Purpose : To evaluate the meaning of Onodera's Prognostic Nutritional Index (O-PNI) for postoperative survival of advanced gastric cancer (GC) patients with a normal preoperative serum level of carcinoembryonic antigen (CEA).
Patients and methods : Among 650 patients who had undergone elective surgery for GC, 160 advanced GC patients with a normal preoperative serum CEA level (≤5.0 ng/ml) were enrolled. Uni- and multivariate analyses were performed to evaluate factors related to overall survival (OS). Kaplan-Meier analysis and the log-rank test were used to compare the survival curves between patients with O-PNI>45 and ≤45.
Results : Univariate analysis using 18 clinical characteristics showed that age (>70/≤70 y), tumor type (3,4,5/0,1,2), and the O-PNI (>45/≤45) were associated with OS. Multivariate analysis using these 3 clinical characteristics demonstrated that the O-PNI was associated with OS (hazard ratio, 0.590 ; 95% C.I., 0.358-0.974 ; P = 0.039), along with age and tumor type. Kaplan-Meier analysis and the log-rank test demonstrated a significant difference in OS between the two groups (O-PNI>45/O-PNI ≤45 ; P = 0.021).
Conclusion : Even if advanced GC patients have a normal preoperative serum level of CEA, the O-PNI is useful for predicting their postoperative survival, and it is able to identify such patients before surgery.

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Recombinant human thrombomodulin (rTM) is considered to have reasonable pharmacological effects for the treatment of septic disseminated intravascular coagulation (DIC) caused by intestinal perforation. However, the efficacy of rTM for septic DIC following abdominal emergency surgery has not yet been established. We evaluated the efficacy of rTM for patients with septic DIC associated with intestinal perforation.
Twenty-one patients operated on in our hospital from May 2011 to July 2016 and postoperatively developed septic DIC caused by intestinal perforation were retrospectively analyzed. Their postoperative DIC scores were more than 4. The patients were classified into the rTM treatment group (n=15) and conventional treatment group (rTM not used, n=6). There were no significant differences in the patient's backgrounds between the two groups. The rate of DIC resolution was significantly improved in the rTM group. DIC score and SOFA score in the rTM group were improved on the 5^th day that was significantly earlier than those in the non rTM group. Time to DIC resolution, survival rate at 28th day and duration of ICU stay tended to improve in the rTM group than the other, without statistical significance.
These results suggest that rTM would be a useful drug for treatment of septic DIC associated with intestinal perforation.

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There have been few reports on intrapleural fibrinolytic therapy for acute empyema in elderly patients and the therapeutic effects for them have not been clarified as yet. We retrospectively studied ten patients with the age of 75 and over who received intrapleural fibrinolytic therapy for acute empyema in our hospital since 2011. The male-to-female ratio was eight to two. The median age was 84 years. All patients had some underlying diseases. The performance status (PS) was more than three in six patients. Cure of empyema could be gained in nine patients, and no serious adverse events were reported. The median values of the drainage period and hospital stay were 6 days and 29 days, respectively. In another study, the patients were divided into two groups according to PS, namely, the good PS group (PS 0-2) and the poor PS group (PS 3-4). Significantly shortened durations in the drainage period (p=0.018) and the hospital stay (p=0.019) were noted in the good PS group.
It can be concluded that intrapleural fibrinolytic therapy which carries no serious complications is a safe therapy for acute empyema in elderly patents. The therapeutic effects were generally favorable, but the effects might be restricted when it is given to a patient whose PS is poor.

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Aim : Malignant ascites in patients with carcinomatous peritonitis is often resistant to medical treatment. Symptoms of ascites result in progressive deterioration of quality of life. A retrospective study was performed to clarify the safety and efficacy of Denver peritoneovenous shunts in malignant ascites.
Patients and Methods : A total of 29 patients with malignant ascites were retrospectively evaluated for clinical factors.
Results : Sites of primary tumors were pancreatic cancer in 15 patients, bile duct cancer in 6 patients, gallbladder cancer in 5 patients, breast cancer in 2 patients, and peritoneal malignant mesothelioma in 1 patient. Palliation of abdominal distension was achieved in 24 patients (85.7%). Postoperative complications of grade 2 or higher were seen in 12 patients (41.4%), with grade 5 in 3 patients (10.3%). Median survival time was 47 (range, 0-291) days.
Conclusions : The Denver peritoneovenous shunt is technically feasible and effective for palliating the symptoms of malignant ascites, but perioperative death and prognosis of less than a month were seen. The indications for Denver peritoneovenous shunts must be considered carefully.

