We investigated the deleterious germline mutation of BRCA genes and the family history of patients in 67 cases of familial breast cancer and the relatives in 41 of their families. The probands in 11 of 41 families, 26.8%, were shown to have the deleterious germline mutation of the BRCA genes. The mutations in BRCA1 were observed in four families, BRCA2 in six families, and the double heterozygosity with both BRCA1 and BRCA2 was found in one family. The detection rate of the mutations was higher in breast cancer patients who had dense family history of breast cancer and ovarian cancer. Comparing the clinicopathological findings of the cases with or without mutations, there was no significant difference in age of onset, the frequency of bilateral breast cancer, pathology, or the frequency of mastectomy. In the cases with deleterious mutations, the rate of node positive cases was higher, the rate of ER/PgR positive cases was lower, the rate of triple negative was higher and histological grade was higher than in those without deleterious mutations. BRCA gene testing is useful in diagnosing hereditary breast cancer, as well as determining the primary prevention of breast and ovarian cancers and selection of a surgical method or chemotherapy.

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Recently, hereditary breast and ovarian cancer syndrome (HBOC) has been increasingly recognized. The number of women with a strong family history of breast and/or ovarian cancer and young-onset triple-negative breast cancer undergoing genetic testing is increasing. At our hospital, we recommend mastectomy for breast cancer patients with BRCA1/2 germline mutations, in accordance with the NCCN guideline. In the present study, 28 patients with breast cancer were diagnosed as having BRCA 1/2 germline mutations, of which 10 had undergone genetic testing prior to surgery. Finally, all of the patients elected to undergo mastectomy. On the contrary, the remaining 18 of the 28 patients underwent genetic testing after the surgery, because they wished to be tested after the treatment of the breast cancer had been stabilized, or when they became aware of the possibility of HBOC by ipsilateral breast cancer recurrence. Of the 17 breast cancer patients who had undergone breast-conserving surgery, 7 developed ipsilateral breast cancer recurrence. We present cases of ipsilateral breast recurrence after breast-conserving surgery in women with BRCA1/2 germline mutations, and consider the optimal surgical management for breast cancer patients with HBOC.

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Background : Imatinib has shown dramatic clinical effects on patients with advanced GIST, however, focally imatinib-resistant diseases often arise during imatinib treatment. The significance of surgical intervention for focally progressive diseases of metastatic/recurrent GIST has not been clearly defined. Patients and Method : Between 2004 and 2012, consecutive 18 patients with metastatic/recurrent GIST received imatinib treatment. Among of them, five patients who had undergone surgical removal of focally progressive disease were enrolled in a retrospective study investigating their surgical outcomes. Results : In all five patients, focally progressive tumors were removed, but no complete resection of metastatic/recurrent GIST was achieved in them. The median time to progression was 412 days and the 2-year progression free survival rate was 20%. The median survival time from surgery to focal progression was 1051 days and the 2-year survival rate was 60%. Conclusion : Surgical intervention may have some benefits for patients with metastatic/recurrent GIST with focally progressive disease. Further studies are needed to confirm the efficacy and feasibility of surgical intervention for them.

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Application of tack fixation of mesh during laparoscopic inguinal hernia repair is controversial in these days. It is reported in overseas countries that there is no significant difference between fixation and non-fixation of mesh in total extraperitoneal repair (TEP) with respect to postoperative recurrence rate. However, no reports on the therapeutic outcomes from such a viewpoint have been presented in our country. Since March 2011, we have performed non-fixation TEP as the basic procedure in consecutive 218 cases. During a mean postoperative follow-up period of 20.1 months, postoperative recurrence occurred in only one case (0.46%). Non-fixation TEP is a reliable method in the inguinal hernia repair when done by experienced surgeons.

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A woman in her fifties consulted our department because of a large neck mass and dyspnea. The bulky and elastic firm mass with clear border and good movability was present in the foreneck region. The blood thyroglobulin level was high, 2779U/ml. The thyroid gland had enlarged remarkably due to well-defiened multiple masses found in both lobes, and the trachea was pressed and constricted, with the narrowest site of 3.2 mm in diameter on computed tomography. We judged that the tracheal intubation was difficult, so performed tracheostomy under local anesthesia with preparation of percutaneous cardiopulmonary support. General anesthesia was introduced sequentially, and total thyroidectomy was performed. The histological diagnosis was adenomatous goiter. It is necessary to recognize that adenomatous goiter entails a risk of going into an extremely critical state during the clinical course. It is recommend to perform surgery positively for the patients with a large mass or a mass extending to the mediastinum.

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The case of a 70-year-old woman with a poorly differentiated thyroid carcinoma and cutaneous needle tract implantation is reported. A fine-needle aspiration (FNA) biopsy for a thyroid nodule measuring about 2 cm in diameter with egg-shell calcification was performed, and the cytology was equivalent to class II. Three years after the FNA, the patient became aware of a cutaneous nodule in the left side of her neck. She regarded it as a senile wart. Three months later, a follow-up CT of the thyroid nodule showed mild growth, and on the same day, physical examination detected the cutaneous nodule measuring about 3 mm at the FNA needle insertion site of her neck. Left hemi-thyroidectomy and resection of the cutaneous nodule were performed. Both nodules showed the same histology, poorly differentiated thyroid carcinoma. The patient is well with no sign of recurrence 3 years after the operation. This appears to be the first case report of simultaneous resection of the primary lesion and cutaneous FNA needle tract implantation of poorly differentiated thyroid carcinoma in Japan. During follow-up of negative cytology of FNA of thyroid nodules, inspection and palpation of the FNA needle insertion site are important.

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A 72-year-old man was admitted to our hospital in September 2012 with a 7-year history of swelling in the neck and discomfort while swallowing. He was diagnosed as having thyroid cancer of the right lower lobe by CT and ultrasonography, therefore, thyroidectomy with lymph node dissection was performed. Although the patient could resume oral intake by day 2 after the surgery, chyle leak via a drainage tube was found on day 3 after the surgery. There was no dyspnea or swelling of the neck. Oral intake was stopped and the patient was started on intravenous hyperalimentation. However, since no improvement was observed in the chyle leak, octreotide administration was started on day 7 after the surgery. On the 3rd day after the start of octreotide administration, the chyle leak decreased markedly, and octreotide was continued for a total of 7 days. The patient started to eat again on day 19 after the surgery, and the chyle leak did not recur. Chyle leak is one of the serious complications after cervical surgery. We report a case of chyle leak developing after thyroidectomy that was successfully treated with octreotide.

