Four patients with recurrent breast cancer who had a favorable course after implantation of an indwelling port that enabled rapid contrast agent injection (power port) as well as intravenous therapy for patients with advanced recurrent breast cancer are reported. The power ports were used to conduct contrast-enhanced computed tomography (CT) examinations and blood collection. Conventional indwelling ports are not pressure-resistant, and accidents injecting contrast agent rapidly via conventional port may therefore occur mix-up of patients. Cognitive education for medical staffs and user's manuals for power ports were developed. Consequently, contrast-enhanced CT tests for breast cancer patients could be performed without adverse events by using power ports. Blood was collected each time anticancer agents were used, but no adverse events were observed other than one case of occlusion that occurred 10 months after implantation. Power ports were well-received by patients, and all patients were able to continue treatment without experiencing fear of blood collection or imaging. Implementation of power ports enables alleviation of suffering in patients with advanced breast cancer for whom securing peripheral blood vessels is difficult. However, sufficient education and creation of manuals within hospitals are necessary, given the risk of mixing the power port with other central venous (CV) ports.

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Background : The aim of this study was to describe the occurrence and clinical characteristics of symptomatic internal hernias after gastrectomy and antecolic Roux-en-Y reconstructions for gastric carcinoma.
Methods : This study retrospectively reviewed 290 cases performed total or distal gastrectomy with RY reconstruction via laparotomy or laparoscopy at our hospital between 2006 and August 2011.
Results ; Internal hernias were identified in a total of eight cases (2.8%) of the 290 cases, with two (1.5%) cases following gastrectomy via laparotomy and six (3.8%) cases following laparoscopic gastrectomy. Although a higher incidence of internal hernias was noted with laparoscopic gastrectomy, no statistically significant difference was observed (p = 0.237). With regard to total gastrectomy, internal hernias occurred in five of 77 (6.5%) laparoscopic total gastrectomy cases and a significant difference (p = 0.013) was observed between the total gastrectomy via laparotomic and laparoscopic total gastrectomy groups. These internal hernias included those at the Petersen's space in five cases and those at mesojejunal space in the remaing three cases.
Concluson ; There is a high risk of internal hernia with laparoscopic antecolic RY reconstruction following curative resection for gastric carcinoma. Closure of the Petersen's and mesojejunal spaces is important for antecolic reconstruction, regardless of mesenteric treatment of the ascending jejunum.

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Laparoscopic distal gastrectomy has been performed in our hospital since January 2010. To evaluate the utility of the laparoscopic surgery, short-term outcomes in distal gastrectomy for gastric cancer were compared with those of open surgery. Between April 2008 and July 2013, 70 patients underwent open distal gastrectomy (OG) and 95 patients underwent laparoscopic distal gastrectomy (LG). The number of the dissected lymph nodes was more in the LG group than the OG group ; 32.2±15.7 versus 25.1±15.3, respectively (p=0.04). A fewer operative blood loss was noted in the LG group than the OG group ; 110.0±385.9 ml versus 206.2±170.8 ml, respectively (p=0.034). The operation time was 322.1±84.1 min in the LG group versus 194.6±58.7 min in the OG group, revealing a prolonged time in the LG group (p<0.001). A lower incidence of the early postoperative complication was noted in the LG group than the other ; about 12% (11/95 cases) versus about 34% (24/70), respectively (p=0.005). The duration of postoperative hospital stay was shorter in the LG group than the other ; 15.2±11.4 days versus 21.6±12.0 days, respectively (p=0.001). In conclusion, laparoscopic distal gastrectomy for gastric cancer was feasible and superior to open distal gastrectomy in the short-term outcomes.

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Compared with the conventional anterior approach, the Kugel method that is the posterior approach has such an aspect as has not widely used as yet, because it is difficult for us to get anatomical understanding and to reach the correct preperitoneal stratum disjunctum. In the original Kugel method, the inferior epigastric artery and vein are defined as the first indicator to identify the preperitoneal space, and parietalization is started from the center side to the outer side ; we call it as “center side approach” in this paper. In our method, however, without being conscious of the inferior epigastric artery and vein and by seeing the deep preperitoneal fascia and preperitoneal fat to be indicators, the parietalization is started from the outer side to the center side ; we call it as “lateral approach”. With this method, we are able to reach the correct stratum disjunctum far easier than the conventional method. As a result, the operating time significantly shortened from 43 minutes by the center side approach (n=1,093) to 33 minutes by the lateral approach (n=1,316), and the recurrence rate also decreased from 1.2% to 0.2%, respectively.

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A 61-year-old woman noticed a mass in her left breast about one year previously. The tumor was palpable, 40 mm in diameter, and a firm consistency. The fine needle aspiration cytology was indeterminate, while the core needle biopsy revealed ductal hyperplasia. Clinically the tumor had a probability of malignancy, and an excisional biopsy was performed. Pathological examination revealed the tumor to be composed of mammary gland and stroma with spindle cells. Immunohistochemical staining showed that these spindle cells were positive for α-smooth actin, and the diagnosis was myoid hamartoma. The patient has been tumor-free for the past one year. Myoid hamartoma of the breast is a rare breast tumor resembling breast cancer. We must include myoid hamartoma as a differential diagnostic consideration in cases of breast tumor : such as fibroadenoma, phyllodes tumor, leiomyoma, adenomyoepithelioma and fibromatosis, if spindle cells are observed in pathological samples.

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We report a case of Paget-type recurrence 10 years after breast-conserving therapy.
The patient was a 51-year-old woman who, at first surgery, had undergone quadrantectomy and axillary dissection with radiotherapy for non-invasive ductal carcinoma of the left breast. An erythematous lesion appeared in the ipsilateral nipple-areolar region 10 years after the first surgery. Skin biopsy revealed that it was a Bowen's disease-like lesion associated with no lesion in the breast. She underwent local excision involving the subdermal and mammary tissue under the skin lesion. Postoperative pathohistological examination revealed Paget-like cells in the epidermis and ductal carcinoma in situ in the nipple. The tumor cells were positive for CK7 and HER2 but negative for CK20, ER, PgR, and GCDFP15 by immunohistochemical study. We concluded that it was Paget-type recurrence 10 years after breast-conserving therapy. She received adjuvant chemotherapy and no recurrent lesion has been detected.