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A 63-year-old man was referred to our hospital for further evaluation and treatment of cervical lymph node swelling. CT and PET examinations revealed a tumor of the left thyroid gland and cervical lymphadenopathy. Fine-needle aspiration cytology led to the suspicion of malignant lymphoma. We made a tentative preoperative diagnosis of indolent malignant thyroid lymphoma with cervical lymphadenopathy, and performed total thyroidectomy with cervical lymph node dissection for a definitive diagnosis. We predicted a good clinical outcome of this patient with localized follicular lymphoma of the thyroid gland with cervical lymph node involvement based on the absence of both BCL2 expression and IGH-BCL2 translocation. This case of follicular lymphoma localized to the thyroid gland with cervical lymph node involvement and lacking both BCL2 expression and IGH-BCL2 translocation corresponded to Stage I-II disease encountered at other extranodal sites, which has a good clinical outcome. Similar to localized MALT lymphomas of the thyroid gland, surgical treatment alone may also be useful for localized follicular lymphoma of the thyroid gland.

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A 29-year-old woman who presented to our department because of a mass with bloody discharge at the left nipple had a 2-cm tumor of the left nipple and was diagnosed with adenoma of the nipple by a biopsy. After the biopsy, she was found to be at 6 weeks pregnant. Since the tumor was benign, we decided to perform the surgical resection after her childbirth. Until her delivery, we had observed her clinical course by measuring the size of the tumor with periodic ultrasonography every 6 weeks. The tumor did not enlarge during pregnancy, she was delivered a baby at the 41st week of pregnancy, and the tumor was removed one month after her delivery. Adenomas of the nipple are clinically similar to Paget disease and can be misdiagnosed as invasive carcinoma histologically. These tumors predominantly affect women in their forties, but they are also reported to affect childbearing women around 30 years old in many cases. When we encounter a tumor of the nipple, even in pregnant women, we have to consider the possibility of this disease and treat them not to give excessive therapies that might be crucial.

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A 70-year-old woman, who had been followed after surgery for gastric cancer and left breast cancer, suddenly revealed high CA19-9 level (4,339U/ml) in the serum. She was asymptomatic. Chest CT scan showed an anterior mediastinal cyst 20 mm in diameter, and no other lesions were found. FDG-PET showed no accumulation of FDG on the mass. Preoperative diagnosis was benign thymic cyst and the cyst was removed via median sternotomy. The removed cystic mass was multilocular and 40mm in diameter, and contained a yellowish fluid. The CA19-9 and CEA levels in the fluid were also abnormally high (17,020,000U/ml and 73,400ng/ml, respectively). Thymic cyst was diagnosed histologically. Immunohistochemical staining of the cystic epithelium showed positive for CA19-9 and negative for CEA. The serum level of CA19-9 rapidly reduced within the normal range after the operation and has not increased again. We report a rare case of a thymic cyst with elevated CA19-9 level not only in the cystic fluid but also in the serum.

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A 69-year-old man had been on hemodialysis since age 54 years. The patient was now evaluated for a chief complaint of exertional dyspnea, and ultrasound showed severe aortic stenosis. Bioprosthetic aortic valve replacement was performed. The patient developed worsening exertional dyspnea starting 9 months postoperatively, and an ultrasound showed a large aortic valve pressure gradient. Another valve replacement was scheduled, but the patient had a cardiopulmonary arrest during hospitalization and died. Autopsy showed severe calcification and restricted opening of the bioprosthetic valve. This case of acute progressive bioprosthetic valve dysfunction occurring 10 months after surgery is reported.

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We report a case of expanded abdominal aortic aneurysmal wall caused by clot from a bleeding lumbar artery 10 years after abdominal aortic aneurysm resection.
A 68-year-old man had undergone resection of an abdominal aortic aneurysm with bifurcated graft implantation. Some clotting was observed around the graft on computed tomography (CT) 1 month after surgery. However, the clot was still apparent on a CT scan 6 years later, and it had expanded to 62 mm in diameter 10 years later.
Reoperation was performed when the patient was 78 years old. Fresh clot was noted around the graft in the wrapped aneurysmal wall due to bleeding from a lumbar artery that had been ligated in the prior operation.
We concluded that improper ligation of the lumbar artery led to slow bleeding in the early postoperative period.
Antiplatelet drugs administrated after carotid endarterectomy might have contributed to clot enlargement.

