Purpose : We evaluated nutritional status following pancreaticoduodenectomy (PD) in terms of fatty liver development and primary disease recurrence.
Methods : Following PD, 34 patients were divided into a fatty liver group (FLg) and a non-fatty liver group (NFLg). We assessed albumin and total protein levels as well as the psoas muscle area via computed tomography.
Results : Over a median observation period of 12 months, 8 cases (23.5%) developed a fatty liver. The rate of primary disease recurrence was the same in the FLg and NFLg, and there was no difference in preoperative, intraoperative, or postoperative factors between the two groups. In the NFLg, albumin and total protein levels after PD were not different from their preoperative values, while significant decreases were observed in the FLg. After PD, the psoas muscle area decreased in both groups, with a greater reduction in the FLg than in the NFLg. Regarding primary disease recurrence, the post-PD psoas muscle area reduced significantly in patients with recurrence but not in those without recurrence.
Conclusion : Loss of muscle and nutritional deterioration was observed in patients with a fatty liver or primary disease recurrence after PD, and nutritional support was considered important for improving prognosis and quality of life.

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Angiosarcoma is a rare disease and it extremely rarely involves the gastrointestinal tract. Here we report a very rare case of angiosarcoma presented with intestinal perforation. An 83-year-old man was referred to our hospital because of upper abdominal pain and was diagnosed with generalized peritonitis due to intestinal perforation. Then an emergency laparotomy was performed. Upon laparotomy, a tumor 2cm in diameter was present at the jejunum near the Treitz ligament, and the center of which had perforated. Similar gastrointestinal tumors were felt in the stomach, small intestine, and descending colon. We removed all lesions and reconstructed with the parts as possible as we could. The mucosa surface of the all resected tumors showed a type 2 tumor like appearance having a necrotic ulceration in the center of a brown bump. The immunohistochemical staining which were positive for factor VIII, CD31 and CD34 indicated the diagnosis of angiosarcoma. He was complicated by postoperative ileus and gastrointestinal bleeding, and finally died of respiratory failure resulting from pneumonia 47 days after the surgery. A biopsy of the forehead rash which has been presented since two years before was performed often surgery and offered a diagnosis of angiosarcoma. An autopsy revealed metastases to the lung lobes and liver. It would suggest that the primary angiosarcoma of the forehead rash had spread to the whole body.

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Although crycothyroidotomy is often used to obtain an airway in treating patients with trauma or those in whom endotracheal intubation is impossible, we have used this procedure for two patients with respiratory failure due to head and neck cancer, with favorable outcomes. Case 1 involved a 59-year-old man who developed respiratory failure due to pulmonary aspiration caused by abrupt onset of massive bleeding from a locally recurred lesion of pharyngeal cancer. Endotracheal intubation was done. Since the cervical lymph node metastasis had invaded from the anterior cervical region to the caudal side skin of the cricothyroid ligament, tracheotomy was considered to be hazardous. Accordingly cricothyroidotomy was performed. After discharge, he spent times at home until his death. Case 2 involved a 70-year-old man who developed respiratory failure because undifferentiated thyroid cancer had invaded the trachea. He had to be managed by transnasal endotracheal intubation for artificial respiration under sedation. We performed crycothyroidotomy to escape from the artificial respiration. We aimed at home care, however, his cachexia gradually progressed and he died in our hospital.
In instances in which we have lost the time of tracheotomy like our cases, crycothyroidotomy can be performed as a palliative therapy that might serve to stabilize respiratory status.

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A 46-year-old premenopausal woman was found to have an abnormality on a breast ultrasound examination during her company checkup, and she came to our department for detailed examination. A lobulated mass lesion was observed in her inferior medial right breast, and she underwent follow-up observation. Two and a half years later, an architectural distortion was discovered on mammography. Since only an atypical lobule was observed on needle biopsy, a diagnosis could not be made, and an incisional biopsy was performed. The tissue diagnosis was tubular carcinoma ; nearby, columnar cells and non-invasive lobular carcinoma were observed. Pathologically, the findings included the triad of tubular carcinoma of the breast, columnar cells, and non-invasive lobular carcinoma coexisting together, which have been proposed as constituting the Rosen triad. The present case was diagnosed as tubular carcinoma of the breast with the Rosen triad. With the introduction of mammography for breast cancer screening, there has been an increase in the discovery of low-grade breast cancer cases, and pathological diagnosis has become more difficult, but the presence of this triad can be a basis for a definitive diagnosis of tubular carcinoma. Reaching a definitive diagnosis clinically enables determination of a treatment strategy and prediction of the prognosis, and therefore it is useful to have recognized the Rosen triad.

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A 44-year-old woman was admitted to the hospital because of a rapidly enlarging mass in the right breast. A well-demarcated tumor measuring 9.0×7.0 cm was noted, mainly in the outer quadrants of the right breast. A core needle biopsy revealed findings suggestive of a borderline phyllodes tumor. Simple mastectomy and axillary lymph node sampling were performed under the tentative diagnosis of phyllodes tumor. Histopathological examination of the resected specimen revealed that the tumor was a borderline phyllodes tumor, with coexisting ductal carcinoma in situ and lobular carcinoma in situ. Ours is the first case report from Japan of ductal carcinoma in situ and lobular carcinoma in situ arising in a phyllodes tumor. While it is an extremely rare occurrence, phyllodes tumor can be associated with breast carcinoma, therefore, serial sectioning of the specimen is recommended.

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A 74-year-old man who felt chest pain but let it alone 4 days earlier had chest pain again and was brought into our hospital by ambulance because of cardiogenic shock. Emergency coronary angiography (CAG) revealed complete occlusion of the left circumflex coronary artery (#13). Echocardiography showed thinning posterolateral wall of the left ventricle and large volumes of pericardial effusion. Acute myocardial infarction and cardiac tamponade due to left ventricle free wall rupture were diagnosed. Since several days had elapsed after the onset of the disease, percutaneous coronary intervension (PCI) appeared to entail a risk of reperfusion injury. We did not employ PCI and immediately performed pericardial drainage for cardiac tamponade. We could get through the acute stage with only conservative therapy, but echocardiography conducted 3 months later disclosed a 30-mm diameter left ventricular pseudoaneurysm at the posterolateral wall of the left ventricle. We were worry about rupture of the aneurysm and performed surgical left ventricular reconstruction and coronary artery bypass grafting as early as possible. The pseudoaneurysm comparatively firmly adhered to the surroundings and thrombus was present within the aneurysm.
Left ventricle free wall rupture (oozing type) requires not only treatment in the acute stage but also careful follow-up using echocardiography in the chronic stage by keeping a possible occurrence of ventricular pseudoaneurysm in mind. It is important to perform surgery as early as possible if a ventricular pseudoaneurysm occurs.

