The surgical outcome of patients with superior mesenteric arterial occlusion (SMAO) was investigated by comparing patients with and without vascular treatments. In total, 11 patients who underwent surgical treatment for SMAO were evaluated. Six patients underwent angioplastic surgery (APS group), and five patients did not (No APS group). There were no significant differences between the two groups in the ASA-PS, APACHEII, E-PASS, and the Glasgow prognostic score. The nutritional index was significantly lower in the No APS group than in the APS group. The time from onset to operation was shorter in the APS group than in the No APS group. The length of the resected intestine was shorter and the length of the remnant intestine was longer in the APS group than in the No APS group. The operative mortality was 18.2% (2 cases) ; they died of multiple organ failure with severe heart disease. The survival rate of patients who underwent surgical treatment for SMAO was 81.8% ; the survival rate was especially high with angioplastic surgery for cases of occlusion around the origin of the superior mesenteric artery.

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Objectives : The outcomes of patients with anal canal carcinoma who underwent inguinal node dissection (IND) were evaluated.
Methods : During the past 9 years, a total of 13 patients underwent curative resection for lower rectal and anal canal adenocarcinomas. Eight of the 13 patients had inguinal node metastases histologically. Four patients showed synchronous metastases, and the other 4 patients showed metachronous metastases. IND was performed on only the metastatic side.
Result : Six of 8 patients showed recurrence after IND, including one peritoneal dissemination, 2 intrapelvic node metastases, and 4 distant metastases. No patient had local inguinal recurrence. All patients who underwent IND developed lower limb edema. Seven of 8 patients were given postoperative chemotherapy. Seven patients survived more than 3 years with postoperative chemotherapy, and 2 patients survived relapse-free for more than 3 years.
Conclusion : IND for metastases has a high risk of lower limb edema, but a favorable prognosis can be achieved in patients with anorectal carcinoma when curative resection is possible with postoperative chemotherapy.

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[Background] We performed laparoscopic cholecystectomy with full-thickness dissection (LC-F) and laparoscopic resection of the gallbladder bed (LC-GB) for patients with wall thickening or polypoid lesions, including cancer of the gallbladder. The utility of these procedures were analyzed. [Methods] Short-term clinical results of 23 patients who had undergone LC-F and 3 patients who had undergone LC-GB between April 2010 and March 2013 were evaluated. [Results] There were no conversions to the open approach. Intraoperative gallbladder perforation occurred in one patient with LC-F, who was not diagnosed as malignant. The average blood loss of LC-F and LC-GB was 9.5 ml and 73.3 ml, and the average length of hospital stay was 2.6 days and 6.6 days, respectively. No morbidity was observed. Five (19.2%) of these patients were finally diagnosed with gall bladder cancer. All of the final surgical margins were pathologically negative. Of the five patients one patient died without recurrence due to other disease, and the others have no signs of recurrence. [Conclusions] LC-F and LC-GB allow complete resection of early stage cancer, and they are considered safe and less-invasive procedures.

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Metaplastic thymoma is a rare, biphasic, thymic epithelial tumor consisting of a mixture of polygonal cell components and spindle cell components. A case of metaplastic thymoma treated with surgery is reported along with a review of the relevant literature. The patient was a 69-year-old woman in whom abnormal right hilar shadow was seen on chest X-ray during a medial checkup. Chest computed tomography (CT) showed an irregularly shaped, 80 mm×69 mm×36 mm tumor with a solid, heterogeneous interior in the anterior mediastinum. Positron emission tomography-CT (PET-CT) showed high accumulation, with an SUVmax of 10.2 A thymic tumor was diagnosed, and the thymus was resected with the surrounding fat tissue by performing a median sternotomy. The resected sample was an encapsulated 8 cm×6 cm tumor, and its cut surface was uniformly yellowish-white and solid. Pathological findings included a mixture of polygonal cell components and spindle cell components, with a well-defined border. AE1/AE3 and E-cadherin were strongly positive in the epithelial components composed of polygonal cells, while vimentin was positive in the spindle cell components. The patient was diagnosed with biphasic, metaplastic thymoma showing polygonal cell and spindle cell components.

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The usefulness of combined 3-D reconstruction imaging using CT angiography (CTA) and CT bronchography (CTB) data for the preoperative assessment of lung cancer was studied. Abnormalities or variations in pulmonary blood vessels and bronchi could be identified. We report 2 cases of lung cancer in which anomalous V² branches were clearly depicted by this method ; in one case the anomalous branch travelled dorsally to the main bronchus and, in the other, it travelled to the intermediate bronchus. The accurate preoperative assessment of pulmonary blood vessels and branching bronchi is necessary for doing the surgery safely. Combined 3-D reconstruction imaging using CTA and CTB data serves this purpose well.

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The patient was in his seventies who had undergone subtotal esophagectomy and anastomosis of the cervical esophagus and gastric tube for esophageal cancer 12 years previously. Five years later, he suffered from anastomotic stenosis during chemoradiotherapy for cervical node recurrence. Eight months previously, he suffered from intractable esophageal fistula because of anastomotic leakage from re-anastomosis surgery. We performed pectoralis major muscle prombage because we judged that the repair with a free jejunal graft was not acceptable due to his poor general condition. The fistula was repaired by patching the iliotibial tract and pectoralis major muscle prombage. The patient had an uncomplicated postoperative course and changed hospitals on the 38th post-operative day. Pectoralis major muscle prombage for esophageal fistula requires blocking sialic leakage for engraftment of the prombage tissue. Patch repair with a skin flap for the closure of the fistula is a cumbersome procedure and often requires skin grafting. By contrast, patch repair using the iliotibial tract was easy and useful for the closure of the esophageal fistula.