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We report the case of a patient in whom breast-conserving surgery (BCS) was performed for a non-palpable breast cancer (BC) with microcalcifications diagnosed using calcification detection mode (MicroPure^TM) and contrast-enhanced ultrasonography (CEUS). The patient was a 70-year-old woman, in whom mammography showed segmental pleomorphic calcifications in the right breast. The tumor was not palpable, and could not be detected by conventional ultrasonography or enhanced MRI. Vacuum-assisted breast biopsy (VAB) revealed ductal carcinoma in situ (DCIS). The calcifications could be detected using MicroPure^TM with the patient under general anesthesia. Heterogeneous enhancement around these calcifications was detected by CEUS. We performed BCS, after determination of the surgical resection line using MicroPure^TM and CEUS. We could identify the calcifications by intraoperative xeroradiography. The pathological diagnosis of the tumor was apocrine DCIS, 13 mm in diameter. The DCIS was in a small portion of the side margin of the nipple, with no involvement of any other part. We could perform BCS safely and certainly by the use of MicroPure^TM and CEUS, which are reliable for early diagnosis of non-palpable BC with microcalcifications.

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Two cases of chylorrhea following breast cancer surgery that improved with conservative treatment are described.
Case 1 : A 52-year-old woman was referred to our department after being diagnosed with invasive ductal carcinoma of the left breast by a previous physician. Partial mastectomy with axillary dissection was performed. On day 1, 300 mL of milky drainage fluid was observed from the indwelling drain, and chylorrhea was diagnosed. Fasting and intravenous hyperalimentation were started on day 7. The drainage fluid changed to a slightly bloody color thereafter, and on day 25, the drain was removed, and the patient was discharged.
Case 2 : A 63-year-old woman visited our department after noticing a mass in her left breast from around July 2012. A diagnosis of invasive ductal carcinoma was made based on detailed examination, and partial mastectomy with axillary dissection was performed. On day 2, 680 mL of milky fluid was observed from the drain, and chylorrhea was diagnosed. The patient was followed up without discontinuing dietary intake, the amount of drainage fluid decreased gradually, and on day 10, the drain was removed, and the patient was discharged.
Chylorrhea following breast cancer surgery is a rare complication, and the present cases are reported with reference to the literature.

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A 67-year-old woman with recurrent breast cancer and multiple lung and bone metastases developed shortness of breath and palpitations while receiving combination chemotherapy with trastuzumab combined with gemcitabine. Her electrocardiogram showed T-wave inversion from a flat T in V1-3, and T-wave inversion and ST-segment elevation in V3-6. Echocardiography demonstrated severe left ventricular apical hypokinesia. The ejection fraction (EF) was 47%. Coronary angiography showed normal coronary arteries, and left ventriculography demonstrated severe, extensive, apical hypokinesia. Takotsubo cardiomyopathy was diagnosed. The patient was treated with human atrial natriuretic peptide (hANP), heparin, and furosemide, and left ventricular function evaluated with echocardiography improved gradually. EF was 66.6% on the 19th day of hANP treatment. She was discharged from the hospital on the 26th day. Reports of Takotsubo cardiomyopathy during chemotherapy are rare. Anti-cancer agents such as anti-HER2 drugs and anthracyclines are often administered for breast cancer treatment, and stress cardiomyopathy must also be considered in the differential diagnosis.

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We report a rare case of a patient with a hypopharyngeal metastasis from breast cancer. A 56-year-old woman had undergone mastectomy with axillary lymph node dissection for left breast cancer at 32 years of age. She received tamoxifen for 2 years after the surgery. Lung metastasis from the breast cancer was found when the patient was 42 years old, and resection of the upper lobe of the right lung was performed with lymph node dissection. More than 10 years after the lung resection, when the patient was 56 years old, she was referred to our hospital complaining of dyspnea. Laryngoscopy revealed bilateral vocal cord paralysis and a tumor in the hypopharynx, therefore, a tracheotomy was performed, along with biopsy of the tumor. Based on the biopsy findings, the patient was diagnosed as having hypopharyngeal metastasis from breast cancer (ER-positive, PR-positive, HER2-negative). The hypopharyngeal tumor reduced in size with oral aromatase inhibitor therapy.

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Descending necrotizing mediastinitis (DNM) is a rare and fatal infection arising from the deep neck tissue and spreading downwards into the mediastinum. We report a case of successful treatment of DNM with empyema. A woman in her seventies visited a neighboring hospital because of fever and a sore throat. The therapy conducted with a diagnosis of acute adenoiditis was ineffective. Six days later, she was transferred to our hospital with a diagnosis of DNM with empyema that was made based on CT findings. We performed emergency operation in partnership with the department of otolaryngology in our hospital. After drainage of the superior mediastinum and tracheostomy, thoracoscopic mediastinal drainage and decortication were performed. Chest CT-scan on the next day revealed effective drainage. She was discharged from our hospital 55 days after the surgery. Preoperative planning of a drainage route and postoperative checking of un-drained area by CT scanning are useful for the prompt and accurate drainage that is of most important in treating DNM.

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An 87-year-old woman presented to our emergency clinic because of a lasting abdominal pain after defecation in September 2012. When she was first seen, she had decreased oxygen saturation index and intermittent severe abdominal pain. A blood analysis showed anemia, dehydration, and increased levels of LDH and CK ; metabolic acidosis was absent. Based on findings of various imaging methods, right diaphragmatic hernia associated with right massive pleural effusion and deviation of the mediastinum to the left was diagnosed, and an emergency laparotomy was performed. During surgery, we confirmed a ruptured portion about 3 cm in diameter in the right diaphragm, which was just above the right hepatic lobe, through which an about 150-cm long portion of the small intestine had herniated and incarcerated in the right thoracic cavity. The herniated small intestine was easily reduced. There was 2,100 ml of bloody pleural effusion including coagulates in the thoracic cavity. No fragile areas were found at the ruptured portion of the diaphragm, but the rupture extended to the full thickness of the diaphragm. As she had not any apparent episodes of trauma, non-traumatic right diaphragmatic rupture was diagnosed.
We present a case of non-traumatic right diaphragmatic rupture, which is relatively rare, together with a review of the literature.

