Purpose: We retrospectively evaluated the significance of closed suction drain placement in sphincter saving surgery for rectal cancer, and risk factors of anastomosis leakage.
Methods: One hundred fifty one patients who underwent elective sphincter saving surgery for rectal cancer with the closed suction drain at anterior site of sacrum were subjected. We investigated the frequency of anastomosis leakage, treatment for the leakage, amount of intrapelvic fluid through the drain, and risk factors of the leakage. The incidence and severity of anastomosis leakage was determined using the criteria established by the International Study Group of Rectal Cancer (ISREC) group.
Results: The anastomosis leakage was found in 6 patients (4.0%), three patients with the leakage at posterior site of the anastomosis were classified as Grade A, one patients with the leakage at stump of the side-to-end anastomosis was classified as Grade B, and two patients with the leakage at anterior site of the anastomosis were classified as Grade C. Amount of intrapelvic fluid of patients with the leakage was significantly higher than that of patients without the leakage in the postoperative day 1 (p=0.04), but there was not significant different between these patients in the postoperative day 2 and 3. In the univariate logistic regression analysis, the lateral lymph node dissection (performed, p<0.01) and the time of drain removal (≧ 6 day, p=0.06) were selected. The lateral lymph node dissection (performed, p=0.04) was recognized as a significant independent risk factor for anastomosis leakage by the multivariate logistic regression analysis.
Conclusion: Our current results suggested that closed suction drain placement in sphincter saving surgery for rectal cancer might be useful for a part of patients considering the risk of anastomosis leakage.

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Purpose: We examined the time to initiation of enteral nutrition (EN) in patients who underwent esophagectomy for thoracic esophageal cancer.
Methods: Thirty patients who underwent esophagectomy with right thoracotomy were enrolled and divided into two groups according to the time of EN initiation: the early group (n=13), comprising patients who received EN within 2 days after surgery, and the late group (n=17) comprising patients who received EN more than 3 days after surgery. We then compared the clinical data between the two groups.
Results: Total parenteral nutrition was significantly less frequently administered in the early group than in the late group. The duration of systemic inflammatory response syndrome was significantly shorter in the early group than in the late group. There were no significant differences in postoperative or EN-associated complications. However, we did detect significant differences in the postoperative changes in serum albumin and C-reactive protein (CRP) levels; the CRP level on postoperative day 3 was lower in the early group than in the late group.

Conclusion: Early administration of EN after esophagectomy can be considered useful and safe.

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The patient was a 38-year-old woman. She had been followed-up by previous doctor about calcification in mammography. 3 months ago, a lump in her left breast was appeared and grown rapidly. She was performed core needle biopsy, and was diagnosed that the tumor was invasive ductal carcinoma of breast. She visited our hospital for treatment. The tumor was palpated as a hard mass measuring 50mm (MRI: 42mm) in the AC-region of left breast, also we touched some enlarged axial lymph nodes. Computed tomography showed a nodule of right lung 10mm in diameter, we suspected a metastases of breast cancer. Adjuvant chemotherapy was underwent. The chemotherapy was effective. We recognized partial response for the breast tumor and the lymph nodes metastases. However, the pulmonary lesion was showed stable disease. Video Assisted Thoracic Surgery was performed, the pathological diagnosis was hamartoma. After chemotherapy, the wide excision and axillary lymph nodes dissection. Now she was treated by endocrine therapy, with no recurrence 3 years after operation. We should consider a tissue diagnosis actively, when chemotherapy has the effect primary tumor but not observed in lung lesion.


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A 51-year-old man visited hospital presenting with hematemesis and tarry stool. He was diagnosed as having esophagogastric junction cancer with multiple liver metastases. He received combination chemotherapy with capecitabine, cisplatin, and trastuzumab because HER2 overexpression was observed. After 3 courses, the size of the liver metastases decreased, and was judged as PR by RECIST 1.1. After 8 courses, PR continued. Radical resection with partial hepatectomy was considered in order to improve the prognosis. He underwent total gastrectomy, lower esophagectomy, D2 lymph node dissection, splenectomy, and partial hepatectomy (3 lesions). A pathological examination revealed complete disappearance of cancer cells in primary the stomach lesion. However, a few degenerative cancer cells remained in the S8 lesion of the liver. We performed fifteen courses of adjuvant chemotherapy with trastuzumab and capecitabine. He is free of recurrence at eighteen months after operation.

