[Background] A purgative medicine is usually used for preoperative preparation of general thoracic surgery in Japan. We also use sennosides for preoperative patients. However, the benefit of the preparation has not been proved as yet. [Methods] In this study, we prospectively examined one hundred consecutive patients performed thoracic operations in our hospital from September 2012 to February 2013. They were divided into two groups. The first group comprised 50 patients in whom purgative medicines were given. Two out of these 50 patients rejected purgative medicines and they were excluded from the study. The other group comprised remaining 50 patients in whom no purgative medicines were given. These two groups were compared for preoperative, operative and postoperative characteristics. [Results] There were no patients who had preoperative abdominal pain, intraoperative fecal incontinence and wound infection in the groups with or without purgative preparation. However, a significantly higher stool frequency from the preoperative to operative days was noted in the group with purgative preparation (p=0.017). There were no significant differences in postoperative first flatus day, postoperative first defecation day, and postoperative complications between both groups. [Conclusions] Patients safely underwent thoracic surgery regardless of the presence or absence of preoperative purgative preparation.

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[Background] In our hospital, computed tomography (CT) has been available for use in the emergency department since 1996 and has changed the diagnosis of obturator hernia. [Methods] A total of 61 consecutive patients who underwent surgery for obturator hernia from 1973 to 2011 in our hospital were divided into the before 1995 group (n=30) and the after 1996 group. The background factors, preoperative diagnosis, surgical outcomes, and postoperative courses were compared between the two groups. [Results] The average duration of symptoms of obturator hernia was 2.8 days in the after 1996 group versus 3.2 days in the before 1995 group, with no significant difference. There were significant differences between the after 1996 group and the before 1995 group in the rate of preoperative diagnosis (93.5% vs 53.3%) and the average length of hospital stay (20.0 days vs 26.1 days). However, there were no significant differences between the groups in the incidence of bowel resection (54.8% vs 56.7%) and of complications (38.7% vs 36.7%). [Conclusion] CT scan improved the preoperative diagnosis rate of obturator hernia. However, the bowel resection rate remained unchanged because the duration of disease symptoms was not significantly different.

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To clarify the usefulness and limitations of multidetector-row CT (MDCT) for the diagnosis of acute abdomen in pediatric patients, we examined the MDCT findings and clinical medical records of 235 pediatric patients in whom MDCT had been performed as part of the investigation for acute abdominal pain at our hospital. The correct diagnosis of one of 12 diseases was made in a total of 161 cases (68.5%), including acute appendicitis (104/120 cases), intussusception (4/5 cases) and mechanical ileus (3/4 cases). On the other hand, a wrong diagnosis was made in 74 cases (31.5%), and in 17 of these 74 cases, the correct diagnosis was made based on the operative findings. MDCT is an excellent tool for detecting enlargement of the appendix and the surrounding inflammation, the position of the intussusception and thickening of the intestinal wall, and the region of obstruction and extent of dilated intestinal loops in ileus, however, it shows limited detectability of perforation of the appendicular wall, the band causing ileus, and strangulation of intestine with mild disturbance of the blood flow.

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Colorectal perforation is a fatal disorder. We hypothesized that the prognosis would be worse in patients on chronic hemodialysis because of their complications. Therefore, operated cases of colorectal perforation on chronic hemodialysis during 2006 and 2011 were investigated retrospectively. Patients' characteristics, the duration of hemodialysis, features of perforation such as the sites and the causes and the method of treatment were analyzed. In addition, the preoperative laboratory findings, onset-operation time, and prognostic scores were compared between survivors and non-survivors. Of the 10 cases identified, 6 were survivors, and 4 were non-survivors. Kidney diseases included 5 autosomal dominant polycystic kidney disease, 2 chronic glomerular nephritis, and others. Six cases were on long-term (>=15 years) dialysis. Perforation involved the left-side colorectum most frequently. The most common cause of perforation was diverticulitis. In the comparison of survivors and non-survivors, preoperative white blood cell counts were the sole significant factor affecting prognosis, but onset-operation time was also considered to be useful to predict the prognosis. In conclusion, the prognosis of colorectal perforation in patients on chronic hemodialysis was poor. Rapid diagnosis and operation before the white blood cell count decreases are still very important.

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Objective : To investigate the effects of obesity on perioperative outcomes in laparoscopic surgery for right-sided colon cancer.
Subjects and methods : The subjects were 80 patients who underwent laparoscopic surgery for right-sided colon cancer between April 2010 and December 2013. They were classified into obese and non-obese groups using a body mass index (BMI) of ≥25 kg/m² and a visceral fat area (VFA) on X-ray computed tomography (CT) of ≥100 cm² as reference values. Patient background characteristics and perioperative outcomes were investigated retrospectively.
Results : No significant intergroup differences were found for patient background characteristics or postoperative outcomes. As for surgical outcomes, operative time was significantly longer (P=0.026) and intraoperative blood loss was significantly higher (P=0.025) in the high VFA group, but no significant intergroup differences were observed by BMI classification.
Conclusion : In laparoscopic surgery for right-sided colon cancer, VFA, which reflects the amount of visceral fat, was considered a better obesity-related indicator than BMI for accurately predicting the level of surgical difficulty.

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[Objective] To clarify the therapeutic outcomes and prognostic factors of simultaneous resection of colorectal cancer and hepatic metastases. [Methods] We retrospectively examined 64 consecutive patients (1991-2010) with simultaneously recognized primary colorectal cancer and liver metastases who underwent curative simultaneous colonic and hepatic resections. Postoperative complications were examined as short-term outcomes, and recurrence and survival were examined as long term survival outcomes. [Results] Nineteen out of sixty-four patients (19/64 ; 29.7%) had Grade2 or more severe postoperative complications. Lager hepatic tumor size (>50mm) was a significant risk factor for postoperative complication. Forty-five out of sixty-four patients (45/64 ; 70.3%) had tumor recurrence, and the most common site for initial recurrence after the operation was the liver (n = 33 ; 73.3%). Three-year survival and 5-year survival rates were 66.5% and 49.2%, respectively. Multivariate analysis revealed high preoperative CA19-9 level (>37 U/ml) and lymphatic invasion of primary cancer were independent risk factors for both recurrence and survival. [Conclusion] Patients with high CA19-9 level and lymphatic invasion of primary cancer have poorer prognosis even after curability B resection. Therefore, multidisciplinary therapies, such as neoadjuvant chemotherapy or postoperative intensive adjuvant chemotherapy should be considered for these patients.

