Background/aims : It is sometimes difficult to diagnose acute appendicitis in emergent setting. Postoperative histopathology discloses the appendix to be lack of inflammation in such cases. We assessed characteristics of misdiagnosed cases as acute appendicitis. Patients and Methods : Between 4/2009 and 10/2012, 25 misdiagnosed cases and 119 cases of pathologically confirmed acute appendicitis were compared for age, gender, clinical symptoms, laboratory data, and CT findings. Results : The misdiagnosed cases were finally diagnosed as diverticulitis (10 cases), colitis (five cases), gynecological diseases (three cases), and pyelonephritis (one case) ; the remaining six cases were undetermined. Between the two groups, no significant differences were observed in age and gender. In the misdiagnosed group, fewer cases had nausea (8.0 vs.33.6%, P=0.01). There were no significant differences in the laboratory data between them. In CT findings, the appendixes in the misdiagnosed group were fewer identified (44.0 vs. 94.1%, P<0.0001). In the misdiagnosed group, the mean diameter of appendixes was shorter (7.1 vs. 9.9mm, P=0.016) and fluid collection in the appendix (27.2 vs. 90.2%, P<0.0001) and ascites (8.0 vs. 55.5%, P<0.0001) were fewer found than in the properly diagnosed group. Conclusion : We could reduce the misdiagnosed cases of acute appendicitis if we pay more attention to the digestive symptoms and CT findings.

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The utility of breast magnetic resonance imaging (MRI) for the detection of microcalcification without other findings was examined. Calcified lesions that were indicated for stereotactic vacuum-assisted breast biopsy (ST-VAB) were divided into two groups (grouped and segmental microcalcifications), and the histopathological findings of the ST-VAB and breast MRI findings were examined. Mammographic examination of 68 patients who were candidates for ST-VAB identified 49 cases of grouped microcalcifications and 19 cases of segmental microcalcifications. Histological examination revealed 24 malignant lesions and 44 benign lesions. Of the 24 malignant lesions, 3 were determined to be invasive ductal carcinoma, 15 were ductal carcinoma in situ, and 6 were border-line lesions. The analysis of 68 MRI findings identified 28 cases of lesions requiring biopsies, and the histological findings of 19 of the 28 cases were malignant, including border-line lesions. In the grouped microcalcification group, MRI sensitivity and specificity were 79% and 77%, respectively, and in the segmental microcalcification group, these values were 80% and 86%, respectively. Of 24 patients, 5 showed negative findings on MRI, but demonstrated border-line lesions on histological examination. These results suggest that ST-VAB may be unnecessary if microcalcification detected by the first breast MRI seems to be benign, and ST-VAB may be indicated when mammography shows that the number of breast microcalcifications increases during the follow-up period.

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An 83-year-old woman was evaluated at our hospital for a painful mass in her right breast that she noticed two weeks earlier. The preoperative diagnosis was infiltrating ductal carcinoma of the breast (T2N0M0, Stage IIA). A right mastectomy and sentinel lymph node biopsy were performed. The final histopathologic diagnosis was spindle cell carcinoma of the breast (ER 0, PgR 0, HER2 score 0, Ki-67 labeling index 30-40%).
The patient and her family did not want any postoperative adjuvant therapy. She was discharged on postoperative day 7, but on day 18, she was re-evaluated for a chief complaint of malaise. Contrast CT showed multiple lung, liver, and lymph node metastases. The patient had a rapidly downhill course and died 30 days after surgery.
Spindle cell carcinoma of the breast is a rare subtype of infiltrating carcinoma, and there is no uniform consensus regarding its prognosis. This case of spindle cell carcinoma of the breast with a rapidly downhill course is reported.

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The case of a patient with a fibroadenoma who then developed primary pure squamous cell carcinoma (SCC) of the breast is reported. This 52-year-old woman was being followed at our department for a previous fibroadenoma. She noticed that the mass was enlarging and was re-evaluated. Ultrasound of the mass showed a partial cystic component in the mass, and needle biopsy confirmed a diagnosis of SCC.
Breast-conserving surgery and sentinel lymph node biopsy were performed. The histopathologic diagnosis was a pure SCC without an adenocarcinoma component. Fibroadenoma-like lesions were seen surrounding the tumor, and it was thought to be a cancer within the fibroadenoma. SCC arising within a fibroademona is rare. This case is reported along with a discussion of the relevant literature.

