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小腸innammatory fibroid polyp (以下IFP)による血便の1例および成人腸重積症の1例を経験したので報告する.症例1: 61歳,男性.血便を主訴に当院受診,上部および下部内視鏡検査では明らかな出血源は不明であった.再び下血し当院受診,貧血を認めたため入院となり,諸検査にて小腸出血を疑った.入院中に再度下血したため緊急開腹術を施行した.術中所見では回腸に腫瘍を先進部とした腸重積を認め,回腸部分切除術を施行した.切除標本では頂部にびらんを伴った有茎性腫瘤を認めた.症例2: 59歳,女性.繰り返す腹痛と便秘を主訴に近医受診,腸炎と診断されたが腹痛が増強したため当院受診.腸重積疑いによるイレウスと診断し入院.保存的治療にて軽快,明らかな病変指摘しえず退院したが,再び便秘,腹痛出現,イレウスの診断で再入院となった.イレウス管造影および腹部CT検査にて小腸腫瘍による腸重積と診断し,開腹手術を施行した.術中所見では回腸に腫瘍を先進部とした腸重積を認め,回腸部分切除術を施行した.切除標本では表面平滑な球状有茎性腫瘤を認めた.病理組織学的検索にていずれの症例もIFPと診断された.小腸のIFPは比較的稀で,そのほとんどは腸重積で発症し,下血での発症は稀である.本疾患は術前および術中での質的診断はきわめて困難で,術後の病理組織学的検索に委ねられることがほとんどである.今回われわれは血便および成人腸重積症でそれぞれ発症した回腸IFPの2例を経験したので,若干の文献的考察を加えて報告する.

We encountered a case of rectal leiomyosarcoma with perianal Paget's disease. A 74-year-old man visited our hospital complaining of anal pain and bloody stool. Barium enema examination showed a protruding lesion in the rectum, and endoscopic diagnosis was a submucosal tumor of the rectum. The patient underwent Miles operation for a malignant rectal tumor. Hpwevers, histological diagnosis is unexpectedly determined to be leiomyosarcoma and perianal Paget's disease. Perianal Paget's disease is often associated with a rectal or anal malignant tumor, but is rarely associated with a rectal leiomyosarcoma.

Torsion of the greater omentum is a relatively rare entity in which the greater omentum twists with ischemic change of its periphery. Two cases of primary torsion of the greater omentum which were preoperativly diagnosed as acute appendicitis are reported. The patient 1 was a 40-year-old man complaining of right lower abdominal pain. With a preoperative diagnosis of acute appendicitis, a laparotomy was perfomed. At laparotomy, it was found that the greater omentum was twisted clockwise by 5 terns with serous bloody ascites. The definitive diagnosis was made as primary torsion of the greater omentum, and the patient underwent a resection of the necrosed part of the omentum and an appendectomy. The patient 2 was a 70-year-old woman complaining of right lower abdominal pain after taking a laxative for her constipation. With a preoperative diagnosis of acute appendicitis, and operation was perfomed. At laparotomy, it was found that the greater omentum was twistwd clockwise by 3 terns without ascites. She underwent a resection of the necrosed part of the omentum and an appendectomy. Their postoperative courses were uneventful. It is etiologically thought that abrupt change in patient's posture might cause the torsion, because the patient 1 was apt to twist the body on busines; and in patient 2, accelration of bowel movement due to taken laxative for constipation might cause the condition. The disease presents difficulty in differential diagnosis from acute appendicitis, but we must consider the disease in the case of acute abdomen complaiing of right lower abdominal pain. Pathogenesis of the disease is discussed with a brief survey of the literatures.

Endometriosis of the umbilicus is rare, and account for about 0.2% of all endometriosisexterna. We report a case of endometriosis of the umbilicus with a review of the literature. A 47-year-old woman was seen at the hospital because of umbilical pain and bloody discharge from the umbilicus throughout menstrual period. A spherical mass, 1cm in diameter with slight tender, was palpable around the umbilical region. Abdominal CT scan revealed a solid tumor 12mm in diameter. Based on the clinical symptoms and histopathological features of the biopsied specimen, we diagnosed the tumor as endometriosis of the umbilicus. Under general anesthesia, an enucleation of the tumor was performed. It was diagnosed as endometriosis histopathologically. There have been no signs of the recurrence after the operation.

