Purpose: To clarify the characteristics of lower gastrointestinal lipomas causing intussusception needing surgical treatment.

Methods: We retrospectively investigated the data of 11 consecutive cases of lower digestive tract lipomas that had been treated by surgery at our hospital, and describe the background characteristics, findings of preoperative examinations, and intraoperative findings of these cases.

Results: In terms of the preoperative clinical features, all of the 11 patients had abdominal pain, 8 patients had abdominal tenderness, and 7 patients had melena. Emergency operation was performed in 6 patients, and elective operation was performed on 5 cases. Eight out of 11 patients kept having the intussusception during the operation, however, 3 patients showed spontaneous reduction of the intussusception. Partial ischemia of the colon was recognized in 3 patients who underwent emergency surgery. There were more cases with abdominal tenderness and a palpable mass in the emergency group than in the elective group, moreover, the value of the white blood cell count also tended to be higher in the emergency group. There were no significant differences in the tumor factors or postoperative complications between the two groups.

Conclusion: In patients with intussusception caused by lower gastrointestinal lipomas, it is of greatest importance clinically to diagnose gut ischemia promptly and determine the appropriate timing of operation.

Background: Incarceration of calculi in the cystic duct or gallbladder neck is a significant cause of acute cholecystitis (AC). We evaluated the difference in the clinical outcomes of laparoscopic cholecystectomy (LC) between patients with a cystic duct stone and those with a gallbladder neck stone.

Methods: A total of 36 patients who underwent LC within 7 days of onset of AC between April 2012 and March 2018 were enrolled in this study. The subjects were divided into 2 groups (Group D and Group N) according to their preoperative CT and/or MRI findings; group D comprised 7 patients with a cystic duct stone and group N comprised 20 patients with a gallbladder neck stone. The preoperative characteristics and intra- and postoperative factors were compared between the two groups.

Results: The number of patients with remnant gallbladder mucosa was significantly higher in group D. Intraoperative cholangiography was relatively difficult to perform in group D, and 2 patients developed cholangitis due to a remnant common bile duct stone (CBDS). The rate of difficult LC was not remarkably different between the two groups.

Conclusion: In group D, remnant gallbladder mucosa and remnant CBDS were considered as risk factors for LC.

A 48-year-old woman presented with the chief complaint of a right breast mass. She gave a history of having undergone bilateral transaxillary breast augmentation (TBA) (physiological saline bags inserted under the greater pectoral muscles) at the age of 25 years. Physical examination revealed a palpable mass measuring 2 cm in diameter directly below the right nipple. The findings of imaging examinations led to the suspicion of breast cancer. A needle biopsy was proposed for definitive diagnosis, however, the patient declined to undergo the procedure. Therefore, we proposed a one-stage diagnostic-and-surgical procedure, i.e., dissection and biopsy of the mass under general anesthesia, followed by rapid intraoperative histopathological examination; in the event of breast cancer being diagnosed, mastectomy and sentinel lymph node biopsy(SNB) plus removal of the physiological saline bags and insertion of tissue expanders. The patient provided consent for this plan. Histopathological findings of the tumor indicated early-stage breast cancer. Axillary lymph node dissection was omitted because of the negative findings of SNB. At present, the patient remains alive without any evidence of cancer recurrence. The number of patients with breast cancer after TBA is expected to increase in Japan in the future. Herein, we report our experience with such a patient in whom SNB could be performed, with a discussion of the relevant literature.

A 70-year-old woman complained of muscle weakness in July 2016. In November, erythema appeared on the face accompanied by impaired swallowing. Dermatomyositis was diagnosed. An endoscopy disclosed a squamous cell carcinoma in the middle third of the thoracic esophagus. After performing preoperative chemotherapy, reducing steroid administration, and administering nutritional therapy, a thoracoscopic subtotal esophagectomy with gastric tube reconstruction was performed via the retrosternal route. Pathological examination of the resected specimen showed a well- to moderately-differentiated CT-pStage Ⅲ squamous cell carcinoma (CT-pT3pN2pM0). No critical, perioperative complications occurred. After the esophageal cancer was resected, the symptoms of dermatomyositis resolved, and the steroid dosage was able to be reduced. The patient is doing well more than 17 months after the operation and has shown no signs of recurrence.