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We report the case of a 4-year-old male with an antenatally detected superior mediastinal mass that remained stable in size. Because no aberrant artery could be detected by preoperative CT, differential diagnosis between congenital cystic lung disease and mediastinal tumor was difficult. We performed thoracoscopic-assisted surgery for resection of the mass. Intraoperative findings revealed a extra-lobar pulmonary sequestration with a thin aberrant artery measuring 2 mm in diameter. It is necessary to detect an aberrant pulmonary artery for definitive diagnosis of pulmonary sequestration. However, in some cases, accurate diagnosis is difficult because of a thin or undetectable aberrant artery. Recently, thoracoscopic surgery has been reported to be feasible and safe for the treatment of congenital cystic lung disease. Although extra-lobar pulmonary sequestration is sometimes difficult to distinguish from mediastinal tumor, thoracoscopy can be useful for intraoperative diagnosis and minimally invasive resection.

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We report a case of lung cancer arisen from an emphysematous bulla in the right upper lobe of the lung in a 63-year-old man. The patient had medical histories of diabetes mellitus and pulmonary tuberculosis. The smoking index was 1,200. He had been pointed out a bulla occupying the upper lobe of the right lung. Although a chest computed tomography did not reveal any growths in the bulla in August 2013, a 34 × 32 mm mass, highly positive for fluoro-D-glucose accumulation, was found in the bulla on positron emission tomography in December of the year. Other examinations did not show any evidence of lung cancer or aspergilloma, and a biopsy via bronchoscopy resulted in Class I. The tumor tended to enlarge. Subsequently, thoracoscopic surgery was performed. Needle biopsy after dissection of firm adhesions revealed only necrotizing tissue, and no diagnosis was obtained. Right upper lobectomy was performed and the tumor was identified as lung cancer by intraoperative frozen section diagnosis. The pathological diagnosis was squamous cell carcinoma, pT2aN0M0, pStage IB. Lung cancer arising rapidly from an emphysematous bulla within only 4 months is rare.

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We report therapeutic experience with three cases of corrosive esophagitis. Case 1 involved a 58-year-old woman who had obstruction of the pharynx, because of taking caustic soda. Dissection of the esophagus was impossible due to serious inflammation and the stomach wall had severely deformed Four months after taking soda, inferior laryngopharygectomy and cervical esophagectomy were performed. The patient was discharged from the hospital on the 45th postoperative day. Case 2 involved a 24-year-old woman. She had stenosis of the esophagus, which was resistant to endoscopic balloon dilatation, because of taking caustic soda. The inflammation around the thoracic esophagus was mild and the cervical esophagus was kept intact. Fifteen months after taking soda, she underwent esophagectomy and reconstruction using gastric tube. The patient made satisfactory progress, and was discharged from the hospital on the 19th postoperative day. Case 3 involved a 63-year-old man. He had adhesion of the epiglottis and stenosis of the esophagus, because of taking alkali cleanser. He underwent laryngopharygectomy and esophagectomy 5 years after taking soda, because inflammation surrounding the esophagus was mild. The patient was discharged from the hospital on the 51st postoperative day.
We present our therapeutic experience with three patients with corrosive esophagitis who were operated on at different times after taking soda and followed favorable postoperative courses.

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A 70-year-old female was admitted to our hospital for close examinations of an esophageal submucosal tumor. Chest computed tomography showed a soft tissue tumor 60 mm in longer diameter at the cervical and upper intrathoracic esophagus. Upper gastrointestinal endoscopy revealed a submucosal tumor at a point where was 25 cm apart from the incisors. We performed the endoscopic ultrasonography-guided fine needle aspiration biopsy (EUS-FNA). A histopathological examination of the biopsy specimen showed increased eosinophilic spindle-shaped cells, and gastrointestinal stromal tumor (GIST) was strongly suggested by immunohistochemical staining. FDG-PET scan showed high uptake of FDG in the tumor with the SUVmax of 9.9, and it was diagnosed as submucosal tumor including malignant GIST. We performed subtotal esophagectomy accompanied with gastric role reconstruction. An immunohistochemical staining of the tumor showed the positive reaction for S-100 and the negative reaction for desmin, αSMA, CD34, KIT and DOG1. The Ki-67 index was less than1%. Hence, the final diagnosis was made as an esophageal schwannoma.
Leiomyoma is the most common submucosal tumor of the esophagus and schwannoma is rare. There have been few reports of benign esophageal schwannoma in which FDG-PET scan was conducted. We herein report this case with a review of the previous reports.

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We report a case of an esophageal schwannoma which is comparatively rare. A 60-year-old man visited a local physician because of epigastralgia and heartburn. Upper GI series showed a filling defect of the esophagus and he was referred to our hospital. Gastrointestinal endoscopy revealed a submucosal tumor with smooth surface in the lower thoracic esophagus. Chest computed tomography revealed an 85×50mm tumor without contrast enhancement. Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) to make the definite diagnosis was planned at another hospital, but the patient hoped to undergo an early operation. Therefore we performed surgery with a diagnosis of submucosal tumor. A 10-cm tumor was found at the lower esophagus. The tumor had not invaded the surroundings but enucleation of the tumor was difficult. Lower esophagectomy was thus done. The resected tumor was 100 × 58 × 65 mm in size and the section revealed a yellowish-white solid tumor. Microscopically, the tumor consisted of many spindle-shaped cells. Immunohistochemically the cells were positive for S-100, but negative for SMA, c-kit, CD-34 and DOG-1. From these findings we diagnosed the tumor as benign schwannoma. Esophageal schwannoma is rare, so we report this case with some literature review.

