Purpose: Hepatic portal venous gas (PVG) is relatively rare pathology caused by severe abdominal disorders including intestinal necrosis. PVG had been assumed to be a sign of poor clinical outcome, and also a symptom requiring emergency surgery. However, some cases of PVG were reported to resolve with conservative therapy. We examined eleven serial cases of PVG in our hospital in order to reveal the characteristics of patients who can be managed conservatively. Methods: Eleven serial cases of PVG in our hospital from January 2005 to November 2013 were examined retrospectively. Results: The eleven PVG cases consisted of 2 cases of non-occlusive mesenteric ischemia including 1 suspected case, 2 cases of superior mesenteric artery embolism, 1 case of paralytic ileus, 2 cases of perforated colon, and 3 cases of infectious enterocolitis. One patient, who already was in shock state on arrival at our hospital, died from sepsis. Therefore, the primary disease of PVG could not be identified. Six patients underwent operations (54.5%), and 5 of them needed intestinal resection, because of perforated colon or intestinal necrosis. Five patients did not receive operations. Four patients (3; enterocolitis, 1; non-occlusive mesenteric ischemia), except for the 1 dead case mentioned above, improved by conservative therapy. The mortality of our cases (9.1%) was relatively lower than previously reported. Conclusions: This study suggested that PVG is not always an indication for surgery, and that evaluation of primary diseases of PVG might provide an appropriate therapeutic strategy. Operation should be performed for patients with PVG caused by bowel ischemia and perforation. On the other hand, conservative therapy could be considered for PVG patients with stable vital signs who have no bowel ischemia or perforation.

We examined the postoperative bowel function in 38 elderly patients with ulcerative colitis (UC). We defined elderly patients as over 65 years old. UC patients over 65 years old with favorable preoperative bowel function underwent ileal pouch anal canal anastomosis (stapled anastomosis). At the final consultation (median postoperative follow up period: 4.3 [1.0–11] years), the frequency of bowel movements was 6 times per day. Soiling was found in 5.3% and spotting was found in 2.6% of the patients. We examined the frequency of bowel movements over time (3 months, 6 months, 1 year after surgery, and then yearly) in each case and found that the frequency of bowel movements decreased or did not increase in 81.6% of the patients. We also examined the age at the time of surgery and found that postoperative bowel function did not deteriorate with aging. In the elderly patients with UC who showed favorable preoperative bowel function, postoperative function was also favorable with ileal pouch anal canal anastomosis. Thus, this procedure was considered an optimal surgical treatment for selected elderly UC patients.

Here we report a case of a survivor who twice underwent surgical resection for recurrences. A 67-year-old man underwent total gastrectomy and D2 lymph node dissection for a stage IIIA adenocarcinoma of the esophagogastric junction. Three years later, he underwent partial resection of the liver for metastasis of segment 8 of the liver. One year and 5 months after hepatectomy, he underwent distal pancreatectomy and splenectomy for metastasis of the lymph nodes along the distal splenic artery. At 6 years and 6 months after initial surgery and 2 years after the last surgery, no sign of recurrent cancer has been identified by endoscopical and radiological follow-up examinations. This case report shows the benefit of surgical resection for recurrent cancer of the esophagogastric junction.

The case presented here is a 63-year-old woman. A liver tumor 76 mm in diameter was detected and diagnosed as hepatic angiomyolipoma. Although there was no change in the size and shape of the tumor from November 2000 to March 2014, it had grown to 126 mm by September 2014. The patient was admitted to our hospital in November for tumor evaluation, and the tumor was 140 mm in size by December 2014. Right hepatectomy was performed. The resected specimen was 1,230 g in weight and 150 mm in size, with a massive hematoma in the tumor. Gross inspection of the resected specimen showed a dark brown mass with light brown hard tissue accompanied by adipose tissue in the right lobe of the liver. Pathological examination showed proliferating smooth muscle cells that were positive for both HMB45 and α-SMA on immunohistochemical studies and adipose cells similar to a lipoma. The tumor was diagnosed as hepatic angiomyolipoma. The greater part of the tumor consisted of hematoma and necrosis, and hemorrhage leading to necrosis was considered the cause of the rapid tumor growth. Continuous follow-up is necessary for patients with hepatic angiomyolipoma without change in size for a long period.

The patient was a 63-year-old woman presenting with a tumor of 6 cm at the head of the pancreas on abdominal US. She was referred to our hospital to receive treatment. It was diagnosed as a pancreatic neuroendocrine tumor based on CT and MRI findings. Endoscopic US showed a continuous tumor shadow in the superior mesenteric vein, giving a suspicion of a tumor thrombus in the superior mesenteric vein. She underwent subtotal stomach-preserving pancreaticoduodenectomy and tumor thrombus extraction through an incision on the superior mesenteric vein. In pathological tissues, neoplastic cells formed cordlike and rosette structures. In immunostaining, the Ki-67 labeling index was positive for 20.5% of the primary tumor site, chromogranin A, synaptophysin, CD56. However, she had no hormone-producing symptom and received a diagnosis of non-functional pancreatic neuroendocrine carcinoma. Since only radical resection achieved long-term survival, the first-line therapy of a pancreatic neuroendocrine carcinoma is surgical resection. Even if the tumor were resected, because of its high grade malignancy, the prognosis of pancreatic neuroendocrine carcinoma with tumor venous thrombus is poor. However, this patient achieved a recurrence-free survival of 31 months.

