Here, we report a case of esophageal perforation due to accidental ingestion of a chopstick that was treated conservatively. A 72-year-old woman, who had been hospitalized because of dementia and epilepsy, ingested a chopstick accidentally which was quickly removed manually. The next day, she suffered from fever and dyspnea. A chest X-ray image revealed pneumothorax and pleural effusion on the left, and she was transported to our hospital. Drainage of the left thoracic cavity was performed immediately and the discharge was digestive juices, so her condition was diagnosed as esophageal perforation. CT revealed pneumothorax, pyothorax, and mediastinal abscess due to esophageal perforation. We performed upper gastrointestinal endoscopy and detected the perforation site in the upper esophagus 18 cm from the incisors. The hole was closed with endoscopic clips. Furthermore, we inserted a drain tube into the mediastinal abscess percutaneously using CT guidance. Thereafter, her condition improved, and she resumed oral intake on the 16th hospital day, and was discharged on the 50th hospital day. Our experience suggests that there are some cases of esophageal perforation which can be treated conservatively using appropriate interventions even if the patient shows severe symptoms.

A 76-year-old man with a diagnosis of synchronous gastric and sigmoid cancer underwent a total gastrectomy and sigmoid colectomy. In the gastric specimen, we found a 25-×21-mm submucosal tumor in the posterior wall of the middle portion of the stomach, in addition to the primary gastric cancer. A final diagnosis of metastatic gastric cancer derived from sigmoid colon cancer was reached following histopathological and immunohistochemical analyses. The gastric neuroendocrine carcinoma was classified as stage IB and the following pathological features were found: large-cell type; U; less; post; type 2; size, 34×27 mm; pT2; ly0; v3; pN0; M0; P0; CY0; and H0. The colon cancer was classified as stage IV and its pathological features included: S; type 2; size, 24×22 mm; pT2; ly0; v1; pN0; sH0; sP0; and pM1 (stomach). Metastatic gastric cancer from colon cancer is extremely rare; 33 cases have been reported including those diagnosed following pathological autopsy. To the best of our knowledge, only 4 patients have undergone resection for synchronous metastasis in Japan.

A woman had had melena since April, 2014 and consulted a local doctor. She was found to have an early gastric cancer and was referred to us. Pancytosis was found on admission laboratory data and polycythemia vera (PV) was diagnosed by some examinations. Treatment for PV was going to start after the gastric cancer surgery. She underwent laparoscopic distal gastrectomy with Billroth I reconstruction in May, 2014. Postoperative abdominal bleeding was observed but it could be managed conservatively and she discharged from the hospital on postoperative day 14. There are no guidelines of perioperative management for patients with PV although they have high risks of perioperative bleeding and thromboembolism because there are few cases of surgery for patients with PV, which are rare.

A 75-year-old man was referred with abdominal pain 5 years previously and was diagnosed with ischemic enteritis. CT scan showed obstruction of the supramesenteric vein. He was associated with no symptoms after discharge for 4 years. Since the patient complained of recurrent hematemesis and melena from 1 year previously, upper and lower gastrointestinal endoscopy was performed. However, both examinations showed no bleeding point, thus, he was referred to our hospital for identifying the lesion of bleeding. CT scan and arteriography revealed ileocecal arteriovenous malformation and duodenal varices, which were suspected for the lesion of gastrointestinal bleeding. Though embolization for ileocecal arteriovenous malformation was performed twice, melena could not be stopped, and the patient was referred to our department for operation. To resect the bleeding lesion and reduce the pressure of the portal vein, pancreaticoduodenectomy, resection of ileocecal part, obstructed supramesenteric vein and vascular reconstruction was performed. After the operation, gastrointestinal bleeding has been stopped for one and a half years. We consider the operation is essential for repeated gastrointestinal bleeding when non-invasive treatment fails.

A 64-year-old man was referred to our hospital after an endoscopic retrograde biliary drainage (ERBD) tube was inserted for obstructive jaundice due to hilar bile duct stenosis. Although initial examinations suggested hilar cholangiocarcinoma with elevated tumor marker (CEA, CA19-9), the bile duct stenosis relieved during precise examination. Together with mild elevation of serum IgG4, IgG4-related sclerosing cholangitis was highly suspected. The follow-up ERCP one month later, however, showed re-stenosis of hilar bile duct and FDG-PET/CT demonstrated moderate accumulations at the stenotic site, gallbladder wall and the lymph node in the hepatoduodenal ligament. We therefore decided to perform the operation: the cut end of the cystic duct and dissected lymph nodes in the hepatoduodenal ligament showed cancer cell negative, and the cholecystectomy alone was performed. The gallbladder had characteristic histological features of hyalinizing cholecystitis (HC) and IgG4-related disease. Finally, we diagnosed IgG4-related sclerosing cholangitis associated with HC. To the best of our knowledge, this is the first case which can be referred to an association between IgG4-related sclerosing cholangitis and HC.

