Gastric cancer simultaneously complicated with extrahepatic bile duct metastasis and portal vein tumor thrombus: a case report.

BACKGROUND: Gastric cancer metastatic to the extrahepatic bile duct or accompanied by portal vein tumor thrombus (PVTT) is rare. To our knowledge, there have been no cases complicated with both of these factors. CASE PRESENTATION: A 72-year-old man presented with icterus and melena. A biochemical blood test showed abnormal values for hepatobiliary enzymes and a tumor marker, and abdominal computed tomography scan revealed wall thickening of the lower bile duct with intra- and extra-hepatic bile duct dilatation and PVTT. A biopsy of the lower bile duct during endoscopic retrograde cholangiopancreatography demonstrated a moderately differentiated tubular adenocarcinoma. Moreover, gastroduodenoscopy showed a type 3 tumor at the lesser curvature of the gastric antrum, and an endoscopic biopsy demonstrated a moderately differentiated tubular adenocarcinoma. We diagnosed concomitant gastric cancer and distal bile duct accompanied by PVTT, and pancreatoduodenectomy with combined resection of the portal vein was performed. The resected specimen revealed a tumor in the lesser curvature of the gastric antrum and circumferential wall thickening in the lower bile duct. In pathological findings, infiltration of a moderately differentiated tubular adenocarcinoma from the mucosal layer to the subserosal layer of the stomach was observed. In contrast, a moderately differentiated tubular adenocarcinoma demonstrating the same histological type as the gastric cancer had spread not to the mucosal layer but mainly to the fibromuscular layer of the lower bile duct. Immunohistochemical staining showed identical patterns between gastric cancer and the bile duct tumor: negativity for cytokeratin 7 (CK7), and positivity for CK19 and 20. Therefore, the final diagnosis was extrahepatic bile duct metastasis from gastric cancer with PVTT. Unfortunately, multiple liver metastases occurred in the early postoperative period and chemotherapy was conducted, but the patient died 12 months after the surgery. CONCLUSIONS: In the diagnosis of extrahepatic bile duct metastasis, immunohistochemical staining of gastric cancer and the bile duct tumor was essential and helpful as decisive evidence.

Incidence and risk factors of pneumonia following acute traumatic cervical spinal cord Injury.

OBJECTIVES: To elucidate the incidence and risk factors for pneumonia after acute traumatic cervical spinal cord injury (CSCI). DESIGN: Retrospective cohort study.Setting: Spinal injuries center in Japan.Participants: Of 184 individuals who were admitted within 2 weeks after acute traumatic cervical spinal injuries, 167 individuals who met the criteria were included in this study.Interventions: The occurrence of pneumonia, degree of dysphagia using the Dysphagia Severity Scale, patient age, history of smoking, presence of tracheostomy, vital capacity, level of injury, and the American Spinal Injury Association Impairment Scale (AIS) 2 weeks after injury were assessed.Outcomes: Incidence of pneumonia were analyzed. Moreover, the risk factors of pneumonia were evaluated using logistic regression analysis. RESULTS: From the 167 individuals who met the criteria, 30 individuals (18%) had pneumonia; in 26 (87%) of these individuals, pneumonia was aspiration related, defined as Dysphagia Severity Scale ≤ 4. The median occurrence of aspiration pneumonia was 11.5 days after injury. A logistic regression analysis revealed that severe AIS and severe Dysphagia Severity Scale scores were significant risk factors of pneumonia after CSCI. CONCLUSIONS: It was highly likely that the pneumonias following CSCI were related to aspiration based on the Dysphagia Severity Scale. In addition, most of the patients developed aspiration pneumonia within 1 month after injury. Aspiration and severe paralysis were significant risk factors for pneumonia. The treatment of dysphagia in the acute phase should be considered an important indicator to prevent pneumonia.

[Long-Term Survival with Distal Pancreatectomy and Postoperative Chemotherapy in a Patient of Pancreatic Invasive Ductal Adenocarcinoma of the Tail with Peritoneal Dissemination].