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A 58-year-old woman had silicone breast implants (SBIs) placed under the pectoralis major muscles for breast augmentation about 25 years earlier. She now felt a mass in her left breast, and after further evaluation, she was diagnosed with left-breast cancer (cT2N0M0, Stage IIA). Since preoperative ultrasound and MRI showed SBI degradation, the SBI was removed together with the breast + sentinel node, and a tissue expander was inserted for primary two-stage reconstruction. There was marked silicone gel bleeding from the SBI, with gel adhered to the surrounding tissues, but there was no other damage, infection, or foreign-body granulomas.
SBIs often deteriorate over many years, but many patients who have breast augmentation are not followed-up regularly. In addition, since SBIs are covered by insurance for breast reconstruction, the number of patients with SBIs who are seen on an outpatient basis is increasing. Therefore, patients with SBIs should undergo appropriate imaging studies, and if there are abnormal findings, they should be referred to a plastic and reconstructive surgeon for removal and other appropriate care.

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This 67-year-old woman had a history of surgery for rectal cancer and liver metastases. About 1 year 5 months previously, she was found to have liver metastases with invasion into the inferior vena cava (IVC), and a partial hepatectomy, together with resection and reconstruction of the IVC, was performed. The patient now presented with abdominal distention, and she was admitted to the hospital with bowel obstruction. CT showed that the vascular graft used for IVC reconstruction had migrated into the small bowel in the lower abdomen. Emergency surgery was performed by the diagnosis of bowel obstruction.
The small bowel was opened, the vascular graft within the bowel was removed, and then the small bowel wall was closed by suturing. Upper GI endoscopy after surgery showed a duodenal ulcer scar, thus suggesting that the vascular graft migrated from the duodenum into the small bowel, thus causing bowel obstruction. Bowel obstruction caused by migration into the small bowel of a vascular graft used for IVC reconstruction has not previously been reported. Thus, this case is reported with the literature review.

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A 34-year-old man visited a hospital complaining of chest pain which appeared during baseball practice. Chest X-ray film revealed pulmonary collapse and hemopneumothorax in the left lung. A chest tube was inserted. He was brought into our hospital because the bloody discharge persisted that appeared to require surgical therapy. So thoracoscopic emergency operation was performed with the diagnosis of left hemopneumothorax. Removal of hematoma disclosed two torn pleural adhesion bands showing bleeding in the thoracic apex, and another bleeding point which was present near the superior intercostal vein. We coagulated all three bleeding points by video-assisted thoracic surgery, and diagnosed the case as spontaneous hemopneumothorax. The post-operative course was uneventful, and he was discharged on the 3rd postoperative day. Emergent operation is recommended for spontaneous hemopneumothorax, and it is very important to search the thoracic cavity thoroughly to detect all bleeding points.

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Schwannoma is a benign tumor which can occur in all sites where peripheral nerves exist. Shwannomas which occur in the head, neck, and chest wall are well known. But those which occur intrapulmonary and/or in the bronchus are extremely rare, accounting for only 0.2% of all pulmonary tumors. This time, we have experienced two cases of an intrapulmonary shwannoma, in the peripheral lung field and in the segmental bronchus, treated with surgical resection. Both schwannomas affected the left upper lobe of lung. One had arisen in the peripheral lung field, whereas another in the vicinity of the segmental bronchus. We report these cases, together with a review of 79 cases, including ours, of intrapulmonary schwannoma from the literature.

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An 82-year-old woman was admitted to our hospital because of repeated nausea and vomiting for a week. An upper gastrointestinal endoscopy revealed convergence of the stomach mucosa. Additionally, a computed tomography scan showed an upside-down stomach, which is an esophageal hiatus hernia, complicated by gastric volvulus. The hernia sac contained most of the stomach, transverse colon, and omentum. Because conservative therapy using a nasogastric tube or upper gastrointestinal endoscope failed, emergency surgery was performed via laparotomy with a hypochondrial incision. The stomach was incarcerated by the esophageal hiatus, tightly restricting the body and pylorus. The incarcerated organs were reduced by making an incision in the esophageal hiatus ; however, the stomach could not be preserved because the gastric wall was severely damaged. Therefore, distal gastrectomy and Billroth I reconstruction were performed. The hernia sac was resected, and the esophageal hiatus was repaired directly with interrupted sutures. No esophageal regurgitation occurred after the operation without any additional procedures such as fixation of the gastric wall or fundoplication. Although gastric volvulus is relatively rare in adults, most cases of acute onset or incarceration require emergent surgery, occasionally with gastrectomy, as in the present case.

