PURPOSE : The purpose of this study was to clarify the validity of the mechanical bowel preparation (MBP) for thoracic esophageal surgery.
METHODS : Consecutive 59 patients who underwent curative surgery for esophageal cancer between January 2005 and Decomber 2009 in our center were enrolled in this study. These 59 patients, comprising 32 patients with MBP (MBP group) and the remaining 27 patients without MBP (non-MBP group), were compavatively studied to elucidate effects of MBP on the surgery and postoperative course.
RESULTS : The mean body weight on the day of the operation significantly decreased in comparison to the day before operation in both groups (P<0.05). The body weight loss in the MBP group was significantly greater than in the non-MBP group (-1.1kg vs. -0.8kg, P<0.05). No intra-operative fecal incontinence was observed in either group. The day of first evacuation after surgery in the non-MBP group was earlier than in the MBP group (6 days vs. 4 days, P<0.05). There was no significant difference in the postoperative complications or in the hospital stay after operation between the two groups.
CONCLUSIONS : MBP tended to cause the patients to develop dehydration. We concluded that the routine use of MBP was not necessary when performing surgery for thoracic esophageal cancer.

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Objectives : We evaluated the postoperative risk factors with regard to complications using the Surgical Apgar Score (SAS) and rated the usefulness of the SAS in elderly patients over 75 years of age. Methods : We analyzed the postoperative morbidity and mortality in 99 elderly patients (age : 75-99 years) who underwent surgery for colorectal cancer between 1995 and 2010 in our hospital. Results : Of the 99 patients, 88 patients (88.9%) underwent curative resection and 11 patients (11.1%) underwent non-curative resection. Preoperative disorders were noted in 32 patients (32.3%), of which cardiovascular morbidity was the most common. The rate of Grade III or IV postoperative complications was 18.3% (18 patients), and the postoperative mortality rate was 4.0% (four patients). In accordance with the SASs, 19, 76, and four patients were identified to be at low risk of postoperative complications (low risk group), at average risk (average risk group), and at high risk (high risk group), respectively. The rates of patients who developed Grade III or IV postoperative complications were 5.3%, 14.5%, and 50% in the low risk, average risk, and high risk groups, respectively ; and those of mortality were 0%, 3.9%, and 25%, respectively. The results of a ROC analysis indicated that the SAS was correlated with the complications (AUC 0.732, p=0.002). A multivariate analysis identified that the SAS (hazard ratio HR2.091, p=0.005) was a significant independent prognostic factor. Conclusion : The SAS appears to be useful for predicting the postoperative risk in elderly patients with colorectal cancer.

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Purpose : The aim of this study was to compare the outcomes between stapled anastomosis and handsewn anastomosis for the closure of the temporary loop ileostomy.
Method : Consecutive 129 patients undergone ileostomy closure from 2002 to 2006 in our hospital were divided into the handsewn group (n=57) and the stapled group (n=72) to compare for operating time, hospital stay, wound infection, and bowel obstruction.
Results : There were no significant differences between the both groups in the incidence of wound infection (p=1.000) and the operating time (p=0.225). A significantly less freguency of postoperative bowel obstruction was noted in the stapled group than (24.6%) in the handsewn group (4.2% vs. 24.6%, p=0.001).
The mean length of hospital stay was 10.0±6.1 days in the handsewn group versus 7.1±1.2 days in the stapled group, with a significant difference (p=0.00004).
Conclusion : The stapled ileostomy closure is safe with a low risk of bowel obstruction and reduces the length of hospital stay.

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We investigated all the anastomotic recurrence cases after functional end-to-end anastomosis (FEEA) for colon cancer in our hospital between April 2000 and March 2010. In 401 FEEA cases, five recurrent cases at the anasitomosis site of FEEA were identified. Pathological findings of the first operation showed that the depth of tumor invasion were subserosa, lymph node metastasis were positive, and the period until recurrence were less than 2 years in all of the five cases. It is etiologically inferred that implantation of free cancer cells in the intestine might cause the anastomotic recurrence, and we considered two possible mechanisms for the implantation. The first is that free cancer cells are caught into suturing line by the linear stapler, and second is that free cancer cells graft onto the raw surface of the FEEA after anastomosis. We discuss preventive procedures against anastomotic recurrence in FEEA with these mechanisms in mind. It is necessary to define a standard procedure to prevent anastomotic recurrences of colon cancer.

