An 82-year-old woman underwent laparoscopic hiatal hernia repair for a giant hiatal hernia type IV seven years ago. The size of the crural defect was extremely large and thus, we performed a relaxing incision on the left side of the diaphragm to allow tension-free crural closure. The left-sided relaxing incision was closed, and then the cruroplasty was reinforced with a mesh that also covered the closed relaxing incision. A few years after surgery the patient began to complain of dyspnea, and in the sixth year after hiatal hernia repair, home oxygen therapy was introduced by a family physician. CT showed that the intestinal tract had markedly prolapsed into the left thoracic cavity through a diaphragmatic defect positioned along the left side of the hiatus, compressing the left lung. Iatrogenic diaphragmatic hernia secondary to disruption of the closure of the relaxing incision was suspected, and laparoscopic diaphragmatic hernia repair was performed. The hernia orifice was approximately 10 cm and was firmly adhered with the prolapsed intestine. The herniated organ was reduced and mesh reinforcement repair with closure of the orifice was performed. No evidence of recurrent diaphragmatic hernia was seen 15 months after surgery. We report this case as an example of diaphragmatic hernia caused by a diaphragmatic relaxing incision.

A 75-year-old man underwent endoscopic treatment for squamous cell carcinoma of the thoracic esophagus, and then received palliative care for recurrent lung metastases, adrenal metastases, and peritoneal dissemination. He complained of abdominal pain and vomiting, and was diagnosed with duodenocolic fistula after abdominal CT and upper gastrointestinal tract radiography. Abdominal pain and vomiting symptoms were temporarily relieved by conservative treatment with fasting, gastric tube placement and antibiotic administration, and he was able to ingest orally, but the symptoms recurred within one month. We determined that the duodenocolic fistula was resistant to conservative treatment, and gastrojejunal anastomosis and separation surgery of the right-sided colon were performed as palliative surgery. There were no severe complications and the patient was able to eat at 3 months after surgery. This case indicates that gastrojejunal anastomosis and separation surgery of the right-sided colon are useful as palliative surgery for duodenocolic fistula from the perspectives of safety and quality of life.

The patient was a 21-year-old female who had undergone extrahepatic bile duct resection via Roux-en Y choledochojejunostomy for congenital biliary dilatation at age 10. Eleven years after the surgery, she visited our hospital with a chief complaint of epigastric pain. Blood tests revealed an elevated inflammatory response, and CT showed a 50-mm cystic lesion in the pancreatic head, leading to a diagnosis of residual intrapancreatic cholangitis. Based on the previous surgical findings, we considered that inadequate resection of the dilated bile duct was the cause, and performed a residual dilated bile duct resection. In the operation, a thinned pancreatic parenchyma in front of the residual dilated bile duct was dissected to identify the residual bile duct. The intrapancreatic residual bile duct was removed just above the confluence of the pancreatic ducts. The standard treatment for congenital biliary dilatation is resection of the extrahepatic bile duct and biliary tract reconstruction. This case shows that inadequate resection of a dilated bile duct may result in postoperative bile duct inflammation and carcinogenesis.

An 81-year-old man was referred to our hospital for hepatic dysfunction that was identified in an outpatient visit to another hospital. Abdominal contrast-enhanced CT revealed a tumor extending from the hepatic portal region to the left hepatic duct. Thus, the patient was diagnosed with hilar cholangiocarcinoma. Before surgery, EBD tube placement was performed because of obstructive jaundice. Subsequently, pancreatitis developed. CT revealed an inflammatory thrombus from the main trunk to the right branch of the portal vein. Thrombolytic therapy through the superior mesenteric artery was ineffective, with concurrent postoperative bleeding from the papilla. Four days after thrombus formation, catheterization was performed via the ileocolic vein under laparotomy for intraportal thrombus aspiration. Thirty days after the start of thrombosis treatment, left hepatectomy and bile duct resection were performed because portal vein blood flow resumed. The patient was diagnosed with carcinosarcoma. He has survived without recurrence for three years after surgery. We herein report this case of portal thrombosis in the remnant liver, for which radical surgery was performed postoperatively.