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A 63-year-old woman was referred to our hospital for close examination of a growing abnormal shadow in the left middle lung field on chest X-ray. Chest computed tomography revealed a chest wall tumor, 7 cm in maximum diameter, slightly destroying the fourth rib and protruding into the thoracic cavity. Signal intensity of the tumor on magnetic resonance imaging was low on T1-weighted images and high on T2. She was scheduled to undergo surgery according to the primary diagnosis of a tumor of the rib or pleura. Intraoperative histological examination by frozen section suggested the diagnosis of chondroma. However, we performed a wide excision with a 3 cm-wide margin because a possibility of low-grade chondrosarcoma could not be ruled out. The final histopathological diagnosis was grade I chondrosarcoma. She had been free from recurrence and metastasis until her death from cerebral hemorrhage 32 months after the surgery. In the treatment of chondrosarcoma, appropriate surgical excision with a wide margin like in our case is essential because both chemotherapy and radiotherapy are less effective and preoperative diagnosis is difficult.

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A 78-year-old woman who presented to our hospital because of heartburn and sensation of food sticking in swallowing was found to have a huge submucosal tumor on the right-sided wall of esophagus 25-29 cm distant from the incisor teeth by esophagogastroduodenoscopy. A chest contrast-enhanced CT scan revealed a 44-mm diameter tumor in the posterior mediastinum just under the tracheal bifurcation which had obstructed the esophageal lumen from the right side. She was operated on with a diagnosis of a submucosal tumor of the esophagus. Right thoracotomy revealed a tumor at the arch and tail side of azygos vein which continued from the right-sided wall of esophagus. Enucleation of the tumor left a defect in the esophageal muscle layer which was 55 mm in long axis and encircled a half of the circumference of the esophagus. We harvested a pedicled intercostal muscle flap from the right 4-5 intercostal muscle to cover the defect in the muscle layer. The enucleated specimen was a 40-mm pale-yellow solid tumor, and the histopathological diagnosis was esophageal schwannoma. The postoperative course was uneventful and her difficulty in swallowing completely improved. Sometimes we encounter case reports of esophageal submucosal tumor in which esophageal resection could be avoided by covering the esophageal wall defect after tumor enucleation with an intercostal muscle flap. Among of such cases, our case in which the defect was as largest as 55 mm in diameter might serve as a valuable experience in considering the appropriate candidates for this surgical procedure.

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A woman in her seventies complaining of sensation of food sticking in her throat was diagnosed as having squamous cell carcinoma of the lower thoracic esophagus by esophagogastroduodenoscopy. A chest CT scan revealed a tumor-forming mass 5 cm in diameter at the lower thoracic esophagus which had protruded into the left thoracic cavity, suggesting pleural invasion. In order to decide the therapeutic course, exploratory thoracoscopy was performed before treatment. The thoracoscopic findings disclosed no cancer invasion on the parietal pleura corresponding to esophageal cancer, but showed whitish changes in a part of the diaphragm and thickening of the pleura. In order to rule out a possibility of pleural dissemination, parietal pleura at the same site and pleural effusion were collected. Histopathology showed no malignant findings in the both collections, so that cT3N0M0 was diagnosed. We determined that radical resection could be achieved and conducted two courses of neoadjuvant chemotherapy (FP : CDDP 80mg/m² × 1 day + 5-FU 800mg/m² × 5 days), of which outcome was rated as PR. Three weeks after the neoadjuvant chemotherapy, we performed subtotal esophagectomy under right thoracotomy and laparotomy and 2-field lymph node dissection. The final pathological diagnosis was SCCypT3N0M0. The radical therapy could be achieved. The patient has been alive without recurrence, as of 20 months after the operation.

