Backgrounds : Delayed gastric emptying (DGE) is said to occur from ischemia of the pylorus and we always pay attention to the blood flow in the pylorus so as not to induce ischemia, when we perform pylorus-preserving pancreatoduodenectomy (PPPD). Methods : We enrolled 221 patients undergoing pancreatoduodenectomy in our hospital from January 2000 to April 2011. These patients were divided into two groups, 168 undergone PPPD and 53 undergone subtotal stomach-preserving pancreatoduodenectomy (SSPPD) and were comparatively evaluated for demographics of the patients, postoperative complications including DGE, removal of nasogastric catheter and start of oral intake. Results : A total of 44 patients (19.9%) developed DGE, including 32 patients (19.0%) of PPPD group and 12 patients (22.6%) of SSPPD group. There was no significant difference in frequency of DGE between two groups. Conclusions : In performing PPPD, much attention to the blood flow in the pylorus so as not to induce ischemia and congestion might result in the frequency of DGE that is not significantly different from that of SSPPD.

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Patients with unresectable cancer often need palliative surgery to improve the quality of life. However, there have been few reports that examined the outcomes of the palliative surgical procedures. The aim of the present study is to clarify the effectiveness of the palliative surgery. Data on 165 consecutive patients who underwent palliative surgery in our department of gastrointestinal surgery were retrospectively analyzed in terms of survival, mortality, and leaving hospital. Food-intake was also examined in patients with bowel obstruction. Origins of these cancers involved 23 organs, including the pancreas in 24 patients, the ovary in 23, the stomach in 22, and 20 other organs. Reasons for palliative surgery were as follows ; malignant bowel obstruction in 124 cases, malignant fistula in 22 cases, obstructive jaundice in 10 cases, intestinal bleeding in six cases and intestinal perforation in three cases. The median survival time after the palliative operation was 4.5 months and the 30-day mortality rate was 12.7%. The operation enabled 60.6% of the patients to be discharged from the hospital. Higher mortality rate (31% P=0.007) was noted in emergency operations compared to elective operations. Among the patients with malignant bowel obstruction, the operation allowed 74% of the patients to take solid diets. The rate of oral intake was lower in patients with gastric cancer (45% P=0.004) and in those with multiple obstructions (63%, P=0.003). Palliative surgery can improve quality of life of the patients with unresectable cancer. Sufficient informed consent should be obtained especially regarding the high mortality rate.

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Background : Definitive chemoradiotherapy (dCRT) plays an important role in the treatment of esophageal cancer, however, many types of adverse events are caused by dCRT. Hematotoxicity is one of the most frequent and serious one. When we choose the method of treatment, how to predict the hematotoxicity becomes an issue.
Method : Twenty-five patients treated with dCRT (JCOG9906 regimen ; 5-FU/CDDP and radiation 60Gy) for thoracic esophageal cancer in our hospital from 2004 to 2009 were enrolled in this study to analyze CCL2/MCP-1-2518 A>G and IL-6-634 C>G genetic polymorphisms from DNA extracted from their peripheral blood by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). We investigated the hemototoxicity (decrease in white blood cell count and decrease in platelet count) from the initiation of dCRT until 3 weeks after the completion and retrospectively analyzed the relationships between the hematotoxicity and genetic polymorphisms.
Results : White blood cell decrease (CTCAE Grade 3 or higher) occurred significantly more in patients with the CCL2/MCP-1-2518 G/G genotype than in those with the A/G+A/A genotype. Platelet decrease (CTCAE Grade 2 or higher) occurred significantly more in patients with the IL-6-634 C/G genotype than those with the C/C genotype.
Conclusions : The hematotoxicity of dCRT for thoracic esophageal cancer can be predicted by the CCL2/MCP-1-2518 A>G genetic polymorphism and IL-6-634 C>G genetic polymorphism, which are related to the hematogenous functions.

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Purpose : The purpose of this study was to examine postoperative complications and delayed outcomes in patients who underwent surgical repair of Crawford II thoracoabdominal aortic aneurysm.
Subjects & Methods : We enrolled 15 patients operated on for Crawford II thoracoabdominal aneurysm out of consecutive 40 patients who underwent elective surgeries for thoracoabdominal aortic aneurysm in our hospital in a 6-year period from January 2006 to December 2011.
Results : No hospital death (0%) occurred, but there were two cases of delayed neurologic deficit. Four (27%) patients needed artificial respiration for more than 72 hours after the operation, and four (27%) patients developed renal failure which required postoperative hemodialysis. The five-year survival rate was 83.3%.
Conclusions : The surgical treatments of Crawford type II thoracoabdominal aneurysms for selected patients are considered satisfactory in terms of the surgical as well as long-term outcomes at present. Strategies and adjuncts for the surgery using at present are considered appropriate.

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Purpose : Treatment of perianal infection with febrile neutropenia is still controversial. The aim of this study is to investigate the efficacy of surgical intervention and the prognosis of patients with perianal infection with febrile neutropenia. By reviewing the previous literature, we searched for the appropriate treatment for this disease. Subjects & Method : Consecutive nine patients with perianal infection with febrile neutropenia were retrospectively reviewed. Their ages ranged from 18 to 75 and there were eight men and one woman. Results : All patients were affected with hematological diseases with neutropenia. Five of them had undergone bone marrow transplantation, three, chemotherapy, and one who presented neutrspenia due to the underlying disease. All patients were diagonosed as having perianal infection with febrile neutropenia because of perianal pain and fever. Seven of nine patients underwent incision and drainage of the perianal region. Of the seven patients, serous discharge was noted in four patients and pus discharge, in the remaining three. One patient in whom perianal pain recurred required re-incision, with resultant serous discharge again. After the surgery, all seven patients were relieved from fever and perianal pain, and the infection was put under control. Conclusion : Surgical management for perianal infection with febrile neutropenia was effective in controlling infection and relieving the symptoms.

