No consensus has been reached regarding treatment methods for recurrent inguinal hernia. Treatment methods were investigated by analyzing 64 cases of recurrent inguinal hernia treated at our department.
A total of 34 patients had recurrence after undergoing conventional surgery. The type of recurrence was indirect inguinal hernia in 22 patients and direct inguinal hernia in 12 patients, while the type of surgery for the recurrence was the plug procedure in 19 patients and inlay methods such as the direct Kugel patch method in 15 patients. A total of 30 patients had recurrence after undergoing mesh placement. The type of recurrence in these patients was indirect inguinal hernia in 3 patients, direct inguinal hernia in 20 patients, and femoral hernia in 7 patients, indicating a different pattern of recurrence than after conventional surgery. The type of surgery for the recurrence in these patients was the plug procedure in 25 patients and the direct Kugel patch method in 4 patients, with one patient undergoing conventional surgery combined with intestinal resection. As of a mean of 7.8 years postoperatively, no further recurrences have occurred. Indirect inguinal hernia was common among cases of recurrence following conventional surgery, while direct inguinal hernia and femoral hernia were common among cases of recurrence following mesh placement. As for the type of surgery, the inlay method was used in cases in which the preperitoneal cavity could be detached widely, while placement of plugs of other devices in the orifice of the recurrent hernia was often performed in cases in which the preperitoneal cavity had become scarred.

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Petersen's hernia is an internal hernia that is peculiar to the patient who underwent gastrectomy with Roux-en-Y reconstruction. It develops when the small intestine herniates through the Petersen's defect, a mesenteric defect of the transverse mesocolon. It is likely to be caused by laparoscopic surgery because of fewer adhesions than celiotomy. Between January 2008 and December 2011, we experienced six cases (five patients) of the disease. All the patients underwent laparoscopy-assisted distal gastrectomy with Roux-en-Y reconstruction. In all the cases, abdominal computed tomography showed dilatation of a part of the small intestine involving periphery of the superior mesenteric artery (whirl sign), causing obstruction. We performed repair of the internal hernia, strangulation of the ileus, and suture of the Petersen's defect to prevent relapse of the disease. All the patients did not show obvious bowel necrosis. Their postoperative courses were uneventful, and all the patients were discharged.
Now in our hospital we suture the Petersen's defect preventively at Roux-en-Y reconstruction, and the patients treated by the suture have not developed the disease to date. As laparoscopic gastrectomy has increasingly been performed, Petersen's hernia is expected to increase. It is important to conduct abdominal CT scanning as early as possible from the clinical history and physical findings, and to determine the surgical indication.

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A postoperative pancreatic fistula continues to be a common complication after pancreatoduodenectomy. Although most fistulas occur in the perioperative period and are caused by leakage of the pancreaticoenteric anastomosis, a delayed pancreatic fistulas may sometimes occur in the follow-up period after US-guided drainage of a perianastomotic pseudocyst. These fistulas usually heal spontaneously with conservative treatment. However, some develop into a persistent external pancreatic fistula as a result of a complete dehiscence of the pancreaticoenteric anastomosis. In such cases, conservative management with radiological and endoscopic intervention is now more frequently employed ; this sometimes results in a prolonged hospital stay and increased costs. On the other hand, early repeat laparotomy and surgical repair are rarely instituted in these cases, because it is thought that surgical intervention may be associated with a high postoperative complication rate and technical difficulties. We report 3 cases of delayed pancreatic fistula successfully treated with repeat laparotomy and repair of the pancreaticojejunostomy. The results indicate that early surgical intervention is preferable for treating a delayed pancreatic fistula.

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Obturator hernia is a rare disease, which commonly occurs in thin, elderly women. Conventionally surgery for the hernia was performed by abdominal approach, but recently an inguinal approach has been increasingly performed as a less-invasive procedure. In our hospital, we have experienced eleven consecutive cases of obturator hernia operated on via the inguinal approach. The average age of the patients was 83.8 years, the average BMI was 16.9, and ten of the patients were women. Preoperative computed tomography (CT) scan revealed obturator hernia in all patients. The operations were performed by an inguinal approach and a Direct Kugel Patch was inserted in the preperitoneal cavity. The average operating time was 76 minutes, and only two cases required bowel resection. One case of pneumonia and one case of pelvic fracture were recognized as a postoperative complications. The average postoperative hospital days was 12.3 days. The inguinal approach is less-invasive, and supports early recovery. The inguinal approach is considered to be a standard operative procedure for obturator hernia except for generalized peritonitis cases.

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Granulomatous mastitis (GM) is a rare disease characterized by infiltration of multinucleated giant cells and inflammatory cells, and its relationship to Corynebacterium kroppenstedtii (C. kroppenstedtii) infection has recently been reported. The case of a patient who was diagnosed with GM after C. kroppenstedtii was identified on bacterial culture of the cytology sample is reported. The patient was a woman in her thirties who visited our department due to induration that remained after administration of antibiotics for a diagnosis of mastitis. A small amount of pus was collected on cytology, and C. kroppenstedtii was identified on bacterial culture. GM was diagnosed based on needle biopsy. The GM resolved with antibiotic administration and incisional drainage, and no recurrence has been observed after one year. While C. kroppenstedtii has attracted attention as a causative agent of GM, it is often difficult to identify under normal culture conditions. It was considered necessary in the treatment of mastitis to conduct appropriate tests for C. kroppenstedtii infection.