A 61-year-old woman with a chief complaint of epigastric discomfort was referred to our hospital. Contrast-enhanced CT revealed a tumor in the gallbladder and swelling of lymph nodes with arterial invasion in the hepatic hilar region. Thus, the patient was diagnosed with unresectable gallbladder cancer and underwent chemotherapy with gemcitabine and cisplatin administered on a 3-week schedule (2 weeks on/1 week off: GC therapy). After 4 courses of GC therapy, the lymph nodes, which were considered having hepatic artery involvement, almost completely disappeared. In exploratory laparoscopy, there were no unresectable factors such as liver metastasis and peritoneal metastasis. Therefore surgical resection was performed. Operative findings revealed that the primary tumor did not invade the serosa of the gallbladder and hepatic parenchyma, and extensive fibrosis of lymph nodes. To minimize surgical stress and resume the chemotherapy early after the operation, we chose extended cholecystectomy with resection of extra-hepatic bile duct and regional lymphadenectomy. Small quantities of viable cells in resected lymph nodes were pathologically observed. However, there were no residual carcinoma cells at the surgical margin. We performed adjuvant chemotherapy with GC therapy for 12 courses. The patient remains alive and well at present, 24 months after the operation. In conclusion, we experienced the rare case of conversion therapy for initially unresectable gallbladder cancer after GC therapy.

Bleeding from jejunal loop varices caused by portal vein (PV) stenosis is one of the most critical and refractory late complications following pancreatoduodenectomy (PD). An 82-year-old man who underwent PD 14 years previously for carcinoma of the papilla of Vater with a recurrence in the superior mesenteric lymph nodes with PV stenosis and jejunal loop varisces, was admitted to the emergency room with massive melena. Preoperative 3D-CT could identified both the obvious inflow to the jejunal loop varices through a mesenteric vein and the collateral vessel to the PV through the left gastric vein. Surgical transmesenteric embolization of the jejunal loop varices via a radiologic interventional technique could be performed as planned through the mesenteric vein following preoperative 3D-CT. Postoperative CT showed clear deposition of embolic materials in the varices and stable patency of PV. Bleeding did not recur after the procedure. Based on the simulation using 3D-CT, surgical mesenteric embolization of jejunal loop varices could be performed safely and is one of the most useful therapeutic options for bleeding from the varices.

We report a case of a 17-year-old girl with solid-pseudopapillary neoplasm (SPN) of the pancreas with a peritoneal dissemination. She came to our hospital with upper abdominal pain and feel of vomiting after being hit in the upper abdomen in a basketball game. A huge mass was palpable in her upper abdomen by physical examination. CT showed that a solid enhanced tumor (84×75 mm) was located in the pancreatic body and tail. MRI after admission showed mixed signal on T2-weighted image and poor high signal in T1-weighted image in the mass. We diagnosed SPN of the pancreas with a hematoma caused by blunt abdominal injury. We performed distal pancreatectomy preserving the spleen and splenic artery. In the operative findings, a white solid peritoneal nodule was found near the primary tumor. We also resected this nodule curatively. The main tumor of the pancreas and a combined resected nodule of the peritoneum were both diagnosed as the SPN histopathologically. She was discharged from our hospital and comes to us at fixed intervals.

A 54-year-old woman with obstructive jaundice was referred to our hospital. Abdominal contrast enhanced CT scan showed an enhanced wall thickness of 25 mm in the distal bile duct and a low-density mass which filled the pancreatic duct of the body. These two tumors appeared to look separated on CT scan, and was thought to be two independent primary cancers, pancreatic ductal carcinoma and distal bile duct cancer, respectively. Total pancreatectomy was successfully performed based on this preoperative diagnosis. Macroscopic findings of the resected specimen showed a junction of the pancreatic and bile ducts located outside the duodenal wall, forming a markedly long common channel, which lead to the diagnosis of pancreaticobiliary maljunction. Microscopic examination revealed that the dilated pancreatic duct was filled with a high grade atypical epithelium with complicated papillary structure. Tumor cells in the pancreatic duct was morphologically similar to those in the common channel, indicating that tumor cells in the pancreatic duct might spread to the bile duct through the common channel. Finally, a pathological diagnosis of pancreatobiliary type intraductal papillary mucinous carcinoma (IPMC) was made according to morphological features, distribution, and immunohistochemical MUC5AC staining. The patient was discharged 9 days after surgery without any complications, and has shown no signs of recurrence at 6 month follow-up.

A 62-year-old man was flown to a hospital because of intraabdominal hemorrhage caused by blunt trauma immediately after an accident. He went into hemorrhagic shock, then he received emergency operation 2 hours after injury. The patient’s extrahepatic portal vein was interrupted from the superior mesenteric vein at the distal side of splenic vein. The damage of portal vein was complicated, therefore direct venorrhaphy was impossible. Fortunately, the patient’s hemodynamic state was stable, and we reconstructed the portal vein with interposition right greater saphenous vein graft. The patient’s small bowel became congested during the operation, hence we performed second look operation 18 hours after first operation. Necrosis of the small bowel was not observed, and we confirmed portal vein and graft had good blood flow. The patient was discharged from hospital on the 68th postoperative day. Traumatic injuries to the portal vein are uncommon and carry a high mortality. According to statistics in the USA, the frequencies of portal vein injuries were 0.06–0.08%, and the mortality rates of patients with portal vein trauma were from 50 to 70% on average. We report here successful treatment of extra-hepatic portal vein injuries by interposition graft for the first time in Japan. When venorrhaphy is impossible, interposition graft may be considered if the patient’s hemodynamic state is controlled.