We conducted a multicenter retrospective study to evaluate the relationships between various clinicopathological factors and the risk of biliary injury during laparoscopic cholecystectomy (LC). From January 2009 to December 2011, 1618 cases with LC were collected from 12 related facilities. Among these, conversion to open cholecystectomy was recorded for 72 cases (4.4%), and there were 7 cases (0.43%) with biliary injury. Intraoperative cholangiography was performed in 60.8% of all cases. There were no correlations between biliary injury and any of the various preoperative and intraoperative factors, except for a history of acute cholecystitis (P=0.002). In 6 cases with biliary injury, the operators were young surgeons, before they obtained their qualifications as board-certified surgeons. In conclusion, LC in cases with history of acute cholecystitis should be performed with the utmost care by an experienced surgeon.

Neoadjuvant chemotherapy (NAC) is considered to be effective to improve the outcome of advanced gastric cancer patients with multiple lymph node metastases. We examined the data of 8 resectable advanced gastric cancer patients with multiple lymph node metastases who received preoperative NAC with the SOX regimen between 2015 and 2019 at our hospital. Clinical evaluation by RECIST version 1.1 revealed PR in 6 cases, SD in 2 cases, and PD in 0 case. The histopathological staging was as follows: stage ⅠB, 3 cases; stage ⅡA, 1 case; stage ⅡB, 2 cases; stage ⅢA, 2 cases. Downstaging was noted in 7 of the 8 patents (87.5%). The histopathological effects were as follows: Grade Ⅰa, 3 cases; Grade Ⅰb, 2 cases; Grade 2a, 2 cases; Grade 2b, 1 case. Adverse events during the NAC classified according to the CTCAE were as follows: anemia, 1 case (Grade 1); nausea, 1 case (Grade 1); peripheral neuropathy, 1 case (Grade 1); anemia, 2 cases (Grade 2). There were no adverse events that were more than Grade 3 in severity. Distal gastrectomies in 3 cases and total gastrectomies in 5 patients were performed, with D2 dissection. There were no postoperative complications and all the patients remain alive without recurrence.

We considered that NAC with SOX may be the treatment of choice for patients with resectable stage Ⅲ advanced gastric cancer with multiple lymph node metastases.

We present the case of a patient with breast cancer suffering from intestinal obstruction due to peritoneal dissemination. With chemotherapy (eribulin mesylate), we were able to maintain her quality of life. The patient was a 50-year-old woman. At the age of 43, she received neoadjuvant chemotherapy (NAC) followed by breast-conserving tumor resection surgery and axillary dissection, followed by adjuvant radiation therapyadjuvant hormonal therapies. A mass at the operation site and bilateral axillary lymph node enlargement were found soon after the adjuvant hormonal treatment, and the hormone treatment was changed. However, the local mass and bilateral axillary lymph nodes only increased in size. At the same time, right upper limb numbness and restriction of movements from the fingers to forearm appeared. The hormone therapy was again changed to a CDK4/6 inhibitor and selective estrogen receptor downregulator, and an LHRH agonist as the second-line hormone therapy. However, an increase in the size of the locally recurrent tumor was noted in 6 months. The patient also developed nausea and vomiting at the same time. We diagnosed the condition as intestinal obstruction caused by peritoneal dissemination of breast cancer, and changed the hormonal treatment to chemotherapy (eribulin mesylate). After the end of one cycle, the patient could eat and the numbness of the upper limb disappeared.

A 66-year-old man with a gastric tumor detected by screening was referred to our hospital. Esophagogastroduodenoscopy revealed a submucosal tumor with an ulcer located on the posterior wall of the lower gastric body. Endosonography-guided fine-needle aspiration biopsy revealed the diagnosis of submucosal invasive gastric cancer on a gastrointestinal stromal tumor derived from the muscle layer. Distal gastrectomy with D1 + lymph node dissection was performed. The histopathological diagnosis was submucosal gastric cancer on a low-risk gastrointestinal stromal tumor.