A 68-year-old man was referred to our hospital for detailed examination of the pancreatic tail tumor. The tumor was diagnosed as the pancreatic invasive ductal adenocarcinoma and the distal pancreatectomy was scheduled. During surgery, a 2 mm white nodule was observed on the posterior wall of the stomach. Intraoperative frozen section showed no obvious malignant findings, suggesting leiomyoma or gastrointestinal stromal tumor. Distal pancreatectomy with D2 lymphadenectomy was completed as planned. However, this nodule was later confirmed by permanent pathological specimen to be peritoneal dissemination of pancreatic cancer and final diagnosis was invasive ductal carcinoma of pancreatic tail, pT3, pN1a, M1 (PER), pStage Ⅳ. He received chemotherapy for 17 months. Although liver metastasis was appeared 26 months after surgery, the disease is still being controlled with chemotherapy at 33 months.

99mTc-GSA scintigraphy for assessing the functional volume ratio of the future liver remnant in the routine practice of liver resection.

BACKGROUND: The significance of incorporating regional functional heterogeneity assessment by liver scintigraphy into the calculation of the future liver remnant has been reported. However, liver scintigraphy entails additional costs and radiation exposure. Nevertheless, studies describing when liver scintigraphy demonstrates an actual benefit over computed tomography liver volumetry are lacking. Thus, we evaluated the degree of agreement between future liver remnant % values calculated by technetium 99mTc diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy (galactosyl human serum albumin-based future liver remnant %) and those by computed tomography volumetry and investigated the practical impact of performing regional functional heterogeneity assessment. METHODS: The Bland-Altman method was used to retrospectively analyze the agreement between computed tomography- and galactosyl human serum albumin-based future liver remnant % measurements in 84 patients. RESULTS: In ordinary patients with a computed tomography-based future liver remnant % greater than 50%, there was a good agreement between both measurements. However, in cases with a computed tomography-based future liver remnant % less than 40%, galactosyl human serum albumin-based measurements were significantly smaller than computed tomography-based values, with 88% of these patients exhibiting a galactosyl human serum albumin-based future liver remnant % less than 30%. After portal vein embolization, galactosyl human serum albumin-based measurements were primarily greater than or in agreement with computed tomography-based values, even in cases with a computed tomography-based future liver remnant % less than 40%. CONCLUSION: Adding 99mTc diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy to computed tomography liver volumetry is advised when deciding on hepatectomy in patients with a computed tomography-based future liver remnant % less than 50%. If the computed tomography-based future liver remnant % is smaller than 40%, it is strongly recommended to check future liver remnant % by 99mTc diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy. In other cases, computed tomography-based future liver remnant % calculation alone can be regarded as the gold standard of safe hepatectomy.

Outcomes of lung metastasis from pancreatic cancer: A nationwide multicenter analysis.

BACKGROUND: Although distant metastasis from pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, some single center studies reported that lung metastasis has a favorable prognosis. The aim of this study is to evaluate the prognostic value of site-specific metastasis after pancreatectomy for PDAC, with a focus on lung metastasis. METHODS: Data from 117 cases of lung metastasis after pancreatectomy were collected retrospectively from 23 institutions in Japan. To compare the sites of metastasis we also collected the data of 134 patients with liver only metastasis, 67 patients with peritoneal only metastasis and 121 patients with locoregional recurrence alone. RESULTS: In patients with lung only metastasis, the median time from recurrence to death (RTD) was 23.1 months, which was better in comparison to other sites of recurrence. In lung metastasis group, the patients who underwent pulmonary resection had better long-term outcomes in comparison to those who did not. (RTD: 29.2 vs 15.2, P < .001). In the multivariate analysis, solitary metastasis (HR 5.03; 95% CI 1.195-21.144, P = .022) and postoperative chemotherapy (HR 14.089; 95% CI 1.729-114.77, P = .023) were identified as significant prognostic factors after lung resection. CONCLUSIONS: Surgical resection is a favorable option for selected patients with a solitary lung metastasis and for whom adjuvant chemotherapy can be administrated.

Imaging Changes and Immune-Checkpoint Expression on T Cells in Bronchoalveolar Lavage Fluid from Patients with Pulmonary Sarcoidosis.

Sarcoidosis is a systemic, granulomatous disease caused by unknown immunological abnormalities. The organs most vulnerable to sarcoidosis are the lungs. Patients often resolve spontaneously, but the lungs can also be severely affected. Although details regarding prognostic factors in sarcoidosis patients with lung involvement remain unclear, several reports have suggested that immune checkpoint molecules are involved in the pathogenesis of sarcoidosis. In this study, we divided sarcoidosis patients into two groups based on chest computed tomography (CT) findings and compared immune checkpoint molecules expressed on T cells in bronchoalveolar lavage fluid (BALF) in the two groups, using flow cytometry. We found elevated programmed cell death 1 (PD-1) or T cell immunoglobulin- and mucin-domain-containing molecule-3 (TIM-3) expression on T cells in BALF in patients with spontaneous improvement in CT findings, compared with those in patients without improvement in CT findings. In conclusion, our study implies that PD-1 or TIM-3 expression on T cells in BALF may be a prognostic factor for pulmonary lesions in sarcoidosis.

