Purpose : Gastrointestinal bypass surgery is widely practiced as a palliative treatment for malignant bowel obstruction, but few studies evaluating the effectiveness have been reported. The purpose of this study was to evaluate the efficacy and safety of the bypass surgery.
Methods : A retrospective review of consecutive 28 patients who underwent surgical bypass for malignant bowel obstruction in our hospital from January 2003 to December 2010 was performed. The rate of patients who had improvement in their levels of dietary intake, duration of oral intake, survival time, and the other factors affecting these results were assessed.
Results : After the surgery, 21 patients (75%) were able to eat more than soft solids. The median duration of oral intake was 76 days, and the median overall survival was 133 days. Patients who received postoperative chemotherapy showed significant prolongations in the duration of oral ingestion and survival time, compared to those who did not.
Conclusions : Gastrointestinal bypass surgery is relatively safe and effective for palliation of patients with malignant bowel obstruction. However, patient selection for this treatment is a clinical issue requiring thorough consideration.

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We present four cases with perihilar cholangiocarcionoma complicated by portal vein and hepatic artery invasion. The patients underwent hepatoligamentectomy.
The mean age was 60 ; there were two men and two women. Three patients underwent an expanded left hepatectomy, and one patient underwent an expanded right hepatectomy. One patient underwent pancreatoduodenectomy during the same surgery. All portal veins were reconstructed using a right femoral vein graft. The mean operative time was 532 minutes and the mean blood loss was 1,240 ml. The mean reconstruction time was 23 minutes for the portal vein and 23 minutes for the hepatic artery. Although two patients had postoperative complications (groin bleeding and hyperbilirubinemia) all patients were discharged from hospital after surgery. Two patients died due to cancer two years after the operation. Two patients are alive with no recurrence (51 months and 14 months). Patency of all reconstructed vessels was confirmed after discharge from hospital.
The portal vein was reconstructed using a continuous suture ; the hepatic artery was formed into a spatula shape using a slit and was then reconstructed via the parachute technique.
A general surgeon should be able to safely reconstruct the portal vein or the hepatic artery.

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A 76-year-old woman who had undergone splenectomy combined with total gastrectomy for advanced gastric cancer was admitted to our hospital because of high fever, dehydration and mental confusion 10 months after surgery. The patient began receiving antibiotics, intravenous immunoglobulin, and thrombomojulin for disseminated intravascular coagulation.
The result of blood culture revealed sepsis due to Streptococcus pneumonia, which we diagnosed as OPSI. Splenectomized patients have been recognized as immunocompromized hosts, for whom fulminant bacterial infection can be associated with high morbidity and mortality. Therefore, early diagnosis and urgent treatments are important to reduce the mortality of such infections. To prevent OPSI, adequate vaccination and prophylactic administration of antibiotics seem to be effective. Physicians should always be aware of the onset of OPSI for splenectomized patients.

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A 78-year-old woman who had noticed a palpable left breast mass since April 2006 was seen at a hospital in June of the year, when a 4.9×4.5 cm tumor in the B area or the left breast with fixation to the thoracic wall was identified. From CT, MRI, US and MMG findings, breast cancer was suspected, but fine needle aspiration cytology performed twice demonstrated no malignant cells. Subsequently the patient was referred to our department for close exploration and treatment. On physical examinations, a 5-cm diameter, elastic-hard, and ill-movable tumor was palpated in the B area of the left breast, but no axillary lymph node swelling was noted. Breast US disclosed an ill-defined and irregular-shaped mass with heterogeneous inner portion in the B area of the left breast, but the chest wall was not involved and malignant findings were lacked. The mass was suggested to be an inflammatory change. Mycobacterium tuberculosis was isolated from the aspirated fluid and smear staining resulted in Gaffky 6. The culture of the fluid was also positive. Tuberculosis of the mammary gland was thus diagnosed. Sputa culture for M. tuberculosis performed at the same time was negative, and there were no findings suggestive of pulmonary tuberculosis on chest CT scan. Treatments according to those for pulmonary tuberculosis were carried out and thereafter the patient has strictly been followed on an ambulant basis.
As tuberculosis of the mammary gland unassociated with pulmonary tuberculosis is extremely rare, this case is presented here, together with some bibliographic comments.

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A 68-year-old female had been diagnosed with sarcoidosis of the lungs, eyes, and skin 22 years earlier Prior to the current admission, abnormalities were diagnosed on screening mammography. On mammography, a focal asymmetric density (FAD) was noted ; ultrasonography showed an irregular mass. Needle biopsy was performed ; breast cancer was suspected. Sarcoidosis of the breast was diagnosed. Since the mass was small, an excision biopsy was performed using a vacuum-assisted breast biopsy system (Mammotome : MMT). She has had no recurrence for 6 months since the resection. We report a rare case of breast sarcoidosis and review the literature.