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The patient was a 73-year-old man who had directly been injured his anterior cervical region by a broken blade when he was at work to smash concrete. Emergent operation was performed with the diagnosis of complete disruption of the cervical trachea combined with injury of the cervical esophagus and bilateral recurrent nerves. We evaluated that primary end-to-end anastomosis of the trachea was risky because the recurrent nerves were bilaterally completely disrupted, correspondingly anastomosis of the disrupted esophagus with dark colored edematous mucosa was unsafe. Therefore, we performed laryngo-tracheal separation with definitive tracheostomy and two esophago cutaneo stomies esophageal fistulostomy, and then we created feeding gastrostomy. After a 43-day continuous drainage of saliva using a nasogastric tube inserted to the proximal esophageal fistula to prevent wound infection, we performed the staged operation of digestive reconstruction. After performing laryngo-pharyngectomy and cervical esophagectomy, we reconstructed the defect of the alimentary tract using a free jejunal graft with vascular anastomosis. The postoperative course was smooth, and he resumed oral intake of rice gruel. He was discharged from the hospital on the 38th day after the reconstruction surgery. We here report a case of traumatic complete disruption of the cervical trachea and esophagus treated successfully by using a strategic two-stage operation.

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The patient was a man in his 50's. In July 2014, during wood splitting, a part of a metal wedge that a colleague was using 4m away broke off and hit the patient's abdomen on the left side. The puncture wound in the skin was about 5mm in diameter. There were no metal pieces at the scene. The patient was hospitalized with the chief complaint of wound pain. Examination revealed no evidence of peritonitis. An abdominal X-ray and CT revealed a foreign body in the duodenum, with a little intraperitoneal gas. We diagnosed gastric perforation by a foreign body, and performed emergency surgery. At surgery, we found gastric perforation, but no other organ damage. We removed the foreign body by fenestrating the small intestine. We report a case of abdominal penetrating trauma and gastric perforation encountered by us, along with a discussion of the literature.

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A 33-year-old man who became aware of dizziness and palpitations on effort visited a neighboring hospital, when the Hb level was 7.3 g/dl, revealing anemia. A type 2 tumor was demonstrated in the third part of duodenum. Pylorus-preserving pancreaticoduodenectomy was performed in our hospital with a diagnosis of duodenal cancer. The histopathology revealed a growth of small round cells. Immunostaining of the cells revealed positive for MIC2 and NSE, but negative for myogenic and epithelial markers. Furthermore we confirmed the same translocation of chromosome as Ewing sarcoma. Peripheral primitive neuroectodermal tumor (pPNET) was thus diagnosed. Adjuvant chemotherapy was conducted, and the patient has been alive without having recurrence, as of 4 years after the operation.
These pPNETs are tumors of soft tissue arising in the extremities and in the chest wall. Recently these tumors have been clarified to have the common translocation of chromosome to that of Ewing sarcoma, and thus they are collectively called Ewing sarcoma family of tumors. Since the Ewing sarcoma family of tumors extremely rarely affects the intestine, this case is presented here, together with a review of the literature.

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A 64-year-old man who underwent distal gastrectomy with Billroth-II reconstruction for gastric ulcer 15 years earlier was pointed out having a submucosal tumor of the stomach growing within the lumen at the lesser curvature of the cardiac part of the remnant stomach. Cytodiagnosis under endoscopic ultrasonography was gastrointestinal stromal tumor (GIST), and we planned surgery for the patient. Taking the minimal invasiveness and preservation of function into consideration, we performed local resection of the stomach using laparoscopic endoscopic cooperative surgery (LECS). We put a holding thread around the surgical defect under laparoscopy and closed it by using a stapling device. The operating time was 288 min and the blood loss amounted to 153 ml. The postoperative course was uneventful and the patient was discharged from the hospital on the 11^th postoperative day.
The use of LECS enabled us to maintain the minimal invasiveness, preservation of function, and radicalness of surgery at the same time even for such a patient as should be performed total gastrectomy of the remnant stomach by laparotomy in accordance with the conventional surgical standards.

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An 89-year-old woman was admitted to our hospital complaining of vomiting after eating. Endoscopic examination showed a bulky polypoid lesion with a stalk on the antral greater curvature of the stomach, prolapsing into the duodenal bulb. The pathological findings of the biopsy specimen showed well-differentiated tubular adenocarcinoma. Using the intrabulbar retroflexion method, the tumor was pushed back into the stomach. Since a good view of the stalk of the tumor could not be obtained, endoscopic submucosal dissection (ESD) was not performed. Therefore, distal gastrectomy was performed. The tumor was 0-I type, 90 mm×65 mm in size, on the antral greater curvature of the stomach.
Histological examination showed tub1, pT1a (M), ly0, v0, pPM0, pDM0, n0. The patient recovered gradually, and she was discharged 26 days after the operation. A rare case of ball valve syndrome with 0-I type gastric cancer was described.

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A case of long-term survival with a solitary cerebellar metastasis from gastric cancer is reported. A 62-year-old man complaining of headache and a feeling of dizziness had undergone curative resection of gastric cancer three months earlier. Magnetic resonance imaging (MRI) revealed a mass lesion of about 3.0 cm in the left cerebellum. Computed tomography (CT) showed no other lesions. The patient underwent total tumor resection. The pathological diagnosis was metastatic gastric cancer. There was no recurrence of the tumor for more than ten years after the second operation. In the case of a solitary cerebellar metastasis of gastric cancer without other metastases, long-term survival can be expected with appropriate treatment.

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A case of cardiac tamponade because of metastasis from gastric cancer is reported. A 68-year-old man underwent distal gastrectomy for gastric cancer ten years earlier. Eight years after the surgery, he developed multiple bone metastases, which were recurrent gastric cancer, and he received systemic chemotherapy. He was admitted to our hospital with general malaise and anorexia. Computed tomography disclosed a large cardiac effusion. Cardiac tamponade and right-sided heart failure were diagnosed, and pericardiocentesis was performed. Cytodiagnosis of the pericardial effusion showed class V (poorly differentiated adenocarcinoma). His symptoms disappeared with drainage. After discharge from hospital, he refused chemotherapy. He died 12 months after the diagnosis of carcinomatous pericarditis, but no pericardial effusion re-appeared. It is rare that cardiac tamponade due to carcinomatous pericarditis develops from gastric cancer, but it requires emergency treatment. When a patient with recurrence of cancer presents with slight symptoms, the possibility of cardiac tamponade caused by carcinomatous pericarditis should be considered.

