[Purpose] The purpose of this study was to demonstrate the pertinence and the clinical significance of making differential diagnosis by computed tomography (CT) for closed-loop bowel obstruction that is indicated emergency operation.
[Subjects and Methods] We enrolled a total of 62 patients hospitalized and treated for small bowel obstruction in our hospital from January 2012 to March 2013 whom we were able to point out the mechanisms of the onset of bowel obstruction by CT. Their CT findings and clinical courses were retrospectively studied.
[Results] There were 15 cases of closed-loop bowel obstruction (the closed-loop CT finding group) and 47 cases of open-loop bowel obstruction (the open-loop CT finding group). Fourteen out of the 15 cases from the closed-loop CT finding group were performed operation. The incidence of operations in the closed-loop CT finding group was significantly higher than that in the open-loop group. If cases of strangulating obstruction and of closed-loop bowel obstruction are to be candidates for emergency operation, the sensitivity and the specificity of indications of emergency operation in the closed-loop CT finding group were 80% and 93.6%, respectively.
[Conclusion] The differentiation of CT findings of closed-loop bowel obstruction is useful in deciding the indication of emergency operation.

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Objective : Patients with hemophilia may show only a slight prolongation of the activated partial thromboplastin time (APTT) and the diagnosis may be overlooked during conventional preoperative testing. In the present study, an attempt was made to ensure identification of patients with latent hemophilia by setting the APTT cutoff value at 35.1 s (reference cutoff value at our hospital, 40.0 s) during testing prior to planned surgery.
Method : The subjects comprised 445 patients who underwent testing of the coagulation profile prior to planned surgery between April 1, 2011 and November 30, 2013. A detailed medical history was obtained from the patients with APTT ≥35.1 s ; those who gave no history of coagulation abnormalities were excluded. All the remaining patients were subjected to further testing (prothrombin time, repeat APTT, fibrinogen, antithrombin III, double-filtration plasmapheresis, D-dimer, and factor VIII, IX, and vW activity) to confirm the presence or absence of hemophilia.
Results : The APTT was ≥35.1 s in 40 patients (9.0%), of which 10 were excluded based on their negative medical history. The final diagnoses of the remaining 30 patients were as follows : no coagulation abnormalities, n=28 ; normalization during follow-up, n=1 ; hemophilia A, n=1. The patient with hemophilia A had no family history and the initial APTT value was within the reference cutoff value at 39.5 s.
Conclusion : Efforts must be made to ensure preoperative identification of patients who may have undiagnosed latent hemophilia. Screening using an APTT cutoff value lower than the current reference value is required in order to ensure identification during preoperative testing.

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High-dose rate radiotherapy for pelvic and retroperitoneal tumors is difficult due to the proximity of the gastrointestinal tract. Dose reduction to the gastrointestinal tract is difficult even for Proton beam therapy, which has better dose concentration than x-ray therapy. On the occasion of proton beam therapy to near-gastrointestinal tract tumors, we insert a spacer between the tumor and the gastrointestinal tract. We treated a total of six cases, including two cases of cervical cancer, each one case of endometrial cancer, uterine sarcoma, sigmoid colon cancer, and rectal cancer. Of these six cases, one had a history of radiation to the primary tumor, with proton beam therapy for a recurrent tumor after the spacer insertion. In this operation, gore-tex was wrapped by greater omentum in order to ensure safety margin and fixed between a recurrent tumor and the gastrointestinal tract. In one case, we used mesentery as a spacer because we had resected the small intestine. After the operation, we confirmed the safety margins between the recurrent tumor and the gastrointestinal tract by using CT, and safely achieved high-dose rate radiation to near-gastrointestinal tract tumors.

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Carcinosarcoma of the esophagus is a relatively rare histological type in esophageal malignancies. We clinicopathologically analyzed consecutive seven cases diagnosed with carcinosarcoma of the esophagus pathologically and treated by the surgical resection during 2000 and 2013. All patients were male with an average age of 71 years old. The main tumor location in three cases was in the lower, two cases in the middle, one case in the upper third of thoracic esophagus ; the remaining one case in the abdomen. Macroscopic type of the tumor was 0-Ip in 4 four out of the seven cases. Histological depth of tumor invasion was T1b in three cases, T2 in two cases and T3 in two cases. Five patients underwent esophagectomy and two underwent both esophagectomy and total gastrectomy. Lymph node metastasis was found in 57.1% of them. On immunohistochemical studies, the tumor cells were G-GSF positive in two out of seven cases. Five of seven patients have been free from the disease and three of them survive more than 5 years. One patient died of cerebral hemorrhage on postoperative day 30. One patient experienced lung metastasis which required chemotherapy one year after the surgery. It should be considered that the treatment with a focus on esophageal resection with lymphadenectomy and adding chemotherapy or radiotherapy as needed for carcinosarcoma of the esophagus.

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We developed a new operative technique for laparoscopic transabdominal preperitoneal (TAPP) hernia repair that involves the use of two 2-mm punctures and a 5-mm port (TAPP-252). The operative technique and the initial clinical outcomes of TAPP-252 are reported. We have performed TAPP-252 in 6 adult female patients, including one with bilateral type 1-1 inguinal hernia, and 5 with type 1-2 hernia according to the Japanese Hernia Society classification. To facilitate performance of TAPP-252, 5 different kinds of newly developed needle instruments with a diameter of 2 mm were used ; a rigid laparoscope, a grasping forceps, an electrocautery device, a needle driver, and a scissors. The 2-mm laparoscope played an important role in the utilization of the 5 mm port, which enabled insertion of such items as an ultrasonically activated device, tacker, mesh, gauze, and sewing needle. The average operation time was 53 minutes. The perioperative morbidity was nil. The cosmetic results seemed excellent in all patients. TAPP-252 was safely performed with minimal destruction of the abdominal wall. Further investigation is necessary to devise criteria for patient selection and assess the long-term outcomes.

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Gastrointestinal polyposis was diagnosed in a 39-year-old man following fecal occult blood examination. He was suspected of having Cowden disease with facial trichilemmomas, a cobblestone pattern of the oral mucosa and gingiva, and thyroid tumors. On genetic analysis of the PTEN gene, a missense mutation at codon 170 was found. Cowden disease is characterized by hamartomas and germline PTEN mutation. Early medical examination and treatment of Cowden disease are of great importance because malignant tumors may develop.