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A 60-year-old woman was consulted with a mass in the right breast. On physical examination a tumor measuring 1.5×1.0 cm was palpable in the right breast C area. Ultrasonogram showed an irregular-shaped tumor and we diagnosed as category 4 by mammogram. Core needle biopsy of the right breast was diagnosed as invasive lobular carcinoma. We performed a breast quadrantectomy of the right breast and a sentinel node biopsy. Pathological findings revealed a tumor consisting of lobular carcinoma with a component containing many signet-ring cell carcinoma, and micrometastasis to the sentinel lymph nodes. Immunohistochemically tumor cells were GCDFP-15-positive and E-cadherin-negative. We diagnosed this case as primary signet-ring cell carcinoma derived from lobular carcinoma. She was followed by postoperative chemotherapy, radiation, and chemoendocrine therapy. We reviewed the cases of primary signet-ring cell carcinoma derived from lobular carcinoma from the Japanese literature with consideration of the characteristics.

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A case of a 39-year-old man, whose chest computed tomography (CT) during a health examination, pointed to a nodule with calcification in the left upper lobe. After 6 months, the nodule was diagnosed as an inflammatory nodule because the size of the nodule had not changed. After 4 years from the initial health examination, a positron emission tomography (PET-CT), showed that the nodule was enlarged and he was admitted in our department of surgery because lung cancer was suspected. Partial lung resection which included the calcificated nodule was performed in video assisted thoracoscopic surgery, and the resected specimen was examined pathologically. There were no malignant findings. The final pathological diagnosis was dendriform pulmonary ossification, because there were bone trabeculae with bone marrow in the lung interstitium.

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Spontaneous rupture of the esophagus still remains a life-threatening disorder, requiring urgent surgical intervention. Although primary closure of the perforation site is considered, poor general conditions of the patient and fragility of the lacerated esophageal wall make the procedure very dangerous. We performed transthoracic T-tube esophagostomy with thoracic drainage using thoracoscopic and endoscopic techniques for two elderly poor-risk patients. After the fistula formation was accomplished, the T-tube was removed inward to the stomach via gastrostomy and replaced by a straight thoracic tube, phased out slowly. This method is simple and less-invasive without need for time-consuming deep-site measures, nor differential lung ventilation, and can be a reliable alternative in treatment of esophageal perforation.

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We report a case of superficial esophageal cancer surgically treated by mediastinoscope-assisted transhiatal esophagectomy in an aged man who had undergone left thoracoplasty. An 84-year-old man who had received yearly upper gastrointestinal endoscopic examination was admitted to our hospital with a diagnosis of superficial esophageal cancer infiltrated into the submucosa. He had been performed left thoracoplasty in his youth, and he had restrictive impairment in preoperative respiratory function test. We performed mediastinoscope-assisted transhiatal esophagectomy for superficial esophageal cancer in clinical stage I. The surgical space in the mediastinum had been narrowed because of the thoracoplasty, but esophagectomy could be performed safely and successfully, though we had a hard time with dissecton of the esophagus.

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A case of repetitive gastric perforation is presented. A 57-year-old woman developed acute abdominal pain, and free air was detected in the abdomen on computed tomography (CT) scan. The patient was given an antibiotic intravenously ; while the patient was fasting, total parenteral nutrition was administered. This scenario was repeated three times in nine months. Wedge resection of the stomach and abdominal drainage were performed because an intra-abdominal abscess was detected on CT scan during the third episode. The patient was discharged without postoperative complications on the 11th day after surgery. No specific inflammation or cause of perforation was detected on histopathlogy ; chronic fistula formation after endoscopic treatment for a hemorrhagic ulcer was the suspected cause of the gastric perforation.

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A 69-year-old woman was seen at the hospital because of general fatigue, appetite loss, and newly developed fever and cough lasting for two days. As blood examination showed high degree of inflammatory reaction, she was admitted to the hospital. Antibiotics were ineffective for inflammatory reaction and the patient began to complain of abdominal pain when she moved. She was thus referred to our department. On palpation, a tumor was felt at the midline of the upper abdomen, and there was tenderness at the same area. Ultrasonography and CT of the abdomen revealed a 10×8 cm intraperitoneal abscess adjacent to the gastric wall of the upper abdomen and a 2.5-cm diameter linear shadow of hyper absorption in the abscess. Upper gastrointestinal endoscopic study showed large quantities of residual foods in the stomach, but any foreign body, ulcer, or perforated site was obscure. Laparotomy disclosed an abscess covered with the greater omentum which lay between the stomach and the transverse colon. The abscess could be dissected from the transverse colon but it was communicated with the gastric wall, so that removal of the abscess with associated resection of part of the greater curvature of the gastric antrum was performed. The resected specimen was 11×10×6 cm in size and involved a fish bone, extensive abscess, and purulent fluid.
Here we report a case of an intraperitoneal abscess which had been formed by perforation of the stomach due to a fish bone which was incidentally ingested.

