[in Japanese]

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The working environment of doctors largely differs depending on the form of medical care, the department of medical care, gender, and regions, but extensive data have not been available. The Japanese Breast Cancer Society conducted a comprehensive field study asking the society members about their work conditions and lives. Responses were obtained from 9% of them. Eighty-one percent of the respondents were male, 19% female, and 92% listed surgery as their basic field of specialty. From the questionnair survey, a composition has emerged in which a great deal of breast medical cares (mainly for breast cancer) are conducted with affiliated hospitals of the university medical departments and university hospitals as the center, with doctors in the leadership position sent by the personnel affairs of the university medical departments. Most institutions are relatively large general hospitals, however, each hospital has one to three doctors specializing in the breast medical care. The average working hours per week of 61 hours or more was 39% in male hospital-based doctors and 44% in female hospital-based doctors. Approximately one third of doctors indicate poor working conditions as one item acting as a barrier against building a career. In addition, 60% of doctors listed the clarification of service/working conditions as an item that is desired to support the building of a career. Many female doctors are working while dealing with various issues such as marriage, childbirth, and child care, but it is evident that they are also working with pride, considering breast medical care to be a job worthwhile. Doctors who specialize in breast medical care tend to work long densely-packed hours in the same manner or greater than general hospital-based doctors. In order to maintain the offering of stable medical care even in a fast aging society with a rapidly decreasing labor force, the maintenance of a working environment for hospital-based doctors and the reconstruction of its mechanism are necessary. Consequently, it is believed that preparing an environment for female doctors that is pleasant to work in is also important.

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We report a total of ten cases of thymoma (in Stage I/II according to the Masaoka's classification) performed thymo-partial thymectomy by anterolateral incision with video-assisted thoracoscopic surgery. The subjects were three men and seven women, with an average age of 58±11.0 years old. Of the ten patients, three underwent associated resection of other organs, another three had postoperative complications, one had phrenic nerve paralysis associated with combined resection, and one had been suffering from atrial fibrillation before the operation. In accordance with the WHO classification, the most common histopathological diagnosis was Type AB in five cases (50%), and six (60%) was noted in StageI according to the Masaoka's classification after the operation. An average operating time was 92.3±39.2 minutes. An average operative blood loss was 20.5±34.1 ml. An average time of a chest tube drainage was 1.50±0.85 days, and an average hospital stay was 7.4±4.62 days. There have been no signs of recurrent disease in all the patients.
Thoracoscopy-assisted thymo-partial thymectomy by anterolateral incision is considered to be a minimally invasive and safe operative procedure for selected thymoma patients.

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The development of laparoscopic techniques and the availability of lightweight mesh has facilitated the use of various operative procedures for adult inguinal hernia surgery. We performed totally extraperitoneal preperitoneal (TEP) repair using 3D Max Light^® (C.R. Bard, Inc.) without balloon dilation 3D Max Light, an anatomically contoured 3D lightweight mesh, is used in laparoscopic inguinal hernia repair. This mesh has a large-pore knit that provides good visibility while allowing the creation of a flexible and compliant abdominal wall. Twenty patients (mean age, 60.9 years), including 7 with unilateral hernias and 13 with bilateral hernias underwent TEP using 3D Max Light^® in our hospital between May 2011 and September 2011. The mean operative time was 81.8 min (range, 55-166 min) for unilateral hernia and 133.0 min (range, 88-173 min) for bilateral hernias. The mean hospital stay was 3.0 days (range, 1-5 days). The average follow-up period was 3.2 months (range, 1-6 months). One patient showed seroma 1 month after surgery, but no recurrences or complications were observed. This method is economical and useful for decreasing postoperative complications such as neuralgia and recurrence. We suggest that this operative method with 3D Max Light^® should become a standard approach for the management of inguinal hernia.

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Case 1 : A 70-year-old man was admitted to receive neoadjuvant chemoradiotherapy (CRT) for esophageal cancer in our hospital. PICC was inserted in his left basilic vein to administer the chemotherapeutic agents. On day 29, we removed the PICC because of suspicion of catheter-related fever following neck phlegmone. Enhanced CT revealed thrombosis from his left jugular vein to the superior vena cava. Rapid anticoagulation therapy successfully improved the symptons. The thrombosis tended to shrink by continuous oral administration with warfarin. Case 2 : A 68-year-old woman had a scheduled operation for advanced gastric cancer. Due to undernutrition, a PICC was inserted in her left basilic vein for total parenteral nutrition. Three days later, we comfirmed thrombosis from her left jugular and subclavian to superior vena cava by CT. Then we removed the PICC and started anticoagulation thrapy. Seven days later, we comfirmed by CT that the thrombosis had improved moderately. It is suggested that PICC associated venous thrombosis can be related to long term PICC placement, undernutrition and dehydration in digestive surgery.

