Background : Combined chemotherapy with docetaxel, cisplatin and 5-FU (DCF therapy) for esophageal cancer is expected as a treatment alternative to the combination of 5-FU and cisplation (FP therapy). On the other hand, it has been reported that DCF therapy causes myelosuppression and febrile neutropenia (FN) in a high frequency. Methods : A total of 108 patients who received DCF therapy in our hospital from 2010 to 2012 were eligible for this study. We studied the frequencies of hematotoxicity and FN, and factors associated with FN. Results : The patients' characteristics included a median age of 67 years ; the male/female ratio of 100/8 ; and UICC Stage I/II/III/IV of 7/9/53/39. Grade 4 neutropenia and FN were found in 54.6% and 37.0% of all patients, respectively. Advanced age and dysphagia were independent factors associated with FN. Conclusions : DCF therapy for esophageal cancer frequently caused neutropenia and FN. Factors associated with FN were revealed. This study suggested the possibility of individualization in chemotherapy for esophageal cancer.

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Background : Whether chemical bowel preparation (CBP) reduces surgical site infection (SSI) in patients undergoing elective colorectal surgery remains controversial. The aim of this study was to assess the need for CBP with oral antibiotics.
Methods : Two hundred and twenty patients who underwent elective colorectal surgery between January 2009 and August 2010 were prospectively randomized into two groups. One group received preoperative CBP in addition to mechanical bowel preparation (CBP group), and the other did not (no CBP group). Kanamycin 3,000 mg/day and metronidazole 750 mg/day were administered to patients in the CBP group on the day before surgery. The rate of superficial SSI after operation was compared between groups.
Result : The rate of superficial SSI was significantly lower in the CBP group (3.6%) than in the no CBP group (20.4%).
Conclusion : CBP effectively reduces the risk of superficial SSI in patients who undergo elective colorectal surgery.

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We studied 386 patients (453 lesions) with inguinal hernia that was treated via the transabdominal preperitoneal (TAPP) approach using Parietex^TM anatomical mesh M (13 × 9cm).
The surgical outcomes were as follows :
1) The mean surgery time was 98.7 minutes for one side and 136.3 minutes for both sides, the mean bleeding volume was 3.7 mL, and the mean frequency of analgesic use was 1.4.
2) At the time of the first medical examination as outpatients, among 352 patients, 29 patients (8.2%) had pain in the diseased area, 4 patients (6.8%) had discomfort, 29 patients (8.2%) had seroma, and 5 patients (1.4%) had wound infection.
3) A questionnaire survey of 291 patients who were evaluated at more than 3 months after surgery revealed that 8 patients (2.7%) had chronic pain, 34 patients (11.6%) had discomfort, and 1 patient (0.3%) had swelling. None of the patients showed relapse.
4) Patient satisfaction considering the outcome was very good (a score of 5) in 219 patients (75.2%) and quite good (a score of 4) in 69 patients (31.5%).
Until now, as there was no serious complication or recurrence and a low incidence of adverse events after surgery, it is suggested that the TAPP approach is useful and makes it possible to reinforce the diseased site in Japanese patients by using a 13 × 9cm mesh.

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We treated a case of intrathyroidal parathyroid adenoma which was detected by ultrasonography and ^99mTc-sestamibi scintigraphy. The patient was a 70-year-old female who had received treatment with a bisphosphonate for osteoporosis and been initiated on denosumab. At one of her visits, blood tests revealed hypercalccemia and increased serum level of intact-PTH. Ultrasonography showed a hypoechoic mass in the right lobe of the thyroid gland, which we suspected was a parathyroid adenoma. ^99mTc-sestamibi scintigraphy revealed increased accumulation of the radionuclide in the right lobe of the thyroid gland. We detected the parathyroid adenoma in the right lobe of the thyroid gland, and excised the tumor from the thyroid gland. After the operation, the serum calcium and serum intact-PTH decreased rapidly. Histopathology revealed an ectopic intrathyroidal parathyroid adenoma. Non-invasive examinations, including ultrasonography, and ^99mTc-sestamibi scintigraphy can prove to be important aids in the diagnosis of ectopic parathyroid glands.

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This report is about a woman in her 40s who underwent cadaveric right lung transplantation for lymphangioleiomyomatosis (LAM) in our department 3 years previously and received oral immunosuppressants, such as tacrolimus, mycophenolate mofetil, and corticosteroids, as per our protocol. She noticed a mass on her left breast and visited our department for examination. Mammography revealed a 2.0-cm mass in the outer region of the left breast, which was diagnosed as a phyllodes tumor on needle biopsy. However, non-contrast chest computed tomography performed 3 months before the consultation did not show a mass shadow in the breast. Three months after the consultation, the size of the mass had increased to 4 cm, and she underwent resection of the tumor along with the surrounding mammary tissue. Postoperative pathological findings led to the diagnosis of a borderline malignant phyllodes tumor. In some cases, phyllodes tumors rapidly increase, although it could not be determined whether the immunosuppressants caused the phyllodes tumor in the present case. Conversely, it is suggested that the long-term oral administration of immunosuppressants may induce a higher incidence and more rapid progression of malignant tumors in post-transplant patients. As there are no systematic data on malignant tumors after organ transplantation in Japan, we currently lack indicators for screening. Therefore, it is desirable to establish surveillance as early as possible.

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A 76-year-old man was referred to our hospital because of an abnormal shadow on a chest X-ray film at a medical checkup. Chest CT scan showed a mass 45 mm in diameter in the right upper lobe of the lung, PET-CT showed a maximum SUV of 13.5 in the same area and we suspected primary lung cancer. Mediastinal lymph node was not diagnosed as metastasis because the diameter was less than 1cm in shorter axis on CT and fluorodeoxyglucose (FDG) uptake was low on PET. We performed lobectomy of the right upper lobe and the intraoperative frozen section histopathological diagnosis was reported to be carcinoma. We shifted to lymph node dissection and found a white tumor which occupied the superior mediastinum and originated from the vagus nerve. We resected the mediastinal tumor. The pathological diagnosis of the lung tumor was pleomorphic carcinoma and that of the nourogenic tumor was neurofibroma. He had café au lait spots and had undergone the resection of a neurofibroma in the leg. He was diagnosed with neurofibromatosis type 1.