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Basaloid-squamous carcinoma (BSC) is an uncommon type of esophageal cancer and is known for its poor prognosis. BSC patients who could survive for long time after surgical removal of hepatic metastases are rare. We present a patient with BSC with liver metastases, who is alive more than 5 years after resection of the primary lesion followed by twice hepatic resections.
A 59-year-old man complained of dysphagia was found to have lower thoracic esophageal carcinoma by close examinations. Esophagectomy and reconstruction were planned as a two staged operation. Before the second-stage reconstruction, a metastatic liver mass was found in the posterosuperior segment of right hepatic lobe (S7). We performed a partial hepatectomy accompanying with esophageal reconstruction. The pathological diagnosis was liver metastasis of BSC of the esophagus. During followup period, a mass reappeared in the S7. After chemotherapy with cisplatin and fluorouracil, we conducted subsegmentectomy of S7. Currently he is free of recurrence without adjuvant chemotherapy as of 5years and 2 months after esophagectomy (or 4 years and 3 months after surgery for hepatic metastases).

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The case involved a 66-year-old man who underwent esophagogastroduodenoscopy for epigastralgia 4 years earlier that revealed erosion and a small bulge at the greater curvature of the upper body of the stomach. The patient had been followed because a biopsy revealed the bulge to be classified into the Group 2. In addition, he had been treated with oral steroid preparation with the diagnosis of Mikulicz disease on an ambulant basis since about 2 years previously. A recent follow-up esophagogastroduodenoscopy revealed that mucosal irregularity became evident and the bulge enlarged, and a biopsy showed well differentiated adenocarcinoma. The patient was then referred to our department. A CT scan showed remarkable wall thickening of the lesion and swollen lymph nodes, so that exploratory laparotomy was performed with a suspicion of scirrhus gastric cancer. It disclosed an atypical small nodule in the vicinity of the lesion. After conducting neoadjuvant chemotherapy with two courses of S-1+CDDP, we performed total gastrectomy, associated splenectomy and D2 lymph node dissection. The histopathological diagnosis of the swollen and sclerotic lymph node was IgG4-related lymphadenopathy. We have great difficulties in diagnosing the progression of gastric cancer if it is associated with IgG4-relating disease. So we have to decide therapeutic guidelines by keeping the possibility in mind that the gastric wall thickening and lymph node swelling might result from the IgG4-relating disease in the treatment of such patients.

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Duodenal arteriovenous malformations (AVMs) are rare disorders associated with refractory ulcers and GI bleeding, and their treatment can be difficult. A case of a duodenal AVM in which the area of the feeding artery was identified and transcatheter arterial embolization (TAE) was done preoperatively, allowing a segmental duodenal resection to be safely performed, is reported.
A 45-year-old man was brought by ambulance with a chief complaint of hematemesis. Emergency endoscopy showed an ulcer with an exposed blood vessel in the third (horizontal) portion of the duodenum. Contrast CT and angiography showed a duodenal AVM. TAE of the feeding artery was done 2 days before surgery because of concern about massive bleeding from the AVM during surgery. Preoperative TAE to control intraoperative bleeding of a duodenal AVM has not been previously reported. Thus, this case is reported along with a discussion of the relevant literature.

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It is extremely rare that benign fibrous histiocytomas (BFH) arise in the intestine. We have experienced a case of BFH of the duodenum which was surgically resected. The case involved a 60-year-old man complaining of abdominal pain. Esophagogastroduodenoscopy and CT scan revealed a submucosal tumor at the duodenal bulb. Endoscopic ultrasound-guided fine needle aspiration cytology suggested a questionable histiocytic tumor. A possibility of malignant disease could not be ruled out because he was symptomatic, and distal gastrectomy, lymph node dissection, and Roux-en-Y reconstruction were performed. Histopathology did not show any findings suggestive of apparent malignancy but accumulation of histiocytes. A variety of immunohistochemical studies showed diffusely positive reactions for CD68/CD163/CD31. BFH of the duodenum was thus diagnosed. No recurrence has occurred as of 18 months after the operation.
As clinical cases of BFH arisen in the intestine have extremely rarely been reported so far, our case is presented here with a review of the literature.