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Cowden disease is a rare autosomal dominant inherited disorder with variable expression including characteristic mucocutaneous lesions and hamartomatous neoplasms of the whole body. It is well known that the disease is associated with malignant neoplasms in a high incidence in patients past middle age. Recently we have experienced a case of Cowden disease in a postmastectomy patient for breast cancer in whom we found and resected an associated thymic tumor and adenomatous goiter. The patient was a 46-year-old woman. At the age of 23 years when she was treated for diabetes mellitus, she was identified to have multiple small papules on the face and keratotic papules in the body. In addition she had been associated with intestinal polyps and papilloma of the tongue and the pharynx since earlier. Cowden disease was diagnosed based on findings of resected specimen of a nasal papule and a gene analysis at the age of 38. Mastectomy was performed for left breast cancer at the age of 45, when a cystic tumor at the anterior mediastinum and a right pulmonary nodular shadow were disclosed by a chest CT scan. FDG-PET revealed slightly abnormal uptake of fluorodeoxyglucose in the anterior mediastinum. Thymoma was suspected and total thymectomy + total thyroidectomy + partial pneumonectomy were simultaneously performed. The histopathological diagnosis was multiple thymic cysts, adenomatous goiter, and pulmonary hamartoma. The patient's postoperative course was uneventful and she has been followed in our clinic.

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We report a case of primary osteosarcoma of the breast, which is a rare histological type of all breast tumors. A 50-year-old woman was admitted to our hospital because of a rapidly growing tumor in her right breast. The serum level of alkaline phosphatase (ALP) and that of vascular endothelial growth factor (VEGF) were high. Since the elastic-hard tumor was about 22cm in size and was very easy to bleed, the patient underwent subemergency mastectomy and axillary lymph node dissection. Histopathologically, the tumor was diagnosed as osteosarcoma of the breast, which was considered to be derived from metaplastic carcinoma. The elevated levels of ALP and VEGF decreased after the surgery. Since the role of adjuvant chemotherapy is still unclear because of the limited data, radiation therapy was delivered postoperatively to the chest wall, with a total dose of 60 Gy. The patient has been free from recurrence of distant metastasis as of 4 months after the surgery.

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We report a rare case of male intracystic carcinoma of the breast. A 74-year-o1d man complained of a subareolar mass of the right breast. Mammography depicted a high-density lobulated mass with clear margin in the right breast. Ultrasonography showed a multicystic tumor with no intracystic solid components or mural nodules. Magnetic resonance imaging demonstrated a multicystic tumor with a well-enhanced cystic wall. Although a fluid sample aspirated from the cystic tumor failed to provide a definitive diagnosis, it was bloody and we were suspicious of a malignant disease. We thus performed an excisional biopsy of the tumor under local anesthesia. Histological diagnosis was non-invasive ductal carcinoma. Subsequently, the patient underwent a mastectomy without sentinel lymph node biopsy because it was unclear whether or not the resection margin of the tumor following excisional biopsy was cancer-free. There was no residual tumor found in the widely resected specimen. The patient received no adjuvant therapy and the patient's postoperative course was uneventful.

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Primary adenoid cystic carcinoma of the breast is a very rare tissue type, with a fsequency of less than 0.1% of all breast cancer. In this case breast augmentation had been previously performed. We report a rare case of mammary adenoid cystic carcinoma which presented a special form of progress.
A 57-year-old woman was referred to our hospital because of a tumor in her breast. We diagnosed breast cancer with chest wall invasion. She underwent chemotherapy, but it was not effective, so we performed a standard radical mastectomy. Postoperative diagnosis was mammary adenoid cystic carcinoma with axillary lymph node metastasis showing a rare form of progress. She continues to be under observation with no treatment.

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The patient was a 56-year-old woman. She had a Bp + SNB for breast cancer 9 years prior. On pathology, an invasive ductal carcinoma (papillo-tubular carcinoma), HER2-, ER+, PR+ was diagnosed. She received radiation therapy and hormone therapy with tamoxifen for 5 years. She later had an ipsilateral breast tumor recurrence ; another Bp + SNB was done. A second SN located in the subclavian portion was detected by SPECT/CT ; this second SN was negative. On pathology, an invasive ductal carcinoma (solid-tubular carcinoma), HER2 2+(FISH-), ER+, PR+ was diagnosed. She received hormone therapy with an aromatase inhibitor. The patient has had no recurrence for 20 months.
SPECT/CT enables the easy detection of SNs and is particularly useful for detecting extra-axillary lymph nodes as was seen in this case.

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A 54-year-old woman was treated with breast-conserving therapy for the left breast and sentinel lymph node biopsy (SLNB) 6 years ago. Ipsilateral breast tumor recurrence occurred during the standard follow-up period. Ultrasonography showed parasternal lymph node (PsLN) metastasis. Preoperative lymphoscintigraphy revealed lymphatic drainage to the bilateral axillary nodes. The contralateral and ipsilateral axillary lymph nodes (LNs) were defined as SLNs. Total mastectomy with reoperative SLNB, PsLN dissection, and left axillary LN dissection was performed. At intraoperative histopathological examination, SLNB of the contralateral axillary node was positive for cancer. Contralateral axillary LN dissection was performed. Histologically, the PsLN and contralateral axillary sentinel node were positive for metastasis, but no further metastasis was detected in the other nodes (left axillary LN and right non-SLN) that had been removed.
In this case, alteration of lymphatic flow to the PsLN occurred as a result of prior surgery. The lymphatic flow was altered again due to PsLN metastasis and the SLN was eventually detected in the contralateral axillary node region. In patients with ipsilateral breast tumor recurrence, ultrasonography before surgery might be useful to detect LN metastasis to nonaxillary nodes. Preoperative lymphoscintigraphy is recommended for identifying aberrant breast lymphatic drainage.

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Immunohistochemistry of a sample obtained through thoracentesis was used to determine the therapeutic course for a 65-year-old Russian woman with a history of right breast cancer. She underwent a right mastectomy with post-surgical chemotherapy and radiation therapy 15 years ago. She has had thoracentesis multiple times for right pleural effusion in Russia, before being referred to our hospital for further treatment. Right pleural effusion and metastasis to the right pleura were noted at the time of admission. Pleural effusion fluid (920 ml) was obtained by thoracentesis, and the cytology revealed it to be Class V. We were unable to obtain any surgical samples from the original mastectomy, and no immunohistochemistry was performed. However, immunohistochemistry with cell blocks was performed on cells obtained by thoracentesis. The pathological report showed estrogen receptor (ER)-positive cells, progesterone receptor (PR)-positive cells, and human epidermal growth factor receptor 2 (HER2)- negative cells ; therefore, aromatase inhibitor therapy was initiated. Her clinical condition stabilized 10 months after starting hormone therapy.