A 47-year-old woman visited our emergency department complaining of abdominal pain. Contrast-enhanced computed tomography (CT) showed mechanical bowel obstruction due to wall thickening at the end of the ileum. The patient improved with conservative treatment. Two months after discharge, she visited our hospital again with the same symptom, and a repeat CT showed the same findings. Colonoscopic biopsy of the thickened part of the ileum was performed, however, no definitive diagnosis could be made. Because of the recurrent symptoms of intestinal obstruction, we considered the patient as an eligible candidate for surgery and performed laparoscopic ileocecal resection. The postoperative course was satisfactory and the patient was discharged without any complications. Histopathological examination of the resected specimen revealed evidence of endometriosis and we concluded that the intestinal obstruction was caused by ectopic endometriosis. Endometriosis often occurs in the intestinal tract, sometimes causing bowel obstruction; however, intestinal endometriosis occurring in the ileum is relatively rare and we report this case with a brief review of the literature.

The patient, a 65-year-old male, was referred to our clinic from a nearby clinic with anal pain and hemorrhage during bowel movements in March 2014. The patient reported feeling a painful induration within the anal region. A lower gastrointestinal endoscopy revealed a protruding lesion in the left semicircular region of the anal canal, extending from the anal verge to past the dentate line. He also complained of feeling an indurated mass, which was determined to be approximately 2.5 cm in diameter, in the left groin, which was subsequently diagnosed by biopsy as being a neuroendocrine carcinoma (NEC). The patient was finally diagnosed as having NEC of the anal canal with inguinal node metastasis, and abdominoperineal resection of rectum, preceded by preoperative chemoradiation therapy (CRT) was planned. However, PET examination following the preoperative CRT revealed a para-aortic lymph node (PaLN) metastasis. Therefore, after additional irradiation for the anal canal and groin, chemotherapy using a drug regimen used for pulmonary small cell carcinoma was administered. Both the PaLN metastasis and inguinal node metastasis cleared, and 5 years since the completion of treatment, the patient remains alive, without any evidence of disease progression. Overall, the prognosis of NEC of the anal canal is poor. Although most reported cases from Japan have been treated by abdominoperineal resection of the rectum or local excision, in the present case, additional radiotherapy and chemotherapy were effective, and the patient showed a good prognosis. Therefore, we report this case herein, with a short review of the literature.

Bile duct injury during laparoscopic cholecystectomy (LC) has been reported to occur in about 0.6% of all cases of LC. Appropriate treatments are required for proximal bile duct injuries and hepatic artery injuries, such as vasculobiliary injury. We report the case of a patient who required right hepatectomy for a bile duct injury complicating right hepatic artery injury that was caused during LC.

A 66-year-old man underwent LC for cholecystitis at another hospital. Bile leakage was observed after the surgery, and bile duct injury was identified by endoscopic retrograde cholangiography. He was referred to our hospital, where contrast radiography from the percutaneous transhepatic biliary drainage tube revealed that the left and right bile ducts were divided. Angiography revealed injury of the right hepatic artery, and the right lobe of the liver was supplied only by the left hepatic artery via arterial communication at the hilar plate. We diagnosed the injury as a complex injury of the proximal bile duct and right hepatic artery. We performed right hepatectomy, biliary reconstruction, and reconstruction between the left hepatic duct and jejunum. The patient was discharged 16 days after the surgery without any postoperative complications. Four months after the surgery, the patient presented with cholangitis, which, however, improved with conservative treatment. Subsequently, the serum levels of the hepatobiliary enzymes returned to within their normal ranges.