We encountered a patient with a huge retroperitoneal liposarcoma that infiltrated into the descending colon and formed an ulcer. A 77-year-old man was admitted to the hospital because of bloody stool, fever and general weakness. On abdominal ultrasonography and abdominal CT, a tumor pressing the pancreas, left kidney and colon was detected in the left retroperitoneal cavity. Leakage of contrast medium from the descending colon was observed on a barium-enema study, indicating that an ulcer was formed due to tumor infiltration. On examination of the excised specimen, the tumor measured 10×11×10cm and the internal tissue was necrotized. The ulcerative tumor infiltrated into the descending colon, forming a fistula. The tumor was histologically typed as mixed liposarcoma. Retroperitoneal liposarcoma is discovered as a huge mass in many cases, and thus associated resection is frequently demanded due to infiltration into and compression of other organs. However, it is rare that the tumor infiltrates into the colon, forming an ulcer. Therefore, we report this case with a review of the literature.

Video-assisted thoracic surgery (VATS) was successful in the treatment of spontaneous hemopneumothorax. A 57-year-old man was admitted to our hospital because he felt chest pain and dyspnea during sleep at night. Chest X-ray film revealed hemopneumothorax in the left side. As soon as a chest tube was inserted, bloody discharge as much as 500ml was obtained, nad then he developed hemorrhagic shock. So VATS was performed in an emergency. We found a torn vessel that was actively bleeding at the top of the thoracic cavity. An ENDO-CLIP was enough to control the bleeding. An apical bulla of the left lung was then resected. His postoperative course was uneventful. We think that VATS is useful for the treatment of spontaneous hemopneumothorax.

A case of strangulated ileus caused by a knot in a Meckel's diverticulum is reported. A 75-year-old woman was admitted because of sudden diffuse abdominal pain. Her symptoms became worse despite conservative treatment, and she went into shock. Abdominal CT scan and clinical findings suggested strangulated ileus. There fore, an emergency operation was performed. At laparotomy. a large amount of bloody fluid and strangulation of the intestine caused by a knot in a Meckel's diverticulum without adhesions or bands was found. Resection of the necrotic intestine including the diverticulum was performed. Histopathological examination showed a diverticulum containing all layers of the ileum. Strangulation by a knot is a very rare complication of Meckel's diverticulum. Such a diverticulum characteristically has a long neck, an ampulla at its distal end, and is freely mobile.

A 63-year-old woman was admitted to the hospital because of presenting with cough, feeling of heaviness in the chest, and dyspnea. She had a past history of undergoing a left pulmonary upper lobectomy for lung cancer 1 year and 2 months previously. Chest roentgenography showed left pleural effusion. Chest computed tomography (CT) showed the mediastinal shift to the right and the abnormal mass in left thorax. The old bloody pleural effusion was aspirated and its examination revealed that Hb was 4.0g/dl. The pleural effusion was aseptic and cytodiagnosis was class I. She underwent surgery by left thoracotomy and about 2, 000ml old blood was discharged. The bleeding point was not exactly revealed. Pathologically, the pleural biopsy showed that it had collagenous tissue with deposits of hemosiderin and many clusters of iron-laden macrophages. Eleven months after the operation, chest roentgenography and chest CT revealed no abnormal findings and dyspea was diminished. Expanding hematoma rarely occurs in patients with previous history of undergoing thoracotomy or artifitial pneumothorax. It is inferred that the disease often proceeded to chronic or organic pyothorax, if it is left in place for longtime. This case whitch was quickly treated resulting from manifestation of symptoms in a subacute phase of the disease is reported.

Patient 1, a 56-year-old man, was seen at the hospital because of bloody phlegm. Chest CT scan revealed a nodular shadow 1.5cm in diameter with irregular margin in the right S 9. A partial resection of the lung was thoracoscopically performed. Histopathologically, there were granulation and numerous lymphatic follicles with embryonal center in the nodule. Patient 2, a 49-year-old man, was seen at the hospital because of an abnormal chest shadow at a medical checkup. Chest CT scan visulaized nodular shadows with irregular margin and the diameter of 3cm in the right S 8 and 1cm in the right S 4, respectively. Thoracoscopy-aided partial resection of the lung was performed for both lesions. In the resected nodules, lymphatic follicles with embryonal center were formed. Inflammatory pseudotumor of the lung is a relatively rare entity, and presents difficulty in preoperative diagnosis because it lacks characteristic clinical findings and imagings. In these cases which revealed nodular shadows with irregular margin and converged peripheral vessels on chest CT imaging, we had great difficulty in differentiating them from adenocarcinoma of lung field type. The disease usually has good prognosis and so we must try to preserve the pulmonary function at surgery as possible as we can. We think that thoracoscopy-aided operation which is less invasive is of value in the diagnosis and treatment of inflammatory pseudotumor of the lung.