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The patient was a 49-year-old man, who had undergone distal gastrectomy with Billroth Ⅱ reconstruction for perforated duodenal ulcer at the age of 40. He had conservative treatment for stomal ulcer with diarrhea and hypoalbminemia from 9 month ago at another hospital. He was referred to our hospital because of lower thigh edema and physical weariness. On admission, colonoscopic examination, upper gastrointestinal endoscopic examination and upper gastrointestinal series revealed a gastrojejunocolic fistula due to stomal ulcer. Partial resection of the gastrojejunostomy and the transverse colon including the fistula and Roux-en-Y reconstruction were performed. Recurrence of the stromal ulcer after the surgery was improved with conservative treatment.
Gastrojejunocolic fistula due to stomal ulcer was rare, but it should be considered in the differential diagnosis in patients who develop diarrhea, hypoalbminemia after a distal gastrectomy. Thereʼs high risk of recurrence, so that we should perform appropriate operating method and administer proton pump inhibitor immediately after surgery.

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The patient, a 60-year-old woman who was diagnosed as having a duodenal adenoma during a routine medical examination, was referred to our hospital in 2005. Esophagogastroduodenoscopy revealed a whitish elevated lesion measuring 35mm in the superior wall of duodenal bulb.
Biopsy showed low grade adenoma and hence the lesion was monitored. On endoscopic examination, the appearance and size did not change. In 2014, the tumor was identified carcinoma in situ by endoscopic biopsy and diagnosed as a cancer. We considered three therapeutic options for this tumor：partial resection of the duodenum, endoscopic submucosal dissection, or pancreatoduodenectomy. We performed partial resection of duodenum via laparotomy using intraoperative endoscopy. During the operation, the tumor was marked from the duodenal lumen by the endoscopist and confirmed by the surgeon from outside the duct. We safely resected the involved segment of the duodenum and sutured the ends. Histopathology revealed high grade adenoma including carcinoma in situ and the resected margins were free of tumor. We report that intraoperative endoscopy provides radical, safe, and minimally invasive therapy for partial resection of the duodenum.

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A 45-year-old man with right lower abdominal pain was transferred from his doctor to our hospital because a CT scan showed a tumor in the small intestine. On admission, he had right lower abdominal tenderness and rebound tenderness. An abdominal CT scan showed a mass like a Meckelʼs diverticulum with the dirty fat sign. We suspected that there was a Meckelʼs diverticulum with ectopic gastric mucosa because ^99mTc scintigraphy showed accumulation in the mass. On the same day, we performed an emergency operation with single incision laparoscopy-assisted surgery. Meckelʼs diverticulum was enlarged and coated with omentum, and white moss was seen in the abdominal cavity. We performed a diverticulectomy from outside the body via the umbilicus. Histopathology findings were erosion and infiltration of inflammatory cells, with epithelial regenerative changes. There was no ectopic gastric mucosa or pancreatic tissue. The patient was discharged complication-free from our hospital.

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An 83-year-old man was seen at our hospital because of abdominal pain. Stenosis of the ileum was detected by enteroscopy, but there was no evidence of malignancy in the biopsy results. Therefore, he underwent endoscopic dilatation.
Three months later, he was readmitted with recurrence of abdominal pain. Because there was stenosis at the same site and he had symptoms of ileus, we inserted an ileus tube, decompressed the intestinal tract, and performed laparoscopy-assisted surgery. The pathological diagnosis was simple ulcer.
A simple ulcer of the small intestine is classified as a non-specific ulcer, and it is a rare disease that shows histopathologically non-specific inflammation and a macroscopically deep ulcer. As a simple ulcer of the small intestine is often resistant to conservative treatment, most patients require surgical treatment; until recently, open surgery was the standard procedure.
When the case requires emergency surgery due to bleeding or perforation, indication of laparoscopic surgery is sometimes difficult. However, ileus due to a simple ulcer of the small intestine, where decompression is possible, is a good indication of laparoscopic surgery.