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We report a rare case of hyperammonemic encephalopathy after modified FOLFOX6 therapy (mFOLFOX6). A 72-year-old man was diagnosed with ascending colon cancer, sigmoid colon cancer, multiple liver metastasis, lung metastasis, and peritoneal metastasis. Right hemicolectomy and sigmoidectomy were performed. Postoperative TS1 was carried out, but the serum carcinoembryonic antigen level was elevated. We started the mFOLFOX6 regimen. He became confused upon treatment after 49 hours. A blood test revealed that his serum ammonia level was 399μg/dL. We diagnosed 5-fluorouracil-induced hyperammonemia. Conservative treatment with high-volume drip infusion and branched -chain amino acid solutions resulted in improvement of his mental status. We changed his chemotherapy to FOLFOX4 a month later. He received the FOLFOX4 treatment without any significant adverse effect.

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A 52-year-old woman underwent a total gastrectomy and splenectomy for advanced gastric cancer. A fever of 40.1°C with chills and a systemic inflammatory response syndrome (SIRS) were suddenly observed during the night of the 6th postoperative day. The patient started receiving antibiotics, immunoglobulin, and gabexate mesilate for the treatment of disseminated intravascular coagulation. Although she recovered from septic shock, the patient developed a fever of 40.2°C and bloody phlegm on the 13th postoperative day. Streptococcus constellatus was isolated on blood culture. She required intensive treatment including tracheal intubation. Nine months later, she again presented in septic shock with a fever of 40.2°C which escalated into SIRS and multiple organ failure. Escherichia coli and Klebsiella pneumoniae were isolated from the blood culture. Finally, OPSI was diagnosed.
After a splenectomy this entity appears to have a high mortality mostly due to Streptococcus pneumonia infection. Adequate vaccination and prophylactic antibiotic treatment recommended to prevent OPSI. It is important to recognize the possibility of the early onset of OPSI after total gastrectomy with splenectomy in patients with advanced gastric cancer.

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Recently malignant tumors of the liver, bile duct and pancreas have been increasingly detected in very elderly people, but operations of these organs are seriously invasive and are associated with fatal complications in many cases. Accordingly we often have great difficulties in treating them.
An 84-year-old woman was referred to our hospital because of high fever and jaundice. She had underlying diseases such as diabetes mellitus and hypertension. Subtotal stomach-preserving pancreaticoduodenectomy was performed with a diagnosis of cancer of the inferior bile duct. However, intermittent fever persisted after the operation. On the 11^th postoperative day, thrombosis of the right internal jugular vein at where a central venous catheter had been placed and septic pulmonary embolism (SPE) became apparent. Thereafter she was associated with Staphylococcal scalded skin syndrome (SSSS). Administration of appropriate antimicrobial agents gave relief for her. She was discharged from the hospital on independent gait on the 51^th postoperative day.
There is a usual possibility that highly invasive surgeries can cause serious infections in elderly patients, so that we must keep these diseases in mind.

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We report a case of intraabdominal complications due to three ventriculoperitoneal (VP) shunt tubes required conservative therapy followed by laparotomy. A 29-year-old female who had three VP shunt tubes (inserted at the ages of 0, 12, and 28, respectively) developed right lower abdominal pain 10 months after the last insertion. Abdominal CT revealed a shunt tube at the right lower abdomen without apparent appendicitis. The pain subsided by conservative therapy, however, laparotomy was necessary due to the symptom of increased intracranial pressure and intraabdominal fluid collection suggestive of a pseudocyst. Two old tubes which were obstructed with fibrous adhesion were removed, and the latest one was seen in the pseudocyst. Despite the repositioning of the tube in the abdominal cavity, another pseudocyst occurred and the tube was repositioned again. Finally, she needed extraventricle drainage and ventriculoatrial shunt. There have been no previous reports of pseudocysts with three VP shunt tubes, which had been placed for 29 years and all of which were in trouble in the abdominal cavity like in this case.

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Nodular fasciitis is a reactive proliferative lesion of fibroblast cells ; it occurs most commonly in the limbs, particularly the forearms. Cases involving the breast and the chest wall are rare. We treated 1 case of nodular fasciitis involving the pectoral muscles that spontaneously regressed with no treatment. A 74-year-old woman noticed a mass in her left breast ; a mass approximately 3 cm in size could be felt in the superolateral area of the left breast. On ultrasound, a poorly-marginated, hypoechoic mass approximately 3.6 cm in size was noted in the left mammary gland C region ; on needle biopsy, nodular fasciitis was strongly suspected. However, it was difficult to differentiate from a malignant tumor. Thus, an excisional biopsy was required to make a definitive diagnosis. On the day of biopsy, approximately 1 week later, the tumor had spontaneously regressed and was no longer present.

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We report a case of a juvenile breast fibroadenoma in a 12-year-old girl, with related documentation. She first noticed a mass in the right breast 6 months ago and consulted our hospital. On physical examination, a 7-cm elastic hard mass was palpated in her right breast. Ultrasonography revealed a 7-cm diameter hypoechoic solid mass with clear margins. Fine needle aspiration cytology revealed that it was composed of epithelial cells and stromal elements without any evidence of malignancy. The imaging test findings led to us to consider the possibility of a benign mass of the breast. Tumor excision was performed and the diagnosis of juvenile breast fibroadenoma was made on histopathological examination of the resected specimen. The postoperative breast deformity was minimal despite the large size of the extracted mass. Juvenile breast fibroadenoma is rare in the pediatric population, especially at school age. Young women, especially those at school age, can expect development of the remaining normal breast gland postoperatively ; therefore fibroadenoma in this age group should be treated to maximize breast conservation.

