This paper reports three cases of malignant afferent loop obstruction after choledochojejunostomy. In the first case, a 75-year old woman, who had undergone left hepatectomy for bile duct cancer with bile duct resection, was admitted for Roux en Y reconstruction after choledochojejunostomy because of emesis. The local recurrent tumor caused occlusion of the duodenum and afferent limb, and bypass surgery was performed after transintestinal drainage. In the second case, a 57-year-old man, who had undergone pancreaticoduodenectomy for pancreas cancer, was hospitalized with a high-grade fever and epigastric pain. Exploratory laparotomy revealed widespread carcinomatosis causing afferent loop obstruction, and bypass surgery was performed. In the third case, a 60-year-old woman with paraaortic lymphnode recurrence of gallbladder cancer was admitted as she had afferent loop syndrome. Transintestinal drainage was performed. All these three patients were discharged. Bypass surgery for selective patients turned out to be an effective palliative treatment for malignant afferent loop obstruction.

Palliative care is sometimes difficult for medical staff to say to patients with cancer and their families. The late of using the term “palliative care” decrease the opportunity to know about palliative care for the patients and their families. The primary aims of this study were to reveal physicians’ and nurses’ usage of the term “palliative care”, time to use the term for the first time, and a synonym. We conducted a questionnaire survey to 387 physicians and 518 floor nurses at Hiroshima University Hospital in February, 2010. We analyzed the results of physicians and nurses separately. Two hundred and seventy-two physicians (response rate 70.3%) and 284 nurses (54.8%) answered the questionnaire. Many physicians (77.2%) and the majority of nurses (56.0%) explain with the term “palliative care”. the majority of physicians use the term when cancer cause any symptoms and at early stage. Some nurses (31.4%) couldn’t use the term “palliative care” before physicians explained the term. Nurses having longer experience tend to use the term regardless of physicians’ use. Many physicians use the term “palliative care” at early stage of cancer. Many nurses also use the term at early stage of cancer, but some nurses couldn’t use before physicians’ use.

A woman in her 80s who had difficulty walking due to back pain was admitted to our hospital. Until two months earlier, she had been able to live independently in daily life. She was not severely constipated, did not take laxatives, and had not received an enema or undergone stool extraction. She had no abdominal symptoms, such as abdominal pain or distension. Surprisingly, however, computed tomography showed lower rectal perforation with subcutaneous emphysema in the pelvic retroperitoneum, hip, and left inguinal region. Therefore, we urgently performed abdominoperineal resection to save her. The lower rectum is a relatively uncommon site of perforation in the large intestine, and nontraumatic cases are rare. Elderly patients in particular may have only atypical symptoms and thus require careful attention.