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Recently, the use of single-port access surgery in cholecystectomy and other abdominal surgeries has become safe and valid as a treatment option. However, there are few reports regarding the use of complete single-port access surgeries in hepatectomy for neoplasms. Ten single-port laparoscopic hepatectomies (SLAP-Hs) were performed in 6 cases of hepatocellular carcinoma, including patients with high-grade liver dysfunction. Patients were eligible for SLAP-H if they had solitary tumors that were 3 cm or less on the caudal surface of the liver. As a result, there was no need for additional port conversion to laparotomy, and there were no intraoperative complications. Approximately 1 month after discharge, the patients no longer had wound pain or liver dysfunction. In conclusion, SLAP-H is safe and feasible for selected candidates, including patients with high-grade liver dysfunction.

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A 61-year-old woman presented with a two-month history of general fatigue and body weight loss. She was transferred to our hospital from another hospital because her laboratory test results indicated hyperthyroidism. The left lobe of her thyroid gland was swollen, and a solitary nodule (90 × 38 mm) could be palpated in the left thyroid lobe and shift of the trachea. The patient's thyroid function tests revealed high levels of free T3 and free T4 and low TSH secretion. She tested positive for the TSH receptor antibody (third generation). A thyroid scan with 99mTc showed a diffused enlarged gland with increased uptake and greater uptake in the left nodule. On the basis of these findings, a diagnosis of Marine-Lenhart syndrome (coexistence of Graves' disease and an autonomous hyperfunctioning thyroid nodule) was made. Subtotal thyroidectomy was performed. Since immunostaining revealed positivity for type IV collagen, laminin, and MIB-1, we diagnosed this case as an unusual presentation of Marine-Lenhart syndrome with a hyalinizing trabecular tumor located in the autonomous hyperfunctioning thyroid nodule.

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A 64-year-old male was referred to our hospital with hypercalcemia and elevated serum parathyroid hormone level. Neck USG revealed two hypoechoic solid masses in the right thyroid lobe, but no swollen parathyroid glands in the normal location. ^99mTc-sestamibi (MIBI) scintigraphy revealed slight MIBI accumulation in the right thyroid lobe. Based on these findings, a diagnosis of intrathyroidal parathyroid adenoma causing primary hyperparathyroidism was suspected, and right thyroid lobectomy was performed. It was difficult to differentiate intrathyroidal parathyroid adenoma from a thyroid nodule as histopathological examination revealed that the two nodules in the right thyroid lobe showed a follicular architecture. For differential diagnosis between parathyroid adenoma and thyroid nodule, immunohistochemical staining was performed. The upper nodule revealed positive staining for PTH, negative staining for TTF-1 and negative staining for Tg expression, whereas the lower nodule showed negative staining for PTH, positive staining for TTF-1 and positive staining for Tg. Based on the findings, a conclusive diagnosis of intrathyroidal parathyroid adenoma and follicular adenoma of the oncocytic type was made.

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A 63-year-old female presented with urinary incontinence. A cystic lesion was found in the right frontal lobe by magnetic resonance imaging (MRI), and was diagnosed as old cerebral hemorrhage. Thereafter, she had memory disturbance, disorientation, hemiparesis, and gait disturbance. Computed tomography (CT) of the head showed the enlargement of the lesion and perilesional edema. The lesion was resected under the diagnosis of cavernous hemangioma by imaging means. Since the histological examination revealed metastatic adencarcinoma, CyberKnife radiosurgery was added around the resected area. Detailed search of primary lesion showed a 19 × 14 × 13 mm low density area in the right lobe of the thyroid, and it was diagnosed with papillary thyroid carcinoma by fine needle aspiration cytology. After total thyroidectomy, postoperative 131I therapy was added. One month after the surgery, recurrence of brain metastasis was pointed out by urinary incontinence. She received CyberKnife radiosurgery in the recurrent lesion. She has had no recurrence, as of 3 years after the onset of the disease.
Multimodal treatments were effective for the cerebral metastasis from papillary thyroid carcinoma which was difficult to discriminate from cavernous hemangioma.

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A case of radiation-induced breast angiosarcoma that developed following breast-conserving surgery is reported. The patient was a 53-year-old woman who presented with chief complaints of pain and subcutaneous ecchymosis in the left papillary region. She had undergone breast-conserving surgery and radiation therapy to the residual breast for breast cancer of the left breast seven years earlier. The skin in the left breast had thickened and hardened, and ultrasound examination showed small hypoechoic regions dispersed directly below the papilla, while magnetic resonance imaging (MRI) revealed densely-stained areas with irregular margins. Ultimately, secondary angiosarcoma was diagnosed based on resection biopsy. Mastectomy was performed, but because local recurrence was seen at an early stage, repeat surgery (wide resection) was performed. Paclitaxel was administered as postoperative adjuvant therapy, but because bone metastasis was observed four months later, it was switched to pazopanib, which was discontinued after four months because it was no longer effective. It is necessary to recognize radiation-induced secondary angiosarcoma as a rare but important late complication in patients who have undergone breast-conserving surgery.

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Two cases of matrix-producing carcinoma (MPC) of the breast are presented. Case 1 : A 51-year-old woman complained of a mass palpable in the left breast. Left breast cancer (T2N0M0, stage IIA) was diagnosed, and mastectomy and sentinel lymph node biopsy were performed. The histological diagnosis of the excised specimen showed pT2N0, MPC, and sn0/2, and indicated that the tumor was negative for estrogen and progesterone receptors and human epidermal growth factor receptor 2. Four courses of chemotherapy with taxotere and cyclophosphamide were administered postoperatively. Fifty-two months after the operation, the patient is alive and recurrence free. Case 2 : A 48-year-old woman complained of a mass palpable in the left breast. Left breast cancer (T1N0M0, stage I) was diagnosed, and partial mastectomy and sentinel lymph node biopsy were performed. The histological diagnosis of the excised specimen showed pT2N0, MPC, and sn(0/4), and indicated that the tumor was negative for estrogen and progesterone receptors and human epidermal growth factor receptor 2. The patient was administered 4 courses of adjuvant chemotherapy with epirubicin and cyclophosphamide plus bevacizumab followed by bevacizumab monotherapy for 1 year. Twelve months after the operation, lung, bone, and liver metastases were diagnosed. The chemotherapy regimen was changed to weekly paclitaxel ; however, the patient's condition deteriorated, and she died 18 months after the operation.