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A 38-year-old male developed a right breast lump and a right nipple discharge. Needle biopsy suggested the possibility of a neoplasm originating in a skin appendage, and an excisional biopsy was performed. On histopathology, a clear cell hidradenoma of the breast was diagnosed. Clear cell hidradenoma originating from the breast is rare. The clinical characteristics of such hidradenomas based on 30 cases reported in the literature were reviewed. There is a tendency for hidradenomas to occur in men in contrast to breast cancer, and there is little difference among age groups in the incidence. The vicinity of the areola is a preferred site, and a large number of patients have concomitant cystic lesions.

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Adenoid cystic carcinoma (ACC) is a rare type of breast cancer. It is considered to have a good prognosis ; few cases develop distant metastases. We report a rare case of ACC with early relapse and a poor prognosis.
A 67-year-old woman developed a tumor in her left breast. Core needle biopsy revealed ACC. The patient had a left mastectomy with an axillary lymph node dissection. On pathology, the tumor was classified as pT2pN1M0, stage IIB, ER 0%, PgR 0%, and HER2 0. The patient received adjuvant chemotherapy. However, she developed multiple bone metastases 1 year after surgery. Despite chemotherapy, the patient developed multiple liver and brain metastases. She died due to cancerrelated causes less than 3 years after surgery.

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A 66-year-old man noticed a tumor under his left nipple. The mass was elastic hard and had a clear border. On ultrasonography, a hypoechoic tumor, 8 mm in diameter, in the left EA region was seen. On core needle biopsy the tumor was diagnosed as an invasive ductal carcinoma. The patient underwent a mastectomy and a sentinel lymph node biopsy. On histopathology, invasive ductal carcinoma (scirrhous carcinoma) was diagnosed. ER was positive, PgR was positive, and the HER2 score was 0. Postoperatively, oral tamoxifen therapy was given. There have been no signs of recurrence during 6 months of follow up. To the best of our knowledge, this is the seventeenth case report of sentinel lymph node biopsy done in a male with breast cancer in Japan.

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It has recently been found that the biologic mechanisms responsible for early recurrence in breast cancer differ from those for late recurrence in breast cancer and that estrogen receptor (ER)-positive breast cancer often recurs more than 5 years after the initial surgery. Patients who have ER-positive breast cancer with longer disease-free intervals usually respond to endocrine therapy after relapse and have longer post-relapse survival. We report here a rare case of ER-positive breast cancer that recurred 10 years after the initial operation ; it advanced rapidly and the patient died. A 65-year-old woman was admitted to our hospital with backache and headache. She had undergone right mastectomy and axial lymph node dissection for early breast cancer when she was 55 years old. Pathologically, the tumor was classified as pT1 pN0 M0 Stage I and was ER-positive (80-90%), progesterone receptor-negative, and HER2-negative. She received adjuvant endocrine therapy with an aromatase inhibitor for 5 years. At 10 years 2 months after surgery, she developed back pain and headache and was diagnosed with multiple bone metastases, multiple brain metastases, and carcinomatous meningitis. Despite endocrine therapy and radiation therapy for her recurrent breast cancer, she died following rapid exacerbation of carcinomatous meningitis 3 months after relapse.

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A 54-year-old man was admitted to our emergency center with chest pain. Electrocardiography showed ST-elevation in leads II, III and aVf and complete A-V block. We suspected acute coronary syndrome (ACS) of the right coronary area and performed an additional workup. Chest computed tomography (CT) and coronary arteriography were performed, localized aortic dissection of the right Valsalva sinus and right coronary artery occlusion were revealed. We performed patch plasty of the right Valsalva sinus with aortic dissection and coronary artery byass grafting to the right coronary artery (#3) with a saphenous vein graft. Normal sinus rhythm was recovered immediately after the operation. He was discharged on the 21th postoperative day.
We report this rare case of localized aortic dissetion of right valsalva sinus with some discussion of the literature.

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A 67-year-old woman was diagnosed as having an acute thrombosed type A aortic dissection with dissection of the celiac artery. She initially complained of abdominal pain ; an increased serum amylase level was noted. Computed tomography revealed the obstruction of the splenic artery ; acute pancreatitis due to abdominal malperfusion was diagnosed. Although necrosis of the pancreatic body and tail was caused by ischemic progression, the patient recovered with intensive treatment. The ascending aorta was replaced 2 months later since the false lumen had enlarged and ulcers had formed in the ascending aorta. It should be kept in mind that acute pancreatitis can occur in patients with acute aortic dissection, and one should anticipate that the patient can deteriorate due to necrotic pancreatitis in the cases with obstruction of the celiac artery and the splenic artery.

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A 13-year-old female child was referred to our hospital complaining of fatigability and shortness of breath. She had had occasional chest pain at exercise since her elementary school ages and became to feel fatigability and shortness of breath after entrance into a junior high school when she started club activities. Chest X-ray and CT demonstrated an emphysematous giant bulla of the right upper lobe that had occupied half of the thoracic cavity. The segmental bronchus of the right upper lobe was compressed from the outside. In the thoracoscope-assisted surgery, dilated blood vessels existed on the surface of a large thin-wall cystic lesion. After removing the cyst wall, air leakage was found from three points on the lung parenchyma by a water seal test. The cyst base was closed by multiple imbricating mattress sutures. The patient was uneventfully discharged on the 7th day after the surgery. Histology revealed the cyst wall to be composed of fibrous tissue with slight infiltration of inflammatory cells. There was no airway epithelium lining inside the cyst. Therefore, we concluded that the giant bulla increased in size with the same check valve mechanism as adult patients.

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Nocardia infection is a known opportunistic infection that can cause localized or systemic suppurative disease in humans. A 22-year-old male had a video-assisted thoracoscopic (VATS) wedge resection for recurrent pneumothorax. After surgery, the patient developed a prolonged air leakage and an empyema and was transferred to our hospital. A VATS decortication for acute empyema was performed. The chest tube was removed on postoperative day 11. Nocardia species were cultured from the specimens obtained during surgery. The patient was given trimethoprim-sulfamethoxazole (TMP-SMX) and ceftriaxone intravenously for 4 weeks and TMP-SMX orally for one year to prevent relapse of the nocardia infection. We report this case of nocardia empyema successfully treated by surgery.

