We examined 151 cases of colon cancer cases with invasion into other organs based on gross observation treated at our hospital. The aim was to identify a treatment policy paradigm for colon cancer cases with invasion into other organs. Combined resection of the affected organs was performed in 137 cases. The gross and histological diagnoses of invasion into other organs matched in 37.2% of cases. Comparison of the survival rates of colon cancer patients with invasion into adjacent organs with or without distant metastasis revealed that the prognosis was poor among Stage IV patients. Stage II and III patients had a good prognosis. In fStage II and III, no significant difference in outcome was noted based on the presence or absence of histological infiltration. The prognosis was relatively good after R0-1 resection, even among Stage IV patients. These results suggest that aggressive combined resection aimed at R0-1 resection can lead to a better prognosis.

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We have experienced two successfully resected cases of metachronous gastric tube cancer after esophagectomy for thoracic esophageal cancer, when the primary feeding vessels were dissected. (Case 1) A 73-year-old man had undergone right trans-thoracic subtotal esophagectomy for esophageal cancer with gastric pull-up via a posterior mediastinum route. Two years and 4 months after the surgery, metachronous cancer was revealed in the reconstructed gastric tube. The gastric tube was severely adhered to adjacent organs, such as lung and bronchus in the upper mediastinum. Therefore, we resected at 2 cm distal to the gastric tube and reconstructed with pedicled jejunum via a posterior mediastinum route. (Case 2) A 50-year-old man had undergone right trans-thoracic subtotal esophagectomy for esophageal cancer with gastric pull-up via a posterior mediastinum route. Five years and 6 months later, metachronous Type 3 cancer was detected in the reconstructed gastric tube. The gastric tube was severely adhered to adjacent organs, such as bronchus and right recurrent nerve in the upper mediastinum. Therefore, we resected at several cm distal to the gastric tube and reconstructed with pedicled jejunum via a posterior mediastinum route. In both patients, the remnant gastric tube stump showed no ischemic change, with a successful outcome.

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Laparoscopic resection of the umbilical urachal remnant appears to be more efficacious than traditional open excision of the urachal remnant. However, there is the issue of urachal carcinoma, and it is not yet known whether it is better to close the peritoneum after resection. In this paper, the surgical technique and issues related to laparoscopic resection of the umbilical urachal remnant were investigated.
Between March 2009 and February 2012, seven patients underwent a laparoscopic resection of the umbilical urachal remnant. They all had a symptomatic urachal sinus and underwent laparoscopic resection of the umbilical urachal remnant after the urachal sinusitis disappeared. A forward-oblique viewing endoscope was used, and a resection of the urachal remnant in the peritoneal cavity was done using three trocars : a 12-mm trocar at the right mid clavicular line at the height of the umbilicus for the laparoscope, and two 5-mm trocars at the right upper and lower abdomen. The bladder side of the urachal remnant was interrupted twice by intracorporeal knot-tying, and the umbilical side of the urachal remnant was dissected by cutting out a circle in the bottom of the umbilicus ; the peritoneum was closed using a running suture.
Laparoscopic resection of the umbilical urachal remnant was efficacious and should be the standard approach given its benefits vis-a-vis surgical damage and the incision.

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We report a case of metastasis of breast cancer to the thyroid gland that was difficult to diagnose. The patient was a 75-year-old woman who underwent modified radical mastectomy and axillary lymph-node dissection for left breast cancer and resection of right thyroid mass for adenomatous goiter in 1991, after a pathological diagnosis of papillary carcinoma. Nine years 8 months after the first operation, left axillary lymph-node recurrence of breast cancer was detected and removed. After postoperative radiation therapy and chemotherapy, she had undergone hormone therapy. Eighteen years 11 months later, thyroid tumors were detected. Cytological diagnosis was papillary carcinoma, and total thyroidectomy was performed. However, pathological diagnosis was metastasis of breast cancer. Thyroid metastasis of breast cancer is clinically rare ; however, metastatic carcinoma should be considered in patients with a thyroid mass.

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We report 4 cases of granulomatous mastitis, one of which showed Corynebacterium Kroppenstedtii infection. Case 1 : A 38-year-old woman presented with a mass measuring 3.8×3.0 cm in the upper outer quadrant of her left breast. The histological diagnosis was granulomatous mastitis. Treatment with antibiotics and steroids was not effective. Finally, surgical abscess drainage was performed. Case 2 : A 36-year-old woman presented with mass measuring 3.0×2.5 cm in the upper half of her left breast. A diagnosis of granulomatous mastitis was made, and she had no complaints during the follow-up period. Case 3 : A 39-year-old woman presented with a mass measuring 4.2×4.0 cm in the inner half of her right breast. The histological diagnosis was granulomatous mastitis. Treatment with antibiotics was not effective. Finally, surgical abscess drainage was performed. Case 4 : A 34-year-old woman presented with a mass measuring 2.0×2.0 cm in the upper inner quadrant of her right breast. Cytologic examination showed no malignant cells, and the histological diagnosis was granulomatous mastitis. Polymerase chain reaction (PCR) analysis revealed kroppenstedtii infection, and the patient was successfully treated with minomycin.

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Pseudoangiomatous stromal hyperplasia (PASH) is a benign lesion formed by a complex pattern of largely empty, often anastomosing, spaces in the proliferative collagenous stroma. However, histopathologically, PASH is similar to a benign fibrous disease such as fibroadenoma (FA). Therefore, it is important to consider PASH in the diagnosis and to order additional immunostaining investigations to confirm a diagnosis of PASH. We report a case of PASH that was definitively diagnosed with immunostaining after surgery.