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Endobronchial hamartomas are relatively rare. A 57-year-old woman was detected an abnormal shadow on a chest x-ray film at a medical checkup. Chest CT scan showed an intra-bronchial tumor 5 cm in diameter occluding the right B6 bronchus and hilar and mediastinal lymph node swelling. Lung cancer was likely and she was referred to our hospital. When she was first seen, the shadow had shrunk and we conducted antimicrobial therapy with a diagnosis of pneumonia, but it turned out obstructive pneumonia. Bronchoscopic examination demonstrated a tumor protruding from the right B6 bronchus and we obtained the diagnosis of hamartoma by a biopsy. As we had difficulty in treating obstructive pneumonia, the patient was considered to be a candidate for surgery. We performed the operation by thoracotomy. At surgery, severe adhesion and lymph node swelling made us difficult to dissect, and we checked the tumor location directly by cutting the bronchus and performed S6 segmentectomy. The pathological diagnosis was a hamartoma. A favorable therapeutic result was achiedved by segmentectomy.

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We have treated 40 cases of sternal fracture in our hospital over the past 5 years, and performed invasive treatment in two cases, using a locking plate for fixation in both. With the locking plate system used, fixation was achieved via screw holes in the plate and screw heads, and adequate immobilization of the sternum was achieved with fixation of only one side of the bone cortex to the locking plate. This therefore offered a simple procedure with no need for dissection of the medial side of the sternum or protection of the mediastinal organs. Postoperative recovery was uneventful in both cases, suggesting that sternal fixation with a locking plate may offer an effective method for treating sternal fracture.

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We present a case of dermatofibrosarcoma protuberans (DFSP) with metastases to the lung and the small intestine after repeated local recurrences. The patient was a 51-year-old woman, who had experienced repeated local recurrences after the resection of the primary DFSP in the left anterior thoracic region, followed by lung metastasis 25 years after the initial operation. Further two years later, she presented with right lower abdominal pain. A CT scan showed an intussusception caused by a small intestine tumor as a leading mass. Laparoscopic observation of the abdominal cavity revealed a ileo-ileal intussusception and no metastasis in other organs, and small intestine resection was performed. The pathological diagnosis was small intestine metastasis of DFSP, and fibrosarcomatous lesions were seen in a part. No recurrence has occurred as of 3 years after the last surgery.
Bowel metastasis of DFSP is very rare. This is the first case of small bowel metastasis of DFSP in the Japanese literature.

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A 61-year-old man visited the hospital because of abdominal fullness and pain. X-ray showed colonic gas in the left lower thorax. Computed tomography (CT) revealed prolapse of the colon, spleen and left kidney into the left thoracic cavity. The patient was diagnosed with diaphragmatic hernia and hand-assisted laparoscopic surgery was performed. Hernia contents were reduced into the abdominal cavity. The defect of diaphragm was repaired by direct suture and covered with polypropylene mesh. The patient has remained asymptomatic since the operation. Hand-assisted laparoscopic surgery is a safe and less-invasive surgical method for Bochdalek hernia in adults.

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An 84-year-old woman was admitted to our hospital because of vomiting and epigastralgia. Chest radiograph and computed tomography with contrast imaging showed a complicated esophageal hiatal hernia (type IV) involving with the entire stomach, small intestine, and transverse colon in the left side of the pleural cavity. Because the contrast medium was not detected in the small intestine, we performed emergent surgery on the esophageal hiatus hernia because a strangulated ileus was suspected.
Intraoperatively, we found an internal hernia of the mesocolon of the transverse colon in addition to the esophageal hiatal hernia. The internal hernia involved the strangulated jejunum. We resected the necrotizing jejunum. We returned the contents of the esophageal hiatus hernia into the abdominal cavity and repaired the hiatal gate using a mesh-free suture. However, the gastroesophageal reflex persisted and the patient was discharged on the 10^th postoperative day. Here we described a rare case of esophageal hiatus hernia complicated by an internal hernia and strangulated jejunum.

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We present a case of spontaneous esophageal rupture caused by acute gastroenteritis in a juvenile patient.
A 28-year-old man visited a neighboring hospital because of severe chest and back pain occurred immediately after diarrhea and vomiting associated with acute gastroenteritis. Then he was brought into our hospital by ambulance for the purpose of close exploration and treatment. When he arrived at our hospital, a chest x-ray film showed decreased translucency in the left lower lung field. A chest CT scan revealed left pleural effusion and mediastinal emphysema surrounding the lower thoracic esophagus. Upper gastrointestinal series showed outpouring of contrast medium from the left side of the lower thoracic esophagus into the left thoracic vavity. Spontaneous esophageal rupture was diagnosed, and an emergency operation was performed 10 hours after the onset of the disease. A left posterolateral thoracotomy through the seventh intercostal space revealed a 5-mm sized perforation on the left side of the lower thoracic esophagus and food residual in the thoracic cavity. Since the inflammatory findings were slight, the perforated site was closed by sutures in two layers. His postoperative course was uneventful. He resumed to ingest from the 10^th postoperative day and was discharged on the 21^st postoperative day.
Although acute gastroenteritis is a common disease, we should keep in mind that it can cause spontaneous esophageal rupture even in a juvenile patient.