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Epithelioid angiosarcoma is a rare and aggressive tumor of vascular cell origin that frequently involves the skin and subcutaneous tissue. These tumors may also affect internal organs, such as hearts, liver, and spleen, but rarely emerge in the gastrointestinal tract. We report a case of epithelioid angiosarcoma of the small intestine in a 75-year-old male patient who presented with vomiting, nausea, and anemia. Enhanced computed tomography indicated a mass in the jejunum. Double-balloon enteroscopy of the small bowel revealed a hemorrhagic tumor in the proximal jejunum. Subsequently, the patient underwent laparoscopy-assisted partial resection of the jejunum. Immunohistochemistry of the surgically resected specimens demonstrated positive reactions for the vascular markers CD31 and vimentin. Histologically, the tumor was characterized by the presence of large, round epithelioid cells arranged in solid sheets. Focally, the tumor cells formed gaping, vessel-like spaces. Epithelioid angiosarcoma of the gastrointestinal tract has the potential for rapid metastasis. Accordingly, the patient died about 4 months after surgery.

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A 57-year-old woman presented with ptosis, diplopia, dysarthria, and gait disturbance was diagnosed with myasthenia gravis (MG) and was admitted to our hospital. MRI for lumber spine evaluation revealed a tumor at the mesentery of the small intestine. Tumorectomy and partial resection of the jejunum were performed as the diagnostic treatment. The tumor was composed of proliferation of CD21-positive spindle cells with intense lymphocytic infiltration. Accordingly, it was diagnosed with follicular dendritic cell sarcoma of the inflammatory pseudotumor-like variant (IPT- like FDCS). IPT-like FDCS is an extremely rare tumor, and predominantly affects the liver and the spleen. There have been no reports on IPT-like FDCS which occurred in the lymph node in the mesentery of the small intestine. Furthermore, the relevance of FDCS and MG has been suggested as the paraneoplastic syndrome recently. Our case in which both diseases occurred concomitantly strongly supports the relevance of both diseases. We report the case of IPT-like FDCS occurred in the lymph node in the mesentery of the small intestine accompanied by MG.

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A 7-year-old girl presented to the Pediatrics Department of our hospital with worsening stomachache and fever. She was referred to our department with a diagnosis of acute appendicitis. CT revealed a tooth-shaped foreign body in the expanded appendix. Acute appendicitis caused by an ingested tooth was suspected, and emergency single-incision laparoscopic appendectomy was performed. The appendix was found to be phlegmonous, without perforation. A 9-mm deciduous tooth was found in the resected appendix, and histopathology revealed findings consistent with gangrenous appendicitis. The patient's postoperative course was good, and she was discharged from the hospital on postoperative day 4. Appendicitis due to migration of a foreign body into the appendix is rare, occurring at a reported frequency of 0.2%-0.75%. The majority of foreign bodies that have been implicated in the development of appendicitis include fish bones, dentures and seeds, and this is one of the first reports of a deciduous tooth as the implicated foreign body. Appendicitis caused by dentures or teeth can easily result in perforation ; therefore, early surgical treatment is necessary in such cases.

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A 68-year-old man, who had undergone a right inguinal hernioplasty for bilateral inguinal hernias 15 years previously, presented to our hospital in April 2016 because of right lower abdominal pain and inflammation in the right inguinal region. An abdominal CT scan showed abdominal wall abscess and swollen appendix. Emergent laparoscopy was performed with suspicions of acute appendicitis and strangulation due to recurrent right inguinal hernia. Exploratory laparoscopy revealed that the appendix firmly adhered to the mesh plug and penetrated into the right lower abdominal wall through it. We performed laparoscopic appendectomy and removal of the mesh as much as possible. The abdominal wall abscess was treated with percutaneous drainage through the inguinal region. The patient has been free from recurrence of abscess, as of 6 months after the operation. Abdominal wall abscess due to perforated appendicitis with mesh plug is rare, but this possibility must be considered after inguinal hernioplasty. Abdominal CT alone is insufficient to identify the mesh and to diagnose the inguinal region. Laparoscopic approach preceded to the surgery was useful in the diagnosis in our case. Although we couldn't completely remove the mesh, appendectomy and percutaneous drainage resolved the inflammation in the groin.