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Accessory cardiac bronchus (ACB) is a rare anomaly of the tracheobronchial tree, which is usually discovered incidentally during examinations for other thoracic diseases. This report describes a case of ACB associated with lung cancer. A 75-year-old man had primary lung cancer in clinical stage IIA(cT2bN0M0). He was suspected to have ACB by CT and bronchoscopic examination. Intraoperative findings revealed a small anomalous bronchus originating from the truncus intermedius. We performed a right lower lobectomy and combined resection of ACB. Awareness of this anomaly before lung surgery is important to avoid perioperative complications, including bronchial fistula.

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A 74-year-old woman was admitted to the hospital complaining of dyspnea on working. Chest X-ray showed a mass lesion extending from the mediastinum to the both lung fields which, included gas shadows of the digestive tract in the center. Endoscopy showed that the esophagogastric junction was located at 30 cm from the incisor, and the stomach was twisted longitudinally. Furthermore, linear erosion and round ulcer were observed in the upper stomach. Computed tomography showed a hiatal hernia, including the stomach, small intestine, and transverse colon. Laparoscopy-assisted hernioplasty was performed with the diagnosis of complicated hiatal hernia (type IV) with Cameron lesions. We reduced the incarcerated omentum, small intestine and transverse colon to the abdominal cavity. The size of the esophageal hiatus was 11 × 9 cm. The esophageal hiatus was repaired using a polypropylene mesh/polytetrafluoroethylene sheet. After surgical hernia repair, dyspnea and asthma disappeared, and no gastric erosion and ulcer have been detected endoscopically without medication using proton pump inhibitors.

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We report a case of esophageal cancer with a right aortic arch. A 65-year-old man admitted to the hospital for dysphagia was found in endoscopic examination to have Type 3 esophageal cancer in the middle thoracic esophagus, and the tumor was shown histopathologically to be moderately differentiated squamous cell carcinoma. Chest X ray taken on admission showed that he had a right aortic arch and an upper GI series showed a compression defect by a vascular ring in the upper thoratic esophagus and irregular stenosis in the middle esophagus. CT showed esophageal wall thickening but no lymph node metastasis. Three-dimensional computed tomography (3D-CT) showed the right aortic arch with an aberrant left subclavian artery and ductus arteriosus (DA) originating from a diverticulum at the descending aorta (Edwards's type IIIB1). Left thoracotomy was used for this anatomical variation to approach the DA and the esophagus. After division of the DA, we conducted subtotal esophagectomy and intrathoracic esophagogastrostomy because of severe scar after a previous cervical trauma. We saw that the tumor had invaded the left bronchus and could not conduct curative operation. In the treatment of esophageal cancer with a right aortic arch, preoperative 3D-CT is very useful in determining the anatomical relationships among vessels, esophagus, and possible location of recurrent laryngeal nerves.

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Gastro-tracheal fistula following radical surgery for esophageal cancer is rare. Patients with serious intractable complications for which appropriate treatment was successful have been even less frequently reported. We present a case which reguired a free forearm flap to effectively treat a gastro-tracheal fistula. A 55-year-old male had an operation to remove an esophageal cancer. A gastric conduit was pulled up to the neck through the posterior mediastinum during esophageal reconstruction. At postoperative day 8, the patient developed a fever, cough, and cervical subcutaneous emphysema. CT scan and bronchoscopy revealed a gastro-tracheal fistula. Since conservative treatments were of no benefit, on postoperative day 114 a surgical repair was performed. The skin of the neck was incised ; the adhesion between the trachea and the gastric conduit was separated, then a part of a free forearm skin flap was tucked between these structures to cover the membranous defect of the trachea (microsurgical vessel anastomoses were institured). After the closure of the fistula was confirmed, the patient was allowed to start eating ; he had very few problems doing so. A free forearm skin flap could be a useful treatment option for an incidental gastro-tracheal fistula located at the thoracic inlet following esophageal cancer surgery.

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A 22-year-old woman was diagnosed with autism at a local hospital. She was admitted to our hospital for abdominal pain. Abdominal computed tomography (CT) showed residue and fluid in the duodenum and small intestine and a gastrointestinal endoscopy revealed hair bezoar in the stomach. Four days later, the hair bezoar induced a serious intestinal obstruction and an emergency operation was performed. At laparotomy, large hair bezoars were removed from the stomach and small intestine, via gastrotomy and enterotomy. Total weight of the hair bezoars was 800 g. A large hair bezoar in the stomach is not expected to be naturally excreted from the intestinal tract. When the preoperative diagnosis is made, a surgical removal should be chosen immediately. Hair bezoars are commonly found in young females usually with an underlying psychiatric disorder. Hence long-term psychiatric follow-up is necessary.

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After undergoing laparoscopy-assisted total gastrectomy with retrocolic Roux-en-Y reconstruction for early gastric cancer, a 73-year-old man developed abdominal pain. The patient was diagnosed as having superior mesenteric vein thrombosis (SMVT) on enhanced abdominal computed tomography (CT). No signs of peritonitis were noted on the physical examination, and no evidence of bowel infarction was seen on enhanced CT. Therefore, conservative interventional radiology therapy with infusion of urokinase into the SMA was undertaken. However, during the initial stage of interventional radiology therapy, it was noted that the small intestine had migrated through Petersen's space, resulting in a strangulated bowel and mesenteric vessel twisting (whirl sign). Based on these findings, a Petersen's hernia was diagnosed, and surgery was performed after the interventional radiology therapy was completed. The small intestine was removed from Petersen's defect and repositioned. A second course of interventional radiology therapy with urokinase infusion into the SMA was then given. A rare case of internal hernia following gastrectomy with SMVT is reported.