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This case involved a 66-year-old man who underwent esophagectomy by right thoracotomy and retrosternal gastric conduit reconstruction of the esophagus for esophageal cancer 9 years earlier. About 2 months prior to the current visit, he noticed coughing and phlegm. His cough temporarily abated, but he developed difficulty in breathing, so he was seen at a nearby physician. Heart failure was suspected, and he was referred to the Department of Internal Medicine in our hospital. Further tests and exams suggested perforation caused by an ulcer in the gastric conduit. The patient was referred to our department and underwent emergency surgery. “Median laparotomy and median sternotomy disclosed large quantities of necrotic tissue around the gastric conduit and an ulcer in the posterior wall of the gastric conduit. The pericardium was perforated due to the ulcer. The gastric conduit was dissected from the pericardium and removed, and an cervical esophageal stoma was created. On the postoperative day 111, two-stage esophageal reconstruction was performed using jejunal Roux-en Y reconstruction and additional vascular anastomosis via the anterior chest wall. His postoperative course was satisfactory, and he was discharged on the 21st day after the reconstruction. Since few reports of such cases have been described, the present case is reported.

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Desmoid tumor is commonly known as a slow-growing tumor. We report herein a case of sporadic, rapidly growing, intraabdominal desmoid tumor arising from the gastrosplenic ligament. A 54-year-old man showed a round tumor 2 cm in diameter near the greater curvature of the stomach on screening abdominal CT. One year later, the tumor had grown rapidly to 10 cm, and thus the patient was referred to our hospital. Diagnostic investigations suggested that the tumor had arisen from the gastric muscularis propria layer with extraluminal extension, and laparoscopic and hand-assisted tumor resection with splenectomy was performed. Microscopic histopathological findings revealed that the tumor mainly consisted of proliferative collagen fibers and spindle cells without atypia, and the tumor capsule originated from the gastrosplenic ligament. Immunohistochemistry of the resected specimen indicated the tumor cells were positive for β-catenin and negative for c-kit, desmin, and S-100, consistent with desmoid tumor. The patient has survived without evidence of tumor recurrence as of 21 months after surgery. It is necessary to consider that desmoid tumor has a potential to grow rapidly, despite the difficult preoperative diagnosis.

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A 41-year-old woman underwent an upper gastrointestinal contrast examination during a medical checkup, indicating gastric submucosal tumor. She visited our hospital for further examination. Upper gastrointestinal endoscopy revealed an elevated lesion covered with healthy mucosa in the gastric antrum, and she was diagnosed with neuroendocrine tumor (NET)-G1 by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA).
Surgery for laparoscopic gastric local excision was performed alongside intraoperative ultrasonography. Histological findings showed poorly atypical uniform round cells proliferating between rich vasculature, and gastric glomus tumor was diagnosed based on the results of immunostaining. Glomus tumors are non-epithelial tumors that frequently occur under the skin of the limbs and trunk. Although onset in the gastrointestinal tract is rare, when they do occur, many are primary gastric tumors. In light of the rarity of the tumor and the histological features, these tumors are difficult to diagnose, but EUS-FNA and immunostaining are the most important methods for diagnosis. We feel that in surgery for gastric glomus tumors, laparoscopic gastric local excision may be an appropriate surgical technique, and combined use of intraoperative ultrasonography or intraoperative gastrointestinal endoscopy offers the potential for safer surgical procedures.

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The sign of Leser-Trélat is a paraneoplastic phenomenon marked by abrupt appearance of multiple seborrheic keratoses. The rapid increase in their size and number can be caused by an associated cancer. In most cases, the cancer is diagnosed in an advanced stage. The mechanism of the sign has not been clarified. We report a case of early gastric cancer presented with the sign of Leser-Trélat in the trunk. A 75-year-old man seen at the department of dermatology for rapidly spreading seborrheic keratosis with itching on his trunk was suspected of the sign of Leser-Trélat. Upper gastrointestinal endoscopy indicated early gastric cancer. Distal gastrectomy was performed in our department of surgery. After the operation verrucae reduced in the size and itching sensation of the skin disappeared. Seborrheic keratosis characterized by pruritus and rapidly increasing size and number should lead diagnosticians to suspect the sign of Leser-Trélat and the possible association of visceral organ malignancies.

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A 79-year-old woman had undergone total gastrectomy for gastric cancer 5 years earlier, and the pathological diagnosis showed poorly differentiated adenocarcinoma, Stage IB (pT2, N0, M0), according to the Japanese classification of gastric carcinoma. Adjuvant chemotherapy was not employed considering the relatively early cancer and R0 resection.
Following the primary surgery, annual routine colonoscopy revealed multiple submucosal tumors suggested by biopsy to be poorly differentiated adenocarcinoma. Computed tomography and positron emission tomography did not show other organ metastases or abdominal dissemination. We performed subtotal colectomy. Finally, the lesions were definitively diagnosed as metastatic colon cancer derived from the gastric cancer based on pathological findings and cytokeratin immunostaining.
Metastatic colon cancer is rare, comprising 0.1∼1% of all colon cancers, and almost all cases are metastases from progressive cancers. Colonic metastasis of stage I gastric cancer is extremely rare and to our knowledge, only four cases including the present have been reported in Japan. We thus present this case with a review of the literature.

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A 58-year-old man was admitted to our hospital for scrutiny purpose of anemia. He had been diagnosed with partial situs inversus. Esophagogastroduodenoscopy showed a bleeding ulcer in the gastric corpus, for which hemoclipping was effective. A superficial type ulcer was also detected close to lesser curvature of the upper body of the stomach. A biopsy revealed poorly differentiated adenocarcinoma. Preoperative CT scan revealed that the stomach, spleen, and pancreas were located in the reverse ; the liver seemed to be symmetrical, and the gallbladder and Treitz ligament were in the normal position. Total gastrectomy (D1+) with R-Y reconstruction was performed with the diagnosis of gastric cancer, cT1b, cN0, cM0, Stage IIA. His postoperative course was uneventful, and he was discharged on day 13. No cancer recurrence has occurred as of one year and three months after the surgery. CT was especially useful to know the anatomical relations of vessels and organs in the surgical case associated with situs inversus.

