Purpose: To clarify the relationship between prophylactic antibiotics and perineal wound infection by examining the causative bacteria and risk factors for perineal wound infection following abdominoperineal resection (APR) for rectal and anal canal cancer. Methods: We examined causative bacteria in 43 patients given a diagnosis of perineal wound infection among 173 patients who underwent APR between October 2002 and November 2013. The prophylactic antibiotic given during this period was cefmetazole (CMZ), which was converted to ampicillin/sulbactam (ABPC/SBT) from November 2013. Next, we analyzed risk factors for perineal wound infection in 203 patients treated between October 2002 and April 2015 through univariate and multivariate analyses. Results: The most common causative bacteria in perineal wound infections were Staphylococcus species in 72.1% of cases, followed by Enterococcus species, which are not susceptible to CMZ, in 34.9%. The incidence of perineal wound infection caused by the type of prophylactic antibiotic was found in 43 patients (24.9%) in the CMZ group and 3 patients (10.0%; P=0.097) in the ABPC/SBT group, indicating a lower tendency in the latter group. The results of multivariate analysis identified age (≥70 years), diabetes (present), and prophylactic antibiotics (CMZ group) as independent risk factors for perineal wound infection. Conclusions: Our findings suggest that the prophylactic antibiotics ABPC/SBT suppress the onset of retroperitoneal space infection to a greater degree than CMZ following APR.

A 54-year-old man underwent total gastrectomy with jejunal pouch construction for early gastric cancer in 2011. In 2015, He visited a local hospital complaining of abdominal pain, and was transferred to our hospital. Abdominal CT revealed intestinal obstruction caused by invagination. He underwent emergency laparoscopic surgery in which retrograde invagination of the jejunum into the jejunal pouch was successfully reduced. His postoperative course was uneventful, and he was discharged on post operative day 9. To the best of our knowledge, this is the first report of invagination of the jejunum into the jejunal pouch after laparoscopic total gastrectomy.

Leriche syndrome is a chronic abdominal aortic occlusive disease. We encountered a case of gastric cancer with Leriche syndrome, therefore we consider the case in light of the available literature. A 73-year-old man had been followed for Leriche syndrome. Due to development of anemia, he underwent upper gastrointestinal endoscopy for evaluation of the cause of anemia and was given a diagnosis of gastric cancer. The clinical stage was T4aN1M0 Stage IIIA. We carefully evaluated the surgical tolerability of the patient and performed distal gastrectomy and D2 lymphadenectomy after suspending anti-platelett therapy. Laparotomy was performed by an upper abdominal midline incision to avoid damage of collateral circulation to the lower extremities, with careful manipulation of the abdominal wall and shortening of operation time. Although the patient initially experienced wound dehiscence on post-operative day (POD) 1, the post-surgical course was favorable and anti-platelets therapy was resumed from POD 3. The patient was discharged from hospital on POD 16. In patients with Leriche syndrome, blood supply to the pelvic organs and lower extremities is maintained by collateral circulation, and organ damages are frequently seen. In addition, perioperative anti-platelets therapy affects surgical outcomes. Therefore, a cautious and well-prepared abdominal surgical plan, including operative procedures and perioperative management, is essential.

A 71-year-old man suffering from epigatralgia and anorexia, was found to have anemia and a hyperactive inflammatory response. Abdominal enhanced CT showed a tumor at the duodenal bulb. A type 2 tumor was found at the anterior wall of the duodenal bulb, and biopsy revealed adenocarcinoma. Intraoperative findings revealed 5 tumors at the upper jejunum, and 2 at the end of the ileum. A gastrojejunum bypass procedure and resection of the ileum was performed to prevent exacerbation of anemia. Immunohistochemical examination revealed that the duodenal tumor was primary and the intestinal tumors were metastatic. Duodenal adenocarcinoma with multiple metastatic intestinal tumors are very rare.

A 69-year-old man presented to a neighborhood hospital complaining of malaise, and while being examined, developed cardiopulmonary arrest. Cardiopulmonary resuscitation was then carried out using an automated sternal compression device. Thereafter, he was rushed to our hospital, where emergency coronary arteriography was performed after a clinical diagnosis of acute myocardial infarction was made. Coronary revascularization was accomplished by thrombus aspiration, stent placement, and anticoagulant therapy. While the clinical course was uneventful in the initial period after admission to the intensive care unit (ICU), the patient developed circulatory shock of sudden onset at 6 hours after ICU admission. Diagnostic abdominal US and contrast-enhanced CT were performed, which revealed liver injury associated with intraperitoneal hemorrhage caused by sternal compression, therefore, emergency direct surgical ligation was undertaken. Despite a transient worsening of the respiratory condition immediately after the surgery, the patient showed uneventful clinical progress after transfer from the ICU, and he was discharged on foot on postoperative day 28. Hepatic injury caused by cardiopulmonary resuscitation using an automated sternal compression device is extremely rare. The present case underscores the need in medical practice to bear in mind the possibility of serious hepatic injury following cardiopulmonary resuscitation in patients whose hemodynamic state remains unstable despite adequate treatment of the primary disease after resuscitation.