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A 37-year-old man who was detected to have a submucosal tumor of the stomach during a medical checkup was referred to our hospital. The tumor increased in size during follow-up, and on endoscopic ultrasonography, the tumor changed with time from a homogeneous hypoechoic tumor to a heterogeneous hyperechoic tumor. Fine-needle aspiration biopsy (FNA) was performed, but failed to diagnose the tumor, therefore we decided to perform resection surgery for both diagnosis and treatment. Since the tumor was very close to the pyloric ring, we performed laparoscopic distal gastrectomy. Histopathological examination revealed a glomus tumor of the stomach. Glomus tumor of the stomach is very rare and is difficult to diagnose before surgery, however, it has some characteristic features such as its preferred location, namely, the tumor occurs predominantly at the antrum, and its strong enhancement on contrast-enhanced CT because of its hyper vascularity. An understanding of the tumor characteristics may help in the differential diagnosis of submucosal tumors of the stomach and in arriving at appropriate treatment decisions.

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Multiple sporadic gastrointestinal stromal tumors (GISTs) are rare excepting those restricted to von Recklinghausen disease or hereditary conditions. We report a case of a duodenal GIST resected 9 years after resection of a gastric GIST without hereditary nature. The patient was a 75-year-old woman who had been followed up annually with CT examination after pylorus preserving gastrectomy for a gastric GIST at the age of 66. A 20-mm solid tumor was detected in the horizontal part of the duodenum by CT examination 9 years after the stomach surgery. The tumor was diagnosed as a duodenal GIST by a boring biopsy, and we performed wedge resection of the duodenum. The cell type of these GISTs was spindle, and both tumors were positive for c-kit. However, these GISTs showed different stainabilities for CD34 and αSMA, and c-kit gene mutations were different between these GISTs. Therefore, we diagnosed these GISTs to be sporadic multiple GISTs. Because the duodenal GIST entails a very low risk, the patient has been followed up periodically without adjuvant therapy. We should follow the clinical course of GIST by keeping a possibility of the multiple sporadic occurrence in mind.

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A 60-year-old man presenting with severe anemia was referred to our hospital. Abdominal CT showed a well-demarcated and enhanced tumor growing in the lumen of the intestine, in the left-side of the superior mesenteric vessels, measuring approximately 5.0 cm in diameter. Upper gastro-intestinal endoscopy revealed a submucosal tumor with mucosal ulceration. Duodenography showed the tumor in the third portion of the duodenum. From these findings, we diagnosed the tumor as a submucosal tumor of the duodenum, and performed totally laparoscopic resection with duodenojejunostomy by functional end-to-end anastomosis. The operative time was 238 minutes and the estimated blood loss was 75 ml. The patient had an uneventful post-operative course and was discharged on the 10th postoperative day. Histological examination revealed that the tumor was GIST with low-grade malignancy originating from the duodenum.
Laparoscopic duodenectomy, considering the site and size of the tumor, should be a treatment option even for GIST located in the duodenum from the aspects of the less invasiveness and cosmetic benefit, if the safety surgical margin is secured and the organ function can be preserved.

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An 83-year-old woman presented to the emergency department with a 3day history of upper abdominal pain. Computed tomography (CT) scanning showed a cyst-like mass that was 60×45 mm in size and communicated with the small intestine. The CT scan also showed free air around the mass and the surface of the liver. We diagnosed the case as peritonitis caused by perforation of the mass, and an emergency operation was performed. On laparotomy, the cyst-like mass was located 250 cm proximal to the ileocecal valve and was found to be arising from the mesenteric vessels of the native jejunal segment. Although the perforated site was not identified, we diagnosed the perforation of the mass because it was covered with pus. Partial jejunectomy including the mass was performed. Pathological examination revealed that the cyst-like mass was a true diverticulum because the wall contained all of the layers of the intestine and each structure was continuous with the jejunal structure. The abscess was found in the muscle layer, and it perforated the serosa. Therefore, we diagnosed the case as peritonitis caused by perforation of the jejunal duplication. Thus, we report a rare case of jejunal duplication with perforation in an adult.

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A 29-year-old woman visited our hospital complaining of periumbilical pain. Abdominal contrast-enhanced computed tomography revealed intussusception. During enema, the intussusception was reduced, and a neoplastic lesion (approximate diameter, 3 cm) was revealed on the side contralateral to the Bauhin valve. Surgical treatment was considered because of intussusception relapse on the following day and a suspected neoplastic lesion in the cecum. Laparoscopic surgery was performed. Bacause observation from the serosal side and palpation with forceps did not allow the surgeon to determine whether the lesion was neoplastic, the ileocecum was resected. Pathological examination revealed no evidence of parenchymal disease ; therefore, a diagnosis of adult idiopathic intussusception was made. In this case, we limited our intervention to careful observation because of the two-stage operation and avoided bowel resection because parenchymal lesion was excluded based on postoperative lower gastrointestinal endoscopy.

