The purpose of our study was to compare different thyroidectomy techniques for patients with Graves' disease. A total of 124 consecutive patients with Graves' disease underwent thyroid surgery between January 2000 and April 2012 at our hospital. Preoperative, intraoperative, and postoperative variables were analyzed. Reasons for thyroid surgery included : persistent disease despite medical therapy (52%), side effects of medical therapy (33%), ophthalmopathy (8%), multinodular goiter or cold nodules (6%), and patient preference (1%). A total of 124 surgeries was performed : 30.6% (n = 38) were subtotal thyroidectomies (ST), 33.9% (n = 42) were super-subtotal thyroidectomies (SST), and 35.5% (n = 44) were total thyroidectomies (TT). The average gland weight for ST, SST, and TT was 109.4 g, 80.5 g, 88.9 g, respectively. There was no difference in the operative time or the postoperative complication rates (recurrent laryngeal nerve palsy, postoperative bleeding, and tetany). Recurrences occurred in 10.5% of the ST group and 4.8% of the SST group. TT for patients with Graves' disease can be performed safely compared to ST or SST, and there is almost no risk of recurrence. Therefore, TT is recommended for the surgical treatment of Graves' disease.

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Breast cancer that develops during maintenance dialysis should be carefully treated due to problems concerning vascular access of the affected side and pharmacotherapy. In this study, we examined 4 patients who were treated for breast cancer that had developed during maintenance dialysis.
The patients were women aged 50-75 years, one of whom had an internal shunt on the affected side. They underwent total mastectomy or breast conservation for the breast lesions, and dissection or sentinel lymph node biopsy of the axillary lymph nodes. The operative duration was 53-143 minutes, and the amount of bleeding in all patients was small. Regarding anticoagulant therapy, nafamostat mesilate was administered for the first dialysis after surgery. As postoperative adjuvant chemotherapy, standard-dose hormone therapy was administered to all patients, and a standard dose of tegafur/uracil was included for 1 patient. Standard-dose radiotherapy was administered to the patients undergoing breast conservation. All patients are alive without dialysis-related problems or recurrence at 1 year 1 month to 5 years 3 months after the surgery.

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There are many arguments about whether surgical resection or drug therapy is better for pulmonary metastasis after breast cancer surgery. We investigated the therapeutic outcome of patients with pulmonary metastasis from breast cancer at our institution. Between January 1999 and September 2012, nine patients underwent metastatectomy for metastatic breast cancer. Seven cases were isolated nodules, and the possibility of primary lung cancer in four cases was in doubt prior to the operation based on chest CTs. The median disease-free interval (DFI) was 5.4 years (1.1∼12.6), the median survival time was 61.6 months, and the the 5-year overall survival rate was 72.9% after metastasectomy. Long-term survivors were seen in cases that had a long DFI. Drug changes were effective in patients where a receptor change was seen after drug therapy. When recurrence occurred, drug resistance was doubted, and surgical resection is useful for the purpose of the reevaluation of the receptor.

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It is believed that obturator hernias predominate in slender aged women. Incarceration of the intestine into the obturator foramen can frequently cause intestinal obstruction with resultant circulatory disturbance. It demands emergency treatment and early diagnosis is important. However, obturator hernia lacks in physical findings which can be observed from the surface of the body and is comparatively rare, so that the disease is liable to be overlooked. In a series of 132 cases undergone emergency operation with the diagnosis of intestinal obstruction in our hospital for the past three years, obturator hernias represented 9.1% (12 cases), showing a fact that the patients with the disease accounted for some ratio in the total ileus patients. All the 12 patients could be diagnosed by symptoms, detailed questioning, and abdominal CT scanning. In performing surgery for the disease, we often have difficulties in repairing the hernia opening. In our institution, we employ the mesh repair even for patients who require bowel resection by applying our own devices in which the hernia opening is repaired by the preperitoneal approach via a small lower abdominal median incision. Compared to the conventional inguinal approach or lower abdominal median laparotomy, this approach has many advantages and appears to be a rationale and valuable operative procedure.

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We present a case of papillary thyroid carcinoma developed 12 years after liver transplantation from a brain-dead donor.
A 49-year-old man who had undergone liver transplantation from a brain-dead donor for familial amyloid polyneuropathy at an overseas hospital 12 years earlier had been followed in a Japanese hospital while he was given an immunosuppressant. Ultrasonography of the carotid artery received at a brain dock incidentally detected a thyroid tumor. As a result of close examinations in our hospital, papillary thyroid carcinoma was diagnosed. Left thyroid lobectomy and isthmectomy were performed with left D2a dissection.
It is believed that the use of immunosuppressant after organ transplantation may result in an increase in incidence of having malignant tumors. Further increase in the number of long-term survivors due to improving outcomes of organ transplantation might increase the number of patients who experience malignant disease after the transplantation.

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A 13-year-old girl presented with asymmetric breasts 18 months earlier. She visited a neighboring clinic and was referred to our hospital. A firm, elastic, well-defined tumor measuring 9 cm was found on palpation. On ultrasonography, the tumor was found to occupy nearly the entire left breast and compress the normal breast tissue laterally. We suspected juvenile fibroadenoma based on the clinical findings and core needle biopsy pathology. The tumor was resected using an inframammary incision under her left nipple without injuring the normal breast. Juvenile fibroadenomas usually enlarge rapidly in adolescent breasts. It is important to distinguish juvenile fibroadenoma from a phyllodes tumor. The postoperative pathological examination revealed juvenile fibroadenoma. She has had no recurrence 2 years postoperatively. She has no obvious deformity and her left breast is symmetric with her right breast. It is important to preserve a functional, cosmetically acceptable breast because juvenile fibroadenoma is a common benign tumor among young adolescents.