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A 50-year-old woman had noticed a lump in her right breast 2 months earlier, and it was growing rapidly. She visited our clinic in September 2011. On physical examination, a 8.5 × 7.0 cm elastic hard regular mass mainly in the upper outer quadrant of the right breast and swollen lymph nodes in the right axilla were palpable. The tumor was diagnosed as invasive lobular carcinoma by a core needle biopsy. The immunohistochemical results showed that the estrogen receptor progesterone receptor and the human epidermal growth factor receptor 2 were all negative. After neoadjuvant chemotherapy (FEC and nanoparticle albumin bound paclitaxel), the right breast tumor and lymph nodes in the right axilla were no longer palpable. The patient underwent a modified radical mastectomy with axillary lymph node dissection in July 2012. Tumors were observed in the AC and C areas of the resected specimen. Histopathologically, the tumor in the AC area was composed of predominantly invasive lobular carcinoma partially mixed with suquamous cell carcinoma. The first case of invasive lobular carcinoma of the breast mixed with suquamous cell carcinoma was reported by Sentani K in 2007. To our knowledge, this case is the second report worldwide.

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A 47-year-old man was referred for a right neck tumor. Neck and thoracic CT showed swollen supraclavicular lymph nodes and mediastinal lymph nodes. Excisional biopsy showed that it was a metastatic lymph node of adenocarcinoma, though no primary lesion was detected. The patient was treated with chemoradiotherapy, and a complete response was obtained. Then, 75 months later, serum CEA was elevated, and thoracic CT showed swollen subcarinal lymph nodes. The patient underwent right mediastinal lymph node dissection for diagnosis and treatment, which showed recurrence of previous lymph node metastasis from an unknown primary site. Immunohistochemical staining suggested pulmonary adenocarcinoma as the primary lesion. No new lesion has appeared one year since the operation.

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A 65-year-old man, had undergone pacemaker transplantation for complete atrioventricular block in June 2006 at the age of 59 years. In September 2012, his pacemaker became infected with methicillin-sensitive Staphylococcus aureus (MSSA). He required debridement and removal of the generator of the infected pacemaker and antibiotic therapy. However, the infection worsened and progressed to sepsis, and vegetation attached to the residual pacemaker leads was apparent upon cardioechography. We diagnosed the patient with endocarditis, and the residual pacemaker leads were removed under cardio pulumonary bypass. Cardiopulmonary bypass is one of the safest and most thorough methods for the removal of infected pacemaker systems.

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An 87-year-old woman developed a sudden disturbance of consciousness. Her physical findings included : E1M1M1 level of consciousness, GCS 3 points, pulse 50 per minute sinus rhythm, temperature 35.2°C, respiratory rate > 30 per minute. Contrast enhanced CT scan showed an abdominal aortic aneurysm, 30 mm in size, and a left common iliac artery aneurysm, 60 mm in size ; based on the images it was not clear whether a rupture had occurred. There was an inflow of contrast media into the common iliac vein ; an iliac arteriovenous fistula through which a left common iliac artery aneurysm had penetrated to the left common iliac vein was diagnosed. The patient had acute heart failure caused by the iliac arteriovenous fistula ; emergency surgery was required. The area around the iliac aneurysm was opened up, and a bypass graft was placed from the right external iliac artery to the left external iliac artery. Lower limb artery circulation was assessed. Free wall ruptures to the peritoneal cavity often occur with abdominal aortic aneurysm ruptures and iliac aneurysm ruptures, but ruptures to an adjacent vein occur rarely. There are a few reports in the literature of fistula formation related to aneurysms. In these patients, dissecting around the aneurysm and rebuilding the lower limb artery circulation is thought to be effective.

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The patient was a 76-year-old man who suddenly lost consciousness. An aneurysm of the thoracic aorta and an aneurysm of the abdominal aorta were found on computed tomography.
An innovative surgical approach was contemplated because of the presence of a thoracic aneurysm (57 mm). The patient had a history of an old myocardial infarction. Since the patient's general condition was not good, a thoracic endovascular repair was chosen. Once it was confirmed on magnetic resonance imaging that there were no issues with vascular communications in the head and neck surgery was done. The stent was placed directly under the bifurcation of the left common carotid artery. No complications of cerebral ischemia were noted after the operation.
In this case, a good postoperative result was obtained even though the left vertebral artery was blocked.

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A 46-year-old man with sudden-onset chest pain was diagnosed with Stanford type A acute aortic dissection. Emergency total arch replacement was performed ; however, implantation of a left ventricular assist device (Toyobo VAS) was required 2 days later because of low cardiac output syndrome. Ten days after surgery, the patient was diagnosed with pleural effusion that increased to >1,000 ml/day. The effusion could not be controlled despite continuous drainage of a large amount of fluid. Therefore, thoracoscopic thoracic duct ligation was performed 26 days after surgery.
The pleural effusion was reduced temporarily but did not disappear completely, and frequent thoracic puncture was required. A subcutaneous injection of 100 μg of a somatostatin analog (octreotide) was administered twice a day for 67 days after surgery, and the effusion decreased 4 days later and eventually disappeared.
Octreotide has been found to be very effective for postoperative chylothorax and does not cause any side effects. It is believed that the drug is valuable even for use in patients with poor general condition.