The patient was an 85-year-old woman with poor appetite and fatigue. She was referred to us after a giant cystic tumor was observed on abdominal US. CT revealed a 15-cm cystic lesion that extended to the pelvis and scattered nodular lesions with contrast enhancement, which suggested a malignant tumor. ERCP showed communication with the pancreatic duct at the pancreatic head, indicating an intraductal papillary mucinous neoplasm (IPMN). The cyst protruding outside the pancreas was resected, and the surgery was finished after no tumor progression into the pancreatic duct stump was observed. Histopathological examination indicated an IPMN with low-to-intermediate-grade dysplasia. Genetic analysis of a nodular lesion showed a GNAS mutation, confirming the diagnosis of IPMN. The rarity of the morphology in this case provides many suggestions for preoperative and postoperative diagnoses, selecting operative procedures, and other related matters.

Abdominal CT of an 81-year-old woman who was followed up for autoimmune hepatitis revealed intussusception of the jejunum. Because symptoms of peritonitis and intestinal tract necrosis were absent, we reduced the intussusception using the balloon of an inserted nasal ileus tube. However, abdominal CT 3 days later suspected recurrent intussusception and laparoscopic-assisted surgery proceeded as follows. We could not recognize a mass around the intussusceptions of the jejunum by palpation using the laparoscopic forceps. However, the palpation using our hands indicated a mass in the jejunum which was guided to the outside from a small incision, so the small intestine was partially resected. The mass was histopathologically diagnosed as cancer in adenoma. To the best of our knowledge, this is the first successful reduction of intestinal intussusception using the balloon of a nasal ileus tube. This case suggested that it may be one of the treatment plan to try non-invasive reduction first for the intestinal intussusceptions. Furthermore, laparoscopic-assisted surgery for intussusception is minimally invasive, esthetically acceptable and allows radical and safe tumor resection.

A 60-year-old man visited our hospital complaining of pain and a mass at the stoma site. He had a past history of proctocolectomy 30 years previously for familial adenomatous polyposis (FAP). The stoma had easy-bleeding polypoid lesions which caused stenosis at the oral side of the stoma. A biopsy of the polypoid lesion showed adenocarcinoma. The patient underwent en-bloc resection of the stoma with polypoid lesion, adjacent abdominal skin, and the end of the ileum. The resected specimen revealed that the cecum and ileocecal valve remained, and the tumor was developed at the cecum. Histopathological findings showed that the tumor was composed of moderately differentiated adenocarcinoma (pT2N1M0 Stage IIIa). After surgery, the patient underwent adjuvant chemotherapy with CapeOx for 6 months. During 24 months of follow-up, he has been free from recurrence and metastasis. Patients with FAP should undergo prophylactic total proctocolectomy because of the high incidence of colorectal cancer. In some, carcinoma may appear at the stoma site during follow-up. Our case indicated that long-term and close follow-up are imperative for early detection of stoma site cancer.

We report a case of synchronous quadruple cancers including hepatocellular carcinoma (HCC) and liver metastasis from colon cancer (CLM). A 76-year-old man was diagnosed as having a left lung tumor and three hepatic tumors in segment 7 (S7), S3 and S4 by CT at 7 months after operation for the descending colon cancer in another hospital. Furthermore, since carcinoma in situ of the ascending colon was found by colonoscopy, endoscopic mucosal resection was performed. Left upper lobectomy for lung tumor was performed, and this tumor was pathologically diagnosed as primary lung adenocarcinoma. Afterward, he was introduced to our department for treatment of the liver tumors. The S7 tumor was diagnosed as HCC, and S3 and S4 tumor as CLM in imaging examinations. Partial resections for each three tumor were performed and final pathological diagnosis was in accord with a preoperative diagnosis. Since synchronous quadruple cancers including HCC and CLM were extremely rare, we report this case with reviews of the literature.

Various surgical procedures have been performed for sigmoid volvulus without colon necrosis, but we yet to establish a consensus. We introduce Sharon operation and our six cases. From January 2010 to December 2015, we performed 6 cases of Sharon operation after preoperative reduction of the sigmoid volvulus and decompression. Among the 6 patients, one patient experienced superficial surgical site infection, but other patients were on a good course. All cases have been free of relapse so far. Sharon operation is feasible for sigmoid volvulus without colon necrosis in terms of pathological condition, operative duration, and invasiveness.