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A 30-year-old man visited our hospital because of a sudden right lower abdominal pain. He had tenderness and rebound pain of the right lower abdomen. Laboratory tests showed elevated white blood cell count and C-reactive protein level. He was admitted to our hospital for observation of intussusception demonstrated by abdominal CT scan. Barium, colonoscopy and abdominal enhance CT were compatible with the diagnosis of intussusception due to mucinous cystadenoma or cystadenocarcinoma of the appendix, for which ileocecal resection with dissection of regional lymph nodes was performed. Histopathological examination showed mucinous cystadenoma. His postoperative course was uneventful and the patient was discharged 9 days after the operation. Intussusception due to mucinous cystadenoma of the appendix is rare, and preoperation diagnosis is difficult. The operation needs to prevent the onset of the peritoneum false myxoma. If preoperation diagnosis is possible, we can choose an appropriate method and keep a safe maneuver in mind.

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The patient was a 84 years old male with incidentally-detected tumor of transverse colon involving adjacent tissues. Colon fiberscopy revealed narrowing over the entire circumference of the colon, diagnosed malignant lymphoma by biopsy. Resection of primary lesion was performed to avoid perforation of tumor and colon stenosis associated with chemotherapy, though surgery itself is not curative treatment. The histopathological diagnosis was primary diffuse large B-cell lymphoma of the transverse colon. We followed up his subsequent history closely without definitive therapy for the reasons of his advanced age and his severe underlying diseases such as cerebral infarction and dementia. He died 24 months after surgery of peritoneal deseminations and brain metastasis. Primary lymphoma of the transverse colon is very rare. We report our present case with a review of some literature.

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A 45-year-old female underwent partial sigmoid resection in 2003 and right hemi-colon resection in 2007 for colon cancer by functional end-to-end anastomosis (FEEA). She complained of anemia in July 2008, and anastomotic recurrence, subsequent peritoneal penetration, and an intraperitoneal abscess were found by close examinations. She was referred to our hospital and underwent two operations, including emergent surgery. Postoperative chemotherapy failed to prevent multiple liver metastases and she died in August 2009, twelve months after the recurrence. Recently, a number of cases of anastomotic recurrence after FEEA for colon cancer, including repeated cases, have been reported. These anastomotic recurrences could be due to the presence of isolated cancer cells in the intestine, and a cleaning of the anastomosed intestinal tract could be effective in preventing anastomotic recurrence. Since the prognosis of early postoperative recurrence is poor, it is very important to perform appropriate operative procedures and frequent postoperative follow-up to prevent anastomotic recurrence after FEEA.

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We report the cases of two male patients with colovesical fistula due to sigmoid diverticulitis treated in laparoscopic surgery. Pueumaturia was the chief complaint in both patients, one had urinary tract infection symptom.Both patients were underwent laparoscopic resection of sigmoid colon with fistula. The bladder wall required no procedure.
Both patients had no postoperative complications. The urinary drain was removed on 7th day after surgery and they returned to their social activities early. Laparoscopic surgery for colovesical fistula due to sigmoid diverticulitis is safe and feasible.

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A 69-year-old woman had watery diarrhea for three months, but did not receive treatment. She also developed dizziness, and visited our hospital. At the first visit, electrolyte abnormalities (Na 133 mEq/l, K 2.4 mEq/l, and Cl 84 mEq/l) and dehydration (BUN 34.5mg/dl and Cre 1.3mg/dl) were noted. Therefore, she was hospitalized for further examination and medical treatment. Colonoscopy showed a circumferential tumor with a villous structure in the rectum. Biopsy showed a tubular adenoma. CT examination showed an irregular elevated lesion in the rectum and fluid accumulation in the anal side. She was diagnosed with electrolyte depletion syndrome (EDS) due to mucus secretion from villous adenoma. The electrolyte imbalance and dehydration improved. Subsequently, laparoscopic low anterior resection was performed. A circumferential tumor with a villous structure (128×142mm) was noted in the resected specimen. Histopathologically, villous adenomas were found with well-differentiated adenocarcinomas in some regions. Postoperative clinical symptoms and electrolyte abnormalities improved. Villous adenoma with EDS is a relatively rare disease. This case will be described with a review of the literature.

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Epithelioid hemangioendothelioma (EHE) of the liver is a very rare malignant tumor. We report a case of multidisciplinary treatment of EHE of the liver in which there was difficulty in preoperative diagnosis. A 62-year-old woman showed mild elevations of liver enzyme levels, and a computed tomography examination detected a ring-enhanced hepatic mass in S6. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed an accumulation of FDG in the same area and in a cervical lymph node. We diagnosed the tumor as an advanced stage cholangiocarcinoma and combination chemotherapy of gemcitabine and S-1 was performed. After chemotherapy, right lobectomy was performed using hand-assisted laparoscopic surgery; the histological findings were consistent with an EHE. After the operation, FDG-PET demonstrated an accumulation of FDG in the liver and the abdominal para-aortic lymph node. Therefore same chemotherapy was performed again. Post chemotherapy the patient has had no recurrence and no metastasis has been observed. EHE is difficult to distinguish from metastatic liver cancer and cholangiocarcinoma, and we could not diagnose the hepatic EHE before the operation. This case suggests that gemcitabine and S-1 may be a new therapeutic option in cases where there is a recurrence of hepatic EHE and in cases of metastasis.

