An-82-year-old man with squamous cell carcinoma (SCC) of the esophagus was initially treated by esophagectomy. Two months later, mild pain, redness and swelling appeared in the right ring finger. Bone X-ray showed osteolytic lesion of the distal phalanx, and the pathological diagnosis of the biopsy specimen was SCC. Therefore, amputation of the distal phalanx was performed. Twenty six months after esophagectomy, he noticed a tender, redness, and ulcer in the right middle fingertip. With a diagnosis of bone metastasis of esophageal cancer, he underwent amputation of the distal phalanx. Thirty five months after esophagectomy, the patient died of axillary lymph node metastasis, small intestine metastasis and pleural dissemination. Metastatic bone tumor is often seen, but metastasis to peripheral bones of the limbs is rare. Furthermore, the present case was rare because long-term survival was achieved after amputation of metachronous multiple bone metastases to the distal phalanx.

A 56-year-old man was referred to our hospital for treatment of gastric cancer detected during an annual health check. Gastroendoscopy showed a depressed lesion surrounding enlarged folds at the lesser curvature of the middle gastric body. The biopsy specimens revealed well-differentiated adenocarcinoma. Endoscopic US showed the thickened second layer with multiple cystic components. The boundary between the tumor and diffuse cystic lesions was unclear. Enhanced CT showed no evidence of regional or distant metastasis. The patient underwent laparoscopic total gastrectomy with lymph node dissection at the time of diagnosis of early gastric cancer with diffuse cystic malformation (DCM), since heterotopic mucosa widely spread close to the cardia. In the resected specimen, multiple cysts were focally lined in the submucosa under the irregular mucosa under low power view. The histological type of the tumor was well to poorly differentiated adenocarcinoma invading into the muscularis propria. DCM is relatively uncommon. The accuracy of preoperative investigation of tumor depth and lateral spread was not satisfactory because of submucosal cystic lesion with fibrosis.

Hepatic sarcomatous carcinomas are rare and are associated with poor prognosis. We report herein on a case of hepatic sarcomatous carcinoma with a long recurrence-free survival following intensive combined therapy. A 69-year-old Japanese woman with right chest pain visited a local hospital where elevation of CRP and elevation of liver and biliary enzymes were found. She was referred to our hospital and abdominal CT showed a hypoattenuating 60 mm lesion in the left lateral segment and the peripheral areas of the mass were enhanced in the arterial phase, yielding a diagnosis of intrahepatic cholangiocarcinoma. A laparoscopic left hepatic lobectomy was performed. Histopathological examination revealed the resected specimen consisted of spindle-shaped cells and had no component of glandular structure or hepatocytes. The patient was given a diagnosis of hepatic sarcomatous carcinoma. Although adjuvant chemotherapy with S-1 was performed, a recurrent 56 mm tumor was detected in the anterior segment of the right hepatic lobe 4 months after the operation. Gemcitabine+cisplatin therapy was introduced for 6 months and the tumor gradually decreased in size. Subsequently the patient underwent a ventral anterior segmentectomy and Spiegel lobectomy. The patient has survived for 55 months from the first hepatectomy and 45 months from the rehepatectomy with no recurrence and with no adjuvant chemotherapy.

A 68-year-old woman was referred to our hospital because her high inflammatory response and liver mass lesion which was suspected liver abscess became worse despite undergoing antimicrobial treatment for a month. CT showed a solid tumor adjacent to the cystic lesion in segment 6 of the liver. Laparoscopic right lateral sectorectomy of the liver was performed under the diagnosis of liver cancer accompanied with infectious cyst. The pathological diagnosis was hepatic adenosquamous cell carcinoma. The patient was discharged on the 21st postoperative day but was readmitted on the 41st postoperative day due to elevated white blood cell count and C-reactive protein. CT scan revealed multiple nodules with marginal enhancement in the remnant liver. Antimicrobial treatment was performed for 2 weeks as a diagnostic treatment to differentiate between liver abscesses and tumor recurrence. As a result, white blood cell count was elevated further and liver nodules also increased in size. The remnant liver volume was also significantly increased. The patient was given a diagnosis of granulocyte colony-stimulating factor (G-CSF) producing hepatic cholangiocellular carcinoma based on elevated serum G-CSF and IL-6 levels and negative results for several microbial examinations. G-CSF producing hepatic cholangiocellular carcinoma is rare and sometimes difficult to distinguish from liver abscess, and progresses rapidly, resulting in a poor prognosis. It is important to consider G-CSF producing tumor as a differential diagnosis in the case of a malignant tumor accompanied by an extensive inflammatory response without microbial infection, or unnatural liver hypertrophy.

