A 51-year-old man was followed up due to hereditary hemorrhagic telangiectasia (HHT). We pointed out a polyposis lesion of the duodenum by gastroscopy. A duodenal polyp located on the opposite side of the major duodenal papilla was diagnosed as adenocarcinoma by biopsy. We also pointed out a polypotic lesion of the colon by colonoscopy. As the polypectomy for colonic polyposis was difficult to treat, we performed subtotal stomach-preserving pancreaticoduodenectomy for the duodenal cancer, and partial resection of the cecum and descending colon for the colonic polyposis. Although the hepatic artery was dilated because of HHT, we safely achieved a curative operation. Histological diagnosis revealed a well differentiated adenocarcinoma in juvenile polyposis (JP) of the duodenal lesion. Juvenile polyps were also seen in the colon. To the best of our knowledge, this is the first case undergoing pancreaticoduodenectomy for combined syndrome of juvenile polyposis and hereditary hemorrhagic telangiectasia in Japan.

A 40-year-old man was admitted to our hospital for examination and treatment of his gallbladder tumor detected on a medical check-up. Tumor markers (CEA, CA19-9 and DUPAN-2) were at a normal level. Abdominal US revealed a 12 mm irregular-shaped tumor in the cervical part of the gallbladder. On enhanced abdominal CT, the tumor was visualized with contrast medium in the cervical part of the gallbladder and wall thickening around this part was found. We diagnosed it as benign tumor of the gallbladder, then laparoscopic cholecystectomy was performed. The macroscopic appearance of the resected specimen was a polyp of type Ip measuring 10 mm in diameter. Pathological examination revealed that tumor cells with amphophilic and granular cytoplasm grew in lamina propria mucosae in a trabecular pattern and contained round nuclei. Immunohistochemical examination revealed that tumor cells were positive for CD56, chromogranin A and synaptophysin, and Ki67 index was less than 1%. Therefore we finally diagnosed neuroendocrine tumor G1 of the gallbladder tumor according to the 2010 WHO classification.

A 49-year-old woman, with a history of extended hysterectomy and pelvic lymphadenectomy for stage IVB cervical cancer after preoperative chemotherapy, presented with abdominal pain during the course of postoperative chemoradiotherapy. Enhanced CT showed a strangulated loop of the small bowel below the right external iliac artery, for which emergency open surgery was performed. Intraoperative findings revealed that the small bowel had herniated into the space between the right external iliac artery, right ureter, and right umbilical artery. The strangulated small bowel had become ischemic and the small bowel was resected without injury to the structures that were exposed by prior pelvic lymphadenectomy. Here, we describe our experience with a case of small bowel strangulation caused by migration of the intestine into the space after pelvic lymphadenectomy, with a review of previous literature describing similar cases.

A 62-year-old man was given a diagnosis of advanced lung cancer of the right upper lobe (T2N2M1, stage IV, intrapulmonary and brain metastases) and treated with CDDP+S-1, followed by radiotherapy to the brain. Thereafter, nivolumab was administered every 2 weeks at another hospital. The patient complained of abdominal pain and tarry stools for several days after each cycle of nivolumab. On the 63rd day after the first administration of nivolumab, the patient developed sudden severe abdominal pain and was transported to our hospital by ambulance. CT showed pneumoperitoneum, suggesting peritonitis with gastrointestinal perforation. As adverse events associated with nivolumab occurred, therapy using corticosteroids was initially started. Although conservative therapy was effective, stenosis of the ileum related to the perforation became severe, leading to the onset of small bowel obstruction. On the 35th hospital day, partial resection of the ileum was performed. The symptoms disappeared after surgery, and the postoperative course was uneventful. Immune checkpoint inhibition by nivolumab can induce excessive nonspecific immunological activation, possibly leading to the development of immune-related adverse events (irAEs). These irAEs affect mainly the skin, gastrointestinal tract, liver, and endocrine organs, and can manifest at any time point after administration. Careful surveillance is essential for early treatment to prevent the progression of irAEs.

