A 54-year-old woman complained of dysphagia. Esophagogastroduodenoscopy showed an ulcerative tumor (type-2) in the upper esophagus, and biopsy specimens taken from the tumor histopathologically revealed endocrine carcinoma (small cell type). PET showed accumulation of FDG in primary esophageal tumor and metastasis to the No. 101R node. After 2 courses of chemotherapy using CDDP and CPT-11 and 1 course of chemotherapy using CDDP and VP-16, the esophageal tumor was reduced (partial response), but node metastasis was enlarged (progressive disease). The patient underwent thoracoscopic esophagectomy with 3-field node dissections and laparoscopy-assisted reconstruction using a gastric tube. Histopathologically, the esophageal tumor consisted of small cancer cells, and these cancer cells showed positive reaction for chromogranin A, synaptophisin, and N-CAM; therefore, the tumor was diagnosed as endocrine carcinoma (small cell type) of the esophagus. Thirty-six months after starting treatment, the patient is well without any recurrence. We report a case of endocrine carcinoma of the esophagus detected 16 years after postoperative radiotherapy for cancer in the left breast.

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Afferent loop syndrome is a rare complication which can occur in patients who undergo gastrectomy. This syndrome can progress rapidly to necrosis, perforation, and therefore early diagnosis and surgical intervention is essential. We report a case of afferent loop obstruction with duodenal perforation after laparoscopic distal gastrectomy, Roux-en-Y reconstruction. A 74-year-old man was admitted to our department for vomiting and disturbance of consciousness. Computed tomography showed dilated duodenum and jejunum and we diagnosed afferent loop syndrome. Emergency surgery was performed and internal jejunal hernia and necrosis of the duodenum were revealed. We performed resection of the descending and horizontal part of the duodenum and anastomosis of the duodenum and jejunum.

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A 60-year-old man who had received pylorus-preserving pancreatoduodenectomy for pancreatic head cancer 16 years previously underwent total gastrectomy, total pancreatectomy and splenectomy for cancer of the residual pancreatic body in October 2010. On post-operative day 3, he developed hepatorenal failure and disseminated intravascular coagulation and computed tomography revealed an alveolar internal structure in the left liver lobe, indicating a gas-forming liver abscess. Drainage was performed via a midline incision on post-operative day 7, and slight improvement in hepatorenal failure and disseminated intravascular coagulation was achieved. However, as inflammation and computed tomography findings remained unchanged, on post-operative day 15 the left liver lobe was resected to the extent possible and additional drainage was performed. The resected liver tissue exhibited sponge-like degeneration, all vascular tissue had disappeared and complete avascular necrosis had occurred. Based on these findings, gas gangrene of the liver was diagnosed. From post-operative day 40, the necrotized liver tissue naturally exfiltrated from the open midline incision and after 11 sharp surgical debridements, left liver lobe necrotic tissue was absent and inflammation had mostly resolved. Conventional drainage alone is insufficient to cure gas gangrene of the liver accompanying ischemia; removal of the necrotic tissue is required.

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Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) is rare and known as “icteric type hepatoma”. Here, we report a case of recurrent HCC with BDTT which was controlled by anatomical resection and hepatic arterial infusion. A 71-year-old woman was admitted for epigastralgy. She was given a diagnosis of HCC, 15 cm in diameter, at the lateral segment. Lateral segmentectomy combined with resection of the diaphragm was performed. The postoperative course was uneventful. Six months later, she was referred to our hospital due to jaundice and recurrence of HCC with BDTT was diagnosed. After biliary decompression and drainage by endoscopic nasobiliary drainage, median segmentectomy, choledochotomy, thrombectomy were performed. As adjuvant chemotherapy, hepatic arterial infusion of Cisplatin was administered for 6 months. She is well without any evidence of recurrence for 32 months since the second surgery. “Icteric type hepatoma” has been reported in only 1.2–9% of HCC cases. The general treatment strategy is anatomical resection in addition to removal of BDTT, however it has been controversial whether the bile duct should be preserved or resected. Considering the high recurrence rate of “icteric type of hepatoma,” we selected hepatic arterial infusion of Cisplatin as adjuvant chemotherapy. The reason for preservation of the extrahepatic duct was to prevent complications of hepatic arterial infusion and to perform additional radiofrequency ablation therapy in case of recurrence in the future.

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The subject was a 75-year-old man who had been undergoing medical treatment for anamnesis of hypertension and hyperlipidemia since the age of 65. Three months previously, he had symptoms of atheroma thrombotic cerebral infarction and medical treatment of an antiplatelet agent was started. During his hospitalization for rehabilitation of the left hemiplegia after cerebral infarction, abdominal pain appeared. The blood biochemistry inspection showed high inflammatory reaction, but there was no anemia. Acute acalculous cholecystitis was diagnosed based on abdominal US and CT images. While waiting till the operation, the abdominal pain appeared again 9 days after the onset of acute cholecystitis. He was a shock state of the blood pressure 95/66 mmHg and the pulse rate 112/minute. The blood biochemistry inspection showed aggravation of inflammation, anemia, elevation of hepatobiliary enzyme, and jaundice. Gallbladder bleeding by ruptured pseudoaneurysm was diagnosed by abdominal enhanced CT, and laparotomic cholecystectomy was enforced. Although rupture of the pseudoaneurysm of the gallbladder after acalculous cholecystitis is rare, it must be carefully considered when the ischemia in an antiplatelet therapy with a vascular lesion is the cause of the cholecystitis, because gallbladder bleeding may be caused from formation of the pseudoaneurysm several days after the onset of symptoms.

