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A 69-year-old man was referred to our hospital for investigation of leukocytosis and a persistent fever of 38 degrees C, but we could find no evidence of a specific infection. The leukocyte count was 18,000/mm(3), and the serum granulocyte colony-stimulating factor (G-CSF) and alpha-fetoprotein (AFP) levels were both elevated, at 66.3 pg/ml and 1,495 ng/ml, respectively. Computed tomography (CT) showed a gallbladder tumor and we performed extended cholecystectomy. Postoperatively, the fever subsided and the leukocyte count, serum G-CSF and AFP level normalized. Histologically, the tumor was a carcinosarcoma of the gallbladder. Immunohistochemical staining of the tumor cells was positive for AFP, but negative for G-CSF. This is the first report of a carcinosarcoma of the gallbladder producing AFP. The laboratory findings and clinical course strongly suggested that the tumor produced not only AFP, but also G-CSF.

Isolated granulomatous inflammation of the appendix is extremely rare, and its etiology is still unknown. Thus, differentiating between idiopathic granulomatous appendicitis and isolated appendiceal Crohn's disease is difficult. We report a case of idiopathic granulomatous appendicitis with long-term follow-up after surgery. A 26-year-old woman was referred to our hospital for investigation of persistent right lower abdominal pain. Abdominal computed tomography showed a mass, suggesting an inflammatory tumor around the appendix; thus, we suspected subacute appendicitis and performed laparoscopically assisted ileocecal resection. Histological examination of the resected specimen revealed several noncaseous epithelioid granulomas in the wall of the appendix, but no foreign bodies, obstructing lesions, or parasites. Stains for acid-fast bacillus and fungi, and serology for yersinia were all negative. The patient has been followed up for 9 years and remains asymptomatic. This clinical course suggests that her isolated granulomatous appendicitis was idiopathic granulomatous appendicitis unrelated to Crohn's disease.

The effectiveness of using an absorbable suture material for continuous closure of abdominal wounds, especially contaminated wounds, has not yet been determined. Thus, the present study was conducted to investigate the wound complications that developed following continuous closure of clean and contaminated abdominal wounds using polydioxanone (PDS), compared with those that developed following interrupted closure using braided silk. Running closure using PDS was performed in 152 patients (PDS group), while 280 patients who underwent interrupted closure using braided silk served as controls (SILK group). The occurrence rates of wound dehiscence, early wound infection, and incisional hernia did not differ significantly between the two groups; however, the incidence of late suture sinus formation in the PDS group (1.3%) was significantly lower than that in the SILK group (7.1%). Moreover, late suture sinus formation following PDS suturing healed within 1 week after percutaneous drainage alone without removal of suture strings, whereas late suture sinus following braided silk suturing took an average of 16 days to heal and required removal of the infected suture strings in all 20 patients. These findings indicate the potential usefulness of PDS as a suture material to achieve running closure of clean or contaminated abdominal wounds.

We report herein the case of a patient in whom manganese (Mn) deposition in the basal ganglia was detected by magnetic resonance imaging (MRI) subsequent to thoracic esophagectomy, performed following perioperative parenteral nutrition. A multi-trace-element supplement solution which included 20 micromol of Mn per day had been parenterally administered for 7 days preoperatively and 21 days postoperatively. The serum level of total bilirubin reached a maximum value of 5.1 mg/dl postoperatively. The T1-weighted MRI on the 32nd postoperative day demonstrated bilateral and symmetrical hyperintense lesions in the globus pallidus and the whole-blood Mn level on the 34th postoperative day was 4.9 microg/l, the normal range being 0.8-2.5 microg/l. This hyperintensity on T1-weighted MRI was gradually improved following normalization of the blood Mn level. This case report serves to demonstrate that even short-term perioperative parenteral nutrition may result in Mn deposition in the brain following radical surgery for esophageal cancer, especially in patients with hyperbilirubinemia.

A rare case of primary mesenteric tumor of adult T-cell leukemia/lymphoma (ATLL) is reported. A 64-year-old man was admitted to our hospital after the diagnosis of a palpable ileocecal tumor. Although the serologic test for human T-cell lymphotrophic virus type I (HTLV-I) antibody was positive, neither ATLL cells in the peripheral blood nor systemic lymphadenopathy were observed. At laparotomy, the tumor was histopathologically revealed to be ATLL, and was also found to be restricted to the mesentery. An immunohistochemical examination of the tumor tissue using a specific monoclonal antibody was positive for CD2 and CD4, and negative for CD8. Proviral genome integration in the tumor cells was found by Southern blotting using a 32P-labeled HTLV-I probe with EcoRI and PstI digestion. Combination chemotherapy including cyclophosphamide, Adriamycin, vincristine, and prednisolone was begun postoperatively, but the patient did not respond to therapy. Up to now, only two cases of ATLL originating primarily in the abdominal cavity have been reported. These cases all demonstrate the need to consider the possibility of a primary ATLL mesenteric tumor without leukemic manifestation in the peripheral blood.

A case of a Richter hernia at the insertion site of the drainage tube following open abdominal surgery is reported. A 54-year-old man underwent an emergency operation for an idiopathic rectal perforation. A partial resection of the rectum and drainage using four 10-mm (outer diameter) drainage tubes with round cross sections was performed. Despite an uneventful early postoperative course, an emergency reoperation was required for peritonitis due to a bowel perforation 14 days after removing the drain inserted into the rectosacral space. A laparotomy revealed an incarcerated Richter hernia with ileal perforation through the 10-mm drainage site. The postoperative course after a partial resection of the ileum and drainage with Penrose drains was uneventful. This is the first report of a Richter hernia through the insertion site of a drainage tube in abdominal surgery. The possible occurrence of a Richter hernia in cases with postoperative drainage using large-size round drainage tubes should thus be considered in such patients.

Concomitant surgical procedures for coronary artery disease and double cancers are reported. A 61-year-old man with severe triple-vessel coronary disease was found to have early gastric cancer and advanced rectal cancer. We successfully performed a concomitant coronary artery bypass graft using an extracorporeal ultrafiltration membrane and curative surgery for both cancers. Concomitant surgery thus appears to be a benefical and safe approach for the treatment of critical coronary artery disease and intraperitoneal double cancers in carefully selected patients.

We present herein the case of a 73-year-old woman with symptomatic liver cysts and cholelithiasis for whom successful deroofing of the liver cysts and cholecystectomy were performed via laparoscopy. Histopathological diagnosis of the resected cyst wall and direct observation of the inner surface of the remaining cyst wall confirmed that they were benign biliary cysts. The laparoscopic deroofing of liver cysts is therefore not only an effective means of treatment, but it also facilitates the establishment of an exact differential diagnosis.

Although umbilical or cutaneous metastases from asymptomatic internal malignancies are occasionally documented, the literature contains no report of a solitary cutaneous metastasis to an old operative scar from an asymptomatic internal malignancy. A rare case of colonic cancer presenting as a solitary subcutaneous metastasis to a lower abdominal scar resulting from an open prostatectomy is described in this communication. It was impossible to distinguish this subcutaneous metastasis from a pyogenic granuloma caused by residual sutures without histological evidence. Thus, a granuloma that persists despite repeated treatment may be a possible sign of asymptomatic internal malignancy.