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We performed partial mastectomy in a 50-year-old woman with a mass in her right breast. Histological examination revealed tall tumor cells with oval nuclei, increased chromatin, and eosinophilic granules. The tumor cells had a funicular structure with many alveoli, and small glandular, tubular, and rosette-like structures were observed in some sections. Solid alveoli were observed in some small cells, and circulatory stasis was observed in some others. Specific staining revealed many tumor cells to be chromogranin A- and synaptophysin-positive, while Grimelius staining revealed alveoli with clusters of positive cells. The patient was subsequently diagnosed with carcinoid of the breast.

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Apocrine adenocarcinoma arising in the accessory breast is extremely rare. We report a case of apocrine adenocarcinoma of the accessory breast. A 63-year-old woman diagnosed as having adenocarcinoma of the right axilla after biopsy was referred to our department of surgery. We regarded it as metastasis from an occult breast cancer or a tumor of unknown origin. Further examinations did not identify the primary cancer lesion. Extended local excision and lymph node dissection were performed. On pathological examination, apocrine adenocarcioma and tissue of the accessory breast were identified, but no communication with the lateral area of the left breast was found. Consequently apocrine adenocarcinoma of the accessory breast was diagnosed. Metastasis was not found in dissected lymph nodes. The patient has been recurrence free for 2 years, to date since the operation.

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We report a case in which the use of a polytetrafluoroethylene (PTFE) pledget for suturing the brachiocephalic artery led to the formation of a mediastinal abscess 5 years after operation. The patient showed rupture of the brachiocephalic artery caused by inflammation due to anastomotic insufficiency after a previous esophagectomy.
The patient was a 71-year-old man who underwent esophagectomy for esophageal cancer, cervical anastomosis of the esophageal-gastric conduit, and triregional lymph node dissection. Pathological examination revealed the tolloving findings : tumor location, Lt ; tumor type, type 2 SCC ; and tumor stage, stage III pT3N2M0IM0. We recognized anastomotic insufficiency 11 days after the operation and brachiocephalic arterial rupture induced by an abscess 24 days after that. We performed stenotomy and closed the rupture of the brachiocephalic artery by using a pledget. However, the patient showed recurrent superior mediastinitis 5 and a half years later. Computed tomography (CT) showed a high-density area that was suspected to be the pledget in the superior mediastinal abscess. We were able to successfully extirpate the abscess, including the pledget, from the brachiocephalic artery without injury. Postoperative course was good. He was discharged 14 days after the operation. He showed no recurrence of the abscess and esophageal cancer for about 3 years after the last operation.

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A 58-year-old man presented with a mediastinal tumor. Thoracic computed tomography showed a 50-mm mass abutting the anterior chest wall and the pericardium, as well as a narrowed left innominate vein. A diagnosis of invasive thymoma or thymic carcinoma was made, and an operation was performed. A median sternotomy was done ; the mass was incised along with the sternum that it had invaded. Therefore, we reseced the chest wall and the adjacent organs into which invasion was suspected. The postoperative course was uneventful, and there has been no recurrence during follow-up. Thymoma invading the chest wall is rare and difficult to diagnose. If there is any suspicion of chest wall invasion based on clinical symptoms and imaging, it is important during surgery to determine whether chest wall invasion has occurred.

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We report a rare case of a clear cell tumor of the lung. Recent data suggest that it is patristic in origin, and it has been proposed that it should be considered as one of the families of PEComas-neoplasms that originate from perivascular epithelioid cells. A 65-year-old woman, was found to have a round, abnormal shadow in the left upper lung at the time of rectal cancer surgery. After the rectal cancer surgery, a partial resection of the left lung was performed. On histopathology, the tumor cells were found to have abundant and clear cytoplasm containing glycogen and were supported by sinusoid-like vessels. Furthermore, the tumor was positive for PAS and HMB-45. Based on these findings, the tumor was diagnosed as a clear cell tumor of the lung.

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A 58-year-old woman ingested 500 ml of alkali in a suicide attempt. Computed tomography (CT) showed a large fluid collection in the mediastinum around the esophagus. Gastrointestinal fiberscopy (GIF) showed a deep ulcer that was suspected of having a perforation. These findings suggested a corrosive esophagitis and danger of further perforation, which necessitated an esophagectomy. Surgical findings showed inflammation in the mediastinum around the esophagus, but no perforation was found. On histology, necrotic changes were seen throughout the entire mucous membrane. Corrosive esophagitis caused by alkali ingestion result in a delayed perforation. There is no consensus with respect to the extent of surgery required in the acute stage. However, it must be borne in mind that a perforation is fatal ; thus, the opportunity for a definitive solution should not be squandered.