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The patient was a 60-year-old man. He underwent a pancreaticoduodenectomy following a diagnosis of a 10-cm pancreatic tumor when he was 49 years old. In August 2011, a heterogeneous mass of 92 × 71 mm with a clear boundary was found inside liver segment S4 on abdominal ultrasound. On CT, it was a 9-cm mass with a clear boundary that stained strongly inside and at the edge in the early phase and was seen as a low density area in the late phase. Since he had undergone surgery for a pancreatic tumor 11 years earlier, the pathology specimen was re-examined and checked to see whether it was c-kit positive. The diagnosis from the previous surgery was changed to duodenal GIST from a solid, pseudopapillary tumor. With the diagnosis of liver metastases following surgery 11 years earlier for duodenal GIST, liver resection of segment S4 was performed. The tumor was 8 × 7 cm, and immunostaining was positive for CD34 and c-kit. The tumor was diagnosed as liver metastases of GIST.

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A 69-year-old man was admitted to our hospital for left abdominal pain. Abdominal computed tomography (CT) revealed wall thickening and an ischemic change in the jejunum. With a diagnosis of ischemic enteritis, we applied conservative therapy, but follow-up CT showed deterioration of the ischemic change and swelling of the lymph nodes. Endoscopy revealed ulcerated lesions of the ascending portion of the duodenum and the jejunum. Biopsy study showed diffuse invasion of small, atypical lymphocytes that were CD3+, CD8+, CD20-, and CD56+ on immunohistochemistry. From these findings, enteropathy-associated T cell lymphoma (EATL) type II was diagnosed. An operation was performed first because the tumor had a risk of perforation. Tumor invasion of the submucosal layer was evident, and multiple tumors were palpable until the terminal ileum. The horizontal and ascending portions of the duodenum and jejunum were resected. A THP-COP regimen was applied postoperatively, but the patient died 3 months after surgery.

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We present a case of small bowel perforation due to dialysis-related amyloidosis in a patient who had been on hemodialysis for a long time. The patient was a 62-year-old man who was introduced hemodialysis at the age of 30 and underwent left carpal tunnel release surgery for left carpal tunnel syndrome at the age of 47. Thereafter he had undergone surgeries for osteoarthropathy. The patient presented to our hospital because of high fever and abdominal pain. An abdominal CT scan showed a localized wall thickening at the ileum and an increase in the density of mesenteric fatty tissue. A defect was present at a part of the thickening bowel wall, to which gas image continued extramurally. From these findings, small bowel perforation was diagnosed and an emergency laparotomy was performed. Upon laparotomy, we saw a perforated portion in the ileum and performed partial resection of the small intestine including the perforation and functional end-to-end anastomosis immediately. The histopathology revealed deposits of amyloid in the submucosal layer and vessels around the perforated portion. After the operation he developed vomiting and intractable diarrhea, but he was transferred to other hospital on the 52^nd postoperative day. No clinical findings suggestive of suture failure were observed in his postoperative clinical course.

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We report a case of bleeding from the jejunal artery during Henoch-Schönlein purpura (HSP) treatment. A 64-year-old man who underwent total gastrectomy was repeatedly hospitalized owing to adhesive intestinal obstruction. He developed HSP in November 2013, for which steroid treatment was initiated. The patient developed abdominal pain and went into shock. His hemoglobin level decreased to 5.3 g/dl, and a contrast-enhanced computed tomography scan showed active hemorrhage from the jejunal artery. We attempted angiographic hemostasis unsuccessfully. Emergent laparotomy was then performed. The operative findings showed a hematoma of approximately 500 g mainly in the left upper abdomen, which was localized due to the adhesion. The jejunal artery ruptured into the mesojejunum, and the bleeding was active. We then performed ligation. The patient's postoperative course was uneventful, and he was transferred to our hospital's department of internal medicine for HSP treatment. Intraabdominal hemorrhage during HSP treatment is extremely rare and can be fatal, but we were able to save this patient's life because of the intraabdominal adhesion. The present case is reported in the context of relevant literature.

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An 81-year-old man was admitted to our hospital for further examination of anemia with generalized fatigue. An abdominal CT revealed a mass adjacent to the small intestine measuring 40 mm in diameter. A small bowel series revealed an elevated lesion and extra-luminal compression of the near intestine around the tumor, giving the appearance of a submucosal tumor. We preoperatively diagnosed it as a GIST of the small intestine invading the mesentery and performed laparoscopy-assisted partial resection of the small intestine. At the time of the operation, another tumor in the small intestine was newly detected by palpation and the mass noticed on CT was located in its near mesentery. Based on histopathological examination, the tumors were finally diagnosed as a small intestinal carcinoid tumor with a lymph node metastasis.
Previous reports have shown that small intestinal carcinoid tumor can be frequently accompanied by lymph node metastasis. However, radical resection with regional lymph node dissection yields a fairly good prognosis. We think that radical resection should be considered for small intestinal carcinoid tumors without distant metastasis, like our case.

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A 64-year-old man diagnosed with malignant peripheral nerve sheath tumor (MPNST) underwent tumor resection of his left thoracic wall 11 years prior to the study. He had no history of von Recklinghausen disease. Six months before admission, the patient developed a local recurrence and underwent tumor resection, but multiple lung metastases were found 6 months postoperatively. He presented at our hospital with abdominal bloating. Enhanced computed tomography revealed an obstruction of the small bowel with intussusception. We suspected an intestinal metastasis of MPNST, and surgery was performed. We performed the Hutchinson maneuver and reposited the intussusception, followed by tumor resection. The tumor was diagnosed as MPNST. We report a patient with MPNST presenting with bowel intussusception developing 11 years after the initial treatment.

