Transperineal surgery is generally preferred for treating rectal prolapse in the elderly, even though the success rate of transabdominal surgery is higher. Laparoscopic rectal fusion has tended to be the procedure of first choice at many institutions in recent years. Laparoscopic rectal fusion for rectal prolapse began to be covered by the National Health Insurance of Japan in 2012. It is less invasive than open surgery and is highly curative. Rectal fusion has been adopted at many institutions for the treatment of rectal prolapse, but its availability may not be optimal. We report a literature review of 27 cases of laparoscopic rectal fixation performed at our hospital.

A 43-year-old man was referred to our hospital from a nearby clinic with a painful swelling (sense of tumor) in the neck as a case of suspected thyroid tumor. Enhanced computed tomography (CT) at our hospital showed a thyroid mass measuring 60 mm in diameter and another mass in the superior mediastinum with calcification and a clear margin. Aspiration cytology revealed no evidence of malignancy. Left thyroid lobectomy and autologous parathyroid transplant was scheduled based on a preoperative diagnosis of a giant adenomatous goiter. During surgery, no connection was found between the tumor in the superior mediastinum and the tumor in the left lobe of the thyroid. Histopathologically, the patient was diagnosed as having an adenomatous goiter in the excised left lobe, associated with an aberrant ectopic mediastinal goiter. Herein, we report a rare case of aberrant ectopic mediastinal goiter associated with a norm-position giant adenomatous goiter that was difficult to diagnose prior to the operation.

A 28-day-old female infant was brought with a progressively enlarging mass in the left breast that had first been noticed 3 days earlier. She had a history of omphalitis. On physical examination, the skin over the entire left breast was erythematous and a 2-cm mass was noted in the retroareolar area. The yellow contents could be observed through the thinned skin surface of the mass. Although the patient was afebrile, her white blood cell count was 14,880/ul. Ultrasound examination of the breast revealed an ill-defined low-echoic mass with no blood flow. Through a periareolar incision, the purulent contents of the mass were drained, and culture of the pus aspirate grew Methicillin-resistant Staphylococcus aureus (MRSA). The lesion quickly resolved after the drainage and antibiotic treatment. The mastitis could have been caused by the omphalitis.

A 50-year-old man visited our hospital with the complaint of a soft mass measuring 2 cm in diameter near his right nipple. Ultrasonography showed a multilocular cystic lesion containing solid nodules. Color Doppler showed hypervascularity of the solid nodules. Excisional biopsy was performed under the suspicion of a neoplastic lesion. Histological examination revealed a low-papillary proliferation of epithelial cells. The diagnosis of ductal carcinoma in situ (DCIS) was established based on the findings of immunohistochemistry. Although a left mastectomy was performed without axillary dissection, there were no remaining cancer cells in the resected specimen.

DCIS is a very rare disease that accounts for 4.8%-7.0% of all cases of breast cancers in males, which constitute 1% of all breast cancers. We examined the features of 37 cases reported in Japan, along with our case. We found a relatively high percentage of cases of intracystic carcinoma among male patients with DCIS as compared to female cases. Ultrasonography was helpful for the diagnosis. In many cases, the diagnosis was confirmed by excision biopsy, because of inaccurate results of cytology and core needle biopsy.

When a cystic lesion is found in the male breast by ultrasonography, excision biopsy may be necessary to rule out DCIS.

The first patient was a 68-year-old woman who was diagnosed as having right breast cancer with multiple bone metastases to various sites, including both femurs, metastases to the lungs and liver, and lymphangitic carcinomatosis. After chemotherapy, the patient received both endocrine therapy and zoledronic acid. Five years five months following commencement of the latter therapy, she fell down and sustained a subtrochanteric femoral fracture on the right side. She underwent bipolar hip arthroplasty at another hospital. Left coxalgia appeared one year following the accident, but despite palliative radiation, the patient continued to have intractable pain. Thereafter, she was diagnosed as having atypical femoral fracture (AFF) after a detailed examination. Zoledronic acid was discontinued and intramedullary nailing was performed.

