Purpose: We analyzed the clinical pathology of malignant peritoneum mesothelioma, associated with the asbestos exposure and methods for treatment. Patients and methods: The study group of asbestos-related disease that is presently being performed by the Labor Health and Welfare Organization up to 2007–2013, mesothelioma, of which the national Rosai Hospital is part consists of 264 cases. We investigated 25 cases of peritoneal mesothelioma among them. Results: There were more men (22, 88%), than women (3, 12%). Of these, 23 cases were detected from symptoms, 13 cases of which were feelings of abdominal distension, and 8 cases were abdominal pain. Definitive diagnosis was obtained in 19 cases by histological diagnosis of specimens obtained by surgery or needle biopsy. Six cases were diagnosed by examination of ascites cells. Histologically, 19 cases had epithelial, 3 cases biphasic, and 3 cases sarcomatous mesothelioma. Asbestos exposure history was recognized in 23 cases (92%), of which 14 cases (61%) were high concentration asbestos exposures. We recognized various asbestos-related conditions, pleural plaques in 15 cases, pleural effusion in 6 cases and asbestosis 4 cases. Chemotherapy was performed in 22, surgery plus chemotherapy in 2 cases (radical surgery in one case), best supportive care was carried out in one case. The median survival of all cases was 6.0 months. In a multivariable analysis by the Cox proportional hazards model, age, presence or absence of abdominal pain, and histological type were prognostic factors. Conclusion: This disease, which has been suggested to be associated with asbestos exposure, has been treated mainly by the only option available, systemic chemotherapy alone. Its poor prognosis has been recognized.

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A 48-year-old man presented to the emergency room with a chief complaint of severe abdominal pain after drinking alcohol. Based on laboratory and CT findings, we diagnosed severe acute pancreatitis. Three days after admission, abdominal compartment syndrome occurred, necessitating surgical decompression. Debridement of necrotic material and closure of the abdominal wall was undertaken 22 days postoperatively. One month after admission, upper gastrointestinal endoscopy was undertaken to investigate the cause of nausea and emesis, and revealed esophageal circumferential ulceration and mucosal necrosis. H2 blocker therapy resulted in an improvement of symptoms. He was hospitalized for a long period to control the abdominal abscess and was discharged 5 months after admission. Two months after discharge he presented complaining of dysphagia and upper gastrointestinal endoscopy showed esophageal stenosis 5 cm in length. Endoscopic balloon dilation was not effective, so resection of the middle-lower thoracic esophagus was performed. We report a very rare case of refractory esophageal ulcer and esophageal stenosis secondary to severe acute pancreatitis.

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A 72-year-old man admitted to our hospital, had a protruding lesion in his esophagus detected by esophagogastroduodenoscopy. Pathological analysis of the biopsy specimens from the tumor showed poorly differentiated squamous cell carcinoma. CT showed a lymph node near the cardia, which was suspected to be metastatic. We diagnosed esophageal squamous cell carcinoma (Lt, type 1, cT3, cN1 (No. 1), cM0, cStage III). After 2 courses of docetaxel+cisplatin+fluorouracil (DCF) neoadjuvant chemotherapy, the tumor was dramatically reduced. The patient underwent thoracic esophagectomy. Because the tumor consisted of spindle shaped tumor cells, which was immunohistochemically positive by vimentin, cytokeratin-AE1 and AE3, the tumor was diagnosed as carcinosarcoma. Lymph node metastasis was detected near the cardia. Partial effect of neoadjuvant chemotherapy was observed. Six months after surgery, the patient is well without any recurrence. We report a case of esophageal carcinosarcoma treated effectively with neoadjuvant chemotherapy.

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A 61-year-old man was given a diagnosis of esophageal cancer. After preoperative CT revealed azygos continuation of the inferior vena cava with absence of the hepatic segment, we conducted a transthoracic esophagectomy with three-field lymphadenectomy. We recognized the thoracic duct in the normal position and ligated it. On postoperative day 3, we observed a milky-white pleural effusion after starting enteral nutrition. We diagnosed chylothorax. The patient developed severe circulatory and respiratory failure, and required surgery for chylothorax. We performed transthoracic clipping of the damaged lymph vessels after introduction of venovenous extracorporeal membrane oxygenation (ECMO), due to respiratory failure caused by acute respiratory distress syndrome. Chylothorax improved soon after surgery, along with his circulatory and respiratory functions. The ECMO system was removed after 4 days. The patient was weaned off mechanical ventilation on postoperative day 13 and discharged on postoperative day 142. ECMO may be useful for patients with severe respiratory failure who must undergo surgery, despite having vascular dysfunction.

