The present study attempted to clarify the clinical significance of occult metastases in sentinel lymph nodes among breast cancer patients. The subjects were 1,043 patients who had clinically node-negative breast cancer and had undergone sentinel node biopsy. Postoperative pathological examination revealed 49 cases of occult metastases (26 of isolated tumor cells and 23 of micrometastases), despite negative intraoperative results. At a median follow-up of 75 months, 8 patients with occult metastases showed recurrence. The axillary and distant relapse rates were both 8.2%, respectively, which were significantly higher than those for the node-negative cases (P<.001) for both. The relapse rates were not associated with the size of the occult metastases. The relapse rate of the patients who had occult metastasis and did not undergo further axillary surgery was not higher than that of the patients who had been diagnosed sentinel node involvement intraoperatively and had undergone sequential axillary dissections. However, as occult metastases in sentinel nodes have little impact on axillary and distant relapse, performing sentinel lymph node biopsy alone with no further axillary surgery is an appropriate approach for breast cancer patients with sentinel node occult metastases.

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Purpose and Method : Incisional hernia is a frequent complication after living donor liver transplantation (LDLT). A cohort of 94 patients was investigated. Incisional hernia was found in 12 patients (12.8%). We compared hernia patients with non-hernia patients for risk factors such as original disease, gender, body mass index (BMI), model for end-stage liver disease (MELD) score, graft weight / standard liver volume (GW/SLV), blood type, incisional infection and acute rejection. Results : Male gender, BMI>=25 kg/m² and surgical site infection were significant risk factors, while original disease, MELD score, GW/SLV, blood type diabetes mellitus and acute rejection were not. Conclusion : We should consider the possibility of incisional hernia when recipients are male or have a high BMI.

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Immediate breast reconstruction (IR) is a safe and reliable treatment in early breast cancer, but there are few reports about the oncological outcome, including advanced cases. We retrospectively analyzed 260 breast cancer patients under 65 years-old who underwent mastectomy between June of 1995 and March of 2009, where 68 patients underwent IR and 192 patients had only mastectomy (MA). Of the 68 patients, the transverse rectus abdominis muscle flap was used in 63 cases, latissimus dorsi flap in four cases, and a retropectoral implant in one case. The median follow-up was 92 months (range 19-144). The 5-year overall survival was 93.5% in IR and 90.3% in MA. Except for non-invasive cancer, the 5-year disease-free survival (DFS) was in 82.5% in IR and 80.8% in MA, the local recurrence rate (LR) was 4.5% in IR and 5.9% in MA. In cases of more than four axillary positive lymph nodes, the 5-DFS was 62.2% in IR and 60.7% in MA, and the LR was 8.3% in IR and 15.9% in MA. These were no differences in DFS or LR between IR and MA. These results suggest that IR can be considered a feasible treatment in cases of advanced breast cancer as well as early breast cancer.

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Currently, single-port endoscopic surgery is widely performed to achieve improved esthetic outcomes ; hence, surgical procedures and new devices are constantly being studied and developed. However, the special devices used are expensive. The existing lifting devices have disadvantages in that they are cumbersome, their operation is time consuming, and they cannot provide a wide visual field. We developed a retractor (NUMAZU SF4/SF6) that enables the simple and safe performance of single-port laparoscopic appendectomy. In principle, this newly developed device, which has a fan-shaped ring structure, is inserted from the umbilicus and connected to an external lifting system to lift the abdominal wall. Between December 2004 and June 2012, we performed single-port appendectomy in 74 patients. The mean age of the patients was 15.2 years. The male-to-female ratio was 27 : 47. The mean operation duration was 66 minutes. The duration of postoperative hospital stay was 1.3 days. Complications were observed in 2 patients (2.7%). The cost of the medical device ranged from 13,000 to 20,666 yen. Our device can be easily set up and provides a wide visual field, which enables safe performance of surgery. In addition, using this device for this procedure reduce the costs involved in the surgery, thereby making it inexpensive. Thus, performing single-port laparoscopic appendectomy with this device is considered to have many advantages.

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Since the sixth edition of the General Rules for the Description of Thyroid Cancer published in September 2005, the rules have dealt with poorly differentiated thyroid carcinoma as an independent histologic type, namely, malignant neoplasms that are derived from follicular epithelial cells and show intermediate morphology and biological behaviors between well differentiated papillary carcinoma or well differentiated follicular carcinoma and undifferentiated carcinoma. Thereafter a total of 280 cases of thyroid carcinoma have been operated on in our department. Out of them four (1.4%) cases of poorly differentiated thyroid carcinoma were clinically studied. Two of the four patients were diagnosed with poorly differentiated thyroid carcinoma by fine needle aspiration cytology. Further these two patients presented clinical features suggestive of subacute thyroiditis and their tumors showed a rapidly increasing tendency in size. One of the two patients experienced early local recurrence and died of the disease nine months after the operation. In the remaining patient, complete resection of the tumor was impossible. Another two patients in whom poorly differentiated thyroid carcinoma was not diagnosed by fine needle aspiration cytology have been free from recurrence up to now. Poorly differentiated thyroid carcinomas have a variety of biological behaviors. There might be some tumors which have almost similar characteristics to undifferentiated thyroid carcinoma and the others which progress slowly and have similar characteristics to well differentiated carcinoma.

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A 76-year-old woman with thyroid cancer developed a severe acute pulmonary embolism (PE) at postoperative day (POD) 3 after thyroid lobectomy, and intensive cardiopulmonary care was initiated with mechanical ventilation. Although the PE could be managed by administration of heparin, additional heparin-induced thrombocytopenia (HIT) was detected during the intensive treatment when heparin was resumed at POD 11 after a temporal termination for re-operation to remove a massive hematoma. Her platelet count suddenly dropped to 3.5×10⁴/ μl in 2 days. Heparin therapy was terminated again and argatroban therapy was initiated. The platelet count gradually recovered to normal range at POD 20. Warfarin therapy was added at POD 19 and argatroban therapy was terminated at POD 34. With the administration of warfarin, the patient was free from any signs of forming recurrent emboli at 6 months from operation. Caution against these severe postoperative complications is emphasized.