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A 46-year-old woman was referred for a mass in the left breast. She had noted the mass one year before seeking medical attention and complained of bleeding from her breast for one month prior to her visit. A dark brown mass with an ulcer and bleeding was detected at the nipple, and breast cancer was suspected. Needle biopsy was performed, and histologically the tumor showed atypical cells with melanin in the dermis, leading to a diagnosis of malignant melanoma. Computed tomography showed brain metastasis, which was associated with hemiplegia. Therefore, radiotherapy was performed for the brain metastasis. Thereafter, modified radical mastectomy and axillary dissection were performed. Although chemotherapy was administered, the patient died 14 months postoperatively due to chest wall recurrence and brain metastasis. Malignant melanoma of the nipple is extremely rare, and the details of this case contribute to our understanding of the diagnosis and therapy of malignant melanoma.

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Metaplastic carcinoma that is classified into the specific type according to “the General Rules for Clinical and Pathological Recording of Breast Cancer” is a rare malignant tumor of the breast. It is believed to resist against anticancer drugs and to carry a poor prognosis. We have experienced a case of breast cancer in which metaplastic component which was not demonstrated by preoperative needle biopsy had remained in the resected specimen.
A 43-year-old woman complaining of a lump in her right breast was diagnosed as having triple negative breast cancer. MRI showed the presence of a solid mass 31 mm in diameter in the right CD area. The pathological diagnosis was invasive ductal carcinoma, solid tubular. The clinical stage was T2N0M0, stage IIA. Sentinel lymph node biopsy performed before preoperative chemotherapy showed metastatic carcinoma from the breast cancer, pN1mic (sn) (1/4). The patient underwent four cycles of docetaxel (75mg/m²) followed by four cycles of fluorouracil (500mg/m²), epirubicin (100mg/m²) and cyclophosphamide (500mg/m²). After the chemotherapy, MRI showed the solid mass to have shrunk to 16 mm in diameter. Partial mastectomy was performed. The residual tumor was 10 × 8 × 8 mm in size. Pathological examination showed metaplastic breast cancer. We report a case of breast cancer in which metaplastic component selectively remained after preoperative chemotherapy though most parts of typical breast cancer disappeared. The patient has been free from recurrence as of 2.5 years after the operaton.

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A 51-year-old woman underwent tumor resection for an intracystic tumor in the left upper breast, followed by tumor resection for a local recurrence that later developed in the outer region ; the pathological diagnosis was benign for both tumors. Multiple intracystic carcinomas of the breast occurred from the residual breast near the site of the previous tumor resection, and mastectomy was performed. Local recurrence of intracystic carcinoma of the breast occurred three times thereafter, and tumor resection was performed. The patient was referred to our hospital for radiation therapy. Further detailed examination showed intracystic carcinoma of the breast within the pectoralis minor muscle, and it was resected following needle cytology. The surgical specimen showed a negative margin. Radiation therapy was subsequently performed. Recurrence of intracystic carcinoma of the breast within the pectoralis major muscle was observed approximately two years later. The site of recurrence matched that were the needle cytology recurrence had therefore occurred a total of six times in a span of six years and four months. Based on the pathological slides and operative notes from the first surgery, rupture of non-invasive intracystic carcinoma of the breast was suspected. In addition, the needle cytology performed for the intracystic tumor at our department may also, in a way, be regarded as a rupture. The issues suggested by the present case are reported with reference to the literature.

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A 73-year-old woman presented with hemoptysis. Although we could only see a little oral bleeding due to stomatitis, a chest CT scan occasionally showed a calcified tumor measuring 3.5 cm in longer diameter in the anterior mediastinum. Tumor markers were in normal limits. MRI showed a low intensity tumor in T1-weighted, and a high intensity tumor in T2-weighted images, and these findings were compatible with a thymoma with cystic degeneration. We performed total thymectomy with median sternotomy. The tumor 2 cm in diameter was capsulated by thymus and pericardial fat. It consisted of cystic and solid parts by palpation. Histologically it was diagnosed as cavernous hemangioma with calcification. A 1.7-cm cyst adjacent to the caudad aspect of the tumor was found, but there was no thymoma. Post operative course was uneventful and she was discharged 9 days after the operation. Cavenous hemangioma on the mediastinum is essentially rare. In this case, it was hard to diagnose the heterogeneous tumor due to the existence of neighboring cystic part and calcification, which mimicked a cystic thymoma from imagings.
In conclusion, cavernous hemangioma should be considered in differential diagnosis of a mediastinum tumor.

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An 81-year-old woman who had been treated with percutaneous radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) 15 months earlier was admitted because of abdominal pain. Computed tomography revealed a prolapsed large intestine through a defect in the right diaphragm, and emergency surgery was performed. The hernia orifice was 2.5 cm in diameter and adjacent to the HCC treated by RFA ; it was repaired by direct suture. Patients who undergo RFA for HCC should be carefully followed for possible diaphragmatic hernia, even after a long postoperative interval.

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A 50-year-old woman had been receiving chemotherapy for stage IV breast cancer of the right breast with spinal metastasis since 2008. Since the start of therapy, her height had decreased by approximately 10 cm due to a compression fracture. In 2012, the patient noticed epigastric pain, and computed tomography (CT) showed prolapsed of the transverse colon and spleen from the posterior part of the left diaphragm into the thoracic cavity. An adult Bochdalek hernia was diagnosed, and surgery was performed. Reduction of the prolapsed organs into the abdominal cavity and mesh repair were performed laparoscopically, the patient was discharged on postoperative day 4, and chemotherapy was resumed promptly. No recurrence of hernia has been seen as of 12 months postoperatively. In the present patient, the vertebral compression fracture observed during breast cancer treatment may have increased intra-abdominal pressure and caused the hernia. The case of adult Bochdalek hernia caused by a compression fracture resulting from spinal metastasis of breast cancer in which laparoscopic repair was performed and chemotherapy could be promptly resumed is presented.