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A 39-year-old man was found while he had been lying in cardiac arrest at the bottom of a swimming pool. Following cardiopulmonary resuscitation performed by a by-stander, his heart beat regained. When he arrived at our hospital, the blood pressure was 255/107, pulse rate was 137/min, the SpO2 was 70%, and massive intraoral bleeding and abdominal distension were noted. An abdominal CT scan showed large volumes of free air in the abdominal cavity and bloody discharge was observed from a gastric tube. Gastrointestinal perforation was thus diagnosed and an emergency laparotomy was performed. Upon laparotomy, we observed air retention in the lesser omentum, a dilated stomach which was also filled with air and clotts, and an about 7cm-long laceration on the gastric wall extending from the esophagogastric junction to the lesser curvature of the stomach. The laceration was closed by sutures. After the operation the patient was associated with acute respiratory failure, but he was discharged from the hospital on his feet on the 30th postoperative day.
Gastric dilatation due to inappropriate ventilation at cardiopulmonary resuscitation can cause an abrupt rise of the intragastric pressure by oppressing the sternum, with a resultant high risk of developing rupture of the stomach. Appropriate ventilation and sternum oppression are mandatory. When the patient develops gastrointestinal perforation in a state of return of spontaneous circulation (ROSC), emergency laparotomy must be carried out as soon as possible by keeping a possibility of gastric rupture in mind.

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We report the findings for a 78-year-old woman. The patient had gastric cancer and was referred to our hospital for further evaluation and operation. She was diagnosed with type 0-IIc early gastric cancer at the greater curvature of the gastric antrum by endoscopic examination. Chest CT showed swollen hilar lymph nodes and mediastinal lymph nodes. Abdominal CT showed swollen lymph nodes around the common hepatic artery and around the abdominal aorta. The patient underwent distal gastrectomy with D1+ lymph node dissection and lymph node biopsy. Postoperative pathological examination indicated signet-ring cell carcinoma that was limited within the submucosa. No metastasis was observed, but numerous epithelioid cell granulomas were observed in all the dissected lymph nodes. After operation, the patient was diagnosed with sarcoidosis, on the basis of the relevant diagnostic criteria. We report a case of early gastric cancer with sarcoidosis.
The woman is currently doing well and has showed no recurrence 18 months after surgery.

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A 52-year-old man who had been followed for gastric ulcer was found to have a submucosal tumor 10mm in diameter at the papilla of Vater on upper gastrointestinal endoscopy and endoscopic ultrasonography. During a 7 year-follow-up period by endoscopic ultrasonography, the size of the submucosal tumor increased from 10mm to 30mm in diameter. No apparent lymph node metastasis was detected on an abdominal dynamic-CT scan. Based on these findings, transduodenal extirpation of the tumor was perfomed with a diagnosis of submucosal tumor of the papilla of Vater. Histologically epithelioid cells, ganglion like cells, and spindle cells were seen. The tumor was finally diagnosed as gagliocytic paraganglioma. We describe the clinical experience of the present case and review the relevant medical literature.

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We treated a case of synchronous double cancer involving the pancreas and the liver in a patient with duodenal carcinoid. A 78-year-old man was diagnosed with duodenal carcinoid. The preoperative evaluation revealed a 1.2-cm-diameter duodenal carcinoid lesion located opposite the papilla ; there were no metastatic lymph nodes or distant metastases. At laparotomy, a small induration of the pancreatic head and a white nodule in the liver were found. As the intraoperative findings showed a lymph node and liver metastasis of the carcinoid, the patient had a pancreatoduodenectomy and an S4 segmentectomy of the liver. The histological examination showed that the induration of the pancreas was an adenocarcinoma, and that the liver nodule was hepatocellular carcinoma. Curative surgery was undertaken. Generally, gastrointestinal carcinoid lesions are associated with other malignancies. Nevertheless, case reports on multiple cancers with carcinoid are still rare. We describe this case and discuss the literature.

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A 63-year-old woman suffered from abdominal pain and frequent vomiting and lost 7 kg over the previous 2 months. She was referred to our hospital, because fecal vomiting appeared after administration of cathartic before colonoscopy. Strained distention was palpated in the left inguinal region, and computed tomography (CT) scan revealed a left femoral hernia. In the diagnosis of the incarceration of the left femoral hernia, emergent laparoscopic hernia repair was done. Although she was once discharged 6 days later after the operation, she was readmitted because of frequent vomiting. CT scan and small bowel series demonstrated circumferential stenosis of the small intestine and distension of the oral intestine. Laparoscopy revealed enteric intussusception. After manually fixing the intussusception, partial resection of the small bowel was performed. There was no organic disease at the invaginated portion. After reoperation, the patient did well and she regained body weight.

