Present situation of cystostomy with emphasis on complication and patientʼs care was described presenting our experience of 29 patients who undertook cystostomy. There were no notable complications and normal renal function was maintained in most of the cases. From the results it can be reconfirmed that cystostomy is a favorable urinary diversion. However, in general, the measure taken after the accidental withdrawal of the cystostomy catheter was unfavorably slow and inappropriate. Therefore, patients should be given a catheter narrower than catheters such as the 8F beforehand to prevent the necessity for an additional percutaneous cystostomy.

Background and purpose: This retrospective study was undertaken to compare a transabdominal single stapling side-to-end anastomosis (SST) with a transanal double stapling side-to-end anastomosis (DST) in terms of surgical site infection (SSI) and anastomotic leakage in sphincter preserving rectal cancer surgery.

Patients and methods: The subject was 90 patients in the SST group and 53 patients in the DST group. Data of clinicopathologic factors, surgical site infection (SSI), and anastomotic leakage were retrieved from the medical charts and analyzed.

Results: DST was selected more preferably for lower rectum (below the peritoneal reflection) than SST (p<0.01). The rates of SSI (p=0.09) and anastomotic leak (p=0.06) tended to be higher in the DST group than SST group. In univariate and multivariate logistic regression analysis, there were no significant risk factors of SSI and anastomotic leakage regardless of the subjects selected (SST group+ DST group, SST group, or DST group).

Conclusions: These results suggest that SST and DST were identical in terms of SSI and anastomotic leakage, with no significant risk factors for SSI and anastomotic leak identified.

Aim: To evaluate the present career program for surgeons.

Methods: A questionnaire survey of surgeons in Oita Prefecture was performed. The contents of the questionnaire included the background of the surgeons, self-assessments on the career programs used, and their opinions about ideal career programs.

Results: We enrolled 174 surgeons who filled out the questionnaire form (response rate was 75％) in this survey. 56％ of surgeons have desired their own careers; however, 31％ of surgeons were dissatisfied with their own careers. Moreover, 47％ of surgeons were anxious about the inadequacy of their future career programs. Many surgeons want to work at a local high-volume hospital in which they can gain much experience with many kinds of surgical procedures under the guidance of expert surgical instructors.

Conclusion: In the development of career programs for aspiring surgeons, it is important to provide both a variety of surgical experiences as an operator and a better surgical education.

Aim: The aim of this study was to clarify the safety of surgery in elderly patients with colorectal cancer by investigating the clinicopathological features and postoperative complications.

Methods: A total of 112 elderly patients over 75-year-old with colorectal cancer who underwent operation between January 2011 and July 2015 at Kamishirane Hospital were enrolled. We divided the patients into four groups; 75-79, 80-84, 85-89, and 90 years older group. The clinicopathological data and postoperative complications of the patients were retrospectively evaluated. Postoperative complications were evaluated by Clavien-Dindo classification.

Results: In the two groups over 85-year-old, women, lower BMI, worse Performance Status (PS) and American Society of Anesthesiologists (ASA) classification, admission from Nursing home, lower Alb, colorectal cancer with right side, and obstructive ileus were mainly observed. In the over 90 years older group, shorter duration of surgery, little blood loss, and under D2 dissection were mainly observed, but delirium and postoperative complications over grade 2, especially pneumonia, were mainly observed.

Conclusions: In elderly patients with colorectal cancer, especially in over 90 years older, PS, ASA classification and nutrition condition were inferior to the other elderly patients, and we have to be careful of postoperative delirium and pneumonia.

Jejunostomy is performed in some cases because of various reasons such as a patientʼs inability to feed orally, as well as in cases in which total gastrectomy has been performed, or cases of end-stage gastric cancer. However, jejunostomy is difficult to manage because of continuous tube feeding and long catheter. We attempted pouch Roux-en-Y jejunostomy, which was easier to manage, as interval tube feeding could be used. We dissected jejunum and anastomosed by end GIA™ 60 twice to make pouch. We put catheter through abdominal wall into stump of jejunum. Few days later, interval tube feeding could be performed. Interval tube feeding improves patientʼs activities of daily living and prevents decubitus. Thus, patients can maintain a high quality of life. Herein, we report three cases in which pouch Roux-en-Y jejunostomy was performed with no complication.

