Purpose : This study aimed to examine longterm outcomes and prognostic factors, especially the prognostic significance of tumor locations, in patients with resectable pancreatic cancer.
Methods : Consecutive 176 patients with pancreatic cancer, who underwent surgical resection at our hospital between January 2000 and December 2010, were retrospectively analyzed.
Results : Of the 176 eligible patients, 112 had pancreatic head cancer and 55 had pancreatic body and tail cancer. The 5-year overall survival rate was 31% and the median survival time of the patients was 26 months. The 5-year overall survival rate was 24% in the pancreatic head cancer group versus 43% in the pancreatic body and tail cancer group, showing a significantly better prognosis in the latter group (p = 0.0175). Multivariate analysis identified the Japan Pancreas Society's (JPS) classification, histologic residual tumor, and adjuvant chemotherapy as significant prognostic factors. Tumor location was not a significant prognostic factor. There was a statistically significant difference in JPS classification between the two groups (p= 0.0498).
Conclusion : The longterm outcome of patients with resectable pancreatic cancer has improved. In this study, the JPS classification, residual tumor, and adjuvant chemotherapy were identified as the significant prognostic factors. In the pancreatic body and tail cancer group, early cancers outnumbered more advanced cancers that carried a significantly better prognosis for the group than the pancreatic head cancer group.

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Here, we report 77 cases where blood alternatives and surgery were performed in Jehovah's Witness patients, of whom 18 had gastric cancers, 25 had colorectal cancers, and 30 had malignant diseases in hepato-biliary-pancreatic areas. During pancreatoduodenectomy and lobectomy and/or more extended liver resection, the average bleeding exceeded 1,000 ml. From 57 cases of where autologous transfusion was performed, a combination of hemodilution transfusion and salvage transfusion was performed in 15 cases. Twenty-five patients with anemia were treated with preoperative blood augmentation, which enabled planned elective resection. Complications were observed in 7 cases, of which 3 involved anastomosis failure, 3 involved a pancreatic juice fistula, and 1 involved disseminated intravascular coagulation. Two patients died after surgery because of hepatic failure and intestinal perforation. Thus, multidisciplinary management involving autologous blood transfusion for surgery enabled medical treatment of Jehovah's Witness patients.

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BACKGROUND : Systemic trastuzumab chemotherapy given pre-operatively or post-operatively has improved the prognosis of HER2-positive breast cancer patients. Recently, it was reported that patients could be safely given combination chemotherapy involving anthracyclines and trastuzumab using lower doses of anthracyclines.
Combination FEC75 and trastuzumab therapy was given to 14 HER2-positive breast cancer patients as pre-operative chemotherapy. The treatmants effects and safety were assessed.
METHODS : We enrolled 14 HER2-positive(HER2 enriched type or Luminal B type) breast cancer patients who required systemic chemotherapy from September 2010 to December 2011. Patients who were relatively young and had a good cardiac status were selected for the FEC75 and trastuzumab group ; their results were compared to the group treated with conventional FEC100 and the group given 75-Taxan and trastuzumab as preoperative chemotherapy.
RESULTS : Among the 13 patients who were given 5-Fluorouracil/Epirubicin/Cyclophosphamide (FEC)75 and trastuzumab as preoperative chemotherapy the pathological complete response (pCR) rate was 77.8% ; pCR was especially common among HER2 enriched type patients. Compared with the FEC100 treatment group, these 13 patients had milder side effects. We found that pCR with combination FEC75 and trastuzumab therapy may depend on dose density and dose intensity.

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Enteral nutrition (EN) is an important strategy for maintaining gut integrity and function. Catheter jejunostomy is popularly used after esophageal resection with gastric tube reconstruction via a posterior mediastinal route. However, jejunal fixation to the peritoneum can potentially cause jejunal obstruction. The purpose of this study was to evaluate our original technique of placing a feeding catheter gastrostomy (FCG) during esophagectomy with gastric tube reconstruction via a posterior mediastinal route. Between November 2009 and July 2011, 30 patients underwent FCG. The catheter was guided to the anterior abdominal wall along the diaphragm via an extra-peritoneal route ; the catheter entry was overlapped by omentum. The median duration of using the indwelling feeding catheter was 31.5 (6-211) days. EN was interrupted in 3 cases : 2 cases with chylothorax and one case with catheter blockage. There were no cases of spontaneous catheter prolapse or bowel obstruction. Only one patient (3.3%) showed mild and transient localized peritonitis after catheter removal. FCG is a safe technique and is useful for avoiding jejunostomy-related bowel obstruction in cases requiring EN following esophageal resection with gastric tube reconstruction via a posterior mediastinal route.

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We report our experience with a giant pseudoangiomatous stromal hyperplasia (PASH) of the mammary gland in a 15-year-old girl. Her left breast was enlarged and an elastic soft lump was palpated. Ultrasonography showed a low echoic tumor with a clear boundary. Magnetic resonance imaging (MRI) revealed a poor contrast effect tumor on her left breast. A core needle biopsy was carried out under the suspicion of fibroadenoma or a phyllodes tumor. Pathological examination showed enlarged mammary stroma and sparse proliferation of spindle cells, and was diagnosed as PASH. Tumorectomy was performed, and the extracted specimen was covered with a thin coating, measuring 20×19 cm, and weighing 1.2 kg. A vessel-like space was observed in the mammary stroma upon histopathological findings and the inside of the space was coated by a layer of spindle cells. It was found to be CD34, αSMA positive, and CD31, PgR, ER negative upon immunohistological staining. Based on these findings, the patient was diagnosed with PASH of the mammary gland.

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Mondor's disease is a relatively rare benign disease which is characterized by thrombophlebitis of the subcutaneous vein in the anterior chest wall. It involves a painful subcutaneous cord caused by breast surgery, trauma, or infection. We report a rare case of Mondor's disease after an operation for gynecomastia. A 74-year-old man who underwent surgery for gynecomastia, complained of a painful groove in the chest for one week postoperatively. Physical examination revealed a longitudinal groove from the left breast to the upper abdomen. In an imaging study, a subcutaneous cord was observed in the induration. We diagnosed it as Mondor's disease that developed with the resection of gynecomastia. Observation was carried out, and the subcutaneous cord disappeared spontaneously in about one month.