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Cancer arisen in an ileostomy is rare and no previous reports on chemotherapy for liver and lung metastases of the ileostomy cancer have been seen. We have resected cancer arisen in an ileostomy after excision of total colon and rectum and performed chemotherapy for postoperatively appeared liver and lung metastases. The case involved a man in his fifties who underwent total colectomy with a diagnosis of adenomatous coli and colorectal cancer at the age of 27 ; followed by rectal amputation and ileostomy for cancer of the rectal remnant at the age of 35. In 2009, he was diagnosed as having cancer of the ileostomy and underwent removal of the ileostomy and re-creation of an ileostomy. Metastases to the liver and lung were confirmed 2 months after the operation. Because an immunohistochemistry of the primary tumor revealed intestine-type adenocarcinoma, we employed chemotherapy in accordance with colorectal cancer that resulted in disappearance of the lesions. The chemotherapeutic effect was once rated as CR. No consensus of chemotherapy for small bowel carcinoma has been established as yet. Here we present an employment of chemotherapy for ileostomy cancer in accordance with colorectal cancer considering its mucin producing pattern, with which we could have a certain effect.

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A 65-year-old man who was referred to our hospital for intestinal obstruction was diagnosed as having cecal cancer following a colonoscopy. A contrast study through the ileus tube revealed an ileocecal tumor, and the small intestine was located on the right side of the abdomen. An abdominal enhanced computed tomography (CT) scan revealed a superior mesenteric vein (SMV) rotation sign. 3D-CT angiographic findings showed that the ileocolic artery (ICA) branched from the left side of the superior mesenteric artery (SMA) and was running ventral to the SMV. The patient underwent laparoscopic-assisted colectomy based on a diagnosis of cecal cancer with intestinal malrotation. The origins of the ICA were dissected for D3 lymph node dissection. It is important to understand the abnormal anatomy, the site of the tumor, and the path of the vessels using 3D-CT angiography when performing surgery for diseases in patients with intestinal malrotation and when performing laparoscopic-assisted surgery.

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This 70-year-old man was evaluated at our hospital for chief complaints of lower extremity edema and diarrhea. Laboratory tests showed anemia and hypoalbuminemia, and further evaluation revealed a circumferential type 2 tumor of the ascending colon at the hepatic flexure and fistula formation into the descending duodenum. CT and MRI also showed pancreatic invasion. The patient was diagnosed with ascending colon carcinoma accompanied by a duodenocolic fistula, and right hemicolectomy and pancreatoduodenectomy (PD) were performed. The histopathologic diagnosis was pT4b (pancreas, duodenum), muc>tub1, pN0, pStage II.
The patient was treated with FOLFOX4 as postoperative adjuvant chemotherapy for 6 months. Currently, 16 months after surgery, there has been no recurrence. In colon cancer, even with invasion into other organs, complete resection may be recommended. In patients with colon cancer and duodenal invasion, PD, although highly invasive, may improve the prognosis.

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A 21-year-old woman visited a neighborhood clinic with the chief complaints of abdominal pain, constipation, and diarrhea. She visited our hospital when her symptoms became worse. Abdominal CT showed wall thickening of the transverse colon and a right ovarian tumor. Colonoscopy showed a circular stenotic lesion of the transverse colon. A trans-anal decompression tube was inserted to relieve the intestinal pressure. Laparoscopic partial colectomy for transverse colon cancer and right oophorectomy were performed. The histopathological diagnosis was signet-ring-cell carcinoma and metastatic ovarian tumor from colorectal cancer. The patient refused to undergo chemotherapy and left oophorectomy. She was detected as having peritoneal carcinomatosis 8 months postoperatively and died 5 months thereafter.

