Purpose: To review surgical cases with mental disorder at our hospital to determine their clinical features and problems. Materials and Methods: Perioperative data were collected for patients who were admitted to the closed psychiatric ward at our hospital and underwent surgery for gastroenterological disease from 2013 to 2019. Result: During this period, 95 patients with mental disorders underwent surgery. The mental disorders included schizophrenia in 66 patients and dementia in 12, with 65% of patients hospitalized for more than 10 years due to psychiatric illness. Regarding physical disease, there were 59 cases of benign diseases and 36 of gastrointestinal cancer. Of the cancer cases, 30 were in the advanced stage and 1 without symptoms was detected by cancer screening. The mean preoperative serum albumin level was 3.5 g/dl. In terms of body composition, 14 patients (14.8%) were obese and 32 (33.7%) were underweight. Postoperative complications occurred in 18 patients (18.9%). Ileus, urinary tract infection, and aspiration pneumonia were related to medical restraint after surgery. Thirteen patients (13.7%) who did not have a family member or relative experienced difficulty in decision-making. In these cases, the necessity for surgery was decided by surgeons. Conclusion: Physical characteristics and health problems included malnutrition, low level of activity, dysphasia, and poor intestinal peristalsis. Social features and problems included cancer screening and decision-making. Support from a multidisciplinary healthcare team is necessary to solve these problems in this patient population.

Metastatic testicular tumor is a rare disease, whereas gastric cancer is the sixth most common primary tumor. The testis is a special organ with immune privilege that is anatomically and embryologically isolated from the immune system. Thus, it is assumed that anatomical and immunological barrier mechanisms prevent metastasis of malignant tumors to the testis. However, testicular migration of the anticancer drug itself may also be poor due to these barriers. A 42-year-old male was diagnosed with testicular metastasis 6 years after gastric cancer surgery. Chemotherapy (tegafur, gimeracil, oteracil potassium+cisplatin, ramucirumab) did not reduce the size of the metastases, but scrotal resection was performed because the metastases were well controlled without recurrence at other sites. The patient has been recurrence-free for 3 years and 10 months after surgery without chemotherapy. This case suggests that salvage surgery may be effective in patients with metastases confined to the testis and no recurrence at other sites.

Situs inversus totalis and complete agenesis of the dorsal pancreas are both rare diseases, and their coexistence is particularly rare. We experienced a case treated with laparoscopic cholecystectomy for cholelithiasis with complete agenesis of the dorsal pancreas in situs inversus totalis. The operation was performed with the consideration that the left and right sides are anatomically reversed. Although there was low-level confluence of the cystic duct, intraoperative cholangiography using ICG fluorescence enabled a safe procedure without biliary tract or pancreatic injury. This case indicates that intraoperative cholangiography using ICG fluorescence can be effective for avoiding complications in difficult cases with the possibility of biliary damage.

A 48-year-old male was found to have dilatation of the bile duct on abdominal US during a medical check-up. MRCP revealed congenital biliary dilatation and a 2-cm mass at the lower end of the dilated biliary duct. The tumor was mildly enhanced in an abdominal CT scan. Bile cytology by ERCP showed adenocarcinoma. Pylorus-ring preserving pancreaticoduodenectomy with excision of the dilated biliary duct was performed. A pathological examination revealed small cell neuroendocrine carcinoma (SCNEC) of the bile duct. Four months after the operation, CT revealed liver metastasis. Cisplatin and irinotecan were administered as first-line chemotherapy, followed by amrubicin as second-line chemotherapy. Each chemotherapy resulted in stable disease; however, liver metastases gradually worsened and the patient died 34 months postoperatively. SCNEC of the bile duct appears to have a poor prognosis characterized by early recurrence, even if radical resection is performed. We report this case as an extremely rare example of SCNEC of the bile duct with congenital biliary dilatation.

The patient was a 72-year-old man who had undergone lower anterior resection for a rectal neuroendocrine neoplasm four years ago. CT showed a mass lesion in the tail of the pancreas, contrast-enhanced CT indicated an enhanced 16-mm mass, and diffusion-weighted MRI showed a hyperintense mass. On PET-CT, the appearance of a hyperintense mass suggested a malignant tumor. Laparoscopic distal pancreatectomy was performed under a diagnosis of a metastatic pancreatic tumor from a rectal neuroendocrine neoplasm. The tumor was exposed on the ventral side of the tail of the pancreas and was found to have partially invaded the surrounding adipose tissue. A histological examination revealed proliferation of spindle-shaped tumor cells, and an immunohistological examination showed vimentin(+) and β-catenin(+) findings. The pathological diagnosis was a desmoid tumor of the pancreas. Desmoid tumor is often associated with familial adenomatous polyposis, but the etiology is unknown. This tumor is a borderline tumor with no potential for metastasis; however, it exhibits local invasiveness that indicates clinical malignancy. Desmoid tumor of the pancreas is extremely rare and laparoscopic surgery is difficult to perform because of the locally invasive behavior of the tumor. The prognosis of pancreatic desmoid tumor resected laparoscopically is unclear, and careful attention will be paid to the long-term oncologic outcome in our case.