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A 97-year-old man was hospitalized with abdominal pain and fever. We immediately diagnosed acute appendicitis via abdominal computed tomography and initiated conservative therapy for his mild symptoms. An initial hematologic evaluation revealed a white blood cell count of 5,000/μl and C-reactive protein level of 0.38 mg/dl. However, his abdominal pain worsened and his white blood cell count increased remarkably to 20,700/μl on the following day, indicating the need for immediate appendectomy. Goblet cell carcinoid of the appendix was diagnosed postoperatively via pathological examination. Although the tumor depth was ss (T3), complete resection was achieved, and lymphatic and/or vascular invasion was not seen. Additionally, no lymph node swelling was detected clinically. Given the advanced age of the patient, we did not perform additional surgery or adjuvant chemotherapy. No recurrence has been observed after 1 year and 3 months. Goblet cell carcinoid of the appendix is rare, and mostly diagnosed following appendectomy. Additional intestinal resection is often considered because of the biologically malignant nature of this tumor. However, the decision regarding further surgery is difficult in cases involving very elderly patients. We therefore present our case together with a review of the literature, with particular focus on elderly patients.

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A 72-year-old woman with a history of rectal prolapse came to our hospital due to sudden small bowel evisceration through the anus after using a bidet toilet seat. On physical examination, small bowel evisceration through the anus was apparent. We diagnosed traumatic rectal perforation with transanal small bowel evisceration and performed a low anterior rectal resection. She was discharged from our hospital on the 10^th postoperative day.
Reports have suggested that cases of small bowel evisceration through the anus had a history of rectal or uterine prolapse. Furthermore, the small bowel evisceration was thought to be the result of rectal wall laceration by the nozzle of the bidet toilet seat. This case is rare, but we should alert patients with rectal prolapse to the dangers of using a bidet toilet seat.

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A female patient in her 50s was admitted to our hospital with melena and weight loss. A close investigation revealed locally advanced rectal cancer, with suspected sacral invasion (lower than S4 level) and lateral lymph node metastasis. Because curative surgery was difficult, we performed local chemoradiotherapy combined with TS-1. Effective tumor reduction was observed on a computed tomography scan after 1 month. After 2 months, rectal amputation with sacral resection was performed. Histopathologically, small amounts of well-differentiated and mucinous carcinoma were present, although most of the tumor comprised fibrous scar tissue, with a negative resection margin. Grade 2 therapeutic efficacy was achieved with preoperative chemoradiotherapy. This treatment is considered effective for unresectable rectal cancer with sacral invasion because it could cause tumor reduction and down-staging, improve the radical resection rate, control local recurrence, and preserve the functions of surrounding structures.

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Colorectal cancer is often discovered in patients with intestinal obstruction. A case in which colorectal cancer was treated by radical surgery after transanal decompression and cytomegalovirus (CMV) enteritis was subsequently found is reported. A 68-year-old man with a chief complaint of constipation and abdominal bloating was diagnosed with intestinal obstruction due to colorectal cancer. Transanal decompression with a colorectal tube was performed for two weeks, followed by radical surgery with anterior colorectal resection (D3 lymph node dissection). Decompression allowed surgery to be performed safely.
The resected specimen showed a large ulceration at the proximal side of the tumor, and histopathological examination of this site showed CMV enteritis. Upper GI endoscopy was later performed because of postoperative tarry stools postoperatively, and reflux esophagitis and multiple duodenal ulcers were diagnosed. Biopsy of these areas showed no evidence of CMV infection. The symptoms and findings improved with a proton pump inhibitor alone, and the patient was discharged. This rare case of colorectal cancer with CMV enteritis was described.

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We performed laparoscopic hepatic resection for focal nodular hyperplasia (FNH) diagnosed in a 7-year-old girl. The child was referred to our hospital because of an incidentally detected abdominal tumor by abdominal palpation. Abdominal enhanced CT revealed a 75 × 70 mm tumor contiguous with liver segment 5/6, with a central scar and a hepatic artery branch (A5) arising from the central scar. Based on these findings and the findings of further examinations by MRI and sonazoid US, the tumor was diagnosed as FNH. In consideration of the risks of bleeding, infarction and infection of the tumor, laparoscopic partial hepatectomy was performed. The histological diagnosis was FNH with proliferative bile ductules and an abnormal muscular artery in the central scar. The patient was discharged from the hospital 6 days after the surgery ; until now, 2 years 9 months since the surgery, there has been no evidence of recurrence.