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We report two cases with von Recklinghausen's disease (VRD) complicated by gastrointestinal stromal tumor. Patient 1 was a previously healthy 46-year-old man with multiple café au lait spots who presented with abdominal pain having passed a large amount of tarry stool. CT scan and a selective SMA angiogram demonstrated multiple tumor stains in the upper jejunum. Interventional radiology (IVR) was employed to stabilize the patient's hemodynamic state, and then emergency surgery was done. On laparotomy, multiple submucosal tumors in the jejunum were noted, and a partial resection of the jejunum was performed. Patient 2 was a previously healthy 62-year-old man with multiple café au lait spots who presented with a history of tarry stools and a severe anemia. A selective SMS angiogram demonstrated multiple tumor stains in the upper jejunum and duodenum. Laparotomy revealed multiple submucosal tumors in the jejunum and duodenum, and a partial resection of the jejunum and duodenum was performed. Selective angiography and IVR are useful modalities for managing unstable patients who have ongoing bleeding from the small intestine. On immunohistochemistry, both tumors were positive for c-kit and CD34, and they were diagnosed as gastrointestinal stromal tumor (GIST). However, genomic analysis of the c-kit gene and the PDGF-Rα gene did not show any mutations. In the future, we hope to identify the precise etiology and the optimal medical treatment options for VRD patients with GIST.

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A 78-year-old woman had undergone removal of a jejunal tumor with cystic formation showing 7 cm in size eight years earlier. This tumor was diagnosed as a gastrointestinal stromal tumor (GIST) with moderate risk that originated in the jejunum based on histopathological findings with immunohistochemistry. Abdominal CT revealed two small cystic tumors in the eighth segment of the liver in 2009. These tumors were diagnosed as liver metastases from the GIST because pericapsular stain with an increase in tumor size was seen on contrast-enhanced CT in 2010. Metastatic foci were removed by partial hepatectomy and tumor pathology was compatible with findings of the GIST arising from the jejunum. A careful long-term follow-up is required after resection of a GIST because the biological characteristics of GIST are being clarified.

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A 59-year-old woman complaining of tarry stool underwent gastrointestinal endoscopy and total colonoscopy. However, the hemorrhage point was not clear, so she was referred to our hospital.
Double-balloon endoscopy of the small intestine revealed a 30 mm submucosal tumor at the jejunum.
Since gastrointestinal stromal tumor (GIST) of the jejunum was suspected, we injected black ink as preoperative marking. The location of the tumor was easily identified by the marking, and we performed laparoscopic partial resection of the jejunum.
Histopathological diagnosis was a low grade GIST.
For GIST of the small intestine, preoperative double-balloon endoscopy is useful for accurate diagnosis and an appropriate treatment.

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A 20-year-old man presented at another hospital with abdominal pain, weight loss, and edema in the lower extremities. He was admitted to our hospital for treatment of anemia and hepatic tumors. Computed tomography revealed perforated jejunal tumor with multiple lymph-node and liver metastasis. We performed partial resection of the jejunum. Histological examination revealed a sheet arrangement of atypical cells. Immunohistochemical staining (chromogranin A, CD56) yielded positive results, and the tumor was diagnosed as neuroendocrine cell carcinoma of the jejunum. After the operation, the patient received 4 courses of chemotherapy with CBDCA and VP-16. However the chemotherapy had little effect, and he died 5 months after the operation. There have been 24 reported cases of neuroendocrine carcinoma of the small intestine in Japan, and our patient was the youngest among all the patients.

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A 40-year-old woman had a positive fecal occult blood test. On colonoscopy, an ulcer was found in the ascending colon. On examination of the biopsy, Mycobacterium tuberculosis was identified. Tuberculosis was thus diagnosed. Anti-tuberculosis agents such as pyrazinamide, isoniazid, rifanmpicin, and ethambutol were given. During therapy, she developed right abdominal pain. Abdominal CT showed a thickened and enlarged ascending colon. It was proposed that the drugs had caused stenosis of the colon by constricting the lesion. A laparoscopic right hemicolectomy was performed. On pathology, fibrosis granulation tissue but no granulomatous lesion was found, thus confirming that the stenosis was caused by the constriction of the intestine related to anti-tuberculosis drug therapy. The patient's post-operative course was good ; the drugs were stopped. In summary, during treatment of tuberculosis, ileus caused by intestinal tuberculosis may occur. In this situation, a laparoscopic approach should be considered.

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In an 81-year-old woman, para-aortic lymphadenopathy and a tumor in the descending colon (DC) was detected using abdominal computed tomography (CT) 6 months after laparoscopy-assisted distal gastrectomy. The patient lost weight because of malnutrition. Colonoscopy revealed that a circumferential tumor was causing total occlusion. Chest CT and gastroduodenal fiberscopy were performed, but no abnormal findings were observed. Although we could not obtain a preoperative pathological diagnosis, we performed laparoscopy-assisted partial resection of the DC. The tumor was pathologically diagnosed as an active mycobacterial infection. Elderly patients may develop active tuberculosis from latent infection because of the prevalence of mycobacteria in Japan. It is difficult to diagnose extrapulmonary tuberculosis without respiratory infection because there are no specific symptoms. We conclude that it is important to consider abdominal extrapulmonary tuberculosis in elderly patients, especially when they present with abdominal tumors and malnutrition.