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A 53-year-old woman consulted us for fever and lower abdominal pain, and was diagnosed as having acute appendicitis with an intra-abdominal abscess. Appendectomy was performed, with drainage of the abscess. However, since purulent discharge was observed from the drain postoperatively, a residual abscess was diagnosed, which was irrigated and drained on day 10 of hospitalization. However, the infection progressed and the subcutaneous abscess caused necrosis of the abdominal wall and penetration of the sigmoid colon. Sigmoidectomy and ileocecal resection were performed on day 31 of hospitalization. Antibiotics were administered and the local irrigation was continued. However, infection control was extremely difficult. Exposed by a defect in the abdominal wall, the ileocolic anastomosis was found to be perforated. The perforation was closed on day 59 of hospitalization, and the abdominal wall was debrided. Histopathologic examination of the removed tissue revealed Entamoeba histolytica, which led to the diagnosis of amebiasis. With administration of metronidazole, the infection resolved and granulation tissue formed, leading to closure of the abdominal wall. The patient was discharged on day 189 of hospitalization. We have reported a rare case of amebiasis developing after surgery for appendicitis.
Infection control was difficult, however, the patient responded well once the infection was definitively diagnosed.

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A 52-year-old woman had undergone ileocecal resection for carcinoma of the cecum. At 9 years after the surgery, abdominal CT showed a cystic mass measuring 3 cm in diameter in segment VI of the liver. A repeat CT 14 years after the surgery showed that the mass had enlarged to 8 cm in diameter, and had invaded the thoracic and abdominal wall, diaphragm, and segment VI of the liver. Suspecting a malignant tumor from the abdominal wall, tumorectomy combined with thoracic and abdominal wall resection, hepatic resection of segment V and VI, and resection of the tenth and eleventh ribs were performed. The pathological diagnosis was mucinous carcinoma invading the surrounding organs. Thus, the tumor did not originate in the abdominal wall, but was a metastasis from the cancer of the cecum that had been resected 14 years earlier. Such a case of colon carcinoma recurring 14 years after surgery for the primary tumor is rare. Therefore, we report this case with some literature review.

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A 65-year-old man began to experience right lower abdominal pain off and on from April 2013, but ignored it initially. In October 2013, he visited our hospital because of aggravation of the right lower abdominal pain and passing brown-colored urine. The abdominal CT findings suggested the diagnosis of perforated appendicitis with abscess formation, and an emergency operation was performed. During the surgery, we did not find the abscess that was detected by preoperative imaging, but a fist-sized tumor in the pelvis contiguous with the cecum. Thus, ileocecal resection was performed. Histopathologically, the tumor was diagnosed as a low-grade appendiceal mucinous neoplasm. The cause of the mucocele of the appendix was non-infectious occlusion of the root of the appendix, which precluded the existence of emphysema in the mucocele. In this case, however, preoperative diagnosis was perforated appendicitis due to the emphysema in the mococele. Herein, we present a rare case of mucocele of the appendix with emphysema within the mucocele, together with a review of the literature.

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A 46-year-old woman who had undergone a barium study for gastric cancer screening the day before presented with abdominal pain. Abdominal radiography and computed tomography revealed a large amount of residual barium, but there was no evidence of ascites or free air. Emergency lower gastrointestinal endoscopy of the sigmoid colon showed an incarcerated barium mass. Emergency surgery was performed for increasing abdominal pain and concerns of perforation. One perforation with a size of 3 cm was found in the sigmoid colon. Hartmann operation and drainage were performed. Postoperative drainage was performed for a hematoma infection around the site of colostomy. Postoperative recovery and progress were satisfactory. Most patients with colorectal perforations have some underlying colorectal disease such as a diverticulum or tumor, and there are few cases arising solely from barium retention. We report a case of colorectal perforation after barium gastrography.

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The patient was a 42-year-old female with a past history of systemic lupus erythematosus, who presented to the ER with the chief complaint of melena and lower abdominal pain. She was diagnosed as having hemorrhagic colitis and admitted to the hospital. Colonoscopy performed on day 2 of admission revealed findings suggestive of ischemic colitis and a longitudinal ulcer in the transverse colon. Supportive therapy was ineffective. On day 3 of admission, the patient developed abdominal pain with signs of peritoneal irritation and the systemic inflammatory response syndrome. Abdominal CT scan revealed worsening of the edematous changes of the colon and massive ascites. An emergent laparotomy was performed under the suspicion of peritonitis secondary to necrotic ischemic colitis, and based on the findings, a subtotal colectomy was performed. On day of admission, pathogenic Escherichia coli O-157 and vero toxin were detected in a culture of a mucosal biopsy specimen obtained by colonoscopy. The postoperative course was uneventful, and the patient was discharged on postoperative day 57.
We have reported a case of successful surgical treatment of hemorrhagic colitis caused by enterohemorrhagic E. coli O-157 infection.

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A 51-year-old man came to the outpatient clinic of our hospital for a scheduled visit because of chronic abdominal bloating and constipation of four years' duration. Defecation had been relatively well controlled, but sigmoid colon volvulus had started to recur frequently from the last year. He was diagnosed with chronic idiopathic colonic pseudo-obstruction (CICP) with lesion sites in the sigmoid colon and transverse colon, and he underwent a subtotal colectomy for the purpose of preventing volvulus and mitigating his intestinal obstruction symptoms. Resuming oral intake took time, but ultimately he regained sufficient ability to ingest food. Histopathological examination revealed atrophy and reduction of Auerbach's plexus and the ganglion cells at the expansion site. Thus far, no recurrence of intestinal obstruction symptoms has been observed, even though 24 months have elapsed since the surgery. CICP has seldom been reported in Japan, and there are no clear guidelines on its diagnosis or treatment. The details of this case for which subtotal colectomy improved the symptoms are reported, along with a discussion of the literature.

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A 57-year-old man with multiple diverticula of the ascending colon underwent laparoscopic ileocecal resection. Preoperative hematologic data showed an increased concentration of hemoglobin and hematocrit. On day 18 after surgery, the patient complained of back pain and epigastralgia, and CT revealed thrombosis of the superior mesenteric vein (SMV) and portal vein (PV). Treatment with anticoagulation using heparin sodium, urokinase and warfarin potassium was started immediately, followed by a single dose of warfarin potassium after 7 days. CT scheduled on day 92 after the operation showed near-complete resolution of the SMV and PV thrombosis. Herein, we report an extremely rare case of SMV and PV thrombosis developing after laparoscopic colectomy, with a review of the literature.