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A 74-year-old man was admitted to our institution for treatment of a tumor in his upper abdomen. Endoscopy revealed a Borrmann type 3 tumor in the antrum. Biopsy of the tumor specimen showed moderately differentiated tubular adenocarcinoma. Therefore, distal gastrectomy and partial resection of the transeverse colon were performed. Pathological examination of the tumor revealed that the tumor was moderately differentiated tubular adenocarcinoma focus of the neuroendocrine carcinoma, which showed positive results for chromogranin A and synaptophysin in an immunohistological examination. Therefore, the patient underwent postoperative oral chemotherapy with TS-1 after being discharged and has remained free from recurrence. Here, we report a rare case of a patient with synchrous neuroendocrine cell carcinoma and moderately differentiated tubular adenocarcinoma of the stomach, and review the related literature.

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An 80-year-old man with mild anemia was found to have multiple protruding tumors in the upper and middle gastric body on upper gastrointestinal endoscopy. The biopsy specimen revealed adenocarcinoma. He underwent total gastrectomy and splenectomy with a Roux-en-Y reconstruction. Macroscopic findings of the resected specimen included four polypoid tumors in the gastric body. On pathology of the upper gastric tumor, a carcinosarcoma with an intimately mixed adenocarcinoma and a spindle-shaped sarcomatous component was diagnosed. The middle gastric tumors were intramural metastases composed of sarcomatous elements with spindle-shaped cells. A microscopic lymph node metastasis with adenocarcinoma cells was seen in the right paracardial lymph node. Postoperatively, the patient developed a superior mesenteric artery occlusion. In spite of an emergency operation and intensive care, he died on the 64th postoperative day. Based on the results of the autopsy, gastric carcinosarcoma with intimal metastasis in the aorta and sarcomatous elements with spindle cells in the intima of the descending aorta were diagnosed. This is the first case report of a gastric carcinosarcoma with intramural metastases composed of a single sarcomatous component. Furthermore, the sarcomatous elements of gastric carcinosarcoma had spread to the intima of the aorta.

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A 29-year-old man presented with dysphagia. Upper gastrointestinal endoscopy revealed a type-2 gastric cancer ; based on the pathology of a biopsy specimen, a moderately differentiated adenocarcinoma was diagnosed. Laboratory tests indicated leukocytosis (38,800/μl), but no evidence of infection was observed. The serum granulocyte-colony stimulating factor (G-CSF) level was elevated, thus a G-CSF-producing gastric cancer was suspected. A total gastrectomy was performed. On pathology, the tumor was T4a(SE), N2, H0, P0, CY0, M0, Stage III B, and G-CSF immunohistochemical staining was positive. After the operation, both the leukocyte count and the serum G-CSF level decreased. Metastases in the liver and lymph nodes were detected 3 months after surgery. Chemotherapy (1st : TS-1/docetaxel, 2nd : CDDP/CPT- 11) proved ineffective, and the patient died 7 months after surgery ; his highest leukocyte count level was 148,800/μl.

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In cases of isolated Virchow's node recurrence after resection for gastric cancer surgical therapy and chemotherapy may occasionally improve survival. A 76-year-old man who underwent total gastrectomy with splenectomy because of type 3 advanced gastric cancer, which was pathologically wrative, in May 1997, underwent adjuvant chemotherapy. Left supra-clavicular lymph-node swelling was observed 1 year and 1 month after the operation. Two swollen lymph nodes were surgically resected because no other site of distant metastasis was found. Pathological test revealed 2 Virchow's nodes due to gastric cancer metastasis. One year and 5 months after gastrectomy, two swollen Virchow's nodes were found again, and were removed as metastatic lymph nodes. The Virchow's because of self-metastasis. In 2 years and 10 months after gastrectomy, Virchow's node metastasis recurred 3 times, necessitating resection of 3 Virchow's nodes. The patient is alive 12 years and 8 months after recurrence.

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A 66-year-old woman was seen at the hospital because of a 3-day history of epigastralgia. The abdomen was board-like and there was rebound tenderness in the entire abdomen. On blood biochemical examinations, WBC was 12,400/μL and CRP was 0.40 mg/dl, showing increased inflammatory reaction. Abdominal CT scan revealed intraperitoneal free air and ascites. Panperitonits due to upper gastrointestinal perforation was likely and emergency operation was performed on the same day. Upon laparotomy, each about 2-cm diameter perforation was demonstrated at the anterior and at the posterior wall of the duodenal bulb, respectively. Simultaneous perforation of the kissing ulcers was diagnosed. Omentoplasty was tried for the each perforation, but fixation of the omentum to the perforation at the posterior wall was difficult. So the greater omentum which had filled the perforation at the anterior wall was removed, the omentum was filled into the duodenum through the posterior wall perforation, and then this filled omentum was pulled out from the anterior wall perforation to the outside of the duodenum, followed by suture with the anterior wall. As the filled omentum entailed a risk of inducing passage disturbance, gastrojejunostomy and Braun anastomosis were added. The patient's postoperative course was uneventful and she was discharged from the hospital on the 21^st postoperative day.