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A 63-year-old woman was found to have an abnormal thoracic shadow at a regular health examination, and she was referred to our department. Thoracic computed tomography (CT) showed a tumor in the anterior mediastinum, with suspected invasion of the right lung, bilateral brachiocephalic veins, and superior vena cava, as well as pleural dissemination. Thymoma was diagnosed by CT-guided biopsy, and the decision was made to perform surgery. The operation was started with median sternotomy in the supine position, and after the thymus had been divided as far as possible, the bilateral brachiocephalic veins and superior vena cava were reconstructed with artificial graft, and the wound was closed. The patient was moved to the left lateral decubitus position, and the right upper and middle lobes of the lung were also resected via a 5th intercostal thoracotomy with an anteroaxillary incision and the lung, thymus, and tumor removed en bloc. Subsequently, the lesions of pleural disseminasion were also resected as far as possible. At present, 6 years after surgery, no recurrence of thymoma has been observed. Therefore, we consider surgery with the aim of total macroscopic resection to be an effective method for stage IVa thymoma.

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A 59-year-old man with lower abdominal pain was referred to our hospital. Enhanced abdominal computed tomography (CT) revealed a 72×72-mm abdominal aortic aneurysm (AAA) and a 51×39 mm distended appendix. We diagnosed AAA concomitant with appendicieal mucocele. An emergency single-stage surgical operation for both was performed to avoid rupture. First, an aneurysmectomy and Y-graft replacement was performed, then, the graft was wrapped by the aneurysmal wall and the retroperitoneum was closed. Second, an appendectomy was performed. The patient was discharged on postoperative day 19 uneventfully.
We report a case of a single-stage operation for abdominal aotic aneurysm concomitant with appendicieal mucocele.

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The patient was a 63-year-old man who had undergone an anterior resection for sigmoid colon cancer in October 2001. He had been diagnosed as pStage IIIa (tub1, ly1, v0, SS, N1, H0, P0, M0) and had had adjuvant chemotherapy. He was diagnosed as having multiple lung metastases in June 2004, and chemotherapy was given. However, the lesions continued to gradually progress. Thus, a VATS right pulmonary wedge resection was performed in December 2004. A VATS left pulmonary wedge resection was performed in December 2004. In Fevruary 2008, a chest CT scan revealed a recurrence of a right lung apex metastasis and a right anterior chest wall metastasis. Radiation therapy for the right chest wall metastasis was given in March 2008, and then chemotherapy was given. The right pulmonary metastasis disappeared, and the residual chest wall tumor was resected. On pathology, a colon cancer metastasis was diagnosed. Subsequently, the right pulmonary metastasis recurred and was resected. Since then, no recurrences have been observed. Few cases of colon cancer metastasis to the chest wall have been reported. Radical resection can result in disease-free survival in certain cases.

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A 17-year-old woman was admitted to our hospital because of chest pain with a rapidly enlarging mass arising in the anterior chest wall. Chest CT revealed a tumor 3 cm in diameter at the right anterior chest wall. Following incisional biopsy, the tumor was diagnosed as well-differentiated chondrosarcoma. Extended excision was performed and a pathologically free surgical margin was obtained. The pathological diagnosis of the resected specimen was chondrosarcoma (grade 1). The chest wall defect caused by the resection of the stemum and the ribs was reconstructed with artificial products and implantation of the pedunculated latissimus dorsi muscle and a skin flap. Thirty-three months have passed since the operation, and the patient is currently disease-free.

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The patient was an 85-year-old woman who had been conservatively treated at another hospital for six months because of fractures of multiple bones including the right rib caused by involvement in a motor vehicle accident in December 2009. In May 2011 she was referred to our hospital because of constipation and abdominal pain. Abdominal CT scan revealed that small intestines had prolapsed into the thoracic cavity through a defect of the right diaphragm and further prolapsed from the ninth intercostal space to the outer layer of thoracic cage. Traumatic transdiaphragmatic intercostals hernia (TIH) was diagnosed. Operation was performed via the transthoracic approach from an area right above the hernia sac. The small intestines and the greater omentum adhered to the thoracic wall were reduced to the abdominal cavity, and the diaphragmatic defect was closed by sutures using non-absorbable thread. As for the intercostal hernia, we performed closure of the pleura followed by plication suture of the superior and inferior ribs. The patient remains in good condition without clinical and radiological evidence of disease recurrence.
TIH is a rare condition and so far only 18 cases have been reported in the world. This approach that we selected for the patient is an excellent operative procedure because the diaphragmatic defect could be situated under the surgical wound and the intercostal defect as well as the diaphragmatic defect could be easily repaired.

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A 62-year-old woman consulted a local hospital after she was informed of an abnormality in the mediastinal shadow on her chest radiograph. Upper gastrointestinal series revealed no apparent abnormalities ; however, lower gastrointestinal series and CT scan revealed that the transverse colon had migrated into the mediastinum through the esophageal hiatus. Therefore, the patient was referred to our department for surgery. Subsequently, we performed laparoscopic surgery. We found that the transverse colon and the omentum did not contain ischemic-necrotic lesions and were incarcerated through the esophageal hiatus and that the gastroesophageal junction and the gastric fundus remained in their normal positions. We sutured the hernial orifice and performed a Toupet fundoplication. Neither complications nor recurrence has been reported during the first postoperative year.