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We reported a rare case of metachronous metastatic stomach cancer arising from descending colon cancer. A 57-year-old woman underwent an operation for descending colon cancer in January 2014. She was diagnosed with moderately differentiated p-stage II adenocarcinoma of the descending colon by pathology. Five months later, CEA level in the blood increased to 16.9 ng/mL. Dynamic CT revealed a large submucosal tumor in the upper area of the stomach. We strongly suspected recurrence of the descending colon cancer and performed total gastrectomy of the submucosal tumor in the upper area of the stomach. During surgery, we also found a submucosal tumor in the small intestine, which was partially resected. Pathology confirmed that those tumors derived from the descending colon cancer. Six months post-gastrectomy, the patient is alive with no signs of recurrence.

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Umbilical metastasis from a malignant tumor is called as Sister Mary Joseph's nodule and is known as a sign suggesting a poor prognosis. We report a case of umbilical metastasis from sigmoid colon cancer presented with repeated bouts of omphalitis like symptom, together with a review of the literature.
A 90-year-old woman complaining of redness of the umbilicus had repeatedly been treated in previous hospital with a diagnosis of periumbilical inflammation, but no symptomatic remission was gained. Two weeks later, she was referred to our department. On palpation, an about 2-cm induration was felt at the umbilicus, and effusion and foul odor were noted. Umbilical metastasis from a malignant tumor was likely. Umbilical metastasis of adenocarcinoma was diagnosed on a biopsy. As a result of general examinations, the patient was diagnosed with umbilical and hetatic metastases from sigmoid colon cancer. Laparotomy and histopathological findings suggested that the most likely manner of this umbilical metastasis might be of hematogenic. Since the patient was the very elderly, we employed sigmoidectomy + omphalectomy to improve her QOL. After discharge, she had mainly been treated by conservative therapy, and died 6 months after the operation.
When we encounter an umbilical tumor, early diagnosis and treatment are important by keeping this disease in mind.

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A 53-year-old man complaining of dyschezia and diagnosed with rectal cancer with paraaortic lymph node metastasis underwent low anterior resection with D2 lymph node dissection in September 2012. Chemotherapy was applied post-surgery. The paraaortic lymph node metastases had shrunken and a partial response was maintained. The patient presented at our hospital with complaints of dysuria and weakness in the lower extremities. Magnetic resonance imaging (MRI) suggested a metastatic cauda equina tumor. Several days after admission, the patient experienced bilateral sensorineural hearing loss. Gadolinium-enhanced magnetic resonance imaging revealed enhancement of the cauda equina and thoracic spinal cord and diffuse enhancement of the surface of the brain. Furthermore, the bilateral internal auditory canal was enhanced. Therefore, the patient was diagnosed with meningeal carcinomatosis. Whole brain radiotherapy (30 Gy total) was applied. After radiotherapy, combination chemotherapy with folinic acid-fluorouracil-irinotecan and bevacizumab was applied. However, the condition of the patient gradually worsened and he eventually died 9 weeks after onset of the primary symptoms. We hereby report the case together with a short literature review, as meningeal carcinomatosis caused by colorectal carcinoma is rare.

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A 71-year-old woman had indications of rectal cancer on endoscopy during surveillance for recurrent/slowly-developing ulcerative colitis (total colitis type) that had lasted 23 years. Contrast-enhanced computed tomography (CT) and MRI showed a 15-mm tumor in the left lateral lymph node region, and left lateral lymph node metastasis was suspected. She was diagnosed with ulcerative colitis-related rectal cancer, T3N3M0, Stage IIIb, and underwent a left lateral dissection along with laparoscopic total colectomy and ileal pouch-anal anastomosis, during which a somewhat round tumor that was enlarged in a fusiform manner so as to be continuous with the obturator nerve was observed ; the obturator nerve was severed, and the tumor was excised. Histopathological findings were positive for S-100 on immunostaining, with an MIB-1 index of 1.6%, and no atypical mitotic figures were observed. She was therefore diagnosed with a benign schwannoma predominantly of the Antoni A type. She had no neurological symptoms of the left lower limb that interfered with ADL postoperatively. Retroperitoneal schwannoma in the obturator nerve is very rare and is discussed along with a review of the literature.

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A 43-year-old woman who had undergone an annual medical examination was referred to our hospital for surgery for a hepatic tumor. Ultrasonography, contrast-enhanced computed tomography, and magnetic resonance imaging revealed a tumor measuring approximately 14 mm in diameter in segment 4 of the liver. Laparoscopic surgery was conducted under the diagnosis of a hepatic tumor. The tumor was seen to arise from the gallbladder, and cholecystectomy was performed. Pathologically, the tumor had a liver lobule, portal vein, bile duct, and central vein, which was diagnosed as ectopic liver that originated from the gallbladder. Ectopic liver is a rare anomaly of the liver. A review of the Japanese literature using the Igaku Chuo Zasshi search engine was conducted and identified 32 cases, including the present case. The results of the review are presented.

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A 66-year-old man was admitted for further examination of multiple hepatic tumors of segment 8 detected on abdominal computed tomography performed for treatment of acute prostatitis. Tumor 1, 1.5 cm in diameter, was located at the most cranial side. Tumor 2, 6 cm in diameter, had invaded the diaphragm. Tumor 3 consisted of cystic and nodular lesions. The cyst was about 4 cm in diameter and accompanied by distal bile duct distention. A 2-cm nodular lesion had invaded the lumen of the cystic lesion. Although abdominal imaging studies suggested hepatocellular carcinoma (HCC), cystadenocarcinoma and intraductal papillary neoplasm of the bile duct remained in the differential diagnoses. We performed right hemihepatectomy. Histopathological findings revealed that tumor 2 was the main lesion and tumors 1 and 3 were intrahepatic metastases. HCC with invasion of a simple hepatic cyst is very rare, and there have been no previous reports of similar pathological conditions.