We report a case of omental desmoid tumor after partial gastrectomy with gastrointestinal stromal tumor (GIST).

A 64-year old man had a gastric submucosal tumor (SMT). He underwent partial gastrectomy. Histological examination indicated diagnosis of GIST and the margins to be negative. Regular postoperative CT showed an intra-abdominal tumor of about 10mm, 1 year later. The tumor had grown up to 23mm 6 months later, so we performed tumor resection. It was diagnosed as a desmoid tumor after examination by immunohistochemistry staining. The patient continues to be obserbed periodically, and no recurrence has been observed.

A 69-years-old man complaining palpitation was pointed out severe anemia, and diagnosed as advanced carcinoma of the upper stomach by endoscopy. The endoscopic biopsy sample was diagnosed as small cell carcinoma by hematoxylin-eosin staining and immunohistochemical staining. Fluorodeoxyglucose-positron-emission tomography / computed tomography revealed that the tumor was primary gastric carcinoma without detectable metastasis, and then radical operation was performed. Post-operative final stage of disease was Ⅲb (Japanese Classification of Gastric Carcinoma), and two independent lesions of early gastric adenocarcinoma were found in resected specimen. Although post operative adjuvant chemotherapy using 5-Fluorouracil related agent was administered, multiple massive metastases to the liver ware appeared 3 months after surgery. Chemotherapy along with the regimen including CDDP and CPT-11 were done after detection of recurrence, however, progression of disease could not be controlled and the patient died 189 days after surgery. The cases of small cell carcinoma of the stomach with the independent adenocarcinoma have been rarely reported.

The patient was a 64-year old man with advanced gastric cancer. Because of para-aortic lymphnode metastasis, we initiated neoadjuvant chemotherapy with TS-1 and cisplatin. After one course of this neoadjuvant chemotherapy, since HER2 protein was overexpressed in primary tumor immunostaining, we switched to chemotherapy with Trastuzumab, Capecitabine and Cisplatin. After 4 courses, CT scans revealed that the size of the primary tumor and metastatic lymphnodes were considerably decreased, suggesting a partial response (PR). We judged that the curative resection was possible and performed total gastrectomy with D2-No.12a lymph node dissection. Postoperative histopathological examination revealed that the gastric cancer had therapeutic effect of Grade 2 with the findings of Type4, tub1, pT1a (M), N1 (1/19, No6), ly0, v0, pStage ⅠB. The patient was administeres TS-1 after operation, and he is well without recurrence at two years and four months postoperatively. We presented a case of HER2 positive gastric cancer with para-aortic lymphnode metastasis, successfully treated by trastuzumab with chemotherapy followed by surgery.

The patient was a 30-year-old woman who was hospitalized with intermittent bouts of right lower abdominal pain and nausea. A tumor was palpable in the right lower quadrant of the abdomen. Intussusception in the ascending colon was diagnosed by computed tomography, and emergency laparotomy was performed, when intussusception had already been released spontaneously. No specific cause of intussusception was identified other than mobile cecum, and then the condition was judged idiopathic. Because of the rarity, we report such a case and review the literature.

Herein we report our experience treating an extremely rare case of synchronous cancers of the small intestine and appendix. The patient was an 84-year-old man who presented to his local physician with chief complaints of diarrhea, vomiting, constipation, and abdominal bloating. The patient was subsequently referred to our hospital and was admitted with a diagnosis of intestinal obstruction. Symptoms were ameliorated following the insertion of an ileus tube. However, as the intestinal obstruction was not the result of previous operative therapy and CT findings revealed that the ileum was the source of the obstruction, we considered the possibility that the obstruction was due to a neoplastic lesion and recommended the patient for surgical treatment. A tumor was observed approximately 60 cm from the terminal ileum. It had infiltrated the surrounding intestinal mesentery and formed a tumor mass. Furthermore, the caudal end of the appendix had become attached to the nearby mesentery. Based on intraoperative findings, we determined that the ileal tumor had infiltrated the intestinal mesentery and appendix; therefore, we performed partial ileectomy and appendectomy. However, histopathological diagnosis revealed that the ileal tumor was a moderately differentiated adenocarcinoma, whereas the appendiceal tumor was a mucinous, well-differentiated adenocarcinoma. As a result, we comprehensively determined that both tumors were primary cancers.