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Pleomorphic adenoma is a benign tumor that is rare in the breast but common in the salivary grand. A 41-year-old woman presented with a hard mass in the right breast. She had had a breast tumor excised in the same quadrant 5 years and 12 years prior. Core needle biopsy revealed a pleomorphic adenoma. It was excised with free margins. The postoperative and clinical follow-up during the last 2 years has been uneventful.
Recurrences following surgery for pleomorphic adenoma have been attributed to inadequate surgery and multifocality, as well as malignant transformation, which is a well-known entity in the salivary gland. Due to the risk of recurrence and malignant transformation, complete excision of the lesion with an adequate safety margin is required.

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We present a case of a giant metastatic intraperitoneal tumor due to a malignant phyllodes tumor of the breast. A 53-year-old woman underwent mastectomy for a malignant phyllodes tumor of the breast. After 4 months, examinations revealed distant metastasis to the upper abdomen and lungs and local recurrence from the malignant phyllodes tumor. She underwent tumor resection for a metastatic peritoneal tumor and local recurrence. During the operation, the intraperitoneal tumor was found to have arisen from the retroperitoneum of the splenic hilum and the tail of the pancreas. The tumor was excised as thoroughly as possible. It weighed approximately 2,400 g. On pathological examination, the tumor proved to be a metastatic malignant phyllodes tumor of the breast. Chemotherapy with ifosfamide was started and sustained stable disease status for 5 months. However, the patient presented superior vena cava syndrome after 5 months. Although radiotherapy was carried out, she died 15 months after her first operation.
A standard treatment for metastatic malignant phyllodes tumors has not yet been established. Surgery is not a curative treatment but is useful for tumor debulking and improvement of the quality of life (QOL). In this case, tumor-debulking surgery and ifosfamide chemotherapy improved the QOL.

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Adenomyoepithelioma of the breast is a rare breast neoplasm and has basically been considered to be a benign tumor. However, we have sometimes encounter case reports of malignant adenomyoepithelioma in the literature recently. In this paper, we present a case of adenomyoepithelioma of the breast associated with invasive ductal carcinoma. The case involved an 85-year-old woman who was seen at the hospital because she was aware of a tumor in the outer upper quadrant of the left breast. Ultrasonography showed a 1.4-cm diameter hypoechoic tumor which had a smooth and well-defined margin and a lobulated appearance. Fine needle biopsy cytology provided a diagnosis of invasive ductal carcinoma of the breast. Wide excision of the left breast and left axillary lymph node dissection were performed with the diagnosis of stage I breast cancer. Histopathology showed proliferation of both glandular epithelial and myoepithelial cellular elements, keeping a bi-phasic fashion. On immunohistochemistry, the glandular epitherium was EMA positive and myoepitherium was αSMA positive, adenomyoepithelioma being diagnosed. In addition a 2.3-mm diameter papillotubular carcinoma was identified in an extremely limited area at the tumor margin. The adenomyoepithelioma cells were lowly atypical, no mitotic figure was noted, and no findings suggestive of transition with adenomyoepithelioma were observed. Accordingly these neoplasms appear to have occurred independently and clashed with each other.

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A 48-year-old woman developed a left breast mass. Mammography studies showed a rounded and micro-serrated mass ; breast cancer was suspected. The diagnosis of breast cancer was confirmed on core needle biopsy. Small hyperchromatic tumor cells arranged in a sheet, and both synaptophysin and chromogranin A were positive. Thus, small cell carcinoma was suspected. Neo-adjuvant chemotherapy involving a combination of CBDCA (carboplatin) and VP16 (etoposide) was given ; this treatment is used in lung small cell carcinoma. After chemotherapy, the tumor size decreased (partial response), and a breast-conserving surgery was done. Small cell carcinoma of the breast is rarely reported in the literature. We report our case, along with the relevant literature.

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We report identical female twins who had breast cancer exhibiting the same biological features. The elder twin developed a left breast mass. She was diagnosed with left breast cancer. An operation was performed, and on pathology, a mucinous carcinoma with nuclear grade 2, positive hormonal receptor, and low expression of HER2 protein was found. No sentinel lymph node metastases were detected. The younger twin also developed a left breast mass. She was also diagnosed with left breast cancer. An operation was performed, and on pathology, a mucinous carcinoma with the same biological features as the elder twin's was diagnosed.

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Leiomyosarcoma of the inferior vena cava (IVC) is extremely rare. In the case reported here, a 61-year-old woman visited a local hospital because of an abdominal mass. The abdominal computed tomography (CT) scan showed a 15-cm solid, lobulated retroperitoneal mass with a necrotic area and total complete obstruction of the infrarenal IVC. A retroperitoneal tumor was suspected. A complete tumor resection with IVC resection was performed. The tumor was histologically composed of spindle cells that showed nuclear pleomorphism with occasional giant nuclei. The patient was diagnosed as having a leiomyosarcoma of the IVC. Seventeen months later, an abdominal CT scan showed liver metastasis, and the patient underwent a partial hepatectomy. Twenty-nine months after the initial operation, however, multiple lung and liver metastases occurred. To our knowledge, only five cases of radically resected metastasis of leiomyosarcoma of the IVC have been reported in our country. Because of its rare occurrence, we report our case here and discuss some references.

