Background: In recent years, there has been an increasing number of reports of accidental ingestion of press-through-packages (PTPs). Patients in whom the diagnosis is delayed are reported as being at an increased risk of serious complications, making early diagnosis imperative. In this study, we report on the diagnosis, treatment, and clinical progress of cases of accidental PTP ingestion encountered by us over the past 13 years, along with a review of the literature.

Methods: From January 2010 to January 2022, we encountered 25 cases of accidental ingestion of PTPs.

Results: The cause of the accidental ingestion was disturbance of consciousness due to hepatic encephalopathy in 1 patient, intake of a sleep-inducing drug in 1 patient, and decreased alertness in 23 patients. The median time (range) from onset to diagnosis was 4 hours (1-36 hours). The diagnosis was based on the medical history alone in 6 patients, on plain X-ray examination in 1 patient, and on computed tomography in 18 patients. Twenty-three patients underwent endoscopic resection, and in two patients, the PTP was eliminated spontaneously by fecal excretion or vomiting.

Conclusion: Early diagnosis of accidental ingestion of PTPs at our hospital was associated with a favorable clinical course of the patients.

A 76-year-old female patient diagnosed as having a retroperitoneal tumor was referred to our hospital for surgery. Preoperative imaging examinations revealed the diagnosis of leiomyosarcoma arising from the IVC. We performed partial resection of the IVC and reconstruction using a PTPE patch without nephrectomy, because the tumor was not found to invade the renal vein or artery. Histopathology revealed leiomyosarcoma of the IVC with SMA and Caldesmon-positive cells. At present, 5 months since the surgery, the patient has shown no evidence of recurrence. This case serves to underscore the need to consider the appropriate surgical method preoperatively in cases of leiomyosarcoma of the IVC, in order to preserve the kidneys.

We report three cases of catamenial pneumothorax. The first patient was a 46-year-old woman with a 1-year history of experiencing right chest pain during menstruation. A month prior, she had been treated conservatively for a right pneumothorax. At the current visit, she was diagnosed as having a recurrent right pneumothorax that occurred at the start of menstruation, and we performed surgery. Based on the histopathological finding of endometrial stromal tissue in the diaphragm, we diagnosed the patient as having catamenial pneumothorax. The second patient was a 41-year-old woman with a history of six episodes of right pneumothorax, all within a few days from the start of menstruation. We performed surgery at the 7th recurrence of the right pneumothorax. Histopathological examination revealed no endometrial tissue, and we made a clinical diagnosis of catamenial pneumothorax. The third patient was a 46-year-old woman who was treated conservatively for a right pneumothorax a month before. She was admitted for a recurrent right pneumothorax that occurred 2 days prior to the start of menstruation. Because conservative treatment failed to yield clinical improvement, we performed surgery. We diagnosed the patient was having with catamenial pneumothorax based on the histopathological finding of endometrial stromal tissue in the diaphragm.

Gastric diverticulum is a rare form of diverticular disease. Herein, we describe a case of thoracic esophageal cancer and gastric diverticulum, both of which were successfully resected simultaneously. The patient was a 53-year-old woman complaining of sore throat and difficulty swallowing who was referred to our hospital with a suspected diagnosis of thoracic esophageal cancer. Preoperative examinations revealed squamous cell esophageal cancer (cT3N2M0 cStage III) in the middle/lower thoracic esophagus and a 10 cm-gastric diverticulum in the posterior wall of the gastric fundus. After two courses of neoadjuvant chemotherapy (cisplatin+5-fluorouracil), thoracoscopic esophagectomy was performed with gastric pull-up reconstruction. A gastric conduit was formed via an open approach as the gastric diverticulum was included on the excision side. Histopathological examination revealed a lack of the muscularis propria layer in the diverticulum, so that it was diagnosed as a gastric pseudodiverticulum. Her postoperative course was uneventful and she was discharged on the 22th day after surgery.

A 67-year-old male patient who had undergone open distal gastrectomy with D2 lymph node dissection and retrocolic Roux-en-Y reconstruction for antral gastric cancer 14 years ago, and had completed 5-years’ follow-up without recurrence was admitted to our hospital with fever, vomiting and abdominal distension. Computed tomography revealed a dilated Roux-limb and a closed loop on its left side dorsally; based on the findings, we made the diagnosis of internal hernia. Emergency surgery was performed, and intraoperatively, we identified herniation and incarceration, but no necrosis of the Roux-limb through the jejunojejunal mesenteric defect. We reduced the loop and closed the defect with a continuous non-absorbable suture. The postoperative course was uneventful and the patient was discharged on postoperative day 8. Although internal hernias are rare, closure of the jejunojejunal defect, as well as Petersen’s defect, with a continuous non-absorbable suture seems to be imperative for patients undergoing Roux-en-Y reconstruction.