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An 83-year-old woman was admitted to our hospital for evaluation of a right breast tumor. A hard and elastic tumor was palpable in the C area in the right breast. A high density mass with flat margins was detected in the mammographic findings. Histological findings obtained from a core needle biopsy suggested malignancy. The extirpated mass, 2.8 cm in size, did not show any signs of malignancy and was diagnosed as chondromatous hamartoma. Chondromatous hamartoma is a rare subtype of mammary hamartoma, partly composed of chondromatous tissue. It is difficult to differentiate chondoromatous hamartoma from other benign tumors and breast cancer, and a careful comparative diagnosis is required when considering this kind of rare tumor.

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Diagnostic imaging of breast cancer following breast augmentation is difficult. We report our experience with a case that provides useful information for developing diagnostic procedures for breast cancer following breast augmentation. The patient was a 43-year-old woman who noticed a mass in her left breast 2 years after undergoing breast augmentation. Although a 5-cm mass was palpable in the left breast CA area, a diagnosis could not be established by mammography (MMG) / ultrasonography (US) because of the artifact of the foreign body. Breast abscess was diagnosed by computed tomography and this area was removed. The pathologic examination revealed breast cancer in a part of the specimen. A radical operation was performed because magnetic resonance imaging (MRI) performed after removal of the abscess revealed a mass that raised suspicion of breast cancer. When breast cancer occurs after infection of foreign bodies, the cancer is difficult to diagnose with MMG or US. On the other hand, MRI is useful for the diagnosis of breast cancer after breast augmentation, because it can differentiate between breast cancer and foreign bodies. The inability to depict tumors on images inhibits determination of the biopsy site or increases the risk of false negative results, even when a biopsy is performed. If breast cancer is suspected after breast augmentation, a biopsy should be performed and subcutaneous total mastectomy should be considered.

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We have experienced two cases of enlarging rounded atelectasis which were resected for suspected malignancy. In both cases, chest x-ray films showed a tumor shadow in the lower lung field. Chest CT scans showed a pulmonary mass and pleural thickening with calcification in the basal segment. After taking wait-and-see approach, chest CT scans demon strated that the mass had enlarged. Because a possibility of a neoplasm could not be ruled out, operation was done. Intraoperative findings showed non-palpable tumor and extensive adhesions around the lower lobe. After lower lobectomy for definitive diagnosis, these two patients were diagnosed as having a rounded atelectasis from macroscopic and histopathological findings. One patient of them required long hospitalization because of postoperative bleeding and MRSA pneumonia. Rounded atelectasis is a benign disease. There are unusual cases of the disease which shows enlargement of the lesion due to chronic inflammation, for that we have difficulties in making differential diagnosis from malignancy. We present our two cases, together with some bibliographic comments in terms of intraoperative as well as imaging findings that might be crucial for the diagnosis.

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A 77-year-old woman complaining of vomiting after a meal was referred to our hospital with a diagnosis of gastric volvulus based on upper gastrointestinal endoscopic and fluoroscopic studies at another hospital. Abdominal CT scan revealed that the body of the stomach had herniated into the thoracic cavity through a hiatus of the diaphragm (hernia orifice), and that there was the diaphragmatic tissue between the hernia orifice and the esophageal hiatus. From these findings, parahiatal hernia complicated by gastric volvulus was diagnosed. Endoscopic repair of the hernia was difficult. So we returned the herniated gastric body and lateral segment of the liver to the abdomen under laparoscopy, and then closed the hernia orifice with sutures. After the operation, the patient was associated with reflux esophagitis (Los Angeles Classification D), but it subsided with conservative therapy. The patient was discharged from the hospital on the 20th postoperative day. No recurrence has occurred as of six months after the surgery and her postoperative clinical course has been satisfactory.

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We have experienced mediastinoscope assisted transhiatal esophagectomy for a patient with corrosive esophagitis with stricture formation caused by ingestion of a strong solution of alkali. The case involved a 60-year-old woman who drank an alkaline lotion after unsuccessful hanging herself. The patient was admitted to the critical cure center in our hospital. Despite conservative therapy, prolonged difficulty in swallowing was noted. Upper gastrointestinal endoscopic as well as radiological studies disclosed stricture at the middle and lower thoracic esophagus. As endoscopic dilatation of the stricture was considered to be impossible, transhiatal esophagectomy and reconstruction with the gastric tube were performed. We had great difficulties in dissecting the esophagus due to serious adhesions around it, but the esophagus could safely be removed by using the mediastinoscope. After the operation, she still complained of difficulty in swallowing due to stricture of the remnant esophagus, but endoscopic dilatation resolved the problem. The patient was discharged from the hospital on the 24^th postoperative day.
Corrosive esophagitis caused by liquid alkaline caustics is prone to induce deep penetrating inflammation so that dissection of the esophagus is often difficult in non-open surgery. In these circumstances, the use of mediastinoscope may be very helpful.

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A 73-year-old woman was shifted to the hospital ambulance because she had backache and lumbago. When she arrived, she was in shock. Bilateral pleural effusion and left tension pneumothorax were noted, and therefore, she underwent drainage of the left thoracic cavity. Because the effusion in the drainage tube contained digestive juices, we diagnosed her with spontaneous esophageal rupture. Her general condition was extremely poor, and therefore, we decided that she should not undergo an operation. She was kept under intensive care in order to stabilize her general condition. On the second hospital day, the patient underwent nasogastric endoscopy, and the distal esophagus was found to be ruptured. We observed the posterior mediastinum through the ruptured portion and found it to be necrotic. Therefore, we started continuous irrigation by inserting the nasogastric tube into the posterior mediastinum through the ruptured portion. Subsequently, the patient underwent transthoracic mediastinal drainage and we removed the nasogastric tube. We placed a covered stent over the ruptured portion. She could start oral nutrition on the 36th hospital day and was discharged from the hospital on the 89th hospital day.
Spontaneous esophageal rupture is a severe condition and is mostly treated using the operative approach. Only a few studies have reported severe cases that have been treated using a conservative approach. Therefore, we report this case wherein we treated severe spontaneous esophageal rupture by conservative therapy involving a covered stent.