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An 80-year-old man underwent subtotal esophagectomy through right thoracotomy with 2-field dissection, and high intrathoracic esophagogastrostomy for cancer of the middle thoracic esophagus associated with the aberrant right subclavian artery < pT1b, pN1 (2/31), sM0, and fStage II >. Following postoperative chemoradiotherapy, no recognizable recurrence had occurred until 6 years and 2 months elapsed, when the patient was seen at our hospital because of massive hematemesis. On arrival at our hospital, he was in a state of shock. Upper gastrointestinal endoscopy revealed projectile bleeding from the esophagogastrostomy site. Arteriogram of the right subclavian artery visualized defluxion of contrast medium from the right subclavian artery to the gastrointestinal tract. So a stent was placed at the right subclavian artery-anastomotic fistula that was successful to stop the bleeding. However, he died of progressive worsening of the general condition due to prolonged shock state.
In surgical treatment of esophageal cancer associated with the aberrant right subclavian artery, a right subclavian artery-anastomotic fistula can occur like in this case. In order to avoid such events, we can employ either antethoracic or retrosteral route or we must place some tissue like the greater omentum between the vessel and the reconstructed organ.

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A 65-year-old man who was admitted to our hospital with dysphagia was diagnosed with advanced esophageal cancer with synchronous liver metastasis. He was initially treated by systemic chemotherapy with 5-fluorouracil and cisplatin. After four courses, the liver lesion shrunk in size, but the primary lesion showed no change. However, blood transfusion was necessary because of severe anemia due to toxicity. A two-stage operation involving esophagectomy for the primary lesion followed by hepatectomy for the synchronous liver metastasis was planned. Both postoperative courses were uneventful, and the patient has been well with no recurrence 46 months after the esophagectomy. Under limited conditions, surgery could be useful for patients with synchronous liver metastasis of esophageal cancer.

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An 80-year-old man underwent thoracoscopic esophagectomy for advanced esophageal cancer (poorly-differentiated squamous cell carcinoma with severe lymphatic and venous invasion ; pT3 pN4 M0 pStage IVa). Adjuvant chemotherapy was not employed considering his great age. Six months later, he complained of right lower quadrant pain and a hard tumor was palpated in the same area. Total colonoscopy revealed a type 3 lesion encircling two-thirds of the circumference of the ascending colon, and abdominal computed tomography (CT) scan showed wall thickening in the ascending colon with some lymph node swelling. The histological diagnosis was poorly-differentiated squamous cell carcinoma. CT scan did not show ascites, distant organ metastasis or local recurrence in the mediastinum. We performed right hemicolectomy with D3 lymphadenectomy based upon the diagnosis of metastatic colon carcinoma from esophageal cancer. Intraoperative findings showed no liver metastasis and peritoneal dissemination and intraoperative peritoneal cytology was negative. The most probable mode of colon metastasis was lymphogenic or hematogenous. Herein, we report a rare case of ascending colon metastasis derived from esophageal squamous cell carcinoma. Resection for metastatic colon cancer may be useful to prevent various symptoms associated with an increase in the tumor size.

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In children with severe mental and physical disabilities, percutaneous endoscopic gastrostomy (PEG) may be difficult for various reasons. A case of a child with severe mental and physical disabilities along with severe scoliosis for whom laparoscopic gastrostomy was performed is described. The patient was an 11-year-old girl who had been followed up for post-resuscitation cerebral hypoxia and spastic quadriplegia. Nasogastric tube replacement had been performed on an outpatient basis, but because her scoliosis deteriorated and tube insertion became difficult, gastrostomy was scheduled. Surgery was performed laparoscopically. Because the stomach was severely displaced in the upper left direction, and there were concerns that it may become deformed when elevated, the round ligament of the liver was transected and mobilized near the umbilicus, the length from the abdominal wall to the stomach was secured, and a 12-Fr gastrostomy tube was inserted by passing it through the interior of the round ligament of the liver. During gastrostomy tube replacement performed during the third month postoperatively, the tube could be replaced smoothly. The present case shows that, in children with severe mental and physical disabilities requiring regular gastrostomy tube replacement over the long term, it is important to create a route for smooth tube replacement in consideration of displacement due to body type or development, and the use of the round ligament of the liver was considered useful.

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A 70-year-old woman who was hospitalized for schizophrenia with bulimia was referred to our department because of frequent vomiting and epigastric distention. At first physical examination, mild epigastric distention was observed, but there were no signs of peritonitis. Abdominal computed tomography (CT) scans revealed conspicuous gastric dilation with a large amount of intragastric residue and emphysema in the gastric wall, but no intraperitoneal free gas. Subsequent abdominal CT scans performed during follow-up with emergency surgery in mind, revealed decreased blood flow and exacerbation of the gastric wall emphysema along with intraperitoneal free gas. Consequently, the patient was diagnosed as having necrotic gastric emphysema and surgery was performed. The stomach was dark red in color from the fundus to the pyloric zone, and many lacerations were present on the serosal surface of the stomach. Therefore, she was diagnosed as having gastric necrosis and underwent total gastrectomy. Pathological finding showed no vasculitis, arteriosclerosis or gastric perforation.
Despite the limited findings of peritonitis, when gastric emphysema associated with gastric dilation is recognized, rigorous and rapid clinical management should be undertaken.

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A 75-year-old man who underwent distal gastrectomy with Billroth-II reconstruction for a duodenal ulcer 52 years earlier, was seen at the hospital because of anorexia. An abdominal computed tomography (CT) scan showed dilation of the afferent loop. Emergency upper gastrointestinal endoscopic examination showed a type 3 gastric tumor at the area of the previous gastrojejunostomy which also obstructed the afferent limb. Under suspicion of a carcinoma of the remnant stomach, an operation was performed. From laparotomy findings, carcinoma of the remnant stomach with invasion to the retroperitoneal and peritoneal dissemination was diagnosed. For the purpose of drainage, we made a Braun's anastomosis between the afferent loop and the efferent loop. The postoperative course was uneventful, and the patient was discharged from the hospital on the 13^th postoperative day.

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The patient, a 61-year-old man who was diagnosed as having a duodenal adenoma during a routine medical examination, was referred to our hospital. Endoscopic examination revealed an elevated lesion measuring 1 cm in diameter located adjacent to the duodenal papilla in the posterior wall of the second portion of the duodenum. Another lesion detected on the anal side of the aforementioned lesion was diagnosed as a Brunner's gland adenoma with no endoscopic evidence of malignancy.
We considered one of two therapeutic options : partial resection of the duodenum or endoscopic submucosal dissection of the adenoma. We selected the former and performed partial resection of the duodenum via laparotomy using intraoperative endoscopy.
During the operation, the endoscopist marked around the tumor and the surgeon confirmed the line by following the endoscopic light from outside the duct. We resected the involved segment of the duodenum and sutured the ends. Histopathology revealed a duodenal adenoma and Brunner's gland hyperplasia.
We report that intraoperative endoscopy could be useful as a minimally invasive and function-preserving tool for surgery of lesions around the duodenal papilla.

