Purpose: In laparoscopic surgery, low-pressure pneumoperitoneum was demonstrated to reduce postoperative pain and postoperative changes in liver function tests. However, these effects have not been studied in Japan. Materials and Methods: Elective laparoscopic cholecystectomy cases were prospectively randomized into standard-pressure (10 mmHg; 23 cases) and low-pressure (6 mmHg; 25 cases) pneumoperitoneum groups. Postoperative pain was measured using visual analog scale. Results: Preoperative characteristics were similar between the groups. In the low-pressure group, operation was successfully completed in 20 cases. In 5 cases, the pressure was increased to 8–10 mmHg due to adhesion in 2 and restricted operative field in 3 cases, respectively. There was no conversion to open laparotomy. When the successful 20 cases were compared with the standard-pressure group, pain on the first postoperative day was 25.8 in the low-pressure group and 29.3 in the standard-pressure group, which was not statistically different (P=0.8). There were no statistical differences regarding operative time, bleeding, intraoperative change in end-tidal carbon dioxide, postoperative analgesics use, and changes in liver function tests. There were no complications. When the 20 successful cases were compared with the 5 unsuccessful cases, no statistical differences were found in age, gender, body mass index, diagnosis, operative time, and bleeding. Duration of pneumoperitoneum and intraoperative rise in end-tidal carbon dioxide showed a positive correlation in only the standard-pressure group (correlation coefficient=0.54, P=0.008). Conclusion: This study failed to demonstrate clear advantages of low-pressure pneumoperitoneum. Pneumoperitoneum pressure of 10 mmHg seemed reasonable for laparoscopic cholecystectomy.

A 59-year-old woman underwent nutritional administration via a nasogastric tube during psychiatric hospitalization for anorexia nervosa. CT examination which was given because of the abdominal pain that occurred on the 8th day after insertion of the nasogastric tube, showed severe edema of the entire gastric wall, air bubbles in the gastric wall, hepatic portal venous gas, mediastinal emphysema, and subcutaneous emphysema. The endoscopic examination showed focal mucosal necrosis in the greater curvature side of the upper gastric body. Total gastrectomy was performed under the diagnosis of portal venous gas from emphysematous gastritis. In this case, the emphysematous gastritis with the portal venous gas developed due to infection from gastric mucosal injury by insertion of the nasogastric tube. At the same time, it was thought that mediastinal emphysema and subcutaneous emphysema occurred due to elevated airway pressure and alveolar rupture caused by stimulation at the time of insertion of gastric tube, with the background of malnutrition and the tissue vulnerability. We report a rare case where it was assumed that these two pathological conditions coincided at the same time.

We report a case of a 65-year-old woman with a complaint of recurrent hematochezia 13 months after pancreatoduodenectomy for pancreatic head carcinoma. Both of the portal vein and the superior mesenteric vein were resected and reconstructed with the left renal vein graft. The splenic vein was not reconstructed. Colonoscopy detected variceal bleeding at the hepatic flexure, which was successful to arrest hemorrhage by endoscopic treatment. Esophagogastroduodenoscopy revealed bleeding from the pancreatojejunal anastomosis. Enhanced CT showed varices at the pancreatojejunal anastomosis with no findings of recurrence of pancreatic carcinoma. Together with these findings, variceal hemorrhage from the pancreatojejunal anastomosis was caused by sinistral portal hypertension after pancreatoduodenectomy without reconstruction of the splenic vein. Endoscopic treatment was not successful for hemostasis. Partial splenic artery embolization was performed in order to decrease the splenic venous pressure, resulting in failure to manage the hemorrhage. Finally, total remnant pancreatectomy with splenectomy was performed. The postoperative course was uneventful. The patient completed insulin self-administration training and was discharged on postoperative day 24. There were no findings of recurrent bleeding during 12 months of follow-up.

An 18-year-old man presented with a chief complaint of sudden left shoulder pain, back pain and epigastralgia. Abdominal enhanced CT showed the extravasation of contrast agent, and hematoma around the spleen, suggesting splenic rupture. Because the patient’s circulatory dynamics were stable, we selected conservative treatment. Concomitantly, swelling and pain in the submandibular lymph node were observed and a positive finding for EB virus VCA-IgM antibody was obtained. In addition, the number of atypical lymphocytes and monocytes both were found to have increased. Based on these findings, he was given a diagnosis of a splenic rupture due to infectious mononucleosis. The symptoms subsided without any further bleeding thereafter and he was discharged after 21 days. The spleen is an important organ regarding immunity and it is therefore highly desirable to not remove the spleen as far as possible in the case of a splenic rupture in young people. We herein describe a case of a splenic rupture due to infectious mononucleosis in which a successful outcome was achieved through conservative treatment.