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A 31-year-old woman developed an enlarging right breast mass. She was diagnosed as having a fibroadenoma on needle biopsy cytology done at another hospital. A movable and elastic mass measuring 80 mm was palpable in the EDB area of the right breast. Mammography revealed a slightly high density mass with unclear, scattered microcalcification in the right breast. Ultrasonography revealed a low echoic mass with a defined border and posterior echo enhancement. Magnetic resonance imaging showed a heterogeneous tumor in the right breast ; given the dynamic curve study results of mainly a crescendo pattern with a partial early wash-out pattern, the existence of tumors with different characters was suspected. Under a diagnosis of fibroadenoma or tubular adenoma, a lumpectomy was performed. On pathology, the coexistence of tubular adenoma and fibroadenoma, without a defined border between them, was confirmed. We report a rare case of tubular adenoma coexisting with fibroadenoma.

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A 51-year-old woman underwent partial mastectomy and axillary lymph-node dissection after neoadjuvant chemotherapy with trastuzumab and paclitaxel for left breast cancer. The tumor was positive for estrogen receptor, progesterone receptor and HER2. She was treated with trastuzumab for 1 year. The patient developed a huge and rapidly growing right cervical mass 34 months after the operation. Chemotherapy with fluorouracil-epirubicin-cyclophosphamide was administered, but the tumor increased in size. Therefore, we performed right cervical lymph-node dissection. Pathological diagnosis was metaplastic carcinoma metastasis that was triple negative. Then, the patient received radiation at the right neck and has been administered chemotherapy with capecitabine and cyclophosphamide after the operation. The patient has been doing well without evidence of recurrence, for 2 years.

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We report the case of a 60-year-old woman who was diagnosed with solid neuroendocrine carcinoma of the breast. She noticed an elastic hard mass of 30 mm in diameter in the right breast. Mammography revealed a microlobulated mass with segmental calcifications and ultrasonography also revealed a well-defined mass with rough margin and high internal echo spots correspondent to calcifications. The ultrasonography-guided Mammotome^® biopsy was performed for the histological diagnosis and the mass turned out to be a solid neuroendocrine carcinoma that showed positive immunohistochemical staining of Chromogranin A, Synaptophysin and CD56 according to WHO Classification. Total mastectomy and sentinel lymph node biopsy were performed. Following surgery, we planned to do adjuvant TC (docetaxel and cyclophosphamide) chemotherapy followed by aromatase inhibitor.
Neuroendocrine carcinoma of the breast is relatively rare, only 2-5% of all carcinoma of the breast. This carcinoma is characterized by neuroendocrine granules in the cytoplasm that can be identified with immunohistochemical staining of Chromogranin A and CD56. There is little information about its clinical characteristics, treatment or prognosis and also no consensus for adjuvant chemotherapy or hormone therapy. The collection of data from cases is indispensable for further investigation of neuroendocrine carcinoma of the beast.

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A 28-year-old woman presented with clear brownish nipple discharge from her right breast. Ultrasound imaging showed a ductal extension from the outer region around the right nipple. In MRI, enhancement imaging demonstrated ductal extension from a CD area. A noninvasive cancer was suggested because of ducts filled with secretion forming cystic extension. A diagnosis could not be made on the basis of the findings from aspiration cytology and core needle biopsy. Ductal carcinoma in situ (DCIS) has been diagnosed on the basis of biopsy findings of surgical specimens. The patient underwent total mastectomy and a tissue expander was placed in the right breast. Histopathological findings revealed a small number of cystic lesions including secretory components inside. The cyst filled with eosinophilic secretion. Invasive components are not observed. On the basis of the pathological test findings, we made a diagnosis of DCIS, cystic hypersecretory carcinoma. Immunohistochemical staining was positive for ER : positive, PgR : positive, and HER2 : 1+. Adjuvant treatment was not performed because she wished to get pregnant. She is being regularly followed up as an outpatient. The patient gave birth to a girl 24 months after surgery, who is alive and well 76 months after the operation.

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Primary osteosarcoma of the breast is a comparatively rare tumor. It has been reported that fibroadenoma or phyllodes tumor might be related in the genesis of the tumor. This time we have experienced a case of osteosarcoma of the breast which was suspected to have some relation to fibroadenoma. The case involved a 69-year-old woman who had noticed tumors of the both breasts for several decades. She was seen at the hospital because her left breast tumor began to enlarge rapidly with pain. On physical examination, an about 12-cm diameter hard mass which had almost replaced the left breast was found. Fine needle aspiration biopsy produced a diagnosis of old fibroadenoma, but a malignant neoplasm was strongly suggested. The tumor was thus resected and the definite diagnosis of osteosarcoma arisen in the breast was made. No distant metastases were identified and no adjuvant chemotherapy was added. The patient has been alive without recurrence as of one year four months after the operation.

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A 40-year-old woman was seen at the hospital in October 2008 because she was recommended to receive close exploration as a result of a mass-screening examination for breast cancer. A tumor 1.5 cm in diameter was palpable in the left breast. Following core needle biopsy (CNB), invasive ductal carcinoma of the breast containing osteoclast-like giant cells was diagnosed. On November 12, 2008, Bp + SN were performed when the surgical margins and sentinel lymph nodes were negative. As the patient had to be transferred to another hospital on the eighth postoperative day for treatment of autoimmune hepatitis, we could not give her adjuvant therapy. On March 3, 2009 when she had been staying at another hospital, A 5 mm-sized tumor in the subcutaneous area with subcutaneous hemorrhage in the left breast was detected, and she was referred to our hospital. Following fine needle aspiration cytology, local recurrence was diagnosed and mastectomy for the remnant left breast was performed on March 26.
Malignant tumors of the breast with osteoclast-like giant cells are extremely rare and represent about 0.5% to 1.2% of all breast cancers. This paper deals with a case of breast cancer with osteoclast-like giant cells developed local recurrence which might be caused by needle tract seeding after breast-conserving surgery.