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A 46-year-old pre-menopausal woman noticed a right breast lump around July 2010 but left it untreated. In January 2011, experiencing pain in the same region, she consulted us. A 1.5-cm movable hard mass was palpable in the C region of the right breast. Mammography showed no abnormalities, but ultrasonography revealed two vertically aligned hypoechoic masses (4 and 6 mm in diameter), with architectural distortion, in the same breast region. Suspecting breast cancer, we performed a needle biopsy. Pathological findings included marked proliferation of fibroblasts. Three months later, a slight dimple was noted in the same region and we performed a second needle biopsy. Immunological findings suggested fibromatosis. The patient declined surgery, and follow-up ultrasonography in October showed enlargement of the mass. Partial mastectomy was performed. Pathological diagnosis was fibromatosis, a benign neoplastic disease characterized by an invasive proliferation of fibroblasts. Primary mammary fibromatosis is a rare disease and is difficult to differentiate from breast cancer based on clinical findings. First-line treatment is surgical resection, but local recurrence is common, necessitating close follow-up. We report the details of this rare case of mammary fibromatosis and present a literature review.

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Phyllodes tumor accounts for less than 0.5% of all breast malignancies, and 25% of phyllodes tumor is malignant. A case of malignant phyllodes tumor that developed rapidly and relapsed soon after operation is reported.
A 38-year-old woman had been aware of a rapidly growing tumor in the left breast for a month. She visited our department because of bleeding from self-destruction of the mass. The diagnosis on core needle biopsy was suspected phyllodes tumor. Mastectomy and epimerization were performed. The final pathological diagnosis was malignant phyllodes tumor. One month after the surgery, local recurrence and multiple lung metastases appeared. For symptom relief, resection of the recurrent tumor was performed. Ten days later, chest CT revealed growing lung metastases, chest wall recurrence, and bone metastases. Three months after the initial surgery, she developed paralysis of the lower extremities because of spinal cord compression from bone metastases. Neither radiation nor steroid pulse therapy showed any effect, and the patient died five months after the initial surgery.

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A 75-year-old woman was referred to our department after she noticed a lump in her left breast and underwent fine-needle aspiration biopsy at a local clinic, which yielded a diagnosis of malignancy. Tumors with a maximum diameter of 30 and 10 mm were palpated in the upper outer quadrant and axillary tail of the left breast, respectively, with skin findings in the upper outer quadrant. A needle biopsy of the tumor in the upper outer quadrant was performed, and a diagnosis of invasive cancer (estrogen receptor (ER) 0%, progesterone receptor (PgR) 0%, HER2-) was made. No findings suggesting distant or axillary lymph node metastases were observed, and neoadjuvant chemotherapy was selected based on the diagnosis of triple-negative breast cancer. Four courses each of docetaxel therapy and FEC100 therapy were given preoperatively. Clinical therapeutic efficacy was partial response (PR) for both the tumor in the upper outer quadrant and the tumor in the axillary tail, and left mastectomy and sentinel lymph node biopsy were performed. Histopathologically, only residual intraductal components were seen in the tumor in the upper outer quadrant, for which the therapeutic efficacy was assessed as Grade 3, while the tumor in the axillary tail was diagnosed as a matrix-producing carcinoma, with a therapeutic efficacy of Grade 0. A csse of matrix-producing carcinoma of the breast, which is histologically relatively rare, treated with neoadjuvant chemotherapy was described.

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Case 1. A 48-year-old woman who had been taking some Chinese herbal medicine for atopic dermatitis for 20 years presented with the chief complaints of abdominal pain and vomiting. Abdominal plain XR and CT showed dendritic calcification near the right colon. Colonoscopy showed bronze appearance and swelling of the mucosa throughout the colon, mainly around the right colon, with ulceration and lumen narrowing. Case 2. A 65-year-old woman who had been taking some herbal medicine for menopausal symptoms for about 15 years presented with the chief complaint of abdominal pain. Abdominal plain XR and CT showed dendritic calcification near the right colon. Colonoscopy showed a slight bronze appearance and edema of the mucosa in the right colon. Both the patients were diagnosed as having idiopathic mesenteric phlebosclerosis by histology. Case 1 underwent surgery at 3 months after presentation due to repeated episodes of bowel obstruction. Case 2 remains under observation because her only symptom is mild abdominal pain. Idiopathic mesenteric phlebosclerosis is a rare disease of unknown cause. One report suggests long-term use of herbal medicines as one of the potential causes. Since both our patients gave a history of long-term use of herbal medicines, we considered it as one possible causes of the condition in our patients.

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We present a case of leiomyosarcoma of the inferior vena cava (IVC). A 35-year-old woman was admitted to the hospital because leg edema and proteinuria. A large right adrenal tumor, which occupied the right lobe of liver and the IVC was detected by means of computed tomography and abdominal ultrasonography, so she was transferred to our hospital for treatment. After percutaneous transhepatic portal embolization, we performed a partial resection of the inferior vena cava including the tumor, a right liver lobectomy, and a right adrenalectomy. The IVC was reconstructed using a Gore Tex Graft (ringed, 20 mm in diameter). Immunohistochemical staining of the tumor tissue revealed that αSMA and caldesmon were expressed in the tumor cells, and s100, CD34 and CD56 were not expressed. The pathological diagnosis was leiomyosarcoma originating from the IVC. Although postoperative adjunctive therapy was not performed, the patient has been well without recurrence for 2 years and 6 months after the surgery.

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The patient was a 72-year-old woman who was scheduled for aortic arch aneurysm repair ; however, she developed obstructive jaundice before the operation and was referred to our hospital. Thoracoabdominal CT showed a saccular aneurysm measuring 50 × 40 mm in the distal portion of the aortic arch and wall thickening in the distal bile duct. Abdominal MRI showed mild dilatation of the intrahepatic bile duct, and increased signals in diffusion-weighted images. Therefore, the patient was diagnosed as having distal bile duct cancer along with the aortic arch aneurysm. The aortic arch aneurysm was saccular in shape and 50 mm in diameter, and surgery was indicated ; therefore, stent grafting for the aortic arch aneurysm was planned ahead of any other procedure. Then, on day 7 after the endovascular aneurysm repair, pancreaticoduodenectomy was performed. The patient developed fever after the endovascular aneurysm repair, which was managed with antibiotics. Her postoperative course after the pancreaticoduodenectomy was uneventful, and she was discharged on day 23 after the operation. When a malignant tumor requiring surgical treatment is associated with an aneurysm that also needs intervention, we consider that endovascular aneurysm repair prior to the resection of the tumor may be useful.