A 25-year-old man was referred to our hospital with a chief complaint of epigastric pain. Abdominal CT confirmed small intestine dilation with caliber change near the end of the ileum and a mildly swollen appendix. Emergency surgery was performed under a diagnosis of acute appendicitis-associated intestinal obstruction. A cluster in the ileum from the base of Meckel’s diverticulum to the terminal ileum, which was encapsulated with an internal hernia sac in Treves’ field (the terminal ileum mesentery circumscribed by the ileocolic branch of the superior mesentery artery and its anastomosis with the last ileal artery) was revealed. Meckel’s diverticulum tip adhered to the ileal mesentery along the hernia orifice. The sac was incised and trimmed, and Meckel’s diverticulum was resected at its base. Treves’ field pouch hernia (TFPH) is a mesenteric pouch hernia with the orifice in Treves’ field. Our case is an example of a congenital condition in which TFPH and Meckel’s diverticulum coexisted. Including this case, there are four reports of combined TFPH and Meckel’s diverticulum, which suggests that Meckel’s diverticulum may cause TFPH.

A 72-year-old man complaining of diarrhea, fever, and abdominal pain visited a previous hospital and was hospitalized with a diagnosis of infectious enteritis. Despite medication, his symptoms did not improve and he was admitted to our hospital. CT showed extensive necrosis of the colon and an emergency operation was performed. Necrosis was observed throughout the ascending colon, transverse colon and sigmoid colon, and was partially lytic. Total colectomy and ileostomy were performed, and the patient was treated in the intensive care unit after surgery. On postoperative day 5, amoeboid bodies were detected in the pathological specimen, leading to diagnosis of fulminant amoebic colitis. Metronidazole was started, but the patient died on the same day due to acute liver failure and progression of acidemia. This case indicates that in a case of enteritis that is difficult to diagnose, it is important to start treatment as soon as possible after a thorough examination with this disease in mind.

Among bone metastases of colorectal cancer, metastasis to finger bones is extremely rare. We report a case of metastasis to the middle phalanx of the left fourth finger, which was found due to finger pain after surgery for rectal cancer. The patient was an 80-year-old woman who underwent lower endoscopy at a previous hospital due to bloody stool and was found to have a circumferential type 2 lesion in rectosigmoid colon (RSRa). A biopsy revealed adenocarcinoma, rectal cancer was diagnosed, and laparoscopic-assisted low anterior resection and transverse colon colostomy were performed. Five days after the operation, swelling and pain occurred in the left fourth middle phalanx and a fracture was diagnosed. Conservative treatment with immobilization was performed, but reassessment one month later revealed that the fracture had worsened, suggesting bone metastasis of rectal cancer. Left fourth finger amputation was performed for pain control and definitive diagnosis. Pathological findings led to diagnosis of adenocarcinoma, which was considered to be a metastasis of rectal cancer. The patient had a performance status of 4 and decreased activity, and was transferred 70 days after the rectal cancer surgery. Ten months after diagnosis of the fracture, she is still alive. Amputation of the affected finger relieved pain and improved QOL.

Purpose: Palliative surgical bypass can be performed for biliary obstruction or gastric outlet obstruction due to pancreatic head tumor. The aim of the study was to investigate the safety and efficacy of laparoscopic bypass including cholecystojejunal anastomosis and gastrojejunal anastomosis (hereinafter referred to as double bypass). Methods: Short- and long-term postoperative outcomes were retrospectively evaluated in 10 patients who underwent laparoscopic double bypass between April 2014 and March 2021. Results: The median age was 73 years and the most common primary disease was pancreatic head cancer, which was present in 8 cases. Obstructive jaundice and gastric outlet obstruction were found in 3 and 7 cases, respectively, and improved in all cases after double bypass. One patient had a postoperative complication of Clavien-Dindo grade IV. The median postoperative survival time was 6.4 months, and no patients required additional postoperative treatment for restenosis of the bile duct or gastroduodenum. Conclusions: Laparoscopic double bypass is safe and could be an option for palliative treatment.