The second patient was a 58-year-old woman who had undergone a mastectomy (right) + axillary lymph node dissection for right breast cancer (T2N0M0StageⅡA), and was receiving chemotherapy. Distant metastasis to the ribs was detected one year six months after the surgery, and the patient was initiated on treatment with zoledronic acid. A detailed examination was conducted after she complained of pain in the right femur nine years after the start of zoledronic acid administration, which led to the diagnosis of AFF on both sides. Zoledronic acid administration was discontinued and intramedullary nailing was performed.

In breast cancer patients presenting with pain in the groin and femur during treatment for bone metastasis, it is necessary to bear in mind the possibility of AFF, in addition to pain caused by bone metastases, especially if the patient is on long-term zoledronic acid treatment.

A 48-year-old woman consulted her previous doctor with a history of discomfort in her right ribcage, and underwent abdominal ultrasonography and abdominal MRI. As the imagings revealed a liver tumor, she was referred to our hospital. She was a social drinker. Serum tests for HBs antigen, HBs antibody, HCV antibody, and tumor markers were negative. Abdominal contrast-enhanced CT and MRI showed a well-circumscribed tumor measuring approximately 9 cm in diameter in the right liver, and was seen as a heterogeneous high density in the arterial phase. Based on the diagnosis of primary or extrahepatic tumor, we performed tumor resection, partial diaphragmectomy, partial liver resection, and cholecystectomy. The resected specimen revealed a pale yellow solid tumor measuring 13 cm × 9 cm in size with microcystic degeneration and partial hemorrhage. Histopathological examination of the tumor revealed fibrous tissue hyperplasia, and immunohistochemical examination showed a “pattern-less pattern,” so that the tumor was diagnosed as a malignant solitary fibrous tumor arising from the diaphragmatic peritoneum on the right side. The patient was discharged on postoperative day 9. The patient did not receive adjuvant chemotherapy, and until the last follow-up, at 8 months after surgery, there was no evidence of recurrence.

An 83-year-old man presented to our hospital with the chief complaint of breathlessness and generalized edema. Computed tomography revealed a type Ⅳ hiatal hernia, with an upside-down stomach and herniation of the duodenum, transverse colon, small intestine, and pancreatic body. The hernia contents caused severe heart failure due to compression of the heart. Since conservative management was successful, elective laparoscopy-assisted hiatal hernia repair was performed. Although the esophagus and stomach had slid deep into and were tightly adherent to the hernia sac, we reduced them carefully under laparoscopic guidance. However, reduction of the pancreas proved so difficult that we had to convert the surgery to open laparotomy to avoid the risk of pancreatic injury and hernia recurrence. Although this was a case of type Ⅳ hiatal hernia with severe sliding and adhesion that needed laparotomy, it was possible to avoid thoracic surgery because of the laparoscopic visual field in the sac, and we obtained a good postoperative course.

Abstract: A 71-year-old man underwent low anterior resection for sigmoid colon carcinoma that showed direct invasion of the ileum. The histopathological diagnosis was well-differentiated adenocarcinoma. One year two months after the surgery, a solitary liver nodule appeared in liver segment Ⅶ, which gradually increased in size. One year 10 months after the surgery, a solitary nodule appeared in segment Ⅳ of the right lung. The patient was initiated on combination chemotherapy with capecitabine + oxaliplatin + bevacizumab. After 5 courses of chemotherapy, since neither the lung tumor nor the liver tumors showed any response, synchronous thoracoscopic-assisted lung partial resection and transdiaphragmatic liver resection were performed. The histopathological diagnoses were non-keratinizing squamous cell carcinoma and well-differentiated hepatocellular carcinoma, respectively. Complete resection of metastases is, in general, associated with long-term survival in patients with Stage Ⅳ colorectal cancer. Since this approach is safe and useful, tumors that are close to the diaphragm represent a good indication for synchronous lung and liver resections.