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Here we report our modified procedure for inguinal hernia repair by tension-free mesh plug technique using minimum local anesthetic solution in adults. The local anesthesia for adult patients with reducible inguinal hernia is safer especially for elderly patients suffering from cardiac or pulmonary diseases, and is preferred for those under anti-coagulation treatment. During the last 4 years, 20 tension-free groin hernia repairs were performed under local anesthesia. We have used a mixture of 1% lidocaine and either of 0.25% bupivacaine or 0.375% ropivacaine, or 0.375% ropivacaine alone as local anesthetic solution. Except cases using 0.375% ropivacaine alone, total volume of the anesthetic mixture came to approximately 8 to 18 ml (mean of 12.9ml). Our procedure is safe, simple and useful in terms of recognition of the local anatomy, and even inexperienceced surgeons can easily master the procedure.

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A 41-year-old woman visited our hospital complaining of a palpable left breast mass. An approximately 2.5 cm tumor was palpated and breast cancer was suspected by ultrasound examination. Core needle biopsy indicated glycogen-rich clear cell carcinoma (GRCCC) based on histopathological findings. The patient underwent partial mastectomy with axillary lymph node dissection. The tumor was stage IIA(T0, N0, M0). The pathological diagnosis was ER(+), PR(+), HER2(-) and S-100 protein(+). The residual breast was irradiated with 50Gy followed by hormone therapy, LH-RH agonist and tamoxifen citrate. GRCCC is a rare subtype of breast carcinoma, with a calculated incidence of 0.9-3.0%. It is composed almost entirely of polygonal cells with clear cytoplasm, containing large amounts of partly water-soluble glycogen. Recently, more than 50 cases have been reported in Japan, all women. It is necessary to follow-up these cases carefully because the biological characteristics of GRCCC are unclear.

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The patient was a 65-year-old woman undergone a radical mastectomy for right breast cancer at the age of 39 and a radical mastectomy for left breast cancer at the age of 45. In March 2008, she noticed her leg edema progressing during she had been treated for herpes zoster at a hospital, and was referred to the department of internal medicine in our hospital. Echocardiography disclosed pericardial effusion. She was diagnosed with cardiac tamponade and congestive heart failure at the department of cardiology and was emergently admitted. After admission, a decrease in pulse pressure was noted and surgical pericardial drainage was performed. Cytodiagnosis of the drained discharge gave a diagnosis of adenocarcinoma. Metastasis of breast cancer to the pericardium was diagnosed from the histological findings. Her symptoms remarkably improved and the drainage tube was removed one week after the placement. Thereafter she was transferred to the department of breast surgery and endocrine therapy with letrozole was started because the hormone receptor of the resected tumor was positive. She has been followed in our clinic without having distant metastases as well as further episode of pericardial effusion as of about three years after the pericardial drainage.

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Case 1 : A 60-year-old woman underwent conservative breast surgery for breast cancer. Histopathological examination showed invasive lobular carcinoma (ILC) and advanced lymph node metastasis. She received postoperative chemotherapy (anthracycline followed by taxan) and endocrine therapy. Gastric metastasis was diagnosed 22 months after surgery. Case 2 : A 75-year-old woman underwent a modified radical mastectomy for breast cancer. The histopathological results were the same as in case 1. The patient received capecitabine therapy and endocrine therapy. Bone metastasis was diagnosed 9 months after surgery ; gastric and peritoneal metastases were diagnosed 31 months after surgery. Most patients with gastric metastasis from breast cancer have ILC as the primary pathology. In addition, most cases have multiple organ metastases at the time of diagnosis ; consequently the prognosis is poor. In this paper, our two cases of gastric metastasis from ILC of the breast are presented.

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The patient was a 76-year-old man who presented with dysphagia. Endoscopy revealed a protruding tumor in the thoracic esophagus. Laboratory data revealed leucocytosis and a high concentration of granulocyte-colony stimulating factor (G-CSF). The patient underwent an esophagectomy via a right thoracotomy and reconstruction by stomach tube. Histopathological examination revealed poorly-differntiated squamous cell carcinoma with positive expression for G-CSF by immunohistochemistry. The tumor was diagnosed as pT3, pN1, M0 and pStage III according to the TNM classification. The leucocytosis and the serum G-CSF level decreased to within normal limits after the operation. Adjuvant chemotherapy by Cisplatin and 5-fluorouracil was also performed. We herein report a case of G-CSF producing esophageal squamous cell carcinoma. To our knowledge, only ten cases have been reported in the Japanese literature.

