We report a rare case of esophageal hiatal hernia with incarceration of the gastric antrum and duodenal bulb. A 78-year-old woman was admitted for vomiting and upper abdominal pain. Abdominal CT revealed prolapse of the gastric antrum and duodenal bulb into the mediastinum, and the stomach was markedly dilated and retention of fluid contents was evident. The patient received a naso-gastric tube with instantaneous drainage of 2,200 ml of gastric content. Repositioning of the prolapse under gastroendoscopic guidance was unsuccessful. Following unsuccessful conservative therapy, laparoscopic surgery was performed. The incarcerating gastric antrum and duodenum were easily pulled back to the abdominal space. The orifice of the esophageal hiatal hernia was closed by suture, and mesh replacement hiatal hernia repair was added. Laparoscopic surgery is considered to lower the invasiveness of the surgical treatment for this disease that affects elderly people.

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Spontaneous rupture of the esophagus, which occurs as a result of a sudden increase in the intra-esophageal pressure, is a life-threatening disease that requires urgent treatment. We herein report a case of spontaneous rupture of the esophagus that was successfully treated with primary closure and drainage under video-assisted thoracoscopic surgery. A 52-year-old woman presented at the emergency department with a classic history of acute epigastric pain after an episode of vomiting. A thoracic CT scan revealed mediastinal emphysema and bilateral hydrothorax. Spontaneous rupture of the esophagus was confirmed on esophagography, which demonstrated evidence of an area of perforation measuring 20 mm in the left wall of the lower esophagus. We conducted emergency surgery within 12 hours after onset, followed by thoracoscopic drainage and primary closure. No omental patches were used because the level of contamination was considered to be low. The patient demonstrated a good recovery and was discharged on the 23rd postoperative day.

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A 78-year-old man had a hemorrhagic gastric submucosal tumor (SMT) and conservative treatment was performed. Three months later, he returned because of recurrent hematemesis. An upper gastrointestinal endoscopy revealed recurrent hemorrhagic SMT and endoscopic clipping was performed. An X-ray and abdominal CT scan revealed a protruding lesion in the posterior wall of the middle part of the gastric body. Endoscopic ultrasonography findings suggested an SMT. A gastrointestinal stromal tumor was suspected, and laparoscopy endoscopy cooperative surgery (LECS) was performed. Pathological examination showed multiple heterotopic gastric glands in the submucosal layer associated with early cancer in the mucosa layer and heterotopic gastric gland. We experienced a case in which LECS was performed for a recurrent hemorrhagic gastric SMT, postoperatively diagnosed as heterotopic gastric gland associated with early gastric cancer.

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We here report the case of a 26-year-old man who presented with a chief complaint of epigastralgia. Upper gastrointestinal endoscopy revealed a submucosal tumor at the gastric fundus, and the patient was referred to our hospital. Upon endoscopic ultrasonography, a tumor with heterogeneous echogenicity was observed within the third layer of the gastric fundus, and a number of small hypoechoic areas were noted in the inner part. Endoscopic ultrasound-guided fine-needle aspiration biopsy revealed that the specimen comprised short spindle-to-oval cells, which showed positivity for smooth muscle actin. Histologically, a non-epithelial tumor with smooth muscle differentiation, such as leiomyoma, was initially suspected. We conducted laparoscopic gastric wedge resection under gastrointestinal endoscopy guidance. The resected specimen was covered with mucosal epithelium without apparent atypia and demonstrated an inverted growth pattern accompanied by muscularis mucosae in the submucosal layer. In addition, the lesion consisted of a dilated gland duct without any atypia and an area of spindle-to-oval-shaped cells. Based on these findings, the tumor was diagnosed as a gastric hamartomatous inverted polyp.