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A 66-year-old man visited with chief complaints including abdominal pain and blood in the stool. He was diagnosed with superior mesenteric artery thrombosis not involving intestinal necrosis, and conservative treatment was attempted, but exacerbation of his abdominal symptoms on hospital day 2 forced an emergency surgical procedure. About 50 cm of necrotic small intestine was partially resected, and the stump was lifted outside the abdominal wall as a small intestine fistula in a “second-look operation” strategy. On postoperative day 12, about 70 cm of small intestine was additionally excised, and the small intestine fistula was closed. After the second surgery, he experienced repeated abdominal pain and diarrhea induced by oral intake, and detailed examination including computed tomography (CT) and protein loss scintigraphy led to a diagnosis of protein-losing gastroenteropathy complicating ischemic enteritis. In a third surgery, a laparoscope was used for detailed observation, and thickening of the small intestine wall was observed across about 50 cm on the oral side of the previous anastomosis. We report and discuss this case where, despite an attempted “second-look operation” to avoid massive small intestine resection, a third surgery and long-term hospitalization were needed as a consequence of complications from protein-losing gastroenteropathy.

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Transverse mesocolon hernia is a rare type of internal hernia. We report a unique case of transverse mesocolon hernia accompanied by retrograde intussusception and review the literature. A 60-year-old man with no previous surgical history presented with severe upper abdominal pain and frequent bouts of vomiting. Computed tomography scan showed the jejunum protruding to the posterior side of transverse colon with a proximal part invaginating into the duodenum in a retrograde fashion. An emergency laparotomy was performed for a suspected jejunal internal hernia accompanied by retrograde intussusception. Intraoperatively, a 20-cm portion of the most proximal jejunum was found to be herniated and incarcerated in the transverse mesocolon through an orifice formed at duodenojejunal fossa. The hernia and intussusception were reduced manually and the jejunum was revealed to be viable. Without any causes identified intraoperatively, the intussusception appeared to have occurred with an unknown etiology. The operation was completed with the closure of the orifice and good postoperative course followed.

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The patient was a 39-year-old male, whose past medical history included resection of a leiomyosarcoma of the scrotum nine years earlier, and resection of metastatic lung tumors three and two years earlier at another hospital. He was admitted to our hospital with acute-onset epigastric pain. Abdominal CT revealed evidence of small intestinal obstruction, and an emergency operation was performed. Intraoperatively, a 4-cm movable foreign substance was detected in the ileum, and the oral aspect of the small intestine was dilated. The serosa of the ileum was denatured and there was a 2-cm mass arising from the wall. We carried out partial resection of the ileum and extirpated the movable foreign substance and mass. The foreign substance was a polypoid mass measuring 3.8 cm in diameter. A tumefactive lesion was also noted in the resected ileum. We judged that it was the stem of the polypoid mass and that the small intestinal obstruction was caused by the freed polypoid mass. Histologically, the mass could not be traced to the muscularis propria or mucosal muscle of the ileum. Immunohistochemistry revealed positive staining for SMA and HHF, and negative staining for c-kit and CD34 ; the Ki67 index was 70%. These findings were similar to those of immunohistochemical examination of the previously resected leiomyosarcoma of the scrotum. Therefore, we diagnosed the patient as a case of metastatic small intestinal tumor from leiomyosarcoma of the scrotum.

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The patient was a 78-year-old female with a history of undergoing appendectomy. After having lunch, she experienced severe lower abdominal pain and presented to our emergency outpatient clinic. Abdominal contrast-enhanced CT scan revealed a closed loop of the small intestine and increased fat concentration in the mesentery. The patient was diagnosed as having strangulated ileus and underwent emergency surgery. Hemorrhagic ascites accumulated inside of the abdominal cavity. Removal of a strangulated funicular substance revealed good beating of peripheral arteries and the presence of intestinal peristalsis in spite of color tone failure of the intestinal wall. Bowel resection was not conducted. Although the clinical course was good, fever with shivering developed on the 6^th and 9^th days after the surgery when the patient started eating. Blood culture showed Bacillus cereus colonies on both occasions. Since there were no abdominal symptoms or infectious sources, bacterial translocation (BT) was suspected and meropenem administration was initiated. There was no fever incidence after that, and the patient resumed eating. She was discharged 22 days after the surgery. Care should be taken for development of BT in addition to perforation and stricture in the case of mucosal membrane damage due to ischemic enteritis following release of strangulated ileus.

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We report a rare case of a patient with ileal duplication presenting with lower abdominal pain. A 74-year-old male visited us with a 10-day history of gradually worsening lower abdominal pain, and was admitted to our hospital. Physical examination revealed severe lower abdominal tenderness with guarding, and blood tests showed evidence of inflammation. Abdominal enhanced CT showed abscess formation in the pelvis, and an emergency operation was performed. A tubular duplication tract was found 120 cm cephalad to the ileocecal junction. The duplication tract was blind and showed formation of an abscess adherent to the sigmoid colon. Ileal duplication with abscess was diagnosed and resection of the small intestine with the duplication tract was performed. Histopathology revealed an adenocarcinoma between the blind duplication and the abscess. This is the first case of adenocarcinoma arising from a tubular-type duplication of the ileum, and the first case of abscess formation arising in a case of ileal duplication with carcinoma.

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The patient was a 50-year-old man who was referred to our hospital with right lower abdominal pain. He had a history of undergoing appendectomy for acute appendicitis 30 years earlier. Abdominal CT showed the presence of a mass in the ascending colon and cecum with calcification. A preoperative diagnosis of inflammatory tumor was made as the patient gave a history of having mistakenly ingested a denture six months previously. Ileocecal resection was performed. Histological examination showed chronic inflammation of the stump of the appendix with no evidence of the denture.

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A 54-year-old man underwent colonoscopic examination following positive results from a fecal occult blood test. Colonoscopy showed a tumor exposed to the orifice of the vermiform appendix. Histological findings of the biopsy specimen from the tumor demonstrated tubular adenoma. Appendectomy and partial resection of the cecum with laparoscopic-assisted surgery was performed. Histopathological examination of the resected specimen revealed low-grade tubular adenoma in the appendix. The postoperative course was uneventful. The patient was discharged on postoperative day 4. Preoperative diagnosis of rare benign adenoma of the appendix is a good indication for laparoscopic surgery.