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We report a rare case of early undifferentiated gastric cancer arisen in the remnant stomach. The patient was a 75-year-old man who had undergone distal gastrectomy and Billroth-I reconstruction for early gastric cancer 21 years earlier, when the pathological diagnosis was signet ring cell carcinoma. He was admitted to the hospital because of upper abdominal pain and discomfort and was found to have a type 1 tumor in the end anastomotic site of the remnant stomach on gastrointestinal endoscopy. Endoscopic biopsy showed poorly differentiated adenocarcinoma. We therefore performed distal gastrectomy of the remnant stomach. Based on histopathological examinations of the resected specimen, undifferentiated carcinoma localized in the submucosal layer was diagnosed. Undifferentiated carcinoma is extremely rare in the stomach and nearly all reported cases of gastric carcinoma are in an advanced stage. No other cases of early undifferentiated gastric cancer arisen in the remnant stomach have been reported as far as we could review. This case is considered extremely rare.

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The case was a 59-year-old male who presented with jaundice and was hospitalized for evaluation and treatment. Blood examinations revealed a slightly elevated carcinoembryonic antigen (CEA) level and CA19-9 level of 9.3 ng/ml and 75.2 U/ml, respectively. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) examinations revealed a tumor with a maximum diameter of 6 cm in the horizontal lesion of the duodenum.
Endoscopic examinations of the upper gastrointestinal tract using a lateral vision mirror revealed ulceration, and in a biopsy of the same region, the patient was diagnosed with a gastrointestinal stromal tumor (GIST) of the duodenum. Based on this diagnosis, a pancreaticoduodenectomy was performed. In histopathological examinations, the findings were positive for c-kit and CD34, the mitotic count was 10 / 50HPF, and the patient was diagnosed with high-risk GIST. After obtaining sufficient informed consent, we performed postoperative adjuvant chemotherapy using 400 mg/day of imatinib. After surgery, the tumor markers became negative, and at 36 months after surgery, no recurrence has yet been observed. Cases of GIST in which the tumor markers exhibit high values are rare and past reports indicate that the degree of malignancy may be high, and we herein report the findings of this case, including the results of immunostaining together with some bibliographic considerations.

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A 74-year-old woman who visited a hospital because of high fever and was pointed out increased levels of biliary enzymes was referred to our hospital. Following close exploration, cancer of the papilla of Vater with lymph node metastasis was diagnosed, and pylorus preserving pancreaticoduodenectomy (D2) was performed. During surgery portal vein tumor thrombus via lymph node metastasis was identified. The portal vein was incised and the tumor thrombus was removed. The histopathological diagnosis was adenoendocrine cell carcinoma of the papilla of Vater, pT4 (pDu2, pPanc3), pN1, ly2, v3, and pn2. The portal vein tumor thrombus and the metastatic lymph nodes were mainly composed of endocrine cell carcinoma component. While she had been given adjuvant chemotherapy with UFT, multiple hepatic metastases, intraperitoneal lymph node metastasis, and portal vein tumor thrombus were found 5 months after the operation. Chemotherapy with CDDP + CPT-11 was started, but she died of exacerbation of the metastatic foci 7 months after the operation.
Adenoendocrine cell carcinoma of the papilla of Vater is extremely rare, and so we present this case together with a review of the Japanese literature.

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Location of bleeding sites by endoscopy is difficult in small intestinal hemorrhage, and diagnosis is often difficult. Wide-ranging methods are available for the diagnosis of gastrointestinal bleeding, such as gastrointestinal imaging, endoscopy, contrast-enhanced CT, bleeding scintigraphy, and selective angiography. Patients presenting with massive melena require rapid identification of the bleeding source and hemostatic treatment. If the bleeding source is identified by abdominal angiography, hemostatic therapy can be administered by inserting a microcatheter into the blood vessel causing bleeding and then performing embolization ; diagnosis and treatment are simultaneously achieved.
We easily diagnosed the bleeding sites in 2 patients who underwent emergency abdominal angiography for small intestinal hemorrhage, embolization with a microcoil using a microcatheter before surgery, and laparotomy after confirming hemostasis for resection of the small intestine with bleeding source. We report these cases with a review of literature.

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The patient was a 64-year-old man with a medical history of distal gastrectomy for gastric cancer. He came to our hospital with the chief complaint of sudden hypogastrium pain after a meal. When he came to our hospital, he had peritonitis, and his abdominal enhanced CT revealed an expanded small intestine and whirl-like sign that led us to diagnose him with a strangulated ileus. An emergency operation was performed. When we opened the abdominal cavity, chylous ascites was discharged and many fine white linear structures were observed on the mesentery, which appeared to be lymph vessels. Torsion of the small intestine was caused by the adhesion around the superior mesenteric artery. We released the torsion by avulsion. As there were no findings of necrosis on the twisted small intestine, we did not perform an enterectomy. The ascites was milk-colored and the value of neutral fat in that ascites was high : 363 mg/dL. Based on this finding, we believed that the ascites was chylous ascites. His progress after the operation was good and he left our hospital 7 days after the operation. There have been only 12 reports of strangulated ileus with chylous ascites in Japan, including our case. However, in all of these 12 cases, though the obvious findings of strangulated ileus were present, enterectomy could be avoided because of the absence of necrosis. From these facts, we assume that the existence of chylous ascites may suggest the possibility of conservation of a strangulated intestine.

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We experienced a case of intestinal obstruction due to a knot-making of Meckel's diverticulum. A 58-year-old man was seen at the hospital because of abdominal pain, and admitted with a diagnosis of intestinal obstruction. But symptoms did not improve, so we performed a diagnostic laparoscopy the day after admission. The long neck of Meckel's diverticulum was found round the small intestine forming a knot to strangulate it. We resected the Meckel's diverticulum and the necrotic intestine. The clinical course was good. The occurrence of strangulated ileus caused by a knot of the Meckel's diverticulum in adults is relatively rare, and hence preoperative diagnosis of the disease is difficult. Laparoscopic surgery is useful in the treatment of ileus due to unknown cause.

