We report a non-hemophilia patient in whom the appearance of coagulation factor VIII inhibitor during the perioperative period for gastric cancer surgery made it difficult to treat intraperitoneal/-thoracic hemorrhage after surgery. The patient was a 69-year-old man. He was admitted with melena. The prothrombin time (PT) was normal at 12.4 seconds. However, the activated partial thromboplastin time (APTT) was prolonged to 50.9 seconds. Under a diagnosis of hemorrhagic gastric cancer, gastropylorectomy was performed. Hemostasis for intraperitoneal hemorrhage was conducted the day of surgery and 7 days after surgery. Thoracocentesis/drainage for bilateral intrathoracic hemorrhage were carried out 8 days after surgery. A coagulation test showed that the APTT was markedly prolonged, and that coagulation factor VIII activity was reduced (11.6%). A coagulation factor VIII preparation was administered, but there was no increase in coagulation factor VIII activity. The appearance of coagulation factor VIII inhibitor (5 BU/ml) was noted. Prednisolone therapy gradually reduced intraperitoneal/-‍thoracic hemorrhage, and the patient was discharged. A bleeding tendency related to the appearance of coagulation factor VIII inhibitor is serious in many patients, as demonstrated in the present case. Recognition of this disease and prompt management may be necessary.

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A 65-year-old man was admitted to the hospital because of fever. The laboratory findings revealed leukocytosis (20,600/μl), an elevation of C-reactive protein level (34.57 mg/dl), and an increase in alkaline phosphatase level (729 IU/l). Enhanced computed tomography showed hepatotorophy of the left lobe, an intrahepatic bile duct stone in the left hepatic duct, and a multicystic lesion 6 cm diameter in segment 1 of the liver. MRI showed a lesion of low signal intensity in T1 weighted images and a lesion of moderate-to-high signal intensity accompanied with strongly high signal intensity on T2 weighted images. Endoscopic retrograde cholangiopancreatography demonstrated bile duct stenosis in the left hepatic duct and bile duct dilatation in the left lobe. Enhanced computed tomography after antibiotic therapy revealed a decrease in tumor size to 4 cm in diameter. Based on these findings, the tumor was suspected to be an inflammatory pseudotumor of the liver. Because of the hepatotorophy associated with hepatolithiasis, a left lobectomy and a caudal lobectomy were performed. The cut surface of the lesion of the liver mostly consisted of a whitish area accompanied with a yellowish and translucent area. Microscopic examination of the tumor showed proliferation of spindle-like cells, infiltration of macrophages and lymphocyte, and no evidence of malignancy. The patient was given a diagnosis of inflammatory pseudotumor of the liver due to segmental cholangitis associated with hepatolithiasis.

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A 78-year-old man under continuous ambulatory peritoneal dialysis (CAPD) due to chronic kidney disease for 2 years previously was given a diagnosis of repeated cholecystitis and cholelithiasis. Despite CAPD, his urine volume was approximately 1,000 ml a day. After the dialysate was drained on the morning of surgery, laparoscopic cholecystectomy was performed. All wounds were tightly closed in two layers. His postoperative course was uneventful and he was able to eat solid foods from the day after the operation. CAPD was restarted on postoperative day 3 with half the volume of dialysate. The dialysate volume was gradually increased and resumed to the normal level on postoperative day 5. As a result, he was discharged on postoperative day 6 without hemodialysis. During the 24-month postoperative monitoring, he has had no complications and CAPD was performed without any problem. We propose that the combination of tight wound closure and modification of dialysate volume prevents the need for transient hemodialysis while patients are able to resume CAPD during the recovery period after the operation.

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We present a case of early neuroendocrine carcinoma of the gallbladder with bile duct extension. A 70-year-old woman with a chief complaint of appetite loss was admitted to our hospital with a diagnosis of obstructive jaundice caused by a gallbladder tumor. Abdominal CT showed the gallbladder wall was irregularly thickened and the extrahepatic bile duct was contiguously filled with the tumor. Tumor biopsy under endoscopic retrograde cholangiography revealed neuroendocrine carcinoma. We performed extrahepatic bile duct resection and cholecystectomy with choledochoduodenostomy. Immunochemical examination revealed synaptophysin (+), chromogranin A (+) and an MIB-I labeling index 70%, which confirmed large cell neuroendocrine carcinoma as defined by the WHO classification, 2010. The final diagnosis was fT1 (fm, pHinf0, pBinf0, pV0, pA0), N0 (0/1), INFα, ly1, v0, pN0, H0, P0, M (–) Stage I. The postoperative course of the patient was uneventful and she was recurrence free 14 months after the operation.

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A 16-year-old boy presented with abdominal pain and fever with physical exam findings showing periumbilical and right lower quadrant tenderness, abdominal distension, and guarding. Abdominal computed tomography (CT) shows a 29×14 cm mass from the top of the right kidney to the pelvis. On the day following admission, because of a severe inflammation reaction, he underwent emergency laparotomy and tumor resection with partial jejunum for a presumed diagnosis of an infected mesenteric lymphangioma. Intraoperatively, the pelvic elastic mass was found to be multilocular originating in the mesenterium. After an uncomplicated postoperative recovery, the patient was discharged in good condition after two weeks. Because of the rare occurrence of mesenteric lymphangioma in adolescents, this patient’s preoperative diagnosis was difficult. This case highlights the importance of considering lymphangioma in the differential diagnosis of abdominal pain in order to deliver prompt therapy.