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This case deals with a 59-year-old female who developed a right breast lump, cough and dyspnea. The right breast showed an irregular mass with redness and edema of the skin. It was diagnosed as an invasive ductal carcinoma (scirrhous carcinoma), ER : >=90%, PgR : 20%, HER2 (1+), Ki-67 : 30% on needle biopsy. Blood testing revealed anemia and thrombocytopenia (Hb 8.7 g/dl, PLT 5×10⁴/μl). On computed tomography (CT) a rib, a vertebral body and the pelvis had multiple bone metastases ; both lungs had multiple metastases. Clumping of cells with an irregular nucleus was seen on bone marrow biopsy ; this was thought to be bone marrow metastasis related to breast cancer. Weekly paclitaxel administration was given ; there were no adverse events such as myelosuppression, and treatment could be continued. The patient's anemia and thrombocytopenia improved after the 5th course ; on CT, the tumor in the right breast and the lymph node metastases in the right axilla and the multiple metastases in the lung were found to be remarkably smaller. We report our treatment of this patient. Weekly paclitaxel was effective for treating bone marrow breast cancer metastasis that had caused anemia and thrombocytopenia.

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This paper reports the case of a 68-year-old woman with recurrence of spleen. She had undergone left partial resection with axillary lymph node dissection for breast cancer in 2005. Due to increasing levels of serum CA15-3 64 months after surgery, she underwent an abdominal CT scan, which detected no metastasis. FDG PET/CT revealed progression of the spleen tumor. Splenectomy was performed. The postoperative histological findings disclosed metastasis from breast cancer.
After surgery, we started chemotherapy, but peritoneal metastasis was detected 7 months later. Recurrence of breast cancer is often seen in the lung, liver, and bone. Solitary splenic metastasis is very rare ; therefore, this case is of interest. We report our experience with a review of the literature.

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The patient was a man in his seventies who was diagnosed as having an abdominal aortic aneurysm and underwent endovascular aneurysm repair (EVAR). The patient developed abdominal pain and anal bleeding 4 days after EVAR. As intestinal necrosis and perforation were not evident on imaging findings, conservative treatment was employed. On the 6^th day after EVAR the abdominal pain was abruptly aggravated and free air was identified in the abdominal cavity. Emergency laparotomy was thus performed. Intraoperative findings included discontinuous necrosis in the intestinal wall from the jejunum to the ileum and a perforated part. Extensive resection of the small intestine by about 300 cm in length was performed. Histopathological study showed no thrombi and occlusion at the mesenteric artery, and non-occlusive mesenteric ischemia (NOMI) was the most likely diagnosis. After the operation the patient developed pneumonia and an infectious aortic aneurysm and died of multiple organ failure on the 57^th postoperative day.
EVAR is less invasive than the conventional operations, however, owing to its less invasiveness, it is apt to be used even for high risk cases. In treating abdominal pain occurring abruptly after EVAR, it is important to consider a possible onset of NOMI and to make fast determination of therapeutic guideline.

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The patient was a 66-year-old man with medical histories of hypertension and chronic renal failure. Since May 2009, his condition needed hemodialysis. Hemodialysis was introduced by a double-lumen catheterization for dialysis through the right internal jugular vein, and simultaneously internal shunt was created in the right forearm. Echography of the thyroid and carotid artery conducted in November 2010 disclosed a 26×11×9 mm tumor in the right internal jugular vein. The tumor was not adjacent to the venous wall and appeared to be anchored to the venous wall at the head side by a cord. In order to prevent pulmonary thromboembolism, the tumor in the right internal jugular vein was removed under general anesthesia. The tumor was clarified to be a thrombus in the shape of a rugby ball that was anchored to the venous wall by cords at its head and tail side, respectively. The cords looked like venous valve.
Surgical treatment for deep venous thrombosis affecting veins of the upper limb, cervical vein and superior vena cava is employed only when internal therapy is unsuccessful. However, we performed thrombectomy in this case, because the thrombus was tumorous and had a specific morphology so that pulmonary thromboembolism was expected to occur in a high incidence if it could migrate.

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A 71-year-old woman who had rheumatoid arthritis, chronic kidney disease (CKD) and peripheral artery disease had acute myocardial infarction due to three-vessel coronary artery disease and was transferred to a hospital. After anticoagulation was achieved with continuous intravenous infusion of heparin, her platelet count decreased, and a definitive diagnosis of heparin-induced thrombocytopenia (HIT) type II was made by a serologic test confirming positive antibodies to the heparin-platelet factor 4 (PF4) complexes. Furthermore, CKD was getting worse because of the contrast media and hemodialysis was needed three times a week, in addition to having vein thrombosis. Then she was transferred to our hospital for surgery, and we performed an off-pump coronary artery bypass (OPCAB) using argatroban as an alternative anticoagulant. The postoperative course was uneventful and platelet count returned to normal. We report a case of HIT that successfully underwent OPCAB using argatroban.

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A 78-year-old man, who underwent a Y-shaped graft replacement 18 years ago for an infra-renal abdominal aortic aneurysm, was admitted to our hospital because of hematemesis and melena. An aorto-duodenal fistula was diagnosed because an abdominal computed tomography scan showed that the duodenum was deformed by an anastomotic aneurysm, which was proximal to the prosthetic vascular graft. He underwent an operation. An axillo-bifemoral bypass was performed first. A fistula between the aorta and the duodenum was observed through the aneurysm, and the fistula was closed from the inside of the aneurysm. The implanted vascular prosthesis was removed leaving the bilateral prosthetic legs, and the aortic stump was closed. Finally, an omental transfer was performed around the closed aortic stump and anastomosed prosthetic legs. The postoperative course was uneventful until the patient died from lung cancer 6 years after the operation.