We report a rare case of small intestinal metastasis from malignant pleural mesothelioma. A 78-year-old man, with a history of lobectomy for lung cancer 6 years previously, underwent total gastrectomy with lymphadenectomy for gastric cancer. Two years and 4 months after gastrectomy, a chest CT revealed pleural effusion, which was gradually increasing. Pathological examination of a biopsy specimen of the pleura was diagnosed as malignant pleural mesothelioma, epithelioid type. Although he received the third line chemotherapy and radiation therapy, his disease progressed, therefore he was treated with best supportive care. He had a sudden onset of lower abdominal pain and CT showed massive ascites and free air in the abdominal cavity. An emergency operation was performed under the diagnosis of suspected bowel perforation. We conducted laparotomy, then found purulent ascites and multiple white nodules on the abdominal wall. Circumferential wall thickening with a central perforation of 7 mm was detected in the jejunum, so partial resection of the small intestine was performed. Immunohistochemical examination for the lesion was positive for mesothelial markers, therefore the definitive diagnosis was small intestinal metastasis from malignant pleural mesothelioma.

FDG-PET/CT is a highly sensitive tool for detecting new or recurrent cancer lesions, however, it has been pointed out that it can also yield false-positive results in some cases. A 79-year-old man underwent right hemicolectomy for ascending colon cancer. His serum CEA level increased 20 months after the initial operation. FDG-PET/CT showed abnormal accumulation at the anastomosis and in the right lower-quadrant abdominal wall. Colonoscopy did not reveal any changes suggestive of anastomotic recurrence. There were tumors in the abdominal wall and a biopsy was performed, which yielded a negative result for cancer. Nevertheless, since the possibility of cancer recurrence could not be ruled out, we decided to administer chemotherapy. Since colonoscopy revealed anastomotic recurrence 24 months later, colectomy and tumorectomy were performed. Histologically, anastomotic recurrence was confirmed, and the tumors were finally diagnosed as foreign body granulomas caused by the suture thread.

We report two cases of desmoid tumor with postoperative colorectal cancer. Case 1: A 69-year-old man underwent low anterior resection for Stage I rectal cancer. In CT scan at 14 months after operation, soft tissue tumor was found in the aortic bifurcation with slight uptake on FDG-PET (SUV max: 4.47). We diagnosed it as recurrence of colorectal cancer, and performed resection. Based on pathological findings, the tumor was diagnosed as desmoid tumor. Case 2: A 69-year-old man underwent laparoscopic left hemicolectomy for Stage IIb transverse colon cancer. In CT scan at 24 months after operation, a tumor was found in the mesenteric membrane with no uptake on FDG-PET (SUV max: 2.41). We diagnosed it as recurrence of colorectal cancer, and performed resection. Based on pathological findings, the tumor was diagnosed as desmoid tumor. Desmoid tumor with postoperative colorectal cancer is not only rare, but also difficult to distinguish from colorectal cancer recurrence.

Purpose: We investigated the efficacy and safety of neoadjuvant chemoradiotherapy with docetaxel and 5-fluorouracil (DF-NACRT) followed by esophagectomy to treat advanced esophageal cancer. Methods: We reviewed data from 12 patients with advanced esophageal cancer who underwent trimodality therapy comprising DF-NACRT followed by esophagectomy between December 2007 and August 2017. Results: Patients consisted of cStage II: 2 patients, III: 1 patient, IVA: 8 patients, IVB: 1 patient, and the median age was 68 years [range, 50–82]. Hematologic toxicity and non-hematological toxicity (≥Grade 2) was observed in 4 (33.3%) and 6 patients (50%), respectively. Four patients (33.3%) had complete pathologic responses (pCR) of the primary tumor, and the T or N status was also down-staged in 9 patients (75%). Mortality due to postoperative morbidity was zero. Conclusions: This regimen with docetaxel and 5-fluorouracil is promising as a safe and effective neoadjuvant chemoradiotherapy for esophageal cancer.