Extramedullary plasmacytoma is a plasma cell tumor that arises outside of the bone marrow. The upper aerodigestive tract is the most common location of the tumor. Finding the tumor in the mesentery is very rare. A 68-year-old man was referred to our hospital with an abdominal mass. CT scan revealed a solid tumor in the upper abdominal cavity. Gallium-scintigraphy showed intense ⁶⁷Ga accumulation in the upper abdomen. We performed tumor excision. The histopathological diagnosis was an extramedullary plasmacytoma in the mesentery which produced a monoclonal IgGκ component. He did not receive postoperative adjuvant chemotherapy but has been alive without recurrence for 101 months after operation.

A 38-year-old woman, who had had fever and abdominal pain, was admitted. Upper gastrointestinal endoscopy showed two longitudinal ulcers in the lower esophagus. Lower gastrointestinal endoscopy revealed many deep irregular longitudinal ulcers in the terminal ileum. Twenty-one days later, she had severe abdominal fullness and pain. CT showed free air and ascites, and emergency laparotomy was performed. Because many perforations were observed in the small intestine, subtotal resection of the small intestine was performed. Macroscopic findings of the resected specimen showed many fissure-shaped ulcers. Histopathological examination showed bleeding, necrosis, infiltration of inflammatory cells including neutrophils, and fibrinoid necrosis of the arterial wall, indicating polyarteritis nodosa (PN). She has had a normal social life with home parenteral nutrition since hospital discharge. Although PN rarely presents with gastrointestinal symptoms, the small intestine is the most common organ involved. It should be noted that patients with small bowel PN frequently have acute abdomen due to intestinal necrosis or perforation.

We herein present our initial experience of laparoscopic bowel surgery in 5 patients with intestinal endometriosis. Three patients had ileal endometriosis and 2 had rectal endometriosis. Four of the 5 patients presented with intestinal obstruction, while 1 patient underwent emergency surgery for bowel perforation. All patients wished to conceive children in the future, and laparoscopic resection of the affected lesions was performed with preservation of the uterus and uterine appendages in all patients. The endometrial glands were found within the thickened bowel wall of the resected specimens in all patients. The patients’ postoperative courses were uneventful, and none developed postoperative recurrence of intestinal endometriosis during the follow-up period. Laparoscopic surgery for intestinal endometriosis can be safely performed and may be useful as a minimally invasive surgery for young women.

A 49-year-old man was admitted due to the abrupt onset of abdominal pain which initially appeared approximately 1 year and 6 months previously. Abdominal CT showed isolated dissection of the proximal superior mesenteric artery and a whirl-like pattern around the superior mesenteric artery. Therefore, we diagnosed midgut volvulus with intestinal malrotation. Superior mesenteric artery dissection was treated conservatively. On this admission, the patient was admitted due to abdominal pain and vomiting. Abdominal CT showed dilatation of the stomach and the duodenum. The findings were also suggestive of bowel obstruction due to midgut volvulus. Because the bowel obstruction did not resolve with conservative therapy, laparoscopic surgery was performed. Laparoscopy showed that the proximal portion of the jejunum was twisted without intestinal ischemia. Laparoscopic repair of the midgut volvulus and appendectomy were performed. The postoperative course was uneventful. Laparoscopic surgery is feasible for the treatment of midgut volvulus without intestinal ischemia.

Gastrointestinal stromal tumor (GIST) usually has a relatively monotonous histological appearance and partial dedifferentiation is rare. We report a case of GIST of the small intestine with dedifferentiation. A 59-year-old man presented to a local clinic with left-sided abdominal pain and anorexia. A mass was detected in the left side of the abdomen and he was admitted to our hospital. Abdominal CT showed a 12-cm mass containing fluid and a niveau. Small bowel enteroclysis showed that gastrografin flowed into the mass. 3D CT-angiography demonstrated that the mass was supplied by the left gastroepiploic artery, superior mesenteric artery, and inferior mesenteric artery. At operation, the tumor showed extraluminal growth and arose from the jejunum. The patient underwent jejunectomy, omentectomy, descending colectomy, and resection of the left Gerota fascia. The tumor was completely resected. Histopathological examination identified GIST of the small intestine with partial dedifferentiation.

