[Background] Recently the usefulness of outpatient drainage treatment for pneumothorax with Thoracic Egg^® (TE) has sometimes been reported, but few reports have discussed the indications of TE. [Methods] We enrolled consecutive 150 patients who were placed TE in our outpatient clinic from August 2005 to March 2014 and studied the usefulness, safety, and indication criteria of TE. [Results] A median age was 31 years, ranging from 14 to 81. The ratio of primary onset to recurrent cases was 99 : 51. There were nine mild, 133 moderate, and eight severe cases. The outpatient management with TE was accomplished in 94.0% (141/150) of all patients. The total days when TE outpatient drainage management was done amounted to 600 days, showing the successful rate of TE outpatient management to be 82.1% (600/731). Nine outpatients were shifted to inpatients on the day when TE was just placed. There were four cases of pulmonary collapse which progressed, one case of bilateral pneumothorax, one case of vagovagal reflex, and three other cases. [Conclusion] By using TE outpatient drainage management for pneumothorax, we were able to manage such patients in our clinic for 82.1% of the total treatment days. Careful attention for the safety might enable us to use TE even for patients with severe pneumothorax and for aged ones. Our created criteria for the indications of TE are generally available.

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In recent years, the prosthetic repair of incisional hernias has drastically reduced the incidence of recurrence. However, when a prosthesis is placed intraperitoneally, there is a risk of intestinal adhesions and injury as well as recurrence caused by incomplete coverage of the suprapubic hernia defect by the intraperitoneal mesh. Therefore, here we introduce a preperitoneal mesh repair technique (PMR) for abdominal incisional hernias.
Sixty patients underwent this technique between April 2005 and April 2014.
The median operating time was 100 minutes.
Two cases of recurrence (3.3%) and one wound infection (1.7%) occurred. However, no cases of mesh infection occurred. Other complications occurred in seven cases, but all recovered conservatively. Our findings suggest that this PMR is a feasible operative technique for incisional hernias.

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Here we report our laparoscopic surgical techniques for hydrocele of the canal of Nuck in seven adult patients treated in our department between April 2008 and December 2014. The median patient age was 46 years (range, 24-83 years). Four cases involved lesions on the right ; three cases involved lesions on the left. The median inguinal lesion bulge was 3 cm (range, 2-5 cm) and the median maximum peritoneal hydrocele on computed tomography and ultrasonography was 2.4 cm (range, 1-3 cm). The operation was performed with patients in the supine position under general anesthesia with three trocars inserted into the extraperitoneal cavity (as with inguinal hernia surgery). Delamination of the peritoneal hydrocele, as in the case of an inguinal hernia, was accomplished with relative ease. The mean operating time was 97 minutes (range, 85-119 minutes). In all cases, blood loss was minimal and no postoperative complications were observed. Equally important, no hydrocele or hernia recurrence was observed. Our findings show that total extraperitoneal laparoscopic hernia repair for hydrocele of the canal of Nuck is an effective procedure.

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A 35-year-old woman presented to her neighborhood clinic with a painful mass in her right breast that had persisted for two weeks. Surgical abscess drainage was performed. She also reported noticing a painful and reddish swelling on her left ankle. As her symptoms did not improve and walking became increasingly difficult due to the pain in the lower limb, she was referred to our hospital and admitted. The symptoms persisted despite administration of antibiotic therapy. As the results of CNB of the breast suggested the diagnosis of granulomatous mastitis, the lesion on her leg was suspected to be panniculitis or erythema nodosum. The patient was started on oral prednisolone at 30 mg/day, which led to rapid improvement of the mastitis as well as marked improvement of the leg lesion. The prednisolone dose was gradually tapered and finally, the drug was discontinued at approximately 20 months. The patient required a long duration of therapy due to the risk of recurrence of granulomatous mastitis. The patient has since suffered no relapses.
We report this rare case of granulomatous mastitis with concurrent panniculitis, with a discussion of the relevant literature.

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A 66-year-old woman with a 3-year history of left breast pain visited our hospital after noticing a gradual increase in pain. A 15-mm mass with good mobility was palpable in the AC area of the left breast, and no axillary lymph node swelling was observed. Mammography (MMG) showed a Category-4 mass shadow with indistinct boundaries in the left AC area. Ultrasonography showed an indistinct, hypo-to-iso echoic, 14-mm mass in the left AC area, with HALO sign and interruption of the anterior boundary mammary gland. As a result, a Category 5 lesion was diagnosed, and either papillary ductal carcinoma or scirrhous carcinoma was suspected. A strong, non-uniform contrast effect was observed peripherally on contrast-enhanced ultrasonography. Core needle biopsy (CNB) diagnosed adenoid cystic carcinoma, and left breast-conserving surgery and sentinel lymph node biopsy were performed. Pathological findings showed the formation of large and small nests with a trabecular arrangement, and invasive adenoid cystic carcinoma was diagnosed. Vascular components were abundant at the tumor edges, and the strong contrast effect at the edges from contrast-enhanced ultrasonography was consistent with these histopathological findings.

