We present a patient suffering from esophageal stenosis due to metastatic breast cancer. With a combination of endocrine and radiation therapy, symptom relief was obtained at an early stage and she was able to maintain her quality of life long-term. A 79-year-old woman visited our hospital with the chief complaint of dysphagia. Esophagography showed esophageal stenosis without mucosal change and computed tomography revealed a mass lesion in the left breast, swollen thoracic/abdominal paraaortic lymph nodes, causing esophageal stenosis, multiple lung masses, and osteolytic lesions. Histopathological examination of the breast lump showed invasive ductal carcinoma (estrogen-positive and human epidermal growth factor receptor [HER2]-negative). Because she had difficulty taking drugs orally due to the esophageal stenosis, Fulvestrant administered by intramuscular injection was selected for systemic therapy considering the patient’s age and pathological features. Local radiation therapy was also performed for the paraaortic lymph nodes. Soon after treatment induction, passage through the esophagus improved allowing the patient to eat again. For the nearly 4 years, to date, since these improvements the patient has continued treatments, while maintaining her quality of life.

A 63-year-old man with esophageal cancer was admitted to our hospital for post-operative endoscopic submucosal dissection. He needed additional resection of the esophagus due to submucosal (SM) invasion. The preoperative diagnosis was cT1b cN0 M0 cStage Ⅰ, cystic emphysema in the trachea, which was found to be a tracheal diverticulum. The patient underwent video-assisted thoracoscopic surgery of the esophagus after neoadjuvant chemotherapy. The diverticulum was located dorsally on the right side of the trachea. Although it often swelled up with intraoperative ventilation, there was no adhesion around the diverticulum, and the operation was completed without damaging it. Examples of esophageal cancer with tracheal diverticulum are few in Japan. This report is significant because it provides useful information regarding an effective and safe esophageal cancer surgery.

The prevalence of obesity in Japanese society is increasing, and as a result encounters requiring emergency surgery for obese patients are increasing. We describe a case in which we performed laparoscopic omental filling in an obese patient.

A 70-year-old female with a height of 149 cm, a body weight of 105 kg, a BMI of 47.2, and a history of heart failure related to obesity, experienced abdominal pain during treatment for carbon dioxide narcosis. We made a diagnosis of duodenal perforation and performed emergency surgery.

A perforation of approximately 10 mm in diameter was found in the front wall of the duodenal bulb. Abundant adipose tissue in the abdominal cavity obscured the visual field of the duodenum, thus the placement of an additional port to the normal 3 ports was required. There was no suitable omentum for buttressing, thus we undertook reconstruction of the omentum.

The postoperative course was good and the carbon dioxide narcosis improved. Following the discontinuation of artificial ventilation, the patient was able to be discharged from the hospital without ambulatory assistance.

We experienced a case in which laparoscopic omental filling was performed on a highly obese patient, and good results were obtained following surgery.

A 62-year-old man was examined closely because of anemia in the periodic inspection for his diabetes mellitus (DM). CT showed a small intestinal mass 6 cm in diameter surrounded with multiple mesenteric LN swelling. Capsule endoscopy revealed a submucosal neoplastic lesion in the middle of the small intestine, followed by an enteroscopic biopsy which revealed caldesmon-positive spindle type tumor cells. Therefore, we preoperatively diagnosed the tumor as an intestinal leiomyosarcoma. Laparo-assisted partial resection of the small intestine with lymph nodes dissection was performed. Immunostaining of tissue specimens showed c-kit (-), CD34 (-), caldesmon (+) and desmin (+), which led to the definitive diagnosis of a small intestinal leiomyosarcoma. The swollen LNs had no tumor cells. Two years and a half passed without recurrence. Leiomyosarcomas have been rarely reported in small mesenchymal intestinal tumors. Distal metastases often occur, associated with a very poor prognosis. Regional LN dissection should be required, because LN metastases also often occur. Our case is the first one in Japan, in which a small intestinal leiomyosarcoma was preoperatively diagnosed.

A 74-year-old man was admitted with acute abdominal pain. Plain abdominal CT showed hepatic portal venous gas (HPVG) with edema of the wall of the small intestine. On emergency laparotomy, there was no intestinal ischemia or necrosis.

After 43 days, the patient developed abdominal distension. Plain abdominal CT showed small bowel obstruction. Contrast study of the small intestine using an ileus tube showed segmental stenosis of the small intestine. Partial resection of the small intestine was performed and pathological examination of the resected specimen showed the characteristic feature of ischemic stricture of the small intestine. Based on the clinical presentation and the results of the pathological examination, the patient was diagnosed as having stricture type ischemic enteritis. Following surgery, the patient was discharged in good health.