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An 81-year-old man was scheduled to undergo surgery for an aortic arch aneurysm. The patient was admitted to a local hospital because of congestive heart failure. Computed tomography showed an aortopulmonary fistula due to an aortic arch aneurysm. The patient was therefore transferred to our hospital for undergoing total arch replacement with closure of the fistula and coronary artery bypass grafting (AO-SVG-#4PD). It was difficult to maintain circulation during the cardiopulmonary bypass because of an aortopulmonary shunt. The patient required percutaneous cardiopulmonary support for 2 days and was discharged 49 days after the operation. Aortopulmonary fistula is a rare, potentially fatal condition that can lead to death because of right heart failure.

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We report the case of a 71-year-old woman who developed a 43-mm mass lesion that was detected by CT on postoperative follow-up examination of right breast cancer. The lesion was preoperatively diagnosed as a gastrointestinal stromal tumor (GIST) that developed outside the gastric wall. First, we carried out a diagnostic laparoscopy to confirm the tumor site. On observation, we found that the tumor originated mainly from the diaphragm. Securing a sufficient margin, we laparoscopically resected a 4-cm × 5-cm section of the diaphragm, including the tumor. The diaphragmatic defect was repaired using Gore-Tex^®. Histopathological examination revealed that the tumor was a rare primary diaphragmatic neurilemmoma. For tumors developing around the diaphragm, identification of the primary lesion is often difficult because of the presence of many neighboring organs, including the liver, stomach, and esophagus.
Therefore, it is difficult to determine whether a diaphragmatic tumor should be accessed by the thoracic approach or abdominal approach. Diagnostic laparoscopy was feasible for determining the appropriate approach and resection procedure. To our knowledge, this is the first case of laparoscopically resected primary diaphragmatic neurilemmoma.

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We report the cases two patients who underwent a laparoscopic repair using a mesh after endoscopic repositioning for a large esophageal hiatus hernia complicated by an upside down stomach. Case 1 was an 86-year-old woman who was admitted because of frequent vomiting. CT revealed pneumonia and an upside down stomach. She was treated by endoscopic repositioning, and laparoscopic repair was performed after her general condition improved. Case 2 was an 88-year-old woman who was admitted because of loss of consciousness. CT and upper gastrointestinal endoscopy revealed an upside down stomach and multiple gastric ulcers. She underwent endoscopic repositioning, and oral medical treatment was started. However, gastric ulcer bleeding recurred. Since the bleeding could not be controlled by oral treatment, laparoscopic repair was performed. Neither case has had recurrence of the esophageal hiatus hernia or the appearance of complications using a mesh after laparoscopic repair.

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We report a case of bronchial necrosis after esophagectomy, treated using a percutaneous cardiopulmonary support system (PCPS). The patient was a 63-year-old man who underwent a thoracic esophagectomy with gastric tube reconstruction via the posterior mediastinum route for esophageal cancer. The respiratory condition worsened on postoperative day (POD) 5, following which anastomotic leakage, mediastinal abscess, and necrosis of the right membranous bronchus was diagnosed on POD 7. An emergency operation was performed under the PCPS, with the patient in a state of severe respiratory failure. The esophagogastric anastomosis was divided, and then a cervical esophageal fistula was created. The necrotic portion of the right main bronchus was covered by the omentum adhering to the gastric tube. PCPS use was continued after the operation and changed to veno-venous extracorporeal membrane oxygenation (V-V ECMO) on POD 3. The ECMO system was used until POD 7. The patient could be weaned off mechanical ventilation on POD 77 due to improvement in respiratory status accompanied by granulation of the bronchial necrosis. He was transferred to the previous hospital on POD 118. Bronchial necrosis after esophagectomy is commonly followed by a critical general condition because of concomitant severe respiratory failure ; therefore, a pump oxygenator such as the PCPS or ECMO may be useful in severe respiratory failure during the perioperative period.

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We report the case of a 56-year-old man with a gastric carcinoid tumor associated with type A gastritis. In December 2010, multiple ulcerative lesions were detected during a barium meal examination. Gastric endoscopy revealed erosive lesions, ulcer scars and multiple small red spots all over the stomach and he was diagnosed with a gastric carcinoid tumor histologically. The serum gastrin level was 1,900 pg/ml. We determined that this gastric carcinoid was associated with type A gastritis and performed laparoscopy assisted distal gastrectomy to decrease the serum gastrin level. The serum gastrin level dropped down to normal range and all carcinoid tumors disappeared.

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We herein report a case of single-incision laparoscopic surgery for a gastric gastrointenstinal stromal tumor (GIST) with an intraluminal growth pattern. The patient was an 87-year-old woman who was admitted because of anemia. Gastric endoscopy revealed the presence of a gastric submucosal tumor (4 cm in diameter) in the lesser curvature of the cardiac lesion. Based on endoscopic ultrasonography-guided fine needle aspiration biopsy, the pathological diagnosis was GIST, and an operation was performed. A laparoscopic partial gastrectomy was performed by inserting three 5-mm trocars into a single access port attached to the umbilicus. Through transillumination and serosal dissection methods, the intraluminal growth pattern was changed to an extraluminal growth pattern, and the tumor was easily dissected with a linear stapler.
A sufficient surgical margin was assured in this case. This method is useful for laparoscopic surgery of GISTs of the stomach.

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A 75-year-old man with anorexia was found to have leukocytosis and a huge gastric tumor which had invaded the pancreas in an abdominal computed tomography (CT). Upper gastrointestinal endoscopic examination showed a type 1 tumor on the posterior wall of the corpus ventriculi. Biopsy specimen revealed poorly differentiated adenocarcinoma. Total gastrectomy and D2 lymph node dissection with a combined resection of the body and tail of the pancreas, transverse colon and left adrenal grand was performed. Pathological findings, according to the Japanese Classification of Gastric Carcinoma (The 14^th Edition), were poorly differentiated adenocarcinoma solid type, T4b(SI), int, INFβ, ly3, v2, N2, H0, P0, CYX, M1(LYM), Stage IV. Immunohistochemical examination using Granulocyte-Stimulating Factor (G-CSF) antibody revealed positive staining in the gastric cancer cells. A definite diagnosis of G-CSF-producing gastric cancer was thus made. The white blood cell (WBC) count initially returned to normal, however recurrent disease in the paraaortic lymph nodes was detected early after the operation. The man died 84 days after the operation.