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A 56-year-old woman who had been diagnosed with bilateral mastopathy 3 years previously was referred to our hospital with a palpable mass in her left breast. The physical examination revealed a hard mass in each breast ; 1.8 cm in the right and 3.0 cm in the left. Mammographic examination and ultrasonography followed by core needle biopsy, led to a diagnosis of bilateral breast cancer. Her left breast cancer was accompanied with an EIC lesion which was demonstrated as the enhanced frame towards her nipple by computed tomography (CT). Histologically she had right scirrhous carcinoma, and in her left breast she had both scirrhous and invasive lobular carcinoma.
Bilateral breast cancer has an overall incidence of 1-20% and the incidence of synchronous bilateral breast cancer is about 1%. It is thought to be important to evaluate the contra-lateral breast in patients with primary operable breast cancer.

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A 43-year-old male was admitted to hospital because of repeated episodes of right pneumothorax. Chest CT showed a cystic lesion of the right upper lobe without a mass in the cavity. Therefore, video-assisted thoracic surgery was performed. On histopathology, the resected cystic lesion showed wall thickening. Aspergillus hyphae were detected in the necrotic wall tissue. A healthy individual wituout an underlying disease may develop pulmonary aspergillosis. It is necessary to consider the possibility of productive aspergilloma on the inner wall of a cavity (PAIC), even in cases without a fungus ball.

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We report a case of esophageal achalasia of the sigmoid type associated with epiphrenic and Zenker diverticula. Since 2002, a 63-year-old man with achalasia had frequent balloon dilatations. In November 2009 he complained of dysphagia and a 5kg weight-loss. Barium esophagography revealed sigmoid-type achalasia with epiphrenic and Zenker diverticula. We performed a hand-assisted laparoscopic Heller myotomy with Dor fundoplication and resection of an epiphrenic diverticulum. The postoperative course was uneventful. To date, after two years of follow up he can eat semi-solid foods and has had no weight-loss.

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Gastric carcinoma with lymphoid stroma (GCLS) is classified as a special type of gastric cancer because of its characteristic features in histology and more favorable prognosis than usual gastric cancers. We report our experience with a case of GCLS presented with ball valve syndrome (BVS). The case involved a man in his fifties complaining of vomiting and epigastralgia. Following abdominal CT scan, impaction of a gastric tumor in the duodenum was diagnosed. The impaction was released endoscopically. A biopsy resulted in moderately differentiated tubular adenocarcinoma. Preoperative EUS showed that the tumor was localized in the submucosal layer, and laparoscopic-assisted distal gastrectomy was performed. Pathological studies of the permanent preparation revealed remarkable lymphocytic infiltration and GCLS was diagnosed.
Grossly GCLSs often present as type IIc or type IIa + IIc in early stages and as type 2 or 3 in advanced stages. This case which was of type 1 and presented with BVS is considered to be rare.

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A 60-year-old woman was referred to our department of surgery for further examination of early gastric cancer. Preoperative Multidetector-row computed tomography (MDCT) showed a vascular anomaly of Type VI in Adachi's classification ; in which the common hepatic artery (CHA) arising from the superior mesenteric artery (SMA) runs behind the portal vein (PV). In Adachi type VI, CHA cannot be detected at the superior border of the pancreas. Since it was diagnosed as Adachi type VI by preoperative MDCT, laparoscopic-assisted distal gastrectomy with D1+β dissection was performed safely without damaging the portal system by exposing the anterior side of the portal vein. The left gastric vein was identified while keeping this layer in the No.8a lymph node dissection. In laparoscopic surgery, the running pattern of the vessel cannot be confirmed by manual palpation during the operation. Consequently it is important to understand the vessel running pattern prior to laparoscopic surgery by using MDCT.

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Here, we report a rare case of primary volvulus of the small intestine. The patient was a 72-year-old man who complained of severe epigastralgia and vomiting after supper was admitted to our hospital. He had no history of laparotomy. Enhanced CT revealed a so-called “whirl sign.” On the basis of the CT findings, we made a diagnosis of volvulus of the small intestine, and emergency operation was performed. A part of the small intestine (about 180-cm long) was found to be twisted clockwise by 360° at the superior mesenteric artery, and excision of this part was performed. On the basis of these findings, we made a diagnosis of primary volvulus of the small intestine because there were no viewes on band, adhesion and malformation.

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A 97-year-old woman visited our hospital with chief complaints of vomiting and abdominal pain. Abdominal computed tomography (CT) showed a whirl sign in the small intestinal loop around the superior mesenteric artery (SMA). On the basis of this finding, we made a diagnosis of small intestinal volvulus. Emergency surgery revealed a 360° clockwise twist of the small intestine around the SMA and a solitary diverticulum (diameter, about 10 cm) at a distance of about 30 cm from the Treitz' ligament in the jejunum. We reduced axis rotations and performed wedge resection for the diverticulum.
Forty-three days later, the patient revisited our hospital because of symptom recurrence. Abdominal CT showed a whirl sign, on the basis of which a diagnosis of recurrence of small intestinal volvulus was made. Emergency surgery revealed twisting of the small intestine similar to that observed the first time. Because there was no adhesion, we reduced axis rotations and performed mesentery fixation to prevent recurrence. Recurrence has been rarely reported, but additional procedures such as mesentery fixation have been suggested for the treatment of small intestinal volvulus.