A 56-year-old man with a family history of pancreatic cancer was referred to our hospital for upper abdominal pain. Contrast-enhanced CT showed enlargement of the pancreatic tail and peripancreatic fluid collection. MRCP and ERCP revealed localized main pancreatic duct (MPD) stenosis of the pancreatic body and dilatation of the upstream MPD, but endoscopic ultrasound revealed no mass. An endoscopic nasopancreatic drainage tube was inserted and serial pancreatic-juice aspiration cytological examinations were performed, however, the histopathological diagnosis remained elusive. Under the suspicion of pancreatic cancer, distal pancreatectomy was performed. Intraoperative ultrasonography revealed an iso to hyperechoic lesion in pancreatic body, and the pancreatic resection line was determined safely. The histopathological diagnosis was moderately differentiated adenocarcinoma (tumor size 14 mm) with lymph node metastasis.

The patient was a 61-year-old male who was referred to our hospital. Abdominal dynamic CT revealed an unclear lesion measuring about 20 mm in diameter in the head of the pancreas, which was in contact with the superior mesenteric vein at an angle of about 90 degrees, but no deformation of the blood vessel was observed. The patient was diagnosed as having pancreatic head cancer (cT3cN0cM0 cStage ⅡA, Resectability: Resectable), and we planned treatment by surgery. A subtotal stomach-preserving pancreatoduodenectomy (D2 dissection) with portal vein resection, including the splenic vein junction, was performed. In order to reconstruct the splenic vein, it was detached from the pancreas about 50 mm from the junction. The splenic vein was cut at the junction, and the central end of the splenic vein was anastomosed to the anterior wall of the left renal vein. The blood vessel anastomosis time was 24 minutes, and the time required for reconstruction was about one hour, including the release of both blood vessels. The postoperative course was satisfactory, and the patient was discharged with no thrombocytopenia. No signs of left portal hypertension, such as splenomegaly or thrombosis, have been found in the patient after discharge.

A 68-year-old man visited our hospital with a bulge in the right inguinal region. We diagnosed right inguinal hernia and performed laparoscopic operation under the general anesthesia in October 2015. However, we were unable to find the hernia sac, changed the diagnosis to a right inguinal region mass, and performed resection of the mass. Histopathology of the resected mass revealed the diagnosis of lipoma of the right spermatic cord. Subsequently, the patient visited us again with a bulge in the right inguinal region in February 2017. We diagnosed the bulge as a recurrence of lipoma of the right spermatic cord and performed mass resection under the spinal anesthesia in March 2017. However, histopathology at this time revealed the diagnosis of liposarcoma of the right spermatic cord. Thereafter, we have been following up the patient semiannually, and until now, two and a half years after the surgery, there has been no evidence of recurrence. We report a rare case of liposarcoma of the spermatic cord which appeared after resection of lipoma of the spermatic cord.

[Case] The patient is an 82-year-old female. An esophageal hiatal hernia, through which the gastric arch invaded the thoracic cavity, was observed for 8 years and the stomach gradually entered the thoracic cavity. The patient developed intra-abdominal hemorrhage post-operatively, but was treated conservatively and discharged on the 18th hospital day. Six months post-operatively, the patient had symptoms of obstruction. The upper gastrointestinal endoscope showed obstruction caused by mesh that entered the esophagus. Laparoscopic mesh removal was performed with an endoscope. Because the esophageal wall was open 2 cm in the long axis direction, all layers were sutured with an absorbent thread. The omentum was covered with a suture and the operation was completed. Subsequently, the stenosis symptoms due to the residual mesh recurred, thus the mesh was removed by upper endoscopy and no stenosis symptoms were observed thereafter. Although placement of mesh for esophageal hiatal hernia is considered a useful method, mesh intrusion is a complication that occurs with a low frequency and is an important complication that will increase in the future.