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A 69-year-old man was admitted to our hospital because of blackish stool. Endoscopic examination revealed a tumor of the lesser curvature consisted of type 1 and type 3 from the upper body to the antrum. Contrast computed tomography (CT) showed regional lymphnode metastasis and solitary liver metastasis in the posterior segment which was poorly enhanced. The result of a biopsy was poorly differentiated adenocarcinoma, and a total gastrectomy with D2 lymphnodes dissection and a partial hepatectomy was performed. Postoperative diagnosis was endocrine carcinoma combined with carcinoma with enteroblastic differentiation, which is a α-fetoprotein (AFP) -producing adenocarcinoma, and the metastasis of the liver and lymphnodes were all endocrine carcinoma. Only two cycles of CPT-11 + CDDP regimen could be administrated, unable to continue. Solitary liver metastasis recurred before he was 6 months after the gastrectomy. The tumor showed an enhanced pattern likely due to hepatocellular carcinoma in the dynamic CT, and proved to be endocrine carcinoma after partial hepatectomy. CPT-11 was administrated for 6 months, and now he is alive without recurrence 22 months after the gastrectomy. Here, we present an extremely rare combined case of endocrine carcinoma and carcinoma with enteroblastic differentiation which is a AFP-producing adenocarcinoma.

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An 87-year-old woman complaining of appetite loss and general fatigue was strongly suspected to have gastric cancer and was referred to our hospital. A chest X-ray film demonstrated stomach bubble which was identical with the cardiac shadow. Gastric fluoroscopic study revealed that the entire stomach from the cardiac part to the pylorus had deviated to the posterior mediastinum, showing the upside down stomach. Gastric endoscopy showed an ulcerative lesion from the angular notch to the pyloric antrum, a biopsy of which showed poorly differentiated adenocarcinoma. Advanced gastric cancer associated with the upside down stomach was diagnosed, and distal gastrectomy + resection of the hiatal hernia sac were performed under laparotomy. Reconstruction was done by means of Roux-en-Y method. The remnant stomach was sutured and fixed to the crus of the diaphragm so as not to be impacted again into the thoracic cavity. The final histopathological diagnosis was pT4apN3aM0, INFb, ly3, v2, and Stage IIIC. The postoperative course was uneventful. No regurgiatation symptoms have been noted.
We would have to consider different reconstruction methods and procedures to prevent regurgitation for different cases of gastric cancer associated with the upside down stomach.

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An 82-year-old man was admitted for diarrhea and loss of appetite. Gastrofiberscopy revealed a type 2 lesion-like submucosal tumor at the greater curvature of the upper corpus. Colonofiberscopy revealed a gastrocolic fistula leading into the stomach. Biopsy specimens from both the stomach and the colon indicated adenocarcinoma. A gastrocolic fistula was identified by abdominal CT and radiographic contrast study. On the basis of a diagnosis for gastric cancer with gastrocolic fistula, total gastrectomy, left hemicolectomy, and resection of the pancreas tail and spleen were performed. In spite of the curative operation and postoperative adjuvant chemotherapy, the patient died from recurrence 8 months later. Identification of the origin of a malignant tumor with gastrocolic fistula may often be difficult, but preoperative diagnosis is important because of the differences in operation methods and prognoses.
We believe that the macroscopic type was useful in the identification of the origin of the tumor.

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A 62-year-old male was found to have a stomach tumor. Abdominal CT revealed multiple abnormalities : a polyspleen, pancreatic hypoplasia, and malrotation of the intestine. He had no other abnormalities, such as heart malformations. The patient underwent a total gastrectomy and a preventive appendectomy. The pancreas showed severe fatty degeneration ; the peripancreatic lymph node dissection was very difficult. The patient's post-operative course was uneventful. This report describes a rare case of stomach carcinoma complicated by multiple abnormalities.

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We report a case of wide-ranged non-occlusive mesenteric ischemia (NOMI) associated with duodenal ischemia. A 79-year-old man underwent a stent graft replacement for thoracic aortic aneurysm. Three days after the procedure, he developed infectious enteritis associated with diarrhea and abdominal pain. Thirteen days after the procedure, abdominal distention and vomiting appeared and a computed tomography (CT) scan revealed paralytic ileus, hepatic-portal venous gas, and pneumatosis cystoideus intestinalis. Judging from the severity of the illness, we treated conservatively by decompression of the gastrointestinal tract. However, 8 hours thereafter, the patient developed shock and a CT scan demonstrated poor enhancement of the part of the small intestine. We performed an emergency laparotomy.
The intraabdominal findings showed a wide range of ischemic bowel from the duodenum to the transverse colon and we resected the necrotic bowels. The patient could not recover from the shock state and died of multiple organ failure on the postoperative day 11. Pathological examination detected no thrombus in the mesenteric arteries. Therefore, the patient was diagnosed as NOMI. This patient is the fourth case of wide-ranged NOMI associated with duodenal ischemia in the literature search and it seems to have a poor prognosis.

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The case involved a 48-year-old man who had undergone emergency operation for a hemorrhagic duodenal tumor 15 years earlier, when the tumor was located in the third part of the duodenum. It was measured 30 × 28 mm in size and was histopathlogically diagnosed as leiomyoma. However, gastrointestinal stromal tumor (GIST) of the duodenum was diagnosed, because the tumor was c-kit positive on re-examination. This time, the patient was accidentally detected to have a 9 × 6 cm cystic tumor at the mesocolon during treatment for other disease. The tumor had no continuity with the gastrointestinal tract, and there were no lymph node swelling and ascites. Mesocolonic tumor was diagnosed and surgery was performed. The resected tumor was a monolocular cystic tumor and was c-kit positive, so that epithelioid tyte GIST was diagnosed. The postoperative course was uneventful . The patient had been given oral imatinib mesylate for one year as the postoperative adjuvant chemotherapy. No recurrence has occurred, as of one year and 4 months after the operation. Since the patient had the previous history of undergoing surgery for duodenal GIST 15 years before admission which was close to the tumor treated this time, recurrence to the mesocolon was diagnosed. There are some cases of GIST which can cause late recurrence. Long-term follow-up would be mandatory even if the initial lesion is classified into the low risk neoplasms, like in our case.