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In the case of therapy for cervical esophageal cancer, especially superficial cancer, it is difficult to decide between excision or chemoradiotherapy in terms of radical cure and laryngeal conservation in consideration of the quality of life (QOL). Herein, we report our experience with a case of extensive superficial esophageal cancer wherein successful preoperative chemotherapy allowed laryngeal conservation. The patient was in his sixties man who was diagnosed as having extensive superficial esophageal cancer ranging from the esophageal orifice to the lower thoracic esophagus (Ce-Lt, sq, cT1b [SM2] N0M0 Stage I). In order to achieve laryngeal conservation and to obtain the stump on the oral side, preoperative chemotherapy (docetaxel/5-fluorouracil/cisplatin) was administered. Although the biopsy result for the mucous membrane was negative, surgery was performed because PET revealed persistent accumulation. Intraoperative rapid diagnosis confirmed that the stump on the oral side was negative for tumor, which permitted high-level esophagogastric anastomosis and radical surgery. Moreover, the results for the resected specimen indicated pathological complete remission. In case of esophageal cancer wherein long-term survival can be expected, an dffective combination of surgery, chemotherapy, and radiotherapy allows for treatment with maintenance of the QOL.

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We report a case of esophageal basaloid squamous cell carcinoma (BSCC) treated with salvage esophagectomy for the local recurrence after the definitive chemoradiotherapy (CRT). A 60-year-old man was seen for advanced pharyngeal cancer and found to have a synchronous early middle thoracic esophageal BSCC by screening endoscopy, and a consecutive CRT was attempted to control both cancers. Despite good control of the pharyngeal cancer, the patient developed local recurrence of esophageal BSCC one year after CRT and underwent a salvage esophagectomy. The histopathological stage was pStage I and no remarkable effect on the tumor from the CRT was observed (Grade 0). Microvascular invasion was not observed. The patient has survived 58 months since the salvage esophagectomy (84 months since the primary treatment) without any evidence of recurrence. BSCC of the esophagus has been reported with highly positive pathological microvascular invasion, even in early cancer, with poor prognosis. We considered that CRT using a combination chemotherapy of cisplatin and 5-FU was insufficient, therefore multi-modality treatment may provide a survival benefit for the patients with Stage I BSCC of the esophagus.

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Calcification in gastrointestinal stromal tumor (GIST) is rare. Here we report a case of GIST of the stomach presenting with progressive calcification during imatinib treatment. A woman in her sixties was found to have a 5-cm diameter submucosal tumor of the stomach. It was diagnosed as gastrointestinal stromal tumor (GIST) of the stomach. Exploratory laparotomy revealed multiple nodules disseminated in the abdominal cavity. The histological diagnosis of GIST was made on the excised nodules, and the tumor was found to possess a missense point mutation at exon 11 of KIT gene. Oral treatment with imatinib at 400 mg/day was started. Two months after the treatment, the size of the tumor was reduced, and the density became darker. Fifteen months after initiation of the treatment, calcification was detected in the tumor. The calcified area progressively increased reaching 15.4 % of the section of the tumor 68 months after the initiation, though the tumor growth had been suppressed. Calcification appeared to be associated with the degeneration of the tumor caused by imatinib treatment. It is thus concluded that calcification may reflect the efficacy of imatinib treatment for GIST.

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An 86-year-old man was admitted to a local hospital because of abdominal pain, vomiting, and abdominal distention. He had undergone distal gastrectomy for gastric cancer when he was 67 years old. Abdominal radiograph examination revealed a markedly dilated intestine. Sigmoid colon volvulus was suspected on the basis of colonoscopy. Reduction of the torsion was attempted through colonoscopy but was not successful. As it appeared that surgical detorsion was necessary, he was referred to our hospital. Abdominal CT revealed a large amount of free air and ascites. Under the preoperative diagnosis of diffuse peritonitis, an emergency operation was performed. During the operation, we found that the patient had a long transverse colon that had adhered to the operation scar and had bent and that a hiatus had been formed because of the bending of the colon. The small intestine had prolapsed through the hiatus and had been incarcerated in the form of an internal hernia. The transverse colon had twisted 180°because of the friction of the prolapse, with necrosis. After detorsion, resection of the transverse colon and colostomy were performed. We have reported this case because cases of volvulus of the transverse colon with internal hernia occurring after gastrectomy are very rare.

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A 71-year-old man was referred to our hospital for further examination and treatment, based on a previous contrast study. The contrast study showed three lesions suspected as gastric carcinoma. Upper endoscopic examination showed four lesions contained another lesion from a previous study. Computed tomography (CT) showed the swollen lymph node of the lesser curvature of the stomach. We diagnosed this case as four synchronous gastric carcinomas. Total gastrectomy with Roux-en-Y reconstruction and D2 lymph node dissection was performed. Macroscopically we found other two lesions. Total segmentation showed another lesion. Finally, postoperative pathological evaluation disclosed seven gastric carcinoma lesions. The gastric carcinomas were well to poorly differentiated tubular adenocarcinoma and signet ringcell carcinoma. Recently, synchronous multiple gastric carcinomas have been increasingly reported. However most of them are only two or three lesions. The synchronous gastric carcinoma in seven lesions like this case seems to be rare. This case is presented here with some bibliographic consideration.

