Purpose: Needlescopic surgery mainly using 3–5 mm trocars have been introduced for resection of rectal cancers in our hospital in the past 3 years. Here we describe this technique and investigate it regarding short-term outcomes. Methods: Sixty rectal cancer patients underwent the technique between September 2011 and December 2012. One 5-mm trocar in the right lower quadrant is used for insertion of a 5-mm scope for anterior rectal transection. The linear stapler is inserted from an umbilical 12-mm trocar in this technique. In very low anterior resection, however, a 12-mm trocar in the right lower quadrant is needed for insertion of the linear stapler. Short-term outcomes were investigated comparing the results with those of 189 patients who underwent conventional laparoscopic surgery in the same period. Results: No open conversion or conversion to conventional laparoscopic surgery was recorded in this series. The operating time and estimated blood loss in this series were 214 minutes and 12 ml in the anterior resection patients, 261 minutes and 16 ml in the very low anterior resection patients, and 279 minutes and 74 ml in the intersphincteric resection and abdomino-perineal resection patients, respectively, which were all similar to those of conventional laparoscopic surgery patients. The rate of postoperative complications was 15% in this series and there was no significant difference compared with those of conventional laparoscopic surgery patients. Conclusions: Needlescopic surgery for rectal cancer may improve cosmesis, while maintaining the same quality of operation and the same level of safety as conventional laparoscopic surgery, despite the learning curve required to master the unique technical skills necessary.

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A 47-year-old man was transferred to our emergency room for abdominal pain, vomiting, and loss of consciousness (III-200 on the Japan coma scale). On admission, he was in shock with marked abdominal distention and arterial blood gas analysis showed severe metabolic acidosis. Abdominal contrast enhanced CT scan revealed massive free air and ascites in the abdominal cavity. Contrast enhancement of the liver and bilateral kidneys was poor. An emergency operation was performed. On laparotomy, massive ascites with food debris was observed. The stomach was perforated 8-cm in length on the anterior wall of the fundus and the body, necessitating total gastrectomy with Roux-en-Y reconstruction. The appearance of the liver was whitish and ischemic just after laparotomy. During the operation, the color of the liver returned to normal as the intra-abdominal pressure was decreased, leading to a possible diagnosis of abdominal compartment syndrome. In spite of intensive systemic treatment, the patient died of multiple organ failure on postoperative day 40. Spontaneous rupture of the stomach in adults is rare. The pathophysiological mechanisms include rapid elevation of intra-gastric pressure due to vomiting, extreme dilation of stomach due to bulimia, and necrosis of the gastric wall due to circulative disturbance. In general, the perforation size is larger than that of gastric ulcers and massive leakage of gastric content often results in extreme elevation of intra-abdominal pressure leading to abdominal compartment syndrome with poor outcome.

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An 87-year-old woman was admitted to our hospital because of nausea and dysphagia. A CT revealed that the entire stomach was dislocated toward the mediastinum and a large tumor arising from the gastric wall. An upper gastrointestinal series showed an upside-down stomach with an esophageal hiatal hernia, located in the mediastinum. There was a filling defect in the middle of the gastric corpus. A gastrointestinal endoscopy revealed a large submucosal tumor at the antrum with a deep ulcer on its mucosal surface. Based on these findings, the tumor was diagnosed as a submucosal tumor, which arose from the gastric wall and was complicated by an esophageal hiatal hernia. Laparotomy revealed that the entire stomach was dislocated toward the mediastinum. After the incarcerated stomach and greater omentum were easily reduced into her abdominal cavity, subsequent distal gastrectomy was performed and the hiatus was directly closed. Immunopathological findings yielded a definitive diagnosis of a gastric gastrointestinal stromal tumor. The postoperative course was uneventful, and she was discharged on the 20th day after the operation.

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A 65-year-old woman was admitted to our hospital because of fever. Gastrofiberscopy revealed an ampullary tumor and biopsy specimen showed adenocarcinoma of the ampulla of Vater. This patient underwent subtotal stomach-preserving pancreatoduodenectomy with regional lymph node dissection. Pathological examination showed a neuroendocrine carcinoma (NEC) with concurrent adenocarcinoma of the ampulla of Vater and regional lymph node metastasis of NEC. This case was finally diagnosed as mixed adenoneuroendocrine carcinoma (MANEC) in accordance with the 2010 WHO Classification of Tumours of the Digestive System. This patient has been alive for more than one year following surgery, without recurrence, with no postoperative chemotherapy. Several studies have reported that most patients with adenoendocrine cell carcinoma, including MANEC, relapse within one year after surgery, and few patients remain disease-free for a long time after surgery. The present case suggests that curative surgery may be effective in improving the prognosis in patients with MANEC.

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An 81-year-old woman was admitted to our hospital with suspected gallbladder cancer. Abdominal ultrasonography and computed tomography showed an elevated lesion in the gallbladder. She underwent cholecystectomy with full-thickness dissection with regional lymph node dissection (D1). She had no postoperative complications. The resected specimen revealed a 17×12 mm irregular elevated lesion on the mucosal surface of the abdominal side of the resected gallbladder. The pathological diagnosis was signet ring cell carcinoma infiltrating into the subserosa, and no malignant cells were detected in the dissected lymph nodes. She is alive without recurrence, 32 months after the operation. Signet ring cell carcinoma of the gallbladder is rare, and only 18 resected cases have been reported in Japan. Some reports have indicated that signet ring cell carcinoma has poor outcome because of its high biological malignancy. We have re-investigated these patient outcomes in order to evaluate the prognostic impact of signet ring cell carcinoma in gallbladder cancer, which suggests that radical resection may promote long-term survival.