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A female patient in her sixties with gastric follicular lymphoma is presented. She was initially diagnosed as having double cancers in the rectum and ascending colon. As pre-operative screening, gastrofiberscopy was performed and a submucosal tumor was found in the stomach. It was 5mm in diameter and was deemed to require follow-up only. A year later, the tumor had grown to 15mm in diameter. Endoscopic ultrasonography showed the tumor to exist in the second and third layers. Immunofluorescent staining indicated a diagnosis of follicular lymphoma. With no evidence of metastasis on other examinations, we performed laparoscopic wedge resection of the stomach including the tumor. Ten months after laparoscopic surgery, there are no symptoms of recurrence.

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The patient was a 71-year-old woman undergone total gastrectomy and splenectomy with D2 dissection for gastric cancer, of which histological diagnosis was signet ring cell carcinoma, pT4a (SE), pN0, P0, CYX, M0, and Stage IIB. No postoperative adjuvant chemotherapy was done. Barium enema study performed 4 years and 2 months after the operation revealed a whole-circumferential narrowing of the descending colon. Histological biopsy did not give any diagnosis, but colonic stenosis caused by peritoneal dissemination from the gastric cancer or type 4 primary colonic cancer was the most likely diagnosis. The patient was thus operated on. Histopathology showed signet ring cell carcinoma. Hematogenic colonic metastasis of gastric cancer was finally diagnosed. The patient has been recurrence free as of six years after the second operation.
This case has suggested a possibility that the patient with solitary hematogenic colonic metastasis of gastric cancer can survive for a long time by surgical resection.

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Repeated ingestion of foreign bodies is often classified as pica, an eating disorder defined by a pathologic craving for non-food substances, lasting for 1 month or longer. A 44-year-old man had undergone surgery to remove gastrointestinal foreign bodies seven times due to pica. Radiographic examination and endoscopic removal immediately after ingestion are preferable. However, in patients for whom immediate endoscopic removal is impossible, periodic radiographic observations and timely surgical removal are necessary. It was difficult to care for those patients if they had bronchial foreign bodies and pneumonia.

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A 58-year-old woman visited our hospital because of fever was detected to have an inflammatory response and elevated biliary enzyme levels on blood examinations. Subseguent abdominal ultrasound and CT scan revealed a 3×4 cm mass with enhancement effect in the center of the abdomen and a 3cm low-density region on the lateral segment of the liver. Small bowel endoscopy suggested the mass to be a suspicious GIST of the small intestine. Blood investigations and imaging findings indicated that the low density area might be a suspicious liver abscess, but a possibility of liver metastasis of GIST could not be ruled out.
Laparoscopy-assisted partial small bowel resection along with a needle biopsy of the liver was performed one month later. Results of pathological investigations confirmed the diagnosis of GIST in the small bowel region and an abscess in the lateral segment of the liver. Abdominal CT scan performed one month after the operation revealed that the liver abscess almost disappeared.

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A 69-year-old woman underwent partial resection of the jejunum for jejunal gastrointestinal stromal tumor (GIST) with multiple liver metastases in January 2000, and was treated with TACE, PEIT and RFA for the liver lesions. In July 2003, she started treatment with imatinib mesylate and was thereafter maintained in a stable disease state for more than 5 years. In April 2009, CT scan showed a 3cm in diameter new lesion in S6 of the liver. Four months later, CT scan showed progression of only the S6 lesion because dose escalation was not allowed due to a side effect. In October 2009, she underwent partial resection of the liver for localized progression of the S6 tumor. Adjuvant imatinib mesylate at a dose of 300mg/day was restarted and no progression has been detected for 14 months. Combined modality therapy with TACE, PEIT, RFA, imatinib mesylate and surgery for GIST with multiple liver metastases contributed long-term survival exceeding 10 years.

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We experienced an adult case of Burkitt's lymphoma with ileocecal intussusception. A 76-year-old male was admitted for the treatment of epigastric abdominal pain. Ileocecal intussusception was diagnosed and as a result of abdominal ultrasonography and abdominal CT, an open surgery was performed afterwards. Laparotomy showed intussusception due to an ileocecal tumor, and we performed an ileocecal resection with lymph node dissection. The histological diagnosis was Burkitt's lymphoma and he was given chemotherapy and showed good progress. Adult intussusceptions is an uncommnon disease, and approximately 80% are caused by a tumor. The outbreak frequency of malignant lymphoma is relatively high, but Burkitt's lymphoma is a rare disease, and the convalescence is poor. Remission is becoming more common since the development of recent chemotherapy, but progress is extremely early, and introduction in the early stage is very important. Therefore, it is necessary to give combined modality therapy including an immediate operation for the intussusception in adults.