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A 45-year-old male developed sudden-onset chest pain. Computed tomography revealed a Stanford type B acute aortic dissection with infarction of two-thirds of the left kidney. Initially, conservative pharmacotherapy was started. However, on the 14^th day, the serum creatinine level increased (5.8 mg/dL), and right lower extremity ischemia due to the compression of the true lumen occurred. An axillo-femoral bypass was performed. After surgery there was no renal dysfunction or lower limb ischemia. An axillo-femoral bypass is one treatment option that improves organ ischemia caused by the compression of the true lumen.

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We report a case of spontaneous pneumothorax developed re-expansion pulmonary edema (RPE) associated with hypovolemic shock after chest drainage. The patient was a 43-year-old man suffering from right spontaneous pneumothorax. Chest drainage was conducted on the 10^th day after the onset of the symptoms. Thereafter the patient produced a large amount of frothy sputum and his cardiopulmorary dynamics became unstable. He was diagnosed with RPE and respiratory management using mechanical ventilation with PEEP was started. The systolic blood pressure was 60 mmHg, the heart rate was 120 times per minute, and the patient went into shock. Cardiovascular management was done by transfusion loading and administration of a vasopressor. Eventually his life could be saved by administration of sivelestat sodium hydrate and steroids.
RPE that occurs after chest drainage or thoracentesis for pneumothorax is a serious complication. RPE can be associated with hypovolemic shock as well as respiratory failure, so that careful cardiopulmonary management would be mandatory for the treatment.

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Primary lung cancer usually relapses relatively early after curative resection and rarely recurs after a lapse of five years or more following operation. Recently we experienced a case of lung cancer relapsed with peritoneal carcinomatosis 11 years after curative resection of the primary lesion. The case involved a 71-year-old man who underwent left upper lobectomy with lymph node dissection for lung cancer at the age of 60. His treatment was completed after a nine-year follow-up in the clinic, without any recurrences. He noticed abdominal discomfort when 11 years had elapsed after the operation and the symptom did not improve. Abdominal CT was thus performed and peritoneal carcinomatosis was suspected. Fine needle aspiration cytology of ascetic fluid gave findings of adenocarcinoma. On immunostaining, metastasis of lung cancer was suspected. Laparotomic biopsy to make the definite diagnosis revealed multiple nodes in the abdominal cavity, as well as multiple occurrence of stenosis due to peritoneal dissemination in the small intestine and the left side colon. Pathologic findings of the disseminated foci were compatible with immunostaining findings of the lung cancer resected 11 years previously. Furthermore the both lesions were very similar in morphology in microscopic study. Peritoneal dissemination of lung cancer was diagnosed. The patient died of lung cancer eight months after the diagnosis of metastasis.

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We encountered a rare case of well-differentiated duodenal adenocarcinoma with scirrhous stroma. An 85-year-old man was admitted due to vomiting. Abdominal CT showed thickening of the duodenal wall. Barium enema studies revealed stenosis of the duodenal bulb. Endoscopic examination revealed an irregular sore with a small granule on the mucous membrane of the duodenal bulb. The biopsy specimen from the region was diagnosed as Group IV. Preoperative examination disclosed a tumor confined to the duodenal wall but no lymph node metastasis, and we performed a pancreatoduodenectomy. The resected specimen contained a 60×50-mm Borrmann type 5 tumor in the duodenum. Pathology revealed scirrhous stroma of well-differentiated adenocarcinoma invading the serosa with lymph node metastasis.

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A 33-year-old woman, who had undergone Caesarean section at a hospital at 31 years of age, visited our hospital because of nausea and vomiting. A plain abdominal X-ray showed an intranslucent thread-like mass in the pelvis. CT revealed small-bowel distention with an air-fluid level and a 3.5-cm mass like area in the small intestine in the lower abdomen. Intestinal obstruction due to a foreign body was diagnosed, and surgery was performed on the same day. An approximately 20-cm segment of the small bowel had become markedly kinked, forming a conglomerated mass. Detachment of the conglomerated small bowel revealed a perforation at that site, and a solid object was palpable in the proximal bowel segment. The conglomerated small bowel segment was resected along with the solid object, which was found to be gauze containing a radiopaque thread.
Postoperative intraperitoneal foreign body is an iatrogenic complication that can rarely lead to sepsis and intestinal obstruction or perforation, so it is required careful medical attention. This patient represents a case of an aberrant medical gauze that had been left in the abdominal cavity during the previous surgery and migrated into the vowel. Such a case is rare in the literature, and also interesting in terms of its pathogenesis.

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A 47-year-old woman, who had a total hysterectomy for a uterine myoma 7 years prior, presented with epigastralgia. The abdominal X-ray and CT images showed a small bowel obstruction due to an intra-intestinal foreign body. An ileus tube was inserted to reduce intestinal pressure. However, urgent surgery was required because the patient developed peritonitis. During the operation, a small bowel perforation located 50 cm from the terminal ileum on the oral side was observed. Furthermore, in the intestine, a tumor-like lesion located 20 cm from the terminal ileum on the oral side was found. A detailed examination showed that it consisted of surgical gauze. The migration of intraperitoneal retained surgical gauze into the small bowel is very rare ; only 14 cases have been reported in Japan, including this case.

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Introduction : Vitelline vessels are blood vessels feeding the primitive gut and the remnants of these vessels after birth are called mesodiverticular bands. We present a case of strangulation ileus caused by a mesodiverticular band.
Case : A 26-year-old man without previous history of undergoing laparotomy was seen at our hospital because of abdominal pain and vomiting. Abdominal CT scan showed remarkable dilatation and swelling of the small intestine, with a part suggestive of strangulation. Emergency operation was performed with a diagnosis of strangulation ileus. At laparotomy, we saw the small intestine to be incarcerated by a cord which extended from the abdominal wall to the intestine, resulting in strangulation ileus. The cord had originated from the mesentery about 80 cm proximal to the ileocecal region. The root of the cord was ligated and resected. Histopathological study revealed a ductal structure accompanied by congestion within the cord that was considered to be the mesodiverticular band.
Consideration : Meckel's diverticulum that is the mesodiverticular band occurs in about 2% of the population, among of which the mesodiverticular band is associated in an incidence of 1-6%. There are some reports describing that about half number of cases of the mesodiverticular bands are not associated with Meckel's diverticulum. In treating strangulation ileus in this patient who had no previous history of laparotomy, the mesodiverticular band appeared to be the probable cause.