Evaluation of Liver Function and the Role of Biliary Drainage before Major Hepatic Resections.

BACKGROUND: Prevention of posthepatectomy liver failure is a prerequisite for improving the postoperative outcome of perihilar cholangiocarcinoma. From this perspective, appropriate assessment of future liver remnant (FLR) function and the optimized preparation are mandatory. SUMMARY: FLR volume ratio using CT volumetry based on 3-dimensional vascular imaging is the current assessment yardstick and is sufficient for assessing a normal liver. However, in a liver with underling parenchymal disease such as fibrosis or prolonged jaundice, weighing up the degree of liver damage against the FLR volume ratio is necessary to know the real FLR function. For this purpose, the indocyanine green (ICG) clearance test, monoethylglycinexylidide (MEGX) test, liver maximum capacity (LiMAX) test, 99mTc-labeled galactosyl human serum albumin (99mTc-GSA) scintigraphy, albumin-bilirubin (ALBI) grade, and ALPlat (albumin × platelets) criterion are used. After the optimization of FLR function by means of portal vein embolization or associating liver partition and PVL (portal vein ligation) for staged hepatectomy (ALPPS), SPECT scintigraphy with either 99mTc-GSA or 99mTc-mebrofenin compensates for misestimation due to the regional heterogeneity of liver function. The role of preoperative biliary drainage has long been debated, with the associated complications having led to a lack of approval. However, the recent establishment of safety and an improvement in success rates of endoscopic biliary drainage seem to be changing the awareness of the importance of biliary drainage. KEY MESSAGES: Appropriate selection of an assessment method is of prime importance to predict the FLR function according to the preoperative condition of the liver. Preoperative biliary drainage in patients with perihilar cholangiocarcinoma is gaining support due to the increasing safety and success rate, especially in patients who need optimization of their liver function before hepatectomy.

Adenosine A2a Receptor Stimulation Attenuates Ischemia-Reperfusion Injury and Improves Survival in A Porcine Model of DCD Liver Transplantation.

Orthotopic liver transplantation (OLT) using allografts from donation after circulatory death (DCD) is potentially associated with compromised clinical outcomes due to ischemia-reperfusion injury (IRI)-induced organ damage and graft-related complications. The aim of this study was to provide in vivo data on the effects of adenosine A2a receptor stimulation in a clinically relevant large animal model of DCD liver transplantation. Cardiac arrest was induced in German Landrace pigs (n = 10; 20-25 kg). After 30 min of warm ischemia, the donor liver was retrieved following a cold flush with 3 L of histidine-tryptophan-ketoglutarate-HTK solution. Animals of the treatment group (n = 5/group) received a standard dose of the selective adenosine receptor agonist CGS 21680 added to the cold flush. All grafts were stored for 4.5 h at 4 °C in HTK-solution before OLT. Hepatocellular injury, apoptosis, protein kinase A-PKA activity, graft microcirculation, liver function, and animal survival were assessed. Compared to untreated livers, adenosine A2a receptor stimulation resulted in improved tissue microcirculation (103% ± 5% vs. 38% ± 4% compared to baseline; p < 0.05), accelerated functional recovery of the graft (indocyanine green-plasma disappearance rate (ICG-PDR) of 75% ± 18% vs. 40% ± 30% after 3 h), increased PKA activity ratio (56% ± 3% vs. 32% ± 3%; p < 0.001 after 1 h), and consequently reduced tissue necrosis and apoptosis. The potent protective effects were clinically manifested in significantly improved survival in the treatment group after 72 h (100% vs. 40%; p = 0.04). The ex vivo administration of adenosine A2a receptor agonist during the back-table flush mitigates IRI-mediated tissue damage and improves functional graft recovery and survival in a large animal model of DCD liver transplantation.