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A 72-year-old man, who had for 10 years been treated for diabetes mellitus and who had a left hemiplegia due to a cerebral infarction, was admitted for surgical treatment of synchronous esophageal and gastric cancer. A superficial esophageal cancer, 0-IIa+IIc, was detected in the middle thoracic esophagus, and a squamous cell carcinoma was diagnosed on biopsy specimens. Two gastric cancers were detected : an elevated tumor (type 1) of the pylorus with invagination into the duodenal bulbus and a superficially protruding tumor (type 0-IIa) of the antrum. The patient required a transhiatal mediastinoscopy-assisted esophagectomy and total gastrectomy with digestive reconstruction using the right colon. To remove the gastric tumor prolapsing into the bulbus, the anterior wall of the bulbus was incised, and the tumor was returned into the stomach. After surgery, no serious complications were observed. In patients with co-morbidities transhiatal mediastinoscopy-assisted esophagectomy and total gastrectomy are useful for synchronous superficial esophageal and gastric cancer.

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A 62-year-old woman was admitted to the hospital because of upper abdominal pain and high fever. An abdominal X-ray film showed no demonstrable free air. An abdominal CT scan showed an about 3-cm long linear high density foreign object, which had penetrated the anterior wall of the gastric antrum, and free air around it. Perforation of the stomach by a fish bone was likely, and emergency surgery was carried out. Laparotomy disclosed a funicular foreign object to have penetrated the anterior wall of the gastric antrum. The object was removed and the perforation site was filled with the lesser omentum. The foreign object was a hollow funicular material about 3.5 cm in length. It was considered to be a fish bone based on the patient interview and its macroscopic findings.
We also made an analysis of a total of 446 cases of perforation or penetration of the digestive organs due to a fish bone reported in the Japanese literature during 10 years from 2001 to 2010. Cases of perforation of the stomach by a fish bone were few, accounting for 7.8% (35 cases) of all cases. The correct diagnosing rate before surgery is recently increasing with a preoperative use of CT. In this paper, we present a relatively rare case of perforation of the stomach by a fish bone, together with a review of the Japanese literature.

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This paper deals with a case of ruptured α-fetoprotein-producing nodal metastasis of gastric cancer presented with hematenesis. The patient was a 63-year-old male who had undergone distal gastrectomy for gastric cancer with lymphadenectomy (R0) at another hospital in January 2004. The pathological findings showed moderately differentiated adenocarcinoma (L, Type 2, 1.5×1.0cm, tub2, pT2, ly2, v0, pN1(1/3), Stage IIA). This time he was admitted to our hospital because he vomited blood in October 2010. Gastric endoscopy showed a submucosal tumor with an easily bleeding ulcer at the posterior wall proximal to the anastomosed site. Abdominal CT scan revealed the protruding tumor into the gastric lumen. His anemia progressed. He underwent total gastrectomy with a diagnosis of a ruptured tumor in the remnant stomach. The resected specimen involved a solid tumor mainly located in the extralumen. No evidence of any malignancy was observed in the abdominal cavity. The histological diagnosis was nodal metastasis and the same moderately differentiated adenocarcinoma as the primary gastric cancer. Immunostaining resulted in positive and negative responses to cytokeratin-7 and 20, respectively. AFP-immunostaining was positive in the nodal metastasis, but negative in the original tumor. The patient has been alive with cancer as of 1.5 years after the surgery, and is followed in the outpatient clinic. Good QOL has been maintained.

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A 72-year-old woman who was diagnosed with psoriasis vulgaris 8 years ago consulted our hospital, complaining of exacerbation of skin rash and epigastric pain. An upper gastrointestinal endoscopy revealed an advanced gastric cancer (type 2) at the greater curvature of the antrum. A distal gastrectomy with D2 lymphatectomy was performed. Histological study showed poorly differentiated adenocarcinoma had invaded into the propria muscle of the stomach, with metastasis of regional lymph nodes. Skin rash disappeared 3 months after the operation, and treatment for psoriasis vulgaris was finished 7 months after the operation. In Japan, eight psoriasis vulgaris cases who were complicated with gastric cancer have been reported. In six cases, skin rash improved or disappeared after gastric resection. Gastroenterological cancer is likely to be one of the exacerbation factors of psoriasis vulgaris.

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We report a case of multiple liver abscesses caused by hematogenous infection from the “broken” mucosal barrier associated with advanced gastric cancer.
A 68-year-old man, who was found having a type 3 tumor 5 cm in diameter in the lower body of the stomach, was admitted to the hospital for the purpose of operation. He had no high fever. A barium enema examination revealed no abnormal findings. There were no findings suggestive of metastasis to the liver and liver abscess. He developed a high fever of 39°C on and after the second hospital day. Blood test revealed that he developed severe inflammatory response and antibiotics therapy was started. An abdominal CT scan showed multiple target signs in the liver. A gram-negative bacillus was isolated by blood culture. Based on those results, liver abscess was diagnosed. The inflammatory response and findings of liver abscess on abdominal CT scans gradually improved due to administration of antibiotics. After the inflammatory response abated and findings of liver abscess on imaging diagnosis disappeared, total gastrectomy, distal pancreatectomy, splenectomy, cholecystectomy, surgical removal of the ileocecal tumor and D2 lymph node dissection were performed. He has been free from recurrence of hepatic abscess or gastric cancer, as of 42 months after the operation.

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A 72-year-old man had a total gasteroctomy for gastric cancer when he was 67 years old. S-1 adjuvant chemotherapy was continued for two years. Four years after the gastrectomy, on abdominal CT scan, a cystic tumor in the tail of the pancreas was detected. On follow-up, the tumor was found to have increased in size ; a tentative diagnosis of intraductal papillary mucinous carcinoma was made, and a distal pancreatectomy with splenectomy was performed. On histopathology, a pancreatic tumor that was the same type of adenocarcinoma as the previously diagnosed gastric cancer was found ; the final diagnosis was pancreatic metastasis from the previously diagnosed gastric cancer. Pancreatic metastasis from gastric cancer is rare. It is thought that very few cases are candidates for surgery. Herein, we report our case with a review of the literature.