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A 72-year-old woman who had undergone laparoscopic right hepatectomy for hepatocellular carcinoma was admitted due to vomiting. Abdominal CT revealed incarceration of the transverse colon in the right thoracic cavity. A diaphragmatic hernia was diagnosed, and video-assisted thoracic surgery was performed. Diaphragmatic hernia after hepatic resection is a rare and not well-described complication. Successful thoracoscopy-assisted surgery for diaphragmatic hernia after hepatectomy is reported.

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A 55-year-old woman with a previous history of esophageal diverticulum was referred to our hospital because of recurrent bouts of pneumonia. Contrast-enhanced CT scan revealed an irregularly thickening wall of the esophageal diverticulum with enhancement effect, and involvement of the left atrium of heart and the right inferior pulmonary vein was likely. Upper gastrointestinal endoscopy showed a type 3 tumor in the diverticulum, with fistulation to the lung. A biopsy offered a diagnosis of squamous cell carcinoma. We performed neoadjuvant chemotherapy (2 courses of FP regimen), followed by operation. The operative procedures included resection of the thoraco-abdominal esophagus and upper part of the stomach by right thoracotomy and laparotomy, and reconstruction through retro-sternal route using a gastric tube. Furthermore involvement of the right inferior pulmonary vein was identified and combined resection of the right lower lobe of the lung was done. Intraoperative frozen section diagnosis of the surgical margin dissected from the descending aorta was reported to be cancer negative, however, the final pathological diagnosis was cancer positive. After the operation, irradiation therapy was conducted mainly for the dissected surface from the descending aorta.
Esophageal cancer arisen in an esophageal diverticulum is rare and easily invades the surrounding tissues. We report a case of cancer in a lower esophageal diverticulum invading the right inferior pulmonary vein which was removed with combined lung resection, together with a review of the literature.

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The patient was a 71-year-old man who underwent subtotal esophagectomy by right thoracotomy with gastric tube reconstruction through retro-sternal route and lymph node dissection of three regions for cancer of the middle thoracic esophagus in 1996. Suture failure occurred after the operation, for that the anastomosed site was removed and jejunal interposition with vascular anastomosis reconstruction was performed between the cervical esophagus and the gastric tube. The patient improved and was discharged from the hospital. After radiation therapy for the tumor remnant at the left main bronchus, he had had uneventful clinical course until December 2012, when he developed a cutaneous fistula and myelitis of the sternum at the precordia where coincided with the location received irradiation. Although a radical operation was scheduled, we preceded the therapy with conservative treatments including drainage of abscess cavity, administration of antibiotics and a proton pump inhibitor, and enteral nutrition. As a result, the fistula gradually improved and he was discharged in March 2013. Thereafter until January 2014 when he died of other disease, he had been free from recurrence of symptoms.
It is frequently reported that cutaneous fistula after operation for esophageal cancer often affects patients who received irradiation therapy and requires surgery for the radical cure. As it appears rare that cutaneous fistula is conservatively cured like in our case, we here present our case.

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We report a case of successful dissolution therapy with cola for bezoars in the small intestine and the stomach. A 74-year-old man was admitted to our hospital because of nausea and vomiting. Computed tomography (CT) revealed intestinal obstruction caused by a 3-cm mass in the proximal jejunum, and he was diagnosed as having a food-induced ileus. Conservative therapy by placing a long tube into the jejunum was unsuccessful to reduce small bowel obstruction, and another CT examination suggested the mass to be a bezoar. We then performed dissolution therapy with cola injected through the long tube, and with this treatment the bezoar in the small intestine was dissolved and the small bowel obstruction improved rapidly. An upper gastrointestinal endoscopy revealed an additional 7-cm bezoar which remained in the stomach. We performed a direct endoscopic dispersion of cola to this bezoar, and softened it ; we were able to safely fracture it endoscopically. For patients with small bowel obstruction due to bezoars, early diagnosis and surgical treatment are often considered to be necessary, but in the present case, the dissolution therapy with cola-lysis through an ileus tube has been proved to be an effective and less-invasive treatment.

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Neoadjuvant chemotherapy (NAC) is considered to be effective to improve the outcomes in patients with advanced gastric cancer. We encountered three patients who were confirmed as showing pathological complete response (pCR) following gastrectomy after NAC. Two patients had clinical stage III gastric cancer, while the third had clinical stage II gastric cancer. The first two patients received NAC with four courses of paclitaxel plus cisplatin while the third patient received four courses of S-1 plus cisplatin. All of the patients were treated by D2 gastrectomy after the NAC, and remain alive without recurrence. While several phase II/III clinical trials of gastric resection after NAC for advanced gastric cancer have reported pCR rates of around 2%, we obtained a pCR rate of as high as 20% (3/15) in our series. This difference might conceivably be explained by the difference in the number of NAC cycles. Therefore determination of the optimal number of NAC cycles may be needed to obtain an optimal pCR rate and further improvement of the outcome.

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A 68-year-old male patient was detected as having gastric cancer by upper gastrointestinal endoscopy.
We also found that the patient had a right-sided round ligament, intestinal malrotation, a preduodenal portal vein, a floating gallbladder and an accessory spleen. We performed total gastorectomy with D2 lymph node dissection. The postoperative course was uneventful. We report the case, along with a review of the literature.

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A 70-year-old woman was admitted because of epigastric pain. Upper gastrointestinal endoscopy did not reveal any tumor, however, abdominal CT showed swelling of a peripancreatic lymph node, and a diagnosis of neuroendocrine tumor was made by endoscopic ultrasound-guided fine needle aspiration biopsy. PET-CT showed intense accumulation in the duodenal wall. Pancreatoduodenectomy was performed for the preoperative diagnosis of duodenal neuroendocrine tumor with lymph node metastasis. The resected specimen only had a slightly convex lesion in the duodenum adjacent to the pylorus. However, pathological examination revealed a tumor measuring 20 mm in diameter, which infiltrated into the muscular layer, and a pathological diagnosis of duodenal neuroendocrine tumor was made. The tumor failed to be detected by upper gastrointestinal endoscopy, conceivably because it was in the blind spot. We encountered a rare case of duodenal neuroendocrine tumor, which scarcely appeared as an elevated lesion despite its large size.