We report herein on a case of a malignant lymphoma in the small intestine discovered accidentally after intestinal perforation; the lymphoma was treated with laparoscopic resection. The patient was an 82-year-old woman who was transported by ambulance to the emergency outpatient department of this hospital with abdominal pain. At initial examination, the patient presented with peritoneal irritation signs, including rebound tenderness in the lower right quadrant. A CT scan revealed thickening of the small intestine walls within the pelvis and free air in the surrounding area; therefore, she was diagnosed as having panperitonitis caused by a small intestine perforation and underwent emergency surgery. When the abdominal cavity was examined with laparoscopic assistance, a tumorous lesion was detected with purulent ascites and perforation of the ileum in her lower abdomen. After a mini-laparotomy, partial ileectomy and intraperitoneal drainage were performed. The pathological diagnosis was a small intestinal lymphoma (diffuse large B cell lymphoma). In cases of peritonitis where the causative site of the gastrointestinal perforation cannot be identified, it is useful to conduct an exploratory laparotomy and select an appropriate surgical procedure. Perforation caused by a malignant lymphoma in the small intestine is rare and difficult to diagnose preoperatively, but it is essential to consider this condition as a possible cause of gastrointestinal perforation.

A man in his 80s had undergone laparoscopic total cystectomy and ureterostomy in March 2017. He visited our hospital in April 2017, complaining of abdominal pain. He was diagnosed as having bowel obstruction with strangulation. The abdomen in the area of the ureteral fistula part was tender at the visit, but no significant findings were present elsewhere. The blood chemistry showed inflammatory signs and an increase in the lactate level. Abdominal computed tomography (CT) revealed two caliber changes of the small bowel in the left lower quadrant, and due to the findings of closed loop obstruction, the patient was diagnosed as having strangulated bowel obstruction and he underwent emergency surgery. Upon laparotomy, the small intestine was adapted as a hernia gate between the mobilized ureter and the abdominal wall. We reduced the intestinal tract and completed the surgery without closing the hernia gate. The patient’s postoperative course was unremarkable, and he was discharged on the 17th postoperative day. To the best of our knowledge, this is the first report of a strangulated bowel obstruction due to reconstruction of the ureter after the placement of the ureterocutaneous fistula. We report herein on such a case and review the appropriate literature.

A 71-year-old female with a history of endometriosis and hysteromyoma was treated for reflux esophagitis. A cecal tumor was diagnosed on screening colonoscopy. According to the colonoscopy and abdominal computed tomography, tumor of approximately 20 mm overhung the cecum and we diagnosed her condition as an appendiceal tumor. A laparoscopic ileocecal resection was performed. The resected specimen showed appendiceal intussusception, and endometriosis was present in the appendiceal muscle layer based on the postoperative pathology. The patient was discharged from our hospital on the 10th postoperative day.

A 51-year-old man developed somnolence, vomiting and diarrhea while working outside under the blazing sun in summer, and was transported to our hospital. We diagnosed him as having heat stroke with consciousness disorder, liver disorder and disseminated intravascular coagulation (DIC). A high grade fever persisted after the recovery from the severe heat stroke, with right lower quadrant pain and clearly apparent muscular defense. Computed tomography (CT) showed perforated appendiceal diverticulitis and thus an appendectomy was performed. The pathological findings revealed strong inflammation in the appendiceal diverticula and a perforation at its tip. Appendiceal diverticulitis is relatively rare. It entails perforation at a high rate, leading to increased severity. An operation should therefore be considered when appendiceal diverticulitis is diagnosed. To differentiate appendiceal diverticulitis from “normal appendicitis,” the typical image of appendiceal diverticulitis should be identified: a small round-shaped structure bulging from the appendix with an enhanced rim surrounding a low density center and fat stranding. We report herein on an example of being able to diagnose appendiceal diverticulitis preoperatively with a CT study.

An 81-year-old woman undergoing colonoscopy for regular screening was found to have a type 1 tumor, 30 mm in size, in the cecum. The result of the biopsy was signet-ring cell carcinoma. Based on the diagnosis of primary signet-ring cell carcinoma, laparoscopic ileocecal resection with D3 lymph node dissection was performed. The postoperative histopathological diagnosis was signet-ring cell carcinoma, type 1, T2, ly3, v1, N1, M0, p-Stage ⅢA. The patient remains healthy without tumor relapse 18 months after surgery.

Signet-ring cell carcinoma of the colon is very rare. Frequent lymphatic invasion and frequent peritoneal dissemination are common features of signet-ring cell carcinoma. On the other hand, liver metastases are rare. Most cases are detected at an advanced stage. Therefore, its prognosis is poorer than that of other histological types.

We report herein on a case of primary signet-ring cell carcinoma of the cecum with a review of the literature.

Situs inversus totalis is a rare congenital disease that occurs to 3,000-5,000 people. An 80-year-old man had been diagnosed in infancy with situs inversus totalis. Because of a sense of lower abdomen distension, he was referred to our hospital. Based on the colonoscopy findings, he was diagnosed as having type 3 sigmoid colon cancer. We performed a laparoscopic-assisted resection of the sigmoid colon. The operator, assistant and scopist stood on the opposite sides compared to the standard operations. The monitors and ports were also placed in the mirror-image position. Because the surgeon’s dominant forceps came out from the opposite side with situs inversus totalis, it was difficult to remove and vascularize the tumor, but the procedure was completed without complications during the operation. It is important that we comprehend the tumor location and its relationship with the feeding arteries by preoperative three-dimensional CT findings and the surgeon deployed the first assistant considering the direction of the dominant forceps. We report herein on a case of sigmoid colon cancer in a patient with situs inversus totalis treated with laparoscopic-assisted colectomy.