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A 79-year-old woman visited a primary-care doctor with lower abdominal distension. She was referred to our hospital for further examinations. Abdominal computed tomography showed sharp calcifications and abscess in the lower abdomen. Laparoscopic surgery was performed on suspicion of abdominal abscess due to silent fish bone perforation. Laparoscopy showed that the omentum had covered the abscess in the abdominal cavity and adhered to the peritoneum. There was no evidence of perforation in the intestinal wall. We resected the mass, which comprised abscess and omentum with fish bones inside. Histological examination of the resected specimen revealed abdominal actinomycosis. She recovered uneventfully and was discharged after 3 days. We report a case of abdominal actinomycosis due to silent fish bone perforation successfully treated by laparoscopic surgery.

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The patient was a 61-year-old woman complaining of left lower abdominal pain. She had undergone total hysterectomy and bilateral salpingo-oophorectomy about 20 years ago. Laboratory examination revealed evidence of acute inflammatory response (WBC count 11900/mm³, serum CRP 14.1mg/dl) and the serum tumor marker levels were within normal range. Abdominal CT showed a 4-cm protruding mass adjacent to the sigmoid colon. Colonoscopy and a contrast study showed stenosis of the sigmoid colon. Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed intense uptake in the periphery of the mass (maximal standard uptake value : 14.1) which was found to show a ring-shaped appearance. Retained gauze packing was the most likely diagnosis, however, based on the possibility of colon cancer, we carried out resection of the sigmoid colon with lymph node dissection. Pathological examination of the resected specimen showed that the tumor was located in the mesentery of the sigmoid colon and penetrated into the colon. Artificial materials and abscess were present in the tumorous lesion, on the basis of which we made the diagnosis of retained gauze packing. It is difficult to make a diagnosis of retained gauze packing preoperatively. However, a ring-shaped appearance on FDG-PET may provide a clue.

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A 67-year-old woman was admitted with urinary urgency and a lower abdominal mass. Abdominal CT showed a tumor 120 mm in diameter that was vascularized by the sigmoid colon artery in the abdominal cavity. The tumor was diagnosed as liposarcoma. We performed sigmoidectomy in June 2011. Intraoperatively, the tumor was about 15cm in diameter and located at the sigmoid mesocolon adjacent to the sigmoid colon. Histological examination confirmed the diagnosis of malignant peripheral nerve sheath tumor (MPNST) originating from the sigmoid mesocolon. She received two operations for tumor recurrence, and adjuvant chemotherapy after the third operation, but died of abdominal dissemination 26 months after the initial operation.

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We report a case of rapidly progressing gangrenous cutaneous mucormycosis. A 53-year-old woman treated with hemodialysis visited our hospital because of gradually worsening lower abdominal pain. Computed tomography (CT) revealed acute generalized peritonitis arising from a sigmoid colon perforation, for which the patient emergently underwent a partial sigmoid colectomy and a single-barrel colostomy.
On postoperative day (POD) 21, the skin around the stoma became necrotic. A CT scan revealed air accumulation in the subcutaneous layer as well as intraperitoneal and retroperitoneal abscess formation, and bowel necrosis and perforation were subsequently suspected. In the second emergent operation, no bowel perforation was observed, but extensive necrosis and abscess formation of the abdominal wall were found. Therefore, resectional debridement of the necrotic abdominal wall and a left-sided colectomy concomitant with a new colostomy were performed.
Mucorales was detected in the mesenterium of the resected specimen by histological examination. Antifungal therapy for mucormycosis was initiated, but the patient died of multiple organ failure on POD74.

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In April 201X, a 60s old man was admitted to the hospital with a history of worsening headache, anorexia and vomiting. Brain MRI revealed the presence of a small brain tumor. A contrast-enhanced CT of the head performed after neurosurgical consultation revealed a metastatic tumor measuring 3.5 cm in diameter, with edematous change in the cerebellum. Abdominal contrast-enhanced CT was performed to identify the primary lesion. There was wall thickening of the bowel from the cecum to the ascending colon and enlargement of the regional lymph nodes, but no other lesions were observed. The patient had gait disorder, therefore, resection of the mass in the cerebellum was first undertaken in May. The resected tumor was diagnosed histopathologically as a metastasis from the colon cancer. Therefore, a second operation, namely, ileocecal resection, was performed in June, and the patient was discharged on the 11th postoperative day. Tumor recurrence in the brain was detected two months after the surgery, and whole—brain radiation was administered. However, since the patient again developed gait disorder, resection of the mass in the cerebellum was performed again. After surgery, he underwent γ knife therapy of the residual tumor. The patient has been followed up for 9 months, and no evidence of recurrence of the non-intracranial lesion has been observed. In stage IV cases of cancer with brain metastasis, long-term survival may be obtained by controlling the local lesion.

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A 73-year-old man with a chief complaint of defecation difficulty was examined in detail, and diagnosed with rectosigmoid colon cancer, cT4N0M0 cStage II, complicated by vesicocolonic fistula. Radical surgery was deemed to necessitate total cystectomy, so we elected for a strategy of preoperative chemotherapy aimed at sparing the bladder. A double-barrel colostomy in the sigmoid colon was followed by nine courses of a FOLFIRI+Bevacizumab (10 mg/kg) regimen and three courses of a FOLFIRI regimen. Abdominal computed tomography (CT) showed a reduction in bladder invasion and disappearance of the vesicocolonic fistula, and cystoscopy showed normalization of the mucosa, so sparing the bladder was deemed possible, and surgery was performed. Surgical findings revealed a reduction in the invasion range, and high anterior rectal resection+partial cystectomy yielded pathological radical treatment. We report herein a case in which preoperative chemotherapy was performed for rectosigmoid colon cancer complicated by bladder invasion and total cystectomy was successfully avoided.