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Although rare, intra-abdominal abscess is one possible postoperative complication of gastrectomy for gastric cancer that requires proper management. Generally, CT-guided or echo-guided percutaneous drainage is the first choice as a less-invasive approach, but percutaneous puncture is sometimes difficult because of surrounding viscera. In our case, an obese woman developed intra-abdominal abscess after laparoscopic distal gastrectomy for gastric cancer. The abscess was surrounded by abdominal organs and was difficult to puncture percutaneously. The patient was therefore treated by endoscopic ultrasonography (EUS)-guided drainage through the wall of the remnant stomach. We successfully achieved safe EUS-guided drainage, because EUS clearly showed perigastric abscess and the common hepatic artery. This case demonstrates trans-gastric drainage of perigastric abscess as a safe, less-invasive procedure, even for the remnant stomach after laparoscopic distal gastrectomy.

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Few reports have described the outcomes of hepatectomy for liver metastases from squamous cell carcinoma (SCC). Here, we report three cases of hepatic resection for hepatic SCC metastases. The primary sites of SCC were the oral cavity, lung and pharynx. Two cases were metachronous metastases, and the other was synchronous. In all cases, the primary SCC was previously treated with surgical resection. The mean interval between resection of the primary lesion and liver metastasis was 11 months. At the time of hepatectomy, left adrenal gland metastasis was pointed out in the patient with lung SCC, and direct invasion of the right diaphragm and lung in the patient with SCC of the pharynx. The surgical procedures used were partial hepatectomy, extended right hepatectomy with left adrenalectomy, and posterior segment and diaphragm resection with partial pneumonectomy. The surgical margin was negative in all cases. One patient died of unrelated disease 21 months after hepatic resection, the second is disease-free at 60 months, and the third is receiving follow-up after treatment for cervical lymph node recurrence found 13 months after hepatic resection. Only one patient had hepatic recurrence and underwent a second hepatectomy. Thus, in cases of hepatic SCC metastases surgical resection, with a negative surgical margin, might improve prognosis with multimodal treatment for non-hepatic recurrence.

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A 74-year-old woman with a high level of serum CA19-9 was given a diagnosis of cecal cancer and received laparoscopic ileocecal resection but 7 months later, CT revealed a tumor measuring 3.8 cm in diameter in hepatic segment II. The tumor was followed up by CT or MRI every half year because we considered the tumor to be an inflammatory pseudotumor. The tumor size enlarged to 6.4 cm 39 months postoperatively, and serum level of CA19-9, which had normalized postoperatively, increased to 170 U/ml (normal level <37 U/ml). Because it was possible that the tumor could be liver metastasis of the cecal cancer, she was treated with 3 cycles of FOLFOX (with or without Panitumumab) as neoadjuvant chemotherapy, and which decreased the tumor size and serum level of CA19-9 to 5.5 cm and 55 U/ml, respectively. No additional chemotherapy, however, was designed because of chemotherapy-related adverse events and central venous port-related sepsis. An extended left hepatectomy was performed 46 months after the first operation, and histological examination revealed the tumor to be cholangiolocellular carcinoma. No sign of recurrence has been found during 2 years and 8 months of follow-up after hepatectomy without any adjuvant chemotherapy.

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We report a rare case of acinar cell carcinoma (ACC) of the pancreas concomitant with intraductal papillary mucinous neoplasm (IPMN) of the pancreas. An 83-year-old woman with a past history of colon cancer and breast cancer had been followed up for a branch duct type IPMN of the pancreas for 32 months. Enhanced CT and MRI studies depicted a solid tumor, 3.6 cm in diameter, in the head of the pancreas along with existing IPMN in the inferior head of the pancreas. The tumor involved the main pancreatic duct and the superior mesenteric vein. Under a diagnosis of pancreatic ductal carcinoma associated with branch duct IPMN, subtotal stomach preserving pancreaticoduodenectomy with resection of the portal vein was performed. Histopathological examination revealed an ACC and a branch duct IPMN with high-grade dysplasia. Although IPMN often coexists with pancreatic ductal carcinoma, IPMN concomitant with ACC is extremely rare. This case should alert surgeons to be aware of such rare pancreatic malignancies associated either synchronously or metachronously with IPMN of the pancreas.