A 64-year-old man with appetite loss seen at a local hospital was referred to Kawaguchi Municipal Medical Center for further investigation. Abdominal CT showed a small pleural effusion and ascites, without any evident neoplastic lesion. Additionally, cervical US revealed a tumor measuring 15 mm in diameter. T2-weighted MR images and PET-CT revealed bone metastases to the spine and left scapula. However, gastrointestinal endoscopy and CT failed to reveal the primary tumor. The patient had undergone gastrectomy for advanced gastric carcinoma 14 years ago. Since the possibility of a metastatic tumor could not be excluded, tumorectomy of the neck was performed. Histopathologically, the excised mass was diagnosed as an adenocarcinoma of the lymph node, which was suggestive of a metastatic lymph node from gastric carcinoma based on its morphological and immunohistopathological features. Metastatic recurrence of gastric cancer over 10 years after gastrectomy is extremely rare. Thus, we describe this case with a review of the literature.

The patient was a man in his seventies who was receiving outpatienttreatment for atrial fibrillation and Lericheʼs syndrome at thecardiology department of our hospital. Upper gastrointestinal endoscopy conducted to assess anemia revealed a protruded lesionwith ulceration on the posterior wall of the gastric antrum. Contrast-enhanced computed tomography of the abdomen revealed obstruction of the abdominal aorta extending from the vicinity of the renal artery branch up to the bilateral femoral arteries. Blood flow to the legs was delineated with collateral circulation via the epigastric artery and the artery in the rectus abdominis muscle. While planning for surgery, the care required to not impair the collateral blood flow on the abdominal side during surgery was taken into account. This planning included intraoperative observation of the dorsal artery of the foot, protective usage of retractors, and drain placement via the midline wound. Thus, distal gastrectomy was performed without damaging the collateral circulation. In Lericheʼs syndrome, the collateral circulation passes the abdominal wall, which plays a significant role during abdominal surgery. Therefore, the surgery must be thoroughly planned so that it can be safely and easily completed, which will also help prevent severe complications.

A 51-year-old man without any history of previous surgery visited our hospital complaining of abdominal pain and vomiting. His last meal was “Shabu-shabu,” which he had consumed the previous night. He presented with abdominal swelling and had pain and tenderness below the umbilicus. Abdominal X-ray revealed niveau formation and abdominal-enhanced CT revealed distension and no evidence of strangulation of the small intestine. On the following day, a long tube was inserted. However, his abdominal pain did not improve, and emergent surgery was performed on the fourth day of admission. Two soft lumps were detected at the end of the distended small intestine (120 cm proximal to the ileocecal valve). Ileotomy was performed to remove the lumps and suture the ileal wound. After the operation, the patient revealed that he had eaten a large amount of “Jew’s ear.” In Japan, there has been no report yet of ileus caused by Jew’s ear. In this paper, we present a case of ileus induced by Jew’s ear, with bibliographic consideration.

A 65-year-old man was admitted with a history of melena. Abdominal CT showed an enhancing tumor (30 mm in diameter) in the left lower abdominal cavity. For further investigation of the lesion, a capsule endoscopy was performed, which revealed a submucosal tumor in the small intestine. We performed five-port laparoscopy-assisted partial ileal resection. The postoperative course of the patient was uneventful. Histopathological examination revealed a neuroendocrine tumor of the ileum (G1) with lymph node metastasis. At present, the patient is alive with no evidence of recurrence.

Preoperative capsule endoscopy is useful for confirming multiple lesions of intestinal neuroendocrine tumor.

The patient was a 54-year-old woman with Neurofibromatosis type 1: von Recklinghausen disease (vRD), who presented with the chief complaint of bloody stools. Capsule endoscopic examination led to the suspicion of a small tumor in the upper small intestine, and oral and transanal endoscopies were performed. The patient was diagnosed as having gastrointestinal stromal tumors (GISTs) and laparoscopic surgery was performed. There were multiple GISTs in the small intestine, totalling 12 in number, measuring 2-50 mm in diameter. A small number of vRD cases complicated by GISTs have recently been reported. We encountered a patient with mulitple small-intestinal GISTs associated with vRD who we treated by laparoscopic surgery. For multiple leasions as in this case, laparoscopic exploration may be a useful approach. Herein, we report a case with a review of the relevant literature.