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In May 2009, a 59-year-old woman with neurofibromatosis type 1 was operated for masses of the head and left shoulder growing to 10 cm in diameter over 6 months, and the pathological diagnosis was malignant peripheral nerve sheath tumors (MPNST). In April 2010, she developed anemia. Computed tomography (CT) and positron emission tomography (PET) showed a mass of in both the intestine and the left lung. A 1 cm diameter gastric mass was also shown, but the biopsy was negative and there was no bleeding. Suspecting bleeding from the intestinal mass, a partial resection of the small intestine was performed and the mass was diagnosed as MPNST. After 2 weeks from discharge, she developed anemia again, and gastric mass showed to be growing and bleeding. Partial gastrectomy was performed and after 4 weeks, a left lingular segmentectomy was performed. Both were diagnosed as MPNST. After 4 weeks, she developed pulmonary embolism and multiple masses in the intestine, peritoneum, subcutaneous tissue. She developed small-intestinal intussusceptions, obstructive ileus and bleeding, so a partial resection of the small intestine was performed and diagnosed as MPNST.
The next day she was discharged, she developed disturbance of consciousness and left-side partial paralysis and was diagnosed with multiple brain metastases, and has subsequently died.
MPNSTs are rare tumor entities that originate from peripheral nerve sheaths. Gastrointestinal MPNSTs have been reported in only 15 cases, including ours, in Japan.

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A 57-year-old woman was admitted to our hospital because of epigastric pain and vomiting. Plain abdominal CT scan revealed remarkable dilation of the stomach and stenosis in the third portion of the duodenum between the aorta and the superior mesenteric artery. The patient was diagnosed with superior mesenteric artery (SMA) syndrome. She had been treated conservatively until the third hospitalization, when her symptoms improved with conservative management, but vomiting recurred soon after she resumed oral feedings. After a trial of intravenous hyperalimentation and a month of being unable to tolerate oral feedings, we performed laparoscopic duodenojejunostomy.
SMA syndrome is a relatively rare entity and is usually managed with conservative therapy. Surgical treatment can be indicated when the patient is refractoy to conservative therapy. Several surgical techniques for this condition have been reported. We chose laparoscopic duodenojejunostomy and gained a favorable outcome. Laparoscopic duodenojejunostomy is a definitive and minimally invasive surgical technique for treating SMA syndrome.

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We report the case of a 69-year-old man who had duodenal cancer with hereditary non-polyposis colorectal cancer (HNPCC). His history included intestinal resection and lymph node dissection for transverse colon cancer and sigmoid colon cancer, rectal cancer, and ascending colon cancer. He had also undergone endoscopic submucosal dissection for gastric cancer and duodenal cancer. He underwent pancreaticoduodenectomy for a recurrent gastric cancer lesion and for duodenal cancer at the age of 68. Analysis of his familial history showed that his father had developed rectal cancer, his second oldest brother had developed gastric cancer, his third oldest brother had developed rectal cancer, and his fourth oldest brother had developed gastric cancer, transverse colon cancer, and sigmoid colon cancer. On the basis of the familial history, we considered that the patient was likely to have HNPCC, and therefore, mismatch repair genetic testing was performed. The genetic testing revealed a germline mutation in the MSH2 gene, and HNPCC was diagnosed.
We report this case along with a literature review because duodenal cancer with HNPCC is considered relatively rare.

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Herein, we describe 2 cases of ileus associated with true enteroliths.
Case 1 : An 84-year-old man visited our hospital with chief complaints of abdominal pain and vomiting. Abdominal computed tomography (CT) revealed images of intestinal dilatation associated with a large calcification in the intestine. Surgery was performed, because conservative therapy failed to achieve symptomatic relief. Laparotomy revealed stenosis in the small intestine that was located 150 cm on the oral side from the end of the ileum. An enterolith measuring 3 cm in diameter was found on the inside.
Case 2 : A 39-year-old man visited our hospital with a chief complaint of lower abdominal pain. Abdominal CT revealed images of dilatation of the small intestine in the pelvis and calculi in the intestine. Surgery was performed, becase conservative therapy failed to achieve symptomatic relief. Laparotomy revealed stenosis in the small intestine that was located 80 cm on the oral side from the end of the ileum, and 4 discontinuous areas of stenosis were observed on the oral side. In the 2 most severe areas of stenosis, enterolliths measuring 2 cm in diameter were observed.
Partial small intestinal resection was performed in both cases. Calculus analysis revealed that the main component of the enteroliths was calcium oxalate.
An enterolith is classified as a true enterolith or a false enterolith, and the true enterolith is considered a relatively rare disease. We report our experience with 2 cases of ileus associated with true enteroliths.

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An 86-year-old woman was referred for lower abdominal pain. CT showed three calcifications, 1 cm in size, in the lower abdomen. The differential diagnosis included appendicitis or Meckel's diverticulitis. The patient was observed since her abdominal pain was not intense and her inflammatory response as reflected by laboratory data was low. On day 2, an operation was performed due to increasing abdominal pain and an increasing inflammatory response. On laparotomy, an abscess was found in the lower abdomen, and a Meckel's diverticulum located to the anti-mesenteric side, 100 cm oral from the terminal ileum, was seen. The diverticulum was 7 cm in size. The diverticulum contained three enteroliths composed of calcium. Ectopic mucosa was not present in the diverticulum. Meckel's diverticulitis with true enteroliths is very rare. We report this case, together with a brief review of the literature.

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A 73-year-old man underwent colonoscopy because of the positive fecal occult blood test, and was pointed out having a type 2 tumor in the sigmoid colon. The result of biopsy was well differentiated adenocarcinoma, and he was referred to our department for the purpose of operation. Abdominal plain X-ray showed calcifications in the right lateral region of abdomen. These calcifications were suspected to be stones in a Meckel's diverticulum by abdominal computed tomography. At the operation, we found a diverticulum projecting from the antimesenteric side which was located at 140cm proximal to the terminal ileum. We diagnosed it as Meckel's diverticulum with stones and performed sigmoidectomy and diverticulectomy at the same time. It contained multiple black enteroliths, 3 cm in diameter for each, and an analysis of them revealed to be composed of calcium oxalate.
Meckel's diverticulum with enterolith is rare, often presents with acute abdomen due to diverticulitis or perforation, and demands emergency operation. We report this rare case of silent Meckel's diverticulum with enterolith, with some discussion of the literature.