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An 85-year-old man was brought to hospital on an emergency basis with chief complaints of lower abdominal pain and fever. Although inflammatory findings were mild, he had symptoms of intestinal obstruction and persistent abdominal pain. Contrast-enhanced abdominal computed tomography (CT) showed an increased concentration in the fatty tissue surrounding the intrapelvic small intestine. Since strangulated ileus could not be ruled out, emergency surgery was performed. On laparoscopic examination, a Meckel's diverticulum showing gangrenous changes was seen approximately 40 cm proximal to the terminal ileum. No perforation was present, and surgery was completed by resecting the small intestine. The patient's postoperative course was uneventful. Meckel's deiverticulum is considered relatively rare in the elderly population, and its preoperative diagnosis is often difficult. A case of gangrenous Meckel's diverticulum in an elderly patient that was diagnosed and treated laparoscopically is described, along with a review of the relevant literature.

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A 63-year-old man presented to our emergency department with the chief complaint of right flank pain for 3 days. Abdominal CT revealed an ileocecal abscess with extraintestinal gas and mutiple diverticulum. Emergency ileocecal resection was performed based on the diagnosis of panperitonitis and revealed an ileocecal abscess with purulent ascites. Moreover, there were 9 jejunum diverticula located 10-70 cm from the ligament of Treitz, but no resection was performed because there was no sign of infection or perforation. The specimen revealed an ileocecal abscess due to perforation of the ileal diverticulum which was diagnosed as a true diverticulum by histopathological analysis. The patient was discharged on the 13th postoperative day. Perforation or penetration of the ileal diverticulum is rare and is difficult to diagnose in the emergency room. As the prognosis is poor for patients with perforation, emergency laparotomy should be considered at an early stage for suspicious cases.

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A 72-year-old man with a previous history of percutaneous coronary intervention, coronary artery bypass surgery, aortic valve replacement, and laparoscopy assisted distal gastrectomy, developed abdominal pain after dinner and was admitted to our hospital. An abdominal computed tomography (CT) scan revealed intra-abdominal free air and ascites. The patient was thus diagnosed as having gastrointestinal perforation and underwent partial resection of the small intestine to treat the small intestinal perforation. A histopathological examination indicated that the small intestinal perforation was caused by cholesterol crystal embolization (CCE). The patient was discharged but readmitted to our hospital 7 days later due to abdominal pain. Free air and ascites were again noted on a CT scan, and the patient was again diagnosed with a gastrointestinal perforation, which was treated with another partial resection of the small intestine. However, he died 28 days postoperatively because of an anastomotic leak or a new perforation. Histopathological findings again revealed cholesterol crystals in the resected small intestine. CCE is a disease with poor prognosis that is caused by the release of cholesterol crystals from atherosclerotic plaques. We should be aware of the possibility of CCE when we encounter a patient with an acute abdomen.

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A 77-year-old woman was admitted to a local hospital for fracture of the femur. On the second hospital day, she complained of severe abdominal pain involving shock, and CT revealed free air in the abdominal cavity. She was transferred our hospital and we conducted emergency surgery ; she was diagnosed with peritonitis due to digestive tract perforation. The operative findings showed a perforation of the ileum which was located anal side 200cm from the ligament of Treitz, with 2 circular ulcers located on the anal side of the perforation site. Partial resection of the small intestine was performed. The histopathological findings of the resected specimen revealed inflammatory cell infiltration of the fullthickness of the intestinal wall and epithelioid granulomas containing Langhans' giant cells with caseous necrosis. Based on these findings, we diagnosed the patient with intestinal tuberculosis. As Mycobacterium tuberculosis infections have increased in recent years, we should consider intestinal tuberculosis as a cause of intestinal perforation.

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A 73-year-old man with no history of abdominal surgery visited our hospital with a chief complaint of abdominal pain. He was admitted after a diagnosis of ileus was made on abdominal computed tomography (CT). Intestinal decompression was performed by inserting a decompression tube. Contrast-enhanced imaging using the decompression tube showed findings suggesting obstruction of the ileum by a tumor, and surgery was indicated. Laparoscopic observation of the abdominal cavity confirmed obstruction of the ileum by a tumor, which was exposed on the serosal side and infiltrated the transverse colon. White nodules suggesting peritoneal dissemination were seen throughout the abdominal cavity. Following conversion to laparotomy, partial resection of the ileum and transverse colon was performed. Some of the white nodes were removed for biopsy. On pathological examination, an adenocarcinoma was seen suspended in a large amount of mucus in the tumor and white nodes, and a diagnosis of mucinous adenocarcinoma of ileal origin, classified as se, n0, H0, P3, M0 stage 4, was made. The patient had no complications and was discharged, and he has been undergoing chemotherapy as per colon cancer guidelines on an outpatient basis. In cases of small intestinal ileus without a history of laparotomy it is considered necessary to perform decompression using a decompression tube and detailed examination, given the possibility, albeit small, of ileus secondary to primary small intestinal cancer.