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A 57-year-old woman underwent breast-conserving therapy for left breast cancer (T₁N₁M₀) in February 2008. She received tamoxifen as postoperative adjuvant therapy. In March 2010, she noticed several subcutaneous tumors on her chest and back, which were histopathologically confirmed to be metastatic carcinomas. Subsequent CT examination also revealed hepatic and bilateral adrenal metastases. She was admitted to our hospital with severe vomiting and diarrhea in July 2014. These symptoms quickly improved with non-specific therapy after four days in the hospital. However, the patient presented again to our hospital with a history of loss of appetite, easy fatigability, and body weight loss of 12.6 kg over the previous two months. Addison's disease was suspected based on the observation of marked hyperpigmentation on the patient's face, hands and circumoral area. Her general condition improved dramatically with hydrocortisone replacement therapy. Adrenocorticotropic hormone (ACTH) stimulation did not increase the blood cortisol concentration. Although adrenal metastases are often detected in advanced breast cancer patients, the possibility of Addison's disease should be considered in those with bilateral metastases.

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A 64-year-old woman was referred to our department of breast surgery because of redness and swelling in the right breast. She had received chemotherapy for lung cancer (cT1aN3M1b) for 17 months. A contrast-enhanced CT showed enlargement of the right axillary lymph nodes, and thickening of the skin and edematous subcutaneous tissue in the right breast. However, no mass was evident in the breast. We performed a skin biopsy of the breast for making a definitive diagnosis, because her symptoms looked remarkably similar to those of inflammatory breast cancer. Histopathological examination revealed that the malignant cells were spreading to the subcutaneous adipose tissues, with evidence also of invasion of the lymphatic vessels. Immunohistochemical analysis of the cancer cells showed positive staining for TTF-1 and negative staining for ER. Based on these findings, the patient was diagnosed as having a rare form of metastatic lung cancer mimicking inflammatory breast cancer. Although the patient received additional chemotherapy, she died 27 months later because of the primary disease.

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A 67-year-old female was referred to our department because of an anterior mediastinal mass shadow on MRI performed during surveillance of her multiple hepatic hemangiomas. The nodule was 16mm in diameter partially enhanced with contrast enhanced CT scan. The lesion was depicted by the MRI scan as an iso-intensity area in T1WI, a slightly high intensity area in T2WI, and a marked high intensity area in short T1 inversion recovery (STIR), in comparison to muscular tissue. MRI scan also showed multiple high intensity areas in the thoraco-lumbar vertebrae, and each lesion was suspected of hemangioma. Furthermore, multiple skin hemangiomas were seen in the face, neck, truncus, and extremities, and blue rubber bleb nevus syndrome (BRBNS) was suspected based on these findings. Therefore, while we decided to operate on the patient with a suspicion of thymoma, a possibility of thymic hemangioma could not be ruled out. As a consequence of thymectomy, the nodule was pathologically proved thymic hemangioma. Additionally, postoperative gastrointestinal endoscopy and brain MRI pointed out hemangiomas in the esophagus and cerebellum, thus we diagnosed her multiple hemangiomas as BRBNS. There are few reports of BRBNS with thymic hemangioma, and the present case seems to be rare.

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A 55-year-old man was referred to our hospital for detailed examination and management of a pulsatile abdominal mass. Abdominal CT revealed an abdominal aortic aneurysm measuring 16 cm in diameter, associated with left hydronephrosis. Emergency abdominal aortic replacement was performed because of the huge size of the aneurysm, elevated inflammatory reactions, and renal dysfunction. Intraoperatively, extensive chronic white thrombus formation was observed within the aneurysm, with no evidence of rupture of the wall of the aneurysm. The clinical course was uneventful and the patient was discharged on the 25th postoperative day. This report documents a rare case of an unruptured abdominal aortic aneurysm measuring 16 cm in diameter, associated with left hydronephrosis.