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A nine-year-old girl was admitted with a diagnosis of small intestinal obstruction. On computed tomography (CT) of the abdomen, a small intestine “target sign” caused by intussusception was noted. During emergency surgery, no intussusception of the small intestine was noted. However, an intestinal hemangioma was identified which could have been responsible for the intussusception. A partial resection of the small intestine was performed. The resected specimen was found to contain hemangiomas consisting of the mucosal and submucosal proliferation of blood vessels.
Hemangiomas are rare in the gastrointestinal tract. Hemangiomas of the small intestine rarely present with intussusception. Moreover, there are no reports in the literature dealing with infant small intestinal hemangioma presenting with intussusception. Thus, to the best of our knowledge, the present report is the first such report.

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A 34-year-old woman was referred to our hospital with a complaint of severe abdominal pain and underwent emergency laparotomy with a diagnosis of strangulation ileus. Multilocular yellowish lesion 8 cm in diameter within the mesentery and resultant volvulus of jejunum was observed. The jejunum 30 cm in length and mesentery, including the tumor, was resected and anastomosed. The intracystic fluid was serous, and we pathologically diagnosed lymphangioma. Mesenteric cyst is a relatively rare disease and most are pathologically lymphangioma. Intestinal volvulus induced by mesenteric lymphangioma such as our case is rare, and only seven cases have been reported previously in Japan. Complete resection is essential for cure of this disease, however, that is sometimes impossible because of coexistent severe inflammation and the poor condition of the patient in an emergency setting. Some antecedent symptoms as chronic abdominal pain were reported in previously treated cases with volvulus. Resection should be done before onset of acute abdomen with well recognition and precise preoperative diagnosis of this disease.

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An 80-year-old man who had a history of bronchial asthma and had been treated with prednisolone was admitted with acute severe abdominal pain. Abdominal computed tomography (CT) scan showed intramural gas, diffuse diverticula of the colon, and emphysema in the mesentery of the small intestine, without intraperitoneal free air or portal venous gas. Intramesenteric bowel penetration due to diverticula of the colon was diagnosed, and he underwent a laparotomy. The laparotomy revealed an expanded and significantly kinked ileum and the mesentery with snow-ball crepitation. Thus partial resection of the small intestine was performed. Pathologic examination demonstrated emphysema in the mesentery due to pneumatosis cystoides intestinalis (PCI). PCI patients often present with intraperitoneal free air without intestinal perforation. But cases of PCI with emphysema in the mesentery that are difficult to differentiate from intramesenteric bowel penetration are rare. Although a diverticulum of the ileum, a foreign body aspiration, and a malignant tumor are given in differential diagnosis when emphysema in the mesentery of small intestine is demonstrated on CT, PCI was the cause of the emphysema in our case.

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A 61-year-old woman was admitted due to watery diarrhea. Abdominal CT revealed an intraperitoneal abscess, 65 mm × 37 mm in diameter, which pressed on the descending colon. Colonoscopy revealed the orifice of the fistula in the descending colon. Fluoroscopic examination showed outflow of contrast medium into the small intestine via the intraperitoneal abscess. Under the diagnosis of a fistula between the jejunum and descending colon and an intraperitoneal abscess, surgery was performed. A partial resection of the jejunum and descending colon was carried out, and a transverse colostomy was performed. On histology, medium-sized lymphocytes were seen to diffusely invade all layers of the jejunum and the descending colon ; on immunohistochemistry, these cells were positive for CD3, CD7, and CD56, and negative for CD8. The patient was diagnosed as having enteropathy-associated intestinal T-cell lymphoma (EATL). The CHOP regimen was given in 2 courses after the operation. Nevertheless, the patient died due to perforative peritonitis 4 months after surgery.

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A man in his sixties was diagnosed with malignant melanoma of the nasal cavity for which he had been treated with heavy ion radiotherapy and chemotherapy in 2010, and he underwent surgery for local recurrence in 2011. Due to melena, he was examined with upper gastrointestinal endoscopy and colonoscopy, but no abnormalities were seen. Enhanced abdominal CT and transanal double-balloon endoscopy revealed a small intestinal tumor, but the result of the biopsy indicated necrotic tissue. However, we suspected a malignant tumor and performed laparoscopic surgery, placing 1 port each in the left and right lower abdomen and the umbilicus. Distant metastases and peritoneal dissemination were not observed. We extracted the small intestine from the abdominal cavity by extending the umbilical wound and performed resection and reconstruction. The postoperative course was uneventful, and he was discharged at postoperative day 11. The resected specimen was a type 2 tumor that spanned the entire intestinal circumference, measuring 7 cm × 6 cm, and the patient was histologically diagnosed with metastatic malignant melanoma of the nasal cavity. Cases of distant metastases of malignant melanoma have a poor prognosis. However, when curative resection is possible in a solitary metastasis, the less invasive laparoscopic surgery may prolong survival in a patient.

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We report a rare case of ileus caused by an appendix epiploica of the sigmoid colon. A 41-year-old man was referred to our hospital with sudden abdominal pain and vomiting. He had no past history of abdominal surgery. He was diagnosed with strangulated ileus by abdominal computed tomography (CT), and an emergent operation was performed. We found that about 30 cm of the small intestine was incarcerated due to a band formed from the appendix epiploica of the sigmoid colon which was attached to the retroperitoneum. The appendix epiploica was resected, and the ileus was relieved. Because the incarcerated intestine was not necrotized, bowel resection was not performed.