Association between Telomere-Related Polymorphisms and the Risk of IPF and COPD as a Precursor Lesion of Lung Cancer: Findings from the Fukuoka Tobacco-Related Lung Disease (FOLD) Registry.

BACKGROUND: Lung cancer coexisting with idiopathic pulmonary fibrosis (IPF) or chronic obstructive pulmonary disease (COPD) can lead to poor prognosis.  Telomere-related polymorphisms may be implicated in the pathogenesis of these three lung diseases.  As to elucidate the mechanism of lung cancer via IPF or COPD may enable early detection and early treatment of the disease, we firstly examined the association between telomere-related polymorphisms and the risk of IPF and COPD in a case-control study. MATERIALS AND METHODS: A total of 572 patients with IPF (n = 155) or COPD (n = 417), who were derived from our on-going cohort study, and controls (n = 379), who were derived from our previous case-control study, were included in this study.  Telomerase reverse transcriptase (TERT) rs2736100, telomere RNA component (TERC) rs1881984, and oligonucleotide/oligosaccharide-binding fold containing1 (OBFC1) rs11191865 were genotyped with real-time PCR using TaqMan fluorescent probes. Unconditional logistic regression was used to assess the adjusted odds ratios and 95% confidence intervals. RESULTS: TERT rs2736100 was significantly associated with the risk of IPF; increases in the number of this risk allele increased the risk of IPF (Ptrend = 0.008).  Similarly, TERT rs2736100 was associated with the risk of COPD.  In regard to the combined action of the three loci, increasing numbers of "at-risk" genotypes increased the risk of IPF in a dose-dependent manner (P trend=0.003). CONCLUSIONS: TERT rs2736100 was associated with the risks of both IPF and COPD in a Japanese population. A combination of the "at-risk" genotypes might be important to identify the population at risk for IPF more clearly.

[Advanced Adrenocortical Carcinoma with Vena Caval Tumor Thrombus Treated with Extended Surgery and Subsequent Chemotherapy].

A 36-year-old female was referred to our hospital for a giant abdominal mass found by ultrasound examination. A computed tomographic scan showed a large retroperitoneal mass measuring 11 cm in diameter suspected to be liver invasion,a right atrial and inferior vena cava (IVC) tumor thrombus with obstruction of hepatic vein junction of IVC,and small lung metastases. She was diagnosed with cT4N0M1 adrenocortical carcinoma (ACC) by a needle biopsy and radiographic examination. Right adrenalectomy and thrombectomy were successfully performed without cardiac arrest and without liver dissection. The operative time was 485 minutes,and the estimated blood loss was 7,533 ml. No major peri- or postoperative complications were observed. For the residual lung mass,a first line combination chemotherapy with etoposide,doxorubicin,cisplatin and mitotane followed by a second line chemotherapy with gemcitabine and capecitabine were administered. She has been alive with disease for 45 months under mitotane treatment against residual lung metastases. In conclusion,extended surgery could be successfully performed for advanced ACC with right atrium and IVC tumor thrombus. Although careful planning is needed for successful surgery,combination therapy with extended surgery and subsequent systematic chemotherapy may provide a substantial benefit in patients with advanced ACC.

Recurrent idiopathic pulmonary hemosiderosis after long-term remission presented with Sjogren's syndrome: Idiopathic no more?

We report a case of recurrent idiopathic pulmonary hemosiderosis after a long-term remission presented with Sjögren's syndrome. The patient was diagnosed with IPH due to repeated pneumonia and blood sputum in his childhood. He was admitted to our hospital due to exertional dyspnea and dry cough with bilateral ground-glass opacity in chest computed tomography at the age of 32. Video-assisted thoracoscopic surgery was performed and the specimens showed nonspecific interstitial pneumonia pattern with diffuse, chronic alveolar hemorrhage, suggesting recurrence of IPH. He was also diagnosed with Sjögren's syndrome. Further immunological studies will reveal the pathogenesis of IPH.

Fetal gut-like differentiation in gallbladder cancer.