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An 86-year-old woman was admitted to the hospital complaining of vomiting. Abdominal enhanced CT revealed a cystic lesion that extended retroperitoneally from the cecum to the dorsal kidney and diaphragm, and a portion of the cystic wall was enhanced. MRI revealed a 22 cm × 7 cm × 6.5 cm diameter cystic lesion, and found that the ovaries were normal, but not the. The tumor markers CEA and CA19-9 were elevated. Preoperative diagnosis was mucinous cyst adenoma or adenocarcinoma of the appendix. We performed ileocecal resection and removal of the D3 lymph nodes. Macroscopic findings of the resected specimen revealed a giant cystic tumor measuring 25 cm × 9 cm × 8 cm diameter. Histological diagnosis was mucinous cyst adenoma of the appendix. A giant mucinous cyst adenoma extended retroperitoneally is rare. Therefore, we report this case with a review of the literature.

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A 75-year-old man arrived at our hospital by ambulance due to abdominal pain and fever and was admitted under a diagnosis of iliocecal abscess due to acute appendicitis. The abscess increased despite conservative treatment ; therefore, we performed percutaneous drainage on hospital day 13 and he was discharged on day 28.
Subsequently, colonoscopy revealed a tumor protruding from the appendix and biopsy revealed that it was a tubular adenoma requiring laparoscopic ileocecal resection. The resected pedunculated tumor of the appendix measured 15 × 10 mm and the histologically confirmed diagnosis was tubular adenoma. The postoperative course was complicated by an umbilical wound infection and retroperitoneal emphysema, but these were cured by conservative treatment. He was discharged on postoperative day 30. A preoperative diagnosis of rare benign adenoma of the appendix is a good indication for laparoscopic surgery.

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An 81-year-old woman underwent laparoscopically assisted low anterior resection and partial resection of the transverse colon at out department for rectal cancer and transverse colon cancer. Based on histopathological tests, the rectal lesion was diagnosed as tub1-2, type 0-IIa, pSM, int, INFb, ly0, v0, pN0, pPM, pDM0, pRM0, pStage I rectal cancer. In addition, Schistosoma japonicum eggs showing calcification were seen in the submucosa of the rectal lesion. Reports of rectal cancer presenting with Schistosoma japonicum eggs in areas not endemic for schistosomiasis japonica are exceedingly rare. Lesion in the transverse colon was diagnosed as carcinoma in adenoma with 50×30mm in size. The present case is reported along with a review of the relevant literature.

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A 64-year-old woman with upper abdominal pain was admitted to our hospital. Plain computed tomography (CT) scan and colonoscopy showed advanced descending colon cancer. A followup enhanced CT scan revealed thromboembolic occlusion of the superior mesenteric artery with localized ischemic change of small intestine. Additionally, thromboses in the main right pulmonary artery, descending aorta, left femoral vein, and superior mesenteric vein were found. An emergency thrombectomy and resection of the ischemic small intestine were performed, followed by systemic anti-coagulant treatment. Although malignancy often cause venous thromboembolism by malignancy-induced abnormal coagulation and fibrinolysis, arterial events are quite rare. Furthermore, to our knowledge, a case of malignancy which developed acute thromboembolic occlusion of the superior mesenteric artery has never been reported previously in our country.

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A solitary duodenal metastasis of colon cancer is very rarely a site of recurrence. A 73-year-old woman underwent sigmoidectomy for sigmoid colon cancer in 2007. Macroscopically, the tumor was type 2, and 40×30 mm in size. Histopathological examination revealed tubular adenocarcinoma (se, n3, ly3, v2, p1, stage IV). She received fluorouracil and irinotecan hydrochlorede-based adjuvant chemotherapies for 10 months. Forty-six months after the operation, she presented with nausea. Enhanced computed tomography (CT) demonstrated a type 2 tumor with stenosis in the third and fourth portions of the duodenum, leading to a diagnosis of moderately differentiated tubular adenocarcinoma. She underwent segmental resection of the duodenum. The histological examination revealed that the tumor was moderately differentiated tubular adenocarcinoma similar to the pathological findings of the previous colon cancer, with tumor cells invading the muscular layer from the serous membrane side. The definitive diagnosis was a solitary peritoneal metastatic tumor from sigmoid colon cancer.

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We often encounter the coexistence of colorectal cancer and an iliac arterial aneurysm. When each disease requires each emergency treatment, we have often difficulties in deciding that either treatment should precede the other. We present our experience with a case of sigmoid colon cancer with severe stricture associated with an iliac arterial aneurysm at a high risk of rupturing, in which we performed endovascular aneurysm repair flowed by sigmoidectomy. The case involved an 81-year-old man diagnosed with sigmoid colon cancer with severe stricture by colonoscopy. Furthermore, abdominal CT scan performed before operation revealed a 60-mm diameter right iliac arterial aneurysm. Both lesions needed emergency treatments, but we determined that the risk of rupturing of the iliac arterial aneurysm was higher than the other. Endovascular aneurysm repair was performed, followed by sigmoidectomy, on the 22^nd postoperative day. The postoperative course was uneventful and the patient was discharged from the hospital on the 19^th day after the second operation.
In the treatment of colorectal cancer associated with an iliac arterial aneurysm, the approach like ours in which surgery for colorectal neoplasm was preceded by endovascular aneurysm repair appears useful in terms of surgical invasion, shortening of therapy time, and the safety.