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A 69-year-old man was admitted for left lower abdominal pain computed tomography (CT) scan found a tumor of the sigmoid colon with extraluminal growth. Based on a diagnosis of malignat tumor-like gastrointestinal stromal tumor (GIST), we conducted a sigmoidectomy. Histopathological examination showed no findings suggestive of endocrine cell carcinoma, so that undifferentiated carcinoma was diagnosed. The depth of tumor invasion was SE, no lymph node metastasis were seen, and it was in stage II. He developed peritoneal metastasis after about 1 month and died of cancer 2 months after the curative operation without chemotherapy.
An undifferentiated colorectal carcinoma is very rare and its prognosis is very poor. Colorectal cancer with extraluminal growth is also rare and often detected after progression because of poor symptoms.
We report a case of undifferentiated carcinoma of the sigmoid colon with extraluminal growth who died only 2 months after a curative operation.

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Intestinal endometriosis is a benign disorder characterized by the ectopic growth of endometrial tissue in the intestinal wall, causing various clinical symptoms. However, endometriosis may develop into precancerous lesions due to its neoplastic nature. We report a surgical case of rectal endometriosis in which endometrial tissue was present in the regional lymph nodes as well. The relevant literature is also reviewed.
The patient was a 44-year-old woman with the chief complaints of a feeling of abdominal distension and abdominal pain. Sigmoidoscopy revealed clustered papillary polyps associated with stenosis of the rectosigmoid lumen. A biopsy suggested regenerative lesions without findings of malignancy. CT scans showed the circumferentially thickened rectosigmoid wall as well as marked dilatation of the proximal colon. Based on these findings, intestinal obstruction caused by rectal tumors was strongly suspected, though not definitively diagnosed, and low anterior resection with lymph node dissection was performed. Histopathology revealed glands, similar to endometrial glands in the proliferative stage, in the submucosa, muscularis propria, and subserosa. Intestinal endometriosis was thus diagnosed. The glandular structure was also present in the regional lymph nodes.

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A laparoscopic-assisted low anterior resection along with a D2 dissection was performed on a 68-year-old man who had stage I lower rectal adenocarcinoma.
Postoperatively, two submucosal tumors (3.5 mm and 3 mm in diameter) were found on the oral side of the main rectal tumor in the resected specimen.
On pathology, both of these submucosal tumors were gastrointestinal neuroendocrine tumors (GI NET) G1 (WHO classification, 2010) ; lymphvascular invasion was present. Four pararectal lymph nodes were found that had GI NET involvement. The main tumor was diagnosed as a well-differentiated adenocarcinoma without lymph node metastasis.
Risk factors, including lymphvascular invasion, should be taken into consideration in predicting the metastatic potential of GI NET, irrespective of tumor size.

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Metastatic colorectal cancer is relatively rare. Herein, we report a case of metastasis to the rectum from primary transverse colon cancer. The patient was a 65-year-old man who underwent curative partial colectomy due to transverse colon cancer. The pathological findings of the resected specimen were well-differentiated tubular adenocarcinoma with regional lymph node metastasis. An increase in his carcinoembryonic antigen (CEA) level was observed during the follow-up of 2 years 7 months after the primary surgery. Positron emission tomography revealed a solitary tumor in the submucosal layer of the rectum, though a biopsy could not prove that it was a metastatic tumor. A laparoscopic low anterior resection was performed for this tumor. The pathological findings revealed that the tumor was a tubular adenocarcinoma similar to the primary transverse colon cancer, which existed in the submucosal, muscular, and subserosal layers. We therefore considered it to be metastatic cancer to the rectum, even though the metastatic route was unclear. Although metastatic colorectal cancer is rare, physicians should keep it in mind as a potential diagnosis.

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A 65-year-old man had undergone a subtotal esophagectomy due to esophageal cancer in 2006. The pathological diagnosis was squamous cell carcinoma, pT1b (sm) N0M0 Stage I. He underwent surgery for repeated ileus in November 2007, and a preoperative imaging examination revealed no recurrence or primary tumor. In February 2008, ultrasonography detected multiple bilateral liver tumors. Pathological analysis of biopsy specimens from the liver tumors showed anaplastic carcinoma, but we could not distinguish whether the carcinoma was metastatic or primary. The patient received chemotherapy (nedaplatin + 5-fluorouracil), but he died due to hepatic failure 6 months after the appearance of the liver tumor. An autopsy was performed. Immunohistochemically, tumor cells were positive for chromogranin A, CD56, and cytokeratin, and the MIB labeling index was 45.8%. The histopathological diagnosis was neuroendocrine cell carcinoma of the liver. Primary hepatic neuroendocrine carcinoma is extremely rare, and the prognosis is poor.

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So-called carcinosarcoma is a malignant tumor which has a histological appearance of carcinoma showing sarcomatoid change. We report a rare case of so-called carcinosarcoma of the gallbladder which was composed of squamous cell carcinoma and spindle cell tumor ; although the carcinomatous component of this tumor is generally adenocarcinoma. A 68-year-old woman was admitted with a complaint of vomiting and loss of appetite. She was diagnosed as having cancer of the gallbladder with an invasion to the duodenum and underwent subtotal stomach-preserving pancreaticoduodenectomy with extended cholecystectomy. Histopathology showed the coexistence of squamous cell carcinoma and spindle cell tumor with transformation between them. The sarcomatous component was immunoreactive to keratin which is an epithelial marker. Finally, she was diagnosed with so-called carcinosarcoma of the gallbladder associated with squamous cell carcinoma. Unfortunately, she died at 3 months after operation because of liver metastasis and peritoneal dissemination.

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A 67-year-old man was seen at the hospital because of right hypochondralgia and high fever. Abdominal magnetic resonance imaging revealed a tumor mainly located in the anterior segment of the liver. Subsegmentectomy, cholecystectomy, partial resection of the duodenum, and partial resection of the transverse colon were performed. The H.E. staining revealed poorly differentiated cholangiocellular carcinoma. The patient developed dry mouth, polydipsia, polyuria, general fatigue, and disorientation since around postoperative 30^th day. No hyperglycemia and bone metastasis were noted, but increases in Ca and PTHrP levels (14.6 mg/ml and 7.0pmol/l, respectively) were confirmed. Immediately calcitonin and zoredronate were administered. His symptoms were alleviated with this regimen, but soon he developed disseminated metastasis and died on the 64^th postoperative day. Immunohistochemically the tumor cells were positive for CEA, cytokeratin (CK)-7, CK-8, CK-19, and PTHrP, but negative for AFP, hepatocyte specific antigen (HSA), CK-20, and PTH. PTHrP producing cholangiocarcinoma was finally diagnosed.