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The patient was a 68-year-old woman who presented to our hospital because of a traffic accident in May 2011, when a chest CT scan revealed an about 7-mm diameter nodule in the segment 10 (S¹⁰) of the left lung. Bronchoscopy and percutaneous fine needle biopsy of the nodule which showed a gradually enlarging tendency failed to make the definite diagnosis. The patient was referred to our hospital for the purpose of surgery in April 2014. A chest CT scan showed a tumorous lesion 46 mm in diameter in the S¹⁰ of the left lung. FDG-PET scan revealed an abnormally high uptake of FDG at the same area. Since a possibility of primary lung cancer could not be ruled out, thoracoscopy-assisted left lower lobectomy was performed. Intraoperative frozen section diagnosis reported the presence of severe infiltration of plasma and lymphatic cells and the absence of malignant findings. The final histopathological diagnosis was inflammatory pseudotumor.
Preoperative diagnosis of pulmonary inflammatory pseudotumor is difficult in many cases and surgical resection first offers the precise diagnosis in not a few cases. This paper deals with our case of pulmonary inflammatory pseudotumor which had enlarged during a 3-year observation period and was so difficult to differentiate from lung cancer that required surgical resection, together with a review of the literature.

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Retroperitoneal leiomyosarcoma is a rare tumor of the soft tissue and metastasizes relatively early after the resection of primary lesion. We experienced a case of retroperitoneal leiomyosarcoma which metastasized to the lung six years after the resection of the primary lesion.
A 76-year-old woman who had undergone surgical resection of a 4.5-cm right retroperitoneal leiomyosarcoma 7 years earlier consulted us due to a nodule in the right lung detected on a chest computed tomography scan. It appeared as a tumor of 4 mm in diameter 6 years after the primary operation and gradually. We performed a video-assisted thoracoscopic surgery for the diagnosis and therapy and resected the tumor of 8 mm in diameter in the right lower lobe. Histopathological examination revealed growth of pleomorphic smooth muscle cells which were immunohistochemically positive for α-smooth muscle actin and desmin. Therefore pulmonary metastasis of the retroperitoneal leiomyosarcoma was diagnosed. No recurrence has been found for 6 months after the pulmonary resection. Pulmonary metastasis of retroperitoneal leiomyosarcoma with a long disease free interval is rare. There are various clinical courses for leiomyosarcoma and further recurrence may occur in the future. Follow-up observation would be mandatory.

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We report a case of intractable costal osteomyelitis. A 61-year-old woman who had been treated with insulin therapy for diabetes since 15 years earlier presented with right hypochondralgia. CT examination revealed a pericostal abscess combined with osteolytic change of ribs. Osteomyelitis with pericostal abscess was diagnosed. Drainage and lavage under local anesthesia was ineffective. Resection of ribs and the abscess cavity under general anesthesia was performed. However, the patient experienced several recurrences, and eventually she underwent the resection of the thoracoabdominal wall and diaphragm including the lesion and musculocutaneous flap transposition using abdominal rectus muscle. The patient's postoperative course was uneventful.

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A 79-year-old man fell down while walking and landed on his upper left abdomen. The next day, he was diagnosed with a left 12^th rib fracture. Sudden abdominal pain and nausea occurred 6 days after the injury for which he was taken to the emergency room. Computed tomography showed contrast extravasation from the spleen and a massive hemoperitoneum. A hemothorax in the left side of the chest was also observed. In a state of hypovolemic shock, he poorly responded to rapid fluid infusion and blood transfusion, then underwent a splenectomy in the diagnosis of delayed splenic rupture. Perioperative searching revealed an omental traumatic diaphragmatic hernia. Neither a chest wall injury nor lung damage was seen, and the diaphragmatic defect was sutured.
Delayed splenic injury accounts for 0.3-1.7% of blunt splenic injuries, while traumatic diaphragmatic hernia comprises 0.8-1.6% of blunt trauma cases, making it a relatively rare disease. Here we described a case of delayed splenic rupture with traumatic diaphragmatic hernia. Prompt surgery resulted in a good outcome.

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A 65-year-old woman who underwent an operation for right breast cancer six years earlier and had been recurrence free was introduced to our hospital because PET-CT scan revealed an abnormal FDG uptake on the upper esophagus. Gastrointestinal endoscopy showed a submucosal tumor and upper gastrointestinal series showed a 35mm-sized smooth defect on the anterior wall of the upper thoracic esophagus, where was 25 cm distant from incisors. Endoscopic ultrasonography revealed a 35×15mm hypoechoic tumor connected to the fourth layer of the esophagus and fine needle biopsy revealed c-kit(+). She was diagnosed as having esophageal gastrointestinal stromal tumor (GIST) and underwent thoracoscopic operation. We approached through 5 ports from the right side of the chest with the patient in the left lateral decubitus position. After we performed enucleation of the tumor which had extramurally grown, the esophageal wall was closed by continuous suture. She was discharged on the 9^th day after the operation uneventfully. Pathological findings showed KIT positive, MIB-1 index of less than 5%, and low risk GIST by Flecher classification. Esophageal GIST is rare and there are few reports about thoracoscopic operation in Japan. We present the case with some literature review.