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Case 1 : A 53-year-old man was on hemodialysis for diabetic nephropathy. He developed abdominal pain after dinner, which worsened thereafter. On the following day, he was brought to our hospital before dawn. Computed tomography showed hepatic portal venous gas. A necrotic small intestine was suspected, and an emergency operation was performed. The operative findings included a segmental necrotic small intestine. The necrotic small intestine was resected. The histopathological examination of the resected specimen did not show thrombi in the blood vessels. Nonocclusive mesenteric ischemia (NOMI) was diagnosed.
Case 2 : A 58-year-old man required hemodialysis for chronic renal disease. He was admitted to the cardiovascular surgery department of our hospital for arteriosclerosis obliterans. He experienced abdominal pain at midnight, which worsened thereafter. Computed tomography showed gas in the branches of the superior mesenteric vein and the small intestine wall. Necrotic small intestine was suspected, and an emergency operation was performed. The operative findings included segmental necrotic small intestine. The necrotic small intestine was resected. The histopathological examination of the resected specimen did not show thrombi in the blood vessels. NOMI was diagnosed. Hemodialysis patients have a high risk of NOMI. Therefore, the possibility of NOMI should be considered in hemodialysis patients.

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A 61-year-old woman complained of general fatigue. She was admitted to internal medicine for gastrointestinal tract investigations since a severe anemia and fecal occult blood were found. After admission, she developed a bowel obstruction. Abdominal CT showed a tumor with interior calcification at the left lower abdomen ; dilatation of the oral small intestine was present. A long tube was inserted, and she was referred to the surgery department. The small intestine examination was done. She was diagnosed as having a bowel obstruction caused by a small intestinal tumor, and surgery was performed. The tumor was located at the small intestine and developed extramurally ; it measured 7×4 cm. The tumor adhered to the omentum and the mesentery of the sigmoid colon. The omentum was partially resected, and the mesentery could be separated without dissecting the vessels. A partial resection of small intestine was done, and the tumor was extirpated. On pathology, the tumor was diagnosed as a cavernous hemangioma.
An intestinal hemangioma is rare ; it accounts for 0.05% of all gastrointestinal tumors and 7-11% of small intestine benign tumors. In this paper, we present a case of a small intestinal hemangioma presenting with anemia and bowel obstruction.

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An 80-year-old woman was transported to our hospital due to lower abdominal pain and vomit, and was found on physical examination to have abdominal distension. Abdominal computed tomography (CT) scan showed a markedly dilated colon and ischemic change of the colon wall. Blood analysis showed metabolic acidosis and serum CEA was elevated to 559.1 ng/ml. Suspecting necrosis of the colon, we conducted a laparotomy. The operative finding showed necrotic change of the ascending to descending colon, and we performed a subtotal colectomy and ileostomy.
Pathological findings showed gangrenous ischemic colitis. In immunohistochemical analysis, the pattern of CEA indicated inflammatory bowel disease. Serum CEA level normalized to 2.4 ng/ml on the 16th hospital day and the patient was discharged on the 34th hospital day. The mechanism of elevated serum CEA is responsible for dysfunction of the drain system for CEA in the mucosal epithelium. It is necessary to consider that ischemic colitis can cause elevation of serum CEA, especially in aged patients with acute abdomen.

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A 55-year-old woman was treated with infliximab for rheumatoid arthritis. She experienced general fatigue, and the results of a blood test showed worsening of anemia. Therefore, colonoscopy was performed, it showed an ulcerative lesion in the terminal ileum. A biopsy was performed, and a diagnosis to the of intestinal tuberculosis was made on the basis of biopsy findings. The results of chest CT were compatible with the findings associated with miliary tuberculosis. Sputum TB-PCR showed positive results for intestinal tuberculosis as well as miliary tuberculosis. Therefore, the patient was admitted to the hospital with a diagnosis of tuberculosis. From that time, she experienced increasing abdominal pain and frequent diarrhea. After adequate treatment of TB, she was referred for increased abdominal pain. CT showed cicatricial stenosis of the cecum, and surgery for the treatment of an ileorectal fistula was suggested. Ileocecal resection and rectal fistula closure were performed. She was discharged after 17 days without any major complications. Infliximab is known to aggravate tuberculosis, but reported cases of intestinal fistula formation are rare.