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A 60-year-old woman consulted her previous doctor with a chief complaint of discomfort in the epigastrium. Examinations showed a cystic lesion in the pancreatic tail, and she was referred to our hospital for closer examination. A unilocular cystic lesion accompanied with a 20-mm mirror surface image was observed in the pancreas tail upon initial close examination, and a follow-up examination was carried out for suspected serous cystadenoma and hemorrhaging inside the simple cyst; however, a rupture of the tumor occurred 2 months later. The rupture contracted 1 month later, and thereafter transformed into a solid lesion. Advanced FDG accumulation was observed on PET-CT, and malignant disease could not be completely ruled out. Therefore, the caudal part of the pancreas body was resected and a pathological diagnosis of xanthogranuloma inflammation of the pancreas (xanthogranulomatous pancreatitis; hereinafter, XGP) was given. XGP is a very rare disease, often accompanying pancreatitis, and characterized by pancreatic cyst lesions; however, specific laboratory findings may be unclear, and such cases are often difficult to differentiate from malignant diseases. XGP should therefore be considered in the differential diagnosis in patients presenting with pancreatic disease in which sudden morphological changes are observed during a short period of time.

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A 69-year-old man with pancreatic head cancer who had received preoperative gemcitabine-based chemoradiation therapy and subsequent pancreaticoduodenectomy, combined with postoperative liver perfusion chemotherapy, was found to have a tumor in the upper lobe of right lung 31 months after the initial pancreatic resection. Because of the absence of recurrence of pancreatic cancer in other sites than the right lung, the patient underwent right upper lobectomy. The diagnosis of lung metastasis originating from pancreatic cancer was confirmed based on histological as well as immunohistopathological assessments. The patient has been alive without tumor relapse for more than 5 years after the second operation for the lung metastasis. This case indicates that an aggressive surgical approach for lung metastasis originating from pancreatic cancer possibly results in a favorable outcome in selected cases.

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A 57-year-old man with obstructive jaundice was referred to our hospital. Endoscopic retrograde cholangiography showed stenosis and left-sided deflection of the lower bile duct, and biopsy revealed adenocarcinoma. Enhanced abdominal CT revealed a low density tumor in the head of the pancreas surrounding the anomalous common hepatic artery (CHA), deriving from the hepatomesenteric arterial trunk. Cancerous invasion to the CHA and portal vein was suspected. The patient underwent pancreatoduodenectomy with resection and reconstruction of CHA and the portal vein. The proper hepatic artery was anastomosed with the descending branch of the left gastric artery. Microscopic examination of the resected specimen showed invasive ductal adenocarcinoma of the head of the pancreas, T4N1M0, Stage IVa according to the Japanese General Rules Classification. S-1 adjuvant chemotherapy was performed after surgery, and he has survived over 5 years without recurrence. In general, invasion to the common hepatic artery is considered a contraindication for resection of pancreas head cancer. We performed resection and reconstruction of the anomalous common hepatic artery with pancreatoduodenectomy for pancreas head cancer, which resulted in longer survival.

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A 64-year-old woman, who presented with abdominal pain and a palpable mass in the abdominal wall, came to the emergency department of our hospital. Umbilical hernia with strangulation of the bowel was suspected, and we decided to perform an emergency operation for the umbilical hernia. However, during the operation, the abdominal mass was revealed to be an abscess with whitish pus, and the transverse colon adhered directly below the abscess. Moreover we found a number of small white nodules scattering on the peritoneum. From these findings, we diagnosed a advanced cancer of the transverse colon with peritoneal metastases, which perforated the abdominal wall. We converted the operation to transverse colectomy with regional lymph node dissection, and debridement of the abdominal wall. After the operation, the patient developed severe pneumonia, and Mycobacterium tuberculosis was detected from the sputum. The patient was transferred to an institute specializing in tuberculosis, and she recovered from the tuberculosis in 3 months. The pathological findings of the resected specimen showed cancer of the transverse colon, accompanied with tuberculosis in the colon, lymph nodes and peritoneum. There were no metastases of the lymph nodes or the peritoneum. The abscess of the abdominal wall was also caused by tuberculosis. Five years after the operation, there have been no signs indicating the relapse of cancer or tuberculosis. Coexistence of colon cancer and tuberculosis at multiple sites is an extremely rare condition, and it is quite difficult to diagnose correctly before or during the operation.

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We present a rare case of malignant peripheral nerve sheath tumor (MPNST) in the pelvic cavity. A 58-year-old woman presented with pain in her buttocks and left leg. She had no signs of neurofibromatosis I. CT and MRI showed a tumor 10 cm in diameter in the pelvic cavity. Since it was very hyperintense on T2-weighted MR imaging, we suspected a neurogenic tumor. Tumor resection, including the capsule, was performed. Histologically, multinuclear tumor cells were seen, and we made a diagnosis of MPNST arising from the pelvic plexus. There are no signs of recurrence 6 years and 3 months after the operation. It is said that about 50% of MPNST are associated with von Recklinghausen neurofibromatosis (NF I). In this case, we could not find any signs of NF I. Furthermore, MPNST are most often located in the limb and the body trunk. We thought that this is a rare case of MPNST originating in the pelvic plexus.

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