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A 64-year-old man presented to a neighborhood hospital with complaints of abdominal pain. He was found to have gallstones and was referred to our hospital for further evaluation and treatment. US examination revealed hypoechoic nodules in the middle bile duct as well as bile duct dilation. Contrast-enhanced CT and MRI scans of the abdomen showed a tumor in the middle and lower bile duct. Based on these findings, the patient was given a diagnosis of middle and lower bile duct carcinoma and underwent pylorus preserving pancreatoduodenectomy. Histopathological examination showed no evidence of anomalous pancreaticobiliary junction but showed two tumors. Specifically, a nodular tumor, measuring 1.5×1.0×0.5 cm, was located in the lower bile duct and a papillary tumor measuring 2.0×1.5×1.0 cm was found in the middle bile duct. Both lesions were tubular adenocarcinomas. There was no histological continuity between the two lesions and only one tumor was immunohistochemically positive for CEA. These findings led to a diagnosis of synchronous multiple cholangiocarcinomas. Herein, we report a very rare case of multiple tumors occurring synchronously in the extrahepatic bile duct with a review of the relevant literature.

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We report a case of autoimmune pancreatitis localized on the pancreatic tail. A 68-year-old man was seen for upper abdominal pain and hospitalized. CT showed swelling of the pancreatic tail, cystic tumor, unevenness enhance of the spleen, and hyper vascular tumor at the pancreatic body. Serum IgG4 level was high. ERCP showed localized narrowing of the main pancreatic duct at the pancreatic tail. Cytologically, the pancreatic juice was false positive for malignant cells. Unable to rule out the pancreatic cancer, we conducted pancreatectomy of the body and tail and splenectomy. Pathological findings showed fibrosis with infiltration of plasma cells, the obliteration of a vein branch and IgG4 positive on immunohistochemical examination in the pancreas tail. The diagnosis was autoimmune pancreatitis, the adjacent cyst was a pseudocyst and the hypervascular tumor was islet cell tumor.

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A 67-year-old woman underwent colonoscopic examination because of a positive fecal occult blood test. Colonoscopy revealed a tumor of the transverse colon. Biopsy examination indicated tubular adenocarcinoma, moderately differentiated type and no metastatic lesion was detected by other examinations. Transverse colon resection was performed. Pathological examination of the resected tumor was adenosquamous carcinoma and its mucin expression was gastric type revealed by immunohistochemistry. In recent years, colon adenocarcinoma has been evaluated by its biological character and mucin expression. Adenosquamous carcinoma of the colon is reported in only 0.1% frequency of total colorectal carcinoma and there have been no reports similar to ours on colon adenosquamous carcinoma examined mucin expression.

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The patient was a 47-year-old man who was given a diagnosis of Crohn’s disease 12 years ago. He noticed a mass growing in his left buttocks and was admitted to our hospital. Physical ex-amination revealed tumors that were 11 cm, 2 cm and 1 cm in diameter in the anus from the direction of 11 o’clock, 9 o’clock, and 7 o’clock, respectively. The primary orifice was not detected because of severe anal stenosis. Pelvic computed tomography and magnetic resonance imaging revealed an 11-cm mass filled with a mucinous substance, and biopsy of the tumor revealed mucinous adenocarcinoma. We considered curative resection to be difficult because the tumor had invaded the pelvic floor muscles to a great extent. Therefore, chemotherapy (S-1, 80 mg/m²) with radiation (total, 40 Gy/20 fr) was administered as neoadjuvant therapy. After chemoradiotherapy, the size of the tumor decreased to 3 cm in diameter (reduction rate, 76%), and the tumor marker level was observed to be within normal range. We performed abdominoperineal resection, and no remnant tumor was observed at the surgical margin. Chemoradiotherapy (containing S-1) may improve radical treatment of invasive fistula-associated anorectal cancer in patients with Crohn’s disease in whom preservation of the surgical margin is difficult.

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Locally advanced rectal cancer, invading the posterior wall of the vagina can be resected with abdominoperineal resection with resection of the posterior portion of the vagina. Total pelvic excision may be avoided by preservation of the anterior portion of the vagina which prevents damage of the bladder and urethra. So far invasive various flaps, such as rectus abdominus myocutaneous flap, gracilis myocutaneous flap, and tensor fascia lata musculocutaneous flap have been used for the reconstruction of the defected vaginal posterior wall. We encountered 3 cases using ‘transposition flap’ designed from the thigh to the defected posterior vaginal wall, which was easy to perform. The operation time for each case was 437 min, 423 min, 659 min, respectively, and about 120 min was needed for vaginal reconstruction. Postoperative complication was infection and partial dehiscence of the flap in 1 case, and neurogenic bladder in 1 case which had no relation to the reconstruction procedure. Long-term follow-up showed no local recurrence in all cases, except a liver metastasis in 1 case. The transposition flap is a less-invasive and easier method, because it can be completed in the same operative field in the perineum and concurrently performed the abdominal procedure.

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