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An 84-year-old woman with a medical history of type I paraesophageal hernia presented to our emergency room with shortness of breath and hematemesis a few hours after polyethylene glycol lavage for colonoscopy. On upper endoscopy, sliding hernia with perforation of the intrathoracic stomach was observed ; computed tomography revealed pneumomediastinum. An emergency midline laparotomy with additional left thoracotomy was performed and partial gastrectomy, hernia repair, and enterostomy were carried out. The patient recovered 27 days after the operation. Gastric perforation in hiatal hernia is rare but can be life-threatening ; therefore, prompt and accurate diagnosis and treatment are necessary.

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Spontaneous esophageal rupture is a disorder requiring urgent care in which the prognosis is affected by rapid diagnosis and treatment. A patient with spontaneous esophageal rupture who underwent surgery after receiving conservative therapy for a diagnosis of acute empyema is reported. The patient was a 73-year-old man who was brought to our hospital on an emergency basis after vomiting at home and experiencing persistent chest pain and dyspnea. Chest X-ray showed left pneumothorax and pleural effusion, and a thoracic drain was inserted. When pleural lavage was initiated based on a diagnosis of acute empyema, food residues were also observed. Esophagography showed leakage of contrast agent from the left wall of the lower thoracic esophagus. Endoscopy revealed a large laceration from which the inside of the thoracic cavity could be seen at the rupture site, and a large abscess cavity having poor drainage was confirmed. Suture closure of the esophageal rupture site and attachment of the gastric fundus over the closed site using the left thoracotomy approach were performed on day 13, and the patient was discharged on postoperative day 30 in good condition. In cases of spontaneous esophageal rupture for which conservative therapy has failed surgery should be considered including appropriate (inventive) suturing and drainage methods even if a long period of time has elapsed since onset.

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A 62-year-old man was detected to have advanced esophageal cancer with pulmonary hypertension (PH) due to atrial septal defect (ASD). We planned to perform radical repair of ASD and neoadjuvant chemotherapy before esophagectomy. However, he went into shock with melena by using an anticoagulant before cardiac catheterization. Endoscopic examination showed hemorrhage from the esophageal tumor, which suggested that ASD repair should be preceded by esophagectomy to remove the hemorrhage source. After esophagectomy, circulatory dynamics was unstable. Pulmonary arterial pressure (PAP) temporarily exceeded arterial pressure (AP) with coughing on the second day after the operation. Strict management with infusion and administration of vasopressin led to stable circulatory dynamics. However, unstable dynamics seemed to recur and we decided to repair ASD. Amplatzer Septal Occluder was inserted with intra cardiac echocardiography (ICE) because trans-esophageal echocardiography could not be used. After amplazter insertion, he became in good condition and was transferred to POD another hospital on 20.

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A 55-year-old man who was diagnosed as having gastric cancer by upper gastrointestinal endoscopy for close examination of cholecystolithiasis underwent total gastrectomy with Roux-en-Y reconstruction in our department. On the 4^th postoperative day he developed high fever, tachycardia, and dyspnea. Chest x-ray examination performed on the 5^th postoperative day revealed bilateral pleural effusion and mediastinal free air. Trocars placed into the both thoracic cavities discharged a mixture of purulent fluid and intestinal juice. Fluoroscopy of the gut revealed major leakage at the esophagojejunal anastomosis and leakage of contrast medium to the mediastinum and both thoracic cavities ; but no leakage to the abdominal cavity was seen. Sustained aspiration with the thoracic drainage, lavage of the thoracic cavity, and tracheal intubation for artificial respiration were started, and intensive treatment was performed. Gastrointestinal fluoroscopy conducted on the 30^th postoperative day showed disappearance of the leakage and on the 35^th postoperative day extubation became possible. Taking meals was started. No recurrence of the symptoms had occurred and the patient was discharged from the hospital on the 120^th postoperative day. We have experienced a patient presented with mediastinitis and bilateral pleural empyema due to leakage of contrast medium to the mediastinum and bilateral thoracic cavities following esophagojejunal anastomotic leakage after total gastrectomy. Since similar case reports have been few, we here present the case together with a review of the literature.

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A 55-year-old female consulted an internist because of abnormalities on a screening upper gastrointestinal series. It showed an elevated lesion in the lesser curvature and the anterior wall of the stomach. Upper gastrointestinal endoscopy showed an elevated lesion in the upper part of the stomach with no abnormalities of the gastric mucosa. Endoscopic ultrasonography showed that the tumor was a submucosal tumor derived from the muscle layer of the stomach. Computed tomography showed a 4-cm tumor in the anterior wall of the body of the stomach. Therefore, laparoscopic endoscopic cooperative surgery was performed suspecting a gastrointestinal stromal tumor. Histopathological examination showed lymphoplasmacytic infiltration and fibrosis, and immunohistochemistry showed infiltration of IgG4-positive lymphoplasmacytic cells. Probable IgG4-related sclerosing disease of the stomach was diagnosed. This appears to be the first case of probable IgG4-related sclerosing disease presenting as a submucosal tumor of the stomach.

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An 81-year-old woman was diagnosed with a gastrointestinal stromal tumor (GIST) with multiple liver metastases in October 2008, and treatment with imatinib was started. The disease was controlled, but in February 2011, both the primary lesion and the liver metastases grew, and ascites was seen on computed tomography (CT). Sunitinib was then given instead of imatinib ; however, it had to be stopped due to renal failure and severe diarrhea. In March 2011, the patient was admitted to our hospital with severe abdominal pain and guarding. CT showed free air in the abdominal space ; therefore, she was diagnosed with peritonitis due to perforation of the GIST, and surgery was performed. There was considerable ascites, and the tumor and tissues were adherent in the left subphrenic space. It was difficult to detect and suture the perforated gastric GIST, so only washing and drainage were performed. Oral intake was started on postoperative day 9, and she left the hospital on postoperative day 32. She was treated with imatinib regularly ; however, she died of her primary illness in October 2011. The case of a patient with peritonitis due to perforation of a gastric GIST was described. The peritonitis was controlled, and her quality of life was maintained with washing and drainage.