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A 75-year-old male developed fever and abdominal pain.
Gastrointestinal endoscopy showed an elevated tumor located in the papilla of Vater. A biopsy revealed adenocarcinoma. A pylorus-preserving pancreatoduodenectomy was performed.
The histopathological findings showed an adenoendocrine cell carcinoma (pT2 (pPanc0, pDu1), pN1, M(-), and fStage III).
Adenoendocrine cell carcinoma arising in the papilla of Vater is extremely rare. Only 18 cases, including our case, have been reported in the Japanese literature.
The prognosis of adenoendocrine cell carcinoma is usually dismal.
Recurrence involving hepatic metastasis is commonly reported. However, our case developed a recurrence which involved peritonel dissemination.
Chemotherapy (oral S-1) was given.
The patient is alive with recurrent disease 51 months after the initial operation.

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An 80-year-old woman complaining of abdominal pain and vomiting was referred to our hospital with a diagnosis of intestinal obstruction. On admission, there was tenderness on the left side of the subumbilical area. Abdominal CT scan revealed dilatation of the small intestine and a hyper absorption foreign body in the small intestine, which was suspected of press through package (PTP). No free air was identified. Symptomatic remission was gained by placing an ileus tube. On the 10^th hospital day, however, abdominal pain recurred. Another abdominal CT scan offered a suspicion of intestinal perforation due to a foreign body. Emergency laparotomy was performed, and small bowel perforation caused by PTP was diagnosed. Following partial resection of the small intestine and irrigation drainage, the patient was discharged from the hospital on 25^th postoperative day.
In this case, symptoms of intestinal obstruction developed because the ingested PTP was retained at the flexion of small intestine. Although the symptoms once improved by conservative therapy, the PTP had still been retained there that might cause small bowel perforation. Adhesions in the abdominal cavity were so firm that peritonitis remained locally. No clear notion has been established as for therapies and emergency treatments of PTP which has reached to the lower digestive tract. Some bibliographic comments as well as this case are presented here.

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A 76-year-old man with rectal carcinoma had a low anterior resection with a diverting ileostomy. His postoperative course was complicated by intestinal obstruction due to severe stenosis of the stoma on POD 8. On POD 19, a second operation was performed, and on pathology, heterotopic bone formation in the mesentery and/or subserosa, suspicious of heterotopic mesenteric ossification (HMO), was found. HMO is a very rare disease that results in the formation of an intestinal stenosis or an intraabdominal mass due to the ossification of abdominal organs. Forty-six cases (27 papers), including two Japanese cases, have been reported in the literature. Surgery is the only therapeutic modality. There are a few reports of patients dying due to operative difficulties ; there are also reports of patients requiring repeat surgeries due to recurrence. Irradiation, diphosphonates, and NSAIDs have been reported to be useful for the prevention of heterotopic ossification. In cases treated with H2-blockers such as cimetidine, the loss of calcification has been reported. The efficacy of the therapies available for HMO needs to be evaluated.

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A 28-year-old woman was admitted to a local clinic after suffering from postprandial abdominal pain and fever. Ultra-sonography indicated an intra-abdominal cystic mass. She was referred to our hospital for exploration and treatment. On admission, she had no abdominal pain or tenderness. Serum CRP was slightly elevated in a blood test. Enhanced computed tomography showed small intestinal intussusceptions caused by a multiple cystic mass, and dilatation of the upward intestine. She underwent single-incision laparoscopic surgery (SILS). Reduction of the intussusception was performed intracorporeally. Partial resection of the small intestine and subsequent anastomosis was performed extracorporeally through the incision. Histopathological examination demonstrated choristoma of the small intestine. There has never been a report about choristoma of the small intestine. This is the first case of small intestinal intussusception caused by choristoma, and treated by single-incision laparoscopic surgery. This case is presented together with a review of the literature.

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The patient was an 83-year-old woman who had accidentally ingested a press-through package (PTP) and was referred to our hospital for lower abdominal pain 3 days after PTP ingestion. She was being treated with anti-TNF-α antibody (infliximab) for rheumatoid arthritis. The day after the accidental PTP ingestion, she was administered infliximab. Two days later, she was treated with methotrexate. An abdominal CT scan showed the PTP in the ileum and ascites around the intestine. The blood test detected an increase in the inflammatory response. A diagnosis of acute pan-peritonitis was made, and emergency laparotomy was performed. There was a moderate amount of turbid ascites, and the PTP was palpable in the ileum. A white moss-like layer had adhered to the ileum, and therefore microperforation was considered. Partial ileum resection and peritoneal lavage were performed. Postoperative complications such as infection were not observed. We report this case with a review of the literature regarding perioperative management during the administration of infliximab and for accidental ingestion of PTP.

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The patient was a 72-year-old woman who noted a right inguinal bulge in January for which she underwent a medical examination at the beginning of April. Right inguinal hernia was diagnosed and surgery was scheduled. She noticed her right inguinal bulge at about 4 : 00 PM in May. She consulted a hospital the same evening. Right inguinal hernia strangulation was diagnosed and we managed to reduce the hernia. The feeling of abdominal distension persisted, necessitating subsequent abdominal CT. A condition such as perforation was suspected, and emergency laparotomy was performed. During the operation, we noted a perforation of the Meckel diverticulum.
We removed only the Meckel diverticulum surgically.
Incarceration of the Meckel diverticulum resulting from an inguinal hernia is very rare. Meckel diverticulum perforation just after hernia reduction is also rare. Close observation should be considered necessary in the event of Meckel diverticulum incarceration accompanying an inguinal hernia to guard against Meckel diverticulum perforation after hernia reduction. Herein, we report this case in addition to an investigation of reported similar cases.