We report the case of a 44-year-old woman who presented with recurrent episodes of intestinal obstruction during menstruation. Abdominal computed tomography revealed an ileocecal mass with bowel wall thickening. Ileal endometriosis was suspected. As the patient complained of dysmenorrhea, pseudo-menopause was induced with a GnRH analogue, and during the six months of pseudo-menopause, the patient reported no symptoms of intestinal obstruction. After she discontinued taking oral contraceptives, she again presented with symptoms of intestinal obstruction on the second day of menstruation. On MR imaging, the ileocecal mass was visualized as a high signal intensity on T1-weighted images and as a low signal intensity on T2-weighted images. Under the preoperative diagnosis of intestinal endometriosis, laparoscopic ileocecal resection was successfully performed. Histopathological examination confirmed the diagnosis of ileal endometriosis with lymph node involvement.

A 77-year-old woman was admitted to our institution complaining of palpitation and dyspnea. She was diagnosed as having acute pulmonary embolism and deep vein thrombosis in the left leg by computed tomography. Anticoagulant therapy was started immediately. Laboratory examination revealed anemia and the patient was diagnosed as having transverse colon cancer based on the findings of abdominal ultrasonography and colonoscopy. After confirming lysis of the thrombus in the pulmonary artery, laparoscopic surgery was performed after placement of a vena cava filter. To prevent recurrent pulmonary embolism, not only anticoagulant therapy was continued, but an Enhanced recovery after surgery (ERAS) program was incorporated into the perioperative management. Consequently, the patient showed no symptoms of pulmonary embolism during the postoperative course. Adequate knowledge and careful treatment are required for colon cancer patients with acute pulmonary embolism, which can be fatal. Herein, we report a case of transverse colon cancer with acute pulmonary embolism that was treated by successful perioperative management, including anticoagulant therapy, placement of a vena cava filter, institution of an ERAS program, and laparoscopic surgery; we also review 12 previously reported Japanese cases of colon cancer with pulmonary embolism that were treated by surgery.

A 78-year-old woman was admitted to our hospital with a suspected abdominal wall hernia. Abdominal enhanced computed tomography showed an abdominal wall abscess and showed findings suggestive of invasion of the duodenal wall by the transverse colon cancer. Colonoscopy revealed a circumferential type 1 lesion of the transverse colon, and we could not insert though the oral canal. An upper gastrointestinal endoscopy revealed a type 2 lesion of the inferior duodenal flexure. The pathological diagnosis of both lesions was moderately differentiated adenocarcinoma. We performed drainage of the abscess and administered antibiotics, and 10 days later, performed a right hemi-colectomy combined with resection of the duodenal wall and abdominal wall. On histopathological examination, the lesion was diagnosed as SI, N0, Stage II, and curability A. There was no evidence of recurrence until 12 months after the surgery, but unfortunately, the patient died of aspiration pneumonia at 12 months after the surgery. We evaluated the clinical course and outcome in 28 patients of colon cancer showing invasion of the duodenum, and long-term survival was achieved in patients in whom underwent curability A resection was achieved. In such cases, we believe that en bloc resection should be attempted if curative resection is possible.

We report a rare of fecal penetration from the rectum into the mesentery. A female in her 60’s presented with acute left lower abdominal pain. She had a history of severe constipation. Physical examination revealed tenderness of the left lower abdomen, but no rebound tenderness. Abdominal computed tomography (CT) demonstrated only hard stools in the entire colon, therefore, conservative treatment was initiated. The following morning, abdominal examination revealed rebound tenderness of the middle and lower abdomen and elevation of the blood markers of inflammation. Abdominal contrast CT revealed free gas along the branch of the lower mesenteric artery at the periphery of the rectum. Rectal perforation was diagnosed and emergency surgery was performed. Hard stools filled the entire large intestine and fecal accumulation in the mesenchyme was confirmed. The sigmoid colon was excised up to the upper rectum and the large intestine was emptied of the hard stools to the extent possible and a colostomy constructed. In the resected specimen, a 22 × 14 mm oval perforation was noted on the mesenteric side of the upper rectum, confirming the diagnosis of fecal rectal penetration into the mesentery.