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A 57-year-old man referred for epigastragia was found on endoscopic examination to have a submucosal tumor in the lower thoracic esophagus. Esophagectomy with gastric tube reconstructuion was performed in October 2001. The histopathological diagnosis was GIST and because the tumor size was 5 cm, with 50 mitoses per 50 HPF, the tumor was considered to be a high-risk GIST (c-kit(+), CD34(+),α-SMA(+)). He came to our hospital with complaint of pain on his right upper arm and was found to have an upper arm bone tumor. So we performed a bone resection in April 2010. Hisotopathological examination was metastatic GIST with >50 mitoses per 50 HPF (c-kit(+), CD34(+), α-SMA(-)). He was found on abdominopelvic CT to have a cystic intrapelvic tumor and underwent an operation in August 2010. The tumor was found on the jejunum at 40 cm on the distal side from the Treiz ligament with extraluminal growth, and was resected by wedge excision. Histopathological diagnosis was a moderate-risk GIST because the tumor size was 6 cm, 2 mitoses per 50 HPF, c-kit(+), CD34(-), and α-SMA(+). Histopathological and immunohisitochemical findings suggested that the bone metastasis was a recurrence of the primary esophageal GIST 9 years after the esophagectomy and the intestinal GIST was a second primary tumor.

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A 60-year-old male was admitted with abdominal pain, abdominal distension, and vomiting ; ileus was diagnosed. The CT scan revealed stenosis in the descending colon, and ileus caused by colon cancer was suspected, but on endoscopy, no tumor was found in the colon. Barium enema radiography demonstrated a narrow sigmoid-descending colon segment. The ileus did not improve with conservative therapy. At laparotomy, operative findings revealed a narrow colon segment, and sigmoidectomy was performed. On histology, a remarkable reduction in the number of ganglion cell of Auerbach's and Meissner's plexuses was noted in the segment ; ileus related to adult segmental hypoganglionosis of the colon was diagnosed. Few cases of adult segmental hypoganglionosis have been reported, and we present this case with a review of the literature.

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We report a 55-year-old woman with a port site recurrence of ascending colon cancer after laparoscopic surgery. She underwent a laparoscopic right hemicolectomy in 2009. On pathlogy, well differentiated adenocarcinoma pSS, n0, ly1, v1, pPM0, pDM0, pstage II was noted. After the operation, chemotherapy was given for 6 months. In 2011, tumor marker levels became elevated. PET-CT showed a hot spot in the left upper abdominal wall. A port site recurrence was diagnosed and an en bloc excision of the abdominal wall tumor was done. Currently, the patient has no recurrence.

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We report our experience with a colorectal cancer case showing an abdominal wall recurrence with herniotomy using composix mesh 3 years after enforcement. The patient was a 74-year-old man. Sigmoidectomy was performed for sigmoid colon cancer in December 2006, followed by hernioplasty using composix mesh for an abdominal incisional hernia 8 months later. We performed abdominal computed tomography (CT) because of mesogastralgia in December 2010 and suspected an abdominal wall recurrence. A mass biopsy was performed for diagnostic purposes, and showed moderately differentiated adenocarcinoma. The site showed accumulation in fludeoxyglucose (18F), positron emission tomography (FDG-PET), and metastasis of sigmoid colon cancer was diagnosed. The tumor showed a reduction tendency when two courses of bevacizumab + IRIS were administered, and no new metastases were found even when PET was performed again. We resected an abdominal wall tumor in May 2011. Adenocarcinoma had spread through the body surface side of the sample from the mesh, but the stump was negative. Abdominal wall recurrence of colorectal cancer developing on a mesh is thought to be rare as there are few reported cases.

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A 57-year-old woman underwent an abdminoperineal resection for rectal cancer 14 yeas ago. The patient visited our hospital because of a gradually increasing tumor at the colostomy site. The tumor at the colostomy site measuring 4 cm had an irregular surface, and a biopsy indicated of adenocarcinoma, but a computed tomography (CT) scan suggested no metastasis. We performed a partial resection, including the stoma and the surrounding skin, and reconstructed a colostoma at the same place. She is still alive without recurrence, as of one year after the operation. Carcinoma rarely occurs at a colostomy site. We propose that we should conduct long-term follow up with patients who have undergone an operation for colo-rectal cancer and consider the facts case-by-case when we operate for adenocarcinoma arising at a colostomy site.

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We report a case of G-CSF producing ascending colon cancer. A 44-year-old man visited the hospital because of pyrexia and right hypochondralgia, and was admitted for examination of a high inflammatory score.
Multiple liver tumors and ascending colon wall thickening were observed, but infectious diseases were ruled out by computed tomography(CT). We diagnosed the condition as ascending colon cancer based on colonoscopic examination. Right hemicolectomy and biopsy of the liver were performed, and was ultimately diagnosed as G-CSF producing colon cancer and multiple liver metastases based on the histopathological examination.
After the operation, pyrexia and the high inflammatory score continued. His general condition was getting worse, but we initiated chemotherapy (mFOLFOX6) because of his family's request, and combined with bevacizumab from the 3rd course. The patient left the hospital because his condition went into remission after the 4th course of chemotherapy, and continued the treatment as an outpatient. But he was rehospitalized for general fatigue presently. After admission, he lost consciousness suddenly and was diagnosed as having a serious cerebral infarction. A few days later he died, 4 months after the surgery.