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A 65-year-old man was pointed out a 9 cm-sized tumor around the pancreatic head by an abdominal CT scan at a medical checkup. On contrast enhanced CT scan, the tumor was densely-stained at arterial phase, and its feeding vessel was the gastroduodenal artery. Upper gastrointestinal endoscopy revealed extrinsic pressure from the antrum to the duodenum. We could not establish a histological diagnosis because of bleeding from erosion at the superior duodenum angle disturbed to obtain a sufficient specimen. The patient was diagnosed with duodenal gastrointestinal stromal tumor (GIST) or pancreatic neuroendocrine tumor preoperatively. The tumor had grown exophytically from the second portion of duodenum, and No.13 lymph nodes were firmly attached with the posterior part of pancreatic head. We thus performed pylorus-preserving pancreatoduodenectomy. The tumor cells were positive for c-kit and duodenal GIST was diagnosed. Duodenal GIST is a tumor showing a variety of imaging findings on CT. It is the matter to distinguish duodenal GISTs from duodenal or pancreatic hypervascular tumors on CT. Furthermore it can be difficult to perform segmental resection in terms of anatomical relations with the duodenal papilla or the pancreas, so that we need to select operative method based on correct preoperative diagnosis and growth pattern of the tumor.

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A 78-year-old man without abdominal surgical history was referred to our hospital because of nausea and epigastralgia. Abdominal plain CT scan showed a low density bubbly mass and impaction in the dilated small intestine, which are characteristic of food-induced ileus. The small bowel obstruction was not resolved after decompression with a long intestinal tube. Small bowel series showed a filling defect in the small intestine located ventral to the ilium. Manual compression against the impacted round mass was carefully performed under radiographic guidance, thereby the mass was crushed to pieces and small bowel obstruction was resolved. We herein report a case of food-induced ileus treated by manual compression and manipulation under radiographic guidance. So far no such cases have been reported in Japan as far as we could review.

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Compared with intussusception in children, intussusception in adults is rare and often requires surgical treatments. With a recent progression in laparoscopic surgery, laparoscopic surgery has increasingly employed for the adult-onset intussusception.
A 45-year-old woman complaining of abdominal pain was diagnosed with enteritis following close examinations and had been treated in our outpatient clinic. However, no symptomatic remission was gained and an enhanced abdominal CT scan showed an ileum telescoping into the ascending colon with an ileal tumor at the leading edge of bowel. She was admitted to the hospital and elective surgery to reduce the intussusception by an endoscope was scheduled. On the day before surgery, intussusception occurred again and it was reduced by enteroclysis. On the next day, single port laparoscopic partial ileectomy was performed. The patient was discharged from the hospital on the seventh postoperative day. The histopathological diagnosis was Peutz-Jeghers type polyp. As she had no family history and pigmentation, incomplete type Peutz-Jeghers syndrome was diagnosed. By performing reduction of intussusception followed by elective surgery, we were able to carry out single-port laparoscopic surgery that is less invasive and has a cosmetic merit.

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A 40-year-old man diagnosed with Peutz-Jeghers syndrome was admitted to our hospital due to intestinal intussusceptions. He had a history of laparotomy for intussusception and gastrointestinal bleeding. Although the preoperative examination revealed more than 100 polyps in the intestine requiring resection, bowel resection or surgical polypectomy was assumed to be associated with short bowel syndrome or a high rate of postoperative complications. The patient underwent laparotomy and repair of the intestinal intussusceptions followed by endoscopic polypectomy via small incisions in the intestinal wall. Large polyps that were difficult to treat endoscopically were surgically resected. We successfully resected nearly 150 polyps larger than 10 mm between the duodenum and the ascending colon. Intraoperative endoscopic polypectomy is an effective and safe procedure for patients with a history of laparotomy and diffuse polyps throughout the intestine.

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Preoperative diagnosis of small bowel bleeding has conventionally been difficult, but in recent years capsule endoscopy has been applied and now contributes to making this diagnosis. We experienced a case of Meckel's diverticulum bleeding, suspected on capsule endoscopy and treated with single-incision laparoscopic surgery. A 20-year-old woman underwent upper and lower endoscopy because of melena in December 2011, but no bleeding point was detected. She had been followed up at our outpatient clinic until January 2013, when she again required hospitalization because of repeated melena. Because several studies failed to reveal a bleeding source, we suspected small bowel bleeding and performed capsule endoscopy. Capsule endoscopy revealed blood and a dip in the lumen of the ileum which was suggestive of an inlet part of Meckel's diverticulum. She underwent segmental resection of the ileum including the diverticulum by the single-incision laparoscopic surgery (SILS) technique via the umbilicus. The diverticulum showed ectopic gastric mucosa and an ulcer pathologically and Meckel's diverticulum bleeding was ultimately diagnosed. We could perform SILS as the curative surgery for Meckel's diverticulum which was suspected preoperatively by capsule endoscopy. SILS for the Meckel's diverticulum is considered to be a useful operative method for achieving radical cure and providing a cosmetic merit.

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A 59-year-old man with a continuous low-grade fever and anemia was referred to our hospital. Abdominal computed tomography showed a 7 cm tumor continuous with the small intestine. Malignant lymphoma was suspected. We scheduled an exploratory laparotomy. Six days before the surgery, the patient presented to our emergency department with sudden abdominal pain. Magnetic resonance imaging was performed, and it revealed ascites and a thickened peritoneum. A diagnosis of peritonitis was made, and an emergency operation was performed because tumor perforation was suspected. We identified a perforated ileal tumor. We resected the small intestine and removed the tumor. The tumor was diagnosed via pathology as a CD8+ and CD56+ T-cell lymphoma of the small intestine, which suggested type II enteropathy-associated T-cell lymphoma (EATL). Anastomotic leakage was found and a subsequent operation was performed. The patient then received chemotherapy. The tumor initially responded well to chemotherapy, but then progressed after 4 courses of cyclophosphamide, hydroxydaunomycin, oncovin, and prednisolone (CHOP) therapy. We initiated gemcitabine-dexamethasone-platinol (GDP) therapy and performed an autologous peripheral blood stem cell transplantation, but the patient died from complications of chemotherapy. Type II EATL is rare with a poor prognosis ; further, treatment of this disease has not been established. We report a case of type II EATL that caused small-intestinal perforation.