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A 70-year-old man was seen at our hospital because of abdominal pain and vomiting. Abdominal computed tomography showed a high-density object in the sigmoid colon and a surrounding air-density area.
We performed an emergency operation with a diagnosis of sigmoid colon perforation by a rice cake. Partial sigmoid resection and anastomosis was performed.
At laparotomy, a hard rice cake was incarcerated at the site of perforation of the sigmoid colon, with ulceration in other parts formed by the pressure from the rice cake.
Because I encountered a rare case of sigmoid colon perforation by a rice cake, I report it herein.

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Six patients with locally advanced colorectal cancer (including 5 cases of rectal cancer and 1 case of sigmoid colon cancer) were treated with a new neoadjuvant chemotherapy using either mFOLFOX6 plus bevacizumab, or SOX plus bevacizumab. No preoperative radiotherapy was applied in any of the cases. All six patients showed good tumor regression, which facilitated tumor resection in the limited pelvic space. Of the 6 patients, R0 resection was accomplished successfully with no local relapse in 5 patients, while the sixth patient developed invasion of the urinary bladder. Furthermore, 2 patients showed a pathological complete response (pCR) or near-pCR. Grade 3 adverse events occurred during the chemotherapy in 3 patients, including neutropenia in 2 patients and liver dysfunction in 1 patient. Anastomotic leakage occurred in 1 patient after the surgery due to a technical error. This new neoadjuvant chemotherapy without radiotherapy appears promising as a viable treatment strategy for locally advanced colorectal cancer.

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Intrahepatic bile duct adenoma is a rare benign epithelial tumor of the liver originated in bile duct cells which is rarely diagnosed from imaging methods and is incidentally detected at autopsy or surgery in many cases. We present a case of intrahepatic bile duct adenoma suggestive of hepatic metastasis of transverse colon carcinoma, together with a review of the literature.
A 74-year-old man who underwent left hemicolectomy for transverse colon carcinoma T4aN1M0 one year earlier was detected on CT to have a 7-mm low density area in the segment 8 of liver. EOB-MRI scan revealed faint high signal intensity on T2-weighted images, high signal intensity on diffusion-weighted images, and low signal intensity on hepatobiliary phase. Hepatic metastasis of the transverse colon carcinoma was diagnosed, and partial hepatectomy was performed. Histopathology revealed the tumor to be composed of growth of small tubular accumulation which was similar to bile duct. Immunochemistry showed the tumor cells to be positive for CK7 and negative for CK20. Intrahepatic bile duct adenoma was thus diagnosed.
Intrahepatic bile duct adenoma grossly mimics metastatic hepatic carcinoma as well and we have great difficulties in differential diagnosis. In making diagnosis of a hepatic tumor associated with malignant neoplasm, we should bear the possible existence of the disease in mind.

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A 39-year-old man who came to our hospital because of an epigastric mass with pain was found to have a solid tumor in the lateral segment of liver on abdominal ultrasonography and CT scan. Blood examination showed a slight rise in inflammatory marker, but hepatic function was normal. Hepatitis virus were negative and tumor markers were within normal ranges. Abdominal CT and MRI scans visualized it as an ischemic tumor. As the tumor was associated with pain and rupture of the tumor was considered probable, left hepatectomy was performed. Histopathology revealed solid proliferation of spindle-shaped cells. On immunohistochemistry, the tumor cells were positive for Vimentin and negative for epithelial markers such as CK, hepatocyte, and CK7. The tumor cells were also negative for S100, smooth muscle actin (SMA), CD34, CD68, and desmin. Undifferentiated sarcoma was thus diagnosed. The patient is alive and has been free from disease recurrence, as of one year and 6 months after the operation.
The disease is a rare malignant mesenchymal tumor in infants and children. It is extremely rare in adults. We present a case of undifferentiated hepatic sarcoma affected a 39-year-old man, with a review of the literature.

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The patient was a 53-year-old man who presented with extrapyramidal symptoms from the age of 13, was diagnosed with Wilson's disease at the age of 19, and thereafter had been administered D-penicillamine. From around the age of 35, he had been given cyclosporine for psoriasis vulgaris. A CT scan performed at a previous hospital revealed a hepatic tumor. An abdominal contrast-enhanced CT scan and a Gd-EOB-DTPA-enhanced MRI scan showed a 6-cm tumor with a pattern of early enhancement and washout in the segment 2 of liver. Hepatocellular carcinoma (HCC) was diagnosed. Although he had neurological symptoms such as dysphagia and there was a risk of taking oral cyclosporin, his hepatic function was rated as Child-Pugh A. Because we thought the patient was tolerable for radical resection, and he underwent limited resection of lateral segment. The histopathological diagnosis was moderately differentiated HCC. The underlying liver histology was cirrhosis. Rhodanine staining demonstrated no copper deposits in the hepatic cells. It has been believed that Wilson's disease is rarely associated with HCC, but in this case, a risk of carcinogenesis might increase by association of psoriasis vulgaris and administration of cyclosporine, resulting in development of HCC with cirrhosis.

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The non-surgical management of benign biliary obstruction consists of endoscopic retrograde cholangiopancreatography and stent insertion whenever possible ; however, the stent must be changed at regular intervals, which involves patients undergoing repeated endoscopic procedures.
A 72-year-old man was referred owing to cholangitis and progressive jaundice. Magnetic resonance cholangiopancreatography demonstrated a stricture in the common bile duct (CBD), while a computed tomography scan revealed an abnormal portal vein that was deemed to be the cause of the CBD compromise. The case was initially managed by endoscopic retrograde biliary drainage and stent insertion. The patient was informed that regular stent changes would be required over the long term ; however, he requested definitive surgical management of his condition and underwent choledochojejunostomy and cholecystectomy. He made an uneventful recovery and remains well 3 years postoperatively with no recurrence of the cholangitis.
Here we reported a case of a patient presenting with biliary obstruction caused by an abnormal extrahepatic portal vein, an unusual cause. The use of definitive surgical management prevented the need for recurrent stent changes and improved the patient's quality of life.