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We report a patient with a perforated pseudo-diverticulum in the terminal ileum, diagnosed at laparoscopy. A 75-year-old man was admitted to hospital with lower abdominal pain of 2 days duration. A physical examination revealed tenderness and muscle guarding in the middle lower half of the abdomen. Enhanced abdominal computed tomography (CT) showed edematous changes in the ileocecal region and a small amount of ascites in the pouch of Douglas, but no free air. Panperitonitis was diagnosed, and diagnostic laparoscopy was performed. Laparoscopy showed dirty ascites and a perforated terminal ileum on the side opposite the mesentery. The laparoscopy was converted to a laparotomy, and an ileocecal resection and intra-abdominal drainage were performed. On histopathology, a small intestinal pseudo-diverticulum with perforation was diagnosed. The postoperative course was uneventful, and the patient was discharged on 7^th postoperative day.

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A 76-year-old woman presented to the emergency room with sudden abdominal pain. There was no rebound tenderness. The white blood cell count was 5,950/μL. Contrast-enhanced abdominal computed tomography revealed thickening of the small intestine and ascites in the right paracolic space without free air in the abdominal cavity. After a few hours, the patient's abdominal pain worsened and rebound tenderness appeared ; thus, an emergent laparotomy was performed. Intraoperatively, perforation of ileal diverticulum was identified ; ileocecal resection and abdominal lavage were carried out. The patient had an uneventful postoperative course and was discharged on the 15^th postoperative day. On pathology, perforation of pseudo-ileal diverticulum and inflammation were noted.
Perforation or penetration of ileal diverticulum is rare. Ileal diverticulosis often occurs on the mesenteric side. However, in our case, the perforation was unusually located on the anterior wall of the ileum.

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A 57-year-old woman who had a previous history of appendectomy visited a hospital because of abdominal pain. Following and abdominal plain x-ray examination, she was diagnosed with intestinal obstruction and was admitted to our hospital. Abdominal distension was noted, but there were no muscle defense and rebound tenderness. No tumor was palpable. Abdominal CT scan revealed a finding suggestive of lamellar structure of the small intestine in the left pelvic cavity. Adhasive intestinal obstruction or intussusception of the small intestine was likely based on CT findings. As she had mild symptoms, conservative therapy was started but was unsuccessful. On the second hospital day anal bleeding appeared as well, so that surgery was performed.
Preoperative barium enema and colonoscopy to confirm colorectal lesions showed no abnormalities. Upon laparotomy, intussusception had already been reduced, but a part showing prominent inflammatory change was present at the ileum. We etiologically considered that the ileo-ileal intussusception had been reduced by preoperative barium enema and colonoscopy, and partial resection of the ileum was performed. No organic lesions including a tumor were involved in the resected intestine. Idiopathic enteric intussusception was thus diagnosed.

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A 47-year-old man complained of mild abdominal pain and melena. Abdominal computed tomography demonstrated an ileo-ileal intussusception due to a fat density tumor of the small intestine. A small intestine series also showed a protruded lesion in the ileum located 40 cm from the ileocecal valve. A single port laparoscopic partial resection of the small intestine was performed. On histopathology, the tumor was found to be an inverted Meckel's diverticulum with ectopic pancreatic tissue. The postoperative period was uneventful, and after 4 days the patient was discharged. Adult intussusception caused by an inverted Meckel's diverticulum is rare. However, single port laparoscopic surgery is considered to be safe and offer less traumatic access ; it is efficient for treating a symptomatic adult Meckel's diverticulum.

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We experienced two rare cases of acute lower gastrointestinal bleeding from the appendix.
Case 1. A 42-year-old man, who had been hospitalized with malignant rheumatoid arthritis, presented with hematochezia. He had been medicated with prednisolone 10 mg/day, methotrexate 8 mg/week, a non-steroidal anti-inflammatory drug, and aspirin. Colonoscopy showed active bleeding from the appendiceal orifice, and emergency appendectomy was performed. The appendix appeared almost normal macroscopically, except for a little blood in the lumen. Histopathological examination revealed no abnormal findings. Rebleeding was not observed postoperatively.
Case 2. A 70-year-old man presented with hematochezia. Colonoscopy showed intermittent bleeding from the appendiceal orifice. Contrast-enhanced abdominal computed tomography (CT) showed extravasation of contrast media into the cecum. Emergency appendectomy was performed. The lumen of the appendix was filled with hematoma, but the mucosa appeared normal macroscopically. There were also no histopathological findings. Rebleeding was not observed postoperatively.

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A 25-year-old male patient complained of upper abdominal pain and was admitted to hospital. Acute appendicitis complicated by a superior mesenteric vein thrombosis was suspected on CT. The patient required an appendectomy and abdominal abscess drainage. On the first postoperative day, a continuous intravenous heparin infusion was started. The postoperative course was uneventful, and oral warfarin treatment was continued. Six months after surgery, the superior mesenteric vein thrombosis was found to have disappeared on CT. In such thrombosis cases complicated by appendicitis, the thrombosis can progress as the inflammation worsens and can cause bowel necrosis. Therefore, it is important to make an early diagnosis and to start appropriate control of the inflammation. Had bowel necrosis occurred, there was a high likelihood that a massive small intestine resection would have been required. In the present case, an appendectomy conducted immediately to control abdominal inflammation prevented bowel necrosis.