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A 64-year-old man was referred to our hospital complaining of dry cough. Chest X-ray demonstrated enlarged right lung hilar shadow. Chest computed tomography (CT) scan revealed an enhanced nodule measuring 2.7 cm in the major axis with clear margin behind the right pulmonary artery. Bronchoscopy showed no abnormal finding in the airway ; however, malignant cells were detected by endobronchial ultrasonography guided-transbronchial needle aspiration at the first bifurcation of the right main bronchus. The cytological diagnosis was large cell carcinoma or adenocarcinoma. Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) scan did not show any other abnormal accumulation, except the tumor. From the results, we decided to remove the carcinoma as a primary lung cancer (cT0 N1M0) or a carcinoma of unknown primary without other metastases. At thoracotomy, we found the tumor existed as a white smooth-surface nodule covered with visceral pleura between the upper and lower lobe. Right upper sleeve lobectomy was performed with pulmonary arterioplasty and mediastinal lymph node dissection. The tumor that adhered firmly to the lobar bronchus was pathologically diagnosed as an undifferentiated hilar lymph node carcinoma of unknown primary. Immunohistochemical stainings excluded the possibility of primary lung cancer or malignant lymphoma. The other dissected lymph nodes were negative for malignancy. Intrapulmonary abnormality suspected as lung cancer was not found by a thin-slice CT scan used for re-screening. The patient was uneventfully discharged from our hospital on the 14th postoperative day, and followed up by the outpatient office after completing a series of adjuvant chemotherapies. We have not detected the primary cancer or recurrence for 2 years since the surgery.

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An about 70-year-old woman underwent a distal partial gastrectomy for gastric cancer in August 2007. She had suffered from dysphagia since March 2012, and was diagnosed to have primary achalasia and referred to our hospital. An esophageal manometry examination was performed. Simultaneous waves were observed at her esophageal body during wet swallows and these results fulfilled the diagnostic criteria of achalasia. Esophagography showed that the length of the narrow segment was longer than that of the primary achalasia and a computed tomography scan of the chest and abdomen showed thickening of the esophageal wall. Therefore, pseudoachalasia was highly suspected and we decided to perform surgery by laparotomy. Frozen sections of the scar tissues of the diaphragmatic crus and the esophageal wall were analyzed and diagnosed as poorly differentiated adenocarcinoma. Finally, she was diagnosed with pseudoachalasia caused by metastases of gastric cancer in the lower part of the esophageal wall. She underwent a distal esophagectomy and total gastrectomy of the remnant stomach. The postoperative course was uneventful and she was discharged on the 14^th day after surgery. As of 10 months after surgery, she has not suffered from dysphagia and has received chemotherapy at another hospital.

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Although esophageal hiatal hernia is a disease that we often encounter, the disease which is associated with volvulus of the stomach and in which the almost whole stomach has prolapsed into the mediastinum, presenting so-called “upside down stomach (UDS)”, is rare. In this paper we present a case of an UDS with chronic respiratory failure which was able to be relieved by laparotmy.
The case involved a 65-year-old man who had a history of chronic respiratory failure and had been induced home oxygen therapy. He was admitted to our department because of hematemesis on an emergency basis. Chest and abdominal contrast-enhanced CT scan showed an extensively prolapsed stomach showing a volvulus into the mediastinum. Upper gastrointestinal endoscopy revealed a huge esophageal hiatal hernia. Accordingly UDS was diagnosed. Attempts of endoscopic repair failed to reduce the stomach and laparotmy was employed. Surgical procedures included reduction of the stomach, reinforcement of the esophageal hiatus, and cardioplasty. After the operation, respiratory function became improved and the patient did not require home oxygen therapy.
Recently we sometimes encounter cases of UDS in the literature, but the disease is so rare that only 32 cases have been reported in Japan. Some bibliographic comments are also presented here.

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A 71-year old woman who underwent distal gastrectomy with a Roux-en-Y reconstruction using a circular stapler for jejuno-jejunostomy 4 months earlier was admitted for abdominal pain, nausea, and anorexia. Abdominal CT scan showed a markedly dilated afferent loop from the stapled end of the Roux-en-Y anastomosis to the duodenal stump, and the patient was diagnosed as having afferent loop obstruction caused by Roux-en-Y anastomotic stenosis. Emergent upper gastrointestinal endoscopy revealed a pin-hole stenosis of the Roux-en-Y anastomosis, for which balloon dilation was performed. She had a good clinical course and was discharged from the hospital on the 9^th postoperative day. This case suggests that endoscopic balloon dilation is a minimally invasive and effective treatment for afferent loop obstruction caused by Roux-en-Y anastomotic stenosis.

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A 71-year-old woman, who had underone coronary artery bypass grafting for unstable angina pectoris in 2006, was admitted because of an abdominal mass. The lesser curvature side of the stomach had a solid tumor, 5 cm in size, on preoperative CT. Three months later, she was diagnosed as having a gastric submucosal tumor on endoscopy and MDL. Although further examinations, such as endoscopic ultrasonography, angiography, and MRI, were suggested, the patient refused. Laparoscopically, the tumor was in the lesser omentum without invasion. To avoid the risk of surgical dissemination, a small laparotomy was selected, and the tumor was resected. There was no continuity between the tumor and stomach macroscopically, but since the tumor was in very closely contact to the stomach, partial gastrectomy was performed.
Pathologically, the tumor had no continuity with the stomach and was composed of spindle cells. Immunohistochemically, it was positive for c-kit and CD34, but negative for S-100, desmin, and alpha-smooth muscle actin. Sequencing of the tumor by SSCP revealed deletion of 1 amino acid on exon 11. Thus, this case was diagnosed as GIST of the lesser omentum. The patients' postoperative course was uneventful, and there has been no recurrence for over 72 months.

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A 59-year-old woman presented to us with anemia in August 2006. Abdominal CT revealed a huge cystic tumor occupying the left upper abdomen. Gatrointestinal stromal tumor (GIST) of the stomach was suspected based on the clinical imaging findings. At laparotomy, the tumor was located in the left abdomen, arising from the stomach. The tumor was completely excised by partial gastrectomy. The resected tumor was 22×22×13cm in size, weighing 3.6 kg, and histopathological examination revealed a high-risk GIST arising from the stomach. The patient refused imatinib chemotherapy after the operation, but lived on for 5 years 11months after surgery, with no recurrence or metastasis. We present the case of a patient with a huge GIST and discuss the management of advanced GIST.