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A 38-year-old woman with severe obesity (BMI : 40 kg/m²) had a huge tumor in the right hepatic lobe. The tumor was 13×8 cm in size, with an intrahepatic metastasis in S3. On pathology of a tumor biopsy, a well-differentiated neuroendocrine tumor was diagnosed. A primary site other than the liver could not be found. On biochemistry, tumor marker and endocrine hormone levels were normal. On immunohistochemistry, tumor cells were positive for chromogranin and synaptophysin, and the Ki67 index was 4.3%. A pre-operative diagnosis of a nonfunctional primary hepatic neuroendocrine tumor (Grade 2) with intrahepatic metastasis was made. A surgical resection was done even though the patient was very obese and had a large tumor with an intrahepatic metastasis, since of the Ki67 index level was low and the tumor was well differentiated which indicated a low biological malignant potential. A right hepatic trisegmentectomy and RFA were performed for the intrahepatic metastatic tumor. The patient has been doing well and is without a reccurence after 2 years of postoperative follow up. Hepatic resection should be considered the first choice of treatment for primary hepatic neuroendocrine tumor in patients with low Ki67 index levels and well-differentiated tumors, even if an intrahepatic metastasis is present.

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An 85-year-old man visited a hospital because of a one-week history of right lateral abdominal pain revealed increases in the hepatobiliary enzymes and jaundice in bolld examinations. The patient was referred to our hospital with a suspicion of acute cholecystitis. Abdominal CT scan showed a swollen gallbladder and wall thickening. MRCP showed a low intensity area suggestive of hematoma inside of the gallbladder. Duodenal endoscopic study showed outflow of blood from the papilla of Vater. Cholangiography showed translucent filling defect in the bile duct. Abdominal angiography revealed extraversation of contrast medium at the fundus of the gallbladder. Hemorrhagic cholecystitis and obstructive jaundice due to hemobilia were diagnosed and emergency laparotomy was performed. Intraoperative Doppler ultrasound disclosed the bleeding site at the gallbladder fundus, and cholecystectomy was performed. Pathology revealed findings of gangrenous cholecystitis and a ruptured artery that had exposed in the ulcerated lesion at the gallbladder fundus.
Although hemorrhagic cholecystitis is a relatively rare entity, hemobilia can rapidly worsen the disease so that early treatment is important.

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We report a case of eosinophilic gastroenteritis. A 69-year-old man had been taking prednisolone 5 mg/day for asthma. Cholecystectomy and bile duct resection was performed for gall bladder cancer in October 2007. After surgery, fever, upper abdominal pain, vomiting, leukocytosis and liver dysfunction were frequently observed, and thought to be due to cholangitis. Symptoms were observed about once a month and urticarial lesion and facial flush were also observed. Symptoms improved in a few hours or half a day. Symptoms then occurred more frequently and severely. The number of peripheral eosinophilia and IgE level also increased. Abdominal computed tomography (CT) scan showed edema of the gastric wall, and gastric biopsy specimens showed massive eosinophilic infiltration. We had already guessed that this was a case of gall bladder cancer before the operation, because upper abdominal pain also occurred after the operation. We eventually diagnosed eosinophilic gastroenteritis, and performed pulse steroid therapy, and the symptoms improved dramatically. We were able to reduce prednisolone without recurrence.

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We present a case of cancer of the cystic duct remnant developed after laparoscopic cholecystectomy. The case involved a man in his seventies who had undergone laparoscopic cholecystectony for chronic cholecystitis 18 years earlier, and operation for lung cancer at the department of respiratory surgety in our hospital five years earlier. An increase in the CEA level was detected by a follow-up examination in the clinic. PET-CT revealed abnormal uptake of FDG around the hepatic portal region. The patient was then referred to the department of gastroenterological medicine in our hospital. ERCP revealed stenosis at the middle bile duct and disruption of the cystic duct remnant at a portion about one cm apart from the confluence. Abdominal CT scan showed an about 2-cm diameter tumor with early blush at the cystic duct remnant just under a clip used for the previous cholecystectomy and comparatively intact continuity was kept in the lumen of the cystic duct. Cancer of the cystic duct remnant was diagnosed and subtotal stomach preserving panreaticoduodenectomy was performed. The lesion was a 3-cm diameter irregular tumor associated with stenosis encircling the entire cystic duct remnant. Cancer invasion into the common hepatic duct, the pancreas head and the duodenum as well as lymph node metastasis were confirmed. The patient experienced metastasis to the hepatic portal lymph nodes nine months and died 22 months after the operation.

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Endocrine cell carcinoma rarely occurs in the bile duct, and cases originating in the cystic duct are exceedingly rare ; the case presented is only the fourth to be reported. The patient was a 58-year-old woman in whom a 3-cm, polypoid, elevated lesion with a well-defined border and smooth surface was observed in the middle bile duct. Since bile duct carcinoma was suspected, bile duct resection and D2 lymph node dissection were performed. The tumor was yellow, had the appearance of a pedunculated polypoid mass with a smooth surface, and originated in the cystic duct. Because it had prolapsed into the common bile duct, it appeared on imaging to be a bile duct tumor. Alveolar proliferation of small, round tumor cells having a high N/C ratio and rich in chromatin was seen, and positive results were obtained for chromogranin A and synaptophysin staining. Karyokinesis was seen in many cells, and the Ki67-positive rare was 50%. Based on the above findings, the patient was diagnosed with endocrine cell carcinoma. Endocrine cell carcinoma of bile duct origin has a poor prognosis due to early hematogenous metastasis, particularly liver metastasis. No chemotherapy has been established for this disease, and responses are often poor. IP therapy was given as adjuvant chemotherapy, and the patient remains recurrence-free 19 months after surgery.