Goblet cell carcinoid (GCC) of the appendix is a relatively rare tumor. We report a case of GCC of the appendix that was treated effectively by laparoscopic findings.

A 45-year-old man, who had been admitted to our hospital with diagnosis of intestinal obstruction repeatedly, underwent laparoscopic surgery. Operative findings showed a slightly enlarged appendix with whitish induration, thickening of appendiceal wall and intestinal obstruction that was starting from terminal ileum. Laparoscopic ileocecal resection with D2 lymphadenectomy was performed under suspicion of malignant tumor of the appendix with invasion into ileocecum. Histopathological findings showed the GCC of the appendix. The patient has chemotherapy because of its peritoneal metastasis 69 months after surgery. There are many cases of GCC that need reoperation, because GCC of the appendix can hardly be diagnosed, and be treated initially by inappropriate surgical procedure. However, reoperation might be avoided by paying close attention during initial surgical operation. We presented a case of appendiceal GCC that had been performed initial operative procedure adequately by laparoscopic findings, and a review of domestic 126 cases.

Intramural metastases are not common in colorectal cancer. Most of them are simultaneous, and there are few reports of metachronous intramural metastases. We report a rare case of multiple intramural metastases in the rectum of the descending colon cancer.

A 72-year old man underwent a left hemicolectomy for descending colon cancer. Pathological examination revealed a moderately differentiated adenocarcinoma with vascular invasion. Nineteen-months after the operation, follow up colonoscopy was performed. Two submucosal tumors (SMTs) were found in the lower rectum. Five months later, one of the SMT turned into an ulcerated lesion. The pathological findings of biopsy from the ulcerated lesion showed moderately differentiated adenocarcinoma. An abdominoperineal resection was performed. Histopathological examination showed two tumors, a 38×28mm ulcerated lesion and a 15mm SMT, which were both moderately differentiated adenocarcinoma. Immunohistological staining demonstrated that all tumors were CK7 (-) and CK20 (+). The rectal tumors were compatible with the primary carcinoma. Consequently, the tumors were diagnosed with metachronous intramural metastases of the primary descending colon cancer.

We report a case of laparoscopic resection for cecal and sigmoid colon cancers complicated with aortoiliac occlusive disease. A 60-year-old woman was found to have fecal occult blood when presented to a nearby hospital with anorexia and nausea, and referred to our hospital for a complete medical examination. Colonoscopy revealed type 0-Ip lesions in the cecum and sigmoid colon, and biopsy specimens from them disclosed adenocarcinomas. Preoperative CT imaging showed findings of occlusion of the abdominal aorta including the origins of superior and inferior mesenteric arteries. Arteriography revealed blood flow to the intestines was kept via celiac artery and pancreaticoduodenal arcades. Her symptom of the aortic occlusion was only a mild intermittent claudication. Endoscopic submucosal dissection (ESD) was not indicated for these lesions because of a suspicion of submucosal invasion. We performed laparoscopic ileocecal resection and sigmoidectomy with just D1 lymphadenectomy so as to preserve the blood flow to the residual intestine. The postoperative course was uneventful and she was discharged without any complications on the 14th postoperative day.

