Chemoradiotherapy can improve prognosis and is the beneficial standard treatment currently available for locally advanced unresectable esophageal cancer, but it can also be associated with esophageal fistula formation to adjacent organs, and may cause fatal bleeding subsequent to the aortoesophageal fistula (AEF) especially when the cancer involves the aorta. We encountered a case of AEF with esophageal cancer undergoing chemoradiotherapy, which was treated using aortic stent grafts. A 67-year-old man with dysphagia was given a diagnosis of locally advanced unresectable esophageal cancer directly invading into the aorta. The patient was treated with definitive chemoradiotherapy and obtained a partial response. He experienced shock due to hematemesis and AEF was diagnosed. Open thoracic surgery was not considered to be feasible in patients with unresectable cancer, therefore aortic stent grafting was planned. The patient tolerated the procedure well and hemostasis was achieved. His general condition dramatically improved and he became stable. An additional esophageal covered stent was applied for esophageal stenosis due to compression by the aortic stent grafts. The patient was able to eat well and was discharged, and followed an uneventful course without hematemesis or dysphagia until he died of cachexia due to progression of esophageal cancer on the 115th postoperative day under home palliative care. AEF remains as a life-threatening condition with a high rate of morbidity and mortality but can be successfully treated using aortic stent grafts, which can prevent sudden death due to fatal bleeding and aortic rupture. Aortic stent grafting is a less invasive and effective palliative treatment for AEF and may be a feasible alternative to open thoracic surgery.

Neoadjuvant chemotherapy for advanced gastric cancer can be effective, but it is under development in Japan because of no strong evidence. As treatment strategy for advanced gastric cancer, we have performed neoadjuvant chemotherapy with S-1 plus oxaliplatin (SOX) after enrollment in a clinical trial. We encountered a case of perforation during neoadjuvant chemotherapy. A 76-year-old man was given a diagnosis of advanced gastric cancer (Type3) of the upper and posterior part of the stomach. The clinical stage was determined to be cT4aN1M0 cStage IIIA and we planned 2 courses of SOX as neoadjuvant chemotherapy. After 1 course of chemotherapy, the patient complained of severe abdominal pain. An urgent laparotomy was performed with a tentative diagnosis of generalized peritonitis. Surgical findings revealed a perforation in the tumor and we decided to perform curative total gastrectomy. Pathological findings demonstrated that there were only few cancer cells with increased fibrosis and inflammatory cells in the lesion of perforation. A report about perforation of gastric cancer during chemotherapy is rare. In this case, we suggest that the perforation was caused by chemotherapy-induced necrosis of gastric cancer cells. Our findings suggest that the risk of gastric perforation should be considered when administering chemotherapy to patients with advanced gastric cancer with a deep ulcer.

We report a case of volvulus of the transverse colon after surgery for esophagogastric junction cancer. A 77-year-old woman visited our department because of dysphagia. The patient was given a diagnosis of esophagogastric junction cancer and underwent total gastrectomy and lower esophagectomy with antecolic Roux-en-Y reconstruction. The patient had cholecystitis on postoperative day 9, which was managed with conservative treatment. On postoperative day 34, the patient had abdominal pain, nausea, and vomiting accompanied by distension of the abdomen and abdominal tenderness. A massive bowel gas image was identified by abdominal radiography, along with disruption of the gas image on the left side of the transverse colon. Barium enema showed the bird beak sign around the splenic flexure. Abdominal CT scans showed that the transverse colon was bent and twisted around the jejunal limb mesentery. Transverse colon volvulus was diagnosed and she underwent another surgery on postoperative day 35. During the operation, the transverse colon was completely displaced to the right side of the jejunal limb, and it was rotated 270 degrees in a counter-clockwise manner from the residual omentum adhering to the jejunal limb mesentery, and further rotated 180 degrees from the jejunal limb mesentery.

This report describes a 60-year-old man with a history of colorectal cancer, renal cell carcinoma, bladder cancer, and prostate cancer. His duodenal cancer was discovered as the sixth cancer and was treated by pancreaticoduodenectomy. He was given a diagnosis of Lynch syndrome based on his status as a carrier of pathogenic mutations in the MSH2 gene, which is a mismatch repair (MMR) gene. This report also describes a 75-year-old man with a history of multiple operations for colorectal cancer and gastric cancer. His duodenal cancer was discovered as the seventh cancer and was treated by pancreaticoduodenectomy. He was also given a diagnosis of Lynch syndrome based on his status as a carrier of pathogenic mutations in the MLH1 gene, which is an MMR gene. Lynch syndrome is a disease with autosomal dominant inheritance and is caused by mutations in MMR genes. The cumulative incidence of small bowel cancer, including duodenal cancer, is low; it is estimated to range from 2.5% to 4.3%. The guidelines for hereditary colorectal cancer recommend that surveillance in patients with gastrointestinal cancer should include endoscopic examinations every 1 to 2 years. However, in older patients such as those described herein, the risk of duodenal cancer should be kept in mind and surveillance should be performed more carefully and precisely.