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A 38-year-old man with retroperitoneal dedifferentiated liposarcoma was treated by retroperitoneal tumor resection. Two months after the surgery, abdominal enhanced CT revealed a nodular lesion in the hepatoduodenal ligament and stenosis of the bile duct. We diagnosed persistence of the residual lipsarcoma with stenosis of the bile duct, because the nodular lesion was also detected in the abdominal CT obtained before the first operation, and performed subtotal stomach-preserving pancreaticoduodenectomy. Histopathologically, the dedifferentiated liposarcoma involved the entire hepatoduadenal ligament and the resection margin was microscopically positive for tumor cells. This is the first reported case of retroperitoneal dedifferentiated liposarcoma causing stenosis of the bile duct. We thought that the retroperitoneal liposarcoma invading the hepatoduodenal ligament formed the nodular lesion constricting the bile duct. The tumor was completely resected macroscopically, however, the resection margin was microscopically positive for tumor cells. It would seem that evaluation of the invasive extent of a liposarcoma is difficult based on either preoperative imaging findings or the intraoperative findings. Therefore, it is important to try and prevent R2 resection and detect recurrences as early as possible.

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Intrahepatic cholangiocarcinoma (ICC) is often unresectable when it is found. Its recurrence rate after operation is high, and, therefore, its prognosis is poor. A case of ICC with invasion to the duodenum surviving for more than two years after operation is reported.
A 63-year-old woman was found to have a low-density area in segment 4 of the liver. She was followed for two years, and the size of the tumor did not change. She was found to have a duodenal submucosal tumor on gastrointestinal endoscopy, and CT showed a tumor in segment 4 of the liver that was invading to the duodenum. The tumor diameter was 33 mm. The patient underwent liver resection of segment 4, partial duodenectomy, and lymphadenectomy. The pathological diagnosis was ICC. Liver metastases were found 9 months later, and the patient was treated by radiofrequency ablation and transarterial chemoembolization. She remains with liver metastases at 28 months after the operation. Invasion to other organs together with very slow growth is very rare in ICC.

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A 61-year-old woman who underwent pancreaticoduodenectomy (PD) for cancer of the middle bile duct in 2004 presented to our hospital because of general fatigue in 2011 after an about 7-year recurrence free period. Abdominal CT and MRI scans revealed multiple tumors in the posterior segment of liver, suggesting a possible presence of a tumor in the bile duct in the posterior segment. The patient was decided to undergo surgery with a suspicion of recurrence at the surgical stump of the bile duct after PD or cholangiocarcinoma. Considering that recurrence involving the surgical stump was probable, we performed extended right lobectomy of liver including the choledochojejunostomy. The histopathological specimen disclosed that the multiple tumors arisen in the hepatic posterior segment were all abscesses, and there was a tumor in the bile duct in the posterior segment neighboring the choledochojejunostomy. Since the tumor was away from the anastomosed site and most part of the tumor involved papillary portion of the lumen, we determined that the tumor was not recurrence at the anastomosed site but metachronous cholangiocarcinoma. The postoperative course was uneventful and the patient was discharged from the hospital on the 20^th postoperative day. She has been recurrence free up to now.
We present this case of metachronous cholangiocarcinoma occurred 7 years after PD in which hepatic resection yielded favorable postoperative course, together with some bibliographic comments.

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A 44-year-old woman who visited a neighboring hospital complaining of diarrhea, itching, and body weight loss of 4 kg during 6 months was referred to our hospital because a tumor of the pancreas head was pointed out by abdominal CT and MRI scanning. Percutaneous transhepatic cholangiodrainage (PTCD) was performed to relieve obstructive jaundice. Cytology diagnosis was made by using endoscopic retrograde cholangiopancreatography (ERCP), and immunostaining revealed a diagnosis of pancreatic neuroendocrine tumor. The tumor diameter was 8.4 cm. Although demonstrable metastasis was absent, tumor emboli were noted in the portal and splenic veins and the hepatic artery appeared to be involved as well. We thus determined the case to be of unresectable and started chemotherapy with everolimus (oral) and somatostatin analog (intramuscular). Seven months later the tumor diameter decreased to 5 cm. The tumor embolus in the portal vein was still left, but the hepatic artery and the tumor were detached each other. We decided the tumor to be resectable and scheduled surgery. Radical operation was done by pancreaticoduodenectomy, associated resection of the portal vein (5 cm) and reconstruction of the portal vein by using right external iliac vein. Since there are few cases of pancreatic neuroendocrine tumor treated by neoadjuvant chemotherapy followed by radical operation, we present our case with a review of the literature.

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Portal annular pancreas, an anomaly consisting of a hypertrophic uncinate process wrapped around by the superior mesenteric vein (SMV), occurs rarely. We report the case of a patient with duodenal papillary carcinoma with a portal annular pancreas and replaced right hepatic artery (RHA). A 62-year-old female with obstructive jaundice was diagnosed as having a duodenal papillary tumor and underwent subtotal stomach-preserving pancreaticoduodenectomy. The anomaly of replaced RHA from the superior mesenteric artery was confirmed preoperatively by CT. During the operation, we found an anomaly in which the uncinate process of the pancreas extended and fused with the dorsal surface of the body of the pancreas surrounding the SMV, with the replaced RHA running along the dorsal pancreas. The main pancreatic duct ran along the ventral side of the SMV. We resected the body of the pancreas along the left side of the SMV. The resected uncinate process of the pancreas was closed. Postoperatively, a pancreatic fistula occurred, which, however, resolved with conservative management.

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A 33-year-old woman with a 1-year history of abdominal distension was referred to our hospital for a more detailed examination. Abdominal computed tomography showed a homogenous cystic tumor 210 mm in diameter with a partial cyst-in-cyst structure. The tumor was continuous with the pancreas. Fluorine-18-fluorodeoxyglucose and positron emission tomography showed positive accumulation in the partition walls. Spleen-preserving distal pancreatectomy was performed with a tentative diagnosis of a mucinous cystic tumor. The resected specimen had a maximum diameter of 21 cm and weighed 3800 g. The cystic tumor contained chocolate-brown mucinous fluid suspected to be due to intracystic bleeding. Tumor cells were positive for ER and PgR on immunohistochemistry, indicating a mucinous cystadenocarcinoma of the pancreas (TisN0M0, fStage 0). We report this case of giant mucinous cystadenocarcinoma originating from the pancreas, together with a review of the literature.