A 65-year-old man underwent gallbladder bed resection for gallbladder cancer located in the body to tail. No metastatic lymph node was observed in the 12c and 12b lymph node areas by intraoperative pathological examination. Final pathological findings were poorly differentiated gallbladder adenocarcinoma, Gfb, papillary expanding type, 30×25 mm, T3 (S). sci INFγ, ly1, v1, ne1, N0, M0, Stage IIIA, R0 resection. CT detected recurrent node (55×38 mm) in the 12a area 1 year and 8 months after surgical resection. Five courses of gemcitabine (GEM) plus cisplatin (CDDP) therapy and 2 courses of GEM plus S-1 therapy were performed. However, the metastatic node increased in size. We performed chemoradiotherapy (CRT: S-1 plus 50.4 Gy). After CRT, the metastatic node shrank remarkably. Since there was no other distant metastasis, we performed surgical resection of the recurrent lymph node. The metastatic node did not show invasion to the surrounding tissues and major vessels, and curative resection was performed. Pathological examination revealed no presence of viable carcinoma cells in the resected lymph node. Prognosis of patients with recurrence of gallbladder cancer was extremely poor. We report a rare case of pathological complete response after chemoradiotherapy for recurrent lymph node with a review of the literature.

Case 1: A 66-year-old man was given a diagnosis of pancreatic head cancer. Preoperative abdominal CT showed an anomaly of the hepatomesenteric trunk as the common hepatic artery (CHA) replaced from the superior mesenteric artery, CHA runnning through the parenchyma of the pancreatic head. There was no tumor invasion to the hepatic artery, so we performed pancreaticoduodenectomy while preserving this artery. No postoperative complications occurred. Case 2: A 52-year-old man was given a diagnosis of distal bile duct cancer. As with case 1, CT showed hepatomesenteric type hepatic artery variation. We performed pancreaticoduodenectomy. Intraoperatively, the aberrant common hepatic artery through the pancreatic head parenchyma was preserved. Also, gastroduodenal artery was absent. Discussion: In surgery of the pancreatic head area with aberrant hepatic artery, we must consider maintaining the hepatic blood flow and keeping the radical curability. Detailed understanding of the hepatic artery anatomy and accurate recognition of the anatomy are important in order to perform safe and curative surgery.

The patient was an 84-year-old man who visited our hospital because of diabetes and had a sudden deterioration in blood glucose control. A pancreatic head tumor was pointed out upon examination and he was referred to our department. The contrast CT revealed a tumor of 15 mm in the head of the pancreas. The tumor was in contact with the portal vein, but no invasion into the major artery was observed, and therefore was diagnosed as resectable pancreatic head cancer. Subtotal stomach-preserving pancreaticoduodenectomy with portal vein resection was performed. Abdominal pain appeared on postoperative day 4, and abdominal CT revealed pneumatosis cystoides intestinalis (PCI). Conservative treatment was performed because no findings of intestinal necrosis was found. Subsequent CT revealed improvement of PCI and he was discharged on postoperative day 22 in good general condition. There are few reports on PCI as postoperative complications, especially after pancreaticoduodenectomy. We herein report a case of PCI treated under conservative therapy after subtotal stomach-preserving pancreaticoduodenectomy.

The patient was a 72-year-old man who visited our hospital because of anemia. CT revealed a 10-cm enhanced mass lesion in the ascending colon. Colonoscopy confirmed a submucosal tumor in the ascending colon, in which erosion was found in the mucosa. Biopsy was attempted, but the tumor cell was not found. Bleeding from the submucosal tumor was considered to be the cause of anemia, therefore right hemicolectomy was performed. Although the tumor was not exposed to the serosa, it was difficult to dissect the ascending colon and retroperitoneum because of inflammation. The resected specimen was approximately 10×8 cm, and was considered to be a pedunculated submucosal tumor. Pathologic examination revealed primary liposarcoma which originated from the ascending colon. The patient received no postoperative therapy, and no recurrences have been observed 24 months after surgery.

We report a case of mesh infection by stomal perforation after recurrent parastomal hernia repair using the keyhole technique. The patient was a 78-year-old woman. She underwent Miles operation for rectal cancer [stage pT3(SS)N0, M0] at the age of 66. She was given a diagnosis of parastomal hernia at the age of 71, and the hernia was repaired using a keyhole technique. However, recurrence of parastomal hernia occurred at the age of 72, and was repaired again using a similar technique. When she was 78 years old, she presented with abdominal pain and visited our hospital. Abdominal CT revealed mesh infection by stomal perforation. She began fasting and was initiated on antibiotics; drainage therapy was performed. A laparoscopic stoma was created in the transverse colon for the purpose of improving her state of nutrition. After the operation, she was given a diagnosis of a fistula from the small intestine to the parastomal abscesses. The mesh was surgically removed. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 43. No recurrence of abscess formation has been observed on follow-up. Thus, we should address and perform mesh removal operations quickly if mesh infections are diagnosed after parastomal hernia repair.

A 66-year-old-man had a lower thoracic esophageal cancer with stenosis which metastasized to his liver and lung. Since chemoradiotherapy was difficult due to inability to take meals and frequent vomiting, the establishment of a nutritional pathway and esophageal decompression became essential. The tip of the PEG-J catheter was placed on the oral side of the tumor. Nutrition was given via the decompression route of the PEG-J catheter, and decompression of the esophagus was performed by the nutrition route. The vomiting improved and radiotherapy could be performed in the outpatient clinic. We report a new method for nutrition management and esophageal decompression using PEG-J catheter in a patient with esophageal cancer with stenosis, which enabled earlier discharge than the conventional method.