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A 57-year-old man was admitted to our hospital because of intractable fistula of the right groin, which had developed 4 months earlier. Seven years earlier, he had undergone right open inguinal hernioplasty with a mesh plug at a local hospital. Abdominal CT revealed abscess formation in the right lower abdominal wall, and the presence of a colocutaneous fistula caused by the plug was suspected. The operative findings showed that the cecum and ileum were strongly adhered to the right lower abdominal wall, with the plug penetrating into the cecum wall. The plug and on lay patch were removed and ileocecal resection was performed. Colocutaneous fistula caused by open inguinal hernioplasty with a mesh plug is a rare complication, but the possibility that the plug may adhere to or penetrate the intestinal tract after mesh-plug hernia repair must be considered.

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A 69-year-old man visited the hospital because of tarry stool. On image inspection, rectal cancer and multiple liver and lung metastases were observed. Disseminative lesions were observed in the abdominal cavity. There was no bleeding from the rectal cancer and no hemorrhagic change based on upper gastrointestinal endoscopy. We decided to operate because bleeding control by conservative therapy was impossible. Three disseminative lesions accompanied by intraperitoneal bleeding were observed in the small intestine. Partial excisions of each lesion were carried out, and high anterior resection was enforced to rectal cancer. Upon histopathological examination, multinucleated giant cells such as syncytiotrophoblasts were scattered throughout the specimen, whereas the small intestines exhibited HCG positivity on immunohistochemical staining, and choriocarcinoma was diagnosed. Four days after the operation, gastrointestinal bleeding and aggravation of liver function were again detected, and all of the metastases, including that of the liver, quickly worsened. The patient died 18 days after the operation.

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A 23-year-old man had been treated for ulcerative colitis four years previously and his symptoms had been controlled by oral steroids. An examination for abdominal pain and subsequent abdominal computed tomography found multiple air-filled cysts along the intestinal wall and intussusceptions as well as free air. We diagnosed intussusceptions associated with pneumatosis cystoides intestinalis (PCI). A laparotomy demonstrated ileocolic intussusceptions, and an elastic mass was palpated at the invaginated ascending colon. At post-reduction, intestine necrosis was not observed. The postoperative course was good. PCI slowly regressed and was no longer detectable. The patient had no subsequent problems related to PCI. We report an extremely rare case of intussesception associated with PCI in ulcerative colitis.

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We report a case of perforation of the descending colon by barium sulfate.
The patient consulted our hospital because of abdominal pain. She had undergone a barium study for a gastric cancer screening 2 days earlier. Subileus because of barium sulfate was diagnosed. On day 3, we decided to perform a laparotomy because her pain persisted and found a perforation of the descending colon.
Perforation by barium sulfate is very rare, but surgical treatment can be considered in such cases on the basis of clinical findings.

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The subject was a 60-year-old postmenopausal woman who had undergone sigmoid colon resection and partial cystectomy for sigmoid colon cancer at 57 years of age. The histological type of the resected cancer was well-differentiated adenocarcinoma, with a mucinous carcinoma component. Two years 9 months after the initial surgery, a multilocular cystic mass extending 30 cm across the lower abdominal region appeared, for which a bilateral oophorectomy was performed. The right ovary was found to contain a giant cyst consisting of a smooth white capsule filled with a large quantity of brown mucus. Peritoneal dissemination of mucinous nodules was also observed. Histopathologically, the features were similar to those of ovarian mucinous cystadenocarcinoma. Cytokeratin (CK)7/CK20 staining, however, demonstrated a staining pattern similar to that of the previously resected colon cancer. Bilateral ovarian metastasis from sigmoid colon cancer was diagnosed following H.E. staining. A similar lesion was also observed in the morphologically normal left ovary. Primary mucinous carcinomas of the colon are rare. There have only been a few reports on ovarian metastasis with this cancer. While prognosis is poor for ovarian metastasis of colon cancer, there have been reports of long-term survival due to surgical resection, and consequently, we can expect to extend prognosis through active treatment of this condition.

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The first case was a 56-year-old woman. The patient underwent low anterior resection to treat rectum cancer. The pathological findings revealed components of conventional tubular adenocarcinoma and micropapillary carcinoma (MPC). There was marked lymphatic invasion and multiple lymph node metastases. In addition, the extension of carcinoma in the lateral direction was remarkable and the surgical margin was positive. The cytology of the ascites revealed adenocarcinoma. The second case was a 78-year-old woman. The patient underwent laparoscopic-assisted right hemicolectomy to treat ascending colon cancer. The pathological findings revealed components of conventional tubular adenocarcinoma and MPC. Although the depth was MP, she had a reccurence of liver metastases 5 months after operation. MPC has been reported in breast, and is known to be associated with poor prognosis and a high propensity for lymphovascular invasion and lymph node metastases. However, reports on colorectal MPC are relatively rare. We report these two cases of colorectal MPC, and review the relevant literature.