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A 23-year-old woman was referred to our hospital because of suspected acute appendicitis. An enhanced CT scan revealed a solid tumor, 11 cm in diameter, without enhancement in the pelvis. Ultrasonography revealed a well-defined, homogeneous, solid tumor, 11 cm in diameter. The tumor was of equal intensity to muscle on T1-weighted MR imaging and low intensity on T2-weighted imaging.
The patient was admitted for intensive examination and treatment. On the day after admission, the abdominal pain increased, and emergency surgery was performed. The preoperative diagnosis was a tumor of the mesentery. The tumor with two twisted vascular pedicles was in the pelvis and excised. On macroscopic examination, the tumor was 14 cm × 11 cm and red inside. Microscopically, it contained congestive splenic tissue. The final diagnosis was torsion of an accessory spleen.
Torsion of an accessory spleen is rare, and this case is presented with a review of the literature.

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A 72-year-old man who visited a neighboring hospital because of a one-week history of lower abdominal pain and dysuria was found to have tumor at the cranial side of the urinary bladder on an abdominal simple CT scan. The patient was referred to our hospital for further examinations and treatment. Blood analysis revealed increases in the WBC count and CRP level. Abdominal contrast-enhanced CT scan showed wall thickening at the top of the urinary bladder and a tumor which continued to the umbilicus right under the midline abdominal wall. Urachal cancer was suspected from the imaging findings, but we identified a linear shadow suggestive of a fish bone within the tumor and pyuria which was noted after admission. Accordingly administration of antibiotics was started, that resulted in an improving tendency in blood and urine findings. Abdominal CT scan revealed shrinkage of the tumor and the linear shadow which had been seen within the tumor moved to the urethra. Cystoscopy confirmed a fish bone stabbed in the prostate. The fish bone was removed through the urethra. The antibiotics therapy was maintained and the tumor completely disappeared. The tumor was thus considered to be perivesical abscess due to the fish bone.
It was difficult to differentiate from urachal disease, but we could accomplish the conservative therapy in the patient due to a rare clinical course. We present this case, together with a review of the literature.

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A 65-year-old woman visited our department complaining of pain and purulent discharge in the umbilical region. Abdominal computed tomography (CT) showed a mass that continued from the navel to the bladder, suggesting a urachal abscess ; part of the boundary with the stomach wall was indistinct. Cystoscopy revealed edematous changes in the posterior wall of the bladder, with findings consistent with a urachal abscess. She was therefore diagnosed with a urachal abscess and underwent surgery. The urachal abscess adhered to the greater omentum and anterior wall of the stomach, and she underwent a urachectomy and concomitant partial resection of the greater omentum, stomach, and bladder. Tissue findings revealed infiltration of inflammatory cells continuing from the gastric mucosa to the abscess. Her course was favorable, and she was discharged on postoperative day 13. The present case had a prior history of being conservatively treated for gastric ulcer penetration three years before the present surgery, and there were no findings of urachal abscess in the imaging findings at that time. Later, the gastric ulcer was refractory, and abdominal CT performed one year earlier showed findings of a suspected urachal abscess in contact with the stomach wall. This report describes a case in which it appears that a gastric ulcer penetrated to the urachal remnant and formed an abscess.

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A 54-year-old man admitted for abdominal pain was found on abdominal computed tomography (CT) to have a retroperitoneal hemorrhage around a middle colic arterial aneurysm and stricture of the celiac artery. Angiography showed the stricture of the celiac artery to be due to constriction by median arcuate ligament syndrome (MALS), with abnormal retrograde flow from the superior mesenteric artery to the celiac artery. Furthermore, angiography showed beading and narrowing change of the transverse pancreatic artery and the middle colic arterial aneurysm. Rupture of the arterial aneurysm owing to segmental arterial mediolysis (SAM) caused retroperitoneal hemorrhage. Though the blood supply of the middle colic artery came from the superior mesenteric artery in one direction, considering the risk of colonic ischemia with interventional radiology, emergency laparotomy was performed.
Two aneurysms and the transverse colon were resected, along with partial resection of the median arcuate ligament. The abnormal blood flow by MALS may have caused rupture of the transverse pancreatic arterial aneurysm.

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A 48-year-old woman medicated for inflammation of the urinary bladder had the chief complaint of unimproved symptoms. She was diagnosed with a bladder tumor by cystoscopy. A computed tomography scan revealed a tumor with calcification anterior to the urinary bladder. Transurethral resection of the bladder tumor revealed it was mesh, which had been implanted for a right inguinal hernia 2 years prior. Segmental resection of the urinary bladder was performed to remove the migrated mesh. After removal of the mesh, the symptoms improved, and no adverse events have been seen to date.

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An 87-year-old man with inguinal swelling on the left side was observed for 1 year at a nearby medical clinic and was diagnosed with an inguinal hernia. Upon experiencing epigastric pain, the patient was referred to our hospital for detailed examination.
Three tumors, 40, 22, and 5 cm in size, were observed, and liposarcoma was suggested by imaging studies. We performed a resection to remove the tumors from the small intestinal mesentery, retroperitoneum, and mesorectum. The retroperitoneal tumor, which passed through the inguinal ring, was drawn out, and the hernia orifice was closed using Parietex mesh. The total weight of the tumors was 5701 g. Pathological findings demonstrated that one tumor was dedifferentiated and two were well-differentiated liposarcoma. There were no signs of recurrence 4 months post-surgery. We hereby report a very rare case of multicentric primary liposarcoma with one tumor passing through the internal inguinal ring with inguinal swelling.

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A 79-year-old woman had a history of bilateral femoral head replacements and multiple abdominal surgeries. She was referred for abdominal pain and vomiting that had persisted for two days, and she was diagnosed with adhesion ileus on abdominal computed tomography (CT). The pelvic floor was difficult to interpret radiographically because of the effects of artifacts. However, when the CT conditions were adjusted so as to reduce the effects of artifacts, it became possible to identify the small intestine, which was incarcerated in the left obturator foramen ; combined with ultrasound, this gave a diagnosis of ileus caused by an incarcerated left obturator hernia, and she was scheduled for emergency same-day surgery. Though the effects of artifacts due to artificial materials may make radiographic interpretation seem difficult at first glance, we believe that, by adjusting the CT conditions and using concomitant ultrasound, it is important to be aggressive in radiographic interpretation, even in an artifact area.

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