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A 72-year-old woman was admitted to our hospital because of right lower abdominal pain. A painful mass (diameter, 6 cm) was palpable at the ileocecal region. Laboratory test results suggested inflammation, and serum CEA and CA19-9 levels were both normal. Computed tomography of the abdomen after administration of a contrast agent showed a heterogeneously stained mass and suggested the presence of multiple cystic lesions within the mass. Colonofiberscopy did not show findings suggestive of malignancy. Because of difficulty in preoperative diagnosis of appendiceal tumors, we conducted laparoscopy-assisted right hemicolectomy and D2 lymph-node dissection under a possible diagnosis of inflammatory tumor with multiple diverticulosis or cystic tumor of the appendix. The resected specimen showed an inflammatory pseudo-tumor containing multiple diverticula with thick inflammatory fibrous tissue. Here, we have presented a rare case of multiple appendiceal diverticulosis forming a mass lesion that mimicked an appendiceal tumor.

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We report a case of rectal perforation caused by vasculitis following systemic lupus erythematosus (SLE). A 41-year-old individual who received steroid therapy for 30 years complained of sudden abdominal pain and developed high fever 15 days after orthopedic surgery. Abdominal CT scan showed free air and fluid collection, suggesting bowel perforation. We performed emergency operation and found purulent ascites and edema around the rectum. On the basis of these findings, we made a diagnosis of rectal perforation. Then, we performed low anterior resection and covering ileostomy for the treatment of rectal perforation. Histopathologic test results revealed vasculitis with thrombus formation, which caused ulcer formation and necrosis of the intestinal wall.
In an SLE patient receiving steroid therapy, abdominal symptoms may sometimes be absent and the diagnosis of bowel perforation may be difficult. Therefore, we should make full use of diagnostic techniques such as enhanced CT and administer the appropriate therapy promptly.

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Pyoderma gangrenosum (PG) is a refractory extraluminal disease that can be complicated by ulcerative colitis. Patients with PG may sometimes have to undergo total proctocolectomy. Although there have been many reports that have suggested that PG can be resolved by total proctocolectomy, hear, we describe 3 cases in which PG developed after total proctocolectomy.
Case 1 : A 37-year-old woman developed PG in the right ankle, 4 years after undergoing total proctocolectomy. Although initially, she showed improvement often steroid administration, the condition aggravated when the dose was decreased. Her symptoms improved often cytapheresis (CAP) and administration of an immunosuppressant.
Case 2 : A 32-year-old woman developed PG in the right leg 5 months after total proctocolectomy. Her symptoms improved often CAP.
Case 3 : A 39-year-old woman with aggravated ulcerative colitis was observed to have renal-cell carcinoma during a detailed examination. PG developed in the left leg 1.5 months after total proctocolectomy and removal of the right kidney. At present, her symptoms have improved with the administration of a steroid and an immunosupperessant and CAP. In all the cases, no relapse of residual rectal mucosa and ileal pouchitis were observed.
Conclusion : In addition to preoperative follow-up, short-and long-term postoperative follow-ups for PG are essential in cases of ulcerative colitis.

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A 60-year-old man was admitted due to abdominal pain and high fever. His white blood cell count and C-reactive protein were 17,000/μl and 25.93 mg/dl, respectively. Computed tomography (CT) visualized hepatic portal venous gas and diverticulitis of the sigmoid colon. We suspected a perforation of the sigmoid colon and an emergency operation was performed under the diagnosis of severe diverticulitis with hepatic portal venous gas. We found the sigmoid colon became a red induration. There was no turbid ascites in the abdominal cavity but we found gastro-intestinal penetration into the mesentery, so we performed a sigmoidectomy. Intraoperative findings revealed anastomotic insufficiency and a colostomy of the transverse colon was performed. After the second operation, he made a good recovery.
Hepatic portal venous gas is considered to be a poor prognostic condition requiring emergency laparotomy ; but recently, many cases have been reported to recover spontaneously without surgical intervention. We report a case of diverticulitis of the sigmoid colon with hepatic portal venous gas, including a discussion of the literature.

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A 44-year-old woman was admitted to our hospital because of abdominal pain. Abdominal radiographic and CT scans showed enlarged colon with a mesenteric tumor. Barium enema revealed colon enlargement due to duplication of the transverse colon. Laparotomy was performed, and the duplicated colon was resected along with the mesenteric tumor. The mesenteric tumor was diagnosed as dermoid cyst on the basis of histological findings.
Intestinal duplication is a rare congenital anomaly that is usually diagnosed during childhood. However, in rare cases, the condition may remain undiagnosed until adulthood. The mesentery is an unusual site for development of a dermoid cyst. Here, we report an extremely rare case of duplication of the transverse colon with a mesenteric dermoid cyst in an adult patient.

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A 60-year-old woman underwent a colectomy for descending colon cancer. Suddenly, on the 3^rd postoperative day she developed a high fever and severe abdominal pain without diarrhea. Although there was no evidence of anastomotic leakage, surgery was undertaken because it was suspected. A large amount of watery greenish stool was pooled in the patient's ascending colon, which was very dilated. The stool sample tested positive for Clostridium difficile toxin A/B. Oral metronidazole was not effective, and hence, oral vancomycin was given. Subsequently, due to intraperitoneal abscess formation, percutaneous abscess drainage was performed, and an infusion of vancomycin and meropenem was started. The patient had repeat episodes of relapses and recurrences, but was eventually discharged on the 94^th postoperative day. To date, the patient is doing well and has not had any recurrence. Recently, the incidence and severity of C. difficile infection has been increasing worldwide, especially in North America and Europe. In the near future, it could become a major problem in Japan as well. We report this case of C. difficile infection to help clinicians focus on the appropriate use of antibiotics.