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Phlebosclerotic colitis is a rare ischemic disorder of the colon associated with phlebosclerosis of the mesenteric vein. Here we report a case of phlebosclerotic colitis treated by laparoscopic surgery. A 74-year-old female diagnosed with phlebosclerotic colitis for 10 years with no medication was admitted to our hospital with a complaint of severe anemia due to bloody bowel discharge. Colonoscopy showed stenosis with mucosal erosion from the ascending colon to the hepatic flexure of the transverse colon. Abdominal computed tomography (CT) showed a thickened colonic wall and nodular calcification of the mesenteric vein at the same site. We conducted a laparoscopic right hemicolectomy. Laparoscopic findings showed the colon was dark-red and the phlebosclerotic change of the mesenteric vein in the diseased lesion.
She was discharged on the 10th postoperative day with no postoperative complications. At the 2-year follow-up, she remained asymptomatic and no recurrence was noted.

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Although barium peritonitis is very rare, it is potentially lethal. We recently treated a 47-year-old woman who developed severe lower abdominal pain after gastrography.
Abdominal plain X-ray and CT scan images revealed extravasation of barium into the peritoneal cavity. Emergency laparotomy was performed under the diagnosis of barium peritonitis with septic shock due to perforation of the digestive tract.
Perforation was noted at the rectum, and peritoneal lavage with warm saline was performed following Hartmann's surgery. Postoperative inflammation and paralytic ileus took a month to resolve. The patient was discharged on the 35th postoperative day ; 8 months after the initial surgery, stoma closure was successfully performed. Barium peritonitis often causes intense and prolonged inflammation with severe complications such as paralytic ileus. Gastrography should be done with an understanding of the potential untoward effects.

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A 54-year-old man without particular family and disease histories visited our facility for the first time with the chief complaints of constipation and abdominal flatulence. We diagnosed his condition as ileus associated with a sigmoid colon tumor on the basis of findings from plain abdominal computed tomography. He underwent emergency lower gastrointestinal endoscopy and a metallic stent was inserted through the anus. After the stent insertion, defecation and intestinal decompression were achieved. Subsequently, barium enema study performed after adequate pretreatment revealed a tumor about 4 cm in diameter affecting the ileocecum and the transverse colon. We attempted to observe the stent from the oral side endoscopically, but it was impossible to insert the endoscope at that point. The patient was diagnosed before the operation with multiple colon tumors, and underwent subtotal resection of the large bowel. Histopathological examination revealed synchronous multiple cancers (eight lesions in total), including a lesion pSS at the stenosed site of the sigmoid colon, six lesions located in the colon proximal to the stenosed site and one rectal lesion for which preoperative endoscopic mucosal resection had been performed.
When dealing with obstruction of the left colon, endoscopic transanal stent insertion is useful in maintaining the quality of life of patients as well as in gaining detailed evaluation of the oral segments of the intestine. When dealing with patients suspected of colorectal cancer, a detailed preoperative examination of the oral segments of intestine is desirable because of possible presence of multiple colon tumors.

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A 53-year-old man was referred to our hospital because of upper abdominal pain. Laboratory data showed eosinophilia, mild liver dysfunction and sight elevation of CEA. Abdominal ultrasonography showed several hypoechoic lesions and computed tomography revealed at least five low density areas with ring enhancement in the liver, which were suspected metastatic tumors or abscesses. We performed a core-needle biopsy of a liver lesion and the pathological findings suggested an eosinophilic abscess. The Toxocara excretory-secretory antibody titer was high in this patient therefore we diagnosed it as a liver abscess caused by Toxocara canis. He took Albendazole, which is the standard treatment for Toxocara canis, and the eosinophilia, liver dysfunction and the liver abscess improved. He had a habit of eating raw venison and wild boar, which might have been the cause of the Toxocara canis infection.

