A 49-year-old man presented to the emergency department with a complaint of epigastric pain. A CT scan showed a diverticulum-like structure in the upper body of the stomach and surrounding free air. He was treated conservatively with a diagnosis of gastric diverticular perforation. After discharge from hospital, upper gastrointestinal endoscopy revealed an ulcer in the diverticulum, which was biopsied and diagnosed as gastrointestinal stromal tumor (GIST). Laparoscopic resection of the gastric diverticulum was performed. Histopathological examination revealed a thin and flat distribution of GIST in the submucosa of the entire gastric diverticulum, suggesting that a flat-type GIST had occurred within a gastric pseudodiverticulum. Such flat GISTs have been reported in the colon, but only rarely in the stomach. When a gastric diverticulum is found, it is important to keep in mind that it may be complicated by a flat GIST, and close observation is required.

A 75-year-old man was referred to our hospital after a CT scan revealed a 20-cm mass in his stomach. Endoscopic examination revealed a gastric submucosal tumor. Pathological examination of biopsy tissue showed spindle-shaped cells that were CD117-positive, CD34-positive, S100-negative, and desmin-negative. The patient was diagnosed with a gastrointestinal stromal tumor (GIST). Neoadjuvant chemotherapy with imatinib mesylate was initiated because CT showed that the tumor had invaded the liver and diaphragm. The tumor shrunk to 11 cm after 7 months, but had not shrunk further at 11 months, at which time we decided to perform resection. However, because the tumor was no longer invading the liver and diaphragm, partial gastrectomy and splenectomy were performed. Pathological examination of the resected specimen revealed highly pleomorphic mesenchymal atypical cells that differed from those in the preoperative biopsy tissue, and CD117 and CD34 were both negative. The tumor was diagnosed as pleomorphic sarcoma dedifferentiated from GIST. We report this case as a rare example of dedifferentiated GIST and we provide a literature review.

We report two cases of metachronous colorectal metastasis after curative resection of early gastric cancer. Case 1 was a 66-year-old man who underwent distal gastrectomy at age 57 years, with pathological findings of T1a (M), tub2>tub1, N1, Ly0, V0, pStage IB. Eight years and five months after surgery, the patient visited our hospital with a chief complaint of abdominal pain. The preoperative diagnosis was duodenal invasion of carcinoma of the transverse colon or colorectal invasion of papillary carcinoma of the duodenum, and radical surgery was performed. Postoperative pathological examination revealed metastasis of gastric cancer. Case 2 was a 77-year-old man who underwent distal gastrectomy at age 75 years, with pathological findings of T1b2 (SM2, 1,700 μm), tub2> por, N1, Ly1, V0, pStage I/IB. Two years and one month after surgery, the patient visited our hospital because of positive fecal occult blood. Colonoscopy revealed an Isp polyp in the descending colon, which was diagnosed as gastric cancer metastasis by pathological examination. Contrast-enhanced CT also showed bone metastasis. The patient is currently receiving chemotherapy.

A 61-year-old woman with a complaint of anemia presented with a flat elevated lesion located in the middle jejunum accompanied by an ulcer at the top of the lesion on oral double-balloon endoscopy. She underwent laparoscopic resection of the jejunum. Pathological findings showed inflammatory cell infiltration and partially lobulated and mildly ectatic capillaries, indicating pyogenic granuloma. Iron deficiency anemia was improved after the operation. Pyogenic granuloma is granulomatous hemangioma that is generally seen in the skin and oral cavity, but rarely in the digestive tract. Pyogenic granuloma can cause obscure gastrointestinal bleeding because it is hemorrhagic.

The patient was a 66-year-old man on maintenance dialysis for chronic renal failure due to Fabry’s disease. Due to worsening of empyema after partial lung resection performed for right lung cancer, small intestine perforation and panperitonitis developed during systemic management in the intensive care unit. The patient was referred to our department and emergency surgery was performed for small intestine perforation of unknown cause. Intraoperative findings showed perforation of the small intestine about 200 cm from the ligament of Treitz, perforation from the mesenteric side into the abdominal cavity, and significant intraperitoneal contamination. A 20-cm length of the small intestine was resected and the remaining intestine was washed and drained. Ileostomy was then performed. The resected specimen showed multiple ulcers on the mucosal surface, one of which was perforated. Immunohistopathological examination revealed cells that were positive for cytomegalovirus (CMV) in the ulcer area, leading to diagnosis of small intestinal perforation due to CMV infection. Gastrointestinal perforation due to CMV infection is rare, but should be considered in immunocompromised patients. Early diagnosis and treatment are particularly important.

Spontaneous esophageal perforation, which is a rupture of the whole layer of the esophageal wall due to an increase in esophageal pressure, is a critical disease with high mortality. The standard procedure for treatment of spontaneous esophageal perforation is surgery with conventional thoracotomy, but some recent reports have described surgery with thoracoscopy or laparoscopy. We reviewed 5 cases of spontaneous esophageal perforation treated with laparoscopic surgery in our hospital between December 2013 and October 2018. The sites of perforation were in the left wall of the lower thoracic esophagus (n=1) and in the left wall of the abdominal esophagus (n=4). The perforated area was repaired by hand-sewn sutures and covered by the fundus of the stomach in all cases. The median operation time was 190 min and the median blood loss was 10 ml. Two cases had pleural effusion and one had pneumonia as postoperative complications, but there was no anastomotic leakage and no mortality. These outcomes indicate that laparoscopic surgery has an acceptable operation time and enables reliable and less invasive repair of the perforated area. Thus, we believe that it is a useful procedure for treatment of spontaneous esophageal perforation of the lower thoracic and abdominal esophagus.

Purpose: The aim of the study was to evaluate the safety and usefulness of interval appendectomy performed as day surgery compared with inpatient surgery. Methods: The study included 256 consecutive patients who underwent interval appendectomy at two centers over five years from January 2017 to December 2021. Patients treated with abscess drainage and pediatric patients were excluded. Outcomes and costs were compared retrospectively between patients who underwent day surgery and those who received conventional surgery. Results: There were 166 patients in the day surgery group and 90 patients in the conventional surgery group. The median operative time was significantly shorter in day surgery (35 vs. 64 min, P<0.001). All patients in the day surgery group were able to return home on the same day. The complication rate did not differ significantly between the groups (P=0.15) and there were no severe complications. The costs were approximately 290,000 yen for day surgery and 460,000 yen for conventional surgery. Conclusion: Interval appendicectomy performed as day surgery is a safe and viable procedure for indicated patients in Japan.