Background: Although centralization of surgical activities for gastric cancer (GC) is required, we cannot neglect the necessity of distribution of those activities bearing in mind the concept of regional completion. However, decentralized small hospitals in the medically rural and depopulated regions cannot demonstrate their performance. The surgical outcomes of GC in these institutes remain unclear.

Methods: We evaluated the outcomes of 320 surgical GC patients at our hospital.

Results: The percentages of patients who were Stage I and over 75 years old were 40% and 59%, respectively, and the number of cases/number of surgeons was decreasing since 2004 into around two. The 5-year survival rate was 70% overall, and that of Stage I patients was 94%, of Stage Ⅱ patients was 75%, Stage Ⅲ patients was 49%, and Stage Ⅳ was 10%, all of which were consistent with the results of the 2009 annual report of the JGCA nationwide registry. In all, 12% of patients underwent nonresection surgery, 23% (13% of resected cases) underwent R2/R1 resection, 2% died without discharge within 30 days, and 3% died without discharge later than 90 days. The recurrence pattern was similar to the previously reported pattern.

Conclusion: The outcome of GC patients at our hospital which is situated in a typical medically rural region is thought to be comparable to the Japanese standard. Therefore, these surgical activities should not be neglected in the region.

The patient was a 73-year-old woman with Parkinson’s disease, for which she was receiving medical treatment. She was referred to our hospital with a 2-day history of fever and dyspnea. The patient was diagnosed as having an esophageal ulcer with pericardial perforation, based on the findings of chest and abdominal contrast-enhanced CT and upper gastrointestinal endoscopy. Both surgical treatment under general anesthesia and percutaneous pericardial drainage were considered, but due to the patient’s poor nutritional status, percutaneous drainage was performed. After drainage, antibiotic therapy, and enteral feeding, the inflammatory response improved and the fistula closed, and the patient was transferred to another hospital on day 54. The patient had no risk factors for an esophageal ulcer, such as a history of gastrointestinal surgery or radiation therapy, or medication, and no obvious precipitating factors could be identified.

The patient was a 40-year-old woman with a clinical history of pulmonary sarcoidosis. She was diagnosed as having esophagogastric junction cancer, cT3N1. PET-CT showed enlarged abdominal paraaortic lymph nodes with FDG accumulation, that suggested the possibility of either sarcoidosis or lymph node metastasis from the junctional cancer. For evaluation of the lymph node metastasis, laparoscopic proximal gastrectomy, lower esophagectomy, D1+ lymph node dissection, esophagogastrostomy, and laparoscopic #16b1 lat sampling were performed. The operation time was 400 minutes, the blood loss was minimal, and the patient was discharged on the 10th postoperative day with no perioperative complications. Postoperatively, the abdominal paraaortic lymph nodes were diagnosed as sarcoidosis, and the cancer was pathologically classified as pT3N1M0, pStage 2B. We had difficulty in evaluating the paraaortic lymph nodes before the surgery, but were able to safely perform laparoscopic paraaortic lymph node sampling.

An 83-year-old woman was referred to our hospital with the chief complaints of anorexia and nausea. Upper gastrointestinal endoscopy revealed advanced gastric cancer of the gastric body. Abdominal CT revealed an upside-down stomach (UDS). The tumor short diameter was greater than the diameter of the esophageal hiatal hernial orifice, suggesting that the tumor was incarcerated. We diagnosed the patient as having esophageal hiatal hernia with incarcerated UDS with advanced gastric cancer, and performed distal gastrectomy and esophageal hiatus suture. Although gastric cancer with an UDS is rare, there is a possibility of incarcerated hernia in cases of advanced gastric cancer. Therefore, it is necessary to select the surgical approach and method for each case taking into account the relationship between the UDS and gastric cancer.

A 79-year-old woman consulted our hospital with a 2-day history of continuous bloody stools. At the time of admission, she refused to undergo contrast-enhanced computed tomography (CT), and a plain abdominal CT was performed, which revealed a mass in the pelvic cavity measuring 10 cm in diameter that was diagnosed as an ovarian tumor. The patient was also diagnosed as having diverticular hemorrhage because of colonoscopic observation of a clot attached to a diverticulum of the ascending colon, even though no active bleeding was found. On the following day, the anemia improved, and the patient resumed eating. On day 16 of hospitalization, however, she developed hemorrhagic shock and an emergency angiography was performed to identify the bleeding source. It revealed a huge oval mass in the pelvic cavity that was supplied by an ileal branch. Even though no obvious bleeding point could be identified, we judged that this huge mass was the source of the repeated intestinal bleeding and performed emergent surgery. As the tumor was 12×10 cm in diameter, and protruded extraluminally, partial resection of the ileum was performed. Histopathological examination of the resected tumor revealed the diagnosis of gastrointestinal stromal tumor, classified as high risk. At present, 4 years since the surgery, the patient remains alive without recurrence.