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A 59-year-old woman admitted for fever and general fatigue was found to have a clear-margined mass at the lower part of the bile duct using computed tomography (CT) and magnetic resonance imaging (MRI). Endoscopic retrograde cholangiography showed a tumor occupying the lower part of the bile duct, and brushing cytology indicated small cell carcinoma of the bile duct. We performed subtotal stomach preserving pancreaticoduodenectomy and lymph nodes dissection under a diagnosis of small cell carcinoma of the bile duct. Finally we diagnosed it as small cell carcinoma of the common bile duct by pathological studies and immunohistochemical analysis. We administered cisplatin/etoposide as an adjuvant chemotherapy for four course based on the regimen of small cell carcinoma of the lung. The patient has been alive for 23 months without recurrence.

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Intraductal papillary neoplasm of the bile duct (IPN-B) is characterized by its pathological similarity to intraductal papillary mucinous neoplasms of pancreas (IPMN). We report a case of IPN-B which recurred 4 years after primary resection. A 76-year-old woman who presented with mild liver dysfunction was diagnosed as IPN-B in the hepatic hilum. We performed a left hepatectomy, caudate lobectomy, and extrahepatic bile duct resection. Histologically, the tumor was identified as non-invasive papillary adenocarcinoma, and it showed neither flat superficial spread nor invasion of the bile duct margins. Four years later, recurrence was found at the intrapancreatic portion of the bile duct on regular CT scanning. We performed a subtotal stomach-preserving pancreaticoduodenectomy. Long-term follow-up examination, such as CT scanning is necessary considering that IPN-B has a potential for recurrence after curative resection.

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We report a case of pancreatic trauma type IIIb in which pancreatic resection could be avoided by employing endoscopic pancreatic stenting and intraperitoneal drainage.
A 19-year-old woman who had fallen down at the stairs and got a bruise on the upper abdomen was brought into our hospital in March 2012. Abdominal CT scan showed pancreatic trauma and fluid collection around the superior mesenteric vein. Emergency endoscopic retrograde pancreatography (ERP) disclosed injury of the major pancreatic duct. Endoscopic nasobiliary drainage (ENBD) tube was thus placed. On the same day emergency operation was performed for intraperitoneal drainage. The postoperative course was uneventful and the ENBD was exchanged for endoscopic pancreatic stenting (EPS) on the 22nd hospital day. The patient improved progressively and was discharged from the hospital on the 39^th hospital day.

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A 40-year-old woman who was seen at the hospital because of upper abdominal pain was found having an 8-cm diameter tumor with an internal echo showing a heterogeneous pattern at the pancreas body by abdominal ultrasonography. Abdominal CT scan showed a sharply demarcated tumor with a low density center and a slightly high density margin. Dynamic CT scan did not enhance the tumor. No abnormal findings were noted on blood examinations and tumor marker tests. Based on preoperative imaging procedures, no definite diagnosis could be gained and a possibility of malignancy could not be ruled out. Accordingly we performed surgery. The tumor existed on the anterior surface of the pancreas body and was a sharply demarcated and elastic-soft oval-sphere. Incision drainage of the capsule of the surface resulted in overflow of massive hematoma. We removed these blood clots and the tumor including the entire capsule as far as possible, taking care not to injure the pancreas parenchyma at the back of the tumor. The histopathological diagnosis of the tumor was cavernous hemangioma. The postoperative course was uneventful and the patient was discharged from the hospital on the 12^th postoperative day.

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We report a case of portal vein stenosis due to pancreatic cancer that was successfully treated with intravenous stent implantation. The patient was a 49-year-old woman who had undergone a pancreatoduodenectomy with the modified Child's method for pancreatic carcinoma and was re-admitted due to melena and severe anemia 20 months after the operation. CT findings revealed that recurrence of pancreatic cancer had narrowed the portal vein and had caused hepatopetal collaterals adjacent to the choledochojejunostomy. Additionally, gastrointestinal endoscopy revealed an exposed vessel at the mucosa of the jejunum, close to the choledochojejunostomy. Bleeding from the varices increased and a hepatopetal collateral was considered to be the cause of the melena ; therefore, an intravenous stent was surgically placed at the site of stenosis of the portal vein. Subsequently performed portography revealed that the collaterals disappeared after the stent replacement and that no further episodes of gastrointestinal hemorrhage had occurred.

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Anaplastic pancreatic carcinoma is rare and is associated with poor prognosis. We encountered an extremely rare case of triple cancer that included anaplastic pancreatic carcinoma. A 71-year-old man was identified as having multiple liver tumors and a tumor near the pancreas head. After careful examination, he was diagnosed with a 2-cm cystic tumor on the dorsal side of the pancreas head, multiple hepatic hemangiomas, left ureter cancer, and right lung cancer. The patient first underwent an operation at the Department of Urology. However, he was referred to our department 1 month later because of obstructive jaundice caused by the rapidly growing pancreatic tumor. Given the sudden change, we strongly suspected that the tumor was malignant and performed a subtotal stomach-preserving pancreaticoduodenectomy. The solid tumor exhibited expansive growth, necrosis, and bleeding at the uncinate process of the pancreas. On postoperative pathological examination, the tumor was identified as a pleomorphic type anaplastic pancreatic carcinoma. We detected multiple liver metastases 2 months after the surgery and performed systemic chemotherapy, but the patient died 1 year 3 months after the surgery.

