Cases of early postoperative intestinal obstruction are sometimes encountered after laparoscopic left hemicolectomy for left colonic cancer. We evaluated the causes and frequency of such intestinal obstruction, and the association of such obstruction with mesenteric closure in cases who underwent laparoscopic left hemicolectomy at our hospital between 2014 and 2019. Four of twenty-one cases (19%) developed mechanical intestinal obstruction within 30 days postoperatively, which was more frequent than that in cases undergoing other colorectal surgeries. In all cases, the onset of intestinal obstruction was within two weeks after the surgery, and the site of stenosis was the upper jejunum, shortly after Treitz ligament. The cause of the intestinal obstruction was internal herniation through the gap in the mesentery in one case, and adhesion to the stump of the IMV in the remaining three cases. The case with internal hernia required re-operation. Evaluation of each mesenteric closure method revealed that while non-closure of the mesentery was not a significant cause of the intestinal obstruction, incomplete closure was a risk factor. The method of mesenteric closure should be carefully considered.

Background: Recently, peripherally inserted central catheter (PICC), use of which is reported to be associated with few complications, have attracted attention, especially because insertion of central venous catheter (CVC) can sometimes lead to serious complications. We introduced upper-arm CV ports, aimed at improved safety, and report results comparable to those reported for conventional chest CV ports. Method: Data of a total of 237 cases who received CV port implantation, including 111 cases of chest CV port implantation and 126 cases of upper-arm CV port implantation, between April 2018 and August 2020 were studied retrospectively. Results: There were no difference in the patient background characteristics, and the average procedure time was significantly shorter in the upper-arm CV port group. 13 cases (including one case of pneumothorax) of chest CV port and 9 cases of upper arm CV port, there was no significant difference. Conclusion: Upper-arm CV port is safe, with an expected shortened procedure time as compared to chest CV port implantation, and may be considered as the procedure of first choice.

The most common site for insertion of an implantable central venous access device is the subclavian vein. This percutaneous procedure is not complicated, but it sometimes causes pneumothorax, arterial puncture, or most seriously, the pinch-off syndrome (damage to or even severance of the catheter). To prevent these complications, we performed the cephalic vein cutdown procedure.

Between June 2011 and April 2018, 740 venous access device placement were planned using the cephalic vein cutdown procedure in patients aged >80 years. The cephalic vein was not recognized in 35 patients (4.5%). Finally, the data of the remaining 705 cases were analyzed. The procedure was successfully performed in 88.9% (627/705) of cases. The mean operative time was 13.9 minutes. The complication rate was 1.6%, and hematoma formation was the most common complication. No cases of pneumothorax, arterial puncture, or pinch-off syndrome were observed until the last follow-up.

The cephalic vein cutdown procedure was performed safely within a short time, even in elderly patients in this study. Thus, it could be the procedure of choice for central venous access device implantation.

We examined the usefulness of diffusion-weighted imaging of the whole body with background body signal suppression (DWIBS) for non-contrast diffusion-weighted imaging for the diagnosis of bone metastases and also for the diagnosis of metastasis to other visceral organs in patients with breast cancer treated by surgery. Bone scintigraphy (BS) and whole-body magnetic resonance imaging (MRI) (1.5 tesla) were performed in 60 breast cancer patients after surgery, and DWIBS-based fat suppression combined with DWI and heavy T2-weighted imaging using a balanced SSFP sequence were used. Cross-sectional images were taken from the parietal region to the pelvis in 30 slices in four areas. Furthermore, the whole spinal cord scanning in sagittal sections by fast spin echo T1-weighted imaging was imaged in two slices with 29 slices. DWIBS showed 100% sensitivity and 96.6% specificity as compared to BS. Metastasis to the visceral organs was suspected in 3 cases by DWIBS, but closer examination revealed a negative result. DWIBS seems to be a useful test method for detecting bone metastasis in breast cancer patients after surgical treatment.

A 56-year-old woman with left breast cancer (ER+, PgR-, HER2+), cT4bN2aM0 StageⅢb, received preoperative chemotherapy and anti-HER2 therapy, followed by total left mastectomy and axillary lymph node dissection. Results of postoperative histopathological examination revealed pT4bN2a (ER+, PgR+, HER2-). New tumors were detected in the liver and transverse colon after the surgery. Based on the biopsy findings, both these tumors were diagnosed as poorly differentiated adenocarcinoma (ER-, PrR-, HER2-).