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Mucocele of the appendix is a rare disease, and dissemination of neoplastic cells and mucoid material in the abdominal cavity, caused by appendiceal perforation, clinically results in pseudomyxoma peritonei. The present study was made on nine cases of mucocele (seven cases of adenoma, one case of adenocarcinoma and one case of hyperplasia) of the appendix treated at the hospital in the recent 16 years. They were from 35 to 65 years old, and the male-to-female ratio was 3 to 6. Six patients were asymptomatic when the lesion was detected. Two patients had right lower abdominal pain and one had abdominal fullness. Preoperative diagnosis was successfully made in six out of nine cases, and the case of peritoneal pseudomyxoma was diagnosed before surgery. Operative procedures included ileocecal resection in four cases, partial cecectomy in four cases and appendectomy in one case. Laparoscopic surgery was performed safely in five cases. All nine patients are doing well, but thirteen months later, one patient with pseudomyxoma of adenocarcinoma was performed the second surgery because of the recurrence. We considered the treatment strategies for the disease from a review of 411 Japanese cases.

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A 60-year-old woman with a history of appendectomy 10 years earlier was admitted due to right lower quadrant pain. Colonoscopic examination revealed a type 2 cecal tumor, analysis of a biopsy suggested signet ring cell carcinoma. Serum anti-p53 antibodies were elevated. At the laparotomy, multiple dissemination in the whole abdominal cavity was seen, so we performed an ileocecal resection. Histopathological examination revealed a goblet cell carcinoid of the appendix. After chemotheraphy, serum anti-p53 antibodies were decreased. Goblet cell carcinoid of the appendix is relatively rare with adenocarcinoma-like features and has a poor prognosis ; there have been 99 cases reported in Japan. Those cases with p53 immunostaining were 11 and 6 were positive, no reported cases measured serum anti-p53 antibodies were detected, we present this first case with a review of the literature.

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A 56-year-old man was found to have a very large lower abdominal mass. The large tumor occupied the pelvic cavity. The mucosa of the rectum and the sigmoid colon was compressed by the tumor. Percutaneous needle biopsy was performed ; SFT was suspected. An operation was performed in June, 2004. The tumor was very large and occupied the pelvis. The tumor could be dissected from the pelvis and was resected via a low anterior resection. It was suspected that it had grown in the mesenterium of the rectum and the sigmoid colon. On pathology, a diagnosis of SFT, with a low-grade malignancy was made ; the diameter of the SFT was 25 cm.
The patient's postoperative course was good. Currently, he is healthy, and he has no signs of recurrence 7 years after the operation.

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A 57-year-old woman was referred to our hospital with melena and anemia. Abdominal computed tomography revealed swollen adrenal glands. After ingesting 24 mg of Sennoside to prepare for a radio-isotope examination, she developed abdominal pain and hypotension. After we performed an emergency sigmoid-colostomy, she was free from hypotension and abdominal pain. An examination by colonoscopy via the colostomy revealed longitudinal colonic ulcerations.
We performed a left colectomy, hysterectomy and partial resection of the small intestine, due to the possibility of direct invasion. We found 3 lines of longitudinal ulceration 25 cm long located 20 cm above the sigmoid colon cancer. We diagnosed her as having obstructive colitis.

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A 41-year-old man underwent a medical examination for close inspection and treatment because a hepatic tumor detected on abdominal ultrasound (US) during a medical check-up. The abdominal computed tomography (CT) revealed that he had a well-demarcated tumor including the structure of a multilocular cyst in the lateral segment and the medial segment of the left liver. Biliary cystadenocarcinoma or sarcoma was suspected and a left hepatectomy was performed. Immunohistochemically, the tumor was diagnosed as a solitary fibrous tumor (SFT). Histopathologically, we did not recognize nuclear atypia or mitosis, but we found partial necrosis and invasion into the bile duct wall. After nine months postoperatively, the patient is alive and well. The SFT is an unusual tumor that arises mostly in the pleura. The primary SFT in the liver is extremely rare. The majority of SFT follow a clinically benign course, but occasionally it follows a malignant course. We consider that it is necessary to carefully follow-up in the present case.

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We report a case of night blindness due to vitamin A deficiency after subtotal stomach-preserving pancreaticoduodenectomy (SSPPD), that might be caused by intra-hepatic bile duct stones, obstructive jaundice and chronic cholangitis secondary to strictures of choledocho-jejuno anastmosis.
The patient was a 73-year-old woman who underwent SSPPD for intraductal papillary mucinous neoplasms (IPMN) three years earlier. One year after SSPPD, she developed strictures of choledocho-jejuno anastomosis, multiple intra-hepatic bile duct stones and obstructive jaundice, and had had recurrent bouts of chronic cholangitis for these two years.
This time, she was hospitalized because of acute cholangitis. Percutaneous transhepatic cholangiodrainage, percutaneous transhepatic cholangioscopic lithotomy and balloon dilatation of the anastomosis improved cholangitis and obstructive jaundice. She also had been suffered from night blindness due to vitamin A deficiency. After intramuscular injection of vitamin A, night blindness improved immediately.
It was speculated that both malabsorption of fat-soluble vitamins according to insufficiency of bile secretion and liver dysfunction due to obstructive jaundice might cause vitamin A deficiency.