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A 62-year-old man presented to the outpatient department complaining of dark urine. Abdominal CT revealed a 30-mm tumor in the second portion of the duodenum. ERCP confirmed an ulcerative tumor with an irregular border in the same anatomical region. Duodenal cancer was suspected, and pylorus-preserving pancreaticoduodenectomy (PPPD) was performed. The resected specimen showed a solid tumor, 31 × 28 × 32 mm in size. Microscopically, there was solid proliferation of small atypical tumor cells with a high nuclear to cytoplasmic (N/C) ratio, and immunohistochemistry was positive for synaptophysin. The diagnosis of duodenal neuroendocrine tumor was made. Forty-seven days after this surgical operation, a liver metastasis was found, and CDDP/VP-16 chemotherapy was started. After 4 courses of chemotherapy, a complete radiographic response was achieved. Unfortunately, 9 months after the initial surgery, another recurrent liver metastasis was found, and partial resection of the liver was performed. One month later, the patient developed the third recurrent liver metastasis and underwent repeat CDDP/VP-16 chemotherapy. He did not respond to the chemotherapy this time and died 19 months after the initial operation. Based on our experience, CDDP/VP-16 chemotherapy may work in some patients with duodenal neuroendocrine tumor.

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Cholesterol crystal embolization (CCE) is a rare systemic atheroembolism caused by showers of cholesterol crystals from a ruptured atherosclerotic plaque.
A 77-year-old man was brought into our hospital because of severe abdominal pain. He had peritoneal sign. Abdominal CT scan showed free air and ascites. Gastrointestinal perforation was diagnosed and an emergency operation was performed. Three perforated sites were identified in the small intestine, and partial resection of the small intestine was carried out. From histopathological findings, we diagnosed the case as multiple perforations of small bowel ulcers caused by CCE. On the third postoperative day, a black discharge was drained from a gastric tube. Upper gastrointestinal endoscopy disclosed further multiple ulcers in the stomach and duodenum. On the fourth postoperative day, an intestinal juice like discharge appeared, suggesting another perforation of the small bowel might occur. As the patient had had unconsciousness and status epilepticus after the operation and a CT scan of the head confirmed multiple cerebral infarctions, we had to give up re-laparotomy. The patient died on the eighth postoperative day.
CCE presents with impaired renal function, skin and gastrointestinal symptoms, however, it rarely causes gastrointestinal perforation. We present previously reported cases, including our case, of gastrointestinal perforation caused by CCE.

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A 65-year-old man who was seen at the department of internal medicine in our hospital because of abdominal pain and vomiting was found having wall thickening of the small bowel, dilatation of the bowel proximal to the thickened portion, and multiple swollen lymph nodes of the mesentery by an abdominal CT scan. Small bowel endoscopy revealed a tumor lesion at the jejunum, a biopsy for which was done. Histopathological studies showed proliferation of atypical lymphocytes. Immunohistohemical staining of the tumor cells revealed CD3(+), CD4(-), CD8(+), CD20(-), and CD56(+). From these findings, enteropathy associated T-cell lymphoma (EATL) was diagnosed. Following eight courses of CHOP therapy, the tumor remnant was identified, so that six courses of DeVIC therapy were added. Small bowel endoscopy for evaluation disclosed the tumor remnant and serious degree of bowel stricture. Partial resection of the small intestine was performed. Since around three months after the operation, suprapubic pain developed. Close examination suggested recurrence of sigmoid colon lymphoma, and Hartmann operation was performed. We added two courses of SMILE therapy after the second operation, but the therapeutic outcome was rated NC. The patient is now on chemotherapy mainly with gemcitabine.
This paper deals with a case of EATL, which is a rare type malignant lymphoma, performed twice resections with a review of the literature.

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Solitary fibrous tumors (SFT) are soft tissue tumors originating primarily in the pleura, and extrapleural occurrence is thought to be rare. A case of SFT that originated in the mesentery of the small intestine is reported.
The patient was a 61-year-old woman who was referred to our hospital for detailed examination and treatment after an abdominal mass was detected by a local physician. Abdominal contrast-enhanced computed tomography (CT) showed a lobulated solid tumor containing small cystic changes within the pelvis. The tumor was hypointense and slightly hyperintense on T1- and T2-weighted magnetic resonance imaging(MRI), respectively. A mesenchymal tumor originating in either the mesentery of the intestines or the small intestinal wall was diagnosed, and the tumor was resected surgically.
Intraoperative findings showed that the tumor originated in the mesentery of the small intestine, with no clear invasion into surrounding organs. Partial resection of the small intestine including the tumor site was performed. Histopathological test results were CD34(+), CD99(+), c-kit(-), and Ki-67 index 10-15%, and an SFT originating in the mesentery of the small intestine was diagnosed.
The patient had an uneventful postoperative course and was discharged on day 10 after surgery. No findings of recurrence have been observed as of 31 months postoperatively.

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A 71-year-old man underwent lower gastrointestinal endoscopy in July 2012, with surgical removal of a colon polyp. One year later, the patient visited our hospital to receive another lower gastrointestinal endoscopy, which detected an erythematous, elevated lesion measuring 1 cm in size located in the ileum, approximately 15 cm from the Bauhin valve. The tumor mass appeared to be distended and showed erosion at the top. Biopsy confirmed a diagnosis of neuroendocrine tumor (NET). On abdominal computed tomography (CT) scan, lymph node metastasis was suspected in the area around the ileocolic artery and vein, but no distant metastases were detected. We performed a laparoscopically-assisted ileocecal resection with D3 lymph node dissection. The histopathological diagnosis was NET (G2), pT4a (SE), INFb, pN1b, pN (+), ly2 and v2 and Stage IIIb. In Japan, NET is a relatively rare disease. However, it is still considered important to observe the terminal part of the ileum, which has a high incidence of NET. In addition, laparoscopic resection is a less invasive procedure than open surgery and is therefore considered to be useful for complete tumor removal.