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Undifferentiated gastric cancer is a rare histological type that exhibits no differentiated components of adenocarcinoma or squamous cell carcinoma. We report the case of a 65-year-old woman with difficult-to-diagnose undifferentiated gastric cancer. After surgical resection, the primary tumor was pathologically suspected to be a gastrointestinal stromal tumor due to marked accumulation of spindle cells. Lymph nodes with metastasis, however, revealed an epithelial component following immunohistochemical staining with CAM5.2 and cytokeratin 8. Eventually, we diagnosed the tumor as undifferentiated carcinoma. Based on our case and the literature review, this tumor can be misdiagnosed because of its rarity, leading to treatment delays. Both the surgeon and pathologist need to consider undifferentiated carcinoma whenever they encounter unusual pathological findings.

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A 36-year-old woman with continuous fever and abdominal pain visited our hospital for further examination. Endoscopy revealed a 0-IIb lesion in the greater curvature of the lower body of the stomach, and biopsy revealed signet-ring cell carcinoma. Abdominal CT showed swelling of multiple lymph nodes around the abdominal aorta. Pylorus-preserving gastrectomy was performed based on the results of intraoperative pathological examinations that showed no regional lymph node metastases. Pathological findings were sig, pT1a(m), ly0, v0, pN0, pPM0, pDM0, cM0, Stage IA and epithelioid cell granulomas were observed in the dissected lymph nodes and mucosal layer of the stomach. Sarcoid reaction of early gastric cancer was diagnosed because this case failed to fulfill the diagnostic criteria for sarcoidosis (bilateral hilar lymphadenopathy, high serum angiotensin converting enzyme level, skin or ocular involvement).

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A man in his 60s had undergone distal gastrectomy for early gastric cancer with perigastric lymph node metastases at an other hospital in April, 2007. Six months later, he developed para-aortic lymph node metastases and underwent para-aortic lymph node dissection in January, 2008 following systemic chemotherapy including, S-1 plus cisplatin. However, para-aortic lymph node metastases recurred with neck lymph node metastases, and he was treated with several different chemotherapeutic regimens, including S-1 alone, CPT-11 plus cisplatin, and docetaxel. After all of these therapies failed in some courses, he underwent para-aortic lymph node dissection for abdominal para-aortic lymph node metastases four times, and he additionally underwent radiotherapy for para-aortic and neck lymph node metastases. Although he did not relapse for a year after the final surgery, he developed peritoneal metastases. He has survived for 5 years and 4 months since the gastrectomy and for 4 years and 10 months since the initial discovery of the para-aortic lymph node metastases. This case shows that repeated loco-regional treatment, such as surgical dissection and radiotherapy, could contribute to longer survival in patients with lymph node recurrence.

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A case of gastric cancer producing α-fetoprotein (AFP) and human chorionic gonadotropin (HCG) that showed various histopathological features is presented. A 70-years-old man was found to have abnormalities of the stomach on a medical examination and was admitted to our hospital. Gastrointestinal endoscopy showed an elevated lesion, similar to type 1 gastric cancer, in the anterior wall of the upper body. In addition, abdominal enhanced CT showed several heterogeneously enhanced lymph node swellings in the side of the lesser curvature. Serum levels of AFP and HCG were high (15.7 ng/mL and 552 mIU/mL, respectively). A diagnosis of cStage II gastric cancer was made, and total gastrectomy and splenectomy were performed. On postoperative histopathological examination, this tumor was seen to consist of 4 components, moderately to poorly differentiated adenocarcinoma, a hepatoid adenocarcinomatous lesion (AFP-positive), a choriocarcinomatous lesion (HCG-positive), and a seminomatous lesion (placental alkaline phosphatase (PALP)-positive). Since the operation was curative, there has been no sign of recurrence up to the present, 6 years and 6 months after the operation. Gastric cancer with high serum AFP and HCG levels is rare. Moreover, it is thought that the prognosis of cases that are positive for these tumor-associated antigens is very poor. Since a long-surviving case with gastric cancer producing both AFP and HCG is extremely rare, this case is presented along with a review of the literature.

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We report here a case in which the left portal vein was detected during a laparoscopic gastrectomy for early gastric cancer. A 38-year-old woman who presented with epigastralgia developed early gastric cancer. Upper gastrointestinal endoscopy revealed a type 0-IIc lesion, 10 mm at its largest point, in the middle third of the stomach. Poorly differentiated adenocarcinoma was confirmed in biopsy specimens. We performed a laparoscopic pylorus-preserving gastrectomy with D1-plus lymphadenectomy and a gastrogastrostomy. During surgery, we observed that the left portal vein, which was an aberrant left gastric vein, directly entered the lateral segment of the liver through the hepatogastric ligament. The left portal vein was transected endoscopically near the lateral segment of the liver with lymphadenectomy of the lesser coverture of the stomach. The patient's postoperative course was uneventful, and maximum serum levels of AST and ALT were 139 U/l and 124 U/l, respectively. The patient was discharged 9 days after surgery and had no complications as an outpatient. The presence of a left portal vein is a very rare disorder, and, to the best of our knowledge, this is the first reported case of the left portal vein being detected during laparoscopic gastrectomy. Although left portal vein transection with lymphadenectomy was needed there were no postoperative complications, including liver dysfunction.

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A 64-year-old woman was transferred to the emergency room of our hospital with fever and treated once with an intravenous transfusion. Three days later, she was admitted for continuous fever due to a liver abscess in the lateral segment demonstrated by computed tomography. Blood culture revealed infection by Klebsiella pneumoniae, and she was treated with antibiotics. Since she had no biliary disorders, examination of the gastrointestinal (GI) tract was done to determine the source of the bacteria. There was no disease in the lower GI tract, but double gastric cancer was found in the upper GI tract. Distal gastrectomy was done 26 days after discharge following recovery from the liver abscess. Pathological examination showed type 2 advanced cancer surrounded with type IIa early cancer in the angle and type IIc early cancer in the antrum of the stomach. Destruction of the mucosal barrier by gastric cancer may have allowed bacteria to enter the portal blood stream, causing the liver abscess. It is important to perform a close examination of the entire GI tract in cases of liver abscess without biliary disorders.