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A 74-year-old man was observed to have a gastric submucosal tumor at our hospital in 2005. There was a tendency for the tumor to increase, so he underwent laparoscopic partial gastric resection in September 2009. Histological examination showed the margins to be negative and indicated a diagnosis of schwannoma. Regular postoperative observation showed a submucosal tumor of about 8 cm in the previous partial resection of the upper gastrointestinal endoscopy in November 2011. The tumor had invaded the body of the pancreas, jejunum, and transverse mesocolon, so we performed total gastrectomy with resection of spleen, body and tail of the pancreas in December 2012 ; and subsequently a partial resection of the jejunum an transverse colon. It was diagnosed as a desmoid tumor after examination by immunohistochemistry staining. The patient continues to be observed periodically on an outpatient basis, and no recurrence has been observed. A desmoid tumor is thought to occur after trauma or surgery, and regular follow-up is required to any postoperative benign submucosal tumors.

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An 88-year-old man who developed sudden onset of abdominal pain after eating lunch was transferred to our hospital. He had undergone total gastrectomy for gastric cancer five years previously. Computed tomography revealed ascites, distention of the small bowel, and signs of closed loop obstruction, suggesting a strangulated ileus. Ultrasound-guided paracentesis showed milky chylous ascites. He underwent emergency laparotomy, and intraoperative findings showed chylous ascites and torsion of almost the entire small bowel into a mesenteric defect at the previous jejuno-jejunostomy. Although the incarcerated small bowel was congested, the color and peristalsis of the small bowel improved after release of the strangulation. Thus, the small bowel was preserved without resection. The patient had an uneventful postoperative recovery and was discharged on postoperative day 19. There have been only 8 cases, including the present patient, of chylous ascites associated with small bowel obstruction reported in Japan. All patients underwent surgery, but bowel resection was avoided in all cases. We recommend emergent surgery for a patient with strangulated ileus presenting with chylous ascites.

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An 81-year-old woman developed multiple organ failure resulting from hemorrhagic shock caused by upper gastrointestinal bleeding. Following intensive care that improved her general status, upper gastrointestinal endoscopy was performed that confirmed the presence of an elevated lesion in the pylorus, and the biopsy result was group V. Since various imaging tests confirmed volvulus of the stomach with prolapse into the thoracic cavity, early gastric cancer occurring concomitantly with an upside-down stomach was diagnosed, and laparoscopic distal gastrectomy was performed. Roux-en-Y reconstruction was selected for reconstruction due to concerns regarding the postoperative onset of reflux esophagitis. The final histopathological diagnosis was type 0-IIc+IIa pT1apN0M0, ly0, v0, Stage IA. Laparoscopic surgery appears to be a useful option for early gastric cancer in patients with an upside-down stomach.

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A 69-year-old man, performed proximal gastrectomy with jejunal interposition for gastric cancer 7 years previously, developed anemia. Upper gastrointestinal series showed a 2-cm protruded lesion located in the anterior wall of the residual stomach. Gastrointestinal endoscopy showed the same protruded lesion resembling a submucosal tumor with delle on the top and its biopsy showed Group I. We performed partial gastrectomy, and the pathological diagnosis was well differentiated adenocarcinoma with rupture of the muscularis mucosa and an inverted growth of atypical cells in the submucosa. Gastric cancer resembling submucosal tumor has often been reported, and these are generally classified into medullary carcinoma with lymphoid stroma, carcinoma with a solid growth, carcinoma with localized fibrosis, carcinoma from heterotopic gastric mucosa and mucinous carcinoma. To our best knowledge, early gastric cancer with an inverted growth pattern resembling submucosal tumor is rare. There exists gastric cancer which entails a problem in distinction from non-epithelial tumor like in this case. Surgical resection is recommended for such a gastric submucosal tumor as might be difficult to examine sufficiently.

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Gastric duplication cyst is a rare congenital malformation, and adenocarcinoma arising from it is a rather rare occurrence. We report the case of a 63-year-old woman who was diagnosed as having adenocarcinoma arising from a gastric duplication cyst. She had been diagnosed as having rectal cancer and treated by low anterior resection at another hospital. She had refused adjuvant chemotherapy despite having Stage IIIb disease. One year later, a routine CT revealed a cystic lesion along the greater curvature of the upper gastric corpus. She came to our hospital for a second opinion two years after her first operation.
She was diagnosed as having GIST, neurogenic tumor, and a gastric metastasis from the rectal cancer, and treated by partial gastric resection.
Pathological examination of the resected specimen revealed primary adenocarcinoma arising from the gastric duplication cyst. Carcinoma arising from a gastric duplication cyst is extremely rare, with only 13 cases reported in the literature until date.
Duplication cysts should be included in the differential diagnosis of cystic masses of the gastrointestinal tract, and the possibility of malignancy within the cysts should always be borne in mind.

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[Case] The case involved a 69-year-old man who had a previous history of undergoing distal gastrectomy with Billroth I (B-I) reconstruction for duodenal ulcer at the age of 30. He visited a neighboring hospital because of something wrong feeling with the pharynx, and was found having an ulcer lesion 8mm in diameter at the anal side of the gastroduodenostomy by upper gastrointestinal endoscopy. A biopsy result could not rule out a possibility of malignancy. Although definite diagnosis was not made, surgical resection was planned after sufficient informed consent was gained from the patient. The depth of the tumor invasion was inferred to be within mucosa so that local resection was considered to be selected. [Surgery] Surgical procedures included partial gastroduodenectomy including the anastomosed site and Roux-en-Y (R-Y) reconstruction. Histopathology revealed well differentiated tubular adenocarcinoma localized within the mucosa, and early duodenal cancer was diagnosed. [Considerations] Duodenal cancer is a rare neoplasm and no efficient therapeutic guidelines have been established as yet. Moreover few cases of duodenal cancer developed and resected after gastrectomy have been reported. In this paper we present a case of duodenal cancer developed after gastrectomy with B-I reconstruction which was detected in an early time and was radically removed by local resection, together with a review of the literature.