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A 29-year-old man visited our hospital because of appetite loss and fatigue. Gastroscopy failed to identify the bleeding source. Abdominal computed tomography (CT) showed a target sign. Jejunal intussusception caused by a small intestinal tumor was diagnosed and laparoscopic assisted operation was performed. The oral side jejunum was intussuscepted into the lumen of the anal side jejunum led by soft tumor. A soft tumor was shown in the distal end of the intussusception. The tumor was located in the jejunum 30 cm distally to the Treitz's ligament. Partial jejunectomy was performed. The resected specimen revealed a Isp tumor, measuring 55×40×35 mm. Histopathological examination of the resected tumor revealed well-differentiated adenocarcinoma with tubular adenoma components. It was confined to the mucosa. In this patient with adolescent small-bowel cancer, which was suggestive of Lynch syndrome, we performed microsatellite instability analysis of the tumor. Molecular testing showed microsatellite stability. Primary jejunal cancer with adenoma components is rare and this case suggests a relationship between adenomas and carcinomas of the small intestine.

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A 65-year-old woman consulted a local physician because of gradually intensifying abdominal pain. Intussusception was suspected on computed tomography of the abdomen, and the patient was referred to our hospital. Abdominal ultrasonography showed a target sign in the left side of the abdomen. Contrast-enhanced computed tomography of the abdomen revealed a tumorous lesion in the ileocecum that had invaginated into the descending colon close to the splenic flexure. Intussusception was diagnosed, and surgery was performed on the same day. Laparoscopic reduction of the intussusception was attempted with a forceps, however, it was difficult to secure an adequate field of vision of the invaginated intestine. The procedure was therefore converted to open surgery, and the intussusception was reduced by Hutchinson's maneuver. The cecum showed a submucosal tumor-like appearance. Because a possibility of malignancy could not be ruled out, ileocecal resection with D3 dissection was performed. A black tumor 5 cm in diameter was found in the resected cecum. Histopathologically, the lesion was associated with pronounced bleeding, necrosis, and degeneration. Multiple emphysematous cysts and fibrosis were present in the submucosal stroma. Pneumatosis cystoides intestinalis was thus diagnosed. The patient progressed satisfactorily, and she was discharged from the hospital on the 7th postoperative day. The patient has been alive without recurrence as of 3 years after the operation.

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A 46-year-old male patient was admitted to our neurology department for medical treatment of sudden-onset muscle pain and numbness in the extremities. On the 5th hospital day after admission, the patient developed severe abdominal pain ; the imaging findings showed a remarkably dilatated right hemicolon, which suggested impending rupture of the ascending colon. Acute colonic pseudo-obstruction (Ogilvie syndrome) was diagnosed because no remarkable obstruction was observed in the colon. Emergency decompression surgery was performed on the same day. First, an appendectomy followed by direct aspiration from the appendix stump was performed for colon decompression ; subsequently, suture repair of the ruptured ascending colon serosa was performed. A nasal ileus tube was intraoperatively inserted for further decompression. The patient was discharged on the 24th postoperative day. Acute colonic pseudo-obstruction due to acute porphyria was suspected in this case because peripheral and autonomic nervous symptoms accompanied by an elevated urinary coproporphyrin level were observed. We considered that emergency surgical decompression without colostomy helped avoid colon rupture in this case.

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We report a rare case of advanced mucinous ascending colon cancer resembling a submucosal tumor in a 74-year-old man. Colonoscopy revealed a submucosal tumor in the ascending colon. Malignant tissue was not detected on biopsy. The preoperative diagnosis of a gastrointestinal stromal tumor was made. A partial ascending colectomy was performed. The tumor was found to resemble a submucosal tumor. Mucin was identified at the ulcer site. The tumor contained a mucin lake, and cancer cells were found floating in the mucin lake. The tumor was mainly located in the submucosal layer and the muscular layer. The final diagnosis of an ascending colon cancer, Type5, 25×25 mm, muc, pMP, ly1, v0, pN1, sH0, sP0, sM0, fStage IIIA was made.

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A 12-year-old girl with chief complaints of stomachache and bloody feces was seen at a local hospital. Colonoscopy and barium enema disclosed a stenotic portion of the descending colon, and an endoscopic biopsy lead a diagnosis of signet ring cell adenocarcinoma. At surgery, the left half of the colon was excised using laparoscopic assistance. Small amount of yellowish ascites and nodules of peritoneal dissemination were found within the Douglas pouch. Cytological classification of the ascites was Class V. The tumor was classified histopathologically as D, SE, N1, M0, P3, and H0 Stage IV. Although 13 courses of treatment with FOLFOX+BV and three courses with FOLFIRI(s) were used as a postoperative chemotherapy, the patient died of peritonitis carcinomatosa at one year postoperative. Child colon signet ring cell adenocarcinoma is very rare, and it would be wise to consider malignancy during medical examination, even in a child.

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An 86-year-old woman was admitted to our hospital because of fever and left lower abdominal pain in August 2010. Physical examination showed a mass in the left lower abdomen and an abdominal computed tomography (CT) scan showed an abscess formation in the left ilio-psoas muscle. Percutaneous abscess drainage was performed after admission. Because she was found to have anemia, a colonoscopy was performed and showed a tumor of the descending colon. The pathological diagnosis of a biopsy specimen was moderately differentiated adenocarcinoma. An operation was performed under the diagnosis of descending colon cancer with an ilio-psoas abscess. Operative findings indicated that the tumor was 5 cm in diameter and located at the descending colon and had invaded the left ilio-psoas muscle. Resection of the descending colon (D2) combined with partial resection of the ilio-psoas muscle was performed. Colon cancer should be considered as a probable differential diagnosis in a patient with an abscess in the ilio-psoas muscle.

