Hereditary diffuse gastric cancer is a genetic cancer susceptibility syndrome characterized by a high risk for gastric and lobular breast cancer. We herein report a case of a 77-year-old woman with clinically suspected hereditary diffuse gastric cancer. The patient had undergone surgery for lobular breast cancer at the age of 45. Endogastroduodenoscopy revealed multiple discolored foci from the prepyloric area throughout the lesser curvature of the gastric body. Histopathological examination showed poorly differentiated adenocarcinoma. The patient underwent total gastrectomy following diagnosis of multiple early-stage gastric cancer. During surgery, we found small nodules on the jejunum and liver S3 segment, and excised these nodules for diagnostic assessment. A histopathological study revealed at least 155 lesions involving signet-ring cell carcinoma spread across the entire stomach, and metastasis to the jejunum and liver. There were no CDH1 germline mutations; however, we clinically suspected hereditary diffuse gastric cancer due to specific pathological findings for the stomach and the history of lobular breast cancer. Hereditary diffuse gastric cancer has rarely been reported in Japan, and accumulation of cases is required for establishing diagnostic and treatment strategies for this genetic disease.

We report a case of multiple gastric cancer with a simultaneous solitary cerebral metastasis. A 69-year-old male visited another hospital complaining of amnesia, agraphia, and dysphasia. Cranial MRI revealed a multilocular tumor of 30 mm in diameter in the left parietal lobe of the cerebrum. He was urgently transferred to our hospital for further examination. Thoracoabdominal and pelvic CT showed no other abnormalities, but serum CEA and CA19-9 were markedly elevated to 1,052 ng/ml and 1,736 U/ml, respectively. Gastrointestinal endoscopic findings revealed [1] 0-IIc+IIa-type (cT1a) and [2] advanced 0-IIc-type (cT2) tumors in the lesser curvature of the upper gastric body and on the anterior wall of the antrum, respectively. First, cerebral metasectomy and postoperative intensity modulated radiation therapy (IMRT: 45 Gy) were performed. After IMRT, ESD with curative resection was performed for the 0-IIc+IIa-type early cancer in the upper gastric body, and laparoscopic distal gastrectomy (LDG) with D2 lymph node dissection and Billroth-I reconstruction were used for the advanced 0-IIc-type cancer in the antrum. Pathological examination revealed [1] U, Less, 0-IIc+IIa, tub1>tub2, pT1a, ly0, v0; [2] L, Ant, 0-IIc, tub1-2/por2, pT1b2, ly1a, v1a, pN1 (#3), H0, P0, pM1 (brain), pStage IV. Adjuvant chemotherapy was not administered after gastrectomy. The patient is currently alive with no sign of recurrence for 30 months since the cerebral metasectomy.

We report a case of pseudoaneurysm that developed after robot-assisted gastrectomy. A 43-year-old man diagnosed with advanced gastric cancer underwent robotic distal gastrectomy with D2 dissection. Suprapancreatic nodal dissection was technically demanding due to a high body mass index, but the operation was completed without any intraoperative problems. On postoperative day (POD) 3, abdominal contrast-enhanced CT was performed to rule out intra-abdominal infectious complications, and revealed a suspected 1-cm pseudoaneurysm near the origin of the splenic artery. An angiography showed a pseudoaneurysm of a branch of the dorsal pancreatic artery, and then coil embolization was performed. A retrospective review of the surgical video suggested that pseudoaneurysm formation may have been caused by dividing the small arteriole running from the dorsal side of the pancreas to the ventral side near the root of the splenic artery using bipolar cutting dissection with insufficient coagulation. The subsequent postoperative course was uneventful, and the patient was discharged on POD 16. This case shows that it is important to recognize that bipolar cutting dissection using Maryland bipolar forceps in robotic gastrectomy can unintentionally divide small arterioles with inadequate coagulation.

A 77-year-old man was diagnosed with ampullary carcinoma in follow-up upper gastrointestinal endoscopy after gastric cancer surgery. Pancreaticoduodenectomy was performed because distant metastasis was not found in a preoperative examination. An internal stent was placed at the site of pancreaticojejunal anastomosis during the operation. Grade B pancreatic fistula and intraabdominal abscess were found and interventional radiology was performed. Contrast-enhanced CT was performed because remittent fever was prolonged despite improvement of pancreatic fistula. CT showed that the end of the internal stent penetrated through the intestine into the portal vein, and portal vein gas and thrombosis were detected. We removed and replaced the stent in the intestinal lumen using a single-balloon enteroscope. The patient recovered after the endoscopic procedure and was discharged from hospital.