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A 51-year-old woman, who had video-assisted thoraco-surgery (right middle lobectomy) two years prior, was admitted to our hospital. Her serum CEA level rose 1 and a half years after the operation. Half a year later, she complained of abdominal pain and abdominal fullness. A colonic neoplasm was diagnosed. She underwent elective right hemi-colectomy. Many lung cancer digestive tract metastases are well advanced at the time of detection ; indications for surgery are rare. However, in this case elective excision was possible. A literature review is also presented.

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Colorectal cancer patients with elevated preoperative serum CEA levels tend to have a poor prognosis. We report a case of advanced cecal cancer with a markedly elevated preoperative CEA level. A 73-year-old female with abdominal pain and an abdominal mass was admitted, and she was found to have type 2 colon cancer in the cecum. Her preoperative serum CEA level was 4500.0 ng/ml ; there were no distant metastases or other cancer lesions. The patient had a laparoscopic-assisted ileocecal resection (with D3 dissection). Her serum CEA level returned to normal four months postoperatively. She has had over 5 years disease-free survival after the curative resection. In many cases of colorectal cancer, an elevated preoperative CEA level is a poor prognostic factor. However, in this case there has been no recurrence and a long disease-free survival.

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A 76-year-old woman who visited another hospital because of abdominal distention late in April 2009 underwent colonoscopy and was found to have a 20-mm diameter elevated lesion at the ileocecal region. Following a biopsy, well-differentiated adenocarcinoma was diagnosed. The patient was referred to our hospital for close exploration and treatment. An abdominal contrast-enhanced CT scan taken in the middle of May failed to show any tumors. At the beginning of June, laparoscopic-assisted right hemicolectomy was performed. The resected specimen involved no tumorous lesions. Intraoperative colonoscopy performed to confirm the absence of tumorous lesions showed no lesions in the other sites as well. It raised the possibility that the lesion might spontaneously be dislodged. On histopathology, neither scar nor residual cancer was revealed in the cecum. The postoperative course was uneventful and the patient was discharged from our hospital late in June.
We sometimes encounter reports on spontaneous regression of hematological malignancy or cancer of the genital organs, however, spontaneous regression of colorectal cancer is extremely rare and this case is presented here with some bibliographic comments.

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We experienced a case of multiple sigmoid colon cancer associated with Japanese schistosomiasis. A 82-year-old woman underwent colonoscopy because of occult blood in her stool. She had never lived in Yamanashi, Hiroshima, or Fukuoka prefectures ; where are endemic areas for Japanese schistosomiasis. Colonoscopy revealed an elevated lesion with slightly depressed top and a pedunculated polyp near the tumor at the sigmoid colon. The patient was diagnosed with advanced sigmoid colon cancer with polyp, and she underwent sigmoid colon resection. Pathological findings showed tub2, pMP, pN0, ly0, v1 for advanced colon cancer and cancer in adenoma for polyp. Furthermore, ova of Schistosoma japonicum were also detected in the stroma of the cancer. In Japan, Oncomelania, a host of Schistosoma japonicum, was exterminated in the past and we have not observed an acute infection of Schistosoma japonicum. However, a researcher has previously reported a case of colon cancer associated with Japanese schistosomiasis. Some reports have suggested a relationship between Japanese schistosomiasis and carcinogenesis ; however, there are also contradictory reports. Therefore, we think it is necessary to evaluate the cases of Japanese schistosomiasis and consider the occurrence of colon cancer in patients with a history of Japanese schistosomiasis.

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We report a case of neuroendocrine cell carcinoma of the rectum presented with an internal hemorrhoid. The case involved a 61-year-old man visited our hospital because of an internal hemorrhoid which was partially incarcerated and necrotized. Colonoscopy showed a submucosal tumor (SMT) located at the anterior aspect of the lower rectum, and the tumor was suspected to be carcinoma or carcinoid. Computed tomography of the abdomen showed a hypervascular lesion at the anterior aspect of the rectum. There were no findings suggestive of metastases to the liver and other organs. Hemorrhoidectomy and local excision were performed. Biopsy revealed a poorly differentiated adenocarcinoma (mp, INFβ, ly2, v0, and cut surface was negative for cancer). Immunohistochemistry revealed that the tumor cells were negative for cytokeranin, slightly positive for chromogranin A and remarkably positive for synaptophysin. The pathological diagnosis was neuroendocrine cell carcinoma. The Ki-67 labeling index was 80%. No metastasis and recurrence have occurred for 10 months after the first visit.

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A 79-year-old man tested positive for fecal occult blood in a medical checkup. Colonoscopy showed an elevated tumor in the transverse colon. The biopsied specimen of the tumor was pathologically diagnosed as adenocarcinoma. Barium enema and abdominal computed tomography (CT) revealed that the colon was not fixed to the retroperitoneum. Three dimension (3D) - CT angiography showed that the distal portion of the superior mesenteric artery which was considered to be the ileocolic artery, was reversed to the upper right side of the abdomen. The arteries of the small intestine branched from the right side of the SMA. He underwent laparoscopic colectomy based on a diagnosis of transverse colon cancer with non-rotation type of malrotation of the intestine. It is possible safety perform laparoscopic surgery for the cases with anatomical anomalies by simulation, using imaging applications like 3 D-CT angiography.