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Possible association of Schistosoma japonicum infection with colorectal cancer has been suggested. This time we experienced a case of synchronous multiple colon cancer in which ova of Schistosoma japonicum were identified in the cancer nests. A 79-year-old man was admitted to the hospital for an occult bloody stool who had lived in Yamanashi Prefecture, an area of past endemic for Japanese Schistosomiasis until the age of 18. Colonoscopy showed advanced sigmoid colon cancer, early descending colon cancer and four adenomas. We conducted endoscopic mucosal resection preoperatively for the early cancer and four adenomas. On histopathology, many ova of Schistosoma japonicum existed in the descending colon cancer but not in the four adenomas. Laparoscopy-assisted sigmoidectomy with D3 lymph node dissection was performed. Pathological findings demonstrated 45×35mm, type 2 moderately differentiated adenocarcinoma, SS, N1(1/13), H0, P0, M0, fStage IIIa. The ova of Schistosoma japonicum were also seen in and around the resected colon tissue. Possible association between Schistosoma japonicum infection and colorectal carcinoma was indicated.

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Signet ring cell carcinoma of the rectum is a very rare disease with a poor prognosis whose incidence rate is about 0.5% of all rectal cancers.
An 82-year-old man was seen in a clinic and at our department of internal medicine for bloody excrement. He underwent a thorough examination and was referred to our department with a diagnosis of rectal cancer. He underwent Mile's operation. The resected specimen was pathologically diagnosed as signet ring cell carcinoma, Rb, circ, type 4, 7.5×6.0 cm, pAI (sacral soft part), ly3, v2, pN2, pStageIIIb. Pelvic irradiation was performed. Anti-cancer drugs were not administered because of his age. Local recurrence in the para-aortic lymph node and bone metastases developed 4 months after resection. Bone marrow suppression and clotting abnormality gradually progressed and he died of the illness 5 months after resection.

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A 72-year-old man was seen at the hospital because of a 9-month history of anal pain. On close examinations, we confirmed type 2 rectal carcinoma (Rb-P-E) encircling the one/third of the lumen at the right side wall from the lower rectum to the anal canal. The tumor had penetrated at the bottom of the ulcer to form a giant perianal abscess with extensive phlegmone in the right gluteal region. A biopsy resulted in tub1 adenocarcinoma. The serum CEA value was 9.6 ng/ml. There was metastasis to the right inguinal lymph node, but no other distant metastases were found. Before surgery, drainage seton procedure, temporary colostomy, and mFOLFOX6 regimen were carried out. The perianal inflammation disappeared and the tumor decreased in size (PR) when four courses of the therapy were completed. The inguinal lymph node metastasis was unchanged, but no new metastatic lesions appeared. Two months later we performed Miles operation, D3 dissection, and right inguinal lymphadenectomy. Histopathology revealed type 5, 35×25 mm, tub1, pA, ly0, v0, pN0, M1 (rt. 292). The chemotherapeutic outcome was rated as Grade 2. The Patient's postoperative course was uneventful. He has been well and free from recurrence for more than 4 years after the operation.

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A rare case of gallstone ileus caused by a stent-stone complex (SSC) is described. The patient was a 71-year-old female who had undergone laparoscopic cholecystectomy for cholecystolithiasis at another hospital 8 years earlier. However, a definite diagnosis of gallbladder carcinoma was made after the operation ; the patient had an additional resection of the common bile duct and hepaticojejunostomy at that time. A metal stent was placed via percutaneous transhepatic biliary drainage (PTBD) into the biliary anastomotic stricture 5 years 10 months prior to the current admission. At the time of the current admission, the patient had an ileus with upper abdominal pain and vomiting. Abdominal X-ray and computed tomography (CT) showed intestinal obstruction due to a migrated SSC from the hepaticojejunostomy. Following conservative treatment with a long intestinal tube, emergency surgery was required. Operative findings showed an impacted SSC in the ileum. Enterolithotomy was successfully performed using a small incision in the umbilical region. It is important to keep in mind that a gallstone can form around a stent after a long period of time and can then act as a nidus for a gallstone ileus.

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A 63-year-old man complained of right back ache and back stiffness. On abdominal CT scan and MRI, an intra-abdominal abscess with calcification was found on the dorsal surface of the posterior segment of the liver, and a subcutaneous abscess was found on the right side. The patient had had cholecystitis and a laparoscopic cholecystectomy for a gallstone 2 years prior. During this operation, the gallbladder wall was injured and the bile spilt out. Nevertheless, his progress after the operation was good. Based on the findings obtained during a follow-up visit 1 year after the surgery, an intra-abdominal and subcutaneous abscess caused by biliary gallstones lost during the laparoscopic cholecystectomy was diagnosed. Surgery was required for drainage and removal of the gallstone. The subcutaneous abscess and the intra-abdominal abscess were connected by a fistula. Two black stones were removed from the abscess percutaneously. The patient's progress after the operation was good. On follow-up, the abscess has not reccurred.
Subcutaneous and abdominal wall abscesses are rare, and only 8 cases have been reported in Japan.

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In performing surgery during pregnancy, we are demanded to select different operative procedures according to different pregnancy periods. We present a case of cholangitis and common bile duct stones in a pregnant woman performed emergency open surgery. The patient was a 33-year-old white woman in the 30th week of gestation. She had many gallstones and had repeatedly presented with abdominal pain and fever in the 24th and 29th week of gestation. In each episode, she was treated by conservative treatment. This time when she was in the 30th week of gestation, emergency MRCP showed a common bile duct stone and dilatation of the common bile duct. Serum bilirubin levels and white blood cell levels were high. We performed cholecystectomy and tube drainage with a diagnosis of cholangitis and common bile duct stone. She was discharged from the hospital 6 days after the operation. Then, the patient was induced to deliver at the 40th week of gestation with resultant transvaginal delivery. Since different therapeutic methods were employed depending on different gestation periods and conditions of the mother and her fetus, the case is reported together with some bibliographical comments.