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An 80-year-old man admitted to our hospital for fever and abdominal pain had previous histories of undergoing gastrectomy for gastric ulcer at the age of 24 and operation for spinal arteriovenous malformation at 42, and thereafter he had had paraplegia and vesicorectal dysfunction. Abdominal computed tomography showed a 7×5×4 cm enhanced solid tumor in the pelvic cavity. Gastrointestinal stromal tumor (GIST) of the small intestine was suspected. We examined small bowel series but no obvious lesion was detected. He developed ileus after the examination. We employed an emergent operation because conservative therapy was ineffective. Laparotomy disclosed a strangulated and dilated intestine consisting of a loop structure at 20cm proximal to the terminal ileum. This structure was caused by a ring-shaped appendix which adhered to the ascending colon on the apex. Only appendectomy was performed against ileus because intestinal strangulation was released and no necrosis was present. In addition, small bowel resection for the ileal tumor 120cm proximal to the ileocecal junction was performed. The strangulated ileus caused by a ring-shaped appendix is very rare. Only seven cases of strangulation ileus caused by the appendix have been reported in Japan, and our case is the only one without relating to mucocele of the appendix.

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A previously healthy, a 28-year-old man visited the hospital because of sudden diarrhea and bloody stool. Abdomen was soft and flat. He complained of mild upper abdominal pain, but not nausea or vomiting. Blood results showed neither inflammatory response nor anemia. Arterial phase of computed tomography (CT) scan showed appendiceal hemorrhage. Findings that would indicate acute appendicitis, such as appendix swelling, were not shown in the CT scan. Emergency colonoscopy examination revealed oozing from the appendiceal orifice. We performed a single incision laparoscopic appendectomy on the unexplained appendiceal hemorrhage. Laparoscopic findings revealed the appendix to be normal with no sign of inflammation. We also examined toward the oral side of the terminal ileum, but did not find evidence to doubt a diagnosis of Meckel's diverticulum. The serosa of the specimen was unremarkable. Histopathological diagnosis was acute phlegmonous appendicitis. Histopathological findings showed the growth of capillaries associated with erosion and abscess formation, but did not show any exposure of vessels nor ulceration that would cause arterial hemorrhage. Histopathological examination indicated the cause of appendiceal hemorrhage to be acute appendicitis with erosion. There were no postoperative recurrences, such as bloody stool or progression of anemia. The postoperative course was uneventful, and the patient was discharged on the 4^th postoperative day. The causes of melena and bloody stool can vary widely. To our knowledge, bloody stool caused by arterial appendiceal hemorrhage is rare.

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Case 1 involved a 51-year-old man who underwent appendectomy with a diagnosis of acute appendicitis. The postoperative histological diagnosis was goblet cell carcinoid (GCC). Laparoscopic ileocecal excision was performed. Case 2 involved a 43-year-old woman who underwent simple abdominal hysterectomy + bilateral salpingo-oophorectomy with a suspicion of bilateral malignant ovarian tumors. During the operation, a swollen appendix was detected and it was simultaneously resected. The postoperative histological diagnosis was GCC of the appendix and ovarian metastasis. Right hemicolectomy was performed. Case 3 involved a 73-year-old man who underwent appendectomy with a diagnosis of acute appendicitis. The postoperative histological diagnosis was GCC. An abdominal CT scan undertaken after the operation revealed a nodular lesion which had oppressed the rectum. Accordingly ileocecal excision + Hartmann operation were performed.
GCC is classified into a subtype of adenocarcinoma and has a high grade of malignant potential. The preoperative diagnosis is difficult and we have to consider some additional therapy. As we recently experienced three cases of GCC diagnosed after appendectomy and performed reoperation, these cases are presented here with a review of the literature.

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The patient was a 20-year-old man who had undergone ventriculo-peritoneal shunt implantation following surgery for myeloeningiocele as a newborn. The V-P shunt was exchanged because of hydrocephalus when the patient was 8 years old. Granulation had been noticed in the V-P shunt insertion wound three months earlier, and the wound had begun to discharge pus from a month earlier. Removal of the V-P shunt tube was scheduled, as infection of the V-P shunt system was suspected. Preoperative CT showed migration of the peritoneal shunt tube into the transverse colon, however there was no tenderness of the abdomen suggestive of infectious peritonitis. Laparoscopic surgery revealed penetration of the peritoneal shunt tube into the transverse colon, and laparotomy with a small incision was subsequently performed for repair of the transverse colon wall after removal of the peritoneal shunt tube. The infection of the V-P shunt insertion wound was controlled by systemic antibiotic administration. V-P shunt implantation was planned when hydrocephalus was detected again. Bowel penetration by a peritoneal shunt tube in a V-P shunt system is rare, and in our case, laparoscopic surgery was useful for the diagnosis and treatment of penetration of the transverse colon by a peritoneal shunt tube of a V-P shunt system.

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An 80-year-old woman visited a neighbor clinic with left lower abdominal pain as a chief complain. White blood cell count was increased. Abdominal pain CT revealed increased density of the adipose tissue around the splenic flexure. And she was carried to our hospital with a suspect of intestinal necrosis. Abdominal contrast CT made on arrival at our hospital revealed that contrast enhancement effects were not good on the ascending to descending colon. Emergency operation was performed with a diagnosis of colonic necrosis. At laparotomy, viscous ascites and some ischemic change of serosa from the cecum to sigmoid colon were found. Based on this, we made a diagnosis of total colonic necrosis by total colonic type ischemic colitis. Pulsation of superior/inferior mesenteric arteries was palpable, indicating absence of occlusion. Total colon from the end of ileum to rectosigmoid colon was resected and ileostomy was carried out. After the surgery, the patient was transferred to ICU and followed-up under hemodialysis. On the postoperative day-42, she was discharged after withdrawal from hemodialysis. Although it is rare in ischemic colitis, colonic necrosis might spread over the entire colon. So we should carefully make a diagnosis and treat patients in consideration of such possibility.

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An 87-year-old woman who had been staying at the department of orthopedics in our hospital for fracture of the neck of thigh bone complained of contamination of stool in leucorrhea. There was a previous history of undergoing transvaginal hysterectomy for prolapse of the uterine. She was referred to our department of surgery. An abdominal CT scan showed multiple diverticula in the sigmoid colon and a luminal structure with an inner portion mixed with gas which appeared to be a fistula between the colon and the surgical stump of the vagina. At colonoscopy, injection of gastrographin confirmed a fistula from the sigmoid colon toward the vagina. From these findings, sigmoid-vaginal fistula probably caused by sigmoid diverticulitis was diagnosed and partial resection of the sigmoid colon and closure of the fistula with sutures were performed. The postoperative course was uneventful. The patient was transferred to the rehabilitation ward on the 15^th postoperative day.
Although colovesical fistula is a relatively common disorder as a complication of diverticulitis, few cases of colovaginal fistula have been reported. We thus present this case with a review of the literature.