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Tuberculous intestinal perforation is rare, and if it affects the elderly patients, even emergency operation can hardly save their lives because their general conditions have deteriorated. This paper deals with a case of intestinal perforation in an elderly patient with intestinal tuberculosis whose life was successfully saved.
An 86-year-old woman presented with abdominal pain and fever was found to have peritoneal sign. Abdominal CT scan showed ascites and intraabdominal free air. Perforative peritonitis was diagnosed. Furthermore nodular shadows were seen in the both lungs. On the same day emergency operation was performed. At laparotomy, two perforations in the ileum were demonstrated, 290 cm and 320 cm distant from the Treitz' ligament, respectively, and peritonitis was evident. Surgical procedures included partial ileectomy, end-to-end anastomosis, jejunostomy for the purpose of enteral nutrition, and abdominal drainage. The resected specimen involved two ulces with perforations and one more ulcerated area. The histopathological diagnosis was small bowel perforation with ulceration due to intestinal tuberculosis. On the next day after the operation antituberculous therapy was started with the diagnosis of active pulmonary tuberculosis. Although her general condition was deteriorating, her life could be saved by the antituberculous therapy and nutritional control.

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We report a case of delayed stenosis of the small intestine after surgery for an incarcerated femoral hernia. An 85-year-old woman diagnosed as having incarceration of a femoral hernia underwent surgery via the femoral approach combined with laparoscopy. The incarcerated intestine was preserved due to improvement of its color. Then, 32 days after the surgery, the patient was admitted with abdominal pain and vomiting, and was diagnosed as having intestinal obstruction. Laparoscopic surgery was performed and the thickened intestinal part was resected.
Histological examination of the resected specimen revealed hypertrophy with fibrosis of the wall, and denuding of the mucosa in the thickened intestinal part. Such patients should be carefully followed up after surgery in an attempt to avoid delayed small bowel stenosis

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A 47-year-old man with benign prostatic hyperplasia was seen as an out-patient and found to have abdominal CT findings that indicated a small bowel tumor. Segmental resection was performed, and a gastrointestinal stromal tumor (GIST) was diagnosed histopathologically. Liver metastasis was found in S8 on postoperative examination 5.5 years later, and partial hepatectomy was performed. Then, 6.4 years after the initial resection, liver metastasis was found again, and percutaneous radiofrequency ablation (RFA) was performed, and 400 mg/day imatinib was added as adjuvant therapy for 2 years. However, the adjuvant therapy was stopped due to pneumonia. Ten years later, a peritoneal tumor was found in the liver bed. Tumor resection was performed, and 300 mg/day imatinib was restarted as adjuvant therapy, but 12 years later, chemotherapy was again stopped due to pneumonia. Finally, 12.6 years later, liver metastasis and peritoneal dissemination were diagnosed, and sunitinib was started. The patient is alive, 13.8 years after initial operation. Generally, patients with liver and peritoneal recurrence due to small bowel GIST are considered to have a poor prognosis. Therefore, this rare case that has shown long-term survival for 13.8 years is reported.

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The patient was a 69-year-old man who presented with a 6-month history of persistent abdominal pain and vomiting. Abdominal CT indicated an obstruction in the small intestine. Following decompression with ileus tube, laparoscopy was performed immediately under the suspicion of internal hernia. The examination revealed that the obstruction was due to a tumor arising from the serosa of the jejunum, 30 cm from the ligament of Treitz. The resection of the jejunum was extended to the mesenterium. Histopathological examination of the resected specimen revealed the diagnosis of well-differentiated adeocarcinoma, with an invasion depth of se, n0, and histological stage II disease. In general, primary cancer of the small intestine is a relatively rare disease and the presenting symptom is variable. Consequently, the most suitable preoperative diagnostic method and the treatment are still undetermined. This is the report of a case in which the low-invasive laparoscopy was shown to be advantageous to diagnose and treat primary cancer of the small intestine.

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We have experienced two cases of type-II enteropathy-associated T-cell lymphoma causing jejunal perforation. Case 1 involved a 71-year-old man who was seen at the emergency clinic in our hospital because of abdominal pain. Following various examinations after he was transferred to our department, upper gastrointestinal perforation was diagnosed and an emergency operation was performed. At surgery a perforation was found at the jejunum and an about 10-cm long portion of the jejunum including the perforated site was removed. Case 2 involved an 84-year-old man who was seen at a neighboring hospital because of lower abdominal pain, and was referred to our hospital with a suspicion of acute abdomen. Following various examinations, he underwent an emergency operation with a diagnosis of upper gastrointestinal perforation. At surgery a perforation was found at the jejunum and the affected intestine including the perforation was removed. In both cases histopathological findings showed deciduation of mucoepithelium at the lesion and diffuse proliferation of intermediate-sized lymphoma cells from the lamina ptopria to subserous layer. On immunohistochemistry, the tumor cells were positive for CD3, CD8, CD56, TIA-1, and granzyme B. Type II enteropathy-associated T-cell lymphoma was thus diagnosed. The Ki-67LI was as high as more than 90%. In addition the tumor cells were slightly positive for CD 20 in the Case 1. We present these two cases together with a review of the literature.

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A 23-year-old woman who had been hospitalized at the department of mental disorders in our hospital because of schizophrenia had the abrupt onset of abdominal pain and fever in the night, and was referred to our surgical department on the next morning. There were tenderness and peritoneal signs in the entire abdomen. Abdominal CT scan showed ascites, free air within the mesentery, and a linear area of hyper absorption in the small intestine. Peritonitis associated with intestinal perforation caused by a foreign body was diagnosed, and emergency operation was performed. Laparotomy disclosed clouded ascites of intermediate degree. A hard foreign body was felt in the ileum about 40 cm proximal to the ileum end, and perforation was seen on the mesentery side. The intestine involving the perforation was resected and anastomosed. Lavage and drainage of the abdominal cavity were performed. The foreign body in the resected intestine was a 5-cm sized plastic package folded in four which contained flaked seasoning for sprinkling over rice, “Furikake”. The edges of the package had stuck in the intestinal mucosa to form ulcer.
Common foreign bodies which can cause intestinal perforation are reported to be fish bones or dentures, but no cases of the perforation caused by plastic package for “Furikake” have been reported so far. In treating acute abdomen in a patient with mental disorder, intestinal perforation caused by a foreign body must be kept in mind and CT is a useful method for diagnosis.