A 36-year-old woman who presented with a history of epigastric pain was found by esophagogastroduodenoscopy to have a gastric submucosal tumor and was referred to our hospital. Esophagogastroduodenoscopy at our hospital revealed a submucosal tumor measuring 20 mm in diameter on the greater curvature in the middle gastric body. Definitive diagnosis could not be obtained by endoscopic ultrasound-guided fine needle aspiration biopsy, as no epithelial or interstitial tissue could be collected. We performed surgical resection of the tumor for diagnosis. Partial gastric resection was performed by laparoscopic surgery. Histopathological examination revealed cystic lesions measuring 16 mm and 8 mm in diameter protruding to the serosal side. Gastric mucosal tissue, including gastric fundic glands, was found in some parts of the inner surfaces of the cysts. The cysts were surrounded by a smooth muscle layer continuous with the proper muscle layer of the stomach. From these histopathological findings, the tumors were diagnosed as gastric duplication. There are relatively few reported cases of resection for gastric duplication in adults, and we report our case together with a review of the literature.

An 81-year-old male patient was referred to our hospital for examination of anemia. Based on the findings of esophagogastroduodenoscopy and computed tomography, the patient was diagnosed as having advanced gastric cancer (cT3N0M0, cStage Ⅱ). Proximal gastrectomy was performed, and a jejunostomy was created. During the postoperative period, the patient showed an exaggerated inflammatory reaction. On the 6^th day after surgery, the serum CRP was 30.9 mg/dL, although there were no abdominal signs or fever. Abdominal CT showed hepatic portal venous gas. As no sign of intestinal necrosis was detected, the patient was observed carefully, without proactive treatment. The hepatic portal venous gas disappeared spontaneously within a few days, and the patient was discharged on the 26th day after surgery. Hepatic portal venous gas was once considered as a sign of intestinal necrosis, and therefore, was a definitive indication for surgery. However, recently, there have been several reports of patients with hepatic portal venous gas who were treated conservatively. Herein, we report the case of a patient who showed appearance of hepatic portal venous gas after gastrectomy and was successfully treated without surgery.

A 70-year-old man was diagnosed as having gastric cancer at another hospital. In late January 2010, he developed hematemesis and was transferred to the emergency department of our hospital.

Clinical examination revealed the cause of the bleeding as rupture of a pseudoaneurysm in the periphery of the gastroduodenal artery.

Although the gastric cancer invaded the pancreaticoduodenum and transverse mesocolon, there was no distant metastasis, and we performed emergency pancreaticoduodenectomy and right hemicolectomy. The histopathological diagnosis was U circumferential, type 5, 100 × 147 mm, adenocarcinoma (tub2>por2), pT4b (duodenum, pancreas), INFb, ly1, v1, pN3c (13/40), pStageⅢc.

A 32-year-old female patient visited a neighborhood hospital complaining of hematemesis at 25 weeks of pregnancy. Careful examination revealed locally advanced gastric cancer with extensive lymph node metastasis, and she was referred to our hospital for treatment. Considering the stage of the pregnancy and the effects of chemotherapy on the fetus, delivery after S-1/DTX treatment was planned to provide for maximum fetal development in utero. After two courses, a baby girl weighing 2,374 g was delivered at 35 weeks of pregnancy. CT after 5 chemotherapy courses showed shrinkage of the primary tumor and lymph nodes. Thereafter, at 11 weeks after delivery, total gastrectomy (D2 + No.10) with splenectomy and Roux-en-Y reconstruction was performed. The histopathological diagnosis was ypT3N1M0, and the histological chemotherapy response was grade 2. She was started on postoperative adjuvant chemotherapy. Gastric cancer during pregnancy is extremely rare and is associated with a poor prognosis, and the effects of chemotherapy on the fetus and mother during pregnancy should be carefully considered.