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We report a case of an 86-year-old man who was given a diagnosis of bowel obstruction caused by cholesterol crystal embolization (CCE) after a lifesaving procedure for superior mesenteric artery (SMA) thrombosis. CCE is a rare systemic embolism resulting from release of cholesterol crystals from atherosclerotic plaques. CCE is caused by vascular manipulation or systemic anticoagulation. Since laparoscopic surgery, including single incision laparoscopic surgery (SILS), allows minimally invasive surgery, we performed SILS on this patient. No report has shown the efficacy of SILS in the treatment of bowel obstruction caused by CCE. Because of the frequency increment of vascular manipulation or systemic anticoagulation, the incidence rate of CCE will increase in the future. Therefore, gastroenterological surgeons should also be aware of presence of CCE. Our report suggests the utility and effectiveness of the SILS procedure in patients with small bowel disease, such as bowel obstruction. In this case, postoperative insertion of a long nasal tube for decompression of intestinal contents and assessment of the stenotic lesion was effective. Because patients with CCE have a background of atherosclerosis, CCE may be onset secondary to critical disease, such as SMA thrombosis. Laparoscopic surgery including SILS may be feasible as a minimum invasive surgery for such patients.

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This was a case of metastasis to the rectus abdominis from the small intestinal adenocarcinoma after surgical resection. A 70-year-old woman underwent a segmental jejunal resection for the small intestinal cancer in December 2009 and moderately differentiated adenocarcinoma confirmed histopathologically. A 3-cm length lump was noted in the patient’s right lower abdomen in May 2011 and FDG-PET revealed a solitary abdominal wall tumor. The tumor was diagnosed as an abdominal muscular metastasis from the small intestinal cancer and resected with the surrounding soft tissue. Histopathologic examination confirmed moderately differentiated adenocarcinoma invading the striated muscle. Recurrent small intestinal cancer of the abdominal wall muscle was definitively diagnosed. She remained recurrence-free after 18 months of follow-up. This is an extremely rare case with recurrent small intestinal cancer in the abdominal wall muscle without metastasis to any other site.

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Our patient, a 70-year-old man, received colonoscopy as part of his employer-provided physical examination. The examiner discovered a 15×8 mm 0-IIc type tumor on the ascending colon, opposite to the ileocecal valve. Examination of the tumor by colonoscopy in our hospital showed VI and VN pit patterns in the depressed area and ultrasonic endoscope showed disruption of the quaternary layer. A CT-scan revealed swelling of the No. 202 lymph node suggesting lymph node metastasis. We performed a laparoscopic ileocecal resection with D3 lymph-node adenectomy. The pathological examination results showed the resected specimen had extensive lymphatic vessel involvement in the subserosa close to the cut end of the oral side. We removed an additional portion of the ileum around the cut end. We did not find any malignant cells in the specimen. Although 0-IIc type tumors are small, they are frequently associated with de novo carcinogenesis as they tend to invade the vascular channel. We thought that this tumor was likely to invade the lymph channel because the CT-scan suggested lymph node metastases. We hope to show through this report that a relatively more aggressive resection of the jejunum is advisable for cases such as this one.

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We describe a rare case of solitary peri-gastric lymph node metastasis from adenosquamous cell carcinoma of the lower rectum with a review of the literature. A 68-year-old man, suffering from advanced rectal cancer, underwent curative surgery with D3 and lateral lymphadenectomy. The resected specimen revealed a type 2 lesion, 30×30 mm in diameter, composed of squamous cell carcinoma and adenocarcinoma. The depth of invasion was beyond the proper muscle layer, and perirectal and intermediate lymph nodes were positive for metastatic tumor cells. Twelve months after surgery, his serum CA19-9 level elevated to 56 IU/ml. A PET/CT scan revealed solitary lymph mode metastasis in the lesser curvature of the stomach which was surgically removed. The lymph node contained both squamous cell carcinoma and adenocarcinoma components, which was similar to the primary rectal tumor. The patient has been given another adjuvant chemotherapy using CapeOX without showing any signs of recurrence at 6 months after surgery.

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A 59-year-old woman was referred to our hospital for treatment of a hepatic mass. She had a history of repeated nosebleeds at a young age, and had received blood transfusions several times. She had been given a diagnosis of chronic hepatitis C by a local physician 9 years previously. On admission, the activated partial thromboplastin time (APTT) was slightly prolonged, and the bleeding time was prolonged. On further examination, the von Willebrand factor (<6%) and factor VIII (52%) levels were found to be decreasing. Hepatocellular carcinoma was diagnosed, and her bleeding tendency was thought to be due to von Willebrand disease. According to the guidelines for coagulation factor replacement therapy, using the APTT as an index, we administered blood clotting factor VIII/von Willebrand factor concentrate for 8 days before and after surgery, and successfully maintained the APTT. The patient’s postoperative course was uneventful. In this case, we successfully and safely performed hepatectomy in a patient with von Willebrand disease by supplying factor VIII/von Willebrand factor concentrate.

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