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A 40-year-old man was admitted to our hospital suffering from postprandial severe epigastralgia. Abdominal magnetic resonance imaging (MRI) and computed tomography (CT) showed cholecystolithiasis and an abscess on the right side of the bladder, and cystoscopy revealed that the abscess penetrated into the bladder. We only performed laparoscopic cholecystectomy in accordance with patient's wish to reduce the severe colicky pain. Operative findings and urinary cytology suggested that the enterovesical fistula originated from the inflammation, so we performed laparoscopic surgery. The fistula of the enteric site was at the terminal ileum, so we performed an ileocecal resection. Meanwhile, the fistula of the vesical site was sutured only. Resected specimen showed a non-specific ulcer 1 cm in diameter at the opposite site of the mesenteric attachment. Histopathological findings showed neither vasculitis nor thrombus, therefore it was hard to consider the perforating ulcer as the cause of the ischemic insult. We diagnosed the ileovesical fistula due to a simple ulcer, because the clinical symptoms did not satisfy the diagnostic criteria for Behçet's disease. Enterovesical fistula due to simple ulcer is a rare entity, we report our case with a review of the literature.

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A 77-year-old man presented to our hospital because of a one-day history of lower abdominal pain. He had no history of peptic ulcer disease. Physical examination showed lower abdominal tenderness and rebound tenderness without muscular rigidity. Abdominal CT scan revealed a small amount of free air in the abdominal cavity probably caused by perforation of the upper gastrointestinal tract, but the exact location of the perforation was not clear. An emergent operation was performed using laparoscopic assisted procedure. A perforated jejunal diverticulum was found to be about 20cm distal from the ligament of Treitz, and partial resection of the jejunum, peritoneal lavage and drainage were performed. Pathological findings revealed a perforation of pseudo-diverticulum. Laparoscopic procedure was useful to detect the location of perforation which was unclear before the operation. Perforation of a jejunal diverticulum is rare and difficult to be diagnosed before surgery, however, we should suspect it in the case of perforation of the gastrointestinal tract.

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Schwannomas are tumors derived from Schwann cells. These tumors rarely develop in the gastrointestinal tract, especially not in the colon. A 64-year-old woman visited a local physician with chief complaints of abdominal pain and diarrhea, and she was referred to our hospital after an abdominal tumor was detected on palpation. Contrast-enhanced abdominal computed tomography (CT) revealed a 38 × 30 mm tumor in the transverse colon, and colonoscopy showed a submucosal tumor in the transverse colon. Gastrointestinal stromal tumor (GIST) was first suspected, and laparoscopic-assisted partial colectomy was performed. The histopathological diagnosis was a well-defined tumor having a fibrous capsular structure, and spindle-shaped tumor cells that were sparsely distributed were seen proliferating in a fascicular and irregular manner. Immunohistochemical staining was strongly positive for diffuse expression of S-100 protein and negative for CD34, c-kit, and desmin, and schwannoma was diagnosed. Schwannomas do not normally metastasize or undergo malignant transformation, and it was thought that treatment and postoperative follow-up should take into account the fact that they are benign tumors.

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A 65-year-old man visited our hospital for melena. Enhanced CT at the emergency department could not reveal the bleeding site. He was admitted to our hospital on the same day. Over-night, he bled several times. The next day, enhanced CT revealed extravasation of contrast medium around the hepatic flexure of the colon. We decided on an interventional radiological approach. The bleeding site of unknown cause was detected.
The bleeding was supplied by the right branch of the middle colic artery and right colic artery. Arterial embolization with coil was successful for the former. However, this was not the case for the latter. We injected N-butyl-2-cyanoacrylate (Histoacryl) and fatty acid ethyl esters of iodized poppy seed oil(Lipiodol) into the right colic artery using an immaturely advanced catheter. Hemostasis was achieved. On the third day after arterial embolization, his body temperature increased to over 39.5°C. Enhanced CT revealed loss of blood supply of the colon at the splenic flexure. We diagnosed this part of the colon as necrotic. Emergency laparoscopic right hemicolectomy saved his life. In conclusion, comprehensive knowledge of embolic materials is critical. Moreover, although the laparoscopic approach is challenging in this situation, it can be feasible when skilful surgeons are involved.

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We report a case of descending colon cancer in a patient with situs inversus totalis treated by laparoscopy-assisted colectomy. A 78-year-old man was referred to our hospital because of a positive fecal occult blood test. He was diagnosed with descending colon cancer at colonoscopy. A chest radiograph and CT revealed situs inversus totalis. We performed laparoscopy-assisted colectomy with no serious complications. Preoperatively, the three-dimensional CT findings provided useful information such as the location of the tumor and its relationship with the feeding arteries. These findings enabled us to perform laparoscopic surgery safely in a patient with situs inversus totalis.

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A 64-year-old man complained of general fatigue and dizziness. He was malnourished and had a large protruding gastric body tumor. He had foul eructations, unrelenting diarrhea, severe trunk emaciation, and edema of his extremities. A gastrocolic fistula originating from a transverse colon cancer was found, as well as a synchronous advanced rectal cancer (Rb). Neither total parenteral nutrition nor enteral nutrition improved his nutritional status. He underwent a left colectomy, a sleeve gastrectomy, a splenectomy for en bloc tumor resection ; an end transverse colostomy and a mucous fistula of the descending colon were constructed. On the 49th -postoperative day, he underwent a Hartmann operation for rectal cancer. On histology, each tumor included identical well differentiated adenocarcinoma with regional lymph node metastases along the inferior mesenteric artery. After the second operation, the patient was given chemotherapy (mFOLFOX6) for the metastatic liver tumor lesion with tumor thrombus in the portal vein. The patient died of multiple liver and distant lymph node metastases 5 years and 4 months after the first operation.

