An 84-year-old man was admitted to our hospital complaining of postprandial abdominal pain. He had undergone distal gastrectomy and Roux-en-Y reconstruction for gastric cancer six years previously, and cholecystectomy and bile duct duodenal anastomosis for cholecystolithiasis, choledocholithiasis, and parapapillary duodenal diverticulum syndrome one year previously. Abdominal MRI revealed a low-signal structure in the afferent loop, and the patient was given a diagnosis of afferent loop syndrome due to incarceration of a calculus. Emergency surgery via an abdominal midline incision was performed. A calculus was palpable in the jejunum 5 cm from the ligament of Treitz on the anal side. An incision was made in this portion of the jejunum, and the jejunum was excised and closed with simple sutures. The patient was discharged from hospital 23 days after surgery. The excised calculi were mainly composed of calcium stearate. The calcium stearate was relatively high in bilirubin calcium among bile stones and was also included in the magnesium oxide that the patient had been taking. We considered the calcium stearate in this patient to have been deposited around a gastrolith as the nucleus. We report a case of afferent loop syndrome caused by bezoar-derived enterolithiasis comprised of calcium stearate as this is a very rare disease.

Perivascular epithelioid cell tumor (PEComa) is a family of rare mesenchymal tumors, derived from perivascular epithelioid cells. We report a case of laparoscopic hepatectomy for primary hepatic PEComa. A 45-year-old woman was referred to our hospital with a diagnosis of hepatocellular carcinoma because screening abdominal US revealed a hypervascular tumor in segment 2 of the liver. Laparoscopic partial hepatectomy was performed. The tumor was 2 cm in diameter and finally diagnosed as primary hepatic PEComa because it was immunohistochemically positive for both αSMA and HMB45. The background liver tissue showed moderate inflammation due to chronic hepatitis B virus infection but showed no fibrosis. The primary hepatic PEComa is extremely rare and criteria for malignancy have not yet been established. We believe this case is worth reporting because it is a rare pathology with difficulty in distinguishing from HCC.

A 66-year-old man was found to have an elevated liver enzyme level and a tumor in the liver by his family doctor and was admitted to our hospital for treatment. A tumor in the liver in Segment 7 and a tumor in the tail of the pancreas were identified at preoperative examinations. Imaging diagnosis was very difficult. Therefore, he underwent surgery for diagnosis and curative treatment. Intraoperative US revealed multiple tumors in the liver. For the purpose of confirming the diagnosis of the tumor in the tail of the pancreas, spleen preserving distal pancreatectomy was performed. Intraoperative specimen of the tail of the pancreas showed inflammatory pseudotumor (IPT). Intraoperative biopsy specimen of the liver showed IPT. Both tumors were histopathologically diagnosed as IgG4-related disease (IgG4-RD). In the case of pancreatic or hepatic tumors with elevated levels of serum IgG4, biopsy or endoscopic ultrasound-guided fine needle aspiration could be considered owing to the possibility of IgG4-RD.

A 78-year-old man was referred to our hospital for further investigation of an 8.5-cm large mass in the right lobe of the liver. Abdominal dynamic CT revealed a tumor that was enhanced in the arterial phase and that showed low-density in the portal phase in the right liver. He was given a diagnosis of hepatocellular carcinoma and underwent right hepatectomy after percutaneous transhepatic portal vein embolization in the right branch of the portal vein. During surgery, the portal vein blood flow of the remnant liver was not confirmed by US after right hepatectomy. In intraoperative portal venography, only the portal vein of the caudate lobe could be observed. Therefore we diagnosed obstruction due to torsion of the left branch of the portal vein. Portal vein stent placement was performed during surgery. After stent placement, portal vein blood flow improved. Postoperatively, he received anticoagulation therapy and was discharged 23 days after surgery with good general condition. At present, 13 months after surgery, the portal vein blood flow is good and remains patent.

A 76-year-old woman was admitted to our hospital with epigastric pain. Laboratory tests revealed white blood cell count, serum amylase, and lipase were elevated. Abdominal CT showed mesenteric edema below the left kidney without continuity to the normal pancreas. Ectopic pancreatitis was suspected and she was hospitalized. Two days after admission, the abdominal pain moved to the right abdomen and exacerbated inflammatory response in blood examination. On abdominal CT, the mesenteric edema moved to the right upper part of the abdomen and a high-density area associated with bleeding was observed inside. Ascites also appeared. Therefore, she was referred to our department, and emergency surgery was performed on the same day. A change in color of the jejunal mesentery and hematoma formation could be observed at 20 cm to 50 cm on the anal side of the ligament of Treitz. We suspected mesenteric penetration due to jejunal diverticulitis, and performed resection of the mesenteric hematoma and the segment of jejunum. Pathologically, the ectopic pancreas developed near the jejunal diverticulum, and had a ductal orifice to the diverticulum, causing acute hemorrhagic pancreatitis.

The patient was a 60-year-old woman, who, at the age of 59, underwent right elbow arthroplasty for rheumatoid arthritis using an autogenous graft from the right iliac crest. She was admitted to our emergency medicine department due to fever and disturbance of consciousness. Contrasted enhanced CT showed prolapse of the transverse colon at the right cranial iliac crest, ascites and free air. We diagnosed digestive tract perforation induced by incarcerated lumbar hernia. We performed right hemicolectomy to resect the perforated transverse colon, and lumbar hernia repair with suturation and omental patch. A tracheotomy was performed because of respiratory failure. Her respiratory condition and state of consciousness improved. She recovered with multidisciplinary treatment and was discharged 79 days after operation.

The specific cause of operative manipulation has not yet been identified. Here, we report a successful case for the detection of impending recurrent laryngeal nerve (RLN) injury during mediastinoscopic subtotal esophagectomy using the continuous intraoperative nerve monitoring system (CIONM). After attaching a monopolar automatic periodic stimulation electrode on the vagal nerve, the latency and the amplitude of the vocal cord contractility were monitored as the RLN function. During the nodal dissection around the left RLN, a 50% or greater decrease in the amplitude relative to the baseline values was temporarily recorded by retracting the left RLN from the dorsal to the ventral direction. However, it improved promptly after relieving the retraction of the RLN. Throughout the operation, the amplitude values of both RLNs were kept at 50% or greater relative to the baseline value, and as a result, RLN palsy did not occur after surgery. CIONM may be useful in preventing irreversible RLN injury by monitoring the real-time function of the RLN and alerting the dangerous maneuver leading to decreased levels of vocal cord contractility.