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Diaphragmatic hernia is one of delayed complications of radiofrequency ablation (RFA), and there are some severe cases due to underlying cirrhosis of the liver or impaction. We experienced a case of diaphragmatic hernia occurred 19 months after percutaneous RFA. An 86-year-old man who had been treated for liver cirrhosis C at our hospital was found to have hepatocellular carcinoma, 13 mm in size, in the S5/8 area of the liver. RFA was performed. The patient visited the emergency room 19 months after RFA because of right upper quadrant pain and constipation. Chest X-ray showed intestinal gas in the right lower lung field, and a large defect 4-5 cm in diameter in the right diaphragm and prolapse in the right thoracic cavity of the transverse colon were observed by abdominal CT scan. Diaphragmatic hernia was diagnosed, and an emergency laparotomy was performed. We observed a 5 cm-sized hernia orifice in the right diaphragm next to the RFA scar and impaction of the transverse colon/greater omentum in the right thoracic cavity. No necrosis was observed in the impacted colon, and the defect was closed by direct suture. After RFA, we would be required long-term follow-up and early treatment not to miss a good timing for surgery at the onset of the hernia.

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A 48-year-old female was hospitalized, complaining of discomfort of the throat immediately after drinking soup made from the bony parts of a fish. Multi-detector raw computed tomography demonstrated a sharp 30mm-sized high-density object in the cervical esophagus, suggestive of a fish bone. The endoscopic approach was attempted, but it failed to extract the impacted fish bone. Considering a possibility of causing secondary injury to the esophagus or some unexpected event due to its size and morphology, we employed transcervical esophagotomy to remove the fish bone which had not perforated the esophageal wall. The postoperative course was uneventful, and the patient was discharged without any complications on the 15th postoperative day. The endoscopic treatment is widely accepted in most cases. However, surgical intervention is still one of options to remove impacted foreign bodies.

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A 71-year-old woman complained of a sense of discomfort during swallowing. On esophagoscopy a 20-mm 0-IIa lesion was found on the posterior wall of the middle thoracic esophagus. On biopsy sample examination, a squamous cell carcinoma was diagnosed. Preoperative CT revealed an aberrant right subclavian artery (ARSA) and a Kommerell diverticulum. The preoperative diagnosis was T1bN0M0 clinical Stage I (Japanese classification). In December 2010 the patient had a subtotal esophagectomy with a three-field lymph node dissection and reconstruction using a gastric tube in the posterior mediastinal route. During the cervical procedure, the non-recurrent inferior laryngeal nerve (NRILN) was identified and preserved. The patient was discharged on the 18^th postoperative day without hoarseness and dysphagia. She continues to do well without signs of recurrence 2 years later. Though ARSA is a relatively rare congenital anomaly, it must be identified preoperatively, and anatomical anomalies such as NRILN must be taken into consideration, in order that the operation be performed safely.

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A 72-year-old patient underwent a subtotal esophagectomy for squamous cell carcinoma of abodominal esophageal cancer (pT3N2M0, ly1, v1, pIM0, pPM0, pDM0, pStage III). No adjuvant chemotherapy was given. The patient developed lower abdominal discomfort 67 months after esophagectomy ; computed tomography showed a cystic tumor with a solid component involving her left ovary. A primary ovarian malignant tumor was suspected based on CT and MRI. Although a resection of the ovary was scheduled, an emergency operation was performed because of perforation of the sigmoid colon that had been invaded by the ovarian tumor. On histopathology, the left ovarian tumor was found to be a squamous cell carcinoma ; it was diagnosed as a recurrent lesion of the esophageal squamous cell carcinoma. The patient died 25 days after surgery.

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An 80-year old woman had previously undergone distal gastrectomy reconstruction by the Billroth II method. She admitted several times for adhesion ileus since the age of 67 years. She was admitted to our hospital with abdominal pain. Computed tomography showed remarkable dilatation of the residual stomach, gastric emphysema, dilatation of the afferent loop and proximal jejunum, and free air in the left subphrenic space. Emergency surgery was performed for gastrointestinal perforation. Laparotomy showed a tear of approximately 3 cm at the anterior wall of the residual stomach dilatation at the proximal jejunum, and a mass formed by the union of the distal jejunum. Partial gastrectomy was performed. After surgery, she required intensive care. She was discharged on postoperative day 92. We report this case of spontaneous gastric rupture triggered by adhesion ileus with a review of the literature.

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We report a case of gastric cancer with intestinal malrotation detected during laparoscopic surgery.
A 72-year-old man diagnosed with early gastric cancer underwent laparoscopic distal gastrectomy. Before the reconstruction, we discovered that the second portion of the duodenum was not fixed to the retroperitoneum and that the Treitz ligament was not formed. The small intestine was located on the right side of the abdomen and the large intestine, on the left. Ladd's ligament was not present, and thus non-rotation type intestinal malrotation was diagnosed. Billroth I reconstruction was performed, but no procedure for the malrotation was performed.
Intestinal malrotation is very rare in adults, and is more commonly found in neonates. Careful examination of images is very important, particularly in laparoscopic surgery.

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A 56-year old woman complaing of occasional mild epigastric pains was diagnosed as having multiple early gastric cancers. Preoperative esophagogastroduodenoscopy revealed two IIc-like lesions on the subcardia and the anterior wall at the lower body in the stomach, which were detected as adenocarcinoma histologically. On an abdominal CT examination, there was no distant metastasis, but the portal vein was positioned in front of the duodenum and the pancreas, and the spleen was lobulated. Arteriographic imaging, which was reconstructed by multidetector CT (MDCT), revealed that the common hepatic artery (CHA) was branched from the superior mesenteric artery and the shape of CHA flow was like a coil. Porteographic imaging showed that the portal vein run from left lateral region to the liver and formed into an arch. During laparoscopic surgery, she was found to have intestinal malrotation because of absence of Treitz ligament and the location of upper jejunum. Laparoscopic total gastrectomy with Roux-en Y reconstruction could be carried out without complications. The patient had no adverse events, and she has had no signs of recurrence of the gastric cancer.
Intestinal malrotation is a very rare abnormality in adults, especially in those associated with gastric cancer. In this case, the preoperative diagnosis and the procedure of reconstruction are important to achieve safe surgery.