Although both tumors showed different immunostaining patterns as compared to the primary breast cancer, we suspected metastasis to the liver and colon from the breast cancer, because the lesions were CDX2-negative. Since the colonic tumor showed rapid growth, we performed transverse colectomy.

Based on the histopathological findings of the resected specimen and positive immunostaining for GATA3, we confirmed the diagnosis of colon metastasis from the breast cancer. At present, 8 months have passed since the operation and the patient has received chemotherapy. Making a preoperative diagnosis was difficult in this patient, because the immunostaining pattern differed between the primary breast tumor and colonic tumor, although the results of CDX2 and GATA3 immunostaining were useful for the diagnosis. In patients with breast cancer presenting with colonic tumor, the possibility of metastasis of the breast cancer to the colon should be borne in mind.

Thymic carcinoid is a rare tumor. Herein, we present a case of atypical carcinoid of the thymus. The 73-year-old female patient was incidentally discovered to have an abnormal mediastinal opacity on a plain chest radiograph prior to an operation for radius fracture. Chest CT showed a lobulated high-density anterior mediastinal mass measuring 65 mm in diameter and FDG-PET/CT revealed abnormal accumulation in the anterior mediastinal mass (SUVmax: 65.4). Tumor resection was performed through a median sternotomy. The histopathological diagnosis was atypical carcinoid of the thymus. After the operation, the patient received adjuvant radiation therapy (60 Gy) to the mediastinum. Until now, 2 years since the surgery and radiation treatment, the patient has remained well, without any sign of recurrence.

A 28-year-old woman was transferred to our hospital with a history of frequent vomiting, which had started after she had overeaten 3 days prior to her visit. She visited the clinic and received fluid infusions, but her condition didn’t improve. She had a history of having lost 40 kg in the previous 2 years. On arrival, she had abdominal distention and unstable vital signs, and arterial blood gas analysis indicated acidosis; there were no signs of peritonitis. Abdominal CT showed gastric dilatation caused by a lot of food residue. There was no intraperitoneal free gas. Therefore, a transnasal gastric tube was introduced under the diagnosis of acute gastric dilatation. Enhanced CT performed the following day revealed decreased blood flow to the gastric wall, and endoscopy showed a defect in the gastric mucosa. Based on the findings, the patient was diagnosed as having gastric wall necrosis caused by acute gastric dilatation, and surgery was performed.

During the operation, while there was no gastric rupture, but near total gastric wall necrosis was seen. Therefore, we performed total gastrectomy, and the patient was discharged on postoperative day 26 without any major problems.

An 84-year-old man underwent laparoscopic distal gastrectomy with a delta-shaped anastomosis. He developed paralytic ileus, but the symptoms improved with conservative treatment. On day 6 after the surgery, he resumed oral intake, and was discharged on day 14. However, on day 20 after the surgery, he presented with abdominal distention and vomiting. Abdominal computed tomography showed obstruction of the jejunum with dilatation of the proximal segment, suggesting intestinal obstruction caused by adhesion at the delta-shaped anastomosis. The symptoms improved with decompression. However, as the symptoms recurred, we decided to perform reoperation. Laparoscopic observation revealed the jejunum climbing over the transverse colon and adhering solidly to the anterior of anastomosis. The cause of the adhesion was considered to be a staple used for the common channel closure. We performed adhesiolysis and partial bowel resection. The patient’s postoperative course was uneventful and he was discharged 10 days after the reoperation.

Delta-shaped gastroduodenostomy is a standard surgical procedure in laparoscopic gastrectomy. Although intestinal obstruction caused by staples is a very rare complication, the possibility of staple-related complications must be borne in mind and appropriate measures should be taken, such as a single-layer suture for the entry hole without a staple, while performing delta-shaped anastomosis.

A 40-year-old female patient visited our hospital complaining of intermittent lower abdominal pain. Abdominal enhanced computed tomography (CT) showed intussusception of the small intestine. We detected ileal intussusception and reduced it laparoscopically. The leading segment of the intussusception showed a pedunculated nodule, which was diagnosed by histopathological examination as an inflammatory fibroid polyp (IFP). The postoperative course was uneventful. Until now, five months after the surgery, no relapse has been detected. Small intestinal intussusception in adults is, in most cases, due to structural disease, so that surgery cannot be avoided. Laparoscopic surgery is the optimal modality for treating intussusception of the small intestine, because it is able to change and treat adequately depending on the intraoperative situation. Herein, we report our case, with a review of the literature.