We encountered a case in which chemotherapy was safely administered during pregnancy, and we present a report of the case, with a review of the literature.

We present reports of three patients with acute superior mesenteric artery occlusion (SMAO) who were treated by surgery, with a review of the literature. Case 1: A 74-year-old woman underwent extensive small bowel resection due to SMAO. The remnant intestinal segments were anastomosed (jejunum: 40 cm, ileum end: 10 cm). The postoperative course was uneventful and the patient is being followed up. Case 2: A 75-year-old man who was diagnosed as having SMAO underwent resection of the small bowel with a part of the ascending colon, followed by creation of an ileostomy and colostomy. The patient’s postoperative course was complicated by the development of catheter infection prior to discharge from the hospital. Thereafter, the patient was hospitalized a total of 7 times for urinary tract infection, renal dysfunction and sepsis, and died 807 days after surgery. Case 3: An 83-year-old man with SMAO underwent extensive small bowel resection followed by jejunostomy (remnant jejunum: 40 cm). The patient died 465 days after surgery, of infection of the central venous access device, pyogenic spondylitis and sepsis. Thus, favorable long-term outcomes would usually not be expected, even in patients rescued by extensive intestinal resection. Inclusive care, including fluid/nutrition management and infection control are indispensable for short bowel syndrome.

A 16-year-old woman visited our outpatient clinic with a history of lower abdominal pain after eating a heavy meal. Enhanced abdominal CT showed a dilated Meckel’s diverticulum with accumulation of food residue, and also stagnation of food residue in the intestinal tract orad to the diverticulum, resulting in bowel obstruction. The small intestine on the anal side was not dilated. There was no evidence of strangulation or necrotic findings. The patient was just observed, with intravenous infusion of electrolytes and prohibition of oral intake, and the obstruction improved. After a month, laparoscopic resection of Meckel’s diverticulum was performed. No cords, adhesions or inflammatory findings around the diverticulum were observed in the surgical field. Based on these findings, the bowel obstruction was classified as dietary bowel obstruction. We report a case of dietary bowel obstruction caused by Meckel’s diverticulum, which is relatively rare.

A 70-year-old man presenting with acute abdominal pain was admitted to our hospital for further examination. Abdominal computed tomography　(CT) showed a multilobulated cystic lesion measuring about 7 cm in diameter in the right lower abdomen. Two days later, the pain disappeared spontaneously. Computed magnetic resonance imaging showed a mass in the middle of the lower abdomen which was visualized as a high signal intensity on T2-weighted images. The findings led to the strong suspicion of a jejunal lymphangioma. We planned elective surgery, but the patient was admitted again a week later for the same type of abdominal pain. Abdominal CT showed a mass in the left lower abdomen. Although the pain again disappeared a day later, emergency surgery was performed, considering the risk of recurrence of the abdominal pain in the short term and of intestinal ischemia or necrosis because of exacerbation of intestinal torsion. Intraoperatively, a yellowish-white soft multilobulated cystic tumor was found in the mesentery of the jejunum, adhering tightly to the jejunal wall. Therefore, tumor removal with partial resection of the jejunum was performed. The histopathological diagnosis was jejunal mesenteric lymphangioma. Until follow-up 3 years after surgery, he remained free of relapse.

A 46-year-old woman underwent surgery for right ovarian tumor. However, while the right ovary was found to be normal, a cecal tumor was detected. Therefore, she was referred to the department of surgery for further examination. Abdominal MRI and CT revealed a cystic lesion measuring 50 mm in diameter on the right side of the pelvic cavity. Colonoscopy showed a submucosal tumor of the cecum. Laparoscopically, the cecal tumor was found to not be adherent to the surrounding structures. We performed ileocecal resection. The tumor measured 50 × 55 mm in size and was soft and rubbery in consistency. Microscopically, it was found to be a unilocular cyst filled with keratin and lined by stratified squamous epithelium without appendages. We diagnosed the lesion as an epidermoid cyst.