A 70-year-old man with bloody stool was admitted for examination. Colonoscopy revealed three synchronous cancers of the rectum. Endoscopic submucosal dissection (ESD) was performed for the most distal lesion. Curative resection was achieved. Secondly, laparoscopic anterior resection was performed 1 month after the ESD. The histological staging classification was Ⅲa but postoperative adjuvant chemotherapy was canceled according to the patient’s wishes. Colonoscopy about 2 years after the first operation showed tumor recurrence on the ESD scar. It could be concluded that rectal cancer cells of the proximal lesion were implanted into the raw surface of the rectum after the ESD. We experienced a case of three synchronous primary rectal cancers with recurrence on the ESD scar. Together with some considerations from the literature, we conclude that it is very important to prevent the implantation of free cancer cells in the intestine when we treat synchronous multiple colorectal cancers.

Case 1 was an 87-year-old woman who underwent Hartmann’s operation for stercoral perforation. On the sixth postoperative day, she was diagnosed as having perforation of the colon close to the colostomy due to stool that remained in the oral intestine, and a colectomy and colostomy were performed. She died of aspiration pneumonia 44 days after the first operation. Case 2 was an 87-year-old man who had laparoscopic-assisted rectal resection for anal canal cancer. On the second postoperative day, emergency surgery was performed for stercoral perforation of the stoma limb. He was transferred to another hospital 85 days after the first operation. Stercoral perforation after colostomy is rare. This is the first report in Japan of cases where perforation due to fecal impaction that remained after the initial surgery has occurred as in our cases. At the time of colostomy construction, attention is not given to the fecal mass of the oral intestinal tract compared to when performing intestinal anastomosis, but if there is a large amount of stool in the remaining intestinal tract, removing as much as possible of the stool is important.

A 72-year-old woman visited our hospital with back and abdominal pain lasting for a week. Contrasted CT showed thrombosis of the portal vein, superior mesenteric vein, pulmonary artery, right renal vein and inferior vena cava (IVC). Liver cirrhosis and essential thrombocythemia was thought to be responsible for the hypercoagulative state. Anti-coagulant therapy was initiated with danaparoid followed by heparin, and the thrombi in the pulmonary artery and IVC disappeared while the portal vein thrombus did not decrease. Heparin was replaced with edoxaban and the patient transferred to another hospital. During the treatment course, a stricture of the small bowel and an intracranial hemorrhage occurred and each necessitated surgical intervention. An effective and safe anti-coagulant therapy is necessary for multiple thrombosis, and in our case danaparoid against the portal vein thrombus was effective to some extent while heparin was not and caused hemorrhagic events. Careful consideration is thought to be necessary to determine the policy and medical treatment for the early and stable phases of treatment.

A-65-year-old woman with multiple liver cysts was admitted to our department with abdominal distension. CT showed enlarged liver cysts. Laparoscopic fenestrations were performed for the multiple liver cysts. Although the cystic fluid was brownish, we could not confirm a connection between the hepatic cyst and the biliary tract intraoperatively. Bile leakage occurred on postoperative day 1. DIC-CT showed a connection between the hepatic cyst and the biliary tract. Because of unsuccessful conservative treatment for bile leakage, an endoscopic nasobiliary drainage (ENBD) tube was placed on postoperative day 13. Bile leakage was improved with ENBD tube drainage. We report herein on a case of bile leakage after multiple liver cyst fenestrations successfully treated with interventional radiology.

A 64-year-old woman with a cystic lesion in the pancreatic tail, which had been detected by abdominal ultrasonography during a routine medical examination, was followed up due to a lack of obvious signs of malignancy. A year later, she underwent magnetic resonance cholangiopancreatography (MRCP) and was referred to our hospital for further investigation under the suspected diagnosis of mucinous cystadenoma of the pancreas. Contrast-enhanced computed tomography showed a 4-cm cystic lesion in the pancreatic tail. Five tumors were detected in the posterior segment of the liver. FDG-PET/CT showed no abnormal FDG uptake in the cystic lesion of the pancreatic tail, except for two tumors in the liver (SUVmax 3.5/3.8). Although the pancreatic lesion showed no signs of malignancy, as metastatic liver tumors could not be ruled out for the liver lesion. Thus we decided to plan the operative procedure according to the result of the intraoperative pathological diagnosis. During the operation, two parts of the partial resection of the liver, including the tumors, were cryo-sectioned for pathological examination, which revealed no signs of malignancy with unknown pathology. A distal pancreatectomy was then performed. Postoperative pathological examination showed pancreatic mucinous cystadenoma and hepatic epithelioid hemangioendothelioma.