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Fistula formation is one of the complications of Crohn's disease, although spontaneous umbilical fistula in Crohn's disease is extremely rare. A 37-year-old man who presented with lower abdominal pain and frequent urination was referred to our hospital for examination of abnormality of the bladder. We diagnosed an urachal abscess on abdominal computed tomography (CT), drainage was performed through the umbilical. Intestinal fluid was discharged from the drain, and a fistulography revealed the urachus penetrating to the ileum. Thirty-seven days after drainage, the fistula did not close, so we performed a laparotomy. The terminal ileum and the sigmoid colon were found to be adherent to the urachus, resection of the urachus and the involved portion of the ileum, the sigmoid colon, and the bladder was performed. The resected specimen of the ileum showed a longitudinal ulcer and stricture. Histopathologically, the lymphoid follicles and ulcer were found in the ileum. He was discharged without complication on the 11^th postoperative day. Eleven months later, he underwent a colonoscopy due to frequent diarrhea and was diagnosed pathologically with Crohn's disease. We performed surgical treatment after drainage for spontaneous umbilical fistula in Crohn's disease.

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We report a rare case of ovarian cancer with fistula formation between the sigmoid colon. A 58-year-old woman was admitted to our hospital for continuous fever and lower abdominal pain with local muscle guarding. She had received chemotherapy for advanced ovarian cancer for 3 months. Abdominal CT scan revealed the ovarian tumor with a thicken wall and internal gas. These findings suggested ovarian cancer with fistula formation between the digestive tract. As the patient also had severe inflammatory response and peritonitis, emergency laparotomy was performed. At laparotomy there was no fecal matter in the peritoneal cavity. On surgical exploration, the right ovarian tumor had invaded the sigmoid colon, uterus and retroperitoneum, and contained fecal mass. Therefore, we diagnosed the case as right ovarian cancer with fistula formation between the sigmoid colon. Bilateral salpingo-oophorectomy, sigmoidectomy and sigmoid colostomy were performed. Histological examination revealed the tumor was squamous cell carcinoma of the ovary, but no viable cells in the fistula. As ovarian cancer complicated fistula formation between the digestive tract may involve severe inflammation, we should diagnose and treat it immediately.

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We report a rare case of disseminated peritoneal leiomyomatosis (DPL). A 57-year-old woman complaining of abdominal fullness and a mass underwent CT and MRI and was found to have intraperitoneal masses at the pelvic space. We diagnosed the case as recurrent DPL because she had undergone surgery for DPL 13 years before and we resected the masses with a part of the major omentum and ileum. Immunostaining of these specimens revealed positivity for smooth muscle actin, vimentin, estrogen receptors, and progesterone receptors. Staining results for c-kit and CD34 were negative. In view of this immunostaining appearance, we diagnosed the patient with DPL.

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Paracecal hernia is a rare disease among internal hernia, and preoperative diagnosis is very difficult. Computed tomography (CT) is useful for an accurate diagnosis of paracecal hernia. Paracecal hernia is often classified into the following four types : (1)superior ileocecal, (2)inferior ileocecal, (3) retrocecal recess, and (4) appendicular fossa.
The present case was a lateral type of paracecal hernia, which could not be classified as shown above. The Meyer's classification was more suitable for our case than the conventional classification.
CT findings were very characteristic of a lateral type in the Meyer's classification. Both the ileocecum and the ascending colon were displaced medially by the dilated small-bowel loop trapped in the hernia pouch as shown in the CT images.
Patients diagnosed with paracecal hernia often need to undergo emergent surgical treatment. CT examination is useful for the diagnosis of paracecal hernia when paracecal hernia is suspected.

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We experienced three rare cases of intersigmoid hernia. Case 1, a 34-year-old woman presented with left lower abdominal pain and vomiting with no history of abdominal surgery. On the third hospital day, abdominal pain became worse and an emergency operation was performed under a diagnosis of strangulated ileus. Case 2, a 36-year-old man presented with left lower abdominal pain. He had a past history of laparoscopic surgery 20 years earlier for duodenal perforation. Strangulated ileus was suspected on abdominal computed tomography, and an emergency operation was performed. Case 3, an 81-year-old woman presented with left lower abdominal pain and vomiting with no history of abdominal surgery. Conservative therapy was started but was unsuccessful, and an emergency operation was performed on the third hospital day. All cases were diagnosed as strangulated ileus preoperatively, and intersigmoid hernias were disclosed at laparotomy. We did not perform any resections of the small intestine.
Intersigmoid hernia is a very rare entity. We report here three cases together with a review of the literature.

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An 80-year-old man visited our hospital complaining of a right inguinal tumor with tenderness and loss of appetite for several days.
The inguinal tumor had strong tenderness, although peritoneal signs were not observed in the abdomen. Abdominal computed tomography (CT) scan showed wall thickening of the ileocecal region, slight swelling of the appendix and liquid accumulation in an inguinal hernia sac. Furthermore, the blood examination showed a high degree of inflammatory reaction.
He was thus diagnosed as incarceration of an inguinal hernia accompanied by intestine or greater-omentum necrosis, or appendicitis. An urgent operation was performed.
Operative diagnosis was an indirect inguinal hernia and abscess formation in a hernia sac. Since appendicitis was suspected as a cause of the abscess, the operative wound was extended and an appendectomy was performed.
We experienced a rare case of appendicitis with symptoms of incarceration from abscess formation in an inguinal hernia sac.

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