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A 77-year-old man was pointed out to have a liver cystic tumor when he received cardiac ultrasonography (US). Abdominal US, computed tomography (CT) and magnetic resonance imaging (MRI) showed a monolocular cystic tumor in the left lobe of the liver, and a nodule in the cystic tumor. Biliary cystadenocarcinoma was suspected and left lobectomy of the liver was performed. Macroscopic findings showed a monolocular cystic tumor to be composed of mucin mixed with biliary sludge, and the nodule in the cystic tumor. Histopathologically, the tumor was cystadenocarcinoma without ovarian-like stroma. The tumor was diagnosed as cystadenocarcinoma according to “the General Rules for the Clinical and Pathological Study of Primary Liver Cancer”. According to the WHO new classification, however, it is considered to be categorized as intraductal papillary neoplasm of bile duct.

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A 77-year-old man with pancreatic-tail cancer and pancreas divisum, as well as cholelithiasis underwent distal pancreatectomy and cholecystectomy. Postoperative pancreatic fistula was confirmed and conservative treatment by fasting and total parenteral nutrition was performed, but there was no tendency of recovery. On postoperative day 18, endoscopic transampullary pancreatic duct stenting was performed and this patient was finally diagnosed with pancreas divisum, based on the findings of the pancreatography at the time. After the pancreatic duct stenting, the amount of the peripancreatic drain was markedly decreased. On postoperative day 57, the drain was removed and he was discharged on postoperative day 61. In pancreas divisum, the dorsal pancreatic duct becomes the main pancreatic duct and drains most of the pancreatic fluid through the minor duodenal papilla, which is smaller than the major duodenal papilla. Therefore, it is necessary to carefully manage patients with pancreas divisum after a distal pancreatectomy.

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The prognosis for pancreatic cancer is poor. We report a case which required surgical resection of a lung metastasis from pancreatic cancer. The patient was a 68-year-old man. He was diagnosed as having pancreatic cancer in 2002. A pancreaticduodenectomy was done ; radiation (20 Gy) and gemcitabine (1,000 mg) were also given. On histopathology, a moderately differentiated adenocarcinoma was diagnosed. After the resection, the patient had gemcitabine chemotherapy for 3 years. In 2010, a chest CT scan revealed an isolated nodule, 3 cm in diameter, in the right lower lobe (S8). A transbronchial lung biopsy was done ; immunostaining revealed that the lung tumor was a pancreatic cancer metastasis. Since the patient had no other metastasis, a right lower lobectomy was performed. After the operation, he was diagnosed as having bone and brain metastases. He died in March 2011. This case suggests that follow-up after pancreaticoduodenectomy is necessary so as to improve the patient's prognosis.

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A case of torsion of a wandering spleen is herein reported. A 25-year-old woman with histories of gastric volvulus and intellectual disturbance visited our hospital because of abdominal pain and fever. Abdominal examination showed the rigidity and tenderness in the entire abdomen. Hematological examination showed elevations of WBC 21,900/μl and CRP 18.9mg/l. Contrast enhanced CT scan revealed the remarkably enlarged spleen (21×12 cm) without enhancement and the twisted splenic artery and vein. She underwent emergency laparotomy with the diagnosis of torsion and infarction of the wandering spleen. The spleen and pancreas were not fixed to the retroperitoneum and were twisted clockwise by 3.5 turns at the hilum of the spleen. In addition the cecum, the ascending colon, the descending colon, and the sigmoid colon were not fixed to the retroperitoneum. Splenectomy and appendectomy were performed with the diagnosis of torsion of the wandering spleen and mesenterium commune. The removed spleen weighed 1.2 kg and histopathologically presented hemorrhagic infarction with extensive necrosis. She was prescribed Aspirin for reactive thrombocytosis and received pneumococcal vaccine after the operation.

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A 73-year-old man, without history of trauma, was referred to our hospital with the diagnosis of acute abdomen. He had a pain in the left hypochondriac region. On the abdominal examination, there was tenderness in the region. Enhanced abdominal computed tomography (CT) revealed fluid collection with high density around the liver and an enlarged spleen. Under the diagnosis of non-traumatic rupture of the spleen, an emergency operation was performed. Because malignant lymphoma and other malignant tumors were suspected, a splenectomy was chosen. The intraoperative pathological evaluation was malignant lymphoma. A peripheral-blood smear showed atypical lymphocytes. His condition progressively worsened from postoperative day nine. Acute exacerbation of the malignant lymphoma was suspected. Soluble prednisone was started so his condition showed a tendency to improve. Pathological diagnosis was CD20 positive diffuse large B-cell lymphoma. A total of eight courses of R-CHOP therapy were given. No evidence of recrudescence of malignant lymphoma was evident at 14 months postoperatively. We reported a case of splenic rupture due to malignant lymphoma where splenectomy was an effective treatment option for diagnosis and treatment.

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A 58-year-old woman visited a local doctor for body weight loss. Examinations revealed a retroperitoneal tumor, and she visited our hospital. CT showed a low-density, round, 9.4-cm mass in the retroperitoneal space behind the liver ; the tumor displaced the inferior vena cava and right hepatic vein to the anterior side. Hematological studies, including that for adrenal function, showed almost normal status. Tumor resection was performed based on the diagnosis of a retroperitoneal tumor in September 2011. The tumor could be divided from the inferior vena cava and hepatic vein smoothly, but it was difficult to divide the tumor from the right adrenal gland, and right adrenalectomy was required. Histopathological findings showed that it was a neurofibroma. Solitary retroperitoneal neurofibromas without neurofibromatosis I (von Recklinghausen disease) are reported to be rare rare. We present this case and include a review of the literature.

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A 62-year-old man consulted a previous doctor because of anemia which had been pointed out at a blood donation, and an abdominal computed tomography (CT) scan showed a huge retroperitoneal mass. He was referred to our hospital for further examination. Enhanced CT scan revealed a large retroperitoneal tumor, which was surrounding the aorta and deviated the IVC to ventral and the right kidney, which presented hydronephrosis to the lateral cranial side.
The patient underwent a surgical operation on a diagnosis of retroperitoneal malignant tumor. The huge mass, 17×14×9 cm in size, was resected en bloc with the right kidney, right psoas muscle, part of the aorta and the inferior vena cava. Vascular reconstruction was performed using an aorta-iliac Y-graft and an IVC-right iliac vein I-graft.
The pathological examination of the specimen revealed dedifferentiated retroperitoneal liposarcoma invading the aorta and IVC.