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A 37-year-old man was brought into a hospital because of abdominal pain when abdominal CT scan and MRI showed a 6×6×5 cm tumor in the abdomen. Two months later he presented to our hospital on referral from the previous hospital. However, there was no tumor on CT image which was taken in our hospital. Further 1 year and 3 months later he was seen at our hospital because of severe abdominal pain with high fever. Abdominal CT scan showed a 6 × 6 × 6 cm intra-abdominal tumor again. Meckel's diverticulitis was likely and we performed surgery after medical treatment for 2 weeks. There was a tumor with the size of a fist of a child in the ileum. Partial resection of the small intestine was performed. The center of the tumor became necrotic with bleeding and communicated to the bowel lumen. This tumor was diagnosed as gastrointestinal stromal tumor (GIST) of the small intestine by pathological and immunohistochemical studies. We present the case which followed such a rare clinical course as the tumor once disappeared and then presented with diverticulitis like symptoms, together with a review of the literature.

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A 43-year-old woman was admitted to our hospital due to right flank pain and vomiting. She exhibited extreme tenderness and peritoneal signs in the right flank and a mass was found. Computer tomography revealed an ileocecal lesion with a target-like appearance. Intussusception accompanied by localized peritonitis was suspected and an emergency operation was performed. During the laparotomy, we found that the base of the appendix and the ileum were partially inverted into the ascending colon. Manual reduction using Hutchinson's maneuver was performed. Since intussusception due to a tumor was suspected, an ileocecal resection was performed. Post-surgical histopathology revealed that a mass at the cecum was a thickened appendiceal root wall. We therefore diagnosed the patient with appendiceal intussusception caused by an abscess due to appendicitis.
Adult intussusception is rare and appendiceal intussusception is particularly rare. The majority of cases of appendiceal intussusception are associated with an appendiceal tumor or a fecal pellet. It is rare for intussusception to develop because of acute appendicitis. We report a rare case of appendiceal intussusception induced by acute appendicitis.

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A 56-year-old man visited our hospital with a chief complaint of right lower quadrant pain that had persisted since the previous day. Appendicitis with abscess formation was suspected based on detailed examination, and it was decided that laparoscopic appendectomy would be performed on an emergency basis. Observation of the ileocecum under laparoscopic vision showed that the adhesion with surrounding tissue was stronger than expected for an appendicitis that had developed the previous day, and it was judged necessary to also consider abnormalities other than inflammatory changes, such as cancer invasion. The operative procedure was changed to drainage surgery, and it was decided that elective surgery would be performed following detailed examination. A diagnosis of appendiceal cancer was obtained on colonoscopy at a later date, and laparoscopic-assisted ileocecal resection and D3 lymph node dissection were performed electively. Accordingly, it was possible to perform radical surgery. It was considered quite feasible that the cancer would have disseminated if it had not been suspected at the time of initial surgery and appendectomy had been performed ; the present case is thus rich in suggestions for future approaches. The present case is described with a review and discussion of the cases of primary appendiceal cancer reported in Japan.

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A 56-year-old woman who visited a neighboring hospital because of intermittent bouts of right lower quadrant abdominal pain was found to have findings suggestive of intussusception by an abdominal ultrasonography, and she was referred to our hospital. There was rebound tenderness in the right lower quadrant of abdomen. On an abdominal CT scan, colonic-type intussusception in which a segment of colon telescopes into the adjacent segment of colon was strongly suspected, but the leading point was unclear. There was ascites in the Douglas pouch and she had peritoneal sign. Since a possibility of shifting to strangulation ileus or some organic disease which might cause intussusception could not be ruled out, an emergency operation was thus performed. Laparotomy disclosed colonic-type intussusception in which the transverse colon had telescoped into the transverse colon. Maneuver reduction was possible, but we selected right hemicolectomy. Because a tumor was felt around the leading point of intussusception and the mesenteric lymph nodes had also swollen, suggesting the involvement of some organic disease. Histopathology revealed no malignant findings ; only intussusception and swelling of the bowel wall were identified. Accordingly, idiopathic colonic intussusception was diagnosed.
As idiopathic colonic intussusception in adults is extremely rare, we present this case, together with a review of the literature.

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A 60-year-old man visited our hospital due to right lower quadrant pain that had developed three months earlier. A protrusion was observed on the right side of the abdomen. A tumor or an abscess having a massive lumen communicating with the transverse colon was suspected, and surgery was performed on a semi-emergency basis. Laparotomy showed a tumor that occupied almost the entire area of the right mesocolon from the ascending colon to the transverse colon, with partial invasion into the duodemum, and many nodular peritoneal metastases were found on the tumor surface and within the abdominal cavity. Right hemicolectomy, partial duodenectomy, and gastrojejunostomy were performed. On macroscopic examination of the resected sample, the tumor was 20 cm × 15 cm in size, and a perforation, 1.5 cm in diameter, was found in the transverse colon. The histopathological diagnosis was mucinous adenocarcinoma originating in the transverse colon, cT4b(duodenum)pNXcM1a(P3), Stage IV. The patient died of the primary disease one year and six months postoperatively.
The present case is the 10th case of extramural growth-type mucinous adenocarcinoma of the colon reported in Japan. Extramural growth-type mucinous adenocarcinoma of the colon is characterized by a high incidence in the transverse colon and a low frequency of lymph node metastases.

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A 64-year-old man who was seen at the department of internal medicine in our hospital because of a 3-month history of abnormal bowel habit was detected having sigmoid colon cancer with invasion into the bladder and multiple liver metastases by an abdominal CT scan. He was referred to our department and was admitted because intestinal obstruction was confirmed. On the second day after admission, a self-expendable metallic stent was placed. Following neoadjucant chemotherapy, high anterior resection of rectum and partial cystectomy were performed. During the operation, we saw a portion about 3 cm distal to the involved area of the bladder to show a cancer invasion-like morphology. Direct invasion of the tumor was suspected and the portion including the surrounding tissues was resected. Histopathology clarified that the portion was not direct invasion of the tumor but the ulcer formed by a contact of the mucosa with the anal-side stump of the metallic stent, of which serosa surface looked like cancer invasion. In addition, the right deferent duct was clarified to be injured at the time of operation.
It is etiologically considered that the stent-relating ulcer might be caused by placement of the metallic stent with strong axial force at the flexure of the intestine in this case. This should be kept in mind as a complication relating to the metallic stent.