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A 57-year-old man was underwent a medical examination at our hospital mainly for right back pain and fever. The results of a blood test revealed high levels of inflammation markers and enzymes of the hepatobiliary system ; acute cholecystitis and portal venous thrombosis were diagnosed in the patient considering the findings of an abdominal computed tomography scan. Therefore, we administered antibiotic and anticoagulant therapy. After that, because the patient's symptom and laboratory findings improved promptly and furthermore, the size of the thrombus reduced, we performed a cholecystectomy 3 months after the onset of the disease.
Portal venous thrombosis is a rare disease that is reportedly caused by malignant tumors, congenital blood-coagulation disorders, or inflammation. As the disease in this patient was possibly caused by acute cholecystitis, the most important treatment step was the control of biliary infection that induced thrombus. In addition, we administered therapy for thrombosis. Herein, we report a case of acute cholecystitis complicated with portal venous thrombosis along with a literature review.

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A 64-year-old-man who had a previous history of ascending colon and left renal pelvic cancers was found to have dilation of an intrahepatic duct at another hospital in 2008. He was referred to our hospital for further examination and treatment of rectal and gastric cancers in June 2010. No marked change in the degree of intrahepatic biliary dilation was shown on CT, and biopsy under the endoscopic retrograde cholangiography revealed no malignancy, so we decided to observe the biliary tract tumor carefully. Tumor growth was shown on CT after one year, and he underwent left hepatic and caudate lobectomy with a preoperative diagnosis of IPNB in May 2011. Histopathologically, the tumor extended from the left hepatic duct to the whole of the lateral segment, and papillary tumor was seen around the bifurcation of the hepatic duct. Slight tumor invasion into the wall of the bile duct was found. The tumor was considered to be slow-growing and low-grade, because of the long clinical course.
In this case, it was important to consider the possibility of Lynch syndrome based on the past medical and family history. We need to think of the possibility of IPNB and consider the indications or resection when localized intrahepatic biliary dilation and papillary tumor are seen.

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We report a case of a 72-year-old man who presented with abdominal pain. Computed tomography revealed stenosis at the ascending colon, while colonoscopy showed extrinsic stenosis at the ascending colon. Intraoperatively, the tumors were palpated in the ascending colon and the jejunum 30 cm distal from Treitz's ligament with peritoneal dissemination. Ileocecal and partial resection of the jejunum were performed. Histopathological findings showed well-differentiated tubular adenocarcinoma originating from a Heinrich type II aberrant pancreas in the jejunum and a metastatic lesion in the ascending colon.
Aberrant pancreatic cancer in the jejunum is rarely encountered. Here we report such a case and review the pertinent literature.

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Portal annular pancreas (PAP) is a rare variant in which the uncinate process of the pancreas extends and fuses with the pancreatic body via the dorsal side of the portal vein (PV). Patients with PAP alone are generally asymptomatic, but careful consideration of this anomaly during pancreatic head surgery is required. We experienced a case of a 60-year-old man with PAP who underwent pancreaticoduodenectomy (PD) for the diagnosis of pancreas head cancer. Intraoperatively, we could not identify the main pancreatic duct after cutting the pancreas above the PV, and we confirmed the existence of the pancreatic substance at the posterior side of the PV with subsequent continuous fusion with the pancreatic body, including the main pancreatic duct. At that time, we noted the PAP. PD required some difficulty to make the cut surface of the remnant pancreas body to make pancreatojejunostomy feasible. The posterior side of the PAP was resected as close as possible to the site of fusion. Despite these efforts, a grade B pancreatic fistula occurred. Thus, it is important to confirm the anatomy of the pancreas in detail to ensure safe pancreatic head surgery.

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A 72-year-old man diagnosed as having pancreatic head cancer was referred to our hospital with obstructive jaundice. An abdominal CT showed an anomalous common hepatic artery branching off from the superior mesenteric artery and penetrating the pancreatic parenchyma behind the portal vein, namely, a hepatomesenteric trunk. After neoadjuvant chemotherapy with gemcitabine and S-1, pancreaticoduodenectomy was performed with concomitant resection and reconstruction of the hepatic artery using the mobilized splenic artery. Histopathological examination revealed invasive ductal adenocarcinoma (mod to por) of the pancreatic head, pT3, pN0, pM0, pStage III, R0. The tumor was closely attached to the anomalous hepatic artery without the histopathological evidence of involvement of the vessel. Contrast-enhanced abdominal CT carried out 6 months after the surgery showed patency of the anastomosed hepatic artery.

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A 77-year-old woman, who had been on hemodialysis due to chronic renal failure, was referred to our hospital for further examination of high fever and abdominal distension. There was a one-month history of poor health and she had been given antimicrobial agent at the previous hospital. When she was first seen at our hospital, tenderness over the abdomen and peritoneal irritation sign were recognized. Blood examination revealed a rise in inflammatory reaction. Abdominal contrast-enhanced CT scan showed free intra-abdominal air, ascites and an intrauterine contraceptive device (IUD). Since there was gas image inside of the uterine, around the IUD, and she had panperitonitis, uterine perforation due to the IUD was suspected. Emergency operation disclosed perforation in the uterine fundus. We performed total hysterectomy and constructed colostomy. Here, we report a rare case of panperitonitis caused by uterine perforation due to prolonged placement of IUD.