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Case 1 involved a 74-year-old man with a several-day history of appetite loss presented to the Critical Care Center in our hospital because of the abrupt onset of abdominal pain. A contrast-enhanced abdominal CT scan showed a tumor in the transverse colon at the splenic flexure and its direct invasion into the stomach. Colonoscopy revealed a tumor of the transverse colon completely encircled the colon. Upper gastrointestinal series revealed infiltrating findings of an extramurally growing tumor in the middle portion of the gastric body. A biopsy of the colon showed poorly differentiated adenocarcinoma. Cancer of the transverse colon with a resultantly caused gastrocolic fistula was diagnosed. Left hemicolectomy and segmental resection of the stomach were performed.
Case 2 involved an 87-year-old man with a 2-week history of appetite loss and right upper quadrant pain. He visited a neighboring hospital and was referred to our hospital with a suspicion of an intraabdominal tumor. A contrast-enhanced abdominal CT scan showed a tumor in the transverse colon at the hepatic flexure. Upper gastrointestinal series showed infiltrating findings of an extramurally growing tumor at the pyloric antrum. A biopsy of the colon revealed poorly differentiated adenocarcinoma. Cancer of the transverse colon with a resultantly caused gastrocolic fistula was diagnosed. Right hemicolectomy and distal gastrectomy were performed.
We present these two cases of cancer of the transverse colon causing a gastrocolic fistula.

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A 16-year-old girl who had had mental retardation since her childhood, visited the hospital complaining of lower abdominal pain developed after ingestion of and anal insertion of a magnet. Magnets were observed in the rectum, but transanal extraction of them was considered difficult. Small intestinal/rectal fistula caused by two magnets was diagnosed from computed tomography (CT) findings. The magnets were expected to be eliminated spontaneously, and conservative therapy was selected. However, the magnets were not excreted spontaneously, and therefore the patient underwent laparoscopic extraction of them on day 20. Two magnets had been attracted to one another and formed a single mass, which was present on the small intestine side submucosa. Because the fistulous lesion at the rectal wall had been cured, the magnets could only be extracted by partial resection of the small intestine. Ingested magnet can cause halation on CT that may make accurate assessment of the location of the magnet difficult. Spontaneous elimination of the ingested magnet does not often take place, so observation of the course must be selected carefully. In this case, delayed surgery enabled extraction of the magnets without giving rectal injury, because the rectal wall had been cured and closed while the magnets retained on the small intestine side.

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A 63-year-old man was admitted to our hospital with the chief complaint of constipation. A rectal digital examination revealed an elastic hard mass located in the posterior wall of the rectum. Colonoscopy showed a submucosal tumor measuring 60 mm in diameter in the lower rectum above the dentate line, near the anal canal. Dynamic CT revealed a rectal tumor measuring 61×59mm in size displacing the lower rectum forward. There was no evidence of either lymph node or distant metastasis. MRI showed the membrane-covered tumor extending to the levator ani muscle bilaterally. A biopsy specimen was positive for CD34 and c-kit (CD117). The Ki-67/MIB-1 index of the tumor cells was 10.7%. Based on the findings, the tumor was diagnosed as a rectal GIST. The patient desired anal preservation, therefore, preoperative imatinib mesylate (IM) therapy was selected. IM was administered at the dose of 400 mg once daily. After 6 months of IM therapy, CT and MRI revealed a decrease of the maximal diameter of the tumor to 45 mm (33% reduction). Seven months after the initial diagnosis, laparoscopic inter-sphincteric resection (ISR) was performed, including partial external sphincter resection and temporary ileostomy, and the anal sphincter muscle was successfully preserved.

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A 50-year-old woman who presented with melena was diagnosed with a liver tumor by ultrasonography. Upper gastrointestinal endoscopy revealed multiple nodules in the gastric body, which were diagnosed as gastric carcinoids by biopsy. Colonoscopy revealed a rectal tumor (Ra lesion) that was diagnosed as both adenocarcinoma and neuroendocrine carcinoma (NEC) by biopsy. Computed tomography revealed para rectal lymph node metastases and a 60-mm tumor in the right liver lobe (S4). Furthermore, neuron-specific enolase levels were increased to 45.8 ng/ml. Low anterior and partial liver resections (S4) were performed. Histopathological examination confirmed the rectal and liver tumors to be NECs with a high mitotic rate and Ki-67 labeling index. Immunohistochemical staining for chromogranin, synaptophysin, and CD56 was positive. A final diagnosis of rectal NEC with liver metastasis comorbid with G1 gastric carcinoids was made according to the WHO classification. The patient remains recurrence-free 1 year after surgery. Herein, we report the first case, to our knowledge, of rectal NEC with liver metastasis comorbid with gastric carcinoids, and we discuss the relevant literature.