While epidermoid cysts in the abdomen have been reported, epidermoid cyst of the cecum is very rare. We report this case with a review of the literature.

A 71-year old woman was admitted to another hospital with a history of persistent fever and body weight loss. Abdominal ultrasonography showed a hypoechoic mass in the right abdomen and she was referred to our hospital. At her first visit to our hospital, she had fever (37.5°C) and an elevated serum CRP level, but no abdominal symptoms. Computed tomography revealed a hypervascular mass of the ascending colon measuring 7 cm in diameter. Colonoscopy revealed a large yellowish submucosal tumor in the ascending colon. Examination of colonoscopic biopsy specimens revealed only necrotic tissue and was not helpful for diagnosis. The patient continued to have persistent fever and show body weight loss despite administration of antibiotics. Because further examination revealed no other inflammatory focus, we performed a right hemicolectomy. The fever and inflammatory response promptly improved after the operation. The histopathological diagnosis was inflammatory myofibroblastic tumor (IMT) of the ascending colon. IMT is an uncommon neoplasm composed of proliferating myofibroblasts and infiltrating inflammatory cells. It occurs most commonly in the lung, and colorectal IMTs are rare. Herein, we report a case of IMT of the ascending colon, with a review of the literature.

A 46-year-old man presented to our hospital with abdominal pain and nausea under the diagnosis of ileus. Abdominal CT revealed a tumor of the ascending colon accompanied by bowel obstruction. Symptoms were relieved successfully by decompression using a long intestinal tube. Eight days after insertion of the tube, the patient complained of left upper abdominal pain of acute onset. Physical examination revealed localized rebound tenderness and muscle guarding. Bloody discharge was observed from the tube. CT revealed intussusception of the jejunum. Emergency operation was performed on the same day. Intraoperatively, a jejuno-jejunal intussusception measuring 30 cm in length was observed, while no tumor as a potential cause was identified, suggesting that the intussusception was caused by the long intestinal tube. The necrosed segment of the intestine was resected. Right hemicolectomy was also performed for ascending colon cancer. Intussusception caused by an ileus tube is relatively uncommon. Herein, we report a case of intussusception caused by a long intestinal tube, with a review of the literature.

Rectal neuroendocrine neoplasms (NENs) are often smaller than 10 mm in diameter, and are associated with a low risk of lymph node metastasis. However, several studies have also described the occurrence of lymph node metastasis in association with small tumors, resulting in disagreement over the optimal treatment. A 70-year-old man was admitted to our hospital with anemia. Sigmoidoscopy revealed a 9-mm submucosal tumor with a central depression in the distal rectum. The biopsy histopathological diagnosis was NEN G1. Abdominal computed tomography revealed a swollen lymph node measuring 10 mm in diameter. Therefore, we performed laparoscopic low anterior resection (D2 dissection). The macroscopic findings indicated that the primary tumor was 9 mm in diameter and confined to the submucosa, with the following characteristics: <2 mitoses per 2 mm2, Ki-67 index <3% , and positive lymphatic invasion. The NEN had metastasized to three of the seven removed 251 perirectal lymph nodes . This case indicates that preoperative imaging studies should be performed even in cases of rectal NEN which usually show a low risk of developing lymph node metastasis.