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We experienced a rare case of gastric cancer with esophageal hiatal hernia complicated by an upside- down stomach successfully treated by laparoscopic surgery. The patient was a 73-year-old woman who was referred to our hospital with a diagnosis of early gastric cancer. Upper gastrointestinal series showed an upside-down stomach, which was prolapsed into the diaphragm. Gastrointestinal endoscopy revealed 0-IIc type tumor on the greater curvature of the antrum. She was diagnosed with an early gastric cancer with esophageal hiatal hernia. Considering the kyphosis, delayed recovery due to wound pain, and visual field in the mediastinum, laparoscopic distal gastrectomy with D1+ dissection and esophageal hiatal hernia repair were performed simultaneously. She had a good postoperative course and was discharged at the 11^th postoperative day.

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A 54-year-old woman was admitted to our hospital owing to vomiting. Imaging examinations revealed a tumor around the duodenojejunal flexure ; this was suspected to be the cause of bowel obstruction The tumor was preoperatively diagnosed as a nonepithelial tumor, such as GIST, and surgical resection was performed. The duodenojejunal flexure, mesentery, greater omentum, transverse colon, and left kidney all appeared to be invaded by the tumor. We performed a partial resection of the small intestine, wedge resection of the transverse colon, and partial resection of the left kidney. Histopathology showed an inflammatory myofibroblastic tumor, which is a distinctive type of lesion composed of proliferating myofibroblastic spindle cells and infiltrating inflammatory cells. It occurs primarily in the lungs and rarely, in the mesentery, omentum, soft tissue, and gastrointestinal tract. In this case, previous CT findings indicated that the tumor originated from the retroperitoneum. Only a few case reports have confirmed rapid tumor growth by imaging examinations. As far as we know, this is the first reported case of bowel obstruction caused by a retroperitoneal inflammatory myofibroblastic tumor in which the tumor doubling time was confirmed.

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A 72-year-old man visited the Department of Otorhinolaryngology in our hospital because of pharyngeal pain which occurred after he incidentally swallowed denture liner. No foreign bodies were detected in the pharynx and larynx and his clinical course was decided to be followed. Two weeks later, the patient was seen at the Department of Surgery in our hospital because of periumbilical pain and fever. On an abdominal CT scan no demonstrable foreign bodies were seen, but free air was noted. He was admitted to our hospital with a diagnosis of small bowel perforation. Conservative therapy was started after admission, and one week later, right upper quadrant pain appeared when an abdominal CT scan showed the perforated site which had moved from the previous situation. Perforation of the digestive tract caused by translucent denture liner was diagnosed and an emergency operation was performed. During surgery a board-like hard denture liner (Tokuyama Rebase II^® was identified. It was removed and partial resection of the small intestine was performed. The postoperative course was uneventful and he was discharged from the hospital on the 19^th hospital day.
Although many case of gastrointestinal (GI) perforation due to dentures have been reported so far, clinical reports on GI perforation due to denture liner are very rare. Furthermore, we have difficulties in making diagnosis in such cases because these materials are radiolucent.

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A 38 year-old woman with cervical cancer was performed a radical hysterectomy followed by adjuvant chemoradiotherapy at the department of gynecology in our hospital in September 2009. In March 2011, she was transferred to our hospital because of the sudden onset of massive melena and serious anemia. On the 2nd hospital day, a colonoscopy was performed and proved the radiation enteritis in the rectum to the sigmoidal colon. On the 3rd hospital day, she presented massive melena again and went into hemorrhagic shock. The dynamic CT proved an extravasation of a contrast medium into the small intestine, and urgent angiography was performed. Aortography showed a fistula between the left external iliac artery and the ileum. The primary closure of the fistula on the external iliac artery and partial resection of the ileum were performed. She was discharged on the 23rd postoperative day. Although arterio-enteric fistula (AEF) is well recognized as one of complications after aortic replacement for the cardiovascular surgeons, but for general surgeons, AEF is rarely known. AEF occurs owing to an aneurysm and irradiation, in addition to aortic replacement. AEF is often difficult to diagnose, and is a surgical abdomen that requires urgent treatment. We report our experience with case reports in the literature.

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A 22-year-old man visited the emergency clinic in our hospital because of exacerbation of upper abdominal pain and nausea lasting for about 1.5 months. On palpation a tumor with the size of an infant's head was felt at the right lower quadrant of abdomen. Abdominal ultrasonography and abdominal CT scan showed a tumor and intestinal obstruction from the ascending colon to the ileocecal region. The patient was admitted to the hospital with a diagnosis of intestinal obstruction due to the tumor and was operated on. At surgery we identified an intussusception at the ileocecal region in which the ileum was invaginated into the cecum. The tumor which had led the intestinal obstruction was palpated and the ileocecal lymph nodes had swollen. Accordingly right hemicolectomy with lymph node dissection was performed. The histopathological diagnosis of the resected material was Burkitt lymphoma. After the operation the patient was transferred to the department of hematological medicine to receive internal treatment including chemotherapy, however, he died eleven months after the initial diagnosis.
Adult cases of Burkitt lymphoma are uncommon, especially those associated with an intussusception of the intestine. The disease progresses extremely rapidly and carries poor prognosis, so that early intensive care including surgery and chemotherapy is important.