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We report long-term survival in a case of rectal cancer with multiple remote lymph node metastases treated via a multidisciplinary approach, including surgery.
A 71-year-old man was admitted to our hospital with positive fecal occult blood. Upon further examination, we diagnosed rectal cancer with multiple, remote lymph node metastases, including in the Virchow, mediastinal, and para-aortic lymph nodes.
In April 2011, we started chemotherapy with FOLFIRI and panitumumab. After two courses, we observed penetration in the necrotic area of the tumor associated with tumor shrinkage, and the patient underwent a colostomy. After seven courses of neoadjuvant chemotherapy, we conducted high anterior resection in August 2011 because of obvious tumor shrinkage and disappearance of the metastatic lymph nodes. Histological examination of the resected specimens showed moderately to poorly differentiated adenocarcinoma, SE, ly2, v1, N1, H0, P0, Stage IIIa. We administered adjuvant chemotherapy for 12 courses, but we observed further disease in the para-aortic lymph node on positron emission tomography (PET) computed tomography (CT) examination. In March 2012, we performed a para-aortic lymph node dissection and colostomy closure. Histological examination of the resected specimens showed rectal cancer metastasis. We administered mFOLFOX-6 and bevacizumab for 12 courses from June 2012, because multiple para-aortic lymph node metastases were observed on the PET-CT examination. The patient refused continued chemotherapy in August 2012 ; however, he is alive without recurrence for 3 years and 3 months.

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Unresectable superficial malignant tumors, such as skin cancer or skin metastases from all kinds of cancer, cause exudate, bleeding, odor, and pain. It is difficult to control these symptoms, and they reduce patients' quality of life. Mohs chemosurgery was originally used as treatment for skin cancer by fixing tissues with Mohs' paste, including zinc chloride. Recently, in Japan, it has been used not only for skin cancer, but also to treat several symptoms associated with unresectable superficial malignant tumors, and the effectiveness of this treatment has been frequently reported.
Herein, we report a case of a 63-year-old man with bleeding from a local recurrence of rectal cancer after surgical resection, who was effectively treated with Mohs chemosurgery.

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Liver abscess caused by Clostridium perfringens is very rare, but its clinical course can be fulminant and fatal. An 84-year-old woman, who had undergone pancreaticoduodenectomy for bile duct cancer twelve years earlier, was seen at the emergency clinic in our hospital for shaking chills and fever. An abdominal computed tomography revealed a low density area containing gas in the segment 5 of the liver. After admission, she developed abdominal pain and the liver abscess enlarged rapidly on enhanced CT. Laboratory data showed extremely high inflammatory response and intravascular hemolysis. The pathogene of the liver abscess was judged to be an aerogen. Because systemic antibiotics treatment was ineffective, percutaneous transhepatic abscess drainage was performed. Gram stain of the drainage content fluid demonstrated gram-positive rods and we suspected of Clostridium perfringens infection. Despite the drainage and antibiotics, intravascular hemolysis took downhill course and the patient went into shock with multiple organ failure. Finally, she died twenty hours after admission. Clostridium perfringens was identified from cultures of the blood and the drainage fluid after her death.

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A 72-year-old woman was referred to our hospital with the complaints of right upper quadrant pain and dyspnea on effort. She was diagnosed as having a solitary liver cyst measuring 14 cm in diameter and treated by laparoscopic deroofing of the cyst. The vessel sealing system LigaSure blunt-tip 5 mm (Ligasure) was used for this operation, because we had experienced bile leakage from the laparoscopic fenestration carried out using an ultrasonically activated scalpel in a previous case. Owing to the slim shaft, good grasp, and long processing stroke of this device, the surgery could be carried out uneventfully. Histopathology showed no evidence of luminal structure sealing, but showed that the denatured tissue at the resection stump sealed by Ligasure was of higher density and showed a wider extent of sealing as compared to that in the previous case in which an ultrasonically activated scalpel had been used and bile leakage had occurred. Hence, Ligasure is thought to be a useful device for secure coagulation and dissection in laparoscopic deroofing of liver cysts.

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We report a case of hepatocellular carcinoma with Child-Pugh A class liver disease associated with marked retention on the ICG test (retention rate at 15 min [R15], 74.9%). A 66-year-old man was admitted to our hospital with the chief complaint of right shoulder pain. Abdominal CT and MRI showed two tumors, one measuring 11.5 cm in diameter located in segment 5-7-8, and the other measuring 1.3 cm in diameter located in segment 6. After transcatheter arterial chemoembolization, right hepatectomy with resection of the diaphragm was performed, without postoperative complications. In HCC patients with constitutional ICG excretory defect, which is defined as a disproportionately high ICG R15, the treatment decision may be difficult. It is important to estimate the preoperative liver function by other examinations and determine the extent of surgical resection for radical operation without facile abandonment of surgical treatment.