We encountered a patient with alpha-fetoprotein-producing sigmoid colon cancer who showed an extremely poor prognosis. The patient, an 86-year-old man, was referred to our hospital with a history of abdominal pain, bloody stools, and difficulty in defecating. Physical examination revealed a fist-sized mass in the lower abdomen. Total colonoscopy revealed a type 1 tumor in the sigmoid colon, and histological examination of a biopsy specimen revealed a moderately differentiated adenocarcinoma. Hematological examination showed normal serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), but elevation of the serum alpha-fetoprotein (AFP) level to 193.4 ng/ml; therefore, the patient was diagnosed as having AFP-producing colon cancer was suspected. Examination of the AFP lectin reactive fractions revealed marked elevation of the L3 fraction (L1 3.6%, L2 0.0%, L3 96.4%). Computed tomography (CT) of the abdomen revealed an irregularly-shaped tumor measuring 50 mm in diameter in the sigmoid colon, and multiple masses in the liver and peritoneum. The patient was diagnosed as having sigmoid colon cancer with multiple concurrent liver metastases and peritoneal dissemination. In order to control the anemia progression and improve the cancerous obstruction of the colon, we performed sigmoidectomy. Intraoperatively, the primary tumor and disseminated nodules were found to be very fragile and to bleed easily; massive bloody ascites was noted. Immunohistochemistry revealed mild immunostaining of the tumor for AFP, and we made a diagnosis of AFP-producing sigmoid colon cancer, pT4b (mesentery proper), NX, M1c2(H,P), pStageⅣC. Although he had had an uneventful postoperative course for 2 weeks, the anemia progressed 2 weeks after surgery. CT showed a rapid increase in peritoneal dissemination and liver metastases, and tumor hemorrhage from the peritoneal nodules. After consultation with his family, we continued conservative treatment, but the anemia progressed gradually and he died about month after the surgery. We report a rare case of AFP-producing sigmoid colon cancer, with a review of the relevant literature.

We report a rare case of an ovarian metastasis from colon cancer, with intra-abdominal hemorrhage. A 72-year-old woman was referred to our hospital with a history of abdominal pain. She had undergone non-curative resection for descending colon cancer with peritoneal dissemination (T4a, N2, M1, Stage IV by Japanese Classification of the Colorectal Carcinoma 8th edition) a year earlier. After the surgery, she had received 12 cycles of chemotherapy with the mFOLFOX6 (5-fluorouracil, leucovorin, oxaliplatin) regimen, but developed neutropenia and peripheral neuropathy. We changed to regimen to UFT® (tegafur uracil), and there were no findings on routine blood tests or computed tomography (CT). Her blood tests showed a slight decrease in the level of hemoglobin and marked elevation of the serum level of carcinoembryonic antigen (CEA) at the onset. Abdominal CT showed a mass of heterogeneous density measuring 15 cm in diameter in the pelvic cavity, and hemoperitoneum. These findings led to the suspicion of ovarian metastasis with intra-abdominal hemorrhage, and we performed right oophorectomy. Histopathological and immunohistochemical findings confirmed the diagnosis of ovarian metastasis from the primary colon cancer. Her postoperative course was uneventful, and chemotherapy was resumed. Until now, 2 years since the first operation, she remains alive. The rapid growth of the metastatic ovarian tumor may have caused rupture of the blood vessels running through the capsule causing the hemoperitoneum.

We encountered two cases of desmoid tumor diagnosed after neoadjuvant chemoradiation therapy and laparoscopic resection for rectal cancer. Case 1: A 65-year-old man underwent a laparoscopic low anterior resection for early rectal cancer. An intrapelvic tumor was identified on follow-up CT. On suspicion of malignancy, an excisional biopsy was performed for diagnosis. Histopathological examination revealed the tumor as an intraabdominal desmoid tumor. Case 2: A 61-year-old man underwent a laparoscopic low anterior resection for advanced rectal cancer. An intra-pelvic tumor was identified on follow-up CT examination. Under thesuspicion of gastrointestinal stromal tumor, laparoscopic resection was performed for diagnosis and treatment of the tumor. Histopathological examination revealed the resected tumor as a desmoid tumor. Intraabdominal desmoid tumor is a relatively rare disease that is sometimes associated with invasive surgical intervention and trauma. It is important to monitor patients carefully, even after neoadjuvant chemoradiation therapy, for the possible occurrence of intra-abdominal desmoid tumor.