A 79-year-old woman was found to have an elevated serum bilirubin level by her family doctor and was referred to our hospital. Enhanced abdominal CT showed wall thickening of the hilar bile duct in a wide area from the proximal common hepatic duct to the right anterior branch, right posterior branch, and left hepatic ducts, resulting in diffuse biliary stricture and dilation of both intrahepatic ducts. The right hepatic artery and A4 were in contact with the thickened biliary wall, suggesting tumor involvement of these arteries. ERCP demonstrated an irregular stricture of the hilar bile duct, which was consistent with the CT findings. The patient underwent biliary drainage from B2. Although cytology of the bile revealed no malignancy, we diagnosed hilar cholangiocarcinoma based on the imaging findings. We conducted right hepatic trisegmentectomy and caudate lobectomy with extrahepatic bile duct resection and lymphadenectomy. Gross appearance of the cut surface of the specimen revealed marked wall thickening in the bile duct of the hepatic hilum. On histological and immunohistochemical examination, the bile duct was lined by normal biliary epithelium and thickened by marked formation of lymphoid follicles with germinal centers and proliferation of fibrous stroma. Only a small amount of IgG4-positive plasma cells was seen. These findings were consistent with follicular cholangitis. She is doing well without recurrence of sclerosing cholangitis for over 4.5 years after the surgery. Although a review of the literature revealed this to be a rare case, follicular cholangitis should be considered as a differential diagnosis of biliary stricture of the hepatic hilum.

We present a 65-year-old man who underwent left hepatic trisegmentectomy and biliary reconstruction for hilar cholangiocarcinoma. Four months after the operation, serum total bilirubin level was elevated to 24.1 mg/dl. CT revealed a migrated biliary stent in the intrahepatic bile duct. The stent was successfully removed under percutaneous transhepatic approach; however, serum total bilirubin level did not decreased. The diagnosis of liver failure caused by refractory cholangitis was made and, intra-arterial antibiotic therapy using meropenem and ciprofloxacin was performed, and thereafter, the serum total bilirubin promptly decreased. This case report suggests that intra-arterial antibiotic therapy seems to be effective for liver failure caused by refractory cholangitis after major hepatectomy with biliary reconstruction.

We report a case of atypical complications in secondary systemic amyloidosis complicating Crohn’s disease after surgery. A 36-year-old man with Crohn’s disease and having a fistula had been treated with medical therapy for 15 years. However, the gastrointestinal symptoms had become worse, and he was referred to our hospital for further treatment. After admission, his renal dysfunction deteriorated rapidly. Therefore, renal biopsy was performed, and hemodialysis was introduced based on the diagnosis of renal amyloidosis. The ileum and rectum had stricture lesions with ileocolic fistula and pelvic abscess. For this reason, ileocecal resection with ileostomy and high anterior resection was performed. At first, the postoperative course was good, but on postoperative day 11, he developed anastomotic leakage with bleeding. An emergency Hartmann’s operation was carried out. After reoperation, he underwent total colectomy due to gastrointestinal bleeding from the colon. Histopathological findings were consistent with a diagnosis of gastrointestinal amyloidosis, because systemic AA amyloid deposition was seen extensively from the intestinal mucosa. Continuous chronic inflammation caused secondary systemic amyloidosis. In this pathological condition, we need to pay careful attention to complications such as anastomotic leakage and bleeding, even if no lesions are found endoscopically in the intestinal wall.

A 36-year-old man under medication for ulcerative colitis (total colon type) for 4 years, developed sudden, severe abdominal pain, and was given a diagnosis of intussusception of the terminal ileum. Emergency laparoscopic right hemicolectomy and ileostomy were performed. Anastomosis was not performed because he was taking immunosuppressive agents. We finally diagnosed idiopathic intussusception of cecum. Postoperative recovery was uneventful and five months later, laparoscopic residual total colectomy was performed. At present he is free of symptoms. Adult intussusception is a relatively rare disease, accounting for only 5–7% of all intussusception cases, and the frequency of idiopathic intussusception is rare. Emergency operation is performed in general for the risk of intestinal necrosis. However, the operation should be decided according to individual background and general condition. In this case, staged operations were performed considering the risk of surgery.

Hepatic sinusoidal injury occasionally arises after oxaliplatin-based chemotherapy. Although esophagogastric varices associated with subsequent portal hypertension occur in some cases, there have been few reports of ectopic varices in Japan. In this paper, we present 2 cases of duodenal varices during the course of oxaliplatin-based chemotherapy for colorectal cancer. Interventional radiology for duodenal varices was successfully applied in both cases to prevent bleeding from varices. Oxaliplatin is one of the key drugs in the treatment of unresectable metastatic colorectal cancer, but it is necessary to pay attention to the onset of complications due to portal hypertension. In addition, our cases implied that interventional radiology is considered to be a promising treatment for varices that occurred concurrently during oxaliplatin-based chemotherapy.

We performed laparoscopic deroofing of hepatic cysts aided by indocyanine green (ICG) fluorescence imaging in 6 patients. All patients were women: average age 63 (52–82), average duration of surgery 152.3 min (103–232), average blood loss 14.6 ml (1–70), no perioperative complications. In no patient was cyst fluid fluorescent by ICG imaging in any patient at laparotomy. When the cyst wall was opened and the interior wall was examined after fluid aspiration, the biliary ducts, which had been invisible under white light, were sharply delineated. Visible ducts relevant to the incision line were clipped or ligated, and resected. The coagulable area of the remaining internal wall was extremely small, and was localized to avoid visible vessels and delineated ducts. This method contributes to a safer laparoscopic deroofing procedure by enabling identification of any bile leakage from the transected liver surface and the assessment of duct paths in the internal wall of the cyst.