A 28-year-old woman visited our hospital for detailed investigation after an elevated gamma-glutamyl transpeptidase level was found on a medical check-up. Abdominal computed tomography (CT) showed a hypervascular, 9 cm × 7 cm tumor in the caudal side of the right lobe of the liver for which the left hepatic artery was the feeding vessel. Magnetic resonance imaging showed that the tumor, which had appeared on the right side on CT, had moved to the left side. On further abdominal palpation, the tumor that was palpated in the left upper quadrant in the supine position was found to have moved to the right hypochondrium in the right lateral position, indicating that the lesion was highly mobile. Based on imaging findings and liver biopsy, focal nodular hyperplasia (FNH) was diagnosed. The lesion was a large pedunculated tumor that moved easily, and surgery was indicated due to the high risk of complications such as volvulus. Laparoscopic partial hepatectomy was therefore performed. Because the peduncle of the tumor was thin and composed primarily of vessels and connective tissue, the tumor was resected using an autosuture device from the beginning, without resecting the hepatic parenchyma. While it is not uncommon for FNH to be pedunculated, cases of tumors so mobile that they cross the midline of the body, as in the present case, are rare. In the present case, laparoscopic surgery was a very useful type of surgery.

An 89-year-old female presented to our hospital complaining of pain in the right abdominal flank region. Physical examination revealed a tender mass in the right lateral abdomen. Laboratory data indicated high inflammatory response and abdominal computed tomography (CT) showed a massively distended floating gallbladder. We diagnosed gallbladder volvulus and performed emergency laparoscopic cholecystectomy. Intraoperatively, we observed, hemorrhagic pericholecystic fluid with a markedly distended and necrotic gallbladder, with its neck twisted counterclockwise by 180 degrees. After release of the torsion, laparoscopic cholecystectomy was performed. The patient had an uneventful postoperative course and was discharged on the eighth postoperative day. With improvements in the diagnostic imaging techniques, accurate preoperative diagnosis of gallbladder volvulus has become possible. Since gallbladder volvulus is accompanied by a floating gallbladder that is not usually adherent to the liver, laparoscopic cholecystectomy is the treatment of first choice if the condition can be diagnosed preoperatively.

An 89-year-old man complained of abdominal pain while undergoing inpatient treatment for pneumonia and renal failure. A blood examination revealed elevated inflammatory marker levels. Abdominal computed tomography revealed a distended gallbladder and high-density material within the gallbladder lumen. We performed percutaneous transhepatic gallbladder drainage. As bloody drainage was noted during the procedure, the diagnosis of hemorrhagic cholecystitis was made. Because the vital signs were stable and the general condition of the patient was poor, we undertook conservative treatment until his general condition improved and then performed laparoscopic cholecystectomy. The resected gallbladder contained clotted blood and several small stones. Histopathology revealed marked congestion of the entire gallbladder wall, with scattered bleeding points. No evidence of tumor, ulcer or vascular disorder was noted and the final diagnosis was hemorrhagic cholecystitis secondary to acute cholecystitis.

We performed gallbladder drainage at an early stage in our patient with hemorrhagic cholecystitis, and obtained successful resolution of the jaundice and inflammation before surgery. The gallbladder drainage may be useful for confirming the diagnosis, and the improvement of the jaundice and inflammation before surgery.

A 76-year-old male was admitted to an another hospital because of jaundice. MRCP revealed an obstruction site in the distal bile duct. He underwent ERCP and an endoscopic nasobiliary drainage (ENBD) tube was placed in the common bile duct. The distal bile duct exhibited stenosis on ERCP. Endoscopic transpapillary biopsy was performed, and histopathological examination revealed adenocarcinoma. He was then referred to our hospital for the purpose of surgical treatment. On laboratory examination, the serum levels of total bilirubin, hepatic enzyme and bilirary enzyme were elevated. The level of tumor marker CA19-9 was slightly elevated, however CEA was within the normal range. Cholangiography via an ENBD tube showed a stenosis of the distal bile duct. Enhanced abdominal CT showed the enhanced tumor in the distal bile duct. We made the diagnosis of the distal bile duct cancer and performed subtotal stomach-preserving pancreaticoduodenectomy. The resected specimen of the distal bile duct showed a 22×13mm nodular-infiltrating tumor. Histopathological findings showed a mixture of adenocarcinoma and squamous cell carcinoma components in the tumor, diagnosed as adenosquamous carcinoma. The post-operative course was uneventful. He had been followed up without adjuvant chemotherapy. However, multiple liver metastases were observed 15 months after surgery, then he received chemotherapy. Adenosquamous carcinoma of the extrahepatic bile duct is a relatively rare. We herein report a surgical case of adenosquamous carcinoma of the distal bile duct and provide a review of the literature.