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A 60-year-old woman underwent laparoscopically assisted left hemicolectomy with D2 lymphadenectomy for descending colon cancer. Approximately 1 year after the operation, systemic CT and MRI scan revealed a 10-mm solitary nodule in the S7 segment of the liver and a 25-mm mass in the spleen. We considered it colon cancer metastasis and performed surgery. During surgery, we found a tumor on the right diaphragm and normal liver ; therefore, we performed partial resection of the right diaphragm and splenectomy. The resected specimen of the diaphragm and spleen revealed the same histological findings as the descending colon specimen. Literature review revealed only 9 reports of colorectal metastatic tumors involving the diaphragm and no reports of concurrent splenic metastasis. Etiologically, the splenic metastasis was considered hematogenous metastasis. On the other hand, the tumor cells might have been generally absorbed or might have infiltrated the peritoneal stomata of the diaphragm, but we consider it hematogenous metastasis in this case.

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We describe herein a case of colon cancer developed metachronous solitary splenic metastasis after sigmoidectomy which was treated by splenectomy.
A 79-year-old man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. The histological diagnosis was moderately differentiated adenocarcinoma, Stage IIIa (ss, ly1, v0, n1), according to the Japanese Classification of Colorectal Carcinoma. As postoperative adjuvant chemotherapy, 12 courses of FOLFOX were carried out. Nineteen months after the surgical resection, the serum CEA level was elevated to 7.9ng/ml and a splenic tumor 18mm in diameter was revealed by abdominal CT scan. FDG-PET revealed abnormal uptake of FDG at the tumor and no other lesions were discovered. We suspected metachronous solitary splenic metastasis, and performed a splenectomy. Pathohistological findings and immunostaining method confirmed splenic metastasis from sigmoid colon cancer. Postoperative cerum CEA levels were decreased to normal level.
Reported cases of solitary splenic metastasis from colon cancer are very rare, but it is considered to be one form of distant metastasis. Further studies of the multidisciplinary treatment for the disease are required.

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We report a case requiring laparoscopic resection of sigmoid colon cancer complicated by a horseshoe kidney. A 47-year-old woman, who had abdominal pain, was diagnosed as having sigmoid colon cancer on colonoscopy. On computed tomography (CT) and three-dimensional CT, the sigmoid colon cancer and a horseshoe kidney with an enlarged right renal pelvis, an anomalous renal artery, and anomalous renal veins were documented. The renal vein of the lower pole of the left kidney was located close to the inferior mesenteric artery. Based on the preoperative diagnosis of sigmoid colon cancer (cSS, N1, P0, H0, M0), a laparoscopic sigmoidectomy was performed, but no anomalous renal vessels were detected. However, the left lumbar splanchnic nerves were found to be located in front of the horseshoe kidney. Anomalous locations of renal vessels, ureters, gonadal vessels, and lumbar splanchnic nerves must be evaluated to avoid laparoscopic iatrogenic injury in patients with a hoeseshoe kidney. To date, there are only two previously reported cases of laparoscopically resected sigmoid colon cancer complicated by horseshoe kidney. Neither mentions the location of the lumbar splanchnic nerves.

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A 71-year-old woman, who had surgery and subsequent irradiation for uterine cancer 29 years prior, developed pain around her left hip and leg. Computed tomography showed a soft tissue density mass around the left iliac bone measuring 13 cm in diameter. An incisional biopsy revealed a pleomorphic sarcoma. On positron emission tomography and colonoscopy, a cecal cancer a sigmoid colon cancer were detected. These two colonic cancers were surgically removed to prevent bowel obstruction. Both of the tumors presented as bulky masses with well-defined margins invading the proper muscle layers and the surrounding colonic wall ; they exhibited dysplasia, foamy cells, and thickened arterial walls that showed hyalinization, indicating radiation-induced colitis. Namely, all these tumors including the pleomorphic sarcoma around the iliac bone were considered to be radiation-induced tumors. Radiation-induced cancer is a late complication of irradiation and when diagnosed is often advanced. Both patients and clinicians should be cognizant of the potential consequences of irradiation ; appropriate follow-up should be instituted.

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The patient was a 51-year-old man. Abdominal CT revealed thickness of the rectal wall and a 10-cm multinodular and hypodense liver tumor. We diagnosed rectal cancer and synchronous solitary liver metastasis with abscess formation. Based on percutanous drainage of the liver abscess, a fistula between the liver abscess and the duodenum was confirmed. Low anterior resection for rectal cancer was performed and he underwent systemic chemotherapy with capecitabine and oxaliplatin subsequently. As no metastatic lesion except solitary liver metastasis was detected after eight courses of systemic chemotherapy, lateral segmentectomy and resection of the antrum of the stomach and the duodenal bulb were performed. The pathological findings revealed that the liver tumor consisted of well-differentiated adenocarcinoma and was compatible with metastasis of rectal cancer. Although liver metastasis had invaded the serosa in the greater part of the stomach and duodenum, the invasion extended to just below the mucosa of the duodenum only at the site of the fistula. This suggested that the fistula was due to the effects of inflammation from the synchronous liver metastasis with abscess formation. We report a very rare case of liver metastasis with abscess formation and fistulization into the duodenum.

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We report the use of a self-expandable metallic stent for a colostomy stricture caused by an abdominal rectal cancer metastasis. A 73-year-old woman was referred for evaluation of abdominal distension, diarrhea, and weight loss first noted in June, 2010. She was diagnosed as having rectal cancer as well as multiple liver and lung metastases. In October, 2010, she had a colostomy and a central venous access port device installed. She was treated with 14 courses of bevacizumab+mFOLFOX6 therapy, 7 courses of bevacizumab+FOLFIRI therapy, and 9 courses of mFOLFOX6 therapy. She complained of constipation and abdominal distension in July, 2012. A colostomy stricture due to abdominal rectal cancer metastasis was diagnosed. A self-expandable, metallic stent (SEMS) was inserted from the colostomy. Immediately following insertion, a lot of stool passed via the stent. The patient could eat a meal the following day. She died on the 28^th postoperative day. A colostomy in a patient with a poor general condition is a psychological and physical burden and negatively impacts on QOL. SEMS therapy is a useful palliative option for improving QOL since it enables ingestion and is minimally invasive.