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A 67-year-old man underwent video-assisted thoracoscopic subtotal esophagectomy with three-field lymphadenectomy and reconstruction using a gastric tube through retrosternal route for superficial lower thoracic esophageal cancer. He received adjuvant chemotherapy with 2 courses of 5-fluorouracil+cisplatin combination chemotherapy (FP therapy) because of histological multiple lymph node metastases. One year and three months after the surgery, mediastinal and abdominal lymph nodes recurrence developed. Chemoradiotherapy (5 courses of FP therapy + radiotherapy at 60 Gy) was administered, and he achieved a complete response (CR). Two years and 10 months after the surgery, multiple pulmonary metastases appeared. He achieved a CR with seven courses of 5FU/Nedaplatin therapy. Four years and 9 months after the surgery, a relapse to the abdominal lymph nodes was discovered. Despite resumed 5FU/ Nedaplatin therapy, tunnel vision and wobbling were observed. A head CT scan showed a solitary neoplastic lesion in the left occipital lobe, and a craniotomy tumorectomy was performed. The pathological diagnosis was brain metastasis from esophageal cancer, so stereotactic irradiation was performed. Subsequently, weekly paclitaxel therapy achieved a CR and the therapy was interrupted. The patient remained in good condition without any evidence of recurrence, as of 6 years and 10 months after the first diagnosis of relapse. Through appropriate multidisciplinary therapy for the recurrent lesions, long-term survival has been achieved in the patient.

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A 55-year-old woman who presented to our hospital because of dyspnea was found to have thickening of the wall from the upper to the middle thoracic esophagus which strikingly compressed the left bronchus. Endoscopic upper gastrointestinal series showed a type 2 lesion encircling one-thirds of the circumference of the esophagus where was 20 cm apart from the incisor tooth. Advanced esophageal cancer cT4 (bronchus) N2M0 Stage IV a was diagnosed. Since her bilateral bronchi had become narrower to cause dyspnea, a Y-shaped silicon stent was placed at the tracheal bifurcation to conserve the airway. After respiratory remission was gained, chemoradiotherapy was performed. Although the tumor had shrunk, the patient developed an esophagotracheal fistula two months after initiation of chemoradiotherapy. Accordingly an esophageal stent with a cover was placed there. During a month after she had tracheal and esophageal double stents, she lived usual daily life without particular problems at home, but she died of recurrent bouts of pneumonia and progression of cancer on the 228^th day after the placement of double stents. We present a case of a patient with advanced esophageal cancer whose performance status (PS) improved and oral ingestion became possible after the placement of tracheal and esophageal double stents, together with a review of the literature.

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Herein we report a case of rapidly increased peritoneal metastases of esophageal cancer soon after preoperative chemoradiotherapy, together with review of the relevant literature. A 72-year-old male patient was admitted to the hospital because he felt to get something stuck in his throat. Radiographic examination showed type 2 esophageal cancer (moderately differentiated squamous cell carcinoma) with upper mediastinal lymph node metastasis (cT3N1M0 cStage III). In our treatment plan, chemoradiotherapy (chemotherapy : cisplatin and 5- fluorouracil, radiotherapy : 41.4 Gy/23 Fr) preceded radical surgery. The main tumor and the metastatic lymph node remarkably decreased in size after the therapy (ycT3N0M0 ycStage II). Fever developed 2 weeks after completion of the preoperative treatment and an abdominal computed tomography revealed several masses around the duodenum, the omentum and the peritoneum. Those masses were diagnosed as peritoneal dissemination of the esophageal cancer by laparoscopic examination and we performed gastrojejunal bypass as palliative surgery. He did not hope to receive adjuvant chemotherapy. His general condition deteriorated, and he died of cancer six weeks after the operation. Although peritoneal dissemination of esophageal squamous cell carcinoma is very rare, the examination to rule out a possibility of peritoneal dissemination should be considered.