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A 50-year-old man with anemia was referred to our hospital to undergo capsule endoscope (CE), which revealed multiple small bowel ulcers despite an incomplete examination. The patient remained asymptomatic for 5 months after CE, and then he returned to our hospital because of recurrent anemia. There were no abdominal symptoms. He could not confirm whether the capsule had been ejected. Abdominal X-p and computed tomography showed the retained capsule in the small intestine at the pelvic cavity. On a follow-up X-p after 7 days, the capsule still remained at exactly the same place. We removed the retained CE by laparoscopy-assisted surgery. Laparoscopy easily detected the retained capsule and ileal stricture with intestinal abnormalities such as serosal reddening and fat-wrapping sign. Resection of the involved small intestine by about 30 cm in length, including the stricture, was performed. On histopathological examination, the lesions were determined to be nonspecific ulcer. The patient's postoperative course was uneventful, and there has been no evidence of anemia recurrence for 2 months after the surgery. Laparoscopy-assisted surgery may be the first choice for the retrieval of a retained CE in the small intestine because this procedure can simultaneously allow diagnosis and treatment.

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A 45-year-old man was hospitalized for paraumbilical abdominal pain. In the past he had twice been hospitalized with the same pain. The computed tomography (CT) revealed that the superior mesenteric artery was located on the left side of the superior mesenteric vein ; this was specific to intestinal malrotation. The appendix wall was thickened and located in the pelvis. He was diagnosed with intestinal malrotation and appendicitis. He underwent an appendectomy with a small lower abdominal midline incision. In the past hospitalizations, he had not been diagnosed with intestinal malrotation based on CT, and he was treated for infectious enterocolitis. Malrotation should be considered in the differential diagnosis of abdominal pain.

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We report a rare case of scrotal abscess caused by acute peritonitis through an inguinal hernia. A 31-year-old man visited the department of urology at our hospital complaining of acute scrotal pain and swelling. We found that the right scrotum showed acute inflammatory features of redness, swollen, tenderness, and local heat. Abdominal computed tomography (CT) scan showed an abscess formation and calcified spot neighboring the ileo-caecal region and a right inguinal hernia with scrotal abscess. We diagnosed it as perforated appendicitis with an abscess spilling over the scrotum through an inguinal hernia and an urgent operation was performed. We performed extensive resection of the intestines ranging from the terminal ileum to the middle transverse colon, which were involved in a massive adhesion forming an abscess wall. For the inguinal hernia, we performed ileo-pubic tract repair after opening the inguinal canal and returned the contents of the great omentum to the abdominal cavity. For the scrotal abscess, we incised and opened the abscess wall detaining the drainage tube and irrigated the open wound daily. The post-operative course was uneventful and the patient was discharged from the hospital 25 days after surgery. We present our case, along with a review of the literature.

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A 61-year-old man had undergone colonoscopic examination regularly as follow-up after resection of a colon polyp. Colonoscopy revealed a tumor exposing the appendix orifice. Histological findings of a biopsy from the tumor demonstrated tubular adenoma and a laparoscopic appendectomy was carried out. The resected sub-pedunculated tumor of the appendix measured 7×5 mm and the histologically confirmed diagnosis was tubular adenoma. The postoperative course was favorable and he was discharged on postoperative day 7. A case of benign adenoma of the appendix diagnosed preoperatively is rare and a good indication for laparoscopic surgery.

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The patient was a man in his seventies who was seen at our hospital because of left lower quadrant abdominal pain. Abdominal echography revealed a tumor at the median of the lower abdomen. Abdominal CT scan showed a 90-mm diameter cystic tumor continuing to the tip of the appendix. Blood analysis showed an increased CEA level, 28.9ng/dl. Mucocele of the appendix was likely and laparotomy was performed. During surgery, a fist-sized tumor was present above the bladder, and from a part of which mucus leakage was identified. Since the tumor firmly adhered to the sigmoid colon and was likely to have invaded it, mucinous cystadenocarcinoma of the appendix was suspected. We performed a removal of the tumor, together with ileocecal resection, D3 dissection, and partial sigmoidectomy. Histopathologically the tumor was diagnosed as mucocele of the appendix and the adhesions to the sigmoid colon were clarified to be inflammatory adhesions caused by leaked mucus. The postoperative course was uneventful and the CEA level was normalized to 4.8ng/dl.
In the past 30 years, only five cases of benign mucocele of the appendix which was associated with adhesions to other organs and required associated resections have been reported in Japan. This case is considered to have followed a rare course and then we present the case together with a review of the literature.

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Mobile cecum syndrome is an embryological disorder defined as a loose attachment of the cecum to the retroperitoneum. Constipation is the most frequent complaint, but some cases present with bowel obstruction due to twisting or invagination of the bowels.
A 27-year-old-man was admitted to our institution with complaints of melena and constipation. He had no previous medical history. A soft elastic mass with tenderness was found in his right lower abdomen. On abdominal ultrasonography, the mass appeared as a target sign with a small amount of ascites. Abdominal enhanced CT showed highly dilated small intestine located within the transverse colon. At operation, the invagination of the bowels was returned to the normal position, but the vascular congestion of the bowels remained. There were no tumors or stenosis in the bowel. However, the highly loose attachment of the cecum and part of the terminal ileum was found at operation. The patient was diagnosed as having an invagination due to mobile cecum syndrome. There was no need for bowel resection, and fixation of the cecum to the retroperitoneum was performed. The patient's postoperative course was uncomplicated. He was discharged on the 11^th day after operation and has had no recurrence after 1 year.

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A 53-year-old woman who presented with a positive test result for fecal occult blood was diagnosed as having ascending colon cancer by colonoscopy. Barium enema examination demonstrated the apple core sign in the ascending colon, and the entire intestine was deviated to the left. Abdominal contrast-enhanced CT revealed that the ascending colon was located at the center of the abdomen, and that the SMA was located to the right side of the SMV, the so-called positive SMV rotation sign. Based on the above findings, the patient was diagnosed as having ascending colon cancer with intestinal malrotation, and laparoscopic surgery was performed. Intraoperatively, the ascending colon was found to be not fixed to the retroperitoneum, and the right ureter and the gonadal vessels were exposed. The right-sided colon could be pulled out easily from the small incision wound, and the malrotation was normalized by turning the intestinal tract 180°counterclockwise ; then, right hemicolectomy was performed. We report this case as laparoscopic colectomy in cases with intestinal malrotation is relatively rare.