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The case was a female of 80 years of age who was pointed out in the other hospital that she had a left intrahepatic dilatated bile duct and a mild hepatic disorder, and was referred to and admitted in our hospital. The abdominal ultra-sonography and CT revealed a tumor image in the hepatic medial region, but the tumor markers such as AFP, PIVKA II, CEA and CA19-9 were found to be normal, and the viral hepatitis test also showed negative. We diagnosed it as cholangiocellular carcinoma, and performed left hepatic lobectomy. The tumor was covered by a film, with a well-defined boundary and its interior was a yellowish white solidity. Pathological diagnosis obtained the finding of mixed presence of well-differentiated tubular adenocarcinoma and sarcomatoid spindle cell carcinoma. However, any transitional form was not found between both the tumor cells. In immuno-staining, the section of well-differentiated tubular adenocarcinoma was positive for Cytokeratin 7 and Cytokeratin 19, and negative for Vimentin and smooth muscle actin (SMA). Also, the section of spindle cells was positive for Vimentin and SMA, and negative for Cytokeratin 7 and Cytokeratin 19. Hence we diagnosed the tumor as hepatic carcinosarcoma. As hepatic carcinosarcoma is a very rare disease, we report, centering on our case in Japan, including literature review.

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We report a case of a gallstone ileus successfully treated with single-port laparoscopy-assisted enterolithotomy. A 56-year-old woman with schizophrenia who did not have a history of surgery developed vomiting and abdominal distention, which was initially treated conservatively. Abdominal X-ray showed distended intestine, pneumobilia, and a 3-cm calculus stone in the mid-lower abdomen ; emergency surgery was required given the diagnosis of gallstone ileus. Single-port access laparoscopy revealed the site of the ileal obstruction, and severe adhesions around the gallbladder were noted. Enterolithotomy was performed using the port incision site. It is now recognized that laparoscopic treatment is feasible for the treatment of gallstone ileus given its safety and decreased invasiveness. We successfully performed single-port laparoscopic surgery, which is safer and less invasive than using the conventional laparoscopic approach in a patient with gallstone ileus.

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We experienced a rare case of cholecystitis discovered due to an abdominal wall abscess. A 54-year-old woman suffering right flank pain for two months had received a pain-killer prescription from a neighborhood doctor. Abdominal pain increased and she consulted our hospital. At the time of the first medical examination, the right hypochondrium showed a flare sign which was accompanied by tenderness. The bottom of the gallbladder was shown to adhere to the abdominal wall on CT and formed an abscess at the abdominal wall. The gallbladder wall was thickened, and a gallbladder calculus was also revealed. An abdominal wall abscess was diagnosed, due to cholelithiasis and cholecystitis. After hospitalization, she was treated with antibiotics, but did not improve. She underwent open surgery. We performed curettage of the abdominal wall abscess and cholecystectomy. Pothologically, the gallbladder did not show malignancy.

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A 76-year-old man was admitted because of a high fever associated with shaking relating to chills. Abdominal ultrasonography and CT showed dilatation of the intrahepatic bile duct ; no tumor was detected. ERCP and MRCP revealed stricture of bile ducts (B2, B3, B4b) and dilatation of peripheral bile ducts. ENBD bile cytology was defined as class III b ; thus, the periductal infiltrating type of intrahepatic cholangiocarcinoma was strongly suspected. In addition, Strongyloides stercoralis filariform larvae were detected in the bile. A left hepatectomy was performed after treatment with Ivermectin (a vermifuge). The histological findings included superficial spreading adenocarcinoma in situ without invasive adenocarcinoma ; atypical biliary epithelium corresponding to BilIN-1-2 was also noted. We report this case of intrahepatic cholangiocarcinoma in situ associated with bile duct stricture that presented similarly to invasive cancer and appeared to be related to the presence of strongyloidiasis.

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A 56-year-old man visited our hospital with a chief complaint of epigastric pain. He was admitted for further examination and treatment after a 15-mm tumor was detected in the gallbladder on abdominal contrast-enhanced CT. Eudoscopic ultrasonography showed gallbladder mucosal hyperplasia and three elevated lesions with a maximum size of 12 mm. While endoscopic retrograde cholangiopancreatography showed no pancreaticobiliary maljunction, accessory pancreatic duct imaging showed reflux into the bile duct of the contrast agent that had been infused into the main pancreatic duct. In addition, the amylase level in the bile collected from the gallbladder was 111,400 IU/L, and the cytological diagnosis was Class III. The patient was diagnosed with a gallbladder polyp complicated by pancreatobiliary reflux without pancreaticobiliary maljunction, and cholecystectomy was performed. Histopathological findings included a hyperplastic polyp with a high-grade atypia. Pancreatobiliary reflux is diagnosed based on bile amylase levels or secretin-stimulated MRCP, but in the present patient, accessory pancreatic duct imaging also contributed greatly to the diagnosis. Patients with pancreatobiliary reflux without pancreaticobiliary maljunction are at high risk for gallbladder cancer, and they require prophylactic cholecystectomy and postoperative follow-up keeping occurrence of biliary tract cancer in mind.