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Leiomyomas arising from the anal canal are rare and so far only one case of the disease has been reported in Japan. Furthermore, FDG-PET-positive leiomyoma in the digestive tract has little been reported. We report a rare case of a leiomyoma arisen in the anal canal showing abnormal FDG uptake on FDG-PET scan.
A 36-year-old woman was admitted to our hospital because of a gradually enlarging anal mass for these three months that had first been noticed 2 years earlier. She complained of frequent defecation and dyschezia. An elastic hard mass 3 centimeter in size was palpated under the anal mucosa and skin. FDG-PET showed abnormal FDG uptake in an area where was identical with the tumor site. We resected the tumor including a part of the internal anal sphincter muscle. The tumor was elastic-hard and 3.5×2.5 cm in size. The pathological diagnosis was leiomyoma originated from the internal anal sphincter muscle.
The anal function was improved and dyschezia disappeared after the operation.

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A 63-year-old man was under observation after the resection of a stomach cancer. Abdominal computed tomography showed a low-density region, 8 mm in diameter, at segment 7 of the liver. Qualitative diagnosis was difficult, and the patient's clinical course was monitored. Six months later, the size of the low-density region increased to 25 mm. Malignant tumor was suspected, and partial resection of the liver (S7) was performed. Hepatic angiosarcoma was diagnosed on the basis of postoperative pathological examination. Because the surgical margin of the tumor was positive, right lobectomy of the liver was performed after 3 weeks. Two months later, recurrence was detected in the remnant liver ; diffuse small metastatic lesions appeared 5 months after the operation. Continuous arterial infusion of recombinant interleukin-2 was administered, and a partial response was obtained temporarily. However, the tumor recurred immediately, and the best supportive care was given. Although the tumor gradually increased in size, the patient's general condition was good for a long period. Around 1 year 9 months after the operation, the tumor began to grow rapidly, and liver dysfunction occurred. Two years 8 months after the onset, the patient died of hepatic failure.

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Chylous ascites after living donor liver transplantation (LDLT) is a rare complication that may result in serious nutritional and immunological problems for the recipients due to loss of proteins and lymphocytes. In this article, we report two cases of chylous ascites after LDLT. In case 1, a 55-year-old woman who underwent LDLT for primary biliary cirrhosis developed chylous ascites 4 weeks after the transplantation. Treatment by fasting and total parenteral nutrition (TPN) resulted in slow resolution of the ascites, but it took about 9 weeks. In case 2, a 43-year-old man who underwent LDLT for liver cirrhosis caused by hepatitis B virus and alcohol abuse developed chylous ascites 9 days after the transplantation. Treatment by fasting, TPN, and octreotide resulted in rapid resolution of the ascites within 4 weeks. Octreotide and TPN are an effective option for the treatment of chylous ascites after LDLT.

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A 64-year-old woman who had been treated in a hospital with the diagnosis of cholelithiasis with acute cholecystitis was seen at our hospital after the treatment for the purpose of cholecystectomy. Abdominal contrast-enhanced CT scan and MRI performed before surgery disclosed a gallstone which had impacted in the head of the gallbladder to compress the posterior segmental branch. Since blood examinations revealed elevations of hepatobiliary enzymes, Mirizzi syndrome was diagnosed. Endoscopic retrograde cholangiopancreatography (ERCP) for close exploration revealed fistula formation at the gallbladder and the posterior segmental branch. Preoperative placement of an ENBD tube enabled us to see the fistula directly and to perform surgery safely. The fistula was closed by suture using a part of the gallbladder wall. No postoperative infectious signs occurred and her postoperative course was uneventful.
Cholangiography is essential before surgery for Mirizzi syndrome. So far no reports on fistula formation at the gallbladder and the posterior segmental branch have been presented in the web Japan Medical Abstracts Society as far as we could review. In this case our device in that the fistula is closed with sutures by using the gallbladder wall was necessary.

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The first case was a 77-year-old woman. She had upper abdominal pain, and imaging tests showed cholangiocellular carcinoma of intraductal growth type in the left lateral posterior segmental bile duct (B2). We performed a left hepatectomy, preserving the caudate lobe. The resected specimen showed a light yellow soft tumor measuring 35 mm. Histological examination showed the tumor was an intraductal papillary neoplasm of the bile duct (IPNB). It contained a lesion consisting of carcinoma in situ. The second case was a 65-year-old woman. She had a fever, and imaging tests showed a mucin-producing cholangiocarcinoma in the left lateral anterior segmental bile duct (B3). We performed a left hepatectomy, preserving the caudate lobe. There was light yellow mucus in the dilated B3. Histological examination showed IPNB in B3. Recently IPNB is recognized as the biliary counterpart of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. We report these two cases of IPNB in B2 and B3, and review the relevant literature.