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A 12-year-old girl with no significant medical or surgical history presented to a practicing physician with upper abdominal pain. Her symptom persisted inspite of medication, and she was referred to our institution. Intravenous contrast material-enhanced computed tomography (CT) was performed, and it showed a round well-margined cystic mass (diameter, 50×48 mm) that had a solid component in the border region of the pancreatic tail. Magnetic resonance imaging (MRI) also showed a simple cystic tumor in the pancreatic tail. T1-weighted MRI showed a high-intensity area in the circumference of the tumor ; this was suspected to be intratumor bleeding. Solid pseudopapillary tumor of the pancreas was suspected, and laparoscopic spleen-preserving distal pancreatectomy was performed. The postoperative course was uneventful, and the patient was discharged from the hospital on the 13^th postoperative day. Minimally invasive surgery such as laparoscopic surgery should be considered for benign or borderline tumor of the pancreas.

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A 39-year-old woman was admitted to the hospital with recurrent attacks of hypoglycemia. Her FBS was 48 mg/dl when she had a consciousness disturbance. An enhanced CT scan showed a tumor, 15 mm in diameter in the pancreatic tail, and a diagnosis of solitary pancreatic insulinoma was confirmed. The tumor location was confirmed by intraoperative ultrasonography, and laparoscopic enucleation was performed using Laparoscopic Coagulating Shears. The operation time was 150 minutes, and bleeding was 10 g. The tumor size was, 12×12×10 mm, and on pathology, an insulinoma was diagnosed. The postoperative course was uneventful. She was discharged on the 7^th postoperative day and currently remains normoglycemic. Single Incision Laparoscopic Surgery is recommended for a solitary pancreatic tail insulinoma such as seen in our case.

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A 70-year-old woman was diagnosed with ascending colon cancer, and a right hemicolectomy was performed in 2008. During her followed up she was admitted to our hospital because of a pancreatic head tumor revealed by computed tomography (CT) in 2010. Tumor markers were within normol range. Ultrasonography (US) revealed a low-echoic mass ; CT revealed a tumor staining in the late phase with invasion to the posterior wall of the stomach and to the superior mesenteric vein (SMV), and magnetic resonance imaging (MRI) revealed a low-intensity mass in both T1- and T2-weighted images. She was diagnosed with invasive ductal carcinoma of the pancreas, and pancreatoduodenectomy and reconstruction of the SMV with a graft from the left renal vein were performed. The histological findings showed similar findings to primary ascending colon cancer, CK7 was negative and CK20 was positive, immunohistochemically. These findings resulted in a diagnosis of the tumor as pancreatic metastasis from the ascending colon cancer. Previous reports suggest that R0 resection results in good prognosis.

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A 77-year-old man showed dilation of the main pancreatic duct on computed tomography (CT) screening performed before sigmoidectomy for sigmoid colon cancer. One year after the operation, he was found to have a pancreas head tumor with a size of 3 cm. Endoscopic retrograde cholangiopancr-eatography (ERCP) showed obstruction of the main pancreatic duct in the pancreas head. The patient was diagnosed with pancreatic cancer, and he underwent pancreaticoduodenectomy. Histological examination showed anaplastic cancer (spindle type), pStage III. Since the posterior retroperitoneal margin of the tumor was positive for cancer cells, Gemstabin administration was started. Colon cancer metastasis was diagnosed, and pulmonectomy of the right superior and mid-lobe was performed, after which the patient received S-1 for 8 months until he quit because of anorexia. The patient has not shown disease recurrence for 4 years after pancreaticoduodenectomy. Anaplastic carcinoma of the pancreas is a relatively rare aggressive pancreatic tumor. This is the first report of long-term survival in a case of spindle-cell-type anaplastic cancer. We suggest some hypotheses with the pathological and clinical features of this case, and we report the relevant bibliographic comments.

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We report three patients who underwent pancreaticoduodenectomy (PD) for pancreatic head cancer with associated resection for other primary neoplasm. Case 1 : A 51-year-old male who had jaundice was found to have a pancreatic head tumor 3 cm in diameter and a right renal tumor 6 cm in diameter. We performed PD and right nephrectomy simultaneously. The pancreatic cancer was in Stage IV b, and the renal cancer was in Stage II. Case 2 : A 72-year-old male complaining of jaundice had cancer of the panrcreas head and cancer of the gastric body. We performed PD with wide-ranged radical dissection. The pancreatic cancer was in Stage IV a and the stomach cancer in Stage I A. Case 3 : A 77-year-old male whose blood glucose level was remarkably high was found to have a pancreatic tumor 1.5cm in diameter which locally invaded the portal vein, and a right renal tumor 5.5cm in diameter. PD with associated resection of portal vein and right nephrectomy were performed simultaneously. The pancreatic cancer was in Stage IV a and the renal cancer in Stage III. Simultaneous operation, including PD and other organ excision, would not be so invasive for the patients with multiple primary neoplasms with pancreatic head cancer.

