We investigated the prediction of postoperative shock using preoperative and intraoperative factors in 176 patients who underwent surgery for colorectal perforation accompanied by diffuse peritonitis at our department from April 2007 to March 2015. Patients given catecholamines after surgery were classified as the catecholamine group, others as the non- catecholamine group. The following 11 items were investigated as predictors: age (≥ 80 years), severity of peritoneal contamination, time from the onset of abdominal pain (≥ 12 hours), presence/absence of chronic renal failure, presence/absence of steroid use, mean blood pressure (< 70 mmHg), presence/absence of systemic inflammatory response syndrome, white blood cell count (<4,000/μL), platelet count (<150,000/μL), serum total protein (<5g/dL), and sequential organ failure assessment (SOFA) score (≥ 3). Univariate analysis showed the severity of peritoneal contamination, mean blood pressure, white blood cell count, serum total protein, and the SOFA score to correlate with shock occurrence. Multivariate analysis of these 5 items revealed the mean blood pressure (odds ratio, 8.46; p=0.0003), white blood cell count (odds ratio, 4.33; p=0.0003), and serum total protein level (odds ratio, 7.51; p=0.0021) to be independent risk factors. Careful postoperative management is required because of the poor prognosis in complicated postoperative shock.

Purpose: We examined the safety of venous thrombosis prevention with enoxaparin during the perioperative period in patients with gastric and colorectal cancer following laparoscopic surgery.

Methods: We retrospectivity investigated the safety in 35 enoxaparin-treated patients who had undergone elective open (n=16) or laparoscopic surgery (N=19) for gastric and colorectal cancer. An abdominal drainage tube and epidural catheter were removed in the morning of postoperative day 3. Enoxaparin therapy was started in the evening the day after surgery.

Results: There were no marked differences in the background factors or postoperative course between the two groups. One case involved suspected postoperative bleeding from the anastomotic area in the laparoscopic surgery group, but the discontinuation of enoxaparin resolved this.

Conclusion: Anticoagulant therapy with enoxaparin in laparoscopic surgery might be safe in gastric and colorectal cancer patients.

Purpose: This retrospective study aimed to evaluate the clinical utility of the optical view method for the first trocar in laparoscopic liver resection.

Methods: Between October 2008 and April of 2016, 37 patients with post laparotomy were underwent laparoscopic liver resection for liver tumor. Among these patients, 13 were underwent surgery using the optical view method for the first trocar (OV group), whereas the remaining 24 patients were underwent surgery using the open method (OP group). We compared the clinical features and surgical outcomes between these two groups.

Results: The time to pneumoperitoneum was significantly lesser in the OV group than the OP group (2.8±2.2 min vs 5.8±5.5 min, p=0.01), and there were no complications during insertion of the first trocar in both groups.

Conclusion: The optical view method for the first trocar in laparoscopic liver resection may be useful, especially for patients who have undergone laparotomy.

Single-incision laparoscopic cholecystectomy has been performed increasingly frequently in Japan in recent years. However, single-incision laparoscopic surgery is more difficult to formalize than normal laparoscopic surgery because of interference of the forceps with the security of the operative field. In the present study in our department, we performed reduced-port surgery, for which we used a non-forceps type traction device (EndoGrab^™; Virtual Ports, Ltd., Caesarea, Israel) and needle forceps to achieve security while performing universal laparoscopic cholecystectomy. We made a vertical 2-cm incision through the umbilicus and used a lap protector (EZ Access^™; Hakko Medical, Nagano, Japan). We then induced pneumoperitoneum and inserted an Endo Relief^™ from the right flank. The EndoGrab^™ (Virtual Ports, Ltd.) was used to elevate the gallbladder and fix it to the abdominal wall. The operation was performed using the hemi-parallel method. The median operation time was 90 min. Blood loss was minimal. The median length of hospital stay was 4 days. Two cases of pneumothorax were observed as perioperative complications. To ensure its safe and universal performance, this surgical technique needs to overcome the onset of pneumothorax.

Case 1 was observed in a 62-year-old man with multiple superficial esophageal carcinomas. The patient underwent subtotal esophagectomy. Histopathological examination revealed pT1b, N0, M0, pStage Ⅰ esophageal cancer, and papillary thyroid cancer component was found in one of the left #104 lymph nodes. Four months after esophagectomy, the patient received a subtotal thyroidectomy. Histopathological examination revealed papillary thyroid cancer.