We report a case of coexisting pancreatic ductal adenocarcinomas (PDACs) derived from intraductal papillary mucinous neoplasm (IPMN) and concomitant with IPMN in a patient with pancreatic divisum. A 73-year-old man visited our clinic for epigastralgia. Endoscopic retrograde pancreatography (ERP) showed a markedly dilated Wirsung duct and IPMN was diagnosed. ERP imaging from the accessory papilla duodeni showed that the Santrini duct continued to the main pancreatic duct and did not connect to the Wirsung duct. This observation was diagnosed as pancreatic divisum. Pancreatic duct stenosis was also found in the pancreatic body. The patient underwent pylorus-preserving pancreatoduodenectomy. Histological examination showed that PDAC derived from IPMN was present in the pancreas head and PDAC concomitant with IPMN was in the pancreas body. Based on our experience and a review of the literature, there is a need for careful preoperative examinations to select an appropriate surgical procedure for such a rare case with coexisting PDACs derived from and concomitant with IPMN.

An 85-year-old woman was admitted to our hospital due to diarrhea, loss of appetite and nausea. Rapid test results of a stool specimen taken on the third day after admission were positive for Clostridioides difficile (CD) antigen and negative for CD toxins. Later that day, she presented with signs of colonic perforation and was immediately brought to the operating room. The left half of the transverse colon and the entire descending colon had turned dark purple in color, and there was a hole in the descending colon. Left hemicolectomy and transverse colostomy were performed. After surgery, the preoperative stool specimen was submitted for a nucleic acid amplification test, which turned positive for CD toxin B. The patient recovered from postoperative disseminated intravascular coagulopathy and was discharged on postoperative day 82. The detailed mechanisms of colonic perforation following CD colitis are still to be unraveled, but pathological analysis in our case suggested that perforation occurred where longitudinal ulcers hit preexisting diverticula. In previous reports, partial colectomy, total colectomy or colon-sparing surgery have been performed in cases of colonic perforation following CD colitis. The operative procedure should be chosen based on the condition of the patient.

A male aged 70 was transported by ambulance with chief complaints of intestinal tract procidentia and proctodynia. Intestinal tract procidentia from the anus was observed and necrosis of a prolapsed intestinal tract was suspected. A CT scan showed that the sigmoid colon had reversed in the rectum lumen and intussuscepted, and its presenting part had prolapsed. Given the possibility of perforation, surgery was chosen without trying reduction. The sigmoid colon was dissected on the oral side of the intussusception by laparoscopy, the posterior rectal cavity was mobilized to the level of the levator ani, the reversed prolapsed intestinal tract was pulled out through the anus, the intestinal tract was dissected on the anal side, and the specimen was removed. A 0-I type tumor in the presenting part of the intussusception and perforation around the tumor were observed in the resected specimen. There are some reports of sigmoid colon cancer developing into a presenting part with intussusception and resulting in procidentia. However, in this case, the intestinal tract was incarcerated out of the anus, which suggested the possibility of perforation or malignancy. Therefore, laparoscopic surgery was performed for intestinal tract mobilization and dissection, without attempting reduction, followed by Hartmann’s surgery with transanal removal of the specimen.

A 55-year-old female had a chief complaint of abdominal pain. Contrast-enhanced CT showed a 16-cm mass with a well-defined internal non-uniform contrast effect. The feeding vessel was the left gastroepiploic artery. A whirl sign was found on the cranial side of the tumor, suggesting that omental torsion was the cause of abdominal pain. A blood test showed an inflammatory reaction and an increase in CA125, but there was no obvious ischemia and an operation was scheduled. Intraoperative findings showed an irregular 20-cm mass on the caudal side and adhesion to surrounding tissue. The omentum was twisted 720° on the head side of the tumor. The torsion was released and the tumor was removed. No abnormalities were observed macroscopically in the bilateral ovaries. Pathological histology revealed proliferation of fibroblasts that contained less than 10% of granulosa cell tumor components. The final diagnosis was fibroma with minor sex cord elements in the omentum. We report this case as a rare example of an ectopic ovarian tumor.