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A 60-year-old female with hepatitis C had undergone transcatheter arterial chemoembolization (TACE) in 2010 and radiofrequency ablation (RFA) in 2011 for hepatocellular carcinoma (HCC) originated in the segment 8 of the liver. The patient was referred to our department because abdominal MRI revealed intra-abdominal lymph node swelling in 2012. The serum concentration of alpha-fetoprotein was elevated to 17.1ng/ml. FDG-PET was positive (SUV=20.15) for the swollen lymph node, but contrast-enhanced CT and FDG-PET revealed neither intrahepatic recurrences nor distant metastasis of HCC. A solitary intra-abdominal lymph node metastasis was suspected, and extirpation of the lesion was performed. The lesion was diagnosed pathologically as poorly differentiated HCC. The patient was discharged on postoperative day 17; however systemic lymph node metastasis was detected on CT four months after the operation. The patient died 14 months after the operation. We herein present a case underwent surgical resection for solitary lymph node metastasis that PET was strongly positive following RFA for HCC.

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The subject, a 58-year old man, presented with the chief complaints of epigastric pain and brown urine. Blood test results indicated jaundice, and a contrast-enhanced computed tomography scan revealed multiple gall bladder stones and dilation of the intrahepatic bile duct. We identified wall thickening extending to the upper bile duct and confluence of hepatic ducts. We diagnosed obstructive jaundice due to stone formation in the vicinity of the triple confluence, and the patient was hospitalized. Endoscopic ultrasound (EUS) results suggested tumor lesions and stone formation in the narrow segment of triple confluence. We suspected stone formation on direct contrast with endoscopic retrograde cholangiopancreatography (ERCP). We did not identify malignancies in the cytodiagnosis from the endoscopic nasobiliary drainage (ENBD) in the biopsy during ERCP. To preoperatively confirm non-malignancy, we used SpyGlass to examine the site of triple confluence. We identified confluence stones and coating due to inflammation, and biopsy indicated no malignant findings. Therefore, as we diagnosed stone formation in the triple confluence, we performed a cholecystectomy and choledocholithotomy. The patient showed good progress was discharged without complications. When EUS and ERCP findings cannot deny the possibility of malignancy, we believe it is useful to perform observations using peroral cholangioscopy and biopsy.

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The 2013 Acute Cholangitis and Acute Cholecystitis Treatment Guidelines recommend minimally invasive endoscopic drainage when selecting a technique for biliary drainage. However, in some cases, the papillary approach is difficult because of the effects of previous surgery and anatomical changes. Here we report a case of endoscopic lithotomy using the rendezvous technique during percutaneous transhepatic gallbladder drainage to treat choledocholithiasis after total gastrectomy and Roux-en-Y reconstruction. We believe that this case illustrates the potential of endoscopic lithotomy as a useful treatment option in cases of problematic choledocholithiasis after total gastrectomy.

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A 64-year-old man, who diagnosed situs inversus totalis in junior high school day, found to have a cystic tumor of the pancreatic head when he had a distal gastrectomy at 61 years old. He admitted to our hospital because of a tendency to increase the tumor. Detailed examination revealed the diagnosis of intraductal papillary-mucinous neoplasm (IPMN). Then pancreaticoduodenectomy with a modified Childʼs method was performed. The abdominal anatomy was preoperatively assessed by computed tomography, magnetic resonance imaging and 3D-simulation. Because we confirmed anatomy and no vascular mutation by preoperative knowledge, therefore we accomplished the operation not to usually change. The postoperative course was uneventful and he was discharged on the 35^th postoperative day. Herein, we report our experience with some bibliographical comments.