A 71-year-old woman underwent treatment at our hospital for chronic hepatitis B. An annual ultrasonography revealed a 15-mm diameter hypoechoic tumor situated in segment 7 of the liver. Abdominal dynamic computerized tomography revealed early enhancement and washout, and prolonged enhancement in a part of the tumor. Abdominal EOB-MRI showed the tumor as a low-signal intensity in the hepatobiliary phase; therefore, the tumor was diagnosed as a hepatocellular carcinoma. Resection of segment 7 of the liver was performed. The tumor did not contain any areas of typical hepatocellular carcinoma (HCC) or cholangiocarcinoma (ChC). We made the diagnosis of combined hepatocellular carcinoma (CHC), CHC subtypes with stem cell features (WHO, 2010), most probably. CHC subtypes with stem cell features is a second type of CHC that was added in 2010.

We report a case of CHC without any tumor areas showing the typical features of HCC or ChC.

A 71-year-old female patient presented to us with the chief complaint of epigastric pain. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed evidence of chronic cholecystitis due to biliary calculi and a 30-mm mass in the S5 region of the liver. As definitive diagnosis by imaging examinations alone was difficult, we performed laparoscopic cholecystectomy for both treatment of the cholecystitis and diagnosis of the liver mass. The S5 region of the liver was atrophied and appeared scar-like. A layer that could be exfoliated easily remained between the gallbladder and this region. Additionally, rapid intraoperative histopathological examination of the gallbladder revealed the diagnosis of chronic cholecystitis, with no evidence of malignancy. Thus, the lesion was diagnosed as an inflammatory pseudotumor and the patient was followed up. Repeat CT scans performed at 2 and 5 months postoperatively indicated no changes in the shape of the mass. At 6 months after the surgery, a percutaneous liver biopsy was performed. Immunohistochemistry showed positive staining for vimentin and factor VIII. Based on the findings, the patient was diagnosed as having epithelioid hemangioendothelioma (EHE) primarily arising from the liver. At 8 months postoperatively, a laparoscopic-assisted S5 subsegmentectomy was performed.

Primary liver EHE occurs at a frequency of less than 1 in 1 million people, and it is difficult to make a definitive diagnosis preoperatively based on the imaging and macroscopic findings alone. In this case too, the final diagnosis was made by histopathological examination.

A 67-year-old woman was pointed out of abnormal ECG, and coronary artery CT incidentally showed an abdominal mass. Abdominal enhanced CT showed a well-enhanced mass adjacent to anterior wall of the stomach, and posterior surface of the liver. Abdominal enhanced MRI showed a mass that was low intensity by T1 weighted-image, high intensity by T2 weighted-image, and enhanced by gadolinium contrast medium. Gastrointestinal endoscopy showed a bulge in anterior wall of the fundus, covered with normal mucosa. Although endoscopic ultrasonography failed to demonstrate continuity between the tumor and the stomach wall, we diagnosed the tumor as extrahepatically growing hepatocellular carcinoma or gastric submucosal tumor with extramural growth, and planned to perform operation. Surgical findings showed a liver tumor, 80mm in diameter, protuberated from the left lateral segment. Because the tumor was diagnosed as hepatocellular carcinoma by intraoperative pathological examination, we performed lateral segmentectomy. It is important that when we diagnose giant tumor that located in posterior surface of the liver, we should keep in mind the differential diagnosis of extrahepatically growing hepatocellular carcinoma or gastric submucosal tumor with extramural growth.

Xanthogranulomatous cholecystitis (XGC) is a subtype of chronic cholecystitis. It is an inflammatory lesion characterized by infiltration of the gallbladder wall by various inflammatory cells, including foamy histiocytes; it occurs as a result of repeated episodes of cholecystitis, and is associated with disruption of the structure of the gallbladder wall. Sometimes, the inflammation extends to the surrounding organs and structures, with fibrosis occurring over time. Because the imaging findings of XGC are diverse depending on the severity of the inflammation and extent of the disease, it is often difficult to differentiate this condition from gallbladder cancer.

