Purpose: There is no consensus on the optimal waiting period between percutaneous transhepatic gallbladder drainage (PTGBD) and cholecystectomy for acute cholecystitis. We evaluated the relationship of waiting period with surgical difficulty, and examined the optimal waiting period. Materials and Methods: Associations of surgical difficulty with waiting period and other factors were retrospectively evaluated in 85 patients who underwent cholecystectomy after PTGBD in our hospital. For endpoints that suggested involvement of the waiting period, cutoff values for the waiting period were set between 2 and 8 weeks, and the detection power was evaluated with ROC curves. Factors associated with the selected waiting periods were examined. Results: The waiting period was significantly longer in patients with automatic suture closure or reconstitution of the gallbladder neck, intraoperative perforation of the gallbladder, an intraoperative finding of mass formation in the gallbladder neck, and an operation time ≥120 min. An cutoff of a waiting period of 3 weeks was identified for the optimal predictive power of these four factors. Patients with a waiting period >3 weeks had more severe cholecystitis, more residual inflammation of the gallbladder, and more frequent mass formation in the gallbladder neck. Conclusion: Many cases of severe cholecystitis require a waiting period. Careful surgical manipulation and postoperative management are still required after this period because the surgical difficulty is likely to remain high.

A 65-year old man was diagnosed with esophageal cancer cStage II and underwent neoadjuvant chemotherapy and subtotal esophagectomy. Anastomostic leakage was observed on postoperative day (POD) 7, and blood sampling revealed a marked increase in inflammatory reaction on POD 10. Chest CT revealed pleural effusion in the right thoracic cavity and empyema was diagnosed. Bronchoscopy revealed three perforations of the membranous trachea on POD 14, and emergency surgery was conducted for cervical esophagostomy, exclusion of the gastric tube, and fenestration. After this surgery, differential lung ventilation was performed with a double lumen tube and two ventilations. The perforations epithelized and extubation was possible 44 days after the emergency operation. Thoracoplasty was performed on POD 94 (after the initial surgery), followed by esophageal reconstruction by free jejunal autograft on POD 153. The patient was discharged on POD 196. We report this case as an example of a successful surgical strategy and postoperative management for perforation of the membranous trachea.

An 83-year-old woman had been followed up after radical resection for ascending colon cancer. Five years after the operation, she underwent contrast-enhanced CT, which revealed a 14-mm tumor in S5 and S4 of the liver with mild contrast in the arterial phase and weaker contrast in the portal venous phase compared to the hepatic parenchyma. Laparoscopic S5/S4a segmentectomy was performed under a diagnosis of hepatocellular carcinoma or metastatic tumor. Histopathological examination showed lymphoepithelioma-like carcinoma of the liver. One year later, CT showed a 43-mm lymph node in the hepatoduodenal ligament. Endoscopic ultrasound biopsy revealed metastasis of lymphoepithelioma-like carcinoma. Radiotherapy was administered to the lymph node recurrence since there were no other metastatic sites. After completion of radiotherapy, the tumor showed a complete response and the patient has been disease-free for 6 months. Lymphoepithelioma-like carcinoma of the liver is extremely rare. A treatment strategy has not been established and further accumulation of cases is warranted.

A 80-year-old man was admitted to our hospital with a diagnosis of choledocholithiasis and underwent endoscopic retrograde cholangiopancreatography. Stone removal with a basket failed and the wires of the basket fractured and impacted in the common bile duct, together with the stone. The patient was referred to our department because of the difficulty of retrieval of the impacted basket from the common bile duct. Open surgery was performed, in which we first tried to remove the basket through a longitudinal choledochotomy, but this was unsuccessful. Next, a papillary bougienage was performed and the basket was successfully released. A T-tube was inserted and the choledochotomy was closed. Impaction of the basket during endoscopic removal of common bile duct stones occurs in 0.8–5.9% of cases. In these cases, papillary bougienage may be a safe and effective method for basket removal.

The patient was a 15-year-old female who was diagnosed with intestinal obstruction after visiting a family doctor due to abdominal pain and distension. The patient was subsequently referred to our hospital. Our diagnosis was colon volvulus because of dilation of the right colon and the presence of a whirl sign on abdominal CT. Endoscopic detorsion of the colon was performed. In reconstructed 3D CT, the sigmoid colon ran along the midline of the abdomen and the descending colon was twisted 270º in a clockwise direction toward the organo-axis. The diagnosis was descending colon volvulus due to persistent descending mesocolon. Due to repeat torsions, a transanal ileus tube was inserted to decompress the intestines and prevent torsion, and elective laparoscopic fixation of the descending colon was performed. Adhesions were dissected between the sigmoid colon that ran along the midline and the mesentery of the small intestine. The left colon was sutured to the left abdominal wall to form the splenic flexure and S-D junction. There was no recurrence at 6 months after surgery. We report this case of laparoscopic colon fixation for descending colon volvulus due to persistent descending mesocolon with a review of the literature.

A 56-year-old woman underwent total colonoscopy (TCF) at another hospital in 2013. A 0-Isp polyp was found in the descending colon and resected by endoscopic mucosal resection (EMR). The polyp was diagnosed as adenoma histopathologically, but it was difficult to evaluate the resection margin because of split excision. Four months later, TCF revealed recurrence of adenoma at the scar from EMR. Although additional treatment was recommended, the patient stopped going to the hospital. In 2017, she underwent another TCF and a type 1 lesion was found in the recurrence region. She was referred to our hospital and underwent left hemicolectomy with D3 lymph node dissection. The tumor was diagnosed as adenosquamous carcinoma with an adenoma component (T1b (SM massive), N0, ly0, v0, fStage I). The patient did not receive postoperative adjuvant chemotherapy and survived without recurrence for 49 months. Adenosquamous carcinoma of the colon with an adenoma component is very rare. We report this case with a review of the literature.

An 84-year-old woman presented with perianal skin redness. Histopathological examination of skin biopsy revealed Paget’s cells, and colonoscopy indicated rectal cancer. Thus, pagetoid spread of rectal cancer was diagnosed. Robot-assisted abdominoperineal resection of the perineal skin lesion was performed. A further histopathological examination revealed that Paget’s cells were not contiguous with rectal cancer cells, and anal gland adenocarcinoma was thus identified. The immunohistochemical staining pattern of the pagetoid spread (CK20+/CK7+) was consistent with that of the anal gland adenocarcinoma (CK20+/CK7+), rather than with the rectal cancer (CK20+/CK7–). Therefore, we ultimately diagnosed pagetoid spread of anal gland adenocarcinoma. Anal gland adenocarcinoma is rare and difficult to detect in the early stage because the lesion is not exposed on the mucosal surface. Since anal gland adenocarcinoma was latent in the present case, a detailed immunohistopathological examination was necessary to diagnose the origin of the perineal Pagetoid spread accurately.