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A liver tumor was detected via abdominal ultrasound in a 40-year-old man undergoing a medical check-up. Blood chemistry indicated unimpaired liver function, virus marker tests were negative, and tumor marker levels were within the normal range. A 36-mm tumor mass projecting from liver S6 was slightly enhanced from the arterial to the portal vein phase on contrast-enhanced computed tomography, with washout during the delayed phase. The differential diagnosis included hepatocellular carcinoma and sereral other benign liver tumors ; As a percutaneous transhepatic biopsy could potentially induce tumor dissemination, a partial hepatectomy was conducted. The surface of the resected specimen indicated a single, solid tumor nodule with somewhat unclear boundaries and a yellowish-white color. Histopathologically, prominent infiltration of small-to-medium-sized lymphocytes was accompanied by lymphoid follicles in the portal vein area. Immunostaining detected CD3 and bcl-2 positivity, strong CD20 positivity, and CD10 negativity, leading to a diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma. Although primary hepatic MALT lymphoma is relatively rare disease, it should be included in the differential diagnosis of a liver tumor with non-specific imaging findings.

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A 68-year-old Japanese woman diagnosed as having a gall-bladder tumor was admitted to our department. Laboratory findings at admission were as follows : serum CEA, 1.3 ng/mL ; serum CA19-9, 26.5 U/mL ; WBC count, 23920/μL ; serum CRP, 9.14 mg/dL ; serum total bilirubin, 1.0 mg/dL ; serum AST, 33 IU/L ; serum ALT, 16 IU/L ; PT, 62% ; serum TAT, 6.9 ng/mL ; serum fibrinogen, 435 mg/dL ; serum D-dimer, 9.8 μg/mL ; serum AT-III, 98%. MRI and dynamic CT revealed a gall-bladder tumor measuring 2 cm in diameter, dynamic CT revealed a portal venous embolus, and PET-CT showed high accumulation of FDG in the paraaortic lymph nodes, portal venous embolus, and gall-bladder. We diagnosed the patient as having advanced gall-bladder cancer with a portal venous tumor embolus, and lymph node metastasis. After admission, the patient developed acute chronic cholecystitis, and we performed emergent cholecystectomy. Histopathological examination revealed that the lesion was, in fact, not a neoplasm, but a fibrin clot ; therefore, we corrected our diagnosis to cholecystitis with portal venous thrombosis. With administration of heparin and edoxisaban, the portal venous thrombus resolved. Acalculous cholecystitis without cholangitis rarely causes portal venous thrombosis. Although only 20 cases have been reported, clinicians should bear in mind the possibility of acalculous cholecystitis with portal venous thrombosis even in cases where the lesion shows enhanced uptake on PET-CT.

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A 73-year-old woman who was diagnosed with rheumatoid arthritis 28 years earlier and had been on internal treatment with 5 mg/day of prednisolone presented to our emergency clinic because of abdominal pain and vomiting. After emergency admission, her blood pressure decreased on the next morning and her abdominal pain also became worse. Blood analysis showed increases in biliary enzymes and inflammatory reaction, a decrease in the platelet count, and an increase in blood FDP level. An abdominal CT scan revealed enlargement of the gallbladder and thickening of the gallbladder wall. She was diagnosed with septic shock and DIC associated with acute cholecystitis. Emergency cholecystectomy under laparotomy was performed. Macroscopic findings of the resected specimen included necrosis of the gallbladder mucosa and thickening of the gallbladder wall. There were no stones within the gallbladder. Histopathology disclosed transmural necrosis of the gallbladder wall and type AA amyloid deposits mainly within the vascular wall.
It was etiologically considered that AA amyloidosis secondary to rheumatoid arthritis might cause gangrenous cholecystitis. After the operation, respiratory condition and circulatory dynamics were unstable. Despite continuous treatments of septicemia and DIC, she did not respond to the treatments and died on the 42^nd postoperative day.

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A 69-year-old woman, who had been treated with an acupuncture needle in the past, had been diagnosed with an abdominal foreign body, which was characterized by pieces of metal on radiographic examination. The metallic foreign body had been present for a few years, with no intervention, until X-ray examinations performed at a local clinic showed that the foreign material had migrated. On review of the migration of the foreign material, the patient was referred to our hospital. Abdominal X-rays showed fragmented, radiopaque, slender objects located on the left side of the abdomen. Computed tomography showed high-density, small pieces of the foreign object, located in the left paracolic gutter, as well as gallbladder stones. Laparoscopic cholecystectomy and extirpation of the foreign body were performed using the same four ports via fluoroscopy. The foreign bodies were easy to break into multiple fragments ; therefore, they were removed in seven pieces. No remnant foreign material remained ; this was confirmed using fluoroscopy. Since metallic foreign bodies may migrate and lead to injury of abdominal organs, or become corroded, early surgical intervention is recommended.