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An 83-year old man presented with exertional dyspnea. Laboratory data showed anemia (Hb 4.9 g/dl). Gastroscopy showed a gastric tumor with an ulcer in the gastric angle, and a biopsy specimen revealed poorly differentiated adenocarcinoma. Subtotal gastrectomy with D2-lymph node dissection was performed. The tumor was 90×80 mm and had hemorrhagic necrosis with a deep ulcer. Histopathological examination revealed poorly differentiated adenocarcinoma in the superficial layer and choriocarcinoma in the invasive layer. The latter component was composed of large eosinophilic polynuclear cells which was human chorionic gonadotropin positive. The final diagnosis was as follows: H0, P0, CY0, M0, pT3, pN1, and fStage IIIA. Postoperative chemotherapy was not performed considering his age. There has been no recurrence 6 years since the surgery. Primary gastric choriocarcinoma is frequently associated with remote metastasis and large, therefore, the prognosis is very poor. Postoperative long-term survivors are rarely encountered in cases with curative resection or effective chemotherapy.

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A 42-year-old woman was admitted to our hospital because of right hypochondrial pain. Enhanced CT identified a tumor protruding caudally from segment 5/6 of the liver, and the lesion was 8×6 cm in size. The tumor was composed of a slightly enhanced solid lesion and an unenhanced septate cystic lesion. MRI also revealed a tumor composed of solid and liquid components. PET-CT revealed no other malignant lesion other than the liver tumor. From these results, we preoperatively diagnosed the tumor as sarcoma of the liver, and partial liver resection including the tumor was performed. Tumor invasion to the colon was suspected, and the invaded colon was also excised. The tumor was diagnosed as undifferentiated sarcoma of the liver with partial rhabdoid differentiation based on histopathological findings. Multiple recurrent tumors were recognized in the remnant liver and peritoneum on CT 42 days after surgery. Chemotherapy consisting of doxorubicin and pazopanib was not effective, and the patient died 89 days after surgery. Undifferentiated sarcoma of the liver is a mesenchymal malignant tumor occurring in the liver. The tumor appears more commonly in childhood, and it is rare in adults. Multimodality therapy including chemotherapy should be used to improve prognosis.

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We report a case of small cell carcinoma of the extrahepatic bile duct in an 80-year-old man who was initially admitted for malaise and jaundice. Cholangiography revealed stenosis at the middle of the extrahepatic bile duct. CT revealed a slightly high-density mass, 25 mm in diameter, in the middle of the extrahepatic bile duct, and biopsy from this lesion identified class IV. These findings led to a diagnosis of middle bile duct cancer, after which a pylorus-preserving pancreaticoduodenectomy was performed. Microscopic examination of the tumor showed small atypical cells with round or oval nuclei, and immunological staining was positive for synaptophysin, chromogranin A, and CD56. These findings were consistent with the diagnosis of small cell carcinoma. The postoperative course was uneventful, and the patient was discharged on postoperative day 32. However, multiple liver metastases were detected on CT at 4 months after surgery, thus chemotherapy consisting of cisplatin and etoposide was employed. Small cell carcinoma of the bile duct is rare, and its prognosis is generally poor, and there is no consensus on the course of postoperative treatment at present.

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We report a very rare case of cholesterin granuloma of the pancreas. A 64-year-old man regularly attended our hospital for treatment of type 2 diabetes. In January 2013, he was admitted for upper abdominal pain after heavy drinking and treated based on a diagnosis of acute pancreatitis. He has been treated for acute pancreatitis in 2004 and 2010. A US study showed a heterogenous and hypoechoic mass, 1 cm in diameter, in the head of the pancreas. CT, MRCP and ERCP studies revealed about 2 cm stenosis of the main pancreatic duct at the head of the pancreas and dilatation of the distal main pancreatic duct. The lower common bile duct was smoothly compressed. The tumor markers of CEA and CA19-9 were within normal ranges. Based on the above findings, the presence of a malignant lesion could not be ruled out, and therefore subtotal stomach-preserving pancreatoduodenectomy (D2, SSPPD-II reconstruction) was performed. Pathohistological examination of the resected specimen showed cholesterin crystals and foreign body giant cells surrounding cholesterin crystals at the center of the tumor and a diagnosis of cholesterin granuloma was made.