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A 79-year-old man was referred to our hospital for close examinations of macrohematuria. Computed tomography (CT) revealed incidentally a solid and cystic tumor in the head of the pancreas with partial enhancement in the solid component, in addition to a renal tumor. Ultrasonography showed a 5-cm solid and cystic mass. Magnetic resonance imaging (MRI) revealed a hypointens mass on T1-weighted images and a heterogenous hyperintens mass on T2-weighted images. The lesion showed high 18F-fluorodeoxyglucose (FDG) uptake. He underwent a subtotal stomach-preserving pancreatoduodenectomy under a tentative diagnosis of malignant cystic neoplasm of the pancreas. The cut surface of the resected specimen showed a well-demarcated solid and cystic tumor within the pancreas parenchyma. Histopathological examination of the tumor revealed proliferation of the spindle cells showing interlacing and palisading patterns. Immunohistochemically, these spindle cells were positive for S-100 protein. As a result, the tumor was diagnosed as a pancreatic schwannoma. Although it is a rare type of lesion, pancreatic schwannoma should be considered in the differentiated diagnosis of cystic neoplasm of the pancreas.

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A 61-year-old man was admitted due to jaundice and upper abdominal discomfort. CT and MRI indicated the presence of a tumor in the lumen of the descending duodenum and dilation of the common bile duct. Gastro-intestinal endoscopy indicated an elevated tumor at the minor duodenal papilla. An interruption in accessory pancreatic duct flow and compression of the lower bile duct were observed on ERCP. The biopsy indicated a moderately to poorly differentiated tubular adenocarcinoma ; a pancreaticoduodenectomy was performed. On pathology, the 3.3 cm in diameter carcinoma, had invaded into the pancreas, duodenum, perineural space, and lymph nodes. There are only a few reported cases of carcinoids, adenocarcinomas, neuroendocrine tumors, and other tumors occurring at the minor duodenal papilla. Since the physiological environments of the major and minor duodenal papillae differ, the therapeutic strategy adopted for tumors at the minor duodenal papilla should be carefully considered with respect to both its genesis and histology.

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The case involved a 77-year-old woman who underwent low anterior resection of the rectum for rectal cancer in March 2006 and lobectomy of lung for pulmonary metastasis in July 2007. No adjuvant chemotherapy was added after the lung resection. Abdominal CT scan performed in June 2011 revealed swelling of the pancreas tail, and FDG-PET was positive. Cancer of the pancreas tail was diagnosed and resection of the pancreas tail and body with associated resection of the spleen was performed. Pathology revealed findings characteristic of adenocarcinoma of the rectum and perineural infiltrating features which should be seen in pancreatic cancer were obscure, so that metachronous pancreatic metastasis after surgery for rectal carcinoma was diagnosed.
Cases of pancreatic metastasis of rectal carcinoma which can be candidates for surgical resection are often detected when more than five years have elapsed after resection of the primary cancer nest. Long-term clinical observation would be mandatory.

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A 60-year-old woman presented for breast cancer screening. Computed tomography showed a 50-millimeter, isolated splenic mass. There were no other lesions in any other organs. A splenic malignant lymphoma was suspected. To confirm the diagnosis, a laparoscopic splenectomy was done. The histological findings revealed a non-caseating epithelioid cell granuloma similar to a sarcoidosis. However, further testing and clinical findings did not fulfill the diagnostic criteria for sarcoidosis ; nevertheless, the patient's findings were similar to those of sarcoidosis. Therefore, the patient requires careful long-term follow-up ; in particular, organs such as the heart and lungs require vigilant assessment. A case of splenic sarcoidosis without extrasplenic lesions is extremely rare. There have been only a few reported cases in Japan.

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Parasitic leiomyoma is a type of myoma of the uterus that separates from the uterus and adheres to other abdominal organs. A case of parasitic leiomyoma that adhered to the small intestine and required partial resection of the ileum to achieve complete extraction of the tumor in a 51-year-old woman is reported. The patient was admitted to our hospital for lower abdominal pain. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a tumor in the upper left of the uterus. A myoma of the uterus and a left ovarian tumor were suspected, and surgery was performed. During the operation, a soft, solid, brown-colored tumor was found. It adhered to the ileum and its mesentery and had no continuity with the uterus or the ovary. The tumor was removed with a part of the ileum. Postoperative histopathological examination revealed that the tumor was a parasitic leiomyoma.

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A 63-year-old man was admitted to the hospital because of a 3-day history of severe right lateroabdominal pain and persistent diarrhea lasting for half a month. Enhanced abdominal CT scan showed a pericecum abscess. The pain was localized at the right lower quadrant of abdomen, with tenderness, muscle guarding and rigidity. We thus diagnosed the case as localized peritonitis caused by perforation of the appendix. He had an emergency operation for abdominal abscess and ileocecal resection was done. Desmoid tumor was diagnosed based on postoperative histologial examination that was supported by positive immunohistochemical stainings for vimentin and β catenin. The postoperative course was uneventful and he was discharged on the 14^th postoperative day. There has been no evidence of recurrence for 23 months.
Desmoid tumors after recur in a high rate even after complete resection and further careful follow-up would be necessary.