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Signet ring cell adenocarcinoma of the rectum is a comparatively rare disease with a poor prognosis. A 70-year-old man visited a medical clinic complaining of diarrhea and was referred to our hospital because of rectal stenosis detected on a barium enema. Blood examination, including that for tumor markers, yielded normal results. A barium enema showed a signature apple-core lesion in the Rb domain. Colonoscopy showed a circular, stricture-causing tumor approximately 5 cm from the anal verge. Abdominal CT showed circular, stricture-causing lesions in the rectum, but no lymph node or remote metastasis. Endoscopic biopsy specimens showed no malignancy. Based on these findings, a diagnosis of rectal cancer was made and low anterior resection was performed. Macroscopically, the rectal tumor was type 3 with respect to RaRb, with marked invasion to the depths. Histologically, the tumor was a signet ring cell carcinoma, INF-γ, intermediate type, se+a2, ly3, v2, ow-, aw-, ew-, n2(+). The patient received adjuvant chemotherapy, but died of carcinomatous peritonitis 3 years after surgery.

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The patient was a 68-year-old man who had undergone surgery for ascending colon cancer 4 years 6 months ago. He was admitted to our hospital for an ache in the right hypochondrium. Abdominal CT revealed a late enhanced 40-mm tumor in the medial segment (S4) of the liver, accompanied by infiltration into the left hepatic duct. Low-density nodular scattering was also confirmed in the left lobe of the liver. Based on a diagnosis of cholangiocellular carcinoma, we conducted an extended left hepatic lobectomy with extrahepatic bile duct resection. Histopathologically, the liver tumor was a moderately differentiated adenocarcinoma, and the multiple small nodules in the left lobe of the liver consisted of infiltrating inflammatory cells and fibrosis. Additional immunohistological study revealed that the tumor was CK7 negative and CK20 positive, and contrary findings were noted in the normal bile duct. Therefore, we diagnosed this case as liver metastasis from colon cancer. Because liver metastasis from colorectal cancer rarely invades the intrahepatic biliary tracts or vessels, its differentiation from cholangiocellular carcinoma should be made with caution.

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A 35-year-old man who visited elsewhere hospital because of abdominal distention due to constipation was referred to our hospital for the purpose of close exploration and treatment for seriousness of his abdominal distention. When he was first seen, physical examinations disclosed bulbar conjunctiva yellowing and abdominal distention. There were no specific previous medical histories. Following close examinations after admission, cancer of the pancreas head was diagnosed. Pancreaticoduodenecomy with reconstruction by means of Child modified procedure was performed. Pathology revealed poorly differentiated tubular adenocarcinoma, with a part of spindle-shaped cells. The disease was rated T4N1M0 in stage IVa. Blood biochemical examination performed on the postoperative day first showed remarkably increased levels of AST, 1,303 IU/l, and ALT, 2,110 IU/l. On contrast enhanced CT scan, a low density area was confirmed in the portal phase rather than in the artery phase, so that liver infarction was diagnosed. Probable cause of his liver infarction might the disturbance of blood flow caused by retractor or taping. Administration of PGE1 preparation, protease inhibitor and antibiotics was successful and the patient was discharged.

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A 68-year-old woman underwent surgical resection combined with local radiation and adjuvant chemotherapy for primary breast cancer. After one year, abdominal CT scan revealed a solitary liver metastasis. She underwent a right hepatectomy for the liver metastasis, which was HER2- positive, as was the primary tumor. Trastumab was administered as adjuvant chemotherapy. Three years after the first hepatectomy, an intrahepatic recurrence developed in the left lateral segment. Multiple chemotherapeutic regimens were given, but failed to reduce the tumor. Because the tumor recurrence was restricted to the liver, surgical resection was considered as a choice of treatment even though repeat hepatectomy is not a standard treatment for liver metastasis related to breast cancer. A left lateral segmentectomy of the liver was performed 5 years after the first hepatectomy. During the last three years the patient has been doing very well without requiring chemotherapy. Repeat hepatectomy may be a choice in patients with a single tumor and recurrence restricted to the liver.

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We report a case of idiopathic perforation of the gallbladder (IPG). The patient was a 57-year-old woman who presented with acute-onset abdominal pain. Physical examination showed peritoneal signs. CT showed ascites ; therefore, she underwent emergency laparotomy. Intraoperative findings showed bile leakage from the gallbladder. Therefore, she underwent a cholecystectomy. Microscopic examinations showed a perforation in the body of the gallbladder. Cholecystitis or gallstones were not noted. Therefore, she was diagnosed with IPG. Microscopic examinations also showed vasculitis and thrombus in the adjacent gallbladder wall, which was likely closely linked to the perforation. Her ascites amylase level was 31,800 IU/L, presumably due to pancreatobiliary reflux in the absence of pancreatobiliary maljunction. IPG should be considered in the differential diagnosis of acute abdominal pain accompanying a high amylase level in ascites.

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A 46-year-old woman visited our hospital after a gallbladder abnormality was found during a complete health check-up in November 2008. Abdominal CT showed extensive lipid accumulation around the gallbladder. On abdominal MRI, a hyperintense region consisting of a partially heterogeneous interior having the same signal intensity as lipid and a septal structure was seen surrounding the gallbladder, suggesting a lipid-containing tumor. A high CA19-9 level was also noted. The diagnosis was gallbladder lipomatosis, but because malignancies such as liposarcoma could not be ruled out, cholecystectomy with liver bed resection was performed in March 2009. The postoperative pathological diagnosis was gallbladder lipomatosis. While gallbladder lipomatosis is rarely reported, it exhibits characteristic findings on imaging and warrants consideration during preoperative diagnosis.

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A 72-year-old woman had a cholecystectomy in December 2006 for early gallbladder cancer accompanied by a pancreaticobiliary maljunction without bile duct dilation. Histopathological findings revealed papillary adenocarcinoma (Tis, N0, M0, stage 0). She was admitted due to obstructive jaundice in April 2010. Under the diagnosis of middle and inferior common bile duct cancer, a subtotal stomach-preserving pancreatoduodenectomy was performed. Histopathological findings revealed papillary adenocarcinoma (T3, N0, M0, stage IIA). The resection and reconstruction of the extrahepatic bile duct in addition to cholecystectomy for pancreaticobiliary maljunction without bile duct dilation remains controversial. In this case, dysplastic changes were seen in the epithelium of the common channel in that the lower side of the pancreaticobiliary junction was invaded by cancer cells. Therefore, resection of the extrahepatic bile duct would not have removed all of the area with malignant potential, even if it had been performed at the time of the first surgery.