Case 2 was a 59-year-old man who received endoscopic submucosal dissection for superficial esophageal carcinoma. As the depth of invasion was assessed to be T1b (sm2) and lymphatic vessel invasion was determined to be Ly2, additional treatments were performed including subtotal esophagectomy. Histopathological examination revealed pT1b, N0, M0, pStage Ⅰ, and metastatic papillary thyroid cancer component was found in one of the left #104 lymph nodes. Thyroid gland examination after esophagectomy revealed no apparent lesions. We agreed with the patient to carefully monitor his thyroid.

Both patients had stage Ⅰ esophageal cancer and are expected to have a long survival period. Additionally, the prognoses for thyroid carcinomas are generally good. Given that metastases from other organs are occasionally found in lymph nodes dissected during surgical procedures for esophageal cancer, lymph node dissection may be important to stage esophageal cancers and to detect any other simultaneously developing cancers.

A mammary phyllodes tumor is relatively rare, and cases associated with breast cancer are extremely rare. We are reporting a case of a non-invasive ductal carcinoma in a mammary gland with a malignant phyllodes tumor.

A 52-year-old woman underwent a lumpectomy on her left breast after becoming aware of a mass in the breast. She was diagnosed with a malignant phyllodes tumor in the postoperative histopathological examination. A non-invasive ductal carcinoma (DCIS) was observed in the vicinity of the tumor. There is a possibility of a remnant of DCIS in the surgical margins. The patient selected radiation therapy rather than additional resection. One year has now passed since her surgery on the phyllodes tumor, and she has not had any signs of recurrence. We note the possibility of a situation in which a phyllodes tumor is accompanied by cancer; careful histological examinations are important.

We are reporting a rare case of combined phyllodes tumor and cancer. The patient was a 74-year-old women, she noticed a lump on her breast 7 days before visiting our clinic. The diameter of the lump was small at that time. She palpated the lump frequently and the tumor started growing rapidly. When she consulted us about the lump, the border of the tumor was unclear and the tumor was hard and the diameter of the tumor was about 10 cm. The color of the skin over the tumor changed to a reddish color. Using MMG, US, MRI, needle biopsy, the tumor was examined. The diagnosis of a phyllodes tumor or fibroadenoma was made. We excised the tumor with the surrounding tissue. Post operative, histopathological examination revealed the phyllodes tumor and noninvasive ductal carcinoma existed within the adjacent mammary gland. Surgery is recommended but, we must consider cancer complications.

We report a case of HER2-positive esophagogastric junction adenocarcinoma with multiple lung and para-aortic lymph node metastases in a 40-year-old male patient in whom surgical treatment was successful following the administration of a trastuzumab containing chemotherapy regimen. After esophageal stent placement, a chemotherapy regimen consisting of capecitabine (2,000 mg/m²/day, days 1-14), cisplatin (80 mg/m², day 1), and trastuzumab (during the first course: 8 mg/kg, day 1; second and subsequent courses: 6 mg/kg, day 1) was administered. After six courses, the patient developed renal dysfunction, thus cisplatin was withdrawn and only capecitabine and trastuzumab were administered (every 3 weeks) thereafter. The patientʼs metastatic lesions were no longer detected on CT, and the primary tumor showed a partial response for 16 months. Subsequently, the primary tumor began to grow in size. Lung and para-aortic lymph node metastases remained invisible on FDG-PET. Total gastrectomy with D2 lymph node dissection and sampling of the para-aortic lymph nodes was performed. No complications observed after surgery. An R0 resection was achieved. The histological effect of chemotherapy was Grade 1a. Cancer cells from the regrowth of the tumor were HER2-positive. The patient is currently receiving capecitabine as adjuvant chemotherapy. A follow-up CT scan at 6 months after the operation detected no recurrence. The patient remains alive at 8 months after surgery.

A 66 year-old woman complaining of fatiguability was admitted to our hosopital for treatment of a gastric submucosal tumor.Abdominal computed tomography (CT) revealed a huge 16×10cm tumor in the gastric fornix and this tumor was suspected to directly invade the pancreas and liver. Pathological analysis of a biopsy sample revealed a gastrointestinal stromal tumor (GIST).

The patient was given imatinib (400mg/day) because she had hoped to receive chemotherapy. After 6 months of administration, positron emission tomography CT (PET－CT) revealed a slightly reduction in tumor size and maximal standardized uptake value (SUVmax:5.6→2.7). But the PET－CT also showed that the drug-induced interstitial pneumonia had developed. So we stopped the medication,and had performed total gastrectomy 7 monts after initiation of chemotherapy. Histopathologial work up showed that the efficacy of preoperative imatinib treatment was Grade 1b and there was no evidence of tumorʼs invasion of serosal membrane and surrounding tissues. Adjuvant therapy was not performed after the surgery and the patient Has now been in a good health without a recurrence for three months.