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A 47-year-old man who had lower abdominal pain was referred to our hospital. An abdominal CT scan detected a tumor measuring 6 cm in diameter in front of the head of the pancreas. The preoperative diagnosis was malignant lymphoma. Tumor resection was performed to enable definitive diagnosis. The histopathological diagnosis of the tumor was paraganglioma. His postoperative course was uneventful. No recurrence was noted in a 10-month period. Paragangliomas usually arise from the extra-adrenal paraganglionic system. We report a rare case of paraganglioma located in front of the head of the pancreas.

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von Hippel-Lindau (VHL) disease is an inherited neoplasia syndrome frequently complicated by neuroendocrine tumors and multiple cysts in the pancreas. We report two familial cases (a son and his mother) of VHL disease with multicentric pancreatic tumors for which a middle-preserving pancreatectomy was required.
A 33-year-old male with pancreatic tumors and multiple cysts in the head and tail of the pancreas, and bilateral adrenal tumors underwent a middle-preserving pancreatectomy and bilateral adrenalectomy. On histopathology, pancreatic endocrine tumors, serous cysts, and adrenal pheochromocytomas were diagnosed. On genetic examination VHL disease was diagnosed.
A 60-year-old female (the patient's mother) was found to have pancreatic tumors and multiple cysts in the head and tail of the pancreas. Genetic testing was done, and a VHL genetic mutation was found. The patient had a middle-preserving pancreatectomy. On histopathology, endocrine tumors and serous microcystic adenoma were diagnosed.

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The patient was a 43-year-old man who had undergone sigmoidectomy with partial cystectomy for sigmoid colon cancer 2 years ago ; he came to our hospital and was hospitalized with the chief complaint of abdominal distension and lower abdominal pain. He did not exhibit any signs of injury. His blood test results showed a slight increase in the blood urea nitrogen/creatinine level. On the same night, his symptoms worsened and he underwent emergency surgery based on the diagnosis of panperitonitis the next day. Before surgery, it was difficult to insert a Foley's catheter in the patient. On laparoscopic surgery, we identified an aperture in the urinary bladder wall after adhesiolysis between the ileum and the bladder. We carried out suturing of the aperture and also suprapubic cystotomy.
In the majority of cases, urinary bladder rupture is due to a wound, and spontaneous rupture of the bladder is comparatively rare. We report a case in which urinary bladder rupture occurred after sigmoidectomy with partial cystectomy.

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A 57-year-old woman, who had a total hysterectomy due to uterine leiomyoma 23 years prior, developed mild abdominal pain. On enhanced CT scan and MRI, multiple subperitoneal or peritoneal tumors of various sizes on the mesentery and peritoneal surface, mimicking a malignant disease with metastases in the abdominal cavity, were noted. To facilitate diagnosis, a laparotomy was performed. Many nodular tumors were found on the greater omentum, the mesentery, and the peritoneal surface. On intraoperative frozen section pathology, the tumors were diagnosed as benign. The greater omentum and several large nodules were resected. On histopathology, leiomyomatosis peritonealis disseminata (LPD) composed of benign smooth muscle cells was diagnosed. A CT scan done 4 years after surgery showed no progression of the remaining tumors ; the patient had received no medications during that time.
LPD is a rare benign disease of unknown etiology. More than 100 cases of LPD have been described in the literature. There are no firm guidelines for the management of LPD. This rare condition must be considered in female patients who have had or had uterine leiomyoma and present with multiple intraabdominal tumors. In this paper, we review the cases of LPD reported in the literature, including the present case.

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A 57-year-old woman underwent an emergent laparotomy because of acute abdomen, and a diversion operation was performed for a duodenal diverticulum perforation along with Cushing syndrome. After the operation, the level of (1→3)-β-D-glucan was elevated and Candida was cultured from the abdominal cavity, therefore, anti-fungal agent was administered for the fungal peritonitis. Although the clinical condition improved, (1→3)-β-D-glucan was prolonged at a high level.
(1→3)-β-D-glucan is very useful for the diagnosis of deep mycosis because the data is obtained immediately, however, the level of (1→3)-β-D-glucan is not always coincident with the clinical condition. Therefore, (1→3)-β-D-glucan should be utilized as one of a bundle including fungal culture or clinical course to determine continuity or completion of anti-fungal treatment.

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A 20-year-old woman who had become aware of a swelling in the right inguinal region since about one month earlier was seen at our hospital. On physical examination, a well-defined and elastic-hard tumor about 4 cm in diameter was felt in the right inguinal region. Ultrasonography and contrast-enhanced CT scan of the abdomen revealed a cystic tumor with a homogeneous inner portion at the right inguinal region. No herniation of the greater omentum, intestine, and ovary was identified. Right Nuck hydrocele was diagnosed and the patient was operated on. The tumor was firmly adherent to the round ligament of the uterus partly, at where the tumor was closed and there was no communication with the abdominal cavity. Following high ligation and transection of the tumor along with the round ligament of the uterus, the internal inguinal ring was treated by plication suture by means of Marcy method. The resected tumor contained dark red fluid and it was a 6.3 cm × 2.6 cm monolocular tumor covered with a thin capsule. Histopathology confirmed endometrial epithelial component, and Nuck hydrocele associated with endometriosis was diagnosed.
Although adult-onset Nuck hydrocele is a relatively rare entity, it must be kept in mind as differential diagnosis of inguinal tumors.

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