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A 58-year-old man presented to our hospital because of abdominal pain and vomiting was diagnosed with obstructive ileus caused by colon cancer at the ileocecum. An abdominal CT scan conducted before surgery revealed thrombi in the right pulmonary artery and the bilateral femoral veins. Deep vein thrombosis and pulmonary embolism were diagnosed. An inferior vena cava filter was placed before surgery, because anticoagulation therapy had to be withdrawn during a perioperative period and so there was a possibility of worsening of the diseases due to recurrence of embolism. Operative procedures included ileocecal resection and ileostomy. His postoperative course was uneventful.
Our experience with this case emphasizes the importance of our recognition that patients with obstructive ileus due to colon cancer entail a great risk of causing thrombosis, because they have been carrying dehydration as well as cancer. We could have a favorable outcome by placing an inferior vena cava filter before operation for a patient with obstructive ileus due to colon cancer associated with deep vein thrombosis and pulmonary embolism. Here we report the case, together with a review of the literature.

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An 81-year-old man was hospitalized with ileus despite regular hospital visits and a radiological procedure for a previous history of chronic hepatitis C with hepatocellular carcinoma treated by transcatheter arterial embolization (TAE). Computed tomography (CT) on admission showed an ileocecal tumor and multiple liver matastases and distant lymph node matastases despite the absence of any liver lesion in a magnetic resonance image (MRI) 2 months previous. We performed an ileocecal resection to release the ileus. Histopathological findings revealed that the tumor was composed of many different histological types such as ; mucinous carcinoma, signet ring cell carcinoma, hepatoid tumor, neuroendocrine tumor, rhabdoid feature, and mainly poorly differentiated adenocarcinoma. CT only 19 days after the operation showed a noticeable increase of liver and lymph node metastasis. He died at postoperative day 27 even though he received chemotherapy with mFOLFOX6.

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Umbilical metastasis from malignant neoplasms, the so-called Sister Mary Joseph nodule, a marker of poor prognosis, is rare. Herein, we report the case of a patient with umbilical metastasis from sigmoid colon cancer who showed prolonged survival.
A 62-year-old man presented to us with a bleeding umbilical tumor. Biopsy of the umbilical tumor revealed adenocarcinoma. Abdominal CT and colonoscopy revealed the diagnosis of sigmoid colon cancer. We performed sigmoidectomy with D3 lymph node dissection and resection of the umbilical tumor. Histopathology revealed that the tumor was type 2, pSE (depth of invasion), pN0, H0, P0, M1(umbilicus). Based on the above findings, the patient was diagnosed as having stage IV cancer of the sigmoid colon. Adjuvant chemotherapy was administered, and the patient has remained well without recurrence for over 3 years.

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An 80-year-old woman presented to a hospital because of a more than one-month history of thinning stool column and constipation was pointed out edema and stricture encircling the rectal mucosa completely by colonoscopy (CS). In addition she had had increased level of CEA. She was thus referred to our hospital for the purpose of close exploration. No malignant findings were found by endoscopic biopsy. However, a possibility of rectal cancer could not be ruled out, because the whole-circumferential rectal stricture and the high CEA level persisted, and laparotomy was performed. The operation confirmed absence of any tumors in the rectum and the pelvic cavity. Intraoperative CS showed the rectal stricture to have improved. We decided not to perform rectal resection but to follow her clinical course conservatively. Another CS taken one week later disclosed only mild degree of rectal stricture. Stricture-type ischemic colitis of the rectum was diagnosed.
Stricture-type ischemic colitis is a relatively rare entity, and such cases associating with high CEA level, like our case, have scarcely been reported so far. We present our case with a review of the literature.

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We experienced a case of rectal cancer with ossification and liver metastasis resected simultaneously by laparoscopic surgery. The patient was a man in his fifties complaining of constipation and abdominal distension. Computed tomography and colonoscopy revealed intestinal obstruction caused by rectal cancer with multiple liver metastases (S2, 6, 8). We performed emergency colostomy, followed by laparoscopic low anterior resection (D3) and partial hepatectomy after an interval of one week. The pathological diagnosis of the resected rectal specimen was well differentiated adenocarcinoma with ossification ; the tumor directly invaded the urinary bladder. The resected liver metastases had no ossification. Despite adjuvant chemotherapy in our clinic, he developed recurrence in the liver remnant and he is on chemotherapy in our clnic as of 3 years and 2 months after the operation.
Previous reports indicate that the bone forming colorectal cancer accounts for about 0.4% of all colorectal cancers and that the tumors have center necrosis and are of low malignancy. However, our case in which bladder invasion and liver metastases were noted did was not of low malignancy. This is the first case of the rectal cancer with ossification and liver metastasis in which laparoscopic low anterior resection and hepatectomy were simultaneously performed.

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A 35-year-old woman visited our hospital because of a submucosal tumor in the gastric cardia that was detected by an upper gastrointestinal series and a gastrointestinal endoscopy performed during a medical checkup. An abdominal enhanced CT scan revealed a small, slightly enhanced tumor. The tumor's feeding artery was diverted from the hepatic artery. An abdominal US revealed an isoechoic ovoid mass between the liver and stomach. A MRI scan revealed an isointense mass on T2-weighted images. Based on the gastrointestinal endoscopy and radiological examinations, the lesion was diagnosed as a GIST ; however, a possibility of hepatoma could not be ruled out because of the feeding artery. Laparoscopic wedge resection for the GIST of the gastric cardia was planned. A solitary mass arising from the left triangular ligament of the liver was found during a laparoscopic examination. Laparoscopic partial hepatectomy, including the hepatic tumor, was performed using ultrasonic laparoscopic coagulation shears. The pathological diagnosis was hepatic focal nodular hyperplasia (FNH). Although a correct diagnosis was not made preoperatively, a laparoscopy was very useful for the diagnosis and treatment in the present case. No cases of a FNH originating from the left triangular ligament of the liver have been previously reported.

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A 67-year-old woman visited our hospital complaining of right upper abdominal pain. Imaging examinations revealed a huge liver cyst measuring 19.9 cm in maximum diameter, occupying the right lobe of the liver. Based on a provisional diagnosis of a simple liver cyst, laparoscopic fenestration by reduced-port surgery was performed. Two ports, one for the right hands and another for the scope, into the peritoneal cavity the umbilicus using an Alexis Wound Retractor (XS) and a surgical glove (the glove technique). A third port, for the left hand, which was planned for postoperative drainage, was inserted from the right hypochondralgia. The patient was discharged 12 days after the surgery without complications. Fifteen months have passed since the operation, and no recurrence of the cyst has been detected. Our procedure involving the glove technique plus one port for postoperative drainage seems to be feasible and rational in comparison to single-incision laparoscopic surgery.