A 91-year-old man who presented with abdominal pain was admitted. Abdominal CT showed an ileus, an intra-abdominal abscess and free air. The suspected diagnosis was perforative peritonitis, and the patient subsequently underwent surgery. At laparotomy, we found a Meckel’s diverticulum about 50 cm from the terminal ileum on the oral side, and a tumor with a perforation in the diverticulum. Additionally, there was a small intestinal obstruction due to the tumor that was adherent to the floor of the pelvis. We performed a Meckel’s diverticulum resection, abdominal irrigation and drainage. Pathologically, the tumor was diagnosed as undifferentiated carcinoma developing from a Meckel’s diverticulum containing ectopic pancreatic tissue. Because of its histological continuity and an identical immunohistochemical staining pattern identical to ectopic pancreatic tissue, this carcinoma was confirmed to arise from the ectopic pancreatic tissue. Carcinoma in a Meckel’s diverticulum has rarely been demonstrated to arise from the ectopic tissue in the diverticulum by histopathological studies of immunohistochemical staining; therefore, this unusual case is presented with a review of the literature.

A 74-year-old man presented with a complaint of abdominal pain. His abdomen showed muscular guarding with tenderness in the right lower quadrant and laboratory data showed a remarkable elevation of an inflammatory response. Abdominal CT showed thickness in the small intestinal wall and an abscess formation with an elevation of surrounding fat density in the right lower abdomen. We diagnosed peritonitis caused by perforation of a diverticulum of the small intestine and performed emergency laparoscopic surgery. A diverticulum was detected on the mesenteric side 30 cm proximal from the ileum end and the tip was perforated. The diverticulum resection was performed with partial ileal resection. Histopathological examination revealed the muscular layer and the mucosal lining of the diverticulum were continuous with those of the ileum. These findings yielded a diagnosis of ileal duplication. We report a rare case of a perforated ileal duplication.

A 72-year-old man given a diagnosis of polycythemia vera (PV) had a high C-reactive protein level of 7.56 mg/dl on a regular blood examination. We diagnosed ascending colon cancer with intestinal obstruction and performed emergency surgery. He had pancytopenia and infection in his postoperative course and unfortunately died due to systemic hemorrhage and multiple organ failure 37 days postoperatively in spite of thorough treatment. PV is an idiopathic malignancy with an increase in hematopoietic stem cells, often resulted in thrombosis and bleeding after surgery. PV has been reported to have chronic low-grade disseminated intravascular coagulation (DIC). Emergency surgery in a patient with PV is associated with high risk of mortality and DIC. Therefore, we should carefully select optimal surgical procedures and control coagulation disorders.

A 66-year-old man who was planning on getting surgery for sigmoid colon cancer with invasion of abdominal wall developed abdominal fullness, redness and swelling of the left lower abdomen a few days before hospitalization. He developed abscess of the abdominal wall around the part infiltrated by the tumor, and subcutaneous emphysema of the neck and the chest at the time of admission. Transverse colostomy and incisional drainage was performed. Forty two days after the first surgery when the general condition became stable, sigmoid colectomy and resection of the abdominal wall were performed. The abdominal wall defect was 13×17 cm in size, and was reconstructed using a pedicled tensor fascia latae myocutaneous flap. Distant metastasis is reported to be rare in spite of locally aggressiveness in patients with colorectal cancer invading the abdominal wall. If a tumor can be removed radically, the outcome is sometimes good. Even though a curative resection required resection of the extensive abdominal wall, we consider that surgical treatment is recommended if the abdominal wall defect can be reconstructed using a myocutaneous flap.

Suture rupture is a relatively frequent postoperative complication after upper gastrointestinal surgery. Treatment consists mainly of drainage and nutritional management; however, the disadvantage of this treatment is that in some cases, formation and growth of granulation tissue may take a long time to complete. The use of an over-the-scope-clip system (OTSC) for the closure of all layers of the gastrointestinal wall has recently been recognized to enable earlier closure of fistulas after surgery. We encountered two cases in which fistula closure was successful after OTSC was used to treat postoperative suture ruptures and fistulas occurring after upper gastrointestinal surgery. Complete closure was achieved immediately after OTSC in Case 1, and at day 3 after OTSC in Case 2. OTSC is an aggressive treatment that differs from the conventional treatment method. It consists of closing ruptured sutures with an endoscope. The use of OTSC markedly reduces the time needed to wait for the growth of granulation tissue, and as a result, it may potentially lead to a shortening of the hospital stay as well as a reduction of the burden on patients. Our findings suggested that fistula closure using OTSC could be a new option in the treatment of postoperative complications.