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We report a case of bile peritonitis due to bile leakage through the gallbladder, not associated with perforation. A 59-year-old man with upper abdominal pain was admitted to our hospital. We suspected panperitonitis due to upper gastrointestinal perforation, and an emergency operation was performed. Laparotomy showed biliary ascites around the gallbladder without cholecystic perforation nor inflammation, and no abnormal hepatic, common bile duct, or upper intestinal findings were made. We considered the possibility of bile leakage through the gallbladder, and performed a cholecystectomy. Histopathologically, the wall of the gallbladder showed thinning but no perforation or necrosis. Only 18 such cases, including our case have been reported in Japan.

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Desmoid tumors commonly occur in women, and it has been shown that the development and progression of desmoid tumors are associated with pregnancy and estrogen. We report the case of a woman found to have an abdominal desmoid tumor after the first month postpartum. A 32-year-old woman was referred to our hospital due to an enlarging left inguinal mass after delivery. General physical examination revealed a large, firm, fixed, and painful mass. Computed tomography (CT) and ultrasonography (UT) demonstrated an enhanced mass (8×5 cm in diameter) attached to the fascia of the left inferior rectus abdominis muscle. Malignancy could not be ruled out preoperatively. The tumor was arisen from the left rectus abdominis muscle, and was radically excised with the left rectus abdominis muscle and fascia. The histopathological and immunohistochemical examination demonstrated an estrogen receptor positive desmoid tumor. No recurrence was found at the 1-year follow-up. This report presents that the growth of desmoid tumors is associated with pregnancy and estrogen.

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The case involved a 36-year-old woman who had undergone cesarian section 10 years earlier when an 8-cm diameter myoma of the uterus was pointed out. In about September 2008, she began to feel something wrong at the right buttock and developed numbness of the lower limbs, and she was referred to our hospital in April 2009. Abdominal CT scan showed a 13-cm diameter well-demarcated tumor at the anterior aspect of the sacrum, which had encircled about two-to-third of the circumference of the coccyx. A biopsy of the tumor was done from the side of the coccyx and ganglioneuroma was diagnosed. Though it was a benign tumor pathologically, surgery was performed in August 2009, because it had been increasing, symptoms appeared, a possibility of malignancy could not be ruled out only by biopsy findings, and there were some reports on malignant change of ganglioneuroma. At surgery, the anterior surface of the tumor was loosely adherent to the surrounding organs so that the intestine could be preserved. The back surface of the tumor was hard where was suggestive of tumor invasion. Associated resection of the forth sacrum and below was thus performed. The resected specimen was a 13 × 9 × 7.5 cm solid tumor covered with a capsule. The histopathological diagnosis was matured type ganglioneuroma with parts showing disappearance of bone parenchyma and progression to the bone marrow.

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A 58-year-old man who visited a local clinic complaining of vomiting was referred to our hospital for further evaluation and treatment. His entire abdomen was slightly distended, and a 10-cm swelling was observed in the right inguen and scrotum. Abdominal X-ray showed dilation of the small bowel. Abdominal CT scan showed intestinal loops in the right inguinal hernia, which caused bowel obstruction. He was diagnosed as having an incarcerated right inguinal hernia. After manual reduction in our clinic, he was admitted to our hospital for observation. Three hours after the reduction, the right inguinal hernia recurred. The patient could not be treated by manual reduction this time ; therefore, emergency surgery was performed. It was an indirect hernia, and the proximal part of the ascending colon, cecum, appendix, and terminal ileum had passed through the hernia entrance. Bowel resection was not performed because the intestine showed no evidence of necrosis. The hernia was repaired using the ULTRAPRO Hernia System (UHS). No complications occurred following surgery, and the patient was discharged 6 days later. An incarcerated ileocecum in an inguinal hernia is rare, and so far only 17 cases have been reported in Japan.

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A 77-year-old woman was referred to our hospital because of gastric cancer with epigastralgia and anemia. Thoraco-abdominal contrast-enhanced CT scan showed wall thickening of the transverse colon, a tumor shadow in the left upper lung field and a right breast tumor. We confirmed the diagnosis of gastric cancer and colon cancer by biopsies using endoscopy. Needle aspiration biopsy cytology revealed breast cancer. The tumor shadow in the left upper lung field was diagnosed radiologically with adenocarcinoma. But observation of the clinical course was employed for the lung lesion by the patient's request. Distal gastrectomy and transverse colectomy were performed in November 2008. Right mastectomy and axillary lymph nodes dissection were performed in March 2009. After an 18-month course observation, the lung tumor was recognized to grow. Left upper lobectomy of the lung was thus performed in May 2010. Histologically, the gastric tumor was well differentiated adenocarcinoma, the colon tumor was well differentiated adenocarcinoma, the breast tumor was scirrhous carcinoma, and the lung tumor was adenocarcinoma with mixed subtype. So curative resections were achieved for synchronous quadruple cancer. She has been well without any signs of recurrence for 3 years after the first operation.

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