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Carcinosarcoma is a malignant tumor that is a mixture of carcinoma (cancer of epithelial tissue and sarcoma (cancer of non-epithelial tissue). It occurs in a variety of organs, but rarely occurs in the gallbladder. So far only 45 cases of carcinosarcoma of the gallbladder have been reported in Japan.
A 71-year-old woman who was found having a 3 cm-sized tumor in the gallbladder underwent resection of the gallbladder bed with D2 lymph node dissection with a diagnosis of gallbladder carcinoma. Histopathology showed coexistence of adenocarcinoma cells and spindle-shaped, sarcomatous tumor cells, as well as transformation between them. Spindle tumor cells in the vicinity of the transformation were partly positive for an epithelial marker, and then “so-called carcinosarcoma” was diagnosed.
It has been reported that carcinosarcomas often present as papillary or nodular morphology. In our case the patient had a nodular tumor with a peducle that might be a difference from usual gallbladder carcinomas which often show the infiltrating property. Carcinosarcomas are believed to carry poorer prognosis than those of usual adenocarcinomas and most researchers agree a consensus that chemotherapies cannot be expected to exert effectiveness. However, our selection of S-1 therapy and the sustained administration for postoperative 24 months have provided a metastasis-free clinical course.

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Here, we report the cases of 2 patients with adrenocorticotropic hormone (ACTH) -independent macronodular adrenocortical hyperplasia (AIMAH) successfully treated with laparoscopic unilateral adrenalectomy. Case 1 : A 51-year-old man with treatment-resistant hypertension was diagnosed with AIMAH. Further examination revealed that the patient had preclinical Cushing's syndrome (PC), and unilateral right adrenalectomy was performed. Case 2 : A 61-year-old woman with early-onset hypertension from the age of 40 years was incidentally found to have AIMAH with PC, and unilateral right adrenalectomy was performed. The blood-pressure levels of the 2 patients improved, and serum levels of ACTH and cortisol became normalized after the operation. Conventionally, bilateral total adrenalectomy is the treatment of choice for a patient with AIMAH, although life-time steroid supplementation is required. The outcomes observed in our cases and in recent reports show that hemi-adrenalectomy is a safe and feasible alternative and should be considered as the standard surgical treatment for AIMAH patients to compensate for the critical demerit of bilateral total adrenalectomy.

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The patient was a 70-year-old woman who underwent right nephrectomy in January 1995. She was diagnosed with renal cell carcinoma on the basis of postoperative examinations. Computed tomography (CT) of the abdomen revealed a mass of size 4 cm in S8 of the liver. Partial hepatic resection of S8 was performed, and a diagnosis of carsinoid tumor of the liver was made on the basis of biopsy findings. The tumor size was 4×3 cm, and it consisted of a solid part enclosed in capsule. We suspected that the renal carcinoid had metastasized to the liver and reexamined the primary renal carcinoid. Thus, we made a diagnosis of metastasis of the primary renal carcinoid to the liver. To our knowledge, this is the first report on the resection of a liver tumor that developed from asynchronous metastasis of a renal carcinoid tumor renal carcinoid more than 12 years after nephrectomy. Thus, carcinoid tumors may recur or metastasize even after follow-up.

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A 79-year-old woman developed abdominal distention and was admitted. She had a history of cerebral infarction and had a right hemiplegia. She accidentally swallowed a piece of a plastic spoon 7 days prior to admission. Emergency endoscopy was performed, but the plastic piece could not found. It was found in the stool 5 days later. On abdominal X-ray, a huge volume of intra-abdominal free air and an emphysematous bulla in the small intestine were found ; abdominal CT scan confirmed these findings. Although, the inflammatory response and physical findings were inconclusive, we could not rule out the possibility of alimentary tract perforation due to the large volume of abdominal free air. During surgery, intramural emphysema was present in almost all of the small intestine and mesentery, but no site of perforation was found. A diagnosis of pneumatosis cystoides intestinalis was made. The postoperative course was uneventful, and the patient was discharged on the 19^th day after the operation.

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We report three cases of adult idiopathic pneumoperitoneum. All patients were incidentally found on a chest X-ray which demonstrated abdominal free air beneath the diaphragm during a routine examination. Computed tomography (CT) scans demonstrated intra-abdominal free air around the liver surface without any ascites. However, the physical abdominal examinations lacked any symptoms of peritonitis, such as Blumberg's sign or muscular defence, and the laboratory data were within normal limits. Nonsurgical managements were chosen and followed-up carefully, and resulted in successful outcomes.
Interestingly, pneumoperitneum recurred in case 2 and case 3. Especially in case 2, she received an exploratory laparotomy with a suspicion of gastrointestinal perforation 15 years previously, but perforated viscus was not detected and but only multiple jejunal diverticula were found. Idiopathic pneumoperitoneum itself is a rare condition, but this condition should be considered when encountering intra-abdominal free air without any symptoms or findings of peritonitis.