Adenocarcinomas showing fetal gut-like (enteroblastic) differentiation can arise in a variety of organs and are frequently accompanied by an elevated serum α-fetoprotein (AFP) level. However, no study has investigated fetal gut-like differentiation in gallbladder cancer in detail. Herein, we performed morphological and immunohistochemical analyses of fetal gut-like differentiation in 49 consecutive gallbladder cancer cases. The expression of Sal-like protein 4 (SALL4), an embryonic stem cell marker reported to represent fetal gut-like differentiation, as well as other oncofetal proteins, including glypican-3 (GPC3) and AFP, was assessed. We found 1 case of fetal gut-like adenocarcinoma that coexisted with conventional-type adenocarcinoma. The fetal gut-like adenocarcinoma component revealed diffuse immunoreactivity for SALL4 and partial positivity for AFP, whereas the conventional-type adenocarcinoma component was negative. We also found 2 poorly differentiated adenocarcinomas with hepatoid morphology and 1 clear cell carcinoma, none of which showed SALL4 positivity. In other conventional-type adenocarcinomas, focal immunoreactivity for SALL4 and GPC3 was occasionally observed. The overall positivity rates for SALL4 and GPC3 were 12.2% (6/49) and 16.3% (8/49), respectively. SALL4 and GPC3 expression was not associated with clinicopathological factors, including T category, lymphovascular invasion, and lymph node metastases. In conclusion, fetal gut-like adenocarcinoma was found in 2% of our gallbladder cancer series. We conclude that fetal gut-like adenocarcinoma is a distinct histological subtype of gallbladder cancer, characterized by SALL4 expression.

Biological interaction of cigarette smoking on the association between genetic polymorphisms involved in inflammation and the risk of lung cancer: A case-control study in Japan.

Chronic inflammation serves an important role in lung carcinogenesis, thus genetic polymorphisms involved in this pathway may affect the risk of lung cancer. The present case-control study focused on the association between lung cancer risk and genetic polymorphisms involved in inflammatory pathways. The study comprised 462 lung cancer cases and 379 controls from Japan. The roles of interleukin 8 (IL8) rs4073, nuclear factor kappa B (NFκB) rs28362491, cytochrome b-245, alpha polypeptide (CYBA) rs4673, NAD(P) H dehydrogenase, quinone 1 (NQO1) rs1800566, nitric oxide synthase 2 and inducible (NOS2) rs2297518 polymorphisms in lung carcinogenesis were investigated. An unconditional logistic model was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for the association between the genetic polymorphisms and lung cancer risk. The multiplicative and additive [relative excess risk due to interaction, attributable proportion due to interaction (AP) and synergy index (SI)] interactions with cigarette smoking were also determined. A significant association was revealed between the TT genotype of NQO1 rs1800566 and an increased risk of lung cancer (OR=1.78; 95% CI=1.14-2.79). The additive interaction evaluations between CYBA rs4673 (AP=0.50, 95% CI=0.15-0.85; SI=2.66, 95% CI=1.01-6.99) and smoking were also statistically significant. NQO1 rs1800566 was significantly associated with lung cancer risk and smoking may influence the association between CYBA rs4673 and the risk of lung cancer. Additional studies with larger control and case populations are warranted in order to confirm the CYBA rs4673-smoking association suggested by the present study.

Domino Reconstruction of the Portal Vein Using the External Iliac Vein and an ePTFE Graft in Pancreatic Surgery.

BACKGROUND: In the portal vein resection of long distance, an interposition by autologous vein is mandatory. External iliac vein (EIV) has been used, but harvesting the EIV is associated with severe venous congestion of the affected lower extremity. We have reconstructed the EIV using a ringed expanded polytetrafluoroethylene (ePTFE) graft. METHODS: Thirteen patients underwent this surgery. The right EIV was used for reconstructing the portal vein, and the retrieved portion of EIV was interposed by the ePTFE graft. We evaluated size and length of the graft, graft patency, girth of thigh, time for reconstruction of EIV, and graft infection. RESULTS: ePTFE grafts of 8 or 10 mm in diameter were used. The length of ePTFE graft used was 4.4 ± 0.5 cm. Graft patency was kept in 76.9% patients. Graft obstruction was encountered in three patients, and the girth of right thigh increased by about 10 cm. Time for reconstruction of EIV was 29.5 ± 6.8 min. Graft infection did not occur in any patients. CONCLUSIONS: Reconstruction of the EIV using a ringed ePTFE graft seems to be a feasible option for preventing the swelling of the affected lower extremity after procurement of EIV for repairing the portal vein.

Association between genetic polymorphisms involved in the hypoxia-inducible factor pathway and lung cancer risk: a case-control study in Japan.