A 68-year-old woman visited our hospital with complaints of abdominal pain and nausea. Abdominal computed tomography (CT) showed a cholecystoduodenal fistula and a dilated loop of the small intestine, with a calcified mass in the small intestine. Emergency surgery was performed under the diagnosis of gallstone ileus, and an impacted gallstone was extracted from the small intestine by enterotomy. Remaining gallstones were suspected from the CT findings. However, because of severe inflammation of the gallbladder and obesity, it was difficult to clearly visualize the duodenum and gallbladder. Therefore, we performed intraoperative endoscopy, which enabled us to confirm and extract all the gallstones from the gallbladder, stomach, duodenum and small intestine. No recurrence has been seen as of two years after the surgery. There have been some previous reports of gallstone ileus during the early postoperative period. Intraoperative endoscopy was effective for preventing recurrence of gallstone ileus.

An 83-year-old man presented our hospital with enlarging cystic lesion in the pancreatic head. The lesion had a solid component, which was found to be irregularly enhancing by dynamic computed tomography. Positron emission tomography revealed high uptake of fluorodeoxyglucose in the lesion. No malignant cells were found in pancreatic juice or biliary cytology, but the lesion was considered as an intraductal papillary mucinous carcinoma because of the progressive increase in size and the radiological findings. Pancreatoduodenectomy combined with portal vein resection was performed. Histopathological examination showed intraductal papillary mucinous adenoma with adjacent granulomas. No atypical cells suggestive of malignancy were found. The histopathological diagnosis was a xanthogranuloma present concurrently with an intraductal papillary mucinous adenoma.

A 21-year-old woman was admitted with the chief complaint of fullness of the upper left abdomen. Her past and family medical history was unremarkable. Abdominal examination revealed a spontaneous swelling and tenderness over the ribs on the left side. There were no signs of peritoneal irritation. Laboratory examination at admission showed no abnormalities, except for elevation of the serum level of the tumor marker CA19-9 to 163 U/ml. Abdominal contrast-enhanced CT showed a cystic mass measuring 170×160×100 mm in size in the upper left abdomen, and the contrast enhancement of the cyst margin suggested a splenic origin of the lesion. The imaging findings showed no apparent evidence of infection. A giant splenic cyst was diagnosed and laparoscopic splenectomy was performed. The operation time was 3 hours and 30 minutes, and the intraoperative blood loss was 50 ml. The postoperative course was uneventful and the patient was discharged 10 days after the operation. Histopathological examination showed epithelial cysts and no evidence of malignancy. The serum CA19-9 levels returned to within normal range immediately after the surgery.

A female patient in her twenties visited a neighborhood hospital complaining of abdominal pain. She was diagnosed as having a left diaphragmatic hernia, and laparoscopic surgery was performed. The herniated organs were reduced, but it was difficult to repair the hernia orifice. The operation was temporarily suspended, and the patient was urgently transferred to our hospital. At the time of transfer to our hospital, we observed left tension pneumothorax, recurrence of the diaphragmatic herniation and incarceration. Therefore, emergency operation was performed via a combined abdominal and left thoracic approach. Intraoperatively, we saw herniation of the stomach, intestine, omentum and spleen into the thoracic cavity through a defect in the left dorsal aspect of the diaphragm, and made the diagnosis of Bochdalek hernia. We reduced the incarcerated organs, and closed the hernia defect. On the 8th postoperative day, she started to complain of vomiting and abdominal pain, and an abdominal enhanced CT showed small bowel obstruction caused by intestinal malrotation. Therefore, we performed the Ladd procedure and intestinal fixation. The postoperative course was uneventful, and the patient was discharged 17 days after the reoperation. In the case of an adult Bochdalek hernia repair, attention should be paid to the possible occurrence of intestinal malrotation as a complication.