A 67-year-old man was admitted to our hospital because of right lower abdominal pain. Abdominal CT scan showed swelling and hypertrophy of the appendix wall and presence of a low density area near the appendix. We thus diagnosed this case as acute appendicitis with abscess and performed an emergency operation. When laparotomy was done, we observed the swelling of the appendix, and a mass bordered on the appendix which adhered tightly to the jejunum. The patient underwent appendectomy and partial resection of the jejunum. A pathological examination revealed mucinous adenoma of the appendix. The mass bordered on the appendix was mucocele. The mucocele adhered to the jejunum and the mucus infiltrated to the muscularis propria of the jejunum. He had an uneventful post operative course and was discharged from our hospital on the 12th postoperative day.Mucinous cystadenoma of the appendix adhered to the jejunum is very rare and we report our case with some literature review.

In Japan, doctors inexperienced stent-graft new devices are required to secure agreement on criteria and choice of the device size in endovascular aneurysm repair (EVAR) from experienced doctors. It was hoped that strict patient selection might reduce the learning curve for initial successes in given procedures. In a leading center in Japan, a number of cases which were scheduled for operation at other institutes were evaluated anatomically. We surveyed the initial success of Zenith AAA system implantation in the remaining cases by inexperienced doctors and evaluated the results. This study aimed to verify the validity of strict patient selection in improving the success rate of inexperienced doctors. We enrolled 112 consecutive patients from 19 institutes, who were scheduled for repair between January and October in 2007. All patients were evaluated on the basis of a less-than-3mm reconstructed CT image. Mean patient age was 76±5.7 years. All cases satisfied the Zenith's anatomic prerequisites. Fifteen cases were excluded for various reasons, the major reason being insufficiency of the proximal landing zone (LZ) length, angle and contour. The second reason was difficulty to approach via the iliac artery. Ninety seven cases were included, of which 17 cases were low-risk candidates for EVAR. Medium-risk seventy two cases requiring some advice to avoid problems with device size, technique of implantation and choice of main-body side. Eight cases were high-risk, requiring the presence of an experienced surgeon. Excluded cases had significantly shorter proximal LZ, larger aortic diameters 15mm below the renal artery and tortuous access routes on preliminary measurement by inexperienced doctor. Perioperative mortality was 0%, while the major complications were injury to the iliac artery in one high-risk case and thromboembolism of the superficial femoral artery in another. Perioperative proximal type I endoleak occurred in 5 cases. In 3 of these cases, the endoleak was eliminated by implantation of a Palmatz stent. In the other 2 cases, it disappeared within a month without additional procedures. These cases had a significantly greater angle between the proximal LZ and the suprarenal aorta and significant amount of mural thromboses in the proximal LZ. Perioperative type III endoleak occurred in 3 cases. In all cases the endoleak was eliminated by additional procedure. Perioperative type II endoleak occurred 8 cases. In 3 of these cases, the endoleak disappeared within a month. In the 5 other cases, the endoleak did not disappear. Mid-term results showed iliac leg thromboembolism in one case and new type II endoleaks in 3 cases. Type II endoleak occurred in cases which had significantly greater angles between the proximal LZ and the aneurysm. The results which were evaluated in our center had excellent perioperative and mid-term outcomes. We think this evaluation system is effective for risk assessment and reduces the learning curve in EVAR. In anatomically marginal cases, it is possible for proximal type I endoleak and injury of the iliac artery to occur. It is impossible to exclude these marginal cases if treatment need for EVAR is a priority. In these cases, lessexperienced operators should be trained in troubleshooting techniques in advance.

  A-77-old man was admitted to our hospital because of melena in August 2010. Colonoscopy was performed on him, and the case was diagnosed as ulcerative colitis. His symptoms did not abate despite the administration of mesaladine and steroid. He was thus diagnosed with reflactory ulcerative colitis, and underwent total proctocolectomy. The patient had an uneventaful postoperative course and was discharged from our hospital on the 31^st postoperative day. Total proctocolectomy was considerd one of the useful operative procedures for old patients with ulcerative colitis.

A 60-year-old male was transferred to a critical care medical center with a complaint of sudden back pain. He already had suffered severe back pain 22 years previously when he was 38-year-old), but was not diagnosed then. On admission thoracic CT scan revealed a three-channeled structure in the descending aorta. The preoperative diagnosis was an acute redissection of a DeBakey III b dissecting aortic aneurysm. An emergency graft replacement of the descending aorta confirmed the three-channeled structure of the aorta. The remaining of media of the aorta, which occurred in the re-dissected lumen, was thin and weak. The patient was alive and well twenty-five months following the operation.