We report a 65-year-old man who developed sclerosing encapsulating peritonitis (SEP) 15 months after converting from continuous ambulatory peritoneal dialysis (CAPD) to hemodialysis because of intraabdominal hemorrhage following a traffic accident. In January 1999, he suffered acute abdominal pain and vomiting. He was referred to our hospital from a nearby clinic with suggested adhesional intestinal obstruction. Physical examination showed a palpable mass in the lower abdomen. He underwent an emergency operation with a diagnosis of strangulated intestinal obstruction. The laparotomy revealed a large amount of bloody ascites and dense fibrous adhesions that entrapped the small intestine in a thick membrane. We resected the loop of the ileum because separation of the bowel mass, simulating cocoon, seemed impossible. The diagnosis of SEP was made postoperatively. He was started on oral prednisolone therapy after the operation. SEP is a rare and serious complications of CAPD, and develops even after CAPD has bees discontinued. The diagnosis of SEP should be kept in mind in CAPD patients presenting with recurrent adbominal pain or intestinal obstruction.

Transepiploic hernia is a rare disease and lacks in specific symptoms. So it is difficult to diagnose preoperatively. We experienced a case of transepiploic hernia which was successfully diagnosed by abdominal CT preoperatively. A 63-year-old woman was admitted to the hospital because of lower abdominal pain and vomiting. A simple abdominal X-ray film showed some enlarged intestinal gas shadow and we diagnosed the case as ileus. The patient was observed conservatively with a long tube. On 4th hospital day, abdominal CT was performed because of lasting abdominal pain. CT showed much of ascites and the small intestine located over the transverse colon. By puncture bloody ascites was confirmed. A diagnosis of strangulated ileus by transepip-loic hernia was made and an emergency operation was performed. Through a hiatus of the omentum about 3cm in diameter, about 130cm of the ileum prolapsed and necrosed. We performed a resection of the necrosed intestine and an open incision of hiatus of the omentum. In the Japanese literature, 34 cases of transepiploic hernia (type A) have been reported so far, but no other cases than this case could be diagnosed preoperatively.

Colitis cystica profunda is a rare benign disease of the colon and rectum, characterized by immigration of the mucosa into the submucosa and formation of the mucocele. We report a case of colitis cystica profunda. A 26-year-old man was seen at the hospital because of bloody stool passage. Total colonoscopy revealed a tender polypoid lesion with a central depression on the anterior rectal wall 5cm from the anal verge. The lesion was so tender that it was easily flattened by the air sent from a colonoscope. Histological features from the biopsy specimens could not rule out a possibility of well differentiated mucinous adenocarcinoma. The diagnosis of colitis cystica profunda was confirmed with intraoperative transanal resection of the whole lesion.

A 58-year-old man visited another hospital at about 2 p.m. on August 31, 1996, because a piece of iron nail perforated his abdominal wall when he was driving in the nail by a hammer and then an abdominal pain gradually appeared. Simple abdominal X-ray film revealed a piece of iron in the abdomen, and so he was referred to the hospital. Abdomincal CT scan revealed the immigrated iron piece in the S3 of the liver, but no intraabdominal bleeding was noted. A mild abdominal pain still lasted but the general condition was stable. As elective surgery for removal of the foreign body was scheduled for the patient. About 8 hours later, however, severe abdominal pain as well as hypotension occurred and the patient fell into a shock state. Abdominal ultrasonography revealed a pool of liquid under the left diaphragm. With a diagnosis of intraabdominal bleeding due to hepatic injury, an emergency operation was conducted. Upon median incision of the upper abdomen, there were about 1300ml of bloody ascites and a ruptured injury about 6mm in length on the surface of the S3 of the liver that might be made by stabbed iron piece, and the ruptured was bleeding site. After the iron piece was removed, the ruptured wound was sutured. Postoperative course was uneventful and the patient was dischaged from the hospital on the 17th hospital day.

Continuous epidural analgesia is getting common for post operative pain relief. However, postoperative suppression of pain can hide painful pathological responses that will alart abnormallities in the body. A 71-year-old man, 48kg in wight, 158cm in height had a cancer of the sigmoid colon and a right inguinal hernia and underwent a resection of the sigmoid colon and a right herniorrhaphy. He had massive hematemesis and bloody stool on the 7th postoperative day that required a gastrectomy. Anesthesia for the first operation was general anesthesia combined with thoracic epidural analgesia and he had been treated post operative analgesia through this epidural catheter by using infuser (Baxter infusion pump, 1.0ml/h, for 5 days), which contained 0.125% bupivacaine 60ml and 10mg of morphine. Postoperative analgesia was perfect and the patient did not have any discomforts at all. This situation led to mask stress gastric ulcer until massive hemorrhage occurred on the 7th postoperative day.