We report a rare case of breast metastasis of gastric cancer in a 67-year-old male. He was diagnosed as primary local advanced gastric cancer and received systemic chemotherapy before and after total gastrectomy. Four years later, he noticed a tumor in his right breast. As the findings of imaging study showed a 21mm enhanced-mass in the D region of the right breast. Breast biopsy suggested scirrhous carcinoma with hormone receptor-negative. We also considered the possibility of the metastasis of gastric cancer, because of atypical male breast cancer and his past history. For diagnostic and therapeutic purpose, tumor resection were carried out. On postoperative histopathological examination, immunohistochemical analysis showed intesitinal epithelia marker-positive in the right breast as well as stomach. We diagnosed this breast tumor as metastasis from gastric cancer.

It was difficult to discriminate between breast cancer and metastasis from other organs. For deciding the line of treatment, it is very important to diagnose primary lesions. So we consider that therapeutic and diagnostic operation should be done in the case having no other metastasis and the case in which the local control is needed.

A 58-year-old man was examined because of anemia. Esophagogastroduodenoscopy identified a bleeding tumor in the duodenum. A biopsy lead to the patient being diagnosed with a gastrointestinal stromal tumor (GIST). A computed tomography (CT) scan showed a tumor measuring 5 cm in diameter in the third portion of the duodenum. The tumor was suspected to be invading into the inferior vena cava and superior mesenteric vein. We judged that complete resection would not be possible. The patient received preoperative imatinib treatment at 400 mg/day. Three months after the treatment was started, a CT image showed a reduction in tumor size and a clear margin separated from important vascular structures. Therefore, we performed pancreaticoduodenectomy as curative surgery. The patient resumed imatinib treatment at 400 mg/day for 35 days after the operation. Currently, 4 years since the operation, the patient remains free of recurrence.

An 83-year old woman visited our hospital for chief complaints of abdominal pain and vomiting. An abdominal computed tomography (CT) scan revealed hepatic portal venous gas (HPVG) of the left medial segment, enlargement of the small intestine and storage of intestinal fluids. There were neither peritoneal irritation signs nor signs of intestinal necrosis. We diagnosed the case, HPVG caused by bowel obstruction. Conservative management was chosen, and CT scan which was performed on the next day showed disappearance of HPVG. Although, bowel obstruction treated by the long tube showed no improvement and operation was performed on the 22nd day of admission. Operative findings revealed a gastrointestinal stromal tumor sized 2×2cm with an extramural growth propensity. And partial resection of the small intestine was performed. The postoperative course was good and the patient was discharged on the 13^th day after surgery. HPVG has been regarded as signs of intestinal necrosis and surgical indication. Several cases of HPVG treated successfully with conservative therapy have been reported recently. When conservative treatment is chosen, it is important to treat while thinking about the possibility that the condition of a patient changes over time.

A 74-year-old woman was admitted to our hospital with sudden onset of right lower quadrant (RLQ) pain. A palm-sized painful mass was palpated in the RLQ of the abdomen. An abdominal computed tomography (CT) scan showed a horseshoe-shaped mass and a target sign of the small intestine in the right lower abdomen indicating a diagnosis of adult small intestinal intussusception. The presenting portion of the intussusception was considered to be a lipoma based on the low CT density. An ileus tube was endoscopically inserted to drain the air-fluid in the small bowel. After drainage completion, emergent laparoscopic surgery was started. Intra-abdominal adhesions caused by a previous appendectomy were divided and the cecum was mobilized using atraumatic forceps. Consequently, intussusception reduction was successful and the tumor was removed by resection of a portion of the ileum. The patient was discharged from our hospital 15 days after surgery and has shown no adverse abdominal symptoms to date. We experienced an adult case of intestinal intussusception caused by ileal lipoma successfully treated by emergent laparoscopic surgery. Accurate diagnosis, decompression of the intestine and timely surgical intervention are needed for emergent treatment of intestinal intussusception.

A 33-year-old woman with fever and abdominal distension was admitted to our hospital. An enhanced computed tomography scan showed intraperitoneal abscess in the lower abdomen. We wanted to perform percutaneous drainage but because there was a risk of intestinal damage, we first administered antibiotic therapy. A diagnosis of appendiceal carcinoma was obtained by colonoscope, and ileoceal resection and D3 lymph node dissection were performed. The patient was under 50 years of age, so we performed the test of microsatellite instability (MSI), which microsatellite stable (MSS), so this case had no relationship with Lynch syndrome. The lymph node examination indicated metastasis, so we treated her with postoperative adjuvant chemotherapy. She has remained in good health, without clinical evidence of recurrent disease for 3 months after the operation. The young - onset appendiceal carcinoma is comparatively rare, and we discuss this case in connection with the published literature.