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A 53-year-old man who was seen at a hospital because of abdominal distension and abdominal pain was revealed to have a moniliform mass on the mesentery of the small intestine by abdominal ultrasonography and abdominal CT scan. Accordingly the patient was referred to our hospital with a suspicion of malignant lymphoma. Laparoscopic-assisted biopsy was performed but it gave no definite diagnosis. Surgery was performed for the purpose of diagnosis as well as treatment. Laparotomy disclosed a mass formed by ranging cysts of various sizes on the small bowel mesentery, and the mesenteric mass was resected together with the small intestine. Histopathology showed that the polycystic lesion comprised the growth of small and large vessels, and hematomas had been formed within the markedly dilated vessels. Cavernous hemangioma was definitely diagnosed.
It is not uncommon that the definite diagnosis of hemangioma of the small bowel mesentery cannot be made before surgery. The disease is so rare that only eleven cases, including our case, have been reported in Japan, and so our case is presented here, together with some bibliographical comments.

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An 82-year-old patient was diagnosed with a giant abdominal tumor in November 2008 and was then admitted to our hospital for further examination and management. Computed Tomography (CT) and magnetic resonance imaging (MRI) showed a massive tumor occupying almost the entire abdomen. Additionally, the surrounding abdominal organs were compressed as a result of tumor growth. Because of the massiveness of the tumor, the patient was given a poor postoperative prognosis and it was thought to be unresectable. Ultimately an attempt at resection was made since there was a chance to improve the quality of life. The tumor was largely removed and was found to weigh 15 kg. Histopathology revealed a myxoid liposarcoma with pleomorphic features. This paper discusses the rationale behind the decision making process in proceeding with resection as compared to other cases of giant abdominal liposarcoma.

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A 57-year-old man had undergone bilateral hernioplasty for a bilateral inguinal hernia at other hospital in October 2004. Purulent discharge appeared from the right inguinal region in April 2011. In June, he was seen at our hospital because of persistent purulent discharge. A cutaneous fistula with purulent discharge was detected 2 finger breadths away from the right inguinal surgical scar. After detailed examinations including computed tomography (CT) and fistulography, he was finally diagnosed with late-onset mesh infection. Because of the late-onset of deep prosthetic infection and cutaneous fistula with intractable prulent discharge, we removed the infected mesh and resected the fistula. The postoperative course was uneventful and he was discharged from our hospital on the 7th postoperative day. After the operation, recurrence of hernia has not occurred. In cases of late-onset prosthetic infection, it should be required to remove the mesh because a complete cure cannot be expected with only conservative therapy.

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We report a rare complication of colonoscopy-the incarceration of the colonoscope into an inguinal hernia.
A 77-year-old man underwent colonoscopy for routine follow-up. During the examination, when the colonoscope was inserted about 45 cm, it was suddenly stuck and could neither be advanced nor removed. The abdominal wall muscles were rigid, a reddish swelling in the left inguinal region was observed. Abdominal CT showed that the sigmoid colon and inside it the colonoscope were incarcerated in the left inguinal hernia ring. Under radiographic guidance, the colonoscope could not be withdrawn. An emergency operation was carried out, during which the incarcerated sigmoid colon was found to be located in the left inguinal fossa. The hernia hilum was repaired using the Direct Kugel method.
It is important to do a careful history and physical examination before colonoscopy since this alert the endoscopist about potential hazards such as the one we encountered in this patient.

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A 77-year-old man who had been treated for myelodysplastic syndrome presented with abdominal pain. On upper gastrointestinal endoscopy, a 0-IIc lesion 10mm in diameter was found in the lower portion of the stomach. Moreover, on colonoscopy, a 0-Is lesion 10mm in diameter was found in the ascending colon. Synchronous double cancer of the stomach and the ascending colon associated with myelodysplastic syndrome was diagnosed. Endoscopic treatment was not appropriate for these lesions. Distal partial gastrectomy (D1+α) and right hemicolectomy (D2) were performed. On histopathology, the 0-IIc lesion of the stomach was diagnosed as well differentiated adenocarcinoma (pM, pN0, ly0, v0, pStage I A) and the 0-Is lesion of the colon, as moderately differentiated adenocarcinoma (pSM2, pN0, ly0, v0, pStage I). The patient followed a favorable postoperative course and was discharged on the 15^th postoperative day. We report a rare operative case of synchronous double cancer of the stomach and the colon associated with myelodysplastic syndrome. So for only one another case has been reported in Japan.

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