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A man in his 60s was admitted with an acute abdomen. Two years earlier, thoracic esophageal cancer was diagnosed (pT3N0M0 pStageII). He had an esophagectomy with reconstruction using a gastric tube via the posterior mediastinal route. At the same time, he received a jejunostomy for enteral alimentation. At the time of the present admission, he was diagnosed as having strangulation ileus due to the jejunostomy, as well as acute pancreatitis. Emergency laparotomy confirmed that the strangulation ileus was due to the jejunostomy and involved 400 cm of jejunum. As well, dilatation of the gastric tube, duodenum, and jejunum, along with redness and edema at the retroperitoneum around the pancreas were noted. The patient's jejunostomy was undone ; the patient reguiced peritoneal lavage and drainage. The patient recovered and was discharged on postoperative day 20. The efficacy of tube feeding with jejunostomy after esophagectomy is established ; however, the risk of ileus due to the jejunostomy should be recognized. This case highlights the potential difficulty of deciding to do a tube jejunostomy at the time of esophagectomy.

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The patient was a 45-year-old woman who had an endocrine carcinoma in the pancreatic body and tail with multiple hepatic metastases and a splenic venous tumor thrombus. First, transcatheter arterial chemo-embolization was performed for the hepatic metastases, and provided favorable locoregional control. Next, the patient underwent distal pancreatectomy along with removal the splenic venous thrombus. Microscopic findings showed extensive expression of trypsin, an acinar cell marker, followed by chromogranin A expression in 40-50% of the tumor cells and of synaptophysin in 20-30%. These are endocrine markers. According to the World Health Organization Classification, the tumor was diagnosed as mixed acinar-endocrine carcinoma. The patient remains alive, with no increase in hepatic metastases, 2 year after the operation.

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A rare case of solitary colon cancer metastasis to the spermatic cord is presented. A 68-year-old man had a right hemicolectomy for stage IV cecal cancer and a partial hepatic resection for liver metastases in October 2008 ; he also received adjuvant chemotherapy : Subsequently, 19 months later a recurrent liver metastasis was found and was resected ; unfortunately, 23 months later another liver metastasis was found and was treated using radio-frequency ablation (RFA). On follow-up, the patient's serum CEA level rose to 62.9 ng/ml (normal : <4.0 ng/ml), and positron emission tomography (PET-CT) suggested right iliac lymph node metastasis and liver metastasis. After partial hepatic resection, the right iliac area was explored ; a spermatic cord tumor was incidentally identified and resected. Histological examination of the resected tumor revealed a well-differentiated adenocarcinoma spermatic cord metastasis compatible with a metastasis from the cecal cancer. The patient's postoperative course was uneventful, and he has shown no evidence of recurrent disease during 4 months of postoperative follow-up.

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An 82-year-old male had a right nephrectomy due to renal cell carcinoma (stageIII) ten years prior to the current admission. He was found to have an ileus and an intestinal perforation because of an intestinal tumor. Emergency surgery was performed, and the tumor was resected. The tumor was found to be a renal cell carcinoma metastasis, since on pathology, clear cell carcinoma features were identified. A total of 40 cases of renal cell carcinoma with small intestine metastases that were reported in Japan from 1983 to 2010 is reviewed in this paper. Most cases of metastatic renal cell carcinoma involve lung metastases, because carcinoma cells are disseminated by venous flow. Our case is rare because the patient did not have concomitant lung metastasis. The case demonstrates that patients with renal cell carcinoma must be observed for a long time after nephrectomy. When renal cell carcinoma metastasizes to the intestine, the prognosis is usually poor. However, surgery can provide longer survival and better QOL.

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A rare case of intestinal obstruction due to a transomental hernia is described. A 40-year-old male was admitted to the hospital due to abdominal pain and vomiting. He had no prior history of surgery. An enhanced CT scan of the abdomen showed the small intestine herniated behind the stomach. A long tube was placed to treat the ileus, but it was unsuccessful, and an operation was performed. During surgery, a portion of the small intestine, the size of a golf ball, was found to be incarcerated in a hiatus of the greater omentum. The omental bursa was opened, and the incarcerated intestine was resected.
A transomental hernia is rare, but it must be considered as a possible cause of intestinal obstruction in patients with no history of surgery.