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A 70-year-old man presented with a slowly growing mass in his left inguinal area. Abdominal enhanced computed tomography revealed a tumor in the spermatic cord, as well as three other tumors in the abdominal cavity and retroperitoneal space. Local excision of the spermatic cord mass was performed to obtain a definitive diagnosis, and the histological examination showed a well-differentiated liposarcoma of the spermatic cord. The patient required further resection with a sigmoidectomy to deal with the other tumors. Follow-up CT performed 8 months after initial surgery showed recurrence in the retroperitoneal space ; the retroperitoneal tumors were excised.

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A retroperitoneal tumor suspected of invasion to the aortic wall difficult to diagnosis and the advisability of a combined aortic resection has not gained consensus. In this article, we report a rare case of retroperitoneal tumor resected together with the adjacent abdominal aorta and a review of the relevant literature. A 42-year-old man developed backache and was found to have a retroperitoneal tumor appressed to the aortic wall in a computed tomography (CT). Although the malignancy of the tumor was strongly suggested by enhanced CT, magnetic resonance imaging (MRI) and 18F-fluorodeoxyglucose position emission tomography (FDG-PET), diagnosis with preoperative needle biopsy was not carried out because of its difficulty. Due to the tight adherence of the tumor to the aortic wall, open laparotomy and tumor resection with adjacent abdominal aorta was conducted with the intent to make a definitive diagnosis and radical cure. The resected aorta was replaced by an artificial vessel. While the intra-operative biopsy showed malignancy whose origin was not determinable, the final pathological findings gave a diagnosis of seminoma. Postoperative course was uneventful without recurrence for over one year.

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A 77-year-old woman who had undergone emergent mesh plug repair for left inguinal incarcerated hernia 11 years earlier, visited our hospital because of left inguinal pain. Left inguinal severe swelling and redness were observed, and a left inguinal abscess was shown on abdominal enhanced computed tomography (CT), we diagnosed late-onset mesh infection. Based on suspicion of a fistula between the plug and small intestine, we performed an operation. The infected plug and onlay patch were entirely removed, and vacuum-assisted closure therapy was performed with the drain under the sutured aponeurosis of the external abdominal oblique muscle. Postoperative course was good, no signs of recurrence of hernia or infection have occurred. To the best of our knowledge, there have been only a few cases of late-onset mesh infection more than 10 years after the inguinal hernia repair in Japan. We present our case with a review of the literature.

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A 51-year-old woman underwent manual reduction of an incarcerated hernia at an emergency clinic. She then underwent palliative repair of the umbilical hernia after 24 days. Thereafter, she developed vomiting, diarrhea and anorexia. She was diagnosed with adherent obstruction in the small bowel 71 days after manual reduction of the incarceration, necessitating direct emergency hospital admission. Gastrografin examination of the intestine from the mouth revealed a stenotic portion of the small intestine on abdominal CT. However, since contrast media appeared in the large intestine, conservative medical management was chosen. As improvement was not anticipated, an operation was deemed necessany. The stenotic portion of the ileum was resected. Pathological examination of the specimen revealed that the stenosis was due to ischemic enteritis. The postoperative course was uneventful and the patient has since been symptom-free. Although umbilical hernias are relatively rare, ischemic small intestine strangulation may arise like an inguinal or a femoral hernia after reduction of an incarcerated hernia. Long-term follow-up is needed after reduction of the hernia considering the possibility of late onset small bowel stenosis caused by ischemic enteritis.

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A 32-year-old man was transported to the emergency outpatient unit by ambulance with right groin pain, protrusion of the right groin, and scrotal swelling. He had been scheduled for a right inguinal hernia repair. On the basis of computed tomography, the content of the hernia was suspected to be a huge mass or hematoma instead of the intestine. Emergency surgery was performed on the day of presentation because manual reduction was not possible. Incarceration of the greater omentum in the right internal inguinal ring was confirmed laparoscopically ; the hematoma covered by the greater omentum was immediately removed through an inguinal approach, and hernia repair was performed. Subsequently, the residual hematoma in the abdominal cavity was removed laparoscopically. The surface of the resected specimen was smooth, elastic, and soft, and the cut surface was composed of a white tumor area and the surrounding hematoma. A connection to the greater omentum was revealed. Histopathological examination revealed the tumor to be an intra-abdominal desmoid tumor that might have originated in the greater omentum. An intra-abdominal desmoid tumor is a rare disease that is often detected as abdominal distension or a mass. We have reported this case with a brief literature review because no previous report has described a tumor causing an incarcerated hernia similar to that observed in our case.

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We report a case of internal hernia through a mesenteric defect after laparoscopic sigmoidectomy for early sigmoid colon cancer. A 66-year-old man operated on in June 2009 for early sigmoid colon cancer was admitted to our hospital with a sudden onset of abdominal pain. Physical examination disclosed abdominal distention with severe tenderness. A plain abdominal X-ray revealed a small amount of gas in the small intestine with air fluid levels. Abdominal enhanced computed tomography (CT) demonstrated small bowel distention oral to the narrowing around the site of the mesenteric defect with a small amount of ascites. Internal hernia through a mesenteric defect after laparoscopic sigmoidectomy was diagnosed and he underwent emergency laparotomy ; in which herniation and ischemia of the ileum 60 cm in length through a mesenteric defect of the sigmoid colon and a small amount of bloody ascites was identified. The herniated ileum was repositioned and resected, the mesenteric defect was closed. Although mesenteric defects are closed in open surgery, such management is not usually performed in laparoscopic surgery due to the technical difficulty. A literature review was also performed on closure of the mesenteric defect in laparoscopic bowel resection.

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A 72-year-old man was seen because of bilateral bulging in the inguinal region ; his scrotum had enlarged to be soccer ball size, and his penis was not visible. Following abdominal CT scanning, a diagnosis of bilateral inguinal hernias containing bowel loops was made. At surgery, a large amount of intestine including an ileocecal portion and the transverse colon were found in the right hernia sac, while the sigmoid colon was found in the left hernia sac. The right hernia hilum was repaired using a Kugel patch (size L), the left hernia hilum was repaired using a direct Kugel patch (size L). No recurrence has been detected during over two years of follow-up.

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