdominal surface elevation is minimal in the early stage of a port site hernia.

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