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A 38-year-old man complained of epigastralgia ; on abdominal computed tomography, a large hepatic tumor was seen. Lactate dehydrogenase, alkaline phosphatase, and serum C reactive protein levels were elevated. The tumor markers which were examined were within normal limits. The CT showed a low-density mass, 19 cm in diameter, in the left lobe of the liver. Swollen lymph nodes were also seen around the stomach and the hepatoduodenal ligament. Due to the large tumor size, and the fact that the patient's symptoms had worsened, a left hepatic lobectomy was performed, before a definitive diagnosis was made. On pathology, the resected tumor was diagnosed as a diffuse large B cell type malignant lymphoma. PET-CT performed after surgery showed an abnormal accumulation of extrahepatic lymph nodes. CHOP with rituximab therapy was given as postoperative chemotherapy. Currently, the patient is in complete remission.

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The case involved a 51-year-old woman undergone left colectomy for cancer of the descending colon. The histopathological diagnosis was moderately differentiated adenocarcinoma, pSS, ly0, v3, pNO, sNO, cPO, cMO, stage II. Adjuvant chemotherapy with tegaful uracil / calcium holynate was carried out. Abdomino-pelvic CT scan performed four months after the operation showed a low density area in the anterior regional branch of the right branch of portal vein. Abnormal uptake of FDG was revealed at the same area by ¹⁸FDG-PET-CT, but no other abnormal uptakes were demonstrated. Tumor thrombosis was diagnosed and right lobectomy of liver was performed. Macroscopic and histopathological findings showed no demonstrable metastatic foci in the hepatic parenchyma. The tumor thrombosis was composed of similar moderately differentiated adenocarcinoma to the primary lesion.
As tumor thrombosis of the portal vein unaccompanied by hepatic metastasis of colorectal cancer is extremely rare, this case is presented here together with some bibliographic comments.

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A 60-year-old man with a chief complaint of epigastric pain was found to have gastric cancer in the lower stomach. Distal gastrectomy with D2 lymphadenectomy and cholecystectomy were performed. The final diagnosis was papillary and moderately differentiated tubular adenocarcinoma, T2, N0, H0, M0, Stage IB, Cur A. Seven months later, abdominal computed tomography (CT) detected two liver metastases in the S5 and S6. Multiple liver metastases appeared within a short period. He was at risk of developing other lesions, which prompted us to administer TS-1 chemotherapy. Three months later, the two liver metastases had decreased in size and no new lesions were observed on abdominal CT ; therefore, we performed two partial hepatic resections. After the completion of hepatic resections, seven courses of TS-1 chemotherapy were administered. At present, i.e., at 3 years and 10 months after the distal gastrectomy and 2 years and 8 months after the hepatic resections, no relapse has been noted.

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A 76-year-old man who was being followed due to a diagnosis of intraductal papillary mucinous neoplasm (IPMN) was admitted because of abdominal pain caused by tumor perforation. There was marked inflammation around the abscess, and a well-enhanced lesion was seen in the tumor on abdominal enhanced CT. While waiting to begin the operation, ERBD and ENBD were performed for cholangitis. The cytology of the mucinous bile from the ENBD was class III, and a biliopancreatic fistula was diagnosed. A pancreatoduodenectomy was performed. IPMN with focal invasive carcinoma and a neuroendocrine tumor were identified in the resected specimen. Pseudomyxoma peritonei should be watched for on follow-up.

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We report a case of small cell carcinoma of the pancreas. This case involved a 58-year-old man admitted to our hospital because of abdominal pain. Abdominal CT scan showed a low density mass 7cm in diameter in the pancreatic body, of which border part was slightly enhanced. We diagnosed it as a tumor of the pancreatic body invaded the stomach and the lateral segment of the liver. We performed distal pancreatectomy with total gastrectomy and resection of the lateral segment of the liver. Histopathological diagnosis was small cell carcinoma of the pancreas. Unfortunately, this patient died of multiple liver metastases and local recurrence two months after the operation.
The prognosis of small cell carcinoma of the pancreas is extremely poor, and only 24 cases have been reported in the Japanese literature.
A review of these reported cases in Japan suggested that long-term survival can be expected by the adjuvant treatments such as chemotherapy, radiotherapy and aggressive curative operation.

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A 74-year-old woman with carcinoma of the pancreatic head underwent pylorus-preserving pancreatoduodenectomy in October 2009. The diagnosis based on histological findings was invasive ductal carcinoma (IDC), T1N0M0, stage I. She underwent adjuvant chemotherapy with gemcitabine and was followed up. Abdominal computed tomography performed 1 year 5 months after the operation revealed a mass in the remnant pancreas. Pancreatic cancer was suspected after careful examination. At the time of operation, 2 tumors measuring around 1 cm were observed in the remnant pancreas. Subtotal remnant pancreatectomy was performed, and about 3 cm of the pancreas body was preserved. Because the pancreas was preserved, the patient showed fairly good glycemic control. On the basis of histological findings, we diagnosed both tumors as IDC. One of them was T1N0M0 stage I and the other was T3N0M0 stage III. Because continuity of the lesions, including the first tumor, was not observed, multicentric occurrence was suspected. Pancreatic intraepithelial neoplasia was evident in the noncancerous pancreatic parenchyma, and this finding could be related to the development of multicentric IDC.

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We report a rare case of long-term survival by a patient who had locally advanced pancreatic body carcinoma with paraaortic lymph node metastasis after combined treatment by surgery, chemotherapy, and radiation.A 48-year-old woman had a pancreatic body carcinoma (2 cm in diameter) with paraaortic lymph node metastasis (lymph node number 16b1 and 17b). She underwent distal pancreatectomy with splenectomy (R0 resection). Histopathological examination revealed tubular adenocarcinoma (T3 M1 Stage IVb). After surgery, she received gemcitabine, S-1, and radiation, and she survived for 44 months. This case demonstrates that the combination of surgery, chemotherapy, and radiotherapy can be effective for prolonging survival in patients with advanced pancreatic carcinoma and paraaortic lymph node metastasis.