The patient reported herein was a 64-year-old male who was referred to us with the diagnosis of a gallbladder mass. Based on the findings of a variety of diagnostic imaging examinations, we strongly suspected XGC and performed laparoscopic cholecystectomy. There were fibrous adhesions to the colon and gallbladder bed, but a partial colectomy and resection of the liver bed enabled completion of the laparoscopic operation. The postoperative course of the patient was favorable, and the final pathologic diagnosis was XGC.

An 80-year-old man who had received conservative treatment for emphysematous cholecystitis developed an intra-abdominal abscess and was transferred to our hospital. Although his general condition was fair, surgery could not be performed at the time of admission in view of the time of onset and the presence of an abdominal abscess. Percutaneous transhepatic gallbladder drainage was performed to control the focal inflammation, followed by a planned surgery 50 days later. The major part of the gallbladder was necrotic, and surgery was considered to be necessary to fully resolve the infection. The gallbladder wall and the surrounding tissue were hardened due to the presence of a previous abscess, which hindered achievement of “critical view” Therefore, the gallbladder neck was opened to complete laparoscopic subtotal cholecystectomy. Emphysematous cholecystitis is associated with severe inflammation and fibrotic changes, resulting in tissue sclerosis over time. Laparoscopic subtotal cholecystectomy should be considered for surgical intervention in cases of emphysematous cholecystitis with severe fibrosis following conservative treatment.

A 73-year-old man with yellowing of the skin was referred to us. On medical workup, the patient was diagnosed as having cancer of the head of the pancreas with a hepatic metastasis; the cancer was assessed as being unresectable. He was begun on systemic chemotherapy with gemcitabine + nab-paclitaxel. At completion of the 4th cycle of therapy, imaging revealed slight shrinkage of the primary lesion and complete disappearance of the hepatic metastatic lesion. Finally, surgical treatment was undertaken upon completion of the 9th cycle. At surgery, the hepatic metastatic lesion was found to have completely disappeared and the primary lesion to have markedly shrunk; the therapeutic effect was rated as histological partial response. Whilst the hepatic metastatic lesion could not be identified even on intraoperative ultrasonography, hepatic lateral segmentectomy and subtotal stomach-preserving pancreatoduodenectomy were performed taking into account the possibility of remnant histologic carcinoma. No tumor component was detected in the resected hepatic metastatic lesion. The prognosis of patients with stage IV cancer of the pancreas is poor, due, at least in part, to the poor response to chemotherapy. However, we encountered a case of unresectable cancer of the head of the pancreas with a hepatic metastasis, in which complete response of the hepatic metastatic lesion was achieved in response to chemotherapy, and radical resection was subsequently performed.

The patient was a 63-year-old man with a 2-week history of left nephelopsia and diplopia; he had been diagnosed as having optic neuritis based on CT and MRI findings and been prescribed prednisolone (5 mg/day). He had developed sudden abdominal pain and was transported to the hospital in an ambulance. He was in a state of shock, and abdominal CT revealed extensive high-concentration ascites, indicative of a hematoma, and bleeding around the spleen. Laboratory examination revealed severe anemia and an abnormally elevated total leukocyte count, and the patient was diagnosed as having splenic rupture due to hematologic malignancy; immediate surgery was performed. A large amount of hemorrhagic ascites was found in the abdominal cavity, and splenectomy was performed to remove the ruptured spleen. The leukocyte count gradually increased postoperatively, with a peripheral smear examination revealing a high proportion of blast cells. On postoperative day 7, the patient was diagnosed as having B-cell prolymphocytic leukemia based on the histopathological findings, and was transferred to a specialized institution on postoperative day 8. Chemotherapy with rituximab was initiated, but brain infiltration occurred. Radiotherapy was also ineffective, and the patient died 50 days after the hospital transfer (58 days following the onset of splenic rupture). A definitive diagnosis of B-cell prolymphocytic leukemia was made based on detailed histopathological examination. In cases diagnosed as having spontaneous splenic rupture, splenectomy must be performed to detect the cause of the rupture at the earliest, considering the possibility of hematological malignancy, which carries a bad prognosis.