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We report a case of anal canal cancer complicated with anal stricture, which was diagnosed 22 years after the onset of Crohn's disease. The patient was a 60-year-old man, who developed Crohn's disease in the small and large intestines in 1980 at the age of 27. In 1990, he developed an inflammatory mass in the ileum, and underwent a right hemicolectomy. In April 2002, 22 years after the onset of Crohn's disease, he was admitted to our hospital because of anal pain and bowel obstruction. Imaging studies indicated a fistula between the ileo-transverse colonic anastomosis and the small bowel. He also developed anal pain and stricture with an induration, which was diagnosed with well differentiated adenocarcinoma based on histological examination of biopsy specimen obtained under spinal anesthesia. In May 2002, he underwent an abdominoperineal resection of the rectum, sigmoid colostomy, the resection of the ileo-transverse colonic anastomosis and small bowel strictureplasty. In April 2004, he developed a peristomal abscess, and required removal of the residual colon and ileostomy construction. At present, there are no signs of cancer recurrence. A careful anal examination is indispensable in Crohn's disease patients with anal stricture because of the potential risk of developing anal canal cancer.

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A 71-year-old man visited a local physician in July 2012 with pain and swelling in the coccyx. He was diagnosed with a coccygeal cyst, and incision resulted in discharge of a jelly-like fluid. An adenocarcinoma was diagnosed based on biopsy of the cyst wall, and the patient was referred to our hospital for surgery. A 4-cm tumor accompanied by hard nodules was seen in the hip between the coccyx and the anus from the skin to the subcutaneous layer. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a 4-cm tumor consisting of both solid and cystic parts in the subcutaneous layer of the tip of the coccyx and the postanal space. Transsacral surgery was performed under general anesthesia with the patient in the jackknife position, and the tumor was resected together with areas of skin infiltration. The pathological diagnosis of the cyst wall was a tailgut cyst, and adenosquamous carcinoma was seen in the thickened cyst wall. Local recurrence occurred in the hip in the fourth postoperative month, and multiple lung metastases were seen in the sixth postoperative month.
Malignant transformation of tailgut cyst is extremely rare, and only six cases have been reported to date in Japan. Our experience with a case of adenosquamous carcinoma that developed from a tailgut cyst is reported with reference to the literature.

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A 75-year-old woman had bloody stools and pain around the anus for a long time. After a detailed examination, anal canal adenocarcinoma with pagetoid spread was diagnosed. The rectum and anal canal were very narrow due to the cancer and its infiltration to surrounding tissue. Thus, the patient had a temporary double-barreled colostomy to rest the bowel ; the cancer site was irradiated prior to an abdomino-perianal resection. In advance of the operation, the resection range was determined by mapping biopsy. On histopathology, no tumor cells were found in the specimen ; the patient has been well and disease-free for 9 month after surgery.
This very rare tumor case appears to have benefitted from pre-operative radiation. Thus, we report on this effective approach along with a review of the literature.

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A 33-year-old woman who noticed epigastric pain visited a neighboring hospital and was detected to have gallbladder stone by close examinations. She was referred to our hospital and underwent laparoscopic cholecystectomy. Intraoperative observation of the abdominal cavity disclosed an about 10-mm diameter liver tissue attached to the ventral aspect of the gallbladder without any connection with the main liver. It was diagnosed as ectopic liver and was excised together with the gallbladder. The liver tissue attached to the gallbladder had the completely same structure as the hepatic lobe. The histopathological diagnosis was ectopic liver.
Ectopic liver is a rare morphological anomaly of the liver. It is usually asymptomatic and is incidentally detected during surgery or autopsy in most cases. There are some reported cases of ectopic liver associated with hepatocellular carcinoma or ruptured hepatocellular carcinoma in the literature. This paper deals with our experience with a case of ectopic liver incidentally found during laparoscopic cholecystectomy.

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A 49-year-old woman developed high fever and increases in white blood cell count and C-reactive protein (CRP) with after chemotherapy for acute myelocytic leukemia. She was diagnosed with multiple liver abscesses by PET/CT. Ultrasound-guided percutaneous fine-needle biopsy of the hepatic lesion was performed, but no causative microorganism was identified. The clinical course supported the diagnosis of fungal liver abscess, and antifungal medical treatment was started. However, CRP remained positive, and PET/CT revealed progression of the liver abscess. Laparoscopic partial resection of three lesions was performed for identification of causative microorganism and susceptibility testing.
Histopathological findings indicated epithelioid cell granuloma with caseation necrosis, and Ziehl-Neelsen staining detected mycobacterium. Although the QuantiFERON^®-TB Gold In-Tube test was negative, the causative microorganism could not be identified from laboratory culture ; therefore, the patient received four-agent combination therapy for atypical mycobacterial disease. She received allo-peripheral blood stem cell transplantation 4 months after the operation, and her condition has been stable.
Identification of causative microorganisms by ultrasound-guided percutaneous fine-needle liver biopsy is difficult and may not provide a definitive diagnosis. Alternatively, laparoscopic partial liver resection can be useful in making an etiological diagnosis and treatment.

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We report a rare case of primary solitary fibrous tumor (SFT) of the liver and review the literature. A 73-year-old man consulted our hospital because a liver tumor had been detected incidentally at a previous hospital. Enhanced CT revealed a tumor stain in the early phase. We strongly suspected hepatocellular carcinoma and performed posterior segmentectomy of the liver. The histopathological examination revealed many spindle cells with complicated proliferation.
Immunohistochemical staining revealed that the specimen was negative for dog1, CK, c-kit and positive for CD34, bcl-2, CD99. The final diagnosis was primary SFT of the liver. Although primary SFT of the liver is rare, physicians should keep this disease in mind when encountering a hypervascular liver tumor. In addition, as some researchers have reported recurrence, careful follow-up after surgery is advised.