An 83-year-old man visited our hospital complaining of a right inguinal bulge. He had no previous history of abdominal surgery. An abdominal CT revealed a right inguinal hernia, and at the same time, a 36 × 33mm solid tumor was found in the small intestine just below the navel. After radical surgery for a right inguinal hernia, we performed open surgery with partial resection of the small intestine. Immunohistochemistry showed negative staining for c-Kit, S-100, and desmin, but positive staining for β-catenin, and the patient was diagnosed as a case of primary desmoid tumor of the small intestinal mesentery.

Desmoid tumors occur at frequencies of as low as 2.4 to 4.3 per million, and it is reported that familial adenomatous polyposis and a history of abdominal surgery may predispose to their onset. We report a case of sporadic primary mesenteric desmoid tumor with no significant medical history, with a review of the literature.

Laparoscopic endoscopic cooperative surgery (LECS) is a minimally invasive technique that enables en bloc resection of all layers of gastric lesions, and there are several reports of LECS for colonic lesions. Herein, we report colorectal LECS in four cases of appendiceal orifice tumors. Case 1 was a 43-year-old male patient who underwent LECS for a 0-Ip polyp, 12 mm in diameter, at the appendiceal orifice. The histopathological diagnosis was tubular adenoma. Case 2 was a 54-year-old male patient who underwent LECS for a 0-Is polyp, 10 mm in diameter, at the appendiceal orifice after appendicectomy. The histopathological diagnosis was a sessile serrated adenoma/polyp. Case 3 was a 56-year-old female patient who underwent LECS for a 0-IIa lesion in the cecum that extended to the appendiceal orifice. The histopathological diagnosis was adenocarcinoma, tub2, T1b (3,250 µm), Ly1b, V1b, BD1. The patient underwent laparoscopic ileocecal resection at a later date. Case 4 was a 73-year-old female patient who underwent LECS for a 20-mm laterally spreading tumor in a post-appendectomy scar. The histopathological diagnosis was tubular adenoma. The technique led to better cosmetic outcomes and allowed resection of the tumors with a secure margin and minimal invasiveness.

A woman in her 50s presented to us with a history of abdominal pain and distention. Abdominal computed tomography revealed bowel obstruction due to a stenotic lesion in the ileocecal region. We performed laparoscopic ileocecal resection after decompression with an ileus tube. Histopathological examination revealed the diagnosis of goblet cell adenocarcinoma of the appendix. In view of the possibility of lymph node metastasis, we performed additional surgery. The final histopathological diagnosis was goblet cell adenocarcinoma, T4b, N0, M0, ly1, v1, PM0, VM0, pStage II. Fourteen months after the first operation, abdominal computed tomography revealed the ovarian metastasis and peritoneal dissemination, and we started the patient on chemotherapy. However, after 5 cycles of chemotherapy, 45 months after the first operation, the patient died of cancer progression. Herein, we report a long-term surviving case of goblet cell carcinoid who received additional surgery and chemotherapy after the initial surgery.

The patient was a 62-year-old man, who visited our emergency outpatient department in late February 2022, complaining of lower abdominal pain.

Physical examination revealed tenderness and peritoneal irritation in the lower abdomen. The body temperature was 37.9℃, the total leukocyte count was 12.400/mm³, and the serum CRP was 6.8 mg/dl, indicating an acute inflammatory response. Abdominal CT revealed a linear foreign body penetrating the sigmoid colon. Free gas in the upper abdomen and a small amount of ascites in the pelvis were also observed. We diagnosed the patient as having peritonitis due to perforation caused by a foreign body and performed surgery. Laparoscopic examination confirmed the presence of a perforation in the sigmoid colon, with the tip of the linear foreign body measuring about 4 cm long protruding from the perforation. The foreign body was removed with forceps and the perforation was covered and closed with a fat drop from nearby. A postoperative review of the history revealed that the foreign body was a duck bone. The postoperative course was uneventful and the patient was discharged 7 days after the operation.