The patient was a 68-year-old male, who had inserted a melon into his anus for the purpose of masturbation, and was unable to discharge it . Abdominal CT showed the melon measuring 16 cm ×７cm at the level of the rectosigmoid and no obvious intestinal perforation. We considered that the rectum could be damaged at the time of extraction, and attempted extraction under general anesthesia. The surgery was started with the patient in the lithotomy position. Although relaxation of the anal sphincter was obtained, the foreign body could not be visualized from the anus. The top of the melon was slightly observed when the lower abdomen was pressed. It was difficult to grasp it with a Muzeaux uterine tenaculum forceps, therefore, we inserted a Myoma borer into the melon in an attempt to retrieve it. However, because the melon was fragile, the inserted part of the Myoma borer broke. By inserting another one from another angle, we were able to disperse the power and compensate for the vulnerability, and succeeded in excising the foreign body, while also using abdominal compression. A wide variety of foreign bodies have been reported as rectal foreign bodies, and it is necessary to devise individual methods to removing them. We report a case of successful removal of a rectal foreign body (melon) using Myoma borers.

We diagnosed common bile duct carcinoma during follow-up in a case of congenital biliary dilatation. A 63-year-old man was incidentally detected to have biliary dilatation on computed tomography (CT) performed for investigating the cause of left back pain. Both magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography demonstrated pancreatobiliary maljunction associated with the biliary dilatation. Although we recommended surgery, the patient refused, and we followed up the patient periodically. One year seven months later, enhanced abdominal CT and MRCP showed a tumor in the hilar portion of the common bile duct. The patient was diagnosed as having cholangiocarcinoma, and pancreaticoduodenectomy was performed. The histopathological diagnosis was poorly differentiated tubular adenocarcinoma (T2aN0M0, Stage Ⅱ, R0). He received adjuvant chemotherapy with S-1. Six months later, enhanced abdominal CT showed a local recurrence and lymph node metastasis around the celiac artery. Treatment with gemcitabine plus cisplatin was started, however, the patient showed poor response and died of the cancer 18 months after surgery. This case report is intended to emphasize the importance of early surgery for congenital biliary dilatation, especially in elderly patients.

A 70-year-old woman presented to our hospital with the complaints of epigastralgia, vomiting, and diarrhea. Plain computed tomography (CT) revealed dilatation of a short segment of the small bowel and a mass in the pancreatic body. Contrast-enhanced CT performed 2 days later revealed reduction in the degree of dilatation of the small bowel segment and gradual contrast enhancement of the mass in the pancreatic body. We suspected pancreatic body cancer and performed surgery. During laparotomy, we detected a small bowel tumor, and partial resection of the jejunum was performed for tumor removal, concomitantly with distal pancreatectomy and partial resection of the portal vein for the pancreatic body cancer. Histopathological examination of the resected specimen confirmed invasive ductal carcinoma of the pancreas with a small bowel metastasis. The patient received adjuvant S-1 chemotherapy postoperatively for 6 months. Local recurrence-induced obstructive jaundice occurred 8 months postoperatively, and an expandable metallic stent was placed for biliary drainage, and the patient was initiated on a 6-month course of gemcitabine plus nab-paclitaxel chemotherapy. Progressive local recurrence resulting in duodenal stenosis was detected 14 months after the pancreatectomy; therefore, the patient received duodenal metallic stent placement and supportive care. The patient died of advanced local recurrence 17 months after the pancreatectomy; however, no recurrence of the metastasis was identified.

A 34-year-old man presented with a mass in the upper abdomen; physical examination revealed an epigastric bulge and tenderness over the bulge. Abdominal computed tomography (CT) revealed linea alba hernia. Because the hernia was tender to palpation and was not reducible manually, elective laparoscopic surgery was performed. During the operation, a hernia orifice was found in the midline of the upper abdomen, with herniation of the omentum through the orifice. The herniated omentum was reduced laparoscopically, and after removing the incarceration, the hernia orifice was repaired with an IPOM (intraperitoneal onlay mesh). Laparoscopic surgery has been performed increasingly frequently in recent years for linea alba hernia, but evidence for the short- and long-term outcomes remains elusive. However, in light of the low recurrence rate, large number of cases, and cosmetic acceptability, expectations for laparoscopic surgery are high. Herein, we report a case of linea alba hernia, which was repaired by laparoscopic surgery using Bard Ventralight ST with Echo2.