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A 67-year-old man who had been treated for hypopharyngeal cancer at the department of otorhinolaryngology in our hospital underwent tracheotomy for glottic stenosis, became impossible to eat orally, and was performed jejunostomy. On the first postoperative day, we started enteral nutrition with liquid semi-digestion nutrition agent (400ml/day, at 33ml/hr) with an increase by 400ml per day. On the 4^th postoperative day, the patient developed diarrhea and there was tenderness extending from the indwelling site of the tube to the right lower abdomen. Abdominal CT scan revealed hepatic portal venous gas, pneumatosis cystoides intestinalis, and ascites. From findings of physical and blood examinations, we determined that bowel necrosis might be unlikely. The enteral nutrition was immediately discontinued and conservative therapy was employed. His abdominal pain persisted on the next day and urine volume decreased. In order to rule out a possibility of bowel necrosis, exploratory laparoscopic study was performed, that showed no remarkable abnormal findings. Abdominal CT scan on the 12^th postoperative day revealed disappearance of hepatic portal venous gas.
Since hepatic portal venous gas associated with enteral nutrition is a rare complication, this case is presented here, with a review of the literature.

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A 60-year-old man was refferred to our hospital with complaints of abdominal fullness, diarrhea and massive ascites. Puncture of the ascites detected chylous ascites. Abdominal computed tomography (CT) scans showed considerable thickness and calcification of the mesentery. High levels of CA125 and sIL-2r were detected in the ascites. Laparotomy was performed for diagnosis, and showed massive chylous ascites and sclerotic, as well as allowing us to shorten the mesentery.
We resected a short segment of the ileum with the thickening mesentery. Histopathological findings showed mesenteric panniculitis. Treatment with steroids temporarily improved the symptoms of diarrhea and ascites ; however, the number of ascites eventually increased. Five months after operation, he suffered from perforative peritonitis and treated with surgery, after which the ascites disappeared and CA125 levels were normalized.

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Idiopathic mesenteric phlebosclerosis is very rare. It has only been reported in Asian countries, particularly in Japan. We present a case of idiopathic mesenteric phlebosclerosis with a ventriculoperitoneal shunt. A 63-year-old female was admitted due to abdominal distension. CT scan revealed that there was an intestinal obstruction and diffuse thickening of the intestinal wall involving the cecum and the ascending colon, as well as string-like calcification along the intestinal wall and in the mesenterium. Colonoscopy revealed dark-purple mucosa with edema in the descending colon and transverse colon as well as narrowing of the intestine in the transverse colon.
A laparoscopy-assisted subtotal colectomy was performed for idiopathic mesenteric phlebosclerosis, which had not improved on conservative treatment. The histological findings revealed collagen fiber deposits around the vessels ; idiopathic mesenteric phlebosclerosis was diagnosed. We present a case of idiopathic mesenteric phlebosclerosis with intestinal obstruction which required a laparoscopy-assisted subtotal colectomy.

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Case 1 involved an 84-year-old woman who presented with abrupt onset of high fever and shock symptoms during conservative therapy for simple obstruction. From both the blood and stool cultures, Klebsiella oxytoca, a kind of enterobacterium, was isolated. The patient was considered to develop septic shock caused by bacterial translocation (BT). Symptomatic remission was gained by administration of antimicrobial drugs and general management, and the patient was discharged from the hospital.
Case 2 involved a 35-year-old woman who suddenly developed high fever and went into shock during follow-up period after reduction of simple small bowel obstruction. Klebsiella oxytoca was isolated from the blood culture like the case 1. Since no other causes of infection than BT could be found, septic shock caused by BT was diagnosed. Symptomatic remission was attained by intensive treatments including administration of antimicrobial drugs and endotoxin absorption therapy. The patient was discharged from the hospital. Although BT can occur by a variety of causes, among of them, intestinal obstruction is a disease which satisfies conditions needed for occurrence of BT. We have to bear this fact in mind.

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An 81-year-old man with no previous history of surgery was referred to our hospital because of abdominal pain. There were tenderness and muscular guarding in the abdomen. Abdominal X-ray showed a dilated sigmoid colon and niveau signs. Abdominal computed tomography demonstrated a dilated sigmoid colon and the whirl sign of the sigmoid artery. Colonoscopy undertaken with a suspicion of sigmoid volvulus showed stenosis of the sigmoid colon and necrosis of mucous membrane. Therefore, an emergency surgery was performed with the diagnosis of sigmoid volvulus. Operative findings included a hernia orifice 8cm in diameter in the mesentery of the transverse colon and necrotic sigmoid colon invaginated through it. We performed repair of the hernia orifice and resection of the sigmoid colon, followed by ileostomy creation. Transmesocolonic hernia in the mesentery of the transverse colon is rare, and in this instance the hernia content is the small bowel in most cases and the transverse colon is rarely invaginated. We report a case of strangulation ileus of the sigmoid colon due to transmesocolonic hernia in the mesentery of the transverse colon.

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A 25-year-old man visited the Department of Gastrointestinal Medicine at our hospital with a chief complaint of a one-year history of epigastralgia. Abdominal computed tomography (CT) at the initial visit showed a cystic lesion on the ventral side of the descending part of the duodenum, but because his symptoms had improved by the time he visited the hospital, he was followed up on an outpatient basis. An increase in the size of the lesion was seen on CT one year later, and the patient was therefore referred for surgery. The patient was diagnosed with a cystic tumor in the transverse mesocolon and underwent laparoscopic surgery. The tumor was located within the transverse mesocolon, and after managing the inflow vessels, the lesion alone was resected using an ultrasonically activated scalpel. Based on postoperative histopathological examination, the lesion was diagnosed as enteric duplication in the transverse colon. Enteric duplication in the colon is relatively rare in adults, and the present case is reported because only two cases in which laparoscopic surgery was performed, including the present case, have been reported in Japan.

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An 84-year-old woman was admitted to our hospital because of a one-week history of loss of appetite and weight loss. Abdominal CT showed irregular thickening wall of the cecum and dilatation of the small intestine. Colonoscopy showed a large tumor in the cecum, and this lesion was diagnosed as cecal cancer by the biopsy specimen. We performed laparoscopic-assisted right colectomy. Surgical specimen showed an irregular shaped tumor, 4.5×5 cm in size, invaded the ileocecal valve. Histopathological findings showed tumor cells proliferated in a solid pattern without gland formation, and there was no tendency to endocrine cell carcinoma immunohistochemically. Undifferenciated carcinoma was diagnosed. This patient has been followed without adjuvant chemotherapy because of patient's consent. No evidence of cancer reccurence has been shown for 32 months after the surgery.
Undifferenciated carcinoma of the large intestine is a rare disease, and the malignant potential is relatively high. Distant metastasis and/or lymph node metastasis are found before surgery in most cases. Therefore, few long-term survivors have been reported. We report a case of undifferenciated cecal cancer in a patient who can survive for a long time after radical surgery without adjuvant chemotherapy.

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We report a case of immunoglobulin G4 (IgG4)-related lymphadenopathy in the lymph nodes of the small bowel mesentery which was found during operation performed with a preoperative diagnosis of rectal cancer.
A 69-year-old woman complaining of anal bleeding was referred to our hospital with a diagnosis of rectal cancer after close exploration at another hospital. Blood examinations revealed mild degree of inflammatory reaction, an increase in IgE, and increases in tumor markers including CEA 7.1 ng/ml and CA19-9 69U/ml. Abdominal CT scan showed several nodes in the small bowel mesentery. Considering a possibility of peritoneal dissemination, we performed exploratory laparotomy when the intraoperative frozen section diagnosis of the removed mesenteric node was reported to be IgG4-related lymphadenopathy. Low anterior resection for rectal cancer and dissection of lymph nodes of the small bowel mesentery were performed. Blood examination after the operation showed an increase in the serum IgG4 level (146 mg/dl). Based on histopathological findings of lymph nodes of the small bowel mesentery, IgG4-related lymphadenopathy associated with rectal cancer was the most likely diagnosis. Oral administration of steroids was started after the operation and her clinical course has been satisfactory. We report this case together with a review of the literature.

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We present a case with long-term survival following the resection of rectal cancer after having a craniotomy to remove brain metastasis. In April 2008, a 49-year-old man presented with a headache and heaviness of the head. A computed tomography (CT) scan of the brain revealed a solid tumor, 3.0 cm in diameter, in the right occipital lobe. Subsequently, rectal cancer was detected on abdominal CT. First, a craniotomy was performed. Twenty-five days after the craniotomy, the rectal cancer was resected. The final diagnosis was rectal cancer, Ra/Rb, type 2, 5.3 × 4.2 cm, pSS-A, ly2, v1, pN2 (No 251 : 7/18, No 252 : 0/6, No 253 : 0/11), sH0, sP0, pM1 (brain), Stage IV. At 15 days after surgery, whole-brain radiation therapy and postoperative adjuvant chemotherapy (oxaliplatin plus 5-fluorouracil/leucovorin : 6-kur, tegafur-uracil [UFT] plus leucovorin : 12 months, UFT : 3 months) were administered. At 60 months (5 years) after surgery, the patient remains well without recurrence.

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A 70-year-old man had undergone a low anterior resection with a D2 lymphadenectomy for rectal cancer. One year after the operation, his serum CEA level increased to 11.3 ng/ml. A liver recurrence originating from rectal cancer was diagnosed and a resection of the posterior part of the liver was scheduled because the systemic computed tomography (CT) scan revealed a 30-mm low density area in the S7 of the liver. During the operation, a tumor on the right diaphragm and normal liver tissue was found. Thus, a solitary diaphragmatic metastasis originating from rectal cancer was diagnosed and we performed a partial resection of the right diaphragm. The resected specimen of the diaphragm revealed the same histological findings as the rectum specimen. On literature review, only eight reports of colorectal metastatic tumors involving the diaphragm were found.

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A 66-year-old woman was seen at our hospital because of appetite loss, diarrhea, body weight loss, and bad breath. Blood biochemical examination showed anemia and serious malnutrition. Following upper and lower gastrointestinal endoscopies, barium enema, and CT scan, anastomotic cancer forming duodenocolic fistula with involvement of the abdominal wall, liver, duodenum and small intestine was diagnosed. After malnutrition was relieved, we performed resection of the ileocolic anastomosis, pancreaticoduodenectomy, partial resection of the ileum, and partial hepatectomy. The histopathological diagnosis was mucinous adenocarcinoma SI (duodenum, pancreas, and jejunum) in Stage II. The patient experienced peritoneal dissemination one year and four months after the operation, but could survive for 3 years and eight months after the operation with effective chemotherapy.
Although patients with advanced colonic cancer forming duodenocolic fistula are often in poor general condition, perioperative nutritional management mainly with enteral nutrition enables us to perform extended associated resection including pancreaticoduodenectomy comparatively safely. By performing extended resection actively, the operation can result in curative resection so that improvement of the prognosis as well as QOL can be expected.

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In this paper a case of adenocarcinoma arising in an ileostomy site after total proctocolectomy for familial adenomatous polyposis is reported.
A 64-year-old man, who underwent proctocolectomy and permanent Brooke ileostomy for familial adenomatous polyposis when he was 37 years old, was seen at our hospital because of a tumor at the ileostomy site. The patient underwent partial resection of the ileum including the tumor and ileostomy reconstruction with a diagnosis of cancer of the ileostomy site. The final pathological diagnosis was moderately differentiated adenocarcinoma. Cancer arising in an ileostomy site is uncommon after total proctocolectomy for familial adenomatous polyposis or inflammatory bowel disease. We report such a rare case of adenocarcinoma arising in the ileostomy site after total proctocolectomy, with a review of the literature. We emphasize the importance of periodic follow-up of the ileostomy site.

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A 76-year-old man was admitted to our hospital because of abdominal pain. He had undergone subtotal gastrectomy 10 years ago. The operative scar was reddish and swelling, and was now 5 cm in diameter. An abdominal computed tomography (CT) showed an abscess in the abdominal wall under the scar ; therefore, we drained the abscess with a drain. Six days after the drainage, we found stool passing from the drain. Fistulography showed a fistula that communicated with the transverse colon. Colonoscopy showed a type 2 tumor at the transverse colon, which was diagnosed as well to moderately differentiated adenocarcinoma, based on the pathological examinations. We diagnosed it as an abscess in the abdominal wall due to penetration by the transverse colon cancer. We resected the transverse colon with the abdominal wall and the cutaneous fistula. Cancer cells were revealed along the fistula in the microscopic examination, and the tumor had invaded the abdominal wall directly. At the last follow-up examination, 18 months after the operation, the patient was in good health with no evidence of recurrence. It is probably less-invasive and safer to perform a curative operation to treat colon cancer with an abdominal wall abscess after conservative therapy.

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We report a case of sigmoid colon cancer presented with multiple liver abscesses in the bilateral lobes. A 46-year-old man was seen at the hospital because of fever up and right hypochondralgia. Computed tomography and ultrasonography of the abdomen revealed multiple liver abscesses. The patient submitted well to the administration, and the treatment with antibiotics was immediately started. Colonoscopic examinations to explore the cause of these liver abscesses revealed sigmoid colon cancer. A biopsy resulted in well differentiated adenocarcinoma. Inflammatory reaction subsided and the liver abscesses diminished with antibiotics. Because no findings suggestive of liver metastasis was seen, sigmoidectomy with lymph node dissection (D3) was carried out. Histopathological findings showed tub1, ss, n1, ly2, v1, and Stage IIIb. The patient has been free from liver metastasis and liver abscesses one year after the operation. It was etiologically inferred that multiple pyogenic liver abscesses might be caused by colon cancer through the portal route, but we could not identify the mechanism why the bilateral hepatic lobes were infected. In the diagnosis and treatment of hepatic abscesses, complete gastrointestinal examinations would be needed by keeping a possibility of colon cancer as a causative disease for liver abscesses in mind.

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A 52-year-old woman developed right upper quadrant pain. Abdominal CT revealed a 13 cm in diameter low-density mass with calcification in the right hepatic lobe. A diagnosis of hepatic alveolar echinococcosis with peritoneal dissemination was made. An extended right hepatectomy was performed, and some disseminated lesions of the peritoneum were resected. The patient is well 2 years and 3 months after surgery and is being treated with albendazole. Aggressive surgical resection is necessary in treating hepatic alveolar echinococcosis with peritoneal dissemination, since reducing the lesion load and subsequent albendazole administration prolongs survival. Few cases of hepatic alveolar echinococcosis with peritoneal dissemination have been reported. In our paper we present this case along with a review of the literature.

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A 74-year-old man who tested negative for various viral markers visited a local physician with a chief complaint of heaviness in the abdomen. He was referred to our hospital after a tumor was detected in the right lobe of the liver on abdominal ultrasound. Magnetic resonance imaging (MRI) showed a tumor lesion, 8 cm in size, in segments 6/5 (S6/5) of the liver. Dynamic imaging showed contrast enhancement in the arterial phase and washout in the portal venous phase within the tumor interior. Based on a diagnosis of hepatocellular carcinoma, subsegmental resention of S6 of the liver and partial resection of S5 of the liver were performed. The tumor had a well-defined capsule, and its interior contained necrotic matter. Histopathological findings included extensive necrosis of cells within the capsule, with no viable tumor cells. Sinusoidal supporting tissue was observed within the tumor interior, and the hepatocellular carcinoma was thought to have undergone complete spontaneous necrosis. In addition, no abnormal findings were observed in the background liver. This very rare case of complete spontaneous necrosis of hepatocellular carcinoma that occurred in normal liver is reported

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We present a case of ruptured hepatocellular carcinoma (HCC) with hepatic subcapsular hematoma. A 47-year-old man who had been diagnosed as to have hepatitis B viral infection 20 years eariler had the sudden onset of upper abdominal pain after playing golf. Intraabdominal hemorrhage caused by ruptured HCC was suspected on abdominal CT scan, and he was treated by transcatheter right hepatic artery embolization. One month after the embolization, he visited our hospital for an operation. Abdominal CT scan and MRI showed HCC 7.5 cm in diameter with hematoma in S7 of the liver, concomitant with wide formation of a subcapsular hematoma. In addition, the tumor firmly attached to the right diaphragm. To prevent tumor cell seeding, HCC with a large subcapsular hematoma was resected en bloc with extended right hepatic lobectomy and partial resection of the diaphragm. The liver tumor was histopathologically diagnosed as moderately differentiated HCC with ruptured large subcapsular hematoma. No invasion of HCC to the diaphragm was observed. The postoperative course was uneventful and he was discharged on the postoperative day 19. He has had no recurrence and is doing well as of 33 months after the resection.

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The patient was in his eighties who had a 15 cm hepatocellular carcinoma (HCC) in the right lobe of the liver, and underwent right hepatectomy 7 years ago. The pathological study revealed poorly differentiated HCC with microvascular invasion. Although no recurrence was found during the 7 years after the operation, multiple tumors were detected in the myocardium of the right ventricle and the right lower lobe of the lung. Percutaneous biopsy obtained from the tumor of the right lung showed HCC cells. The tumor in the myocardium of the right ventricle was enhanced by gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) magnetic resonance imaging (MRI), thus suggesting cardiac metastasis of HCC. No recurrence was found in the liver. Therefore, he was diagnosed with lung and cardiac metastasis of HCC, and then treatment was started with sorafenib. However, because of erythema multiforme, sorafenib therapy was ceased and the treatment was shifted to palliative care. The metastasis of the HCC to the myocardium of the right ventricle is rare, and there are even fewer reports without hepatic recurrence. Herein, we reported this case with a review of the literature.

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Portal vein stent placement for portal vein stenosis due to malignancies is reported to be a safe and effective procedure for decreasing portal vein pressure. We treated a case requiring a portal vein stent for portal vein stenosis due to recurrence of hilar cholangiocarcinoma. After portal vein stent placement, the portal venous flow increased, and liver function was well maintained. Portal hypertension has not occurred during the follow-up period. In selected cases, portal vein stent placement is likely an effective procedure for preventing the complications caused by portal hypertension. It also improves QOL.

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The main cause of gall bladder perforation is acute cholecystitis with stones, but the combination of free air in the abdominal cavity is a very rare condition. Here, we report a rare case of gall bladder perforation with massive free air in the abdominal cavity. A 70-year-old man was transported to our hospital because of sudden abdominal pain during medical treatment for hypertension, cerebral infarction and diabetes mellitus in another hospital. On examination, there was severe rebound tenderness in the upper abdomen with muscular guarding. Abdominal X-ray and computed tomography scan showed massive free air in the abdominal cavity. There was a calculus in the neck of the gall bladder with normal wall thickness and no evidence of emphysematous change. Under the diagnosis of perforation of the digestive tract, an emergency operation was performed. In the abdominal cavity, there was massive biliary ascites. However, the perforation site was not observed in the digestive tract, but in the neck of the gall bladder with a 3 mm hole. Cholecystectomy was performed, and cultures of the ascites detected Escherichia coli. Gall bladder perforation should be considered in a differential diagnosis for patients presenting with free air in the abdominal cavity and an unknown etiology.

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Advances in surgical technique and perioperative and perinatal management of congenital heart disease have decreased the mortality in patients. These patients grow to adulthood and commonly undergo noncardiac surgery. On the other hand, advances in laparoscopic surgery have decreased length of hospitalization and reduced postoperative pain. This surgical technique has become the prefered approach ; however laparoscopic surgery induces hemodynamic changes and rarely induces gas embolism.
We report a case of abdominal wall lift laparoscopic cholecystectomy in a patient with right-to-left shunt associated with Ebstein's Anomaly. A 46-year-old women with Ebstein's Anomaly had a brain abscess and was treated with a drainage procedure. During this treatment, she experienced two gallstone attacks.
She had cyanosis from Ebstein's Anomaly, so she was refered to our hospital.
Cardiac catheterization and transesophageal echocardiography showed a right-to-left shunt from an atrial septal defect.
So, she was scheduled for an abdominal wall lift cholecystectomy because of her cardiac problem. Surgery and anesthesia were perfomed without any serious complication.
For patients with congenital heart disease who need laparoscopic surgery it would be better to avoid pheumoperitoneum laparoscopy, and to perform an abdominal wall lift laparoscopy.

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A 71-year-old man was admitted to our hospital because of hypochondrial pain. Abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed multiple cystic lesions in the pancreatic body and tail. The multilocular cyst in the pancreatic tail was 20 mm in diameter with an enhanced irregular shaped component, so that the malignant disease could not be refuted. We conducted a laparoscopic distal pancreatectomy with splenectomy for the definite diagnosis. There were no postoperative complications and he was discharged on the 14th day after surgery. Final pathological diagnosis of the cystic lesion in the pancreatic tail was a well-differentiated endocrine tumor (benign behavior). Laparoscopic distal pancreatectomy is a useful therapeutic choice for malignant boundary lesions of the pancreatic body and tail, as seen in this case.

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An 81-year-old man was admitted to our hospital because of bleeding from carcinoma of the small intestine. Although an abdominal computed tomography (CT) scan showed bilateral adrenal metastasis and paraaortic lymph node metastasis, partial resection of the small intestine was performed to control the bleeding. The morning after the operation, he entered a state of shock. Adrenal insufficiency was suspected because of low blood pressure, hypoglycemia and hyperkalemia. His symptoms were dramatically improved by hydrocortisone treatment.
He was diagnosed with undifferentiated carcinoma of the small intestine by histopathological and immunohistochemical examination.
An undifferentiated carcinoma of the small intestine is rare and adrenal crisis due to adrenal metastasis is also extremely rare. We report a case of undifferentiated carcinoma of the small intestine and adrenal crisis due to bilateral adrenal metastasis. Adrenal function tests should be done in patients with bilateral adrenal metastasis.

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We report our experience with a case of primary nonfunctional adrenocortical carcinoma. A 69-year-old woman was found to have a mass about 2 cm in the left adrenal gland contingent from a computed tomography (CT). Then, the patient was referred to our hospital where the tumor showed an increase of about 5 cm over an observation of about 6 months. In magnetic resonance imaging (MRI), the T1-weighted image showed low signal intensity, while the T2-weightented image showed a heterogeneous high signal intensity inside the tumor. The tumor grew quickly in a short period of time, so we performed a laparoscopic adrenalectomy. The resected specimen showed a tumor 5.4 × 3.8 cm in size with a capsule and a necrotic inner part. The tumor was a nonfunctional adrenal tumor and the final diagnosis was adrenocortical carcinoma, pT2N0M0 stage II.

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We report 2 cases of patients with umbilical urachal sinus who underwent laparoscopic complete resection of the urachus with partial cystectomy. A 32-year-old woman and a 27-year-old man with purulent discharge from the umbilicus were referred to our hospital. They were diagnosed with umbilical urachal sinus by abdominal CT. After remission of the umbilical infection, both patients underwent laparoscopic complete resection of the urachus with partial cystectomy. In both patients, the histopathological findings revealed urachal remnant in the bladder cuff area. There is no consensus about whether a bladder cuff should be resected routinely. Based on our experience, we believe that complete resection of the urachus with partial cystectomy is desirable, even for umbilical urachal sinus.

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