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An 82-year-old woman was referred to the department of gastrointestinal medicine at our hospital for further examination after a medical check-up revealed a positive fecal occult blood test, and lower endoscopy conducted at a nearby clinic showed a tumor in the terminal ileum. Abdominal computed tomography (CT) showed a tumor on the left side of the abdomen in addition to the ileal tumor, and the patient was admitted for tests. Frequent melena and progressive anemia were observed on the day after admission, but due to difficulty with endoscopic hemostasis of bleeding from the ileal tumor, the patient was referred to our department for surgery. Tumors were palpated in the terminal ileum and jejunum, and because the neighboring mesenteric lymph nodes had become enlarged, malignant lymphoma with multiple lesions was suspected, and the small intestine was partially resected in two locations. The resected samples revealed a total of 7 tumorous lesions (6 in the jejunum and 1 in the ileum). The histopathological diagnosis was carcinoid tumor of the small intestine for all lesions, but lymph node metastasis could not be determined. Octreotide was administered as adjuvant therapy, and relapse-free survival has been achieved for 3 years. The present case of multiple carcinoid tumors of the small intestine, which are extremely rare in Japan, is reported in the context of the literature.

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A 59-year-old man with a complaint of diarrhea was found to have an intra-abdominal mass on computed tomography (CT). The mass was about 8 cm in size and located adjacent to the jejunum. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed irregular uptake areas only in the mass. On contrast ileography, there was no tumor or stenosis in the small intestine. On upper and lower gastrointestinal endoscopy, there was no tumor or stenosis. With a probable diagnosis of a sarcomatous lesion of the jejunum or an unknown primary, laparotomy was performed. At laparotomy, a tumor was present in the jejunal mesentery near the ligament of Treitz. Partial jejunectomy with combined resection of the mesentery was performed. Histopathologically, the tumor was diagnosed as a carcinoid tumor. No other carcinoid tumor was found in the abdomen. Therefore, the tumor was diagnosed as a primary jejunal mesentery carcinoid tumor. This rare case is reported together with a review of the literature.

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A case of cancer in a jejunal pouch that developed 13 years after proximal gastrectomy and jejunal pouch interposition is reported. The patient was an 81-year-old woman who had undergone proximal gastrectomy and jejunal pouch interposition for gastric cardia cancer 13 years earlier. She underwent upper endoscopy at a nearby clinic due to anemia, and a tumorous lesion was detected inside the jejunal pouch. Well-differentiated tubular adenocarcinoma was diagnosed following examination of a biopsy specimen, and the patient was referred to our hospital for surgery. Based on a diagnosis of cancer in the jejunal pouch, total resection of the remnant stomach and jejunal pouch and Roux-en Y reconstruction were performed. An elevated tumor (colon cancer macroscopic classification, type 5), 5.0 × 4.5 cm in size, was found in the resected jejunal pouch. Histological examination showed proliferation of a mixture of papillary adenocarcinoma, moderately differentiated tubular adenocarcinoma, well-differentiated tubular adenocarcinoma, and mucinous carcinoma from the lamina propria to the subserosal layer, with papillary adenocarcinoma being the predominant type. This extremely rare case of cancer in a jejunal pouch that developed following proximal gastrectomy and jejunal pouch interposition is reported along with a review of the relevant literature.

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We herein report a case of small bowel carcinoma associated with ulcerative colitis (UC). The patient was a 42-year-old male patient who had been diagnosed with and treated for UC since 18 years earlier but he interrupted medical treatment by his own decision. This time he was brought into our hospital by ambulance because of the abrupt onset of severe abdominal pain. There was muscular defense mainly around the navel. Peritonitis caused by gastrointestinal perforation was diagnosed and an emergency operation was carried out. Upon laparotomy, we found a 5-cm diameter tumor as well as perforation at a portion of the small intestine 20 cm proximal to the ileocecal region, and then performed small bowel resection and ileostomy. Histopathology of the resected specimen revealed inflammatory findings on the ileal mucosa and adenocarcinoma. Colonoscopy performed after the surgery identified UC involving the entire colon.
Our experience suggests that long-term UC with backwash ileitis could be the cause of small bowel adenocarcinoma. We present details of clinic-pathological characteristics of this rare case and review the literature.

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An 81-year-old female patient was referred to our hospital for right lower quadrant abdominal pain. Abdominal computed tomography revealed swelling of the appendix with fat tissue thickening and fluid collection around the peri-ileocecal region. She was provisionally diagnosed as having a perforated appendicitis, and underwent an emergent laparotomy. The appendix was very swollen, and a proximal bulging region of the wall was perforated ; purulent ascites was present. The patient had an appendectomy. The resected specimen showed a diverticulum ; its proximal region was perforated. An intraluminal polypoid tumor was detected near the distal side of the appendix. On histology, the polyp was diagnosed as an adenocarcinoma in a tubular adenoma, which had infiltrated into the mucosal layer. The patient has remained in good health without clinical evidence of recurrence during 18 months of follow-up after the operation.

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A 68-year-old woman with progressive anemia was diagnosed with ascending colon cancer with stenosis. Pre-operative survey indicated that she had pancytopenia. A detailed examination revealed that she suffered from aplastic anemia. Laboratory tests showed severe pancytopenia as follows : white blood cell count 1,010/μl (neutrophil count, 19/μl), Hb 6.0 g/dl, and platelet count 8.0×10⁴/μl. Since it takes at least several months to treat aplastic anemia, mortal complications due to the cancer may occur during that period. Therefore, laparoscopic right hemicolectomy and ileostomy were performed first. The surgery was successfully executed and she had no complications, such as surgical site infection or bleeding after the surgery that might be caused by aplastic anemia. The present case is reported along with a review of the relevant literature.

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A 78-year-old man was transferred to our hospital because of lower abdominal pain and abdominal fullness. From the results of a computed tomography (CT) scan, we made a diagnosis of ileus caused by a sigmoid colonic tumor. A retrograde bowel drainage tube was placed through the anus and the colon obstruction was relieved. However, 3 days after insertion peritoneal signs appeared and a subsequent CT scan reveal a bowel perforation. A Hartmann operation was performed when sigmoid colonic cancer was confirmed with a perforation at the oral side of the cancer. The surgical findings confirmed the perforation was caused by the insertion of the tube.