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A 59-year-old woman presented with an abdominal mass. Contrast-enhanced computed tomography (CT) revealed a solid mass encompassing the left kidney, consisting mainly of a low-density area suggestive of fat, and containing some heterogeneous high-density areas. Based on imaging findings, we diagnosed retroperitoneal dedifferentiated liposarcoma. During surgery, we suspected the tumor was directly invading into the pancreas and transverse colon. We therefore performed left nephrectomy, combined distal pancreatectomy and splenectomy, and partial transverse colectomy. The excised specimen weighed 3,500 g and was pathologically diagnosed as dedifferentiated liposarcoma. Although the aortic separated surface was tumor cell-positive, we judged that the tumor had been macroscopically resected and discharged the patient for follow-up. Contrast-enhanced CT taken 1 postoperatively revealed a nodular shadow in the right lung field, suggestive of metastasis. The patient then underwent right upper lobe segmentectomy. Postoperative pathological examination gave a diagnosis of lung metastasis of dedifferentiated liposarcoma. No recurrence, distant metastasis, or new lesion has since been detected. We report here this rare case of dedifferentiated liposarcoma that remained recurrence-free after resection of the primary tumor and metachronous lung metastasis, and review some of the literature.

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Here we report a case of a parastomal hernia treated by laparoscopic repair using the sandwich technique. A 71-year-old woman who underwent Hartmann's operation for sigmoid colon cancer with multiple liver metastases (H3) 1 year and 5 months earlier presented with a parastomal hernia. Her abdominal pain had aggravated, and liver metastases were under control owing to chemotherapy. We planned to laparoscopically repair the hernia. At the start of the operation, we inserted three trocars in the flank opposite to the stoma. Because the diameter of the hernia orifice was approximately 8 cm, we performed plication suture of the hernia orifice, followed by a repair of the parastomal hernia using the keyhole technique and the Sugarbaker technique. The patient's postoperative course was satisfactory, and we resumed chemotherapy 4 weeks after the operation. No hernia recurrence has occurred. Laparoscopic repair is minimally invasive and entails a low risk of causing infection. In addition, we do not need to change the way of management of the stoma. Therefore, we consider that this is an effective surgical method.

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A 46-year-old female with abdominal pain and vomiting was admitted to our hospital with a diagnosis of bowel obstruction. She had not received abdominal surgery. Abdominal computed tomography showed small bowel loops dilated in the pelvic floor, which led to thin bowels. A long tube was inserted to the patient and conservative therapy was started. But no symptomatic remission was gained. On the 6^th hospital day, enteroclysis performed through the long tube showed complete obstruction of the small bowel. We performed laparotomy on the 7^th hospital day. The operative findings revealed a peritoneal defect in the pouch of Douglas, through which the ileum was incarcerated. The incarcerated ileum was reduced and then resected because it revealed impaired vascular perfusion. The peritoneal defect was closed by sutures. Her postoperative course was uneventful. The possibility of internal hernia should be kept in mind when examining the case of bowel obstruction offering no obvious reason even if conservative therapy can be employed.

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A 51-year-old man injured in a motor vehicle collision arrived at our hospital by ambulance. Multiple fractures, a splenic injury, and right flank abdominal wall hernia were detected. The fractures were treated by the orthopedics department, while the splenic injury was treated conservatively. The abdominal wall hernia was treated by an elective operation due to the lack of incarceration after the patient underwent 1 month of hospitalization and 3 months of rehabilitation. Use of the transabdominal preperitoneal approach identified the hernial orifice from the intraperitoneal side on laparoscopy, and the abdominal wall hernia was successfully repaired. On the 5^th postoperative day, no hernia was visible on CT. The postoperative course was uneventful and the patient was discharged from the hospital on the 12^th postoperative day. This case represents a rare instance of laparoscopic surgery for a traumatic abdominal wall hernia, and this is the first report of reduced port surgery of a patient treated in Japan. Here we describe a case in which laparoscopic abdominal wall hernia repair successfully treated a traumatic abdominal wall hernia.

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A 73-year-old man was seen at our hospital because of a bulge in the right inguinal region. His height was 159 cm, weight was 84 kg, and body mass index was 32.2kg/m². He first noticed the bulge in his right groin during adolescence. The hernia was reducible until age 55. The bulge was similar in size to an infant's head. With the patient in the upright position, the tip of the scrotum reached the knee. Computed tomography revealed that the hernia included the sigmoid colon and the great omentum. Although the hernia was irreducible, the patient was placed on an elective surgery list since there were no symptoms of incarceration. Before the operation, the hernia content and intra-abdominal volume were reduced using Magcorol P. Transabdominal preperitoneal repair (TAPP) was performed using Ventralight ST Mesh and SorbaFix for stabilization. The Japan Medical Abstract Society database contained no previous reports of the treatment of a giant inguinal hernia using TAPP. Here we discuss three points that merit careful consideration based on our treatment experience : judgment and method of reduction, mesh selection, and abdominal compartment syndrome.

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A 67-year-old man, who had undergone hernioplasty for bilateral inguinal hernias 20 years previously, was referred to our hospital for bilateral inguinal bulges and frequent urination. An abdominal computed tomography (CT) scan revealed bilateral soft-density masses in the groin, the right one of which contained part of the urinary bladder. The patient was diagnosed with bilateral recurrent inguinal hernias with a bladder hernia on the right side. A bilateral laparoscopic transabdominal preperitoneal (TAPP) hernia repair was performed. The patient had an uneventful postoperative course and was discharged on the first postoperative day. CT is considered an excellent diagnostic method for bladder hernia. A preoperative diagnosis is especially important to preventing intraoperative bladder injury. Here we report a case of laparoscopic TAPP repair for an inguinoscrotal bladder hernia and reference the relevant literature.

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The seat belt syndrome consists of intraabdominal injuries and/or lumbar spine fractures that occur in a car accident because the abdomen is compressed by a wearing seat belt. The diagnosis of small bowel injury in the seat belt syndrome is often difficult, leading to delayed laparotomy. The strong association between lumbar spine fracture and intraabdominal injuries is well known. Therefore, the presence of a lumbar compression fracture after a seat belt trauma should prompt further investigation to rule out a possible association of intraabdominal injury, especially to the small bowel. It is important not to miss a timing for laparotomy.

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