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A 58-year-old man was referred and admitted to our hospital for examination of a pancreatic tail tumor detected at a health examination. The level of serum CA19-9 was elevated to 79.6 U/ml. Abdominal ultrasonography showed a well-defined, heterogeneous cystic tumor. Abdominal CT revealed multilocular cystic tumor at pancreatic tail measuring 8.9cm in diameter and enhancing the septum in the tumor. MRI revealed that the tumor showed low intensity on T1-weighted images, and high intensity with partial low intensity on T2-weighted images. The possibility of the malignant cystic tumor could not be ruled out because of high level of serum CA19-9, and we performed laparoscopic operation. The cut surface of resected specimen showed multilocular cysts that included gruel-like fluid. Histopathological examination showed the cystic wall was lined by squamous epithelium and surrounded by lymphoid tissue. These findings led to a diagnosis of lymphoepithelial cyst of the pancreas. Serum CA19-9 was normal range postoperatively. Since lymphoepithelial cyst of the pancreas is relatively rare, we report on this case with some bibliographical comments.

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A 67-year-old woman visited our hospital with the chief complaint of lower abdominal pain and pyrexia. Computed tomography (CT) revealed massive ascites and smooth uniform peritoneal thickening. The ascitic fluid was determined to have high levels of adenosine deaminase but bacteriological examination of the fluid showed no specific findings. Almost the entire peritoneal cavity showed high standardized uptake value on 18-fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT. Tuberculous peritonitis was strongly suspected, and a diagnostic laparoscopy and biopsy were performed to obtain an accurate diagnosis. The diagnosis of tuberculous peritonitis was confirmed by histopathological examination of biopsy specimens obtained from the tiny white nodules on the peritoneum. Early diagnosis of tuberculous peritonitis is important; however, accurate diagnosis is difficult from clinical findings and examination. We determined that FDG-PET/CT and exploratory laparoscopy are useful for obtaining an accurate diagnosis of tuberculous peritonitis.

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A 56-year-old man with no past illness or operation complained of acute abdominal pain and nausea. Computed tomography showed small bowel obstruction in the left lower quadrant and incarcerated intestine behind the sigmoid colon. His illness was diagnosed as an ileus due to the sigmoid mesocolon hernia. We performed a laparoscopic operation after decompression of small bowel obstruction by the long tube. About 15cm of small intestine was incarcerated into a mesenteric defect 3cm in diameter of the left leaf of the sigmoid colon. By pulling the intestine, incarceration was removed. But the serosa of intestine was torn by this maneuver. Because of limited working space, it was difficult to repair the serosal tear of the intestine under laparoscope. We made a 5cm incision at left lower abdomen and repaired the serosal tear of intestine. The hernia orifice was sutured. We consider the sigmoid mesocolon hernia can be diagnosed by computed tomography and good candidate for the laparoscopic surgery. Including our case, 91 cases of the sigmoid mesocolon hernia have been reported in Japan.

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The patient was a 70ʼs male with a past medical history of left nephrectomy for reanal cancer. Six months after the operation, he came to our hospital for a lump in his left posterior back. A CT scan revealed a left lumbar hernia containing the descending colon and the small intestine. At a operation a 7×9cm defect was found under laparoscopy. Operative repair was done using a Composix Mesh^® in the defect. The literature and our case support the notion that laparoscopic repair of lumbar hernias is safe and feasible. Strong consideration to the laparoscopic approach as an initial choice should be given when encountering lumbar hernias.

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A 60-year-old man was diagnosed with esophageal carcinoma. Subtotal esophagectomy via right-sided thoracolaparotomy, three-field dissection, construction of antethoracic route esophageal reconstruction using right hemicolon, and revascularization were performed. From the postoperative day 3, the patient suffered frequent diarrhea due to pseudomembranous enterocolitis, but recovered after administration of vancomycin. On the postoperative day 11, CT revealed marked swelling of the reconstructed intestine on the thoracic wall and enhancement of the entire abdomen; we established a diagnosis of ileus due to the hernia as intestine intrusion into the right side below the anterior thoracic wall. We performed an emergency operation the same day to repair the hernia and released pressure by inserting an ileus tube. Although the patient again had postoperative pseudomembranous enterocolitis, the course went well without major complications. On the postoperative day 35 of the second surgery, he was discharged from the hospital in remission.
Hernia after esophageal carcinoma surgery is very rare. Most of the cases are intrusions into the posterior mediastinum, and intestinal intrusion into the thoracic wall path has never been reported. We report our experience of a case of intestine intrusion into the antethoracic route after esophagectomy.

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