The patient was a 75-year-old man who was under observation after surgery for esophageal achalasia. Blood examination at one of the follow-up visits revealed anemia. Therefore, we performed colonoscopy, which revealed a submucosal tumor in the terminal ileum measuring 10 mm in diameter. Histopathological examination revealed the diagnosis of small-intestinal NET G1, and we performed laparoscopic ileocecal resection with D3 dissection. The postoperative course was uneventful and the patient was discharged from the hospital 7 days after the surgery. Postoperative histopathology revealed lymph node metastasis, NET G1, T1N1M0, Stage Ⅲ. Because small-intestinal NETs, even small lesions, are frequently associated with lymph node metastasis or distant metastasis, surgical intervention with lymph node dissection is necessary, regardless of the tumor size. In this report, we describe a case of laparoscopic surgery with D3 dissection performed for a small-intestinal NET measuring 10 mm in diameter, in which postoperative histopathology revealed lymph node metastasis.

Appendiceal goblet cell carcinoid (GCC) is a rare tumor of the appendix. We report two cases of GCC of the appendix. Case 1 was an 88-years-old woman who was referred to us with the chief complaints of a palpable mass in the lower right abdomen and emaciation. The patient did not wish to undergo surgery and was of advanced age, so that she was initiated on oral anticancer drug therapy; however, the treatment was soon discontinued due to the development of severe adverse drug effects, and instead, radiotherapy was started. In response to this treatment, the tumor shrank, the symptoms improved, and a good quality of life was maintained for about 2 years after the treatment completion. Thereafter, the patient was hospitalized urgently for ileus symptoms, and ileocecal resection was performed with D3 dissection. Local recurrence was detected 5 months after the operation, and the patient died 13 months after the operation. Case 2 was a 57-year-old man in whom the diagnosis was made after laparoscopic appendectomy for acute appendicitis. A second laparoscopic ileocecal resection was performed with D3 dissection. The patient remains alive without recurrence at present, 3 years 8 months after the operation.

The patient was a 59-year-old woman who visited our hospital with the chief complaint of thin stools. Colonoscopy revealed a tumor in the descending colon, and abdominal CT led to the identification of 4 liver metastases (S1,2,4). The patient was diagnosed as having descending colon cancer with multiple liver metastases, and we performed radical resection. XELOX chemotherapy was administered as adjuvant therapy; however, it had to be discontinued after 7 cycles due to the occurrence of liver damage. Chest CT performed 16 months after the surgery showed that the inferior mediastinal lymph nodes were enlarged, and PET-CT further showed excessive accumulation in a mediastinal lymph node. Since there were no other findings suggestive of recurrence, we performed surgical resection of the node. Postoperative histopathology showed lymph node metastasis from colorectal cancer. As there was no evidence of metastasis in the periaortic lymph nodes, it was likely a solitary metastasis originating from the liver metastases. Adjuvant therapy was not given at the request of the patient, and she has been recurrence-free for 8 years since the second surgery. Solitary metastasis from colorectal liver metastases to the mediastinal lymph nodes is rare, and treatment strategies for such cases are not yet well-defined. Our findings suggest that surgical resection may contribute to improved prognosis.

A case of a hypergiant hepatic hemangioma with an arterioportal shunt that led to hepatic and renal dysfunction was cured by three sessions of TAE and subsequent laparoscopic hepatic resection. The patient presented to her previous doctor with the chief complaints of abdominal pain and abdominal distention. She was diagnosed as having autoimmune hepatitis, and CT revealed a hypergiant hepatic hemangioma with an arterioportal shunt. After three rounds of TAE, the arterioportal shunt disappeared. Thereafter, the hepatic and renal dysfunction and ascites improved. Finally, laparoscopic hepatectomy was performed as curative resection. The patient was discharged from the hospital on postoperative day 10 without any complications. Until the last follow-up at 1 year and 1 month after the surgery, there was no recurrence of ascites or the hemangioma, or any deterioration of the hepatic or renal function.

A 70-year-old man was admitted to our hospital with a one-month history of progressively worsening abdominal pain that first developed after he sustained a fall. Enhanced abdominal CT showed a large hepatic cyst and fluid collection around the liver. Abdominal examination revealed slight distension of the abdomen, with diffuse tenderness, guarding, and rebound tenderness. Based on the findings, he was diagnosed as having acute generalized peritonitis caused by hepatic cyst rupture. Therefore, we performed urgent laparoscopic deroofing. The patient was discharged 8 days after the surgery without any postoperative complications. Even in cases of large hepatic cyst rupture, urgent laparoscopic deroofing is feasible and safe as emergency surgery.