Purpose: Fewer women are becoming surgeons than entering other clinical fields, and the number of surgeons is declining. In this study, we investigated the problems facing female surgeons by administering a survey to medical students and residents. Materials and Methods: A questionnaire survey was conducted among third- to fifth-year students in medical school and junior residents (n=418, including 136 women) in our hospital. Results: Surgery was the second most aspired department for a future career. Although surgery was viewed as rewarding, there was a concern about working long hours and on holidays, with the result of having little free time. Concerning maternity and childcare, 56% of women worried about the difficulty of taking maternity or childcare leave. About half of the men answered that they would like to participate in housework and childcare. Change in work styles, reduction of work burdens, and improvement of nursery schools were mentioned as support for female doctors. Compared to men, women more frequently wished for understanding and cooperation from their colleagues and families. Conclusion: The work style of doctors has been changing, and both men and women need to balance office work and housework. Greater acceptance of diverse work styles is required.

A 74-year-old woman underwent subtotal esophagectomy with gastric tube reconstruction via a retrosternal route for thoracic esophageal cancer. She experienced repeated vomiting at 3 months after surgery. Delayed gastric conduit emptying was diagnosed because the gastric tube was redundant and dilated into the right thoracic cavity. Revision surgery was performed two weeks after unsuccessful conservative treatment. Operative findings under laparotomy revealed that the antral zone of the gastric tube was firmly attached to the dorsal side of the xiphoid. We added a right thoracotomy with a sixth intercostal incision to secure a good surgical field. The gastric tube had dilated and bent above the right diaphragm, and the outflow tract of the gastric tube was obstructed by the left liver lobe and xiphoid. We incised the diaphragm and pulled the gastric tube toward the abdominal cavity. The diaphragm was closed and the gastric tube was fixed to the diaphragm. The postoperative course was uneventful and no delayed gastric conduit emptying has been seen for one year postoperatively.

A gastric tumor producing granulocyte colony-stimulating factor (G-CSF) is a rare and aggressive tumor, and a tumor producing parathyroid hormone-related protein (PTHrP) is also rare. Here, we report the first case of gastric cancer with production of GCSF and PTHrP. A 72-year-old woman was referred to our hospital because of leukocytosis and a chest abnormal shadow. A chest CT scan demonstrated a right lung tumor and a bronchoscopic biopsy showed adenocarcinoma. Primary lung adenocarcinoma was diagnosed by immunohistochemistry. Gastric endoscopy revealed a type 2 tumor at the gastric fornix. Endoscopic biopsy showed poorly differentiated adenocarcinoma. Staging laparoscopy revealed a tumor on the surface of the liver and needle biopsy led to diagnosis of liver metastasis from gastric cancer. The patient was started on S-1 and oxaliplatin (SOX). She visited the hospital because of general malaise and appetite loss in the course of chemotherapy. Laboratory data showed severe leukocytosis and hypercalcemia. The serum G-CSF level was high (493.3 pg/dl, normal <39 pg/dl) and the serum PTHrP level was also high (13.7 pmol/l, normal <1.2 pm/l). The patient underwent proximal gastrectomy accompanied by D2 lymphadenectomy combined with partial resection of the lateral segment of the liver because of direct invasion. The serum PTHrP and G-CSF levels normalized after surgery. Immunohistochemical examination of the gastric cancer tissue showed focal staining for G-CSF and PTHrP in the cytoplasm. This is the first published case of gastric cancer producing G-CSF and PTH.

We report a case of intraluminal duodenal diverticulum (IDD) that was treated by surgical resection. A 24-year-old male was treated conservatively for acute pancreatitis, but the disease recurred 3 months later. Thus, he was referred to our hospital for a detailed examination. CT showed a cystic lesion in the lumen of the descending and horizontal portion of the duodenum. Upper gastrointestinal endoscopy showed a false lumen with a blind end at the anal side near the ampulla of Vater. An upper gastrointestinal series showed a gastrografin-filled pear-shape sac of approximately 30 mm surrounded by a well-defined halo zone. Resection of IDD and cholecystectomy with C-tube drainage under laparotomy was performed under a preoperative diagnosis of relapsing pancreatitis caused by IDD. The postoperative course was uneventful, and there has been no recurrence of pancreatitis during a follow-up period of 10 months. Although endoscopic resection is reported to be useful for IDD, resection of IDD with laparotomy was performed based on the size of the IDD and the locational relationship between the IDD and the ampulla of Vater. Herein, we present a case of IDD and discuss the treatment options with a review of the literature.