Due to its superior sensitivity, prostate-specific antigen (PSA) has recently come to replace serum prostatic acid phosphatase (PAP) as the primary tumor marker for prostate cancer. Herein, we report a case of metastatic prostate cancer to the spine that was diagnosed based on abnormal serum PAP levels despite a normal serum PSA level. A 68-year-old man presented to his local doctor with a 3-month history of progressively increasing low back pain. Magnetic resonance imaging indicated metastatic cancer to the spine, and the patient was referred to our facility. Serum tumor marker levels were normal, and the primary cancer site failed to be identified by whole-body contrast-enhanced computed tomography and vertebral biopsy. However, the patient showed a progressive increase with time of the serum PAP level during the course of the disease, and subsequent PAP staining of the vertebral biopsy specimen led to the diagnosis of prostate cancer.

A 48-year-old woman presented with acute abdominal pain and was admitted for further examination. Abdominal computed tomography revealed a solid tumor with calcification in the small intestinal mesentery. On magnetic resonance imaging, the tumor was visualized as a low signal intensity on T1-weighted and T2-weighted images and as a slightly high intensity on fat suppression T1-weighted and diffusion-weighted images.

We were unable to exclude the possibility of a malignant tumor. The tumor was resected and subsequently diagnosed as Castleman’s disease (hyaline vascular type). Abdominal Castleman’s disease is rare, with only 68 cases reported to date. Here, we present our case and a summary of the reported cases in Japan.

Abdominal Castleman’s disease is rare, and only 68 cases have been reported in Japan until date. Here, we present our case along with a summary of the reported cases in Japan.

A 48-year-old woman presented with an abdominal tumor. On abdominal computed tomography, a tumor measuring 50 mm in diameter was seen on the left side of the mesentery. We performed laparoscopy-assisted partial resection of the small bowel for diagnosis/treatment of the mesenteric tumor. Histopathologically, the tumor showed fibroblastic growth. Immunohistochemistry showed negative staining for c-kit, but positive staining for β-catenin. Based on the findings, the patient was diagnosed as having a desmoid tumor. The surgical margin was negative. Although complete resection of an intraabdominal desmoid tumor has been reported to be difficult, we were able to diagnose and completely resect the tumor by laparoscopic-assisted surgery in our patient.

The patient was an 80-year-old man who had undergone laparoscopic total gastrectomy with Roux-en-Y (overlap) reconstruction for gastric cancer. One year later, he presented to us with a history of sudden onset of upper abdominal pain. He was diagnosed as having strangulation of the small bowel caused by incarcerated hernia, and emergency laparoscopic operation was performed. Laparoscopy revealed herniation of the small intestine into the left thoracic cavity through the esophageal hiatus. We then converted the surgical approach to laparotomy and successfully pulled the prolapsed small intestine out into the abdominal cavity and resected the necrotic part of the intestine. The hernia orifice was occluded by suturing the crus of the left diaphragm. Careful review of a routine 6-month postoperative screening CT showed herniation of a segment of the small intestine into the mediastinum through the esophageal hiatus. However, the left pleura was not disrupted. Incarcerated hiatal hernia after laparoscopic total gastrectomy is rare. We describe our case with a review of the relevant literature.

The patient was a 59-year-old man who was admitted to our hospital complaining of fever and anal pain. A secondary orifice scar was detected in the 9 o’clock position and a perirectal abscess in the 7 o’clock position. After incision and drainage of the abscess in the 7 o’clock position, a draining Seton was placed. Subsequently, fistula resection in the 7 o’clock position was performed, and another draining Seton was placed. After 8 months, the lesions had resolved completely. However, subsequently, 7 months later, the abscess recurred in the 7 o’clock position, and incision and drainage was performed, which revealed mucus-like pus and an underlying mass. The mass was diagnosed as adenocarcinoma by biopsy. Computed tomography and magnetic resonance imaging revealed a multilocular cystoid tumor at the same site, and laparoscopic abdominoperineal resection was performed. Histopathological examination confirmed the tumor as an adenocarcinoma, mainly consisting of mucinous adenocarcinoma, spreading through adipose tissue and muscle tissue. The cancer was considered to have arisen from the anal fistula. The patient has shown no evidence of recurrence until date, 2 years after the operation. Our results indicate that patients who undergo Seton treatment for anal fistula require careful follow-up for cancer development.