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An 81-year-old man presenting intrahepatic bile duct dilatation on ultrasound was referred to our department with a diagnosis of hilar cholangiocarcinoma originated from the right hepatic duct. Preoperative radiographic assessments suggested no remarkable anomalies in the intrahepatic vascular structures. The patient was considered to be a candidate for surgical resection because his estimated percentage remnant liver volume was 47%, however, he was found to have anomalous right-sided ligamentum teres hepatis at laparotomy. The bile duct for the region just right side of the umbilical fissure had been involved by the tumor and needed to be resected. However, due to decreased hepatic functional reserve, extended resection was considered to be risky for this patient. Therefore, hepatic parenchyma of the corresponding area was preserved with patient blood flow sacrificing the biliary drainage. R0 resection was achieved and there was no clinical evidence of postoperative hepatic insufficiency or bile leak.

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A female patient in her thirties who had been followed after operation for a pancreatic neuroendocrine tumor presented to our department because of a left breast tumor. Digital examination and palpation revealed an about 2-cm palpable tumor in the AC area of the left breast. Echography of the breast revealed a 21×18×17mm irregular-shaped, ill-defined and hypoechoic tumor. Fine needle aspiration cytology biopsy from the same site resulted in class V, suggestive of dudtal carcinoma. However, an abdominal CT scan showed multiple swollen lymph nodes in the abdominal cavity. From her clinical course, recurrence of the pancreatic tumor was likely, and the breast tumor was suspected to be the metastatic lesion. Ultrasonography-guided Vacora biopsy was performed. The histopathological diagnosis was neuroendocrine tumor. Breast metastasis was strongly suggested, but a possibility of neuroendocrine tumor of the breast could not be ruled out, and excisional biopsy was performed. No ductal lesions were present in the excised tumor. Breast metastasis of pancreatic neuroendocrine tumor was thus diagnosed.
As we experienced a case of a pancreatic neuroendocrine tumor with breast metastasis which is rare and was difficult to diagnose, we report the case here.

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A 78-year-old man was admitted to the hospital because of appetite loss and general fatigue. He was diagnosed as having diffuse large B-cell cell lymphoma following bone marrow examination. Three days after the start of steroid therapy, he experienced upper abdominal pain and a sudden decrease in blood pressure.
A high-absorption region and extravasation in the upper abdominal cavity were observed on a computed tomography scan. Splenic rupture or bleeding from the short gastric artery was suspected. The patient underwent splenectomy to treat a rupture in the upper spleen. Fourteen days after surgery, he was transferred to hematology department without complications. In spite of starting chemotherapy (R-CHOP), the patient's condition worsened, and he died 75 days after surgery. Patients with malignant lymphoma should be carefully followed up to help avoid splenic rupture.

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A 75-year-old man underwent total gastrectomy for gastric cancer invading the mesenterium with partial resection of the small intestine and transverse colon accompanied by splenectomy and cholecystectomy in February 2013. The disease was determined as Stage IIIC(T4a, N3, M0, P0, CY0, H0).
Postoperative adjuvant chemotherapy was administered for 6 months with TS-1 and docetaxel (DTX). Increase of the serum tumor marker levels was detected at 10 months after the surgery. Abdominal CT revealed findings suggestive of a right adrenal metastasis. Despite resumption of chemotherapy with TS-1 and DTX, the diameter of the adrenal metastasis increased to 36 mm by 17 months after the surgery. PET CT showed accumulation with an elevated standardized uptake value (SUV) only in the right adrenal metastasis. The patient was diagnosed as having isolated right adrenal metastasis, and laparoscopic right adrenalectomy was performed. Histological examination revealed findings consistent with adrenal metastasis from gastric cancer. The patient was followed up with CPT-11 treatment and did well without recurrence or metastasis. We report a rare case of laparoscopic adrenalectomy performed for solitary adrenal metastasis from gastric cancer.

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Herein, we report a case of a leiomyosarcoma arising from the left ovarian vein, which is extremely rare. A 65-year-old woman was referred to our hospital because of a palpable mass in her left lower abdomen. The pre-operative diagnosis was left ovarian cancer or leiomyosarcoma of the ovarian vein. The operative findings revealed that the ovary was obviously normal and the left ovarian vein was involved by the mass. We resected the mass and the left ovary. Histopathological findings revealed that the tumor was connected to the left ovarian vein, and immunohistochemical staining demonstrated that the tumor cells expressed smooth muscle cell antigens, such as smooth muscle actin and desmin, but they showed no staining for S-100, CD34, or c-kit. As a result, a diagnosis of leiomyosarcoma was made. The postoperative course was uneventful and the patient has had no recurrence after 6 months.