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A 56-year-old man who became aware of muscle weakness of the left upper and lower limbs visited a neighboring hospital and was found to have a tumor at the right temporal lobe. He was referred to the department of brain surgery in our hospital. After admission his symptoms became worse and an emergency craniotomy to remove the tumor was performed. The tumor was completely removed and the pathological diagnosis was metastatic brain tumor. Close exploration for detecting the primary lesion revealed cancer of the transverse colon. FDG-PET suggested possible metastases to the thoracolumbar area, and the IRIS regimen was started. However, the regimen was discontinued 5 months after the initiation due to the patient's own decision. One year and 6 months later, stenosis of the intestine due to enlargement of the primary lesion was identified. Laparoscopic-assisted partial colectomy was performed. The pathological findings included poorly differentiated adenocarcinoma, SI (greater omentum), ly1, v2, and N0. As for adjuvant chemotherapy, the patient did not give consent to receive chemotherapeutic drugs except for oral S-1 so that oral administration of S-1 was continued for one year. Thereafter he has been alive without having recurrence as of 7 years and 2 months after his first visit.
Brain metastasis of colorectal cancer is often associated with metastases to other organs including the liver and lung when it is detected, and carries a poor prognosis. We here report a patient with transverse colon cancer presented with a solitary metastatic brain tumor who survives for a long time after the resection of the brain metastasis.

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A 32-year-old pregnant woman complained of intermitted abdominal pain since 20 weeks gestation. Her pregnancy had been otherwise uneventful. At 25 weeks and 5 days of pregnancy, she was seen in our emergency room ; because of sever constipation with no bowel movement during the preceding 10 days and worsening abdominal pain. On abdominal X-ray, the sigmoid colon was markedly distended and presented coffee bean sign. We diagnosed this case to be sigmoid volvulus and inserted an ileus tube by the transanal route. On the following day, her abdominal distention improved, but whenever she resumed her diet, volvulus relapsed. We needed to insert an ileus tube six times in total. Although it was difficult, she continued the pregnancy until fetal maturity and gave birth, while continuing with conservative therapy. Finally a cesarean section and sigmoid colon resection were performed at 31 weeks 3 days of gestation. Both mother and infant were doing well after surgery.
Sigmoid volvulus in pregnancy is relatively rare, but it leads to death of the mother and fetus without proper diagnosis. We should select proper treatments to protect their health when diagnose pregnant woman as this.

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The case of a 63-year-old male, who had a 2-month history of black stool and who began having vomiting and diarrhea 2 days before visiting a nearby doctor, is described. Because of acute renal failure and increased systemic inflammation, he was referred to our hospital on the same day. Laboratory blood test results also showed hyperkalemia and an abnormal electrocardiogram due to hyperkalemia, for which immediate hemodialysis was performed. On admission, the physical examination showed a giant left inguinal hernia. On the seventh day of admission, exarcerbation of abdominal pain and tenderness of the left inguinal hernia appeared, so that computed tomography was done, which indicated perforation of the colon in the inguinal hernia. Emergency surgery was performed, and it revealed perforation in the incarcerated portion of the sigmoid colon and colon cancer. The operation involved hernia repair by left inguinal incision and the Hartmann procedure by midline incision. Since perforated colon cancer in an inguinal hernia sac is rare, this case is reported along with a review of the relevant literature.

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A 78-year-old woman who was seen at our hospital because of lower abdominal pain and anal bleeding at defecations was diagnosed as having sigmoid colon cancer following colonoscopy. She underwent sigmoidectomy. Histopathological studies revealed that micropapillary carcinoma component showing clear-cut micropapillary morphology accounted for about 80% of the whole tumor and mildly differentiated adenocarcinoma component accounted for about remaining 20% of the tumor. Lymphatic invasion of minor degree was demonstrated. Micropapillary carcinoma of the colon and rectum has been reported to have the same poor prognosis as that of carcinoma derived from other organs. It occurs in a lowest frequency and so we present the case together with a review of the literature.

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The patient, an 86-year-old woman, presented with a pedunculated tumor of the stomach. The patient had visited her local physician complaining of abdominal pain, and been diagnosed as having the ball valve syndrome (BVS) based on the findings on esophagogastroduodenoscopy. An attempt at endoscopic reduction of the impaction was successful. However, the patient experienced the same symptom again, and as her symptom recurred, the patient was referred to our hospital for surgery. On the 4th hospital day, the patient suddenly developed severe abdominal pain and went into shock. An emergency laparotomy was performed. During surgery, bilious ascites, as well as a perforation in the fundus of the gallbladder measuring 7 mm in diameter was observed. There were no gallstones. The gastric tumor was found to be prolapsing and impacting into the duodenum, and was surgically excised. After surgery, the patient's renal function gradually deteriorated, and she was transferred again to another hospital for hemodialysis. She expired there on the 58th postoperative day. This was a rare case of gallbladder perforation developing while a patient awaited surgery for BVS. Therefore, this case is presented with bibliographic comments.

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A 43-year-old man was admitted to our hospital with severe abdominal injuries from a motor vehicle accident. On enhanced computed tomography (CT) scans, extravasation of contrast media and central liver laceration (grade IIIb liver injury) were revealed. At first, we chose transcatheter arterial embolization (TAE) because the patient was hemodynamically stable. Vital sign were stable under TAE, and had to start eating. Biliary peritonitis caused by bile leakage occurred in the late phase after injury. We tried non-operative management with antibiotics and peritoneal drainage of infected collections. Due to repeated episodes of high-output bile leaks and peritoneal inflammation, he underwent right hepatectomy and operative drainage 47 days after the TAE. Non-operative management has become the standard of care for hemodynamically-stable patients with complex liver trauma. In these patients, however, biliary complications are common. Careful assessment of biliary complications is important in the late phase of non-operative management for severe liver injury.

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We report the case of a patient with intrapancreatic biliary diverticulum (type II in Todani's classification) with stones undergoing resection of the diverticulum and intrapancreatic bile duct. A 68-year-old man presented general fatigue and right hypochondralgia. Routine blood investigations showed liver dysfunction. Computed tomography and endoscopic retrograde cholangiopancreatography revealed intrapancreatic biliary diverticulum with stones in the diverticulum, dilated bile duct and gallbladder. These findings confirmed the diagnosis of a Todani's type II choledochal cyst. Resection of the dilated bile duct with the intrapancreatic biliary diverticulum, cholecystectomy and choledochoduodenostomy were performed safely. The intrapancreatic bile duct formed a diverticulum, which was 22 mm at the maximum diameter, and no microscopic evidence of frank malignancy or hyperplastic changes were identified in the epithelium of the diverticulum or the dilated bile duct. The postoperative course was uneventful with no complications, and carcinogenesis has not recurred.
Todani's Type II choledochal cyst is extremely rare. Excision of the diverticulum is the recommended treatment, but reports of resection of the intrapancreatic biliary diverticulum are few. This time, we could resect the intrapancreatic biliary diverticulum safely, by identifying the intrapancreatic bile duct and diverticulum with bipolar forceps and opening the bile duct.

