A 69-year-old man underwent robot-assisted distal gastrectomy with Billroth I reconstruction for gastric cancer at another hospital 3 years ago. Immediately after surgery, he began to complain of difficulty with eating due to heartburn and chest pain. The patient was referred to our hospital due to medication refractory symptoms and severe esophagitis seen on endoscopy. A 24-hour multichannel impedance pH (MII-pH) test showed an abnormal liquid reflux time rate of 23.4% (normal <1.4%) with an acid reflux time rate of 0%, indicating severe reflux of duodenal fluid into the esophagus. Since conservative treatment was not curative, the patient underwent laparoscopic reanastomosis to Roux-en-Y anastomosis. A distance of 50 cm was constructed between the gastrojejunal anastomosis and jejunojejunal anastomosis at the Y leg. The operation time was 414 minutes and blood loss was 200 ml. The preoperative symptoms were relieved and the patient was discharged home 11 days after surgery. Endoscopic follow-up performed 2 months after surgery showed that esophagitis had disappeared. We report this case as an example of use of a MII-pH test in successful surgical management of severe esophagitis after surgery for gastric cancer.

Killian-Jamieson diverticulum (KJD) is indicated for surgical resection when accompanied by symptoms such as dysphagia. We experienced a case of KJD that was successfully resected using intraoperative neural monitoring (APS-NIM^TM) and intraoperative esophagoscopy. The patient was a 64-year-old woman who presented with difficulty in swallowing. Esophagogastroduodenoscopy revealed an esophageal diverticulum. Since a proton pump inhibitor did not improve her complaint, she was referred to our hospital for further examination and treatment. A diverticulum measuring approximately 30 mm was found on the left side of the cervical esophagus. She was diagnosed with KJD and indicated for surgical treatment. We identified the left vagus nerve and attached an APS™ electrode. The esophageal diverticulum was confirmed and exfoliated. After the endoscope confirmed an appropriate diameter of the remaining esophageal lumen, the diverticulum was resected with a linear stapler. There was no abnormality in the APS-NIM^TM signal during the operation. We report this case as an example of safe resection of KJD using intraoperative APS-NIM^TM and esophagoscopy.

A 76-year-old woman visited our hospital for right hypochondrial pain and nausea. Tenderness in the right hypochondrium was found by abdominal examination. Laboratory data were almost normal. Abdominal CT revealed a stenosis of the gallbladder between the neck and body, and a swollen gallbladder with a less-enhanced area of the fundus. Gallbladder torsion was diagnosed and laparoscopic cholecystectomy was performed immediately. The gallbladder was strangulated by a string that ran from the abdominal wall to the liver, and was dark-red in color at the body and fundus. There was no torsion of the gallbladder. Finally, the patient was diagnosed with strangulated cholecystitis. We were able to perform laparoscopic cholecystectomy by resecting the string. The postoperative course was satisfactory. There are few reports of strangulated cholecystitis due to strangulation by a string. We report this case with a review of the literature.

An 81-year-old male was found to have a cystic tumor of 20 mm in diameter with calcification in the uncinate process of the pancreas on CT. The tumor increased to 33 mm in diameter over 5 years, with diffuse calcification inside the tumor. Upper gastrointestinal endoscopy showed a papillary tumor invading the third portion of the duodenal wall. Invasive intraductal papillary mucinous carcinoma (IPMC) was diagnosed and subtotal stomach-preserving pancreatoduodenectomy was performed. Pathologically, IPMC tumor cells were detected in the main pancreatic duct invading the duodenal wall. Osseous metaplasia was mainly seen in the stroma surrounding the non-invasive area of IPMC. The patient is alive with no recurrence at 7 months after surgery. We report this case with a review of the literature on etiology of osteogenesis accompanied by IPMC. Further accumulation of clinical cases is needed to improve understanding of this rare condition.

Renal transplants are increasing in Japan, but inguinal hernia surgery after renal transplantation is still rare. The patient was a 60-year-old man with a history of renal transplantation to the right iliac fossa, which was discontinued and he was managed on dialysis. The patient presented with a right medial inguinal hernia that had been repaired and was manually repatriated. Three days later, he presented with intestinal obstruction due to edema of the small intestine. There was no evidence of intestinal necrosis and the patient was treated conservatively. Thirty days after the initial visit, a laparoscopic transabdominal preperitoneal approach (TAPP) was performed. As far as we could observe, there were no abnormalities in the small intestine. The anatomy was difficult to identify because of adhesions in the preperitoneal space. Only the hernia portal was covered with mesh, and the ureter and transplanted kidney were not damaged. The Lichtenstein procedure is recommended because of its reduced dissection of the preperitoneal space, although TAPP for transplant side inguinal hernia after renal transplantation is an option for a skilled surgeon.

A 68-year-old man was admitted to another hospital due to abdominal pain. The patient was transferred to our hospital with suspected intussusception based on ultrasound showing a target sign. A tumor was not detected in endoscopic screening, but enhanced CT and abdominal ultrasound showed a 4-cm tumor near the ileum and swelling of regional lymph nodes. Laparotomy revealed the tumor and the swollen lymph nodes located approximately 50 cm proximal to the terminal ileum. Segmental resection of the ileum with lymph node dissection was performed. The pathological diagnosis was hepatoid carcinoma of the ileum. Serum carbohydrate antigen (CA 19-9) decreased from 1,179 U/ml to 78.6 U/ml at 2 months after surgery. However, portal vein tumor thrombus and recurrence of liver metastasis were detected 4 months after surgery, and the patient died 6 months after surgery. We herein report this case as a rare example of hepatoid carcinoma of small bowel cancer.

We report a case of a 62-year-old female who presented with lumbago after low anterior resection for rectal cancer with peritoneal dissemination. Blood tests had already shown disseminated intravascular coagulation (DIC). Based on spinal MRI and histopathological examination of bone marrow tissue, a diagnosis of disseminated carcinomatosis of the bone marrow (DCBM) was made, and FOLFOXIRI plus bevacizumab chemotherapy was immediately initiated. After induction, serum CEA markedly decreased and DIC gradually improved over three courses of administration, which enabled the patient to be discharged to home temporarily. However, there was little improvement in her general condition and signs of delirium appeared just before the fourth administration. Therefore, systemic chemotherapy was discontinued and replaced by palliative care. Subsequently, the patient died about three months after initiation of chemotherapy. The prognosis for patients with rectal cancer with DCBM is extremely poor, but urgent chemotherapy was transiently effective in this case. However, long-term survival was not obtained, which suggests the importance of earlier treatment intervention.

A 90-year-old man suffering from diabetes and hypertension visited a nearby doctor with a chief complaint of anal discomfort. Biopsy of the anal lesion was performed based on suspected rectal cancer, but the lesion was not found to be malignant. The patient was referred to our department for surgery due to rapid progression of ulcerative necrosis and anal pain. A movable type 2 tumor that partially protruded from the anus at about 11 o’clock was found by digital examination. Abdominal CT revealed enhancement of the anal lesion. Although malignancy was not shown by biopsy, laparoscopic abdominoperineal resection with D2 lymphadenectomy was urgently performed due to continued suspicion of rectal cancer based on strong anal pain and the wishes of the patient. The resected specimen revealed a 5×5 cm ulcerative lesion with a circumferential ridge protruding from the anal canal to the anal verge. Immunohistologically, the definitive diagnosis was Epstein-Barr virus-positive mucocutaneous ulcer. The patient has survived without recurrence for 30 months after surgery. We present this case as a rare example of EBV-MCU arising in the anal canal and caused by age-related reduction in immune function.