We report a case of ascending colon cancer associated with Japanese Schistosomiasis. An 80-year old man was admitted to the hospital for occult blood stool who had lived in Kofu, Yamanashi Prefecture, a past endemic area of Japanese Schistosomiasis until the age of 15. Colonoscopy showed a type2 tumor of the ascending colon. Laparoscopic right-hemicolectomy with D3 lymph node dissection was performed. Pathological findings demonstrated moderately differentiated adenocarcinoma, tub2, med, SS, INFb, int, ly1, v0, N0, PM0, DM0, RM0. In addition, Schistosoma japonicum eggs showing calcification were seen in the submucosa of the colonic lesion. This case was considered to be an old lesion.

A 70-year-old-woman underwent laparoscopic sigmoidectomy for sigmoid colon cancer (moderately differentiated adenocarcinoma, pT3N0M0, pStage Ⅱ). A postoperative follow-up CT after 9 months revealed a low density area in the right branch of portal vein and the peripheral portal vein. The portal vein thrombosis was suspected and the anticoagulant therapy was received. The temporal CT findings showed that a low density area in the portal vein remained unchanged, but the subphrenic abscess and the right adrenal nodule were increased. Because both a low density area in the portal vein and the right adrenal nodule showed the ¹⁸FDG-PET uptake and the same echoic pattern, the right portal vein tumor thrombus and the right adrenal metastasis were suspected. Extended right lobectomy combined resection of right adrenal gland and right diaphragm with right portal vein resection and reconstruction was performed. Histopathological findings showed that both the tumor in the right portal vein and the right adrenal tumor are composed of similar adenocarcinoma with fibrous change and necrosis to the primary cancer.

As the portal vein tumor thrombus not associated with liver metastasis of colon cancer is extremely rare, this case is presented here together with some bibliographic comments.

Cancer arising at a colostomy site is rare and few cases have been reported. Here, we report a case of ileus due to adenocarcinoma arising at a sigmoid colostomy site after a surgical treatment for rectosigmoid cancer. A 54-year-old man underwent total pelvic exenteration and resection of ileum for rectosigmoid cancer invading bladder and ileum. Nine months after surgery, a tumor was seen at the sigmoid colostomy site, and CT findings showed peritoneal dissemination and metastases of lymph nodes and rectus abdominis muscle. Two months later, abdominal pain occurred and dilatation of colon was observed. A cancer was seen at the colostomy site, stenosis was observed just oral side of the colostomy, and it caused ileus of colon. It was thought that recurrent cancer at the colostomy site was reduced by chemotherapy, which caused stenosis of colon and ileus. We created transverse colostomy because of obstruction. Chemotherapy was resumed two weeks after the operation, and cancer at the colostomy site was reduced. This is the first case of ileus caused by cancer occurring at the colostomy site in Japan.

The patient was a 75-year-old woman who developed hepatocellular carcinoma in S3 and S5 in August, 2013, detected during hospital visit for the treatment of hepatitis C. She underwent RFA. One year and 8 months later, hepatocellular carcinoma measuring 8 mm in diameter was found in S4, and similarly treated by RFA. Because the AFP level remained high, the patient underwent CT, which revealed a tumorous lesion, densely enhanced in the early phase and measuring 40 mm in diameter, that was located lateral to the ascending colon. Surgery was conducted under suspicion of metastasis of hepatocellular carcinoma. Based on histopathological findings, the lesion was diagnosed as metastasis of hepatocellular carcinoma. Microscopic observation yielded no findings of carcinoma in areas other than the tumor region, indicating that the lesion was an isolated peritoneal metastasis. Peritoneal metastasis from hepatocellular carcinoma is reportedly less frequent than those from cancers of other organs. It is also said that peritoneal metastasis of hepatocellular carcinoma is relatively unlikely to have an infiltrating tendency and diffuse spread, but does usually show localized growth. If the lesion is isolated and not accompanied by distant metastasis, surgical resection of the lesion may achieve prolongation of the patientʼs life.