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A 59-year-old man presented with appetite loss and jaundice was diagnosed as having middle bile duct carcinoma following close exploration. Pancreatoduodenectomy was scheduled. Upon laparotomy, four nodules which were grayish white in color and several millimeters in size were identified on the liver surface. Hepatic metastasis of cholangiocarcinoma was suspected and biopsy was performed. On frozen section diagnosis, malignant neoplasms were suspected so that surgical resection was discontinued. Histopathology of the permanent specimen, however, suggested that biliary microhamartoma (von Meyenburg complex) was most likely. Thereafter pancreatoduodenectomy was performed. Cholangiocarcinoma was moderately differentiated tubular adenocarcinoma in Stage III and its histologic features were different from those of the nodules of the liver. The patient had been given TS-1 orally for about one year as postoperative adjuvant chemotherapy. Serum level of CA19-9 elevated two years after the operation and TS-1 regimen resumed for suspected recurrence. The CA19-9 level once decreased, but started to elevate again three years after the operation. An abdominal CT scan suggested possible occurrence of lymph node or local metastasis, but no hepatic metastasis was demonstrated.
Biliary microhamartomas are rare and often pose a problem of differentiation from hepatic metastasis.

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A 63-year-old Japanese man was referred to our medical center for further examination of a hepatic tumor. Computed tomography (CT) and magnetic resonance imaging showed a strongly ring-like enhanced tumor with a diameter of 65 mm in segment VIII of the liver. There were no other intraabdominal or intrapleural lesions. Since it was diagnosed as intrahepatic cholangiocarcinoma (ICC) or combined type hepatocellular carcinoma, a right hepatic lobectomy was performed. Macroscopically, the excised specimen was a white, non-capsulated tumor which was growing expansively. Histopathological findings showed that the tumor cells had large clear cytoplasm, proliferated in a glandular pattern and formed an irregularly fused solid nest. Periodic acid Schiff (PAS) staining suggested that the cause of the clear cytoplasm was glycogen. Immunohistochemical stainings of CD10, Vimentin, alpha fetoprotein, HepPar1, CK7 and CK20 were all negative. These pathological findings confirmed that the diagnosis of intrahepatic clear cell cholangiocarcinoma (ICCC). ICCC is an extremely rare ICC variant where only nine cases have been previously reported. According to these reports, it is considered that the prognosis of ICCC may not be as poor as that of ICC. The present patient is alive and free from recurrence for 15 months after the surgical operation.

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An 82-year-old woman underwent right hepatopancreatoduodenectomy. The planned procedure for this patient with a Bismuth type IIIa tumor was a right hemihepatectomy, caudate lobectomy and bile duct resection. Although intraoperative examination of frozen sections revealed no cancer in the proximal ductal margin, the distal margin was positive for invasive cancer. Additional resection (2 cm) of the distal margin was performed, but failed to achieve a negative margin. Finally, an additional pancreatoduodenectomy was performed. Pathological findings revealed well differentiated tubular adenocarcinoma and no lymph nodes metastasis. Postoperative complications were pancreatic fistula and pleural effusion. She was discharged from the hospital on the 46^th day after surgery. At present, she is still alive without any evidence of cancer recurrence for 5 years and 6 months after surgery.

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A 32-year-old woman stabbed herself in the epigastrium during a suicide attempt. Her vital signs were stable, but abdominal CT showed injuries in the liver and pancreas. During surgery, a penetrating liver laceration and a few lacerations of the body of the pancreas were noted. Only the bleeding was controlled, and a pancreatic parenchyma repair and drainage were done due to uncertainty about the extent of Main pancreatic ductal injury ; an endoscopic retrograde pancreatography (ERP) for the diagnosis and treatment of the Main pancreatic ductal injury was planned. After the operation, ERP revealed main pancreatic ductal disruption, and a pancreatic stent was placed to bridge the injured site. On the 10th day, the stent slipped from the pancreatic duct, but the patient remained in good condition. She was discharged on postoperative day 44 without a pancreatic fistula. Surgical intervention along with planned ERP and pancreatic stenting are effective in the treatment of Main pancreatic ductal injury following penetrating trauma.

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A 54-year-old man underwent laparoscopic-assisted cholecystectomy for acalculous cholecystitis in July 2012, when swelling and fragility of the liver were pointed out and deposits of amyloids were noted in the resected gallbladder. Postoperative bleeding occurred. Abdominal CT scan revealed a swollen liver and findings of subcapsular hemorrhage of the spleen, however, the patient was asymptomatic. So the patient had been followed until September of the year, when he was seen at the hospital because of the abrupt onset of abdominal pain and anemia. Emergency operation was performed with a diagnosis of hemorrhage due to rupture of the spleen. Upon laparotomy, intra-abdominal hemorrhage and the swollen spleen were seen. Partially ruptured capsule of the spleen and bleeding from the splenic parenchyma was identified. The liver was yellowish and was felt hard. Postoperative pathology showed amyloid deposits of the liver and the spleen.
We report a case in which rapid progress of amyloidosis after the operation was suspected and progressing of amyloidosis was observed by macroscopic findings, together with bibliographic comments.

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A 74-year-old man presented with upper abdominal pain. Abdominal computed tomography scan revealed a huge splenic artery aneurysm (19 cm) with no evidence of rupture. Because of the tumor size and destruction of the vascular dimension, we performed resection of the distal pancreas and spleen. The histopathologic findings revealed arteriosclerosis and severe destruction of the vascular dimension. After the operation, he improved and was discharged from the hospital on the 80th post-operative day. As giant splenic artery aneurysms are very rare, we report this case with a review of the literature.

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