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We report two cases of hepaticolithiasis associated with benign biliary strictures after pancreaticoduodenectomy (PD). Case1 : A 74-year-old woman who had developed cholangitis after undergoing PD for serous cystadenoma was diagnosed 9 years later as having hepaticolithiasis. Case2 : A 79-year-old man was diagnosed as having hepaticolithiasis 5 years after undergoing PD for carcinoma of the papilla of Vater. In both cases, we dilated the biliary strictures by increasing the size of the percutaneous transhepatic biliary drainage (PTBD) tube and performed percutaneous transhepatic cholangioscopic lithotomy (PTCSL). After biopsy confirmation of the absence of any evidence of malignancy at the biliary-enteric anastomosis, both patients were discharged with indwelling transhepatic stents (18-French). They remained asymptomatic at the 4- and 3- month follow-up, respectively. With the increasing frequency of long-term survivors after PD, the incidence of hepaticolithiasis after PD is also increasing. Therefore, long-term follow-up of patients undergoing PD is important.

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A 79-year-old man had been visiting a local physician on an outpatient basis for follow-up of diabetes mellitus and liver function abnormality. He visited our hospital due to onset of general malaise and anorexia. The patient had jaundice, and blood tests showed a positive result for hepatitis C virus (HCV) antibody, mild liver function abnormality, and elevated protein induced by vitamin K absence or antagonist-II (PIVKA-II). Abdominal ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) showed tumor lesions that were densely stained at an early stage in the S6 and S8 segments of the liver, and hepatocellular carcinoma was diagnosed. Laparoscopic-assisted partial resection of the S6 segment of the liver and microwave coagulation therapy for the tumor in the S8 segment of the liver were performed. In the resected sample, the tumor had a macroscopically thick fibrous capsule. The interior was solid and had septum. Histopathological findings only showed granulation tissue and necrotic tissue, accompanied by bleeding and hemosiderosis, and no tumor cells were seen. Narrowing of the lumen and thrombi were seen in blood vessels outside of the tumor. These findings were thought to indicate spontaneous necrosis of hepatocellular carcinoma. While some cases of hepatocellular carcinoma that spontaneously regressed due to angiography or pretreatment have been reported, reports of spontaneous necrosis that occurred without angiography or pretreatment, as in the present case, are rare. Thus, we report a case of spontaneous complete necrosis of hepatocellular carcinoma.

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The case involved a man in his seventies, who underwent repeated transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) due to chronic hepatitis C, was admitted to our hospital for the treatment of a retroperitoneal tumor. The retroperitoneal tumor increased in diameter from 11 to 37 mm during the previous 1 year. Computed tomography (CT) revealed an enhanced retroperitoneal tumor behind the body of the pancreas, as well as a viable HCC in segment 4 of the liver. Levels of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and alpha-fetoprotein (AFP) were within the normal limits ; the level of protein induced by vitamin K absence/antagonist factor II (PIVKA-II) was 62 mAU/mL. On the basis of a diagnosis of metastatic retroperitoneal tumor of HCC, the patient underwent resection of the retroperitoneal tumor. Pathological examination of the resected specimen revealed a metastatic retroperitoneal tumor of HCC, and the serum level of PIVKA-II normalized after resection. Herein, we report a case of metastatic retroperitoneal tumor of HCC, along with a review of the literature.

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A 71-year-old woman was diagnosed with a portal-hepatic venous shunt in 2003. In 2007, she developed hepatocellular carcinoma in the segment 6 of the liver and underwent partial hepatectomy. Computed tomography (CT) performed four years later showed a tumor in the medical segment of the liver. The patient had no previous history of blood transfusions, hepatitis, or metabolic abnormalities. On admission, the patient did not have impaired consciousness or general malaise, but she did have abnormal values for total bilirubin (T-Bil 1.7 mg/dL), NH₃ (122 μg/dL), and the indocyanine green (ICG) 15-min retention rate (34%). CT showed a 3-cm-diameter tumor that was densely stained in the early stage and washed out in the inferior part of the medial segment of the liver, as well as a 17-mm-thick portovenous (PV) shunt connecting the anterior segmental branch of the portal vein to the middle hepatic vein.
Hepatic resection of the inferior part of the segment 4 was performed, the middle hepatic vein was sutured on the peripheral side, and the PV shunt was occluded. The pathological diagnosis was well-differentiated hepatocellular carcinoma.
The patient followed an uneventful course and was discharged on day 13 following surgery. The liver function tests normalized.
A case of a patient who, despite having no risk factors for liver cancer, twice developed hepatocellular carcinoma, was described.

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The patient was a woman in her twenties who visited our hospital with the chief complaint of epigastralgia. Based on the results of blood tests, ultrasonography and CT, the patient was diagnosed as having cholelithiasis with situs inversus totalis. Considering its cosmetic benefits, we scheduled laparoscopic cholecystectomy via a single incision. In condition of broad base, the operator and the assistant had to position themselves inversely as compared to that for usual laparoscopic cholecystectomy because of the situs inversus totalis. In the upper abdominal region, the organs were positioned symmetrically, therefore, the surgical diagnosis was also situs inversus totalis. The operation was performed by the standard procedure and the operator could freely use both hands. As a result of the anatomical assessments of the blood vessels and biliary tree carried out by imaging examinations preoperatively, we were able to perform the single-incision laparoscopic cholecystectomy safely. In addition to the esthetic outcome, our results suggested that single-incision laparoscopic cholecystectomy might have some advantages in terms of the technical aspects of the surgery in cases of cholelithiasis with situs inversus totalis.

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A 75-year-old male presented with jaundice and generalized malaise. Abdominal CT showed upper and lower bile duct masses. MRCP showed filling defects from the right/left hepatic duct bifurcation to the upper bile duct, and in the lower bile duct. Exfoliative cytology of the lower bile duct revealed Group V, adenocarcinoma. The patient was therefore diagnosed as having bile duct cancer in the hepatic portal region and lower bile duct. Percutaneous transhepatic portal vein embolization was performed. Two weeks later, hepatectomy of two segments of the right lobe segments and pancreaticoduodenectomy (modified Child method reconstruction) were performed. In the resected specimens, the papillary tumor in the hepatic portal region was adjacent to the nodular infiltrating tumour in the lower bile duct. Histopathologically, the hepatic portal region tumour was diagnosed as endocrine cell carcinoma showing an extremely solid growth of small atypical cells with high nuclear/cytoplasmic ratios. The lower and surface bile duct tumours were diagnosed as adenocarcinoma. Thus, the final histological diagnosis was extensive adenoendocrine cell carcinoma of the bile duct. An abdominal CT carried out 3 months postoperatively revealed recurrent multiple liver metastases. The patient died 5 months after the surgery. According to the autopsy results, all of the recurrent metastases were histologically diagnosed as endocrine cell carcinoma, and there were no metastases showing the histological picture of adenocarcinoma.