A 68-year-old woman who was a hepatitis B virus carrier was found to have an 8 mm-sized hepatic mass in segment 5 (S5) of the liver adjacent to the gallbladder on ultrasonography during a regular medical check-up. She had a history of having undergone hysterectomy for endometrial cancer, and of thyroid-associated ophthalmopathy. The results of hepatic function tests and tumor marker measurements were within normal limits. On dynamic enhanced computed tomography and gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging, the mass showed slight enhancement in the arterial phase and washout in the portal and equilibrium phases; reduced Gd-EOB-DTPA uptake was observed in the hepatobiliary phase. We performed laparoscopic partial hepatectomy of S5 and cholecystectomy and discharged the patient on postoperative day 5 without any complications. Microscopically, the tumor consisted of accumulated lymphoid follicles without structural atypia，and based on these and the immunohistochemical findings, the tumor was diagnosed as a hepatic pseudolymphoma. Hepatic pseudolymphoma is a rare benign disease, and previous reports have described its associations with viral hepatitis, autoimmune diseases, and malignant tumors, which is consistent with the associations in the present case. However, it was difficult to diagnose preoperatively because of the similarity of the imaging findings to those of hepatocellular carcinoma. For small hepatic tumors located on the liver surface, laparoscopic hepatectomy might be a reasonable diagnostic and therapeutic option.

Sphincter of Oddi dysfunction (SOD) is a condition in which drainage of bile and pancreatic juice into the duodenum is impaired because of dysfunction or stenosis of the papillary sphincter. This condition leads to an increase in the intrabiliary pressure and abdominal pain. Herein, we report a case of SOD diagnosed by biliary scintigraphy before sphincter of Oddi manometry (SOM), to improve the perspective for application in future cases.

The patient was a 65-year-old woman who presented with a prolonged history of persistent hypochondrial pain, in whom various imaging examinations led to the diagnosis of gallbladder stones. Accordingly, she was diagnosed as having symptomatic cholecystolithiasis and laparoscopic cholecystectomy was performed. Two weeks after the surgery, the patient presented with recurrence of the same dull pain radiating from the right costal region to the back. Biliary scintigraphy was then performed to evaluate bile excretion, which revealed delay at the papillary level.

We strongly suspected SOD and performed SOM. The contraction pressure of the sphincter of Oddi was in excess of 120 mm Hg, and endoscopic sphincterotomy (EST) was subsequently performed for the diagnosis of SOD. The pain symptom disappeared after the EST, and no symptom recurrence has been seen until the 60-month follow-up since discharge.

SOD is a condition that should be included in the differential diagnosis in patients with right-sided dyspareunia without any organic cause, and biliary scintigraphy is a useful modality for its diagnosis.

A 69-year-old woman visited our hospital with bilateral inguinal masses. Physical examination revealed a reducible lump in the left groin and a little-finger-sized subcutaneous mass in the right groin which was not reducible regardless of the position, and disappeared with pressure. Abdominal CT showed intestinal prolapse from the inside of the inferior epigastric vessels in the left inguinal region and a low-attenuation nodule not contiguous with the peritoneal cavity in the right inguinal region. We diagnosed the patient as having an internal inguinal hernia on the left side and hydrocele of the canal of Nuck on the right side. Laparoscopic surgery (trans-abdominal-pre-peritoneal: TAPP) was performed using tumescent anesthesia. Complete excision of the hydrocele was performed without injuring it. At present, there is no evidence of recurrence of the mass in the inguinal region. Depending on the localization of hydrocele of the canal of Nuck, we consider TAPP as being very useful. I thought that tumescent anesthesia contributed to the safe resection of the hydrocele of the canal of Nuck.

An 82-year-old man was admitted to our hospital with the chief complaint of a bulge in the left inguinal region. Abdominal computed tomography revealed a left inguinal hernia with no other abnormal findings. We decided to perform laparoscopic inguinal hernia repair for the left inguinal hernia. During the operation, apart from the left inguinal hernia, a 1-cm hernia defect was found in the right medial umbilical fold and the patient was diagnosed as having an external supraclavicular hernia. Therefore, at the same time as the left inguinal hernia, the external supraclavicular hernia was treated by transabdominal preperitoneal repair (TAPP). External supraclavicular hernia is difficult to diagnose preoperatively and may be detected accidentally when TAPP is performed. External supraclavicular hernia is at the risk of incarceration even in the absence of symptoms, and treatment by TAPP is considered desirable at the time of diagnosis.