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A 69-year-old female who presented with epigastric pain and high fever was detected to have liver dysfunction and evidence of systemic inflammation. An upper gastrointestinal endoscopy showed a tumor of the ampulla of Vater. ERC showed stenosis of the lower bile duct, and we performed biliary stenting. Contrast-enhanced CT showed multiple low-density mass lesions in the liver, with peripheral ring enhancement in the early phase. US and contrast-enhanced MRI also showed the distinctive features of liver metastases. However, FDG-PET revealed no accumulation of FDG in the liver lesions. Therefore, the patient was kept under careful follow-up. A month later, the liver lesions could no longer be visualized therefore, we considered that all of the lesions were abscesses. A pylorus-preserving pancreatoduodenectomy was then performed as curative resection. Until now, 2 years after the surgery, she has shown no evidence of either recurrence of the cancer or of the liver abscesses. Since cancer of the ampulla of Vater is occasionally complicated by liver abscess, preoperative distinction between liver metastasis and abscess is critical. FDG-PET was useful for the differential diagnosis in our present case. As usual, careful follow-up of the clinical course provided exact information.

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A 64-year-old woman underwent resection of a congenital choledochal cyst and flow-diversion surgery 13 years earlier, and the pathological diagnosis showed no evidence of malignancy. Following the primary surgery, a yearly routine CT scan showed a mass located at a hilar bile duct, which was diagnosed as hilar bile duct cancer. Right hepatectomy and reconstruction of the bile duct were performed, and R0 resection was achieved. The resected tumor was pathologically diagnosed as papillary adenocarcinoma of the hilar bile duct. Currently, 6 months after the second surgery, the patient is doing well without any signs of recurrence. The current case suggests the necessity of long-term postoperative observation after flow-diversion surgery for congenital choledochal cyst.

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A 65-year-old woman underwent transduodenal ampullectomy of a papillary adenoma of the Ampulla of Vater. The pathological diagnosis was cancer of the Ampulla of Vater (JSBS classification : pT2, pN0, M0, p-stage II).
The patient underwent follow-up examinations with periodic gastroscopy. After 30 months, a lesion similar to a submucosal tumor was detected on the other side of the Ampulla of Vater. The lesion location corresponded to the transduodenal ampullectomy incision site made in the duodenum. The lesion was diagnosed as an adenocarcinoma based on the biopsy findings. Pylorus-preserving pancreatoduodenectomy was performed. The pathological diagnosis was duodenal carcinoma (UICC classification : mucinous adenocarcinoma, type 2. 25 × 25 mm, T3 (SS), N0, M0, stage IIA). This second adenocarcinoma was believed to be a recurrence of the original cancer of the Ampulla of Vater, having been implanted into the duodenum at the time of transduodenal ampullectomy. Although it rarely occurs, this condition should be carefully considered when evaluating and following patients with a similar history.

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A 26-year-old man who had intermittent bouts of upper abdominal pain since the night before admission was seen at the emergency clinic in our hospital on the next morning because of worsening of the symptom late in September 2013. There was muscle guarding in the entire abdomen. Abdominal CT scan showed large quantities of ascites and a 12 × 12 cm atonic, irregular-shaped cyst connecting to the spleen. Echo-guided ascitic drainage denied a possibility of intestinal perforation from its biochemical specifics. Spontaneous rupture of a giant splenic cyst was thus diagnosed. After admission, intraabdominal drainage was conducted via the left lower quadrant of abdomen. We identified about 4,600 ml of brown clouded discharge to be drained from the drainage tube. On the next day his abdominal pain almost completely improved. After his general condition became stable, laparoscopic dome resection was performed on the 10^th hospital day. The postoperative course was uneventful and he was discharged from the hospital on the 11^th day after the operation. No recurrence has occurred as of 4 months after the operation.
A total of 14 cases of ruptured splenic cyst have been reported so far, but no case of a ruptured splenic cyst treated by ascitic drainage followed by elective laparoscopic dome resection has been reported. Accordingly this case is presented here, together with a review of the literature.

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A 75-year-old man was referred to the Department of Urology after prostate cancer was suspected due to elevated prostate-specific antigen (PSA) levels. Because a cystic tumor was seen adjacent to the anterosuperior aspect of the bladder, the patient was referred to the Department of Surgery for operative management. Detailed preoperative examination indicated a low probability of a metastatic tumor. In addition, since it was not possible to determine whether the tumor was benign or malignant, surgery to remove the tumor was performed for a definitive diagnosis. A 6-cm tumor was seen adjacent to the bladder dome within the preperitoneal space. The tumor was not exposed to the inside of the abdominal cavity. Because detachment from the bladder was difficult, part of the bladder wall was resected. Pathologically, the resected sample had the characteristics of a borderline mucinous cystadenoma. Whether the tumor was of urachal origin could not be determined intraoperatively because the urachus could not be confirmed, but on the basis of imaging findings, the location of the tumor, and the pathological findings as a whole, a borderline mucinous cystadenoma of urachal origin was diagnosed. This case of an extremely rare disease is reported along with a review of the relevant literature.

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The patient was a 68-year-old man who underwent a removal of a huge tumor with the size of 90 × 140 × 100mm occupying the pelvic cavity in December 2012. Histopathologically it was perivascular epithelioid cell tumor (PEComa), and the tumor was found to have adhered to the sigmoid colon. Associated resection of a part of the sigmoid colon was performed as well. Since the bowel mucosa surface was normal, the tumor was pathologically considered to have arisen in the mesentery of the sigmoid colon. The mitotic figure was less than 1/10 HPP, but the tumor diameter was more than 5 cm and the center part of the tumor extensively necrotized. Accordingly a possibility of a tumor with malignant potential could not be ruled out and thereafter the patient had periodically been followed in the clinic. A follow-up abdominal CT performed in October 2013 after a one-year interval revealed an about 55-mm diameter tumor in the lower abdomen. FDG-PET showed an abnormal uptake of FDG (SUVmax of 5.828) at the right anterior part of the pelvic cavity where was coincided with the location of the tumor. From these findings, peritoneal recurrence of PEComa was likely. The tumor was thus removed. The same pathological findings as the primary lesion showed were reported. The postoperative course was uneventful. The patient was discharged from the hospital on the 7^th postoperative day. There is a risk of re-recurrence of PEComa, so that further abdominal PET-CT scans are scheduled every 3-4 months.

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