AIM: Hypoxia-inducible factor (HIF) contributes to the adaptation of tumor cells to hypoxic conditions, so genetic polymorphisms involved in this pathway may affect cellular response to hypoxia and be associated with cancer risk. Thus, we examined the association between the lung cancer risk and genetic polymorphisms involved in the HIF pathway. METHODS: This case-control study consists of 462 lung cancer cases and 379 controls from Japan. We examined the effect of HIF1A rs11549467, HIF1A rs11549465, HIF1A rs2057482, HIF2A rs13419896 and vascular endothelial growth factor A (VEGFA) rs833061 on the risk of lung cancer using TaqMan real-time PCR assay. Logistic regression was used to estimate the odds ratio (OR) and its 95% confidence interval (CI) of lung cancer risk. The multiplicative and additive interactions with cigarette smoking were also examined. RESULTS: The AA genotype of HIF2A rs13419896 (OR = 0.54, 95% CI = 0.30-0.99) and the CC genotype of VEGFA rs833061 (OR = 0.42, 95% CI = 0.24-0.75) were significantly associated with a decreased risk of lung cancer after adjustment of potential covariates. Additive interactions between these two polymorphisms and cigarette smoking were also significant. CONCLUSION: HIF2A rs13419896 and VEGFA rs833061 were significantly related to lung cancer risk, with possible interaction between polymorphisms and cigarette smoking. Further studies are needed to confirm these results.

[Outcome of Resection of Inferior Vena Cava Superior to the Renal Vein in Renal Cell Carcinoma with Vena Caval Tumor Thrombus].

Surgical management with radical nephrectomy and thrombectomy has often been performed in renal cell carcinoma (RCC) with tumor thrombus infiltrating the inferior vena cava (IVC). We retrospectively reviewed the outcomes of IVC resection without venous reconstruction in patients with RCC and IVC thrombus at our institution. Eight patients with right RCC underwent radical nephrectomy and IVC resection superior to the level of the renal vein without venous reconstruction from August 2005 to February 2015. Thoracotomy, liver mobilization, and extracorporeal circulation were performed based on the IVC thrombus level. We assessed surgical outcomes, perioperative complications, and survival. At presentation, four patients had level IIIa IVC thrombus, three had level IIIb IVC thrombus, and one had level IV IVC thrombus. Perioperative imaging showed that three of the four patients who underwent neoadjuvant molecular targeting therapy achieved down-staging of the tumor thrombus level. The median operative time was 406 min, and the median estimated blood loss was 3,135 ml. With regard to IVC resectionassociated perioperative complications, one patient needed extracorporeal circulation with IVC ligation and Pringle maneuver owing to low blood pressure. Another patient underwent temporary hemodialysis for 8 days after surgery. There were no perioperative deaths, and none of the patients required permanent hemodialysis. Three patients survived the mean observation period of 25 months, including one patient with no recurrence. Three patients achieved long-term survival of more than 2 years. IVC resection without venous reconstruction may be a feasible option for patients with RCC and IVC tumor thrombus. Further study is needed to determine the most appropriate candidates for this procedure.

Usefulness of Oblique Multiplanar Images on Multi-Detector Computed Tomography for Diagnosing Intersigmoid Hernia.

BACKGROUND: Intersigmoid hernia is a hernia of the small intestine into the intersigmoid fossa. Because the cavity of the intersigmoid fossa is so small, the preoperative detection of incarcerated intestine and/or mesenteric convergence is very difficult. We report a case of intersigmoid hernia in which the incarcerated bowel and mesenteric convergence could be visualized by oblique multiplanar reconstruction (MPR) images on multi-detector computed tomography (MDCT). CASE REPORT: An 82-year-old man with small bowel obstruction was treated conservatively with a long intestinal tube. Axial plane images of MDCT detected only a thickening of the small bowel wall and a narrowing of the lumen in the pelvis. Since a fourteen-day waiting period did not improve the condition at all, he underwent surgery. The small bowel was herniated into the intersigmoid fossa. After surgery, we studied the preoperative images of MDCT once again. However, neither converged mesentery nor hernia orifice had been depicted. We attempted to make oblique coronal/sagittal MPR images using SYNAPSE VINCENT® and succeeded in visualizing not only the incarcerated bowels but also the hernia orifice and mesenteric convergence. CONCLUSION: Creating oblique MPR images from the MDCT volume data would help in making a preoperative diagnosis of sigmoid mesocolon hernias such as intersigmoid hernia with increasing confidence.