A 56-year-old woman with epigastralgia and elevation of the hepatobiliary enzyme levels was referred to our hospital. Abdominal contrast-enhanced computed tomography and magnetic resonance imaging showed a tumor in the pancreatic head with broad extension into the main pancreatic duct. Furthermore, the tumor extension into the pancreatic duct reached up to the tail of the pancreas. Upper gastrointestinal endoscopy revealed a tumor protruding from the duodenal papilla, and an endoscopic biopsy suggested the diagnosis of tubular adenocarcinoma.

Surgery was performed based on the suspected diagnosis of tubular adenocarcinoma arising primarily from the main pancreatic duct. Total pancreatectomy and splenectomy with lymph node dissection were performed. Histopathologically, the resected specimens revealed broad intraductal growth and extraductal invasion over a small area. It was difficult to determine whether the tumor was an intraductal tubulopapillary neoplasm or an acinar cell carcinoma on the basis of the routine microscopic findings. However, immunohistochemistry confirmed the diagnosis of acinar cell carcinoma. The patient was discharged without serious complications, and no evidence of recurrence has been seen until now, 18 months since the surgery. We report this case of acinar cell carcinoma that primarily arose from the pancreatic duct, with a review of the literature.

A 43-year-old man presented at our hospital with fever, abdominal pain and pneumaturia. Abdominal CT showed the abscess and the air between the urinary bladder and the sigmoid colon. Colonscopy revealed a diverticula in the sigmoid colon. Based on these findings, we diagnosed sigmoid-vesical fistula due to sigmoid diverticulitis.

As the patient with ankylosing spondylitis was maintained on prednisolone, we employed two-stage operative strategy. We performed Hartmannʼs operation and stoma closure by single incision laparoscopic surgery through stoma site. No complications or recurrence were seen following the fistulectomy. The single incision laparoscopic surgery through stoma site is found to be safe and feasible. And this enables us to improve the cosmesis and decrease the risk of surgical site infection.

A 77-year-old woman had taken a Chinese herbal medicine for 7 years. She was noted to have fecal occult blood at a routine medical examination and underwent colonoscopy. A type 2 tumor was found at the transverse colon. The mucosa in the cecum and ascending, transverse, and part of the descending colon showed a dark blue-purple discoloration. The tumor was diagnosed as a well-differentiated adenocarcinoma by histopathological examination. At first, we planned to perform only transverse colectomy. Instead, we performed right hemicolectomy because ischemic changes and luminal narrowing of the ascending colon due to idiopathic mesenteric phlebosclerosis could appear in the future. Microscopic examination of the resected specimen showed interstitial fibrosis and thickening of the venous walls in the mucosa and submucosa. We report a rare case of idiopathic mesenteric phlebosclerosis associated with colon cancer.

Reportedly, paraganglioma arises from the retroperitoneum around the abdominal aorta. We encountered a patient in whom paraganglioma arising from the mesocolon was resected. The patient was a 55-year-old male who visited a physician for left upper abdominal pain persisting for 2 months. On contrast-enhanced abdominal CT, a mass measuring 12 cm was present in the left upper abdominal region, and the patient was referred to our department. A non-epithelial tumor in the mesentery was diagnosed, and tumor resection and partial resection of the descending colon accompanied by lymph node dissection were performed. Rapid blood pressure elevation was observed during surgery, but no change in blood pressure was noted after surgery. The patient recovered and was discharged on the 13th hospital day. In the excised specimen, the tumor measured 12.0 × 10.4 × 5.0 cm with a smooth surface and contained cystic and solid components. On pathological examination, a zellballen pattern was observed, and the tumor was chromogranin A staining-positive, based on which paraganglioma was diagnosed. It is difficult to histopathologically diagnose benignity or malignancy of paraganglioma. It should be handled as a potentially malignant tumor and included in differential diagnosis. We report a rare case of a paraganglioma arising from the mesocolon.