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A 74-year-old woman was admitted to our hospital because of itchy skin and obstructive jaundice. CT and endoscopic retrograde cholangiography showed a multilobular cystic lesion with marked calcification in the pancreatic head. Pancreatoduodenectomy was performed in October, 2010. The resected specimen was macroscopically found to have a multilobular cystic mass measuring 40 mm containing mural nodules and a stony hard partition wall. Histopathological examination revealed a moderately differentiated adenocarcinoma with cytoplasmic mucin which invaded to the extra-pancreatic tissue, which is consistent with branch-duct type intraductal papillary mucinous carcinoma. In addition, marked osseous metaplasia was confirmed in the partition wall of the cystic mass. We report this case of pancreatic intraductal papillary mucinous carcinoma with ossification with a review of the literature.

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Extramedullary plasmacytoma (EMP) is a type of plasma cell tumor that develops mainly in the pharynx and the upper respiratory tract, and is rarely found in the retroperitoneum. A 51-year-old man was admitted to our hospital because of acute calculous cholecystitis. Contrast-enhanced CT showed a solid mass, approximately 9 cm size in diameter, in the retroperitoneum of the left iliac fossa. He underwent elective cholecystectomy and excision of the tumor. The pathological diagnosis was EMP (IgGκ) originating from the retroperitoneum. As the surgical margin was judged to be sufficient histopathologically, neither postoperative radiation therapy nor chemotherapy was given. EMP does not have characteristic findings on radiology or biochemistry, and the preoperative diagnosis is difficult. We herein report such a case found incidentally during the treatment of cholecystitis, with a review of the literature.

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We report a case of a ruptured aneurysm of the left gastroepiploic artery caused by segmental arterial mediolysis (SAM) and treated by transcatheter arterial embolization (TAE). A 51-year-old man was admitted because of left lower abdominal pain. Abdominal CT showed intra-abdominal hemorrhage. Dynamic CT showed multiple spindle-shaped aneurysms of the left gastroepiploic artery and hematoma. We attributed these finding to SAM clinically, and performed elective angiography and embolization successfully. Residual aneurysms were undetectable in the follow-up CT performed 6 months later. Gastroepiploic artery aneurysm is a rare disease, and SAM is considered to be one of the contributing factors in the etiology. Because SAM often causes intra-abdominal hemorrhage, surgery was the first choice in previous treatments. However, reports of TAE to treat SAM have recently increased. In our case, TAE was performed safely and less-invasively, and the unruptured aneurysms healed without treatment.

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Internal hernia in a peritoneal defect of the Douglas pouch is extremely rare. To the best of our knowledge, this is the first case that was preoperatively diagnosed by sagittal reconstruction images on enhanced multi-detector CT (MDCT). The patient was a 33-year-old woman who was admitted to our hospital due to abdominal pain and vomiting. MDCT showed a dilated small bowel loop on the right side of the Douglas pouch, and sagittal reconstruction images clearly demonstrated a closed loop which protruded through the Douglas pouch toward the sacrum. Based on a diagnosis of internal hernia in a peritoneal defect of the Douglas pouch, we performed laparoscopic hernia reduction immediately. Laparoscopic findings showed that the small intestine was incarcerated through a peritoneal defect, approximately 1.5 cm in diameter, on the right side of the Douglas pouch. The small intestine was carefully reduced and the hernia opening was closed without intestinal bowel resection because the incarcerated small intestine was intact.

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A 70-year-old woman visited our hospital with a complaint of discomfort in the right upper abdominal quadrant. CT and US revealed a tumor in the lateral segment. This tumor was diagnosed as a hemangioma, and follow-up was planned. Nine months later, follow-up CT revealed growth of the main tumor and a new hepatic lesion in the median segment. Hepatic malignancies were strongly suspected and were resected. The pathological diagnosis was a malignant fat-forming solitary fibrous tumor (SFT) of the abdominal wall. The patient died 27 months later due to hepatic and pulmonary recurrences. SFT is an uncommon neoplasm of mesenchymal origin that usually arises from the pleura. SFT of the abdominal wall is extremely rare, and to the best of our knowledge, only 13 other cases have been reported in the international literature. All 13 cases were benign. Here, we report the first case of a malignant SFT arising from the abdominal wall with a review of the relevant literature.

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[in Japanese]

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