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A 25-year-old woman visited a local physician with acute enterocolitis, and ultrasound examination revealed a hepatic tumor. She had no past history of blood transfusions, oral contraceptive use, or steroid use. She had a history of ovarian cystectomy at the age of 11 years, and she had given birth to her first child one year earlier. Biochemical tests were negative for hepatitis virus markers, and no liver function abnormalities were seen. Although alpha-fetoprotein (AFP) was within the normal range, the protein induced by vitamin K absence or antagonist-II (PIVKA-II) was elevated (329 mAU/ml). Computed tomography (CT) showed a tumor having a diameter of 3.2 cm, with contrast enhancement in the lateral segment of the liver. On ultrasound examination, the tumor interior was hyperechoic, and the margin was hypoechoic. On liver biopsy, well-differentiated hepatocellular carcinoma was suspected. The patient underwent partial hepatectomy and had an uneventful postoperative course. Histopathological tests showed no fibrosis in the background liver. Cellular atypia at the tumor site was mild, however, increased cell density, capillarization of sinusoidal endothelial cells (CD34-positive), and interstitial infiltration were observed. The patient was diagnosed with well-differentiated hepatocellular carcinoma rather than hepatic adenoma.

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We report a rare case of hepatic metastasis of meningeal hemangiopericytoma (HPC) 10 years after primary resection, mimicking hepatocellular carcinoma (HCC). The patient was a 55-year-old man and a follow-up computed tomography (CT) scan after resection of the meningeal HPC revealed two hypervascular hepatic tumors in segments 4 and 6. The hemodynamics of the tumors showed patterns of HCC. Posterior sectionectomy and partial resection of segment 4 was carried out as treatment. Microscopic findings of the resected specimen were massive growth of spindle-like cells surrounding the small vessels, which resembled the findings of the meningeal HPC resected 10 years ago. Therefore, our final diagnosis of these liver tumors was late metastases from HPC of the meningeal membrane, not HCC. The patient is doing well without recurrence 4 years after surgery. Recurrence of meningeal HPC to the liver successfully treated by surgical resection is a rare entity. As the liver metastasis of HPC shows a hypervascular appearance, differential diagnosis from HCC will be important.

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A 71-year-old man underwent surgery with a diagnosis of cancer of the pancreas head, T2N0M0 and Stage II. Upon laparotomy a 1-cm diameter circular white nodule was found at the segment IV/V of the liver. Partial hepatectomy was performed and intraoperative frozen section diagnosis was reported to be high or moderately differentiated adenocarcinoma. According to the therapeutic guidelines, pancreas cancer with distant metastasis is not a candidate for operation and is indicated chemotherapy or best supportive care. In this case, however, preoperative imaging methods did not provide any suspicion of hepatic metastasis, and the possibility of hepatic metastasis should not be high in terms of the progression of the primary foci. Accordingly we determined that the cancer nest should be resected without leaving cancer remnant, and performed pancreaticoduodenectomy with D2 dissection. The resected hepatic tumor was diagnosed as intrahepatic bile duct adenoma on the permanent preparation.
Intrahepatic bile duct adenoma is a rare benign hepatic tumor. It is incidentally detected at surgical resection in many cases and the tumor resembles metastatic hepatic cancer, so that attention must be paid when the disease is associated with a malignant tumor. This paper deals with a case of intrahepatic bile duct adenoma associated with pancreas head cancer.

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A woman in her thirties complaining of upper abdominal pain was admitted to our hospital with a diagnosis of gallbladder stone and choledochitis. Bile stone was not evident on cholangiography. Laparoscopic cholecystectomy was performed. On and after the next day, bile leakage appeared. Endoscopic retrograde cholangiography (ERC) revealed bile leak from the surgical stump of the cystic duct. Endoscopic nasobiliary drainage (ENBD) was thus started. On ERC performed again, a bile stone became apparent and endoscopic sphincterotomy (EST) was performed. Bile leakage was ameliorated and the patient was discharged from our hospital on the 10^th postoperative day. It is etiologically considered that an increase in the bile duct pressure occurred by an incarcerated spilled bile stone might cause rupture at the surgical stump of the cystic duct, resulting in bile leakage. Bile leakage caused by a spilled stone rarely occurs. Clinical reports on the endoscopic intervention for postoperative bile leakage have been increasing. In this case, associated uses of ENBD, biliary stent, and EST would be necessary in accordance with conditions that vary from patient to patient.

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We report a case of gallbladder metastasis from renal cell carcinoma. A 43-year-old man underwent right nephrectomy for renal cell carcinoma with lung metastasis 1 year ago. After the operation, he was treated with IFN for lung metastasis. Approximately 1 year after he started IFN, follow-up CT detected a tumor in the gallbladder and he was referred to our department. Abdominal US demonstrated a 26-mm pedunculated polypoid lesion in the fundus of the gallbladder. Enhanced abdominal CT demonstrated an enhanced 20-mm solid mass in the gallbladder. MRI also revealed a solid mass in the gallbladder, which exhibited high-signal intensity on a T1-weighted image and low-signal intensity on a T2-weighted image. For metastatic gallbladder tumor from renal cell carcinoma or primary gallbladder cancer, the patient underwent extended cholecystectomy. The resected specimen contained a pedunculated polypoid tumor in the fundus of the gallbladder. The tumor was diagnosed as clear cell carcinoma. Immunohistochemically, the tumor cells were positive for EMA and vimentin, and negative for CK7 and CEA. We diagnosed the gallbladder tumor as metastasis from renal cell carcinoma. Gallbaladder metastasis from renal cell carcinoma is comparatively rare.

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A 75-year-old-man with jaundice was found on enhanced abdominal computed tomography and endoscopic retrograde cholangiopancreatography to have a tumor in the lower extrahepatic bile duct. A preoperative diagnosis of carcinoma of the lower extrahepatic bile duct was made and, the patient had a subtotal stomach-preserving pancreaticoduodenectomy. On histopathology, the resected specimen included the tumor which consisted of an admixture of poorly to moderately differentiated adenocarcinoma and squamous cell carcinoma. The tumor was diagnosed as an adenosquamous carcinoma of the lower extrahepatic bile duct. Metastases to the liver and lungs were detected 4 months after surgery. Adenosquamous carcinoma of the bile duct is a rare bile duct carcinoma. If requires a multidisciplinary approach to treatment due to its rapid progression and poor prognosis.