Seprafilm is used to prevent adhesions after surgery. Here we report two cases of characteristic abscess formation under the abdominal wall where Seprafilm was placed after gastrointestinal resection. The first patient, a 60-year-old man, was admitted for colostomy closure. Abdominal computed tomography was performed on postoperative day 7 and revealed an abdominal abscess appeared under the abdominal wall. The abscess was drained and cured. The second patient, a 75-year-old man, was admitted for anemia. He underwent distal gastrectomy for gastric cancer and partial colon resection for transverse mesocolon invasion. Abdominal computed tomography was performed on postoperative day 7 and revealed an abdominal abscess appearing under the abdominal wall. He was administered an antibiotic and was discharged on postoperative day 21. However, he was re-hospitalized on postoperative day 31 because the pus developed from the wound. The abscess was drained and cured. In both cases, we observed intra-abdominal abscess formation postoperatively after using Seprafilm. When Seprafilm is used for gastrointestinal resection, we should be careful to evaluate abscess formation under the abdominal wall.

A 75-year-old woman was admitted to a hospital due to hypophagia. Her white blood cell count was 36,400/μl and her C-reactive protein level was 28.4 mg/l. An abdominal CT scan showed a hepatic abscess with a linear calcified foreign body in the abscess extending from the duodenum. A hepatic abscess caused by a foreign body, thought to be a fish bone, penetrating the duodenum was diagnosed. Percutaneous abscess drainage was performed under ultrasonographic guidance. After drainage, the patient became afebrile, and CT findings showed that the abscess cavity had decreased in size, but inflammation persisted. To remove the fish bone, laparoscopic surgery was performed. The postoperative course was uneventful and the patient was discharged 6 days later.

In this paper, we present a case of omental desmoid tumor. The patient was a 20-year-old woman who was admitted with a history of right lower abdominal pain. Abdominal ultrasound and computed tomography showed a 60×25×34mm tumor, with edge ring enhancement of the tumor. Based on a preoperative diagnosis of omental tumor, we performed laparoscopic surgery. Histopathological examination revealed the diagnosis of an intra-abdominal desmoid tumor possibly arising from the greater omentum. We report this case with a brief review of the literature, because omental desmoid tumor is rarely diagnosed in the absence of a history of familial polyposis coli, operation,trauma or pregnancy.

Desmoids are very rare tumors in the general population but occur frequently in FAP patients. The patient was a 38-year-old man who underwent a prophylactic total colectomy and ileostomy for familial adenomatous polyposis (FAP) 4 years ago. Three years ago, follow-up CT scan revealed multiple intraabdominal and intrapelvic tumors. At surgery, intrapelvic tumor invading around tissues and intraabdominal tumor arising from the mesentery of the small intestine were found, and any tumors could not be completely excised. The patient was diagnosed with desmoid tumor, Stage Ⅱ according to the Churchʼs classification. We then performed sulindac therapy for the residual desmoid tumors after surgery. We added tamoxifen, because there was slight growth of the residual desmoid tumors for 12 months after sulindac therapy. After tamoxifen added, sporadic desmoid tumors demonstrated cessation of growth and have being well under control.

A 67-years-old man was admitted to a local hospital with a diagnosis of bowel obstruction.

Laboratory investigations on admission included WBC of 12,200/mm³, platelets of 49×10³/mm³, C-reactive protein of 40.9mg/dl, and fibrinogen degradation products (FDP) of 65.1μg/ml. Computed tomography revealed dilated small intestine with air-fluid levels and mesenteric convergence. With a diagnosis of small bowel obstruction with strangulation and disseminated intravascular coagulation (DIC), he underwent emergency laparotomy. The operative findings revealed a 4-cm hiatus in the greater omentum. One-hundred and forty cm of ileum had herniated through the hiatus and was necrotic. We diagnosed transomental hernia and performed lysis of the band and partial intestinal resection. Transomental hernia is a rare condition that was to be included in the differential diagnosis of bowel obstruction due to internal hernia.