The patient was an 87-year-old female who came to our hospital with a chief complaint of fever and right upper abdominal pain. After performing abdominal ultrasonography and abdominal computed tomography (CT), a diagnosis of an 11-cm infected cyst in the right lobe of the liver was made. Antibacterial drug therapy was started, but no improvement was seen. On hospital day 4, a laparoscopic dome resection procedure was performed. The contents of the cyst were aspirated using an S.A.N.D. balloon catheter^® (HAKKO), and the cyst wall was cut with a LigaSure^® (COVIDIEN JAPAN), and the dome portion of the cyst was excised. The aspirate consisted of white pus, and cultures grew out Klebsiella pneumoniae. The patient’s course was favorable, and on postoperative day 20 she had recovered and was discharged. Infected liver cyst is a relatively rare disease, and after taking invasiveness and curativeness into consideration, conservative therapy, percutaneous transhepatic drainage, surgery, etc., are selected as treatment. Because in this case it was possible to perform laparoscopic surgery to treat an infected hepatic cyst in an oldest-old patient and to obtain a favorable outcome, we report the case together with some discussion based on the literature.

A 44-year-old man was found to have bilateral polycystic kidney and polycystic liver, and diagnosed with autosomal dominant polycystic kidney disease 9 years ago. The patient experienced the development of chronic renal failure with uremia and ascites, therefore he admitted for initiation of hemodialysis. Because hemodialysis did not only improve ascites but also lead to frequent hypotension during hemodialysis, a Denver peritoneovenous shunt was inserted into the abdominal cavity to drain ascites into the subclavian vein, which resulted in disappearance of ascites and improvement of hypotention. No sign of ascites and catheter-related complications has been found during 10 months follow-up period after Denver shunt operation.

A 58-year-old man who suffered from a blow to the abdomen in a traffic accident was transferred to our hospital. Contrast-enhanced computed tomography (CECT) showed intra-abdominal bleeding. An emergency laparotomy was performed with the diagnosis of traumatic intra-abdominal bleeding. A TypeⅡb (T) injury of transverse mesocolon was found, but no injuries were found in any other abdominal organ. The fifth postoperative day, drainage that appeared to be feces was noted at the incisional line. An emergency laparotomy revealed a perforation of 5mm in diameter on the transverse colon. We performed simple closure and ileostomy with abdominal drainage. We considered that this case is not a postoperative complication but a delayed colon perforation because there were no signs found such as a suspected perforation on preoperative examination and no abnormal findings during the first surgery. The post-operative course was non-eventful. The patient was discharged thirty six days after the initial operation. The colostomy was closed three mouths after the second operation.

A 72-year-old male underwent totally extraperitoneal preperitoneal repair (TEP) for a left inguinal hernia. After the insertion of the preperitoneal dissecting balloon (PDB) and expansion of the preperitoneal cavity under laparoscopic guidance, a tear was visible on the bladder wall beyond the dissecting balloon, with exposure of the urethral balloon, leading to the diagnosis of bladder injury. The cause of the bladder injury in this case remained unknown. However, in a subsequent case, when the preperitoneal cavity was similarly dilated with a PDB, a thinned bladder wall sandwiched between the PDB and the urethral balloon was noted. From this observation, we inferred that the bladder injury in our first case was caused by injury of the already thinned bladder wall by the inflated PDB. When the preperitoneal cavity is dilated with a PDB for dissection during TEP, it needs to be borne in mind that the bladder wall may have become thin as a result of becoming sandwiched between the PDB and the urethral balloon.

A Spigelian hernia is a rare ventral hernia that occurs via a defect in the anterior abdominal wall adjacent and lateral to the abdominal rectus.

We performed two-port laparoscopic surgery in a case of Spigelian hernia using intraperitoneal onlay mesh. A male in his eighties was referred to our hospital because of vomiting and a painful palpable mass over his right lower abdomen. Abdominal CT revealed small bowel obstruction with prolapse at the lateral edge of rectus abdominal muscle. We diagnosed the patient with an incarcerated Spigelian hernia. Following reduction, two-port laparoscopic repair of the hernia was performed. The hernial defect was located in the anterior abdominal wall adjacent and lateral to the abdominal rectus. PCO mesh was used to cover the hernia defect, and the edge of the mesh was fixed to the abdominal wall with absorbable tacks. The duration of the operation was 59 minutes. The patientʼs postoperative course was uneventful, and he has been healthy without recurrence of the hernia.

A 64-year-old woman presented with pain and swelling of the right lower abdomen. Abdominal enhanced computed tomography showed an abscess in the right inguinal canal extending from the cecum to the abdominal wall. Acute appendicitis with an abscess incarcerating into the right inguinal hernia, also called Amyandʼs hernia, was diagnosed. Appendectomy and hernioplasty without prosthesis were performed as an emergency surgery. Gangrenous appendicitis was confirmed on pathological examination. The abscess in the right inguinal canal was complicated and required drainage during the postoperative course. The patient was discharged 27 days after the surgery.