A 77-year-old man was admitted for liver dysfunction and gallstones found in abdominal US. A 3.0-cm cystic lesion at the neck of the gallbladder was also found on abdominal US. Contrast-enhanced CT and MRI also showed many stones in the gallbladder and a 3.0-cm cystic lesion at the neck of the gallbladder. A diagnosis of cholelithiasis and gallbladder adenomyomatosis was made, and laparoscopic cholecystectomy was performed. The resected specimen was a 4.0-cm cyst at the neck of the gallbladder, with communication between the gallbladder lumen and the cyst. An incision showed that the cyst was filled with clear mucus. Histologically, the cyst was an enlarged Rokitansky-Aschoff sinus, and the pathological diagnosis was an intramural cyst of the gallbladder. This kind of cyst is rare, with very few reports, and its clinical and histological features have not been established. There are no reports of cases in which communication between an intramural cyst of the gallbladder and the gallbladder lumen was confirmed, and therefore, the section was examined macroscopically and histologically in detail. We report this case as the first example of an intramural cyst of the gallbladder with communication with the gallbladder lumen.

An 88-year-old woman was diagnosed with acute cholecystitis and choledocholithiasis on CT. At this point, the gallbladder had become stiff, but the case was not diagnosed as right-sided round ligament. Percutaneous transhepatic gallbladder drainage (PTGBD) was scheduled for choledocholithiasis before cholecystectomy. Exacerbation of inflammatory response and abdominal pain developed the day after PTGBD, with increased peritonitis due to bile leakage noted on contrast-enhanced CT. The round ligament joined the branch of the anterior segment of the portal vein, and the gallbladder was located on the left side of the hepatic ligament. The PTGBD tube punctured the skin, liver, intraperitoneal region and gallbladder, and caused bile leakage. This case shows that there is a possibility of bile leakage due to PTGBD in cases of right-sided round ligament, and therefore, it is particularly important to understand the dissection procedure.

A 56-year-old man presented with right lower quadrant pain and was admitted to our hospital. A blood test showed an elevated inflammatory response. A CT scan revealed a cystic low density area around the appendix and an indistinct mass with contrast effect in the proximal area of the appendix. Appendiceal mucocele was suspected and conservative treatment with an antibiotic was initiated. After a month, the inflammatory response improved. However, a CT scan showed similar images of suspected appendiceal mucocele. The patient underwent ileocecal resection, D3 lymph node dissection. Intraoperative findings showed induration of the appendix and hard adhesions to the retroperitoneum, leading to combined resection of the retroperitoneal fascia and testicular blood vessels. Macroscopically, an indurated yellowish tumor was detected in the mesoappendix. Pathological findings showed plasma cells and a foamy cell infiltrate in the mesoappendix. Finally, the patient was diagnosed with xanthogranulomatous appendicitis. Xanthogranulomatous inflammation is a relatively rare subtype of chronic inflammation that is often found in the gallbladder and kidneys. We report this interesting case of xanthogranulomatous appendicitis that mimicked appendiceal mucocele in radiological images.

A 28-year-old man was brought to the emergency room after experiencing abdominal pain and loss of consciousness after exercise. His blood pressure had dropped to 77/49 mmHg and his right upper abdomen was very distended and painful. Abdominal CT revealed a massive 18-cm diameter hematoma in the Morrison fossa, with a 10-cm tumor inside. Adrenal hormone measurements showed no obvious elevation and imaging showed tumor invasion into the liver and inferior vena cava. We diagnosed non-functional adrenal carcinoma of the adrenal glands. Surgery with combined resection of the right lobe of the liver, the inferior vena cava, and the right kidney was performed, and the tumor was completely resected. Immunohistochemically, the tumor was negative for cytokeratin, desmin and S100, but positive for CD99. Extraskeletal Ewing’s sarcoma/primitive neuroectodermal tumor was suspected and the diagnosis was confirmed by identification of the chimeric genes of EWSR1 and FLI-1 in a FISH test. After surgery, the patient was referred to a different facility for adjuvant chemotherapy, but at four years and one month after surgery, he developed local recurrence. The patient died 5 years and 6 months after surgery despite radiotherapy and chemotherapy. We report this case as an example of long-term prognosis with multidisciplinary treatment.

Purpose: Bevacizumab (BV) is a molecularly targeted drug used for several types of cancer, but is known to have specific adverse events. Here, we present cases with acute abdomen during BV administration. Materials and Methods: Between April 2009 and March 2019, 636 patients received BV at our hospital, of whom 13 (2.0%) had acute abdomen. The characteristics and short-term outcomes of these patients were analyzed retrospectively. Results: The patients were 6 males and 7 females, and the median age was 63 years old. The causes of acute abdomen were gastrointestinal perforation (n=10, 77%) (5 colon, 3 duodenum and 2 small intestine), bladder perforation (n=1), ischemic enteritis (n=1) and gallstone attack (n=1). Surgery was performed in 12 patients and conservative treatment was used for one patient with duodenal perforation. Postoperative complications of Clavien-Dindo class ≥IIIa occurred in 6 patients (50%), 8 patients (67%) had surgical site infection and 3 (25%) had wound dehiscence. There were two deaths: the patient who received conservative treatment and the patient with ischemic enteritis. The median postoperative hospital stay was 43 days (4–128 days). Conclusion: In acute abdomen during the course of BV therapy, gastrointestinal perforation was the most frequent cause and the postoperative complication rate was high.