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Adenoendocrine cell carcinoma of the gallbladder is rare with a dismal prognosis. A 77-year-old man was found to have an elevated lesion of the gallbladder following abdominal ultrasonography. CT and MRI revealed a 3-cm diameter tumor at the body of the gallbladder that was diagnosed as gallbladder carcinoma. Extended cholecystectomy was performed. Neither liver metastasis nor peritoneal dissemination was seen. Microscopically, the tumor consisted mainly of small atypical cells with a high nuclear/cytoplasmic ratio forming solid cellular nests, with well-differentiated adenocarcinoma replacing the mucosa. Immunohistochemical studies of tumor cells were positive for chromogranin A staining. The definitive pathological diagnosis was adenoendocrine cell carcinoma. Postoperatively, chemotherapy with CDDP and irinotecan was administered. He has been disease-free for 18 months since resection.

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A 49-year-old woman presenting with an upper abdominal tumor was referred to our hospital. The tumor was detected during routine abdominal ultrasonographic examination at another hospital and had been followed with a diagnosis of an adrenal tumor. Ultrasonography and abdominal CT scan performed at our hospital revealed a tumor located in the greater omentum, measuring 3 cm in diameter. Preoperative reexamination 6 months later did not show any remarkable changes. Laparotomy for the resection of the tumor was performed. Histopathologic findings of the resected tumor led to the diagnosis of Castleman's disease (hyaline vascular type).
Preoperative diagnosis of intraabdominal tumors is difficult and they are diagnosed after surgical treatment in most cases. Among of those tumors, Castleman's disease is rare, but it should be included in the differential diagnosis of abdominal tumors. After complete resection of the tumor, the prognosis of unicentric Castleman's disease is good. However, long-term careful observation is recommended because postoperative occurrence of malignant lymphoma or recurrence of Castleman's disease has been reported.

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A 56-year-old man was admitted for analgia. A mass was palpated on his lower abdomen. He underwent tumor extirpation and was diagnosed with mesenchymal tumor originating from the pelvic retroperitoneum in front of the right piriform muscles without invasion. He was diagnosed with solitary fibrous tumor (SFT) of low potential malignancy because the tumor, measuring 100×90×80mm, presented immunohistological findings as patternless pattern, CD34(+), vimentin(+), c-kit(-), SMA(-), S-100(-), mitotic index(3/10 HPF), p53 labeling index(1%), MIB-1 labeling index(3%). He has been disease-free 5 years after surgery. Since SFT usually arise from the pleura, extrapleural SFT is distinguished as another category. We suggest that even if SFT originating from the pelvic retroperitoneum exhibits malignancy histologically, it might have low malignant potential biologically, as based on our findings.

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We report three cases of obturator hernia operated electively using mesh by preperitoneal approach under spinal anesthesia after being reduced spontaneously. Case 1 : An 88-year-old woman presented to our hospital with right inguinal pain. Incarcerated right obturator hernia was diagnosed by abdominal CT scan. The symptoms disappeared shortly thereafter ; abdominal CT scan was performed again and revealed spontaneous reduction. Thereafter, we repaired it using the Kugel method. Case 2 : An 84-year-old woman presented to our clinic with left hypogastrium pain diffuse to the left leg. Incarcerated left obturator hernia was diagnosed by abdominal CT. She was admitted to our hospital on the same day. Subsequently, her symptoms disappeared ; abdominal CT scan was performed again and demonstrated spontaneous reduction. Thereafter, we repaired the obturator hernia. Case 3 : A 79-year-old woman presented to our hospital with right femoral pain and abdominal pain. Incarcerated right obturator hernia was diagnosed by abdominal CT. However, the symptoms disappeared, and abdominal CT scan was performed again, demonstrating spontaneous reduction. Thereafter, we repaired the obturator hernia.

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An 82-year-old man with a 20-year history of a bulge in the left inguinal region was admitted to our hospital because of vomiting and abdominal pain which occurred, three days after he lost his appetite. On admission, tenderness and muscular guarding were observed in the left lower quadrant of abdomen. Swelling, tenderness, and redness were marked from the left inguinal region to the scrotum. Abdominal CT scan revealed free air in the abdominal cavity, and an incarcerated sigmoid colon and feces in the left scrotum. We diagnosed the case as generalized peritonitis caused by a perforation of the sigmoid colon in the left incarcerated inguinal hernia, and performed an emergency laparotomy. Operative findings showed generalized peritonitis due to leakage of intestinal contents into the peritoneal cavity caused by the perforation of the sigmoid colon in the incarcerated indirect inguinal hernia. Hartmann's procedure and the resection of the hernial sac were performed. The patient was discharged from the hospital on postoperative day 29.
A case of a perforation of the sigmoid colon, without organic disease, by an incarcerated inguinal hernia is extremely rare. The present case is reported with reference to the literature.

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We report on the significance of less invasive surgery for a patient who suffered from malnutrition and decreased performance status.
Previously, the patient had undergone a total gastrectomy for gastric cancer, a right hemicolectomy for multiple colonic cancer, and a lower lobectomy for pulmonary actinomycosis.
During the follow-up period, an endoscopic study discovered multiple early duodenal cancers. Considering his poor general condition, intentional nutritional support was performed for 2 months before surgery, after which a pancreas-sparing duodenectomy was carried out as a less invasive procedure. A cholecystectomy revealed an incidental gallbladder cancer with lymph node metastasis, but neither additional nodal dissection nor pancreaticoduodenectomy were performed. He was discharged from the hospital on the 27th day after surgery. The appropriate nutritional support and less invasive surgery is the treatment of choice in patients with poor general condition after multiple gastrointestinal surgery.

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