A 58-year-old man who was diagnosed with congenital protein C (PC) deficiency at 42 years old and with a family history of this condition visited a previous hospital due to appetite loss. A CT scan revealed a 25-mm cystic tumor in the uncinate process of the pancreas. The portal vein and superior mesenteric vein had thrombotic occlusion, forming a remarkable collateral vein in the hepatoduodenal ligament. The cystic tumor was found to have grown to 53 mm in a CT scan after 5 months. Further examination was then performed at our hospital. The patient was diagnosed with intraductal papillary mucinous carcinoma and underwent pylorus-preserving pancreaticoduodenectomy. The collateral vein in the hepatoduodenal ligament was preserved. Activated PC (15,000 unit/day) concentrate was continuously administered for 24 hours from just before surgery. Unfractionated heparin was continuously administered before and after administration of the activated PC concentrate. A small thrombus was seen in the collateral vein of the hepatoduodenal ligament after surgery, but the patient was discharged 36 days after surgery without liver failure or intestinal congestion. Here, we report the first case of PC deficiency treated with administration of activated PC concentrate during the perioperative period of pancreaticoduodenectomy. This report will be informative for perioperative management of cases with PC deficiency.

Diffuse malignant peritoneal mesothelioma (DMPM) is usually considered to be unresectable in Japan, and chemotherapy based on that used for malignant pleural mesothelioma is selected. However, since DMPM is localized in the abdominal cavity and rarely causes metastasis before the terminal stage, peritonectomy has been reported as an effective treatment strategy. The patient was a 64-year-old man with chief complaints of abdominal distention and edema of the lower limbs. Abdominal CT showed a large amount of ascites and thickening of the peritoneum and greater omentum. DMPM was diagnosed based on cytology of ascites. Total peritonectomy with resection of the rectum, ileocecal region, spleen, and gallbladder, construction of ileostomy, and intraoperative chemotherapy were performed. Intraoperative findings revealed small, disseminated lesions on the peritoneum, mesentery of the small intestine and colon, and greater and lesser omentum (peritoneal cancer index=26, completeness cytoreduction=0). Postoperative complications were diarrhea and delayed gastric emptying (Grade 2), and the patient was discharged on postoperative day 45. Postoperative adjuvant chemotherapy was not administered. Dietary intake and skeletal muscle depletion were improved. A repeat cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were performed for recurrent tumors that were observed one year and ten months after the total peritonectomy. The patient was then followed up at the outpatient clinic.

A 28-year-old male visited our hospital complaining of mild abdominal pain and nausea since the previous day. CT revealed intussusception of the ascending colon into the transverse colon without findings of peritonitis or perforation. Emergency laparoscopic ileocecal resection was performed with the intent to release intussusception. However, reduction of intussusception under laparoscopy was an arduous procedure. During the operation, numerous soft polypoid masses in the colonic submucosa were observed, and a diagnosis of pneumatosis cystoides intestinalis (PCI) was made. The affected portion of the colon was removed during ileocecal resection. Analysis of the resected specimen revealed PCI as the possible cause of intussusception. The postoperative course was uneventful and the patient was discharged on the 7th postoperative day. If diagnosed early based on typical radiographic (CT) features, PCI can be conservatively managed with treatment options including oxygen therapy. For cases requiring surgical treatment, laparoscopic surgery is recommended since this allows radical cure with minimal invasiveness, which permits early rehabilitation and return to normal life.

A 68-year-old man was diagnosed with Cronkhite-Canada syndrome (CCS). He was treated with drug therapy, mainly using steroids, for 3.5 months without success. The patient was managed with oral nutrition and a proton pump inhibitor (PPI) for transit disturbance caused by edema of the terminal ileum due to polyposis. After sudden exacerbation of right-sided abdominal pain, emergency surgery was performed with a diagnosis of upper gastrointestinal perforation. In addition to filling the perforated portion of the anterior wall of the duodenal bulb with the great omentum, the ileum was resected and ileostomy was performed. Postoperatively, CCS symptoms were improved by administration of steroids and anti-TNF-alpha antibody, and the PPI was changed from intravenous to oral immediately after surgery, with no recurrence of duodenal ulcer. This case suggests that surgical resection of the main lesion only should be considered for patients with intractable CCS.

We report a case of renocolic fistula caused by xanthogranulomatous pyelonephritis. A 65-year-old woman underwent abscess drainage for left perinephric abscess associated with renal stone. Her condition improved, but three months after drainage she was hospitalized due to relapse of perirenal abscess. Abdominal CT showed a staghorn calculus in the left renal pelvis complicated by perinephric abscess, and percutaneous abscess drainage was repeated. On day 15 of hospitalization, a contrast study via a drainage tube revealed a fistula from the left kidney into the descending colon. The patient underwent nephrectomy combined with left hemicolectomy and en bloc removal of the site of inflammation. Microscopic findings showed infiltration of lymphocytes and foamy lipid-laden macrophages. The final diagnosis was renocolic fistula caused by xanthogranulomatous pyelonephritis. Septic shock occurred during the perioperative period, but the postoperative course was uneventful and the patient was discharged 9 days after the operation.