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Here, we describe a case of mucinous adenocarcinoma of the distal bile duct. A 67-year-old man was referred to our clinic with liver dysfunction. Although he was asymptomatic, computed tomography revealed bile duct dilation and a mass in the distal bile duct. Following endoscopic biliary biopsy through the duodenal papilla Vateri, which revealed adenocarcinoma, he was diagnosed with cancer of the distal bile duct. A subtotal stomach preserving pancreatoduodenectomy was performed for a cT2, cN0, cM0 tumor. The pathological diagnosis was poorly differentiated mucinous adenocarcinoma, and the discovery of multiple lymph node metastases indicated stage pT3a, pN1, M0, II B disease. Although his postoperative course was uneventful, he died of a cancer recurrence 10 months after surgery. We further address the rarity of mucinous adenocarcinoma of the distal bile duct through a review of the literature.

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A 40-year-old woman visited a hospital due to nausea. On computed tomography (CT), the patient had an intra-abdominal mass. She was then referred to our hospital for diagnosis and treatment. Contrast-enhanced CT at our hospital showed two tumors measuring 32×30×12 mm. The tumors were located in the greater omental space. The patient was preoperatively diagnosed with gastrointestinal stromal tumors or lymphoma. Laparoscopic excision of the greater omental tumors was performed. The histopathological diagnosis was hyaline vascular-type Castleman's disease. At 13-month follow-up, no additional signs of Castleman's disease were observed. Castleman's disease is a lymphoid proliferative disorder that most commonly presents as a solitary mass in the mediastinum. An extremely rare case of Castleman's disease in the greater omentum, which has only been reported in 8 cases in the Japanese literature, is presented.

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In this case, a 66-year-old woman visited our hospital with the chief complaints of losses of appetite and weight, and underwent an abdominal contrast-enhanced computed tomography (CT) scan. A mass with a maximum diameter of 11 cm was detected in the right retroperitoneum. Subsequently, we suspected right adrenal carcinoma and resected the tumor. The histopathological diagnosis, based on the resected specimen, was undifferentiated pleomorphic sarcoma. However, it was difficult to identify the organ from which the sarcoma had originated. After surgery, no adjuvant therapy was administered. A CT scan performed 2 years and 10 months postoperatively revealed a tumor with a diameter of 18 mm in the right pulmonary apex region. A pulmonary metastasis was diagnosed following bronchoscopy and transbronchial biopsy. Because no other lesion was found, the patient underwent resection of the right upper lung lobe. The histopathological findings of this resected specimen were consistent with a metastasis of the earlier retroperitoneal tumor. Eight years, 2 months after resection of the primary lesion and 5 years, 2 months after resection of the pulmonary metastatic lesion, no sign of recurrence has been found during follow-up, despite the lack of adjuvant therapy.

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A 48-year-old man was found to have a 6-cm mass in the right abdomen near the kidney on abdominal ultrasound during a routine medical examination. He was referred to our hospital for further evaluation. Abdominal contrast CT showed a 6-cm, well-defined, tumor-like lesion with uniform contrast adjacent to the transverse abdominis muscle (TAM). Abdominal MRI with T1-weighted fat-suppression imaging showed uniformly low signal intensity. A barium enema showed extrinsic compression of the hepatic flexure and transverse colon.
These findings suggested a lipoma of the TAM, but surgery was planned because a malignant tumor could not be ruled out. Imaging showed protrusion into the abdominal cavity, and laparoscopic surgery was performed. A mass protruding below the right costal arch without invasion into surrounding organs was seen. Resection of the mass with part of the peritoneum, preperitoneal fat, and the TAM was performed.
Histopathological examination showed proliferation of fatty tissue surrounded by a capsule, little atypia, and adherent TAM around the margins. The diagnosis was an intermuscular lipoma. Laparoscopic resection of an abdominal wall lipoma is rare. This case is reported along with a discussion of the relevant literature.

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