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A 60's-year-old man was operated for cecal cancer and synchronous liver metastases. After 7 months, recurrence was found at the liver and the left scapula. While under chemotherapy, he suddenly complained of severe pain in the lower right abdomen. Computed tomographic (CT) scan revealed that the right ureter was involved in the recurrence, and localized fluid was detected in the retroperitoneum, causing the pain by peripelvic extravasation. A double-J stent was placed and the sharp pain disappeared promptly. Chemotherapy was able to be continued without interruption.
We experienced a case of peripelvic extravasation resulting from ureter blockage caused by the recurrence of cecal cancer. This complication is rare, but early diagnosis and treatment improved QOL.

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An 80-year-old man who had operated on for advanced gastric cancer, early prostate cancer and early lung cancer was admitted to our hospital because of appetite loss and general fatigue. The serum levels of LDH and ACTH were high. Abdominal CT scan showed bilateral adrenal masses, measured 7cm in diameter on the left and 6cm on the right. We suspected metastasis of lung cancer to the bilateral adrenal glands, and planed further examinations. But the patient's condition took downhill course and he died of acute adrenal failure 3 days after admission. Autopsy revealed the definite diagnosis of diffuse large B-cell malignant lymphoma of the bilateral adrenal glands. Although primary adrenal malignant lymphoma is extremely rare, it can cause adrenal failure easily. We should take adrenal malignant lymphoma into account as a differential diagnosis of adrenal tumors.

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A-59-year-old man who was seen at the hospital because of swelling of the left inguinal region was found to have a left dilated inguinal canal and a 2-cm diameter low density mass at the same area by abdominal CT scanning. Left inguinal hernia with a lipoma was diagnosed and he was operated on under lumber anesthesia. During surgery a hernia sac with the size of the tip of the little finger was found in the spermatic cord and it was dissected. Further an elastic-soft and yellow-colored tumor with the size of the tip of the thumb was detected in the center of the spermatic cord. It was removed. The removed specimen had smooth surface and was elastic-soft and yellow in color. The histopathology revealed fat cells and interstitial component, and floret type giant cells and rope-like collagen fiver bundle were identified in the interstitial part. Immunohistochemistry of the tumor cells were CD34 positive and S-100 negative. From these findings, pleomorphic lipoma was diagnosed.
This tumor often affects the back of the neck, shoulders, or back of men in their forties to seventies. This paper describes our case of a pleomorphic lipoma in the spermatic cord.

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We present a case of intraperitoneal anisakiasis causing omentitis in which an Anisakis larva was laparoscopically observed. The case involved a 31-year-old woman who was seen at the hospital because of right lower abdominal pain. Abdominal contrast-enhanced CT scan revealed opacity of adipose tissue caused by inflammation on the ventral aspect of the cecum, and, inferior to it, a tubular structure which seemed like an appendix. Acute appendicitis was diagnosed and laparoscopic-assisted surgery was performed. During surgery, we confirmed adhesions between the right side colon and greater omentum in the abdominal cavity, and hardening, thickening, and redness which were especially remarkable in the omentum at the anterior aspect of the cecum. On the surface of the omentum, an about 1-cm long linear structure suggestive of a worm was seen. The appendix was almost normal. Laparoscopic appendectomy and partial resection of the greater omentum showing severe inflammation were performed. Histopathologially the appendix showed chronic appendicitis and an Anisakis larva was identified in the omentum affected by severe inflammation. In this case we etiologically infer that the perforated site of the intestine due to the Anisakis larva was closed without inducing perforative peritonitis, and the larva penetrated into the abdominal cavity through the intestine reached the greater omentum to cause omentitis.

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A 42-year-old man who had undergone appendectomy 30 years ago was referred to our hospital for treatment of pseudomyxoma peritonei (PMP). Because of an episode of mucosuria, he visited the department of urology of another hospital. Radiologic images showed a massive multicystic tumor in the abdominal cavity. Laparotomy and partial resection of the tumor were performed, and histopathological findings showed a low-grade mucinous carcinoma associated with PMP. After being admitted to our hospital, magnetic resonance imaging was performed, and it revealed fistula formation between the cystic tumor below the navel and the urinary bladder. We diagnosed PMP arising from the urachus, and partial resection of the urinary bladder, greater omentectomy, right hemicolectomy, splenectomy, cholecystectomy, and radical peritonectomy were performed. After complete cytoreduction, hyperthermic intraperitoneal chemotherapy was administered. Since PMP arising from the urachus is extremely rare, we have reported this case with a review of the literature.

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We experienced a case of an extrarenal retroperitoneal angiomyolipoma located near the aortic bifurcation. The case involved an 85-year-old woman, and was discovered unexpectedly during examination for lower rectal cancer. Abdominal computed tomography (CT) showed a 37×30 mm retroperitoneal mass with enhancement of its rim. A magnetic resonance imaging (MRI) T2-weighted image showed a high intensity mass, but did not support a preoperative diagnosis. The mass was removed surgically during a cancer operation at the same time. It was desmin-positive, HHF-35-positive and SMA-positive by immunohistostaining, and therefore an angiomyolipoma was diagnosed. Angiomyolipomas are rare benign mesenchymal tumors that usually occur in the kidney. Extrarenal angiomyolipomas are extremely uncommon.

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