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A 75-year-old man was diagnosed with multiple recurrent hepatocellular carcinomas after repeated local therapies, including transcatheter arterial chemoembolization and radiofrequency ablation. Computed tomography showed a local recurrence of the tumor involving the right diaphragm. Central bisegmentectomy and partial resection of the diaphragm was performed. Histopathological examination revealed that the tumor consisted of a well to poorly differentiated adenocarcinoma with a spindle-shaped sarcomatous component and positive surgical margins. Immunohistologically, the tumor was positive for CK19, thus, he was diagnosed as having intrahepatic cholangiocarcinoma with sarcomatous change. He developed a local recurrence 1 year after the first operation, and underwent partial resection of the diaphragm combined with the right lower lung. Six months after the second operation, he developed a recurrence in the mediastinal lymph node. It is sometimes difficult to differentiate small intrahepatic cholangiocarcinoma from hapatocellular carcinoma. As with our case, repeated local therapies for liver tumors might have chance to cause sarcomatous change. Clinically, it is difficult to diagnose sarcomatous change, and an aggressive surgical treatment is necessary in the case of recurrence hepatic tumors after repeated local therapies.

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A 69-year-old man was admitted to hospital with melena and severe anemia 3 years after pancreatoduodenectomy for carcinoma of the papilla of Vater. Portogram findings showed stenosis of the portal vein and dilated collaterals from the jejunal vein. Postoperative inflammatory changes were suspected to be the source of the stenosis. Jejunal varices resulting from portal vein stenosis were suspected as the cause of melena. Therefore, expandable metallic stent placement was carried out under percutaneous transhepatic portography to maintain portal blood flow. After the procedure, there has been no recurrence during 5-year follow-up.
A 75-year-old woman was admitted to hospital with melena 18 months after pancreatoduodenectomy for pancreatic cancer. Radiologic imaging demonstrated portal vein stenosis and collateral formation, which was caused by recurrence of the cancer. Expandable metallic stent placement was carried out in the same way. The patient was asymptomatic for 16 months after the procedure, but she died 38 months after pancreatoduodenectomy.
Expandable metallic stent placement is recommended as a treatment for gastrointestinal bleeding caused by postoperative portal stenosis.

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Development of carcinoma from the remnant bile duct after cyst excision is a critical issue in the surgical management of congenital choledochal cyst. We report a case in which carcinoma from the remnant intrapancreatic bile duct developed 23 years after excision of a congenital choledochal cyst. A 69-year-old woman with a history of excision for a congenital choledochal cyst at age 46 presented with a mass in the pancreatic head detected by abdominal ultrasonography. Abdominal CT showed a cystic mass measuring 28 mm in diameter ; an enhanced nodule was detected in this lesion. ERCP revealed pancreaticobiliary maljunction with a dilated remnant intrapancreatic bile duct ; filling defects, caused by the nodule and mucin, were seen within the bile duct. Under the tentative diagnosis of carcinoma of the remnant intrapancreatic bile duct, substomach-preserving pancreaticoduodenectomy was performed. The patient remains alive and well with no evidence of disease 6 months after the resection. This case and a review of the literature suggest that careful long-term follow-up is necessary for patients undergoing excision for a congenital choledochal cyst.

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Resected pancreatic metastasis of renal cell carcinoma (RCC) has been recently reported, but a standard treatment for pancreatic metastasis of RCC has not yet been determined. We report a case of resected repeated pancreatic metastasis of RCC in a remnant pancreas 4 years after distal pancreatectomy (PD). A 54-year-old man underwent a right nephrectomy for RCC, and 4 years later, he underwent a distal pancreatectomy for pancreatic metastasis. After 1 year, a metastatic tumor was detected in the remnant pancreas and he underwent a total pancreatectomy. The recurrence was detected in the liver and retroperitoneal cavity and he underwent chemotherapy. Now 4 years after the total pancreatectomy, he remains well. We suppose that good prognosis can be provided by surgical therapy against recurrent pancreatic metastasis of RCC.

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A 36-year-old woman who was seen at our emergency clinic because of the abrupt onset of abdominal pain was found to have a 140-mm multilocular cyst in the spleen and ascites by computed tomography. Peritonitis caused by rupture of the splenic cyst was diagnosed. As blood analysis revealed absence of anemia and her symptoms were mild, she was determined to be a candidate for elective surgery. We performed embolization of the splenic artery followed by laparoscopic splenectomy because the cyst was huge and the splenic artery had significantly dilated. Biochemical study of the cystic fluid as well as preoperative blood analysis showed elevated levels of carbonhydrate antigen (CA) 19-9. Immunohistochemistry revealed positive staining for CA19-9 in the fluid component and squamous epithelial cells in the cyst. Her postoperative course was uneventful. The elevated CA19-9 level was confirmed to drop within reference range by blood examination. Rupture of a CA19-9 producing huge splenic cyst was diagnosed.
CA19-9 producing splenic cyst is so rare that only about 50 cases have been reported in Japan. Among of them, ruptured cases have come to only six, including present case, and here we report our case together with a review of the literature.

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A 32-year-old woman with a previous history of undergoing laparoscopic hysterectomy for cervical cancer was admitted to our hospital because of abdominal pain and vomiting. She had a peritoneal irritation sign in the right lower quadrant of abdomen. Abdominal contrast-enhanced computed tomography showed the distended small intestine with a closed loop and the dilated right ureter which had interrupted at the right lower quadrant. An emergency surgery was performed with the diagnosis of strangulation ileus. Operative findings included a loop of necrotic small intestine obstructed by a constricting band crossing the right pelvic cavity. The band was suspected to be the right ureter, but the strangulation was severe. We had to cut the band to reduce the strangulation and performed segmental resection of the small intestine. The band was proved to be the right ureter, and a repair of the ureter was performed. It was considered that the small intestine invaginated in the back side of the right ureter which was isolated during previous laparoscopic hysterectomy. As we encountered an extremely rare case of strangulation ileus with a ureteric band after gynecologic surgery, we report this case here, with a review of the literature.

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