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Schwannomas occur in peripheral nerves mainly in the upper and lower limbs. We treated a patient with a schwannoma in a very rare location, the rectus abdominis muscle. A 53-year-old woman noted an abdominal wall mass in the left lower quadrant and was referred to our hospital for further evaluation. Abdominal ultrasonography showed a 4-cm hypoechoic mass adjacent to the rectus abdominis muscle. Enhanced CT scan of the abdomen demonstrated gradual enhancement of the tumor. Abdominal enhanced MRI scan showed heterogeneous enhancement in T1-weighted images and heterogeneously high intensity in T2-weighted images of the tumor. A desmoid tumor of the abdominal wall was first suspected and excision of the tumor was planned. The operation proceeded without difficulty with resection of the mass including a partial resection of the rectus abdominis muscle. The tumor was diagnosed as a schwannoma by histopathological findings without evidence of malignancy. Schwannomas arising from the rectus abdominis muscle are very rare and so far six cases have been reported, but we should consider this disease when evaluating a mass of the rectus abdominis muscle.

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A 49-year-old woman was found to have a tumor behind the pancreas by abdominal ultrasonography. Abdominal CT showed a solitary tumor measuring 20 mm in diameter, to the right anterior side of the superior mesenteric artery (SMA). Laparoscopic tumor resection was performed based on the preoperative diagnosis of schwannoma. Intraoperatively, the tumor was found to be in proximity to the superior mesenteric plexus, and resected. Histopathologic examination of the tumor revealed that it was composed of spindle cells. Immunohistologically, the tumor cells were positive for S-100 protein and negative for c-kit, CD34 and α-SMA. The tumor was definitively diagnosed as a schwannoma arising from the superior mesenteric plexus. At present, 7 months since the operation, the patient remains alive without recurrence.

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The patient was a 76-year-old man who had been injured when his two-ton fishing boat collided with a ten-ton ship. When he was seen at our hospital, he presented with hypotension, tachypnea and an about 2-cm laceration at the left perineal region. Furthermore he complained of chest pain and bilateral gluteal pain ; and a soft tumor was palpated at the left inguinal region. Contrast-enhanced CT scan of the whole body revealed right hemopneumothorax, multiple fractures of the right ribs, multiple pelvic fractures, hepatic subcapsular injury, intraperitoneal free air, and a left inguinal hernia. In addition an efflux of contrast material from the vessels to the outside structure was observed from the left gluteal region to the abdomen. From these findings, pelvic fractures and traumatic bowel injury were diagnosed. Emergency operation was performed after embolization of the involved vessels and right thoracic drainage. At surgery, we confirmed that the abdominal cavity and the inside of the hernia sac had been contaminated with stool juice and a ruptured sigmoid colon was present. The abdominal cavity was irrigated, the sigmoid colon was partially resected, and an end-to-end anastomosis was done. The internal inguinal ring was simply closed from the abdominal cavity and a drain was placed in the hernia sac through the perineal laceration. As traumatic rupture of the sigmoid colon within the inguinal hernia is very rare, this case is presented together with a review of the literature.

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We present two cases of postoperative perineal hernia repaired by using Bard^® Composix mesh.
Case 1 involved a 68-year-old woman who underwent laparoscopic excision of the rectum for rectal cancer. From six weeks on after the operation, a bulge appeared in the perineum, and perineal hernia was diagnosed. Laparoscopic radical repair for the hernia was performed by using a Bard^® Composix mesh. No recurrence of the hernia has occurred as of 2 years and 10 months after the repair.
Case 2 involved a 67-year-old woman who underwent laparoscopic excision of the rectum and reconstruction using a left musculocutaneous latissimus dorsi free flap for a huge anal canal cancer. From five months on after the operation, she became to have a feeling that something was wrong when she sat. CT scan revealed a myoma of the uterus to have fallen in the floor of the pelvis. Perineal hernia was thus diagnosed. We performed hysterectomy and the plastic operation of the pelvic floor by using the same mesh under laparotomy. No recurrence of the hernia has occurred as of 9 months after the repair.
Radical perineal hernia repair by using the mesh is considered to be a useful operative procedure.

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