Patient #1 was a 70-year-old woman who presented with a left lower abdominal bulge. Abdominal CT showed prolapse of fatty tissue from the groin and a defect in the abdominal wall at the lateral edge of the left rectus abdominis muscle with prolapse of fatty tissue. We diagnosed the patient as having an inguinal hernia as well as ventral hernia, and performed laparoscopic hernia repair via a transabdominal preperitoneal (TAPP) approach. Patient #2 was a 91-year-old female who presented with left lower abdominal pain. Abdominal ultrasonography and CT showed a defect in the abdominal wall in the lateral aspect of the left rectal abdominal muscle with bowel prolapse. We diagnosed the patient as having a ventral hernia, and performed laparoscopic hernia repair using the intraperitoneal onlay mesh (IPOM) technique. Patient #3 was a 68-year-old man who presented with a right lower abdominal bulge. Abdominal CT showed a thin abdominal wall at the lateral edge of the right rectus muscle. We diagnosed the patient as having a Spigelian hernia, and performed preperitoneal repair via the anterior approach. Spigelian hernia is a rare disease, and a number of surgical procedures have been reported for its treatment. Recently, the tension-free repair method was reported to have several advantages, and a laparoscopic approach could add more from the viewpoint of diagnosis and treatment.

A 64-year-old female patient who developed a perineal hernia after laparoscopic abdominoperineal resection for rectal carcinoma presented to our hospital complaining of perineal swelling and pain. Abdominal CT revealed a perineal hernia. Based on the CT findings and physical examination, the patient was treated by hernioplasty with a mesh via a transperineal approach.

Secondary perineal hernia is a relatively rare complication after abdominoperineal resection.

This case serves as an important reminder to consider perineal hernia in the investigation of all possible causes of perineal pain in patients who have undergone abdominoperineal resection.

The patient was a 73-year-old male who was aware of a swelling in his left inguinal region, but had never been diagnosed as having a left inguinal hernia. He was admitted to our hospital for colonoscopy because of a positive result of the fecal occult blood test. During the colonoscopy, we were unable to withdraw the endoscope, and at the same time, the patient complained of severe lower abdominal pain. Examination revealed a reddish swelling in the left inguinal region. Abdominal CT revealed incarceration of the sigmoid colon along with the endoscope in the hernia sac. An immediate attempt at manual reduction was unsuccessful, and we decided to perform emergency operation. Laparoscopic surgery was performed, the diagnosis of indirect hernia was made, and the incarceration was relieved by intra-abdominal operation and external manual reduction; however, serosal injury was noted in a part of the sigmoid colon. As intraoperative endoscopy showed no obvious mucosal necrosis, no sigmoid resection was performed, but the serosal injury was repaired under direct vision. The hernia hilum was repaired using the Lichtenstein method. Incarcerated hernia as a complication of colonoscopy has rarely been reported so far. We treated the patient by a minimally invasive and safe treatment method: laparoscopic surgery and intraoperative endoscopy.

A 60-year-old man with ascending colon cancer and multiple liver metastases had undergone laparoscopic ileostomy 2 years ago. He had received postoperative chemotherapy, however, his general condition deteriorated, and he had been initiated on BSC 6 months ago, along with oral oxycodone for pain control of systemic joint pain. We considered that the pain was caused by tumor-related syndrome, and increased the amount of oxycodone to achieve satisfactory pain control. However, the pain control remained poor, and the patient became drowsy and inarticulate. Joint ultrasonographic examination revealed tendon sheath synovitis of the long head of the biceps, and as the symptoms met the Bird diagnostic criteria for polymyalgia rheumatica (PMR) and the ACR/EULAR classification, we diagnosed the patient as having PMR. Thereafter, we started the patient on prednisolone 10 mg/day, which resulted in remarkable improvement of the symptoms, allowing the oxycodone dose to be reduced and resolution of the various side effects of that drug. Thereafter, the patient’s condition remained stable under a small daily dose of the steroid.

In patients with malignancies, it is often difficult to judge whether multiple joint pain is caused by tumor-related syndrome or comorbidities. It is necessary to pay attention to the possible presence of comorbidities, such as PMR, as the cause of multiple joint pain before increasing the opioid dose, which could, in fact, deteriorate the quality of life.