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We report a case of paraganglioma (PG) that originated from the tissue around the pancreatic head, and was misdiagnosed as a pancreatic neuroendocrine tumor (pNET) before surgery. A 64-year-old woman was found to have a mass in her abdomen by ultrasound in medical examination. Her blood sample did not indicate any rise in pancreatic hormones or tumor markers. The mass in the pancreatic head was heterogeneously enhanced on CT imaging. MRI showed low and high intensity in T1- and T2-weighted images, respectively. We diagnosed the mass as a pNET, and performed an operation. As we found a pedunculated mass that had grown from the tissue around the pancreatic head, we removed the mass by partial excision of the pancreas. The excised mass was positive for synaptophysin, chromogranin A, CD56 and S-100 by immunohistochemical staining. We diagnosed the tumor as PG that derived from the tissue surrounding the pancreatic head.

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Total pancreatectomy is the useful operative method for multiple pancreatic diseases. However, it induces endocrine and exocrine dysfunctions of the pancreas, resulting in impaired QOL. For this reason, it is important to attempt to preserve as much remnant pancreas as possible. Middle segment-preserving pancreatectomy for multiple pancreatic diseases was performed in 4 cases at our hospital between 2007 and 2013. Case 1 was for ampullary carcinoma and intraductal papillary mucinous neoplasia. Case 2 was for multiple pancreatic metastasis from renal cell carcinoma. Case 3 was for intraductal papillary mucinous carcinoma and pancreatic ductal adenocarcinoma. Case 4 was for multiple intraductal papillary mucinous neoplasms. The length of the postoperative remnant pancreas was 5.2 cm on average. Postoperative pancreatic fistula occurred in two cases. Postoperative diabetes mellitus occurred in two cases and one required insulin treatment. No patient developed exocrine dysfunction and there were no concurrent symptoms of diarrhea or weight loss. Remnant pancreatic metastasis was found 4 years after surgery in Case 2, requiring total remnant pancreatectomy. Case 3 showed recurrence 6 months after surgery. Pancreatectomy with middle segment preservation can conserve more pancreatic functions than total pancreatectomy, resulting in improved postoperative QOL in patients.

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A 48-year-old man was admitted to our hospital because of high serum levels of CEA and abnormal findings on CT. Abdominal CT showed a cystic tumor close to the anterior wall of the rectum. Preoperative diagnosis by endoscopic US was duplication of small intestine. Laparoscopic segmental resection of the small intestine was performed. Surgical findings showed a 20-mm large, cystic lesion with a thick wall located in the opposite site of the ileal mesentery. Histological findings showed a muscle layer in the cystic wall continuing from the small intestinal muscularis propria, and the mucosal layer of the cystic wall was replaced by the adenocarcinoma invading to the muscle layer. A number of alimentary tract duplication cases have been reported in adults, but cases of duplication canceration are rare. Preoperative diagnosis of alimentary tract duplications is difficult, but it is necessary to take the duplications and its canceration into consideration when a cystic submucosal tumor is detected by abdominal CT or US. Moreover, it can be suggested that the measurement of serum tumor markers such as CEA and CA19-9 are useful for the diagnosis of alimentary tract duplication canceration.

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We encountered three cases of intractable surgical wounds with enteric or biliary fistulae managed by negative pressure wound therapy (NPWT), with favorable outcomes. Case 1: A 77-year-old man underwent total gastrectomy and transverse colectomy for remnant gastric cancer. His surgical wound had dehisced due to colon anastomotic leakage. Case 2: An 80-year-old man underwent pancreaticoduodenectomy for pancreatic cancer. Surgical site infection (SSI) due to pancreaticojejunostomy leakage occurred. Case 3: A 70-year-old man underwent partial hepatectomy for liver metastasis of rectal cancer. SSI due to bile leakage after hepatic resection was revealed. NPWT was started in these three cases of SSI by placing the drain properly and covering the exposed bowel with dressing material, and these wounds completely healed. To date the presence of enterocutaneous fistula is a contraindication for NPWT because it has been thought that the entericfistula could worsen with the increased secretion. However NPWT is considered to be useful for the treatment of SSI with enteric or biliary fistulae by using the drain properly and covering dressing material.

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An 81-year-old woman presented with abdominal pain and nausea. An abdominal CT revealed a low density mass in the right obturator canal, connecting to the small intestine. A right obturator hernia was diagnosed. Non-operative repositioning was performed 2 hours after the onset of the symptoms. After 4 days of repositioning, she underwent an elective mesh repair of the obturator hernia via a femoral approach. Patients with obturator hernias often undergo emergency open surgery. However, performing closed repositioning of the obturator hernia can result in less invasive surgery.

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