Primary leiomyoma within the peritoneal cavity is not common, and spontaneous leiomyoma rupture is quite rare. The patient was a 34-year-old man. He was admitted due to persistent abdominal distension and lower abdominal pain. Abdominal CT revealed a solid tumor, which had a longitudinal diameter of 18 cm and clear boundaries with the surrounding tissue and a cystic component. The patient exhibited progressive anemia, and angiography was performed. However, no apparent bleeding lesions were detected. According to these findings and abdominal MRI, we suspected GIST or sarcoma and scheduled surgical intervention. However, the patient showed rapid reduction of abdominal distension and massive ascites was detected by abdominal CT, 9 days after hospitalization. Thus, he underwent emergency surgery. Intra-operative findings revealed approximately 1,700 ml of hemorrhagic ascites, and the tumor originated primarily from the appendix or the cecum. Histopathology showed that tumor cells had spindle-shaped nuclei and immuno-staining was positive to desmin and α-SMA with MIB-1 index of 3.1%. Thus, the tumor was diagnosed as leiomyoma. To the best of our knowledge, there has only been 1 report of leiomyoma with spontaneous rupture and bleeding that required urgent treatment. The features of tumors with spontaneous rupture are cystic region, large tumor diameter, and increasing tumor diameter. Furthermore, the risk for tumor rupture increases more when an abdominal symptom develops because intratumoral hematoma increases. Therefore, it is necessary to perform speedy examinations to determine the surgical intervention.

A 61-year-old man developed ulcerative colitis (UC) 23 years previously. Six years later, he required a total proctocolectomy, ileoanal anastomosis (IAA), and diverting ileostomy because of medical treatment failure. The patient did not undergo a subsequent stoma closure. Sixteen years after the surgery, he complained of pus from the anus. Pouchitis was then diagnosed by endoscopy. Medical therapy, including antibiotics and 5-aminosalicylic acid, did not improve his symptoms. One year later, he was referred to our hospital for further examination and treatment. Ileal pouch endoscopy and biopsy showed adenocarcinoma. Finally, he was treated by surgically removing the ileal pouch. Although the occurrence of cancer developing from an ileal pouch is rare, we should be aware of the risks of carcinogenesis with increasing age after creating an ileoanal pouch. Even in the absence of symptoms, the pouch should be examined regularly by endoscopy.

A 68-year-old man with a history of intersphincteric resection and transverse colostomy for rectal cancer underwent diagnostic colonoscopy as a post-operative follow up. Colonoscopy revealed diversion colitis of the sigmoid colon. Two hours after the examination, the patient complained of mild abdominal pain. Blumberg sign was negative and no remarkable changes were observed, but abdominal pain did not improve for 6 hours. A CT scan showed retropneumoperitoneum, pneumomediastinum, subcutaneous emphysema and pneumatosis intestinalis of the sigmoid colon without any evidence of perforation. We diagnosed retroperitoneal emphysema with diversion colitis after colonoscopy and the patient was admitted to our hospital. We decided on a conservative treatment method because of the lack of peritonitis and good general condition. The clinical course was uneventful and he was discharged 11 days after the initial observation. Retroperitoneal emphysema is a very rare complication that occurs after colonoscopy. We report our case with a literature review of 25 cases of retroperitoneal emphysema after colonoscopy in Japan.

The patient was a 69-year-old woman who underwent a subtotal stomach-preserving pancreatoduodenectomy with combined resection and reconstruction of portal vein for pancreatic head cancer. She was found to have portal vein stenosis 2 weeks after the surgery. Abdominal dynamic CT performed 3 months after the surgery revealed a 24-mm cystiform aneurysm of the extrahepatic portal vein without any findings of portal hypertension or cancer recurrence, which was located just close to the anastomosis portion at the side of the liver. The rapidly-enlarged aneurysm was considered to have a risk of rupture or bleeding, therefore she underwent a percutaneous transhepatic portography, and an expandable metallic stent (non-covered type, 10 mm×40 mm) was inserted subsequently to dilate the anastomotic stenosis. The pseudoaneurysm decreased in size and disappeared completely 6 months after the stenting. We considered that the anastomotic false aneurysm secondary to the portal vein stenosis occurred because of abnormal blood streams resulting from the portal vein stenosis, distortion and deformity of the portal vein, and vulnerability around the anastomotic site. Stent placement dilated the portal vein stenosis and could have led to the disappearance of the aneurysm of the portal vein.

We report a case of a 62-year-old woman having leiomyosarcoma of portal vein origin. A large intra-abdominal tumor was detected in the hepatoduodenal ligament using CT in the asymptomatic patient. The tumor was 8 cm in diameter and originated from the portal vein trunk with complete obstruction causing development of the collateral veins. Total excision of the tumor with portal vein resection preserving collateral veins was carried out. Histopathological examination revealed a leiomyosarcoma originating from the portal vein. Leiomyosarcoma of the origin of the portal vein is very rare and typically has a poor prognosis. Although curative surgery in such cases with development of collateral veins is occasionally difficult, aggressive surgery may improve long-term survival.