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A 58-year-old man suffering from schizophrenia was referred to our hospital because of abdominal distension. Abdominal CT scan showed a huge tumor measuring 25.0×23.4×12.4 cm in diameter in the abdominal cavity which was composed of intermingling cystic regions and solid regions. The tumor came into contact with the greater curvature of the stomach and the small bowel was displaced entirely to the posterior side of the tumor. Angiography showed that the tumor was fed by the greater omental branch of the right gastroepiploic artery. The patient was operated on for a suspicion of a tumor of the greater omentum. At surgery we confirmed, the huge tumor that had occupied the entire abdominal cavity and did not come into direct contact with the greater curvature of the stomach. The tumor was considered to originate from the greater omentum. We performed resection of the tumor. The resected specimen was 35×30×18 cm in diameter and weighed 4.2 kg. The tumor had cystic and solid lesions and contained dark red-brown serous fluid. Immunohistochemically, the tumor cells were positive for c-kit, indicating a GIST of the greater omentum.
We present this case of giant GIST originated from the greater omentum, together with a review of the literature.

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An 86-year-old woman with no previous history of undergoing laparotomy visited a hospital because of nausea and abdominal pain and was referred to our hospital for further exploration and treatment because bowel obstruction was diagnosed from a plain abdominal X-ray film. An abdominal plain CT scan revealed dilatation of the small intestine associated with ascites, but no obvious causes of the intestinal obstruction were shown. Abdominal distention was noted, but the abdomen was soft and there was no rebound tenderness. Accordingly the patient was admitted to the department of gastroenterological medicine in our hospital and conservative therapy was started by placing a long tube for intermittent sustained aspiration. However, no symptomatic remission could be gained, and another CT scan done on the 3rd hospital day disclosed no changes in the small bowel dilatation and increased ascites. We determined that the conservative therapy might be ineffective and performed emergency operation. When the abdomen was opened, we saw a defect about 3 cm in diameter in the mesentery of transverse colon locating on the right side of the Treitz ligament, through which an about 40 cm-long portion of the jejunum had incarcerated into the omental bursa at about 80 cm distant from the Treitz ligament. Necrosis was absent in the small intestine and so the operation was completed after reduction of the herniated intestine followed by closure of the defect by sutures. The patient's postoperative course was uneventful.
Retrospective review of these CT scans after the operation demonstrated the presence of hernia opening. This case would thus be one in which we could diagnose the disease preoperatively by using CT.

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We describe two cases with multiple intra-abdominal desmoid tumors (DT) which were successfully controlled by low-dose combination chemotherapy using methotrexate (MTX) and vinblastine (VBL). The first patient, a 26-year-old female, was diagnosed with DT involving both the abdominal wall and the ileal pouch which developed after total proctocolectomy for familial adenomatous polyposis (FAP). We administered conservative therapy with MTX and VBL biweekly for 12 months to prevent an ileal pouch excision. The DT was successfully treated without significant side effects or pouch sacrifice. The second patient, a 25-year-old female with FAP, also had the complication of mesenteric DTs, and was treated with MTX and VBL chemotherapy for 10 months. The DTs were successfully controlled and did not increase in size. DTs arising from mesenteric desmoids involving the ileal pouch were successfully controlled with outpatient chemotherapy using MTX and VBL, which was well-tolerated with few adverse effects, such as myelotoxicity, hepatotoxicity and neurotoxicity.

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A 43-year-old man visited a local doctor for headache in September 2006. The blood test showed CRP 2.1 mg/dl. He was given a blood test again in November, where the CRP was 2.0 mg/dl, and abdominal CT revealed a solid tumor of 40 mm in size, close to the greater curvature of the stomach. Soon after he visited our hospital, but there was no stomach tumor in the gastrofiberscopy or the upper gastrointestinal series. He was admitted with an abdominal tumor which we suspected originated in the greater omentum or stomach subserosa, and scheduled an operation in December.
We performed a transverse colectomy because his tumor originated from the transverse mesocolon. The pathological diagnosis was plasma cell type of Castleman's disease.