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Metastatic rhabdomyosarcoma in the breast is an uncommon event. We report a case with breast metastasis from rhabdomyosarcoma in a 16-year-old girl. At the age of 14, she was diagnosed with alveolar type rhabdomyosarcoma of the anal canal. At her initial presentation, a bone-marrow metastasis was observed. She underwent chemo-radiation therapy followed by bone marrow transplantation from a sibling. These therapies resulted in a complete remission, but 27 months after the bone marrow transplantation, she noticed an enlarging right breast mass and was referred to our department. On physical examination, the tumor was elastic-soft, 4.0×3.0 cm located in the upper outer quadrant area of the right breast and a core needle biopsy was performed for the histological diagnosis. The tumor turned out to be a metastatic mammary tumor originated from rhabdomyosarcoma that showed positive immunohistochemical staining of desmin and myogenin. This patient underwent right mastectomy and axillar lymph node dissection.
We report a case of metastatic breast tumor that originated from rhabdomyosarcoma of the anal canal with some review of the literature.

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A 70-year-old man was admitted to our hospital due to a high fever. A diagnosis of cholangitis following pancreatoduodenectomy (postoperative day 66) was suspected. Abdominal ultrasonography and computed tomography (CT) showed an infected liver cyst, the diameter of which changed from 33 to 36 mm. We performed percutaneous drainage of the liver mass, and a culture of the discharge revealed the presence of E. coli. A contrast test of the cyst showed no connection between the cyst and the biliary tree, and then absolute ethanol was injected into the lesion. The liver cyst disappeared, and the patient has had no further complaints of high fever. Asymptomatic liver cysts are common clinical entities that do not usually require treatment. When patients with liver cysts who have undergone reconstruction of the biliary tree complain of a high fever, physicians should consider a diagnosis of cholangitis and an infected liver cyst, even if the cyst is small. In addition, physicians should consider performing fenestration of giant liver cysts during the first operation.

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We report a case of a primary adenosquamous carcinoma of the liver. A 54-year-old woman was admitted to our hospital complaining of jaundice. Serum concentrations of CEA, CA19-9, SCC, and CYFRA21-1 were markedly elevated, although AFP and PIVKA-II levels were within the normal range. Abdominal CT showed a 7-cm region of low density with peripheral enhancement in the right lobe of the liver. The tumor was suspected to be an adenosquamous carcinoma, and an extended right hepatectomy was performed. Pathologically, the resected tumor was diagnosed as primary adenosquamous carcinoma of the liver. Although the early postoperative course was uneventful, tumor recurrence occurred in the residual liver, and the patient died of cancer 17 months after the operation.

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This report presents a case of an 88-year-old woman who developed emphysematous cholecystitis with intraperitoneal free air. She was diagnosed with gastrointestinal perforation because air-fluid level was not seen in the gallbladder lumen. However, operative findings revealed acute acalculous gangrenous cholecystitis. CT revealed air bubbles in the gallbladder wall, which was presumed to extend into the pericholecystic space, resulting in the intraperitoneal free air.
There have been only 5 case reports of emphysematous cholecystitis without air-fluid level in the gallbladder lumen in the Japanese literature over the past 15 years. Primary physicians should thus be aware of the fact that emphysematous cholecystitis without air-fluid level in the gallbladder could be a cause of acute abdomen with intraperitoneal free air.

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An 86-year-old man was admitted complaining of epigastric pain. Computed tomography of the abdomen showed atrophic gallbladder, pneumobilia, and gas in the gallbladder. Because of the presence of bile with the stench of stool during endoscopic retrograde cholangiography, we suspected cholecystocolic fistula. After preoperative examination, we performed an operation by laparoscopy. Cholecystocolic fistula was identified in the transverse colon. After cholecystectomy, the transverse colon and gallbladder were exteriorized through an additional incision. Partial resection of the transverse colon with fistulas was performed. There were no postoperative complications.

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The case involved a 78-year-old man who underwent laparotomic cholecystectomy for gallbladder stone at the age of 45. Abdominal CT scan performed for aggravated chronic renal failure disclosed a 5.2-cm diameter intraabdominal tumor adjacent to the subhepatic space (S5-S6). The tumor had a thick capsule with calcification and the border with the liver was kept intact. Although a possibility of a tumor arisen in the liver could not be ruled out completely, we first suspected it to be a mesenteric tumor and performed surgery. During surgery the tumor was found to form a conglomerated mass with the liver and the ascending colon, and laparoscopy-assisted partial hepatectomy was performed including partial resection of the serosal muscle layer of the ascending colon. On histopathology, there were no tumor cells, the center part was mainly composed of a degenerated hematoma, and neovascularization and fresh red blood cells were seen within the hematoma and inside of the capsule. Chronic expanding hematoma was thus diagnosed. The patient's postoperative course was uneventful. He is not on hemodialysis and no signs of recurrence have been seen up to now.
This paper deals with a case of intraabdominal chronic expanding hematoma, a rare entity, for which laparoscopy-assisted resection was performed.

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A 69-year-old man was periodically followed up for hepatitis B at our hospital. A simple hepatic cyst was detected in segment 4 of the liver by CT in December 2003. The cystic lesion was found to be increasing in size, and a solid component was detected within the cyst on serial CT scans. The solid component gradually enlarged and was enhanced on CT with contrast medium, which also showed dilatation of the intrahepatic duct in the left lobe. On the basis of these serial changes in CT findings, biliary cystadenocarcinoma was suspected, and left hepatectomy was performed. Examination of the resected specimen showed a papillary lesion inside the cyst. Histopathological examination revealed a mixture of adenoma and adenocarcinoma components in the papillary lesion, without ovarian-like stroma. The postoperative course was uneventful, and no recurrence has been observed in 6 years after the surgery. This case seems to be invaluable in determining the origin of tumors on the basis of CT findings. We reviewed the cases of 12 other biliary cystadenocarcinomas diagnosed during long-term follow up.