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The patient was an 82-year-old man who had been admitted for close examinations of abdominal pain three times during five years, but the cause of the abdominal pain was still obscure. This time the patient visited a neighboring hospital because of the similar abdominal pain when an abdominal simple x-ray examination revealed large quantities of intraabdominal free air. Then he was transferred to our hospital. Exploratory laparotomy with a diagnosis of gastrointestinal perforation revealed a minute perforating site at the lesser curvature of the upper body of the stomach. Local resection of the stomach was performed. Based on findings of the resected material, we diagnosed the case as valvular pneumoperitoneum probably caused by the minute ulcerative lesion.
A condition, in which free air escapes from a minute gastrointestinal perforating site into the abdominal cavity but the reflex of air is not allowed due to the surrounding tissue which serves as a valve to contribute to the development of pneumoperitoneum, is designated vavular pneumoperitoneum. There may be some cases of recurrent valvular pneumoperitoneum which has not been correctly diagnosed. This case was eventually diagnosed by laparotomy, suggesting that surgical treatment can be useful for cases of recurrent intraabdominal free air of unknown cause.

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The patient was a 53-year-old woman presenting with the chief complaint of abdominal pain. She had previously undergone laparoscopy-assisted pylorus-preserving gastrectomy (PPG) for gastric cancer. A gastrointestinal barium series showed no evidence of stenosis or obstruction of the small intestine, and the contrast flowed smoothly out to the colon. The patient was therefore instructed to resume oral intake however, the abdominal pain became worse thereafter. A repeat CT performed under this condition revealed a low-density mass with a sponge-like appearance in the small intestine. A re-evaluation of the first CT revealed a similar mass even at a different site in the abdominal cavity. She was diagnosed as having food-induced ileus, and a laparoscopy-assisted operation was performed. Adhesion formation was minor, and extraction of the obstruent was performed, which was eventually confirmed to be a persimmon bezoar. The incidence rate of phytobezoar following PPG is known to be relatively high, however, as the pylorus is preserved in patients undergoing PPG, a phytobezoar is unlikely to cause small bowel obstruction. We encountered a rare case in which laparoscopy-assisted procedures were performed for both PPG and treatment of a small bowel obstruction caused by a bezoar developing after PPG.

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A 13-year-old girl with no remarkable history who had experienced acute abdominal pain and hematemesis was brought to our hospital in shock. Abdominal computed tomography (CT) showed a large quantity of fluid and free intraperitoneal air. We started CPR based on a diagnosis of pan-peritonitis due to perforation of the digestive tract, but she was unable to be revived. Autopsy revealed two ruptured parts of the anterior wall at the fundus of the stomach showing necrosis, and the gastric wall was very thin just around the ruptured area. This case is unusual and the cause of gastric rupture is unclear. Here we report a case of spontaneous rupture of the stomach in a young girl.

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A 77-year-old man with no significant past medical history visited our hospital with a history of abdominal distention, anorexia and vomiting. An abdominal X-ray revealed small-bowel distention, and the patient was able to consume only liquid, but not solid food. Initially, we attempted conservative therapy by intravenous hyperalimentation and enteral feeding, but no improvement was noted. Eventually, we diagnosed the patient as having a small-intestinal tumor and scheduled treatment by operation. The intraoperative findings included a thin-walled, distended small-intestinal segment measuring 150 cm from Treitz's ligament, which was resected. Histopathology revealed AL amyloid deposits in the wall of the resected intestinal segment. Bone marrow examination revealed monoclonal gammopathy of undetermined significance (MGUS). Japanese guidelines on amyloidosis recommend chemotherapy for AL amyloidosis. However, we decided against chemotherapy for our patient, as he had been able to resume normal oral intake following the surgery alone. Moreover, he had no other severe organ disorder and expressed the fear of side effects of chemotherapy on his quality of life. At present, 3 years since the surgery, the patient remains free of symptoms. Thus, for cases of small intestinal amyloidosis, surgery can represent a useful treatment option, and chemotherapy may not be needed.

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Blind loop syndrome is a recognized complication of intestinal anastomosis that often occurs at side-to-side anastomotic sites. Here we report a case of blind loop syndrome affecting a functional end-to-end anastomotic site following sigmoidectomy. The patient was a 66-year-old woman who underwent laparoscopic sigmoidectomy at another hospital. Reconstruction was performed with the creation of a functional end-to-end anastomosis (semi-closed method). Four years and four months postoperatively, the patient presented at our hospital with the chief complaints of a lump in the left lateral region, abdominal pain, and constipation. The anastomotic region of the intestinal tract had expanded into a sac-like shape. A large fecal mass was incarcerated within. The patient was diagnosed with blind loop syndrome following the creation of a functional end-to-end anastomosis. Intestinal resection including the anastomotic region was performed with reconstruction of the end-to-end anastomotic region using manual suturing. Since blind loop is a known complