Clinical pathway use in gastric cancer surgery has been widely accepted as a tool to guide evidence-based treatment. However, no standardized pathway has been accepted for nationwide use. If one could be developed and used safely, it will provide the same quality of perioperative treatment and may promote an earlier hospital discharge to all patients in Japan. Here we conducted a multi-centric study to develop and verify the new standardized clinical pathway for distal gastrectomy (DG-path) and for total gastrectomy (TG-path). We first developed a DG-path restarting solid food on postoperative day 3, while the TG-path started on day 4. Then, these pathways were followed by 415 DG patients and 163 TG patients. The clinical outcomes and clinical pathway variance of each group were analyzed. The median postoperative hospital stay was 12 days in the DG-path and 14 days in the TG-path. The discharge delay was observed to be 14.5% in the DG-path and 25.8% in the TG-path. However, the incidences of severe complications were relatively low at 3.9% in the DG-path and 6.7% in the TG-path. Our data suggests these pathways can be used with relative safety. These two pathways can be models for standardized clinical pathway for use nationwide.

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Introduction : Attention has come to be paid to laparoendoscopic single-site surgery. We present a retrospective study about transumbilical laparoscopic-assisted appendectomy (TULAA) performed in our hospital. Method : We enrolled 212 patients who were appendectomised for acute appendicitis by TULAA in our hospital between July 2005 and April 2010. The completion rate of TULAA was examined from their medical records. Morbidity and mortality were compared between TULAA and open appendectomy patients treated in the same period. Results : TULAA was completed in 169 cases (79.7%) and conversion to open surgery was needed in eight cases (3.8%). The risk factors of the additional port were the age over 21 years and the Body Mass Index (BMI) over 21. Postoperative complications occurred in three cases (1.4%) in the TULAA patient group and in 40 cases (9.6%) in the open appendectomy group. TULAA showed a significantly lower incidence than open appendectomy in provoking postoperative complications. Conclusions : TULAA appears to be a safe and useful surgical procedure for selected cases of appendicitis. The risk factors were related to the age and the BMI value of the patients.

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We report five cases of non-surgical pneumoperitoneum. Case 1 was a 69-year-old man admitted in an emergency for traffic injury. Case 2 was a 40-year-old woman admitted in an emergency for acute abdominal pain. Case 3 was a 90-year-old man admitted in an emergency for fever and respiratory failure. Case 4 was an 86-year-old man hospitalized with multiple pain from lung cancer metastases. Case 5 was a 50-year-old woman under observation for liver hemangioma. X-ray and/or computed tomography scan were taken of these patients for further examination and revealed intra abdominal free air. Cases 1-4 underwent operations since perforations of gastrointestinal tract were suspected. Case 5 was followed up carefully with nonsurgical management since her symptoms and laboratory data did not suggest peritonitis. All the cases were diagnosed as non-surgical pneumoperitoneum. There are only 74 cases, including our case, of non-surgical pneumoperitoneum reported in Japan. We reviewed those cases including our cases.

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Patients with metastatic colorectal cancer treated with bevacizumab from September 2007 to August 2012 were retrospectively reviewed. There were 228 patients treated, and seven gastrointestinal perforations treated in six patients (2.6%). Primary cancer resection was performed in three patients. The time to perforation from the first bevacizumab dose was 9-550 days (median 181). The time to operation from onset of symptoms was 6-244 hours (median 85). All patients had mild abdominal symptoms compared to patients with typical acute peritonitis. All were ambulatory at the time of admission, and diagnosed by computed tomography (CT) scan. Sites of perforation included three in the ileum, one in the appendix, one in the sigmoid colon, one in the rectum and one unknown. Pathological findings of the resected specimens were obtained from four patients, which showed a diverticulum, ulcer, chemotherapy-induced necrosis, and non-specific findings. No case of perforation at the primary tumor site was seen. There were no significant postoperative complications. Gastrointestinal perforation should be considered in patients treated with bevacizumab even if the abdominal symptoms are not severe. Surgical treatment is optimal for bevacizumab-related gastrointestinal perforation.

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We report 4 cases of congenital cartilaginous rest of the neck found at birth. All 4 cases were males, and the hard cartilaginous mass was palpable at the anterior border of the sternocleidomastoid muscle. Two cases presented in the left lower part of the neck, one case in the left upper part, and one case in the right lower part. The masses were hard and were between 1-1.5 cm in diameter. All cases were operated on at 1-2 years of age. In all 4 cases, the masses were resected ; they had developed in the sternocleidomastoid muscle. On histology, they were found to be composed of normal hyaline cartilage in a fibrous stroma.
A cartilaginous mass in the neck found at birth is rare ; it is referred to as a congenital cartilaginous rest of the neck, a cartilage naevus of the neck, an accessory ear of the neck, or a cervical auricle. Congenital cartilaginous rest of the neck originates in the second and subsequent branchial arches. Many cases are found in the anterior border of the sternocleidomastoid muscle ; the base of the mass developes in the sternocleidomastoid muscle. Mass resection is the operative indication. It is important to recognize that some of these cases have other systemic malformations.

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Breast cancer metastasis to the gastrointestinal lesion is rare. We report a case of rectum and stomach metastasis from invasive lobular carcinoma. A 58-year-old woman came to our hospital for therapy for multiple liver and bone metastasis. She had undergone modified radical mastectomy with axillary lymph node dissection for left breast cancer 8 years earlier. The final diagnosis was invasive lobular carcinoma (T2N1M0 Stage IIB), estrogen receptor (+) and progesterone receptor (-). She underwent 6 courses of chemotherapy with CMF (cyclophosphamide, methotrexate, and 5FU) and hormone therapy with tamoxifen for 2 years after surgery. She underwent radiation therapy and chemotherapy with EC at our hospital for the multiple liver and bone metastasis of the breast carcinoma. During chemotherapy, she developed low abdominal pain and diarrhea and passed bloody stools. Endoscopic examinations revealed a stenotic lesion in the rectum and multiple erosive lesions in the stomach. Biopsy specimens of the rectum and stomach suggested poorly differentiated adenocarcinoma with signet-ring cells. Based on the clinical course and endoscopic examinations, the lesions of the rectum and stomach suggested metastatic breast cancer. The immunochemical studies (CK7, CK20, E-cadherin, GCDFP-15, and 34βE12) confirmed that the lesions of the rectum and stomach were metastasis of invasive lobular carcinoma of the breast.

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The present case was a 67-year-old woman. The patient had operations for metachronous cancer of the bilateral breast at the age of 56 and 62 years. After the oncostatic chemotherapy was completed, the patient did not receive endocrine therapy because both breast cancers were negative for hormone receptors. During the observation, the patient was identified with a right axillar tumor, that was flat shaped, measuring 15 mm in diameter, and having a clear border. The axillary mass was first diagnosed as a possible local recurrence of breast cancer by fine needle cytological examination. Finally, accessory breast cancer was confirmed by pathological examination after the operation. Characteristic microscopic features of neuroendocrine carcinoma were observed histologically.
We reported the case with some of the literature, because accessory breast cancer after mastectomy for bilateral breast cancer is extremely rare.

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We present a case of invasive ductal breast carcinoma present within a fibroadenoma (FA). A 65-year-old woman had a right breast mass, 2.5×2.0 cm in size, which was located in the upper outer quadrant. Mammography showed an oval-shaped, high density mass with grouped-pleomorphic calcifications. The tumor border was almost completely circumscribed, and it was partially microlobulated. Ultrasound examination showed an internal heterogeneous hypoechoic round mass. The tumor margin was almost completely sharply delineated and smooth, but it was partially rough on the side closest to the nipple. On histology of the needle biopsy of the tumor, both a fibroadenoma and an invasive ductal carcinoma were noted. The patient had a mastectomy and a sentinel node biopsy. On pathology, an invasive ductal carcinoma coexsisting within a fibroadenoma was diagnosed.

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A 72-year-old woman was being followed for a polyp in the gall bladder, and an abnormal shadow was detected on abdominal computed tomography. The shadow was in the right costo phrenic angle and was diagnosed as a pleural effusion. Follow-up abdominal computed tomography showed that the shadow had grown over two years ; chest computed tomography with contrast medium showed that the abnormal shadow had an enhanced area. The patient underwent thoracoscopic surgery for diagnosis and treatment. The tumor protruded from the right lower lobe and was resected with a 2-cm surgical margin. On pathology, the tumor was diagnosed as a solitary fibrous tumor arising from the visceral pleura. Solitary fibrous tumor should be considered in the differential diagnosis of a lesion at the costo phrenic angle.

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The patient was a 71-year-old man being treated for Vogt-Koyanagi-Harada disease. On whole body CT scan, thickening of the esophageal wall was identified. Endoscopic examinations revealed a type-2 tumor in the middle thoracic esophagus, which was diagnosed as an endocrine cell carcinoma on pathology. PET scans and contrast-enhanced CTs showed lymph node metastases in 3 fields, including No.101R, 106recR, 109R, and No.3. There were no distant metastases. The tumor was clinically diagnosed as T3 N2 M0 stage III. After two courses of neoadjuvant chemotherapy (NAC) using irinotecan and cisplatin, the patient showed a partial remission, and the tumor size was remarkably reduced. Subsequently, a subtotal esophagectomy was performed, and the histological effects of the NAC were reported as Grade 2. No viable tumor cells were observed in the 123 extracted lymph nodes. Post surgery the patient was given one course of adjuvant chemotherapy with irinotecan and cisplatin. Seven months after surgery, he is still alive and free of reccurence.

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Glomus tumors mostly arise from subcutaneous tissues or the tissues under the nail, and it is considered rare for a glomus tumor to arise from the stomach. A 52-year-old man diagnosed with a submucosal tumor of the stomach was referred to our department to undergo surgery. As a result of various examinations, we diagnosed him with carcinoid of the stomach, and performed a laparoscopic distal gastrectomy. After the resection, we investigated the specimen using imunnostaining and the diagnosis was confirmed as glomus tumor of the stomach. According to current WHO criteria for a glomus tumor, a glomus tumor of the stomach more than 2 cm long or 2 cm in diameter is classified as a malignant glomus tumor. In our review of some of the literature, we found no reports about recurrent cases of glomus tumor of the stomach in the Japanese literature, and only four recurrent cases of glomus tumor of the stomach in the foreign literature. To our knowledge, glomus tumor of the stomach is very rare and we review some citations associated with glomus tumor and discuss our case.

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A 76-year-old man, who had undergone a total gastrectomy 21 years prior, had a sudden onset of abdominal pain. Abdominal CT scan revealed a tumor with a layered structure in the upper abdomen. Jejunography revealed a crab-claw appearance. Intestinal obstruction caused by intussusceptions was diagnosed, and a laparotomy was performed. An invaginated bowel progressing in an antiperistaltic direction was present on the anal side of the Y-anastomosis. After manual replacement, a partial resection of jejunum was performed. No abnormalities were found at the resected jejunum. A year later, the patient again developed abdominal pain. CT scan revealed of an intussusception, and a laparotomy was performed. Retrograde invagination at the anal side of the Y-anastomosis was again found. The patient required a jejunum resection which included the Y-anastomosis. No subsequent relapses have been documented.
Intussusception after gastrectomy occurs rarely. Nevertheless, it must be kept in mind as a probable occurrence after gastrectomy.

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We report a case of left paraduodenal hernia which was asymptomatic, but diagnosed preoperatively, and was successfully treated by laparoscopic surgery. A 50-year-old man was diagnosed by computed tomography (CT) which was performed for evaluation of a left inguinal hernia, and was the referred to our hospital. Multi-Detector CT showed a part of the small intestine which had herniated into the unnatural space behind the pancreas through the dorsal side of the inferior mesenteric vein (IMV). Laparoscopic findings showed the orifice of the paraduodenal hernia, through which almost all of the small intestine had herniated into the paraduodenal fossa, was made up of IMV, inferior mesenteric artery and the retroperitoneum. After repositioning of the small intestine, the hernia orifice was closed by laparoscopic suturing technique. The left inguinal hernia was repaired by the TAP (transabdominal preperitoneal hernia repair) procedure. There have been 76 cases of paraduodenal hernia reported in the Japanese literature from 2002 to 2011. There were only 2 cases, including ours, that were asymptomatic and diagnosed preoperatively. Among them, our case was considered to be the only one which was treated by laparoscopic surgery.

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We report a case of advanced duodenal cancer resected by pancreatoduodenectomy with resection of the portal vein. A 61-year-old man was admitted to our hospital complaining of appetite and weight loss. Gastrointestinal endoscopy showed a type 3 lesion in the duodenal bulb, and abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a giant tumor of the duodenum and pancreas head that was 11 cm in size. We performed a laparotomy with a diagnosis of advanced duodenal cancer invading the pancreas and the portal vein. The tumor was adherent to the portal vein, and we resected the tumor by pancreatoduodenectomy with wedge resection of the portal vein. The tumor was histologically diagnosed as a papillary adenocarcinoma of the duodenum with portal invasion. The patient has been followed without adjuvant chemotherapy because diarrea made it unfeasible, and the lack of established chemotherapy for duodenal cancer. He has been free from recurrence as of 2 years and 2 months after the operation.

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A 75-year-old man with the chief complaint of tarry stool was diagnosed as having a laterally spreading adenoma completely encircling the duodenum from the 2^nd to the 3^rd portion. The lesion had been followed by duodenoscopy and hypotonic duodenogram every six months. We finally carried out pancreaticoduodenectomy because adenocarcinoma was detected in the biopsy specimens six years after the initial diagnosis. The resected specimen revealed advanced cancer with regional lymph node metastasis. Duodenal adenoma is considered as a precancerous lesion and is recommended surgical resection. Because the lesion was mostly composed of adenoma with minimally adenocarcinoma in this case, it was hard to detect carcinoma tissue in the biopsy specimens. In addition, little changes in imaging findings also made difficult to make diagnosis of cancer at an early point of the clinical course. The patient might hesitate to undergo the highly invasive intervention without confirming the definite diagnosis of malignancy that might cause the prolonged observation. This case indicates the natural history of duodenal adenomas and a risk of long-term observation of them.

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A 37-year-old man had a history of eosinophilia and asthma. He was treated by the neighbourhood doctors for fever, stomachache, vomiting, and diarrhea with eosinophilia. Prednisolone (PSL) was prescribed because the symptoms persisted without improvement. Increasing abdominal pain was detected on day 7 after PSL initiation, and CT revealed free air in the abdominal cavity. He was taken to our hospital and an emergency operation was perfomed. An ileac perforation was found and multiple ulcerative lesions were detected in other parts of small intestine. Ileotomy and ileostomy were performed. Steroid pulse and cyclophosphamide combination therapy was administered after the operation. He was discharged on day 57 after the operation.

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We report a case of ileal dissection caused by a fibrous adhesion. A 51-year-old man visited the hospital complaining of abdominal fullness and vomiting over the previous 3 days. He was diagnosed as having adhesive intestinal obstruction based on the examination findings and his previous history of total gastrectomy. Seven days after conservative treatment by insertion of a long tube, an emergency operation was performed. Laparotomy revealed that the small intestine was completely dissected by a fibrous adhesion in the right upper part of the abdomen. There was no evidence of ischemia or necrosis in the mucosal surface of the resected specimen.

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A 48-year-old man was admitted to the hospital because of epigastric pain. He had abdominal tenderness, and inflammatory findings were noticed on the blood test. Computed tomography and ultrasonography revealed a mass with a diameter of 8 cm in the mesentery of the small intestine and abscess formation inside the mass. We performed emergency surgery, as the pain could not be controlled. Partial excision of the small intestine including the tumor was performed. Histological examination revealed a desmoid tumor composed of spindle cells with collagen fibers. Small perforation of the small intestine into the desmoid tumor was also confirmed and the abscess formation was considered the cause of the pain.
We report a case of a mesenteric desmoid tumor of the small intestine which caused acute abdominal pain, and required emergency surgery.

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An 80-year-old woman was admitted due to a large mass in the pelvic cavity found on ultrasonography screening. Abdominal CT scan showed two masses in the pelvic cavity : one was a ventral mass, approximately 10 cm in diameter, containing both solid material and fat ; the other was a dorsal mass, 15 cm in diameter, containing mostly fat. A pelvic liposarcoma was diagnosed, and surgery was performed. During surgery, elastic, xanthochromatic, and smooth surface tumors were found 30 cm and 55 cm from the terminal ileum ; they were poorly demarcated from the wall of the ileum. On pathology, a low-grade, dedifferentiated liposarcoma arising from the ileum was diagnosed. A dedifferentiated liposarcoma arising from the intestine is rare. This is only the fifth case of large or small intestine liposarcoma reported in Japan and only the third small intestine case reported in Japan. We report this case of primary dedifferentiated liposarcoma of the ileum together with a literature review.

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A 37-year-old female with a history of endometriosis and pneumothorax related to menstruation presented with a bloody stool, and a cecal tumor was diagnosed on colonoscopy. On colonofiberoscopy and enhanced abdominal computed tomogoraphy, the tumor overhung the ascending colon. An appendiceal intussusception type V (Fink's classification) was diagnosed. A laparoscopic ileoceacal resection was performed. Endometriosis was present in the appendiceal intussusception based on postoperative pathology. In this paper, we report this case and review the relevant literature.

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An 80-year-old-woman was admitted to our department due to appearance of a mass in the right lower quadrant of the abdomen, with high fever and abdominal pain. She had a history of appendectomy 60 years ago and abscess drainage 30 years ago. Computed tomography (CT) scan of the abdomen showed a large abscess close to the cecal wall. Colonoscopy showed redness, edema and diverticulum of the cecum. We diagnosed an abscess from perforation of cecal diverticulum or neoplasma and planed the operation. During surgery, a giant tumor 10 centimeters long was found adjacent to the cecal wall. We performed ileocecal resection and resected the fistula by drainage tube. The mass, which contained a large quantity of mucus and necrotic tissue had a stump at the appendix. The cytological characteristics of the tumor were well differentiated adenocarcinoma which infiltrated the fibrous wall of the mass. Finally we diagnosed the tumor as mucinouscystadenocarcinoma of the remnant appendix after appendectomy.

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A 79-year-old woman with a diagnosis of interstitial pneumonitis eight months previous has continued a treatment with steroids and immunosuppressive drugs for the long term. She suffered an attack of abdominal pain in the right lower quadrant and abdominal fullness for a few hours. An abdominal computed tomography (CT) examination demonstrated pneumatosis coli from the ileocecal area to the descending colon, retroperitoneal emphysema and free air in the abdominal space.
We suspected perforation of the digestive tract and performed an emergency laparotomy. At the laparotomy, because we found some ascites including stool and the food residue and could not identify a perforated site anywhere in the entire gastrointestinal tract, we believe that the free air in the abdominal space occurred subsequent to interstitial pneumonia and then performed a drainage procedure.
We report a case of pneumatosis cystoides intestinalis (PCI) involving the large intestine during therapy of interstitial pneumonitis, and a review of the relevant literature.

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A 67-year-old woman visited our hospital for abdominal pain and distension. She was given a diagnosis of recurrent pseudo-obstruction associated with progressive systemic sclerosis (PSS) two years ago, and a transverse-colostomy was performed seven months after the first onset of intestinal obstruction because conservative treatment was not successful. She was hospitalized, and a conservative treatment with long tube drainage from the stoma was started. However her condition was not improved. Colonic volvulus and stenosis were found by abdominal computed tomography (CT) and colonoscopy, and subsequently surgery was performed. The wondering right colon was twisted 180 degrees clockwise around the stoma, but was not necrotized. We found the colon at the splenic flexure blind-ended proximal and distal segment with a mesenteric defect. Subtotal colectomy and ileostomy was performed. She was discharged in combination with parenteral nutrition and oral intake. This is a rare case of acquired intestinal atresia in an adult. Local ischemia and ongoing inflammation with further resorption of the devitalized segment and subsequent healing were likely involved.

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An 81-year-old woman was hospitalized due to abdominal pain and vomiting. She had undergone abdominal surgery at 27 years of age, and pulse steroids therapy for anti-aquaporin 4 antibody-positive neuromyelitis optica at age 80. Conservative treatment of methylprednisolone at 15 mg/day has been continued. Abdominal pain worsened on the third hospital day. On laboratory examination, counts of WBC and CRP were remarkably elevated, and abdominal computed tomography revealed free air in an abscess lesion of the abdominal cavity. Emergency operation was performed under the diagnosis of gastrointestinal perforation. Although perforation was not clear, we removed the anastomosis which had been made after the last operation because these areas were most contaminated. After operation, we confirmed that the colon near the anastomosis was perforated by a foreign body ; a scrap of a soft plastic pack containing spices. Although the plastic packaging material is not likely to cause a perforation, usage of steroids and/or the anastomosis shown in this case could induce an intestinal perforation. We reported this peculiar case with a review of the literature.

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A 57-year-old woman was admitted with a diagnosis of ileus due to an adhesion. Abdominal CT scan showed sigmoid colon and liver tumors. Therefore, a sigmoidectomy and an adhesiotomy were performed. On pathology, a sigmoid colon cancer was diagnosed ; the patient received chemotherapy. Subsequently, the liver tumor completely disappeared. However, 1-year after the operation tumor maker levels were found to be elevated ; CT scan revealed no evidence of tumor recurrence. Nevertheless, PET/CT detected intense FDG uptake at the paraaortic lymph node, and sigmoid colon cancer recurrence was suspected. Chemotherapy was restarted, and PET/CT was performed again. FDG uptake was decreased at the paraaortic node, and there was no intense uptake in other area. Radical surgery was performed, and on pathology, a foreign body granuloma (FBG) was found. Post malignant tumor surgery, FDG uptake by FBG can mimic tumor recurrence.

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The patient was a 79-year-old man who had an ileocecal resection and a low anterior resection for multiple cancers of the cecum and rectosigmoid in October 2009. The histopathological diagnoses were mucinous adenocarcinoma of the rectosigmoid and a well-differentiated tubular adenocarcinoma of the cecum. Adjuvant chemotherapy involving oral UFT + LV was given. After 10 months, computed tomography (CT) showed cystic lesions in the right lower abdomen, involving the ileum and colon anastomosis. Myxoma or metastatic tumors were considered, and a partial resection of the colon including the anastomosis was done in February 2011. The lesions were not continuous with the lumen of the colon and were diagnosed as metastatic lesions of mucinous adenocarcinoma on histopathology. The disseminated metastases at the drainage tube site was likely related to the previous surgery.

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We report a rare case of multiple left sided colon cancer with tumor thrombosis in the inferior mesenteric vein (IMV). A 64-year-old man was admitted for investigation of frequent diarrhea with hypokalemic myopathy and rhabdomyolysis. Colonoscopy showed rectal cancer. Preoperative enhanced computed tomography (CT) showed a tumor thrombosis in the inferior mesenteric vein. A low anterior resection with complete excision of the IMV with tumor thrombus was carried out. He also had early gastric cancer, so at the same time we conducted distal gastric resection. The sigmoid colon and rectum were fixed and hardening in the shape of a pillow for the neck. Histological findings of the superior rectum tumor showed type 3, SE, and those of the sigmoid colon showed type 4, SS. Both tumors were confirmed to be N2, (f) Stage IIIb. On pathology, it showed type 4 advanced cancers at the superior rectum and sigmoid colon.
Tumor thrombosis was demonstrated in the IMV and the length was 15 cm. Partial invasion was found in the wall of the IMV. Adjuvant chemotherapy FOLFOX4 was carried out in 6 courses, and he is currently alive with no recurrence for 3 years and 4 months after the operation.

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A 74-year-old woman who complained of abdominal pain and constipation had a total colonoscopy. She had never travelled abroad. On colonoscopy, an advanced ascending colon cancer was found, and, on biopsy, a moderately differentiated adenocarcinoma was diagnosed. At that time, a whitish flattened taenia was detected at the oral side of the tumor, and tapeworm was suspected. She was admitted for surgery. Preoperative deworming was performed by the instillation of 300 ml of Gastrografin into the duodenum under radiographic guidance. This caused a living tapeworm of about 3-meters to be discharged by defecation. We diagnosed the tapeworm as Diphyllobothrium nihonkaiense from the form of the scolex and the retrieved eggs. After the deworming, a right hemicolectomy with D3 lymph node dissection was performed. The postoperative final diagnosis was tub2, SS, N3, H0, P0, M0, stage IIIb. Her postoperative course was uneventful, and she was discharged on the 14th postoperative day.
This paper describes a case of an ascending colon cancer with a tapeworm found incidentally and extirpated preoperatively by Gastrografin. This case shows the importance of preoperative deworming when intestinal tract cestodiasis is diagnosed.

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A 47-year-old man had a total colonoscopy based on a positive fecal occult blood test. It showed a type 2 tumor with 1/2 circle in the anterior wall of the superior rectum. The biopsy offered a diagnosis of poorly differentiated adenocarcinoma. Preoperative diagnosis was SE, N1, H0, M0 cStage 3a. Also the preoperative examination showed the left pelvic kidney was also affected. We performed a laparoscopic low anterior resection in anticipation of the magnifying effect of laparoscopic surgery. We found multiple small liver metastasis during the operation. The pathological diagnosis was por, Ra, type 2, 40^∗ 40mm, pSS, pN2, sH3, sP0, ly3, v1, pPM (-), pDM (-), Stage 4. In this case, we faced rectal cancer with the left pelvic kidney, and expected that the operative view would be very narrow. But because laparoscopic surgery has a magnifying effect, we could operate easily although the narrow pelvic space created by the left pelvic kidney. In this case of rectal cancer with the left pelvic kidney, we considered that laparoscopic surgery was an effective method.

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A 59-year-old woman was found to have an intra-hepatic hypoechoic mass in the left lateral segment of the liver on ultrasound. She had no symptoms. Abdominal CT scan with contrast media showed a 2 cm, hypoattenuating nodule with an unclear margin. The differential diagnosis, included intrahepatic tumor, gastro-intestinal stromal tumor, malignant lymphoma, and inflammatory pseudotumor. Since the possibility of a malignant liver tumor could not be completely excluded, a laparoscopic tumorectomy was performed. On pathology, a granuloma with an eosinophil infiltration was found. Anisakis larva were noted in the center of the lesion. As a result, the lesion was diagnosed as extra-gastrointestinal anisakiasis. Although most anisakiasis is characterized by severe abdominal pain, anisakiasis can be asymptomatic during the initial infection phase. Herein, we reported this rare case of extra-gastrointestinal anisakiasis presenting as an asymptomatic liver tumor.

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An 86-year-old man was admitted to our hospital for liver metastasis due to colon cancer, with the tumor measuring 10 mm in diameter and located in segment 5, 7 months after he was operated on for synchronous cecal and sigmoid colon cancers. Total laparoscopic hepatectomy was performed because it might have been difficult for such an old man to receive anticancer and molecular-targeted drugs and the tumor was located in the surface of the liver at segment 5. An additional 2 laparoscopic hepatectomies were performed for a secondary recurring tumor located in segment 6 and for the third tumor, located in segments 3 and 8. The patient is now doing well and is cancer-free at 2 years 2 months after the initial colectomies.
Repeated laparoscopic hepatectomy is a curative and less invasive treatment and is suitable for elderly patients.

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Liver metastasis is found in approximately 20%-30% of patients with advanced colorectal cancer, and is an important prognostic factor of colorectal cancers. Liver metastasis of colorectal cancer often grows to form a tumor and rarely shows intrabiliary tumor growth.
A 72-year-old man who had undergone low anterior resection for Stage II rectal cancer two years earlier was pointed out an increased level of CEA at another hospital. Close examinations performed in our hospital revealed a liver tumor in the S4 of the liver. The tumor was preoperatively diagnosed as intrahepatic cholangiocarcinoma with intrabiliary tumor growth and hepatic resection was performed. The histopathological diagnosis, however, was liver metastasis of rectal cancer. We here present this case.

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A 74-year-old man was admitted to our hospital because of gallbladder stone, common bile duct stone, and acute cholangitis. Following endoscopic papillotomy for common bile duct stone, laparoscopic cholecystectomy was performed. During the surgery, we confirmed a spilled stone in the abdominal cavity and recovered it by a forceps. After the surgery, the patient had persistent fever and abdominal pain. Abdominal CT scan performed on the third postoperative day revealed massive free air and inflammatory hypertrophy of the duodenum. Intestinal perforation caused by intraoperative manipulation was likely, and emergency operation was done on the same day. Operative findings included pyemic ascites and inflammatory change mainly affecting the gallbladder bed, but no demonstrable perforated site was seen in the gut. Only lavage and drainage were performed. After the operation inflammatory reaction persisted. Abdominal CT scan revealed an image of a stone and abscess formation at the inferior surface of the liver. Conservative therapy was successful and the patient was discharged from our hospital on the 43^rd postoperative day. The patient had been followed in the clinic until around four months after the initial operation, when a tumor appeared at the right region of back. Abdominal CT scan revealed an abscess in the abdominal wall continued from the inferior surface of the liver and high signal areas suggestive of stones in the subcutaneous structure. On the same day we performed incision and drainage for the abscess and removed a total of four stones 5 mm in diameter from the surgical wound. Thereafter abdominal CT scan disclosed no stones. The postoperative course was satisfactory and the patient was discharged.

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Acute cholecystitis is a common disease, but hemorrhage of the gallbladder is a rare complication. We report a case of hemorrhage of the gallbladder with intraperitoneal bleeding. A 48-year-old man had been treated for alcoholic liver cirrhosis and chronic renal failure and had been undergoing hemodialysis. He visited a doctor for right upper abdominal pain and was diagnosed with acute cholecystitis. As conservative therapy was not effective and intraperitoneal bleeding was detected, he was shifted moved to our hospital. He underwent an emergency operation for suspected gangrenous cholecystitis. The gallbladder was enlarged and filled with fresh blood, and there was hemorrhage from the gallbladder wall, although there was no perforation. Cholecystectomy was performed. He was discharged on postoperative day 10. Hemorrhage of the gallbladder shoul be considered in the differential diagnosis of acute cholecystitis in which there are underlying disease complications, as in our case.

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A 77-year-old woman who had been given an oral anti-platelet drug for diabetes mellitus, hypertension, cirrhosis, and carotid arterial sclerosis visited a hospital because of a seven-day history of right hypochondralgia. Conservative therapy for acute cholecystitis was unsuccessful and, three days later, she was referred to our hospital. When she was first seen, she had moderate degree of acute cholecystitis, sepsis, and DIC. We considered percutaneous transhepatic gallbladder drainage (PTGBD), but the patient was not a candidate because of collection of ascites. ETGBD was unsuccessful as well and exploratory laparotomy was performed. As ten days had elapsed after the onset of symptom, she had been on internal medication of an anti-platelet drug, and she had cirrhosis, laparoscopic combined PTGBD was performed for probable risk of complications. After confirmed that no intraoperative bleeding occurred, we terminated the operation while an information drain was placed in the right subphrenic structure. She required artificial respiratory management after the operation, but the drain could be withdrawn on the second postoperative day. The postoperative course was uneventful and she was discharged from our hospital while PTGBD had been dwelt. Three months later, laparoscopic cholecystectomy was performed.
Since lparoscopic combined PTGBD is considered to be a drainage method of choice for acute cholecystitis, the case is presented here.

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We report a case of a very small pancreatic serous cystadenoma. A 43-year-old man was hospitalized for repeat pancreatitis. Computed tomography (CT) showed swelling of the pancreatic tail and dilatation of the main pancreatic duct at the tail. After the acute pancreatitis subsided, CT still showed dilatation of the main pancreatic duct in the tail ; no tumors were detected. Neither on endoscopic ultrasonography (EUS) nor on positron emission tomography (PET)/CT were tumor lesions visualized. Endoscopic retrograde cholangiopancreatography (ERCP) showed stenosis of the main pancreatic duct at the tail and dilatation of the distal duct. On cytology, pancreatic juice was negative for malignant cells. Since small pancreatic cancer could not be ruled out, the patient had a pancreatectomy of the body and tail along with a splenectomy. On pathology cuboidal epithelium (tubular and papillary), was found to be partly positive for PAS staining. A diagnosis of a serous cystadenoma, about 2 mm in diameter, in the main pancreatic duct was made.

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Pancreatic neuroendocrine tumors (pNETs) are rare but their detection has increased due to the development of medical checkup systems, and they are therefore garnering attention recently. Typical cases of nonfunctioning pNET appear to have an asymptomatic clinical course. We encountered a case of nonfunctioning pNET wherein the patient initially seemed to have intra-abdominal hemorrhage.
The patient was a 62-year-old woman who presented with sudden epigastric pain and was admitted to our hospital. Her left upper abdomen showed muscular defense. Laboratory data were almost normal, except for peripheral blood revealing slight anemia. CT revealed an enhanced mass that measured 80 mm in diameter and arose from the pancreatic tail, with bloody ascites adjacent to the tumor. Under the diagnosis of nonfunctioning pNET with intra-abdominal hemorrhage and without symptoms other than an excess of islet cell hormones, distal pancreatectomy combined with splenectomy was performed electively. The cut surface of the tumor showed scattered blood coagula. Histologically, the final diagnosis was well-differentiated neuroendocrine tumor (G2). Although the patient developed multiple metastasis of the liver at 5 months after the operation, no further treatment was performed and she died at 48 months after the operation.

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An 80-year-old woman was undergoing pylorus-preserving pancreaticoduodenectomy (PPPD-IVB-2, Billroth I method) for duodenal cancer when she was age 73. A PTCD tube was inserted for post-operative anastomotic stricture of the choledochojejunostomy. She had suffered mild cholangitis once per year after removal of the PTCD tube. Cholangitis increased in frequency after 6.5 post-operative years. She had repeated readmission for recurrent cholangitis. MRCP showed regurgitation of oral contrast at the choledochojejunostomy, but the intrahepatic bile duct was not dilated. Endoscopic retrograde cholangiography (ERC) showed no anastomotic stricture, but the jejunum at the anal side of the anastomosis of the choledochojejunostomy was kinked by adhesion and contrast media was in stasis at the oral side of the jejunum. We diagnosed that the cause of recurrent cholangitis was mainly food regurgitation, and performed gastrointestinal tract conversion surgery 7 years after the PPPD. She has been free from cholangitis since the surgery. Though post-pancreaticoduodenectomy recurrent cholangitis is relatively rare, surgery should be considered if conservative treatment does not control it.

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A man in his thirties was admitted to our hospital because of abruptly occurring pain in the left hypochondrium. Although he had no episode of trauma, a computed tomography showed an extravasation of the contrast medium in the upper pole of the spleen. Since his vital signs were stable, we selected to perform a transcatheter arterial embolization, which achieved hemostasis of splenic arterial branches. Despite not having any symptoms of heart failure, an echocardiography revealed cardiac dysfunction, after which he was diagnosed as having dilated cardiomyopathy. Laboratory data showed no evidence of a viral infection or other specific causes of non-traumatic splenic rupture. In cases of splenic rupture without history of trauma, the transcatheter arterial embolization for hemostasis could be an initial treatment strategy, which might give us enough time to make the right decision for the spontaneous rupture of the spleen.

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An 84-year-old man who had been in a nursing home because of hypertension, cerebral infarction and cognitive disorder was admitted to our hospital for nausea and bloody stool. He had a fever and tachycardia. Blood examination revealed elevated inflammatory reaction, and computed tomography (CT) showed hepatic portal vein gas, increased wall thickness of the colon and small intestine, and ascites. Although intestinal necrosis was suspected, conservative therapy was initiated, because of his advanced age and multiple comorbidities. His general condition gradually improved, and he began eating food on the 9th day and was transferred to a nursing home on the 55th day. Comparing the findings of a three-dimension angiography reconstructed by multi-detector row computed tomography from 13 hours after the onset of symptoms with that on the 8th day, it is believed that the patient suffered non-occlusive mesenteric ischemia (NOMI) on arrival, and recovered without laparotomy. There have been five case reports of NOMI with hepatic portal gas improved by conservative therapy in the Japanese literature. Both NOMI and portal gas are thought to be an index of critical illness, however, conservative therapy may be effective in selected patients whose general condition, abdominal findings, and image findings are improved by initial treatment.

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A 61-year-old woman was emergently admitted because of sickness during abdominal consultation. On admission, CT was performed for general examination. Subsequently, right breast cancer and a tumor on the left side of the abdominal aorta were identified. The abdominal tumor was preoperatively diagnosed as GIST originating from the mesothelium, and an operation was carried out. First, a muscle-preserving mastectomy was performed for the right breast cancer. Laparotomy was then performed ; however, severe hypertension as well as ventricular tachycardia occurred at the beginning of manipulation of the tumor. The resection was therefore abandoned. Subsequently, several tests were performed and the tumor was highly suspected to be a paraganglioma.
Re-operation was carried out 28 days after the first operation. The 70-mm tumor was growing in the retroperitoneal space. Eventually, the tumor was completely resected. Paraganglioma was pathologically diagnosed.
Paraganglioma is a tumor originating from a neural cell and is intraoperatively diagnosed in 2% of patients. In this case, the first operation was abandoned due to complications based on the outflow of catecholamine from the tumor. In case of a retroperitoneal tumor, preoperative examination considering possible paraganglioma is occasionally necessary. Furthermore, it is very important to preoperatively administer an α-blocker agent, in order to prevent the risk of intraoperative death.

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We report 2 cases of sporadic mesenteric fibromatosis with a review of the literature. Case 1 : A 48-year-old woman came to our hospital complaining of a left lower abdominal mass. A 9-cm-diameter tumor was detected by CT scan.
She underwent resection of the tumor. The tumor was located in the mesentery of the jejunum. Case 2 : A 24-year-old woman came to our hospital complaining of a left lower abdominal mass. A 6-cm-diameter tumor was identified by CT scan and MRI. Laparotomy revealed that the tumor was located in the mesentery of the sigmoid colon and adhered to the mesentery of the ileum. We performed partial resection of the sigmoid colon and the ileum. These tumors were histologically diagnosed as mesenteric fibromatosis. These patients survived without recurrence for 6 years (Case 1) and 1 year 4 months (Case 2) after surgery. Mesenteric fibromatosis is very rare in a patient without a family history of Gardner's syndrome or past history of abdominal surgery or trauma.

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A 77-year-old woman admitted to our hospital due to nausea and vomiting. Enlargement of the gallbladder was detected by abdominal CT scan and she was diagnosed with acute cholecystitis. As she had poorly controlled diabetes mellitus, PTGBD (percutaneous transhepatic gallbladder drainage) was carried out to improve inflammation. Ten days after admission, her transient abdominal pain and pre-shock status were successfully treated by fluid supplementation. Seven days after the initial episode, rapidly progressive anemia (Hb, 8.1g/dL to 5.4g/dL) was indicated. Immediate dynamic CT scan revealed ruptured aneurysm of the left gastroepiploic artery that was not detected by the initial CT scan. Urgent laparotomy was carried out and the partial omentectomy, including the aneurysm, and also underwent splenectomy and cholecystectomy.
Previous case reports of splanchnic artery aneurysm have indicated several pathogeneses for aneurysmal formation, such as segmental arterial mediolysis. However, pathological evaluation of our case demonstrated a ruptured pseudoaneurysm without specific pathogenesis. Further investigation is required to elucidate the mechanism of aneurysm formation.

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We present a case of retroperitoneal schwannoma in a patient with complete situs inversus. A 40-year-old man with complete situs inversus was referred for a retroperitoneal tumor. Abdominal CT and MRI revealed a 25-mm well-demarcated tumor between the inferior vena cava and abdominal aorta. We performed laparoscopic tumorectomy using 5 ports. Microscopically, the tumor consisted mainly of vaguely palisaded spindle cells containing nuclei mildly varying in size and shape. Immunohistochemical staining was positive for S-100 protein. The tumor was diagnosed as a schwannoma. This is the first case report of laparoscopic resection for retroperitoneal tumor in a patient with complete situs inversus in Japan.

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A 32-year-old woman treated 3 years ago for endometriosis presented with right inguinal pain during menstruation. We diagnosed it as Nuck duct hydrocele related to endometriosis. She underwent surgery in March 2010. The right inguinal hernia sac was opened, and its orifice continued to the abdominal cavity. The hernia sac with spots of hemosiderin confirmed endometriosis. The hernia sac was highly ligated and removed with the round ligament of the inguinal canal. She was complained of abdominal pain and anemia at 1 post operative day. Computed tomography (CT) showed intra-abdominal bleeding, and laparoscopic surgery was performed emergently. The bleeding was found in the injured right round ligament which was fragile with inflammation from the endometriosis. The bleeding was stopped using a bipolar electric knife and surgical clip. The second operative course was uneventful. It was considered that the round ligament in inguinal hernia repair should be operated on as gently as possible in patients with endometriosis.

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A transomental hernia is rare, but it can lead to a strangulation ileus. We reported a case of strangulated obstruction caused by a type B transomental hernia (Yamguchi's classification). A 39-year-old woman with upper abdominal pain was diagnosed as having a bowel obstruction and was referred to our department. She had no history of previous laparotomy. Abdominal computed tomography showed massive ascites and marked dilatation of the small intestine. An emergency operation was performed since a strangulated ileus was suspected. The greater omentum exhibited remarkable thinning and atrophy, forming many hiatuses. The small intestine had incarcerated via the omental bursa, exhibiting a type B transomental hernia (Yamaguchi's classification).
The strangulated intestinal loop was released, and the affecting greater omentum was resected. The postoperative course was unremarkable, and the patient was discharged on hospital day 12. The differential diagnosis of intestinal obstruction must include incarceration by a transomental hernia, especially in the absence of previous surgery. This is the first case of a type B transomental hernia (Yamaguchi's classification) reported in Japan.

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An 82-year-old woman had had recurrent bouts of pain from the right hip joint to the inside of the thigh since two years earlier of which cause had been unknown by close exploration performed at every bout. She developed severe pain at the same area during hospitalization in the department of medicine in our hospital for pulmonary aspergillosis, and then we were consulted. On physical examinations, an induration about 1 cm in diameter was felt at the inside of the right thigh, and there was severe tenderness at the same area. Howship-Romberg sign was positive. An abdominal CT scan showed a calcified mass 12 cm in diameter at the interstitium between the right external obturator muscle and pectineal muscle. An abdominal CT scan performed 2 years before showed a similar calcified mass about 8 mm in diameter in the pelvis at the anterior surface of the sacrum. Accordingly a peritoneal loose body might have impacted in the obturator hernia to cause a severe pain. After removal of the foreign body in the obturator hernia via inguinal approach and repair of the obturator hernia, the symptom disappeared thereafter.
We present this case in which a peritoneal loose body impacted in the obturator hernia might cause pains in the inside of the thigh, together with a review of the literature.

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Umbilical hernia in an adult leads to incarceration if elective surgery is not performed. It is important that elective surgery is done safely to avoid incarceration. This paper describes four adult patients with liver cirrhosis and a large quantity of ascites. Case 1 : 49-year-old woman, case 2 : 42-year-old man, case 3 : 73-year-old man, case 4 : 47-year-old woman. Only case 3 had type C hepatitis with cirrhosis, the others were alcoholic cirrhosis, and all patients underwent elective surgery. A circle-shaped skin incision was made on the abdomen surrounding the navel as the center, and the hernia sac along with the navel was dissected out under local anesthesia. Ventralex Hernia Patch^® (VHP) was inserted into the peritoneal cavity through the defect and was stitched to the edges of the hernia defect. There were no serious complications, although one patient had leakage of ascites. There was no recurrence within one year after the operation. Therefore, we were able to perform elective surgery safely using VHP for patients who had liver cirrhosis with a large quantity of ascites.

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