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A 70-year-old woman was admitted owing to right hypochondralgia. Blood biochemistry studies, abdominal ultrasonography, and abdominal CT suggested biliary obstruction caused by a biliary stone. Emergency endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed. Clotted blood was found in the bile duct. Cholangiopancreatography revealed pancreaticobiliary maljunction and a filling defect, suggesting a tumor in the gallbladder. We performed resection of the gallbladder and its bed, and dissection of the lymph node. The preoperative diagnosis was gallbladder cancer with a hemorrhage that caused biliary obstruction. The histological diagnosis was papillary adenocarcinoma. The patient died 4 years later because of multiple metastases in the lung, brain, and lymph nodes. We describe a rare case of gallbladder cancer causing biliary hemorrhage and obstruction with pancreaticobiliary maljunction.

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Splenic angiosarcoma is rare and accounts for only 1% of all sarcoma reported. We experienced a case of spontaneously ruptured splenic angiosarcoma. The patient was a 42 year-old man. He presented to the emergency department in our hospital with sudden onset of abdominal pain. Blood examination showed mild anemia, but other laboratory data were normal. Contrast-enhanced computed tomography showed several atypical-shaped low-density areas in the spleen and hemorrhagic ascites around the spleen, liver and in the pelvis. He was diagnosed as having a intra-abdominal hemorrhage with splenic rupture. An emergent operation was performed because we suspected a malignant tumor of the spleen. The spleen was ruptured therefore we performed a splenectomy. Histopathological examination showed spindle cells with atypical nuclei and the enlarged nuclear bodies and the spindle cells were both CD31 and CD34 positive. We diagnosed this case as splenic angiosarcoma. He received outpatient adjuvant chemotherapy for 6 months, and is currently alive for 18 months after surgery with no recurrence.

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A 12-year-old boy was referred to our hospital with suspected lymphoma when a splenic tumor was detected incidentally on a computed tomography (CT) scan following a fall. Magnetic resonance imaging (MRI) showed a round mass, 5 cm × 4.5 cm × 4.5 cm in size, in the splenic hilum that was hypointense on T1-weighted and hyperintense on T2-weighted imaging. On contrast-enhanced MRI, the mass was strongly enhanced almost homogeneously from the early phase, and the contrast effect was prolonged. A preoperative diagnosis of hemangioma or vascular tumor was made, and laparotomic partial splenectomy was performed. Doppler echocardiography was used to confirm the presence of blood flow between the tumor and healthy tissue, and peripheral branches of the splenic artery were sequentially clamped to identify the vessels feeding the tumor. Indigo carmine was injected via the tumor feeding vessels, and the incision line was determined so as to minimize hemorrhage during the partial resection. The remaining spleen was fixed to the greater omentum to prevent torsion. The patient's postoperative course was uneventful, and he was discharged from hospital five days postoperatively. The pathological diagnosis was cord capillary hemangioma.

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The patient was in her forties who had investigated for intermittent left upper abdominal pain. She had no relevant past history. On physical examination, no abdominal mass was found. Abdominal computed tomography, abdominal ultrasonography (US), and abdominal magnetic resonance imaging (MRI) showed a 7-cm-diameter cystic tumor in the spleen. The patient was followed for one month ; the abdominal pain continued, and the tumor increased. Therefore, a laparoscopic splenectomy was performed, and a splenic mesothelial cyst was diagnosed on histopathological examination. The patient had an excellent postoperative course.

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Adrenal cavernous hemangioma is a relatively rare type of tumor. While 63 cases have been reported in Japan, none has involved a massive pleural effusion resulting from intratumoral hemorrhage that required resection. The present patient was a 38-year-old man who sought emergency help after having difficulty moving due to back pain that had developed 3 days earlier. A tumorous lesion, 8.5 cm in size, appearing to compress the liver was seen superior to the right kidney on computed tomography (CT) and magnetic resonance imaging (MRI), accompanied by a massive pleural effusion. The patient was admitted with suspected intratumoral hemorrhage of a right adrenal tumor. The inflammatory pleural effusion was alleviated with conservative treatment, and on day 20, the right adrenal tumor was resected through an incision below the right costal arch. The resected sample was a fragile, bleeding tumor with a maximum diameter of 8 cm that had a partially calcified capsule and a light to dark brown cross-section. The histopathological diagnosis was adrenal cavernous hemangioma. Most adrenal hemangiomas are non-functional benign tumors, but two malignant cases have been reported. Differentiation from adrenal cancer is necessary in cases of large tumors, and resection is desirable given the risks of hemorrhage and rupture.

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We present a case of pseudo-Meigs syndrome caused by struma ovarii associated with ascending colon cancer.
An 85-year-old woman visited our hospital because her stool examination was positive for occult blood. Colonoscopic examination revealed ascending colon cancer. Abdominal CT scan demonstrated a left ovarian tumor, left pleural effusion and massive ascites. Cytodiagnosis of ascites was reported to be Class II. Celiocentesis performed every day was ineffective and ascites was intractable. Carcinomatous peritonitis was considered likely from clinical findings, but we could not rule out a possibility of ascending colon cancer associated with pseudo-Meigs syndrome. We performed ileocecal resection with D2 lymph node dissection and left oophorectomy. The pathological diagnosis of the ovarian tumor was struma ovarii. After surgical resection, pleural effusion and ascites disappeared and no recurrent retention occurred. The final diagnosis was pseudo-Meigs syndrome caused by struma ovarii associated with ascending colon cancer. The patient is alive without any evidence of recurrence as of 7 months postoperatively. It is very rare that a gastrointestinal tumor is associated with struma ovarii presenting with pseudo-Meigs syndrome.

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A 78-year-old male patient with a history of BPH had a routine medical examination. On radiological examination, a mass, 50 mm in diameter, was observed in the pelvic cavity. Therefore, a provisional diagnosis of a leiomyoma or a peritoneal loose body was made. Laparoscopy was performed. A white, egg-shaped peritoneal loose body was extracted ; it was completely free in the pelvic cavity. Histologically, this body consisted of many layers of laminated fibrous tissue with central necrotic fatty lesions. It likely originated from a free necrotic appendice epiploicae. Peritoneal loose bodies are often seen as unique images on X-ray examination due to the presence of fibrous tissue layers surrounding fat necrosis and calcification. It is fortunate that minimally invasive laparoscopic surgery is an available option when a peritoneal loose body is suspected preoperatively.

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A 70-year-old man undergone distal gastrectomy for gastric cancer (T1, N1, M0, Stage IB) about 2 years earlier showed elevated serum CEA at a follow-up study. Colonofiberscopy and computed tomography (CT) revealed a 3 cm submucosal tumor in the transverse colon. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed abnormal uptake of FDG (standard uptake value : SUV max early 5.7, delay 7.0) in the tumor. Either of lymph node recurrence of the gastric cancer, colon cancer or gastrointestinal stromal tumor was likely as preoperative diagnosis, and laparotomy was performed. During surgery we identified the tumor in the vicinity of the hepatic flexure which was in contact with the colonic wall. It was a whitish and elastic hard tumor. We could not rule out a possibility of malignant neoplasm and performed right hemicolectomy. Histopathological examination showed a desmoid tumor. No signs of recurrence have been seen. We report a case of an intra-abdominal desmoid tumor with FDG uptake on PET.

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A 62-year-old woman complaining of a right lower quadrant tumor was found to have an 8-cm diameter gas collection in the retroperitoneal space, when fluoroscopic study done with a suspicion of communication with the gastrointestinal tract disclosed no recognizable findings including fistula formation. As she had no symptoms such as abdominal pain and no abnormal findings were reported on blood examination, we decided to follow her clinical course. Six months later, gas shadow increased in size and she developed a sense of oppression in the abdomen. Exploratory laparotomy was thus performed. An encapsulated and well demarcated tumor 15 cm in diameter was identified in the right retroperitoneal space, for that drainage was performed. It was found that no liquid component was present within the tumor and only gas component was collected within it. An intraabdominal survey disclosed no findings suggestive of communication with the digestive organs. After the operation, recurrence at the same area occurred and CT-guided drainage was carried out. Thereafter no recurrence has occurred for 15 months up to now.
We consider percutaneous drainage to be a beneficial therapy for retroperitoneal emphysema without accompanying by fiver and inflammation. The paper deals with our experience with a case of atypical cryptogenic retroperitoneal emphysema including the clinical course and imaging findings, together with a review of the literature.

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A 67-year-old female, with a history of steroid use for rheumatoid arthritis, had a partial resection of the small intestine because of intestinal perforation caused by a malignant lymphoma. Postoperatively she developed a wound infection and dehiscence which led to the development of a ventral hernia. Since the hernia repair using a simple closure failed, she was referred to our institution. On admission, a large ventral hernia, 20×9 cm in size, with full-thickness loss of the abdominal wall, 13×9 cm in size, was observed. To avoid the infection risk associated with long-term steroid use, a hernia repair using the components separation technique was planned. At surgery, components separation was performed by incising the aponeurosis of the external oblique muscle longitudinally ; the muscle was then separated from the underlying internal oblique muscle by blunt dissection, to allow the midline closure of the rectus muscle to be done with less tension. The postoperative course was uneventful, and she was discharged on postoperative day 15. She has had no recurrence of the hernia during 21 months of follow-up.

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A 56-year-old woman with no past medical history who visited our hospital with chief complaints of a protrusion in the right groin and abdominal pain. Laparoscopic hernia repair was performed based on a diagnosis of incarcerated right femoral hernia. Because the small intestine was incarcerated in the femoral ring, it was reduced endoscopically. Discoloration was seen in the reduced intestinal tract, but intestinal resection was deemed unnecessary because it improved over time, and mesh repair was performed without any additional procedures. Although ileus thought to be paralytic was seen postoperatively, it improved with conservative treatment, and the patient was discharged on day 10. On postoperative day 27, the patient visited our hospital with sudden, severe abdominal pain. She was in a state of shock, and pneumoperitoneum was observed on abdominal computed tomography (CT). Emergency surgery was performed based on a diagnosis of gastrointestinal perforation. A circumferential, fibrous stenotic site was found in the ileum, and a 1-cm perforation site was detected approximately 30 cm proximal to this site. Intestinal obstruction was thought to have developed due to ischemic stenosis of the small intestine in the incarcerated hernia, causing perforation on the proximal side of the intestinal tract. A few cases of late-onset intestinal stenosis following reduction of incarcerated inguinal hernia have been reported, but cases in which perforation occurred subsequently are extremely rare. The present case is described along with a review of the relevant literature.

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A 62-year-old man who visited a previous hospital because of a sensation of food sticking in the throat was detected to have esophageal cancer, and was referred to our hospital for the purpose of treatment in October 2011. CT scan revealed a tumor in the anterior mediastinum, and then close examination was conducted. As a result, synchronous double cancer consisting of esophageal cancer and thymic neuroendocrine carcinoma was diagnosed. As the neoadjuvant chemotherapy we employed the DCF therapy (5-fluorouracil + docetaxel + cisplatin), which is a regimen for esophageal cancer. The DCF therapy resulted in remarkable shrinkage of both neoplastic tumors. Operative procedures included subtotal esophagectomy, thymectomy, and partial pneumonectomy in a one-stage approach, leading to radical resection. No other treatments were added after the operation. The patient has been free from recurrence as of one year and six months after the operation.
Reports on synchronous double cancer of esophageal cancer and thymnic endocrine carcinoma are extremely rare so that we present this rare case together with a review of the literature.

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