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A 64-year-old woman who had undergone right hemithyroidectomy for papillary thyroid cancer at the age of 46 years and total thyroidectomy for left cervical lymph node metastasis at the age of 52 years had been treated with thyroid stimulating hormone suppression therapy for lung metastasis since she was aged 57 years. She came to our hospital due to melena. Metastatic rectal cancer was diagnosed by colonoscopy and computed tomography. Because the papillary thyroid cancer was slow growing, we performed laparoscopic-assisted anterior resection to improve anemia in spite of multiple lung and right adrenal gland metastases. Papillary thyroid cancer typically has a favorable prognosis and metastasis to the rectum is extremely rare. We report a case of metastatic rectal cancer derived from a papillary thyroid cancer diagnosed preoperatively and resected by laparoscopy.

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Stenting for the portal vein may be performed to treat such problems as portal vein stenosis due to pancreaticobiliary cancer and anastomotic stenosis after liver transplantation. Recently, it has also been performed for benign portal vein stenosis. We encountered a case in which a portal vein stent was placed to treat portal vein thrombosis after completion of left hepatic lobectomy for intrahepatic cholangiocarcinoma. An 85-year-old woman was diagnosed as having intrahepatic cholangiocarcinoma in subsegment 2. We performed left hepatic lobectomy and anastomosed the portal vein branch for subsegment 8 to the right branch, because it diverged from the left branch, posing a risk of tumor invasion. Because portal vein thrombus was identified thereafter, we also performed thrombectomy and angioplasty. After the operation, portal vein thrombosis recurred and a catheter was placed in the superior mesenteric vein from the ileocolic vein for accomplishing thrombolytic therapy. While the portal vein was patent initially, it became occluded again. Therefore, we placed a stent in the portal vein, after which the portal vein thrombosis did not recur. No standard criteria for portal vein stenting have been established yet. Herein, we report our findings on portal vein stenting, with a review of the pertinent literature.

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The case of a 78-year-old man with hepatocellular carcinoma (HCC) that was implanted along the needle tract to the skin, chest wall, and diaphragm 2 years and 9 months after biopsy is reported. A needle biopsy for a 7-cm-diameter tumor was performed, and the tumor was diagnosed as HCC. Extended medial segmentectomy and cholecystectomy were performed. One year and 10 months after the biopsy, two HCC recurrences were recognized, and partial hepatectomies were then performed. Two years and 9 months after the biopsy, tumors at the skin, chest wall, and diaphragm along the needle tract and in the liver were recognized. The excisional biopsy of the skin tumor revealed that this tumor was moderately differentiated HCC. Partial hepatectomy, tumor extirpations of the chest wall and diaphragm, and mesh repair of the chest wall were performed. The resected tumors were all diagnosed as moderately differentiated HCC, and this recurrence was diagnosed as an intrahepatic recurrence with needle tract implantation by biopsy. Thereafter, 4 hepatic resections and 5 lipiodolizations (total 6 times) were performed, and sorafenib was administered for repeated intrahepatic recurrences of HCC, and this patient survived for 9 years and 1 month after the needle biopsy.
As mentioned in the HCC guideline in Japan, the indication for biopsy of a liver tumor should be carefully considered in light of the risk of tumor implantation, and long-term follow-up of patients who have undergone a biopsy should be conducted, keeping in mind the risk of needle tract implantation. Treatment plans for patients with HCC should be developed knowing that aggressive treatments such as repeated resections for HCC recurrence, including needle tract implantation, can lead to long-term patient survival.

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Dieulafoy's lesion of gallbladder is extremely rare, and little is known of its etiology. A 59-year-old male was admitted with fever, epigastralgia, and jaundice. Laboratory data showed severe inflammation, mild liver dysfunction, and obstructive jaundice. Ultrasonography showed the gallbladder tightly filled with debris, but there were no gallstones. Percutaneous transhepatic gallbladder drainage revealed intracholecystic hemorrhage. On the following day, laparoscopic cholecystectomy was performed. The gallbladder was not filled with stones or bile, but with clots. A minute ulceration of the mucosa in the body of the gallbladder was identified. Pathology showed the presence of Dieulafoy's lesion in the gallbladder.

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We report the case of an 89-year-old woman with emphysematous cholecystitis and acute obstructive suppurative cholangitis, and portal venous gas. The woman visited the hospital with the chief complaint of high fever, and was admitted for further examination and treatment. Abdominal CT showed bile duct stones, and proximal bile duct dilatation, and gas in the gallbladder wall and intrahepatic portal vein. We made the diagnosis of emphysematous cholecystitis and acute obstructive suppurative cholangitis with bile duct stones, and portal venous gas. There were several serious challenges in the treatment. Gas in the gallbladder wall meant that ultrasonography could not show the gallbladder or be used for drainage guidance. Percutaneous transhepatic gallbladder drainage was therefore avoided. Instead, we selected endoscopic retrograde cholangiopancreatography with endoscopic nasobiliary drainage. The general condition of the patient improved, and cholecystectomy was performed the following day.

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A 27-year-old-man, who was a morbidly obese man, with a body mass index (BMI) of 41 kg/m², came to our institute with epigastric pain. MRI showed swelling and wall thickness of gall bladder with stones. Laparoscopic chlecystectomy was performed successfully 4 weeks after percutaneous transhepatic gall bladder drainage. Postoperative coarse was uneventful and the patient was discharged on the second postoperative day. In the operation of an extremely obese patient, laparoscopic surgery was more useful than laparotomy. However, there are numerous problems such as preparation of operative bed or stools, preventing from deep vein thrombus or decubitus, and translation of the patient from the operation bed to the ICU bed. Also extreme obesity is responsible for difficulty of tracheal intubation, intraoperative hypoxicemia and hypotension. All stuffs including surgeons, anesthetists and nurses should discuss preoperatively about the management during operation and make a detailed plan of the operative care.