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The patient was a 73-year-old woman who had undergone mastectomy with a diagnosis of breast cancer (T1N1, StageII) in October 2002. Periodic follow-up abdominal CT scan performed in March 2005 incidentally revealed an abdominal tumor. The tumor was 40×30 mm in diameter and had a comparatively homogeneous inner portion with linear enhancement effect partly. Based on the CT findings, malignant lymphoma or GIST was likely. Gallium scintigraphy revealed no accumulation to the tumor. Another CT scan performed 2 months later showed the tumor which had shrunk to 38×20 mm in diameter. Although a possibility of malignant disease could be ruled out from her clinical course and imaging findings, the tumor was removed under laparotomy in May 2005 in response to her and her family's desire. Upon laparotomy, the tumor was found to have arisen from the transverse mesocolon and was adherent to the surroundings, but the tumor was able to be removed without performing intestinal resection. Histopathologically the tumor had structure of lymph node, there were hyalinization of the surrounding connective tissue and remarkable hyperplasia of lymphatic follicle, and partially hyaline vessels were present as they penetrated the germinal center and the surrounding mantle zone. Castleman's disease of hyaline-vascular type was diagnosed. There have been no signs of recurrence, as of six years after the operation.

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We report a case of inflammatory myofibroblastic tumor (IMT) of the mesentery with no symptoms. A man in his 70s was found to have a mesenteric tumor by CT conducted to observe renal cysts at another hospital. The tumor had not been present on CT five months before. There were no abnormal laboratory data. Fluorine-18-fluorodeoxyglucose and positron emission tomography suggested malignancy. Partial resection of the small intestine was performed and the tumor was histopathologically diagnosed as IMT of the mesentery. IMT which develops in the abdomen usually occurs with local or systemic symptoms like abdominal pain, mass, or fever. We rarely find asymptomatic IMT of the mesentery. This case, fortunately, was diagnosed with no symptoms by periodic CT examination for another disease.

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A 56-year-old woman was admitted to our hospital because of acute abdominal pain and fever. She had unresectable cervical cancer and was under chemo-radiation therapy. On admission, white blood cell count was 18,400/mm³ and CRP was 17.3 mg/dl revealing an increased inflammatory response. Abdominal plain X-ray examination revealed no free air. However, a pelvic computed tomography (CT) scan revealed the presence of free air and visualized the swollen uterus with comparatively homogeneous fluid and gas. We suspected gastrointestinal perforation and performed an emergency laparotomy. The perforation was found not in the intestine, but rather in the fundus of the uterus, and cloudy ascites were noted throughout the entire abdominal cavity. We performed primary suture to the perforation site and overlapped the greater omentum, peritoneal lavage and drainage.
In cases of uterus cancer suspected of diffuse peritonitis, surgeons should consider the possibility of perforated pyometra.

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Pseudomyxoma peritonei (PMP) is an uncommon condition arising from mucus-producing appendiceal or ovarian tumors. We experienced two cases of PMP related to pregnancy.
Case 1 : A 37-year-old primagravid woman was diagnosed with PMP during a laparoscopic examination for an ovarian tumor, and was pregnant one year later by in vitro fertilization (IVF). She was referred to our hospital at 19 weeks gestation, and admitted at 32 weeks gestation because of increasing risk to the fetus from a massive abdominal tumor. Reductive surgery was performed under spinal anesthesia to maintain the pregnancy. Caesarian section was performed at 35 weeks gestation, and the metastatic right ovary was removed simultaneously. Complete cytoreductive surgery was performed 7 months after delivery. Appendectomy, greater and lesser omentectomy, hysterectomy, left salpingo-oophorectomy, splenectomy, cholecystectomy and radical peritonectomy were performed. No recurrence is observed 22 months after surgery.
Case 2 : A 34-year-old primagravid woman was diagnosed with PMP during a laparoscopic examination for ascites of unknown origin, and an appendectomy was subsequently performed. One year later she was pregnant by IVF. She was referred to our hospital at 10 weeks gestation, and a caesarian section was performed at 37 weeks gestation. Three months later, complete cytoreductive surgery including low anterior resection of the rectum, hysterectomy, bilateral salpingo-oophorectomy, greater and lesser omentectomy, splenectomy, cholecystectomy and radical peritonectomy were performed. Although serum tumor markers were within normal range, a small amount of ascites was detected 20 months after surgery.
Conclusions : Full knowledge is required to manage PMP patients during pregnancy.

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A 75-year-old woman developed left inguinal pain associated with a left inguinal swelling about 20 cm in size. A plain abdominal computed tomography scan showed an indirect left inguinal hernia with bowel loops within the sac. Emergency surgery was performed for the left incarcerated inguinal hernia. Serosanguineous ascites and ileocecum were found in the hernia sac. Cases of incarcerated iliocecum in an inguinal hernia are very rare in the Japanese literature, especially those occurring in females and on the left side.

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