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A 55-year-old male with pain in the right upper quadrant of the abdomen was referred to our hospital for evaluation of gallstones. Pre-operative drip infusion cholangiographic computed tomography revealed a circular structure in the hilar bile duct. This biliary anomaly was diagnosed as a communicating accessory bile duct (CABD), and laparoscopic cholecystectomy preserving the CABD was performed to minimize unnecessary bile duct damage using intra-operative cholangiography. The patient was discharged from our ward with no complications.
CABD is extremely rare, but many CABD cases are reported using different terminology, such as “double cystic duct,” “double common hepatic duct,” and “double biliary duct,” suggesting that the frequency of CABD is higher than previously believed. A case of CABD is described, along with a review of the 37 previously reported cases from 2000 to 2014 in Japan and a short discussion.

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Herein, we report an extremely rare case of adenoendocrine cell carcinoma of the gallbladder. An 85-year-old male underwent high anterior resection for rectal cancer in April 2008, and was thereafter followed on an outpatient basis. In August 2011, abdominal CT showed a tumor-like mass at the fundus of the gallbladder associated with diffuse wall thickening. There were no findings suggestive of tumor invasion of the liver. Cancer of the gallbladder was strongly suspected, and cholecystectomy was performed. During the operation, a malignant tumor was detected in the cystic duct and a lymph node on the posterior surface of the pancreatic head, therefore, resection of the extrahepatic bile duct and lymph node dissection of the hepatoduodenal ligament were additionally performed. Pathologically, the tumor-like mass at the fundus was diagnosed as an adenoendocrine cell carcinoma. Some of the tumor cells of the small round cell carcinoma showed positive staining for CD56, mainly in the portion extending into the mucosal layer, while a granular-shaped well-differentiated adenocarcinoma extending into the subserosal layer. In the enlarged lymph node, the metastatic carcinoma cells showed features consistent with endocrine cell carcinoma. Three months after the surgery, the patient developed liver metastasis, and he died 14 months after the operation.

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We report a case of gastrojejunostomy that was successfully performed under endoscopic ultrasound (EUS) guidance (transgastrojejunal endosonography-guided biliary drainage). To our knowledge, no such case has been reported in the literature. Six years previously, we had performed pancreaticoduodenectomy in an 82-year-old man for treating distal extrahepatic cholangiocarcinoma, after which he received chemotherapy with gemcitabine. He then underwent follow-up examinations in our hospital for 5 years postoperatively, during which no recurrence was observed. After 5 years, he was hospitalized due to fever, fatigue, and elevated levels of serum bilirubin, transaminase, and C-reactive protein. Abdominal computed tomography showed a liver abscess and a cystic lesion adjacent to the porta hepatis. Double-balloon endoscopy and cholangiography during percutaneous transhepatic cholangial drainage showed that the cystic lesion was an expansion of the free end of the jejunum caused by the isolated recurrence of cholangiocarcinoma at the anastomotic site of the hepaticojejunostomy. Thus, we performed gastrojejunostomy under EUS guidance using the rendezvous technique, and the patient recovered from jaundice. We believe that EUS-guided gastrojejunostomy is a minimally invasive and useful biliary drainage technique in patients who have previously undergone pancreaticoduodenectomy.

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A 75-year-old man presented to a neighboring hospital because of abdominal pain was referred to our hospital with a diagnosis of intestinal obstruction. Abdominal CT scan showed a multilocular giant cyst in the abdominal cavity which had compressed the intraabdominal organs toward the right, at where part of the small intestine had swollen. Intestinal obstruction due to the giant cystic tumor was diagnosed and the patient was operated on. The tumor was present at the retroperitoneum and had replaced the intestine ventrally. As the tumor involved the left kidney, combined resection of the left kidney was performed. The resected specimen involved a 30 × 28 cm multilocular cystic tumor. The histopathological diagnosis was lymphangioma. It is believed that many retroperitoneal lymphangiomas grow slowly, but there are some lymphangiomas which show a relatively rapid growth like in this case. Careful selection of therapeutic methods would be mandatory.

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A 60-year-old man was referred to our hospital because of a left lower abdominal mass with pain. Abdominal computed tomography demonstrated a left abdominal tumor with the size of 12 cm in diameter bordering another retroperitoneal tumor with the size of 4.6 cm in diameter on the right side. After treating inflammation with antibiotics, surgery was performed for diagnosis and treatment. Intraoperatively, the left abdominal tumor was pedunculated from the retroperitoneal tumor which appeared to be a lipoma and the pedicle twisted. After dissection of the pedicle and removal of the left abdominal tumor, the remained retroperitoneal tumor was resected as much as possible. The left abdominal tumor weighed 920 g and the pathological specimens showed both tumors to be retroperitoneal lipoma. Retroperitoneal lipoma, especially pedunculated one, is very rare. We report a case of torsion of a pedunculated retroperitoneal lipoma, together with a review of the literature.

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A 63-year-old woman who had been visiting a local physician due to diabetes and hypertension decided to discontinue her visits seven months earlier. Then, about 10 days earlier, she began to experience right-sided abdominal pain and saw a local physician. Abdominal contrast-enhanced computed tomography (CT) revealed a massive retroperitoneal abscess, based on which the patient was referred to our hospital. CT examination showed a retroperitoneal abscess with a maximum diameter of 24 cm from below the right side of the diaphragm into the pelvis. No findings of appendicitis, diverticulitis, or pancreatitis were seen, and no tumor lesions were detected. No clear images of free air were seen in the abdominal cavity, and there were no findings of urinary tract infection. The patient was diagnosed with primary retroperitoneal abscess, and laparotomy was performed for drainage surgery. Intraoperatively, the retroperitoneum was incised for drainage, and a drainage catheter was placed. Subsequently, antibiotic administration and drainage treatment were continued, and the patient recovered. This rare case of primary massive retroperitoneal abscess in which drainage was performed by laparotomy is reported.

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A 67-year-old male patient was admitted to our hospital with lower left abdominal pain. The patient had undergone herniorrhaphy by direct Kugel repair for a left inguinal hernia approximately 8 years previously at another hospital. An abdominal computer tomography scan revealed a non-enhanced mass in the lower left abdomen. Based on the results, the patient was diagnosed with a retained surgical sponge and laparoscopic surgery was performed. The intra-abdominal tumor was covered by hard peritoneal fascia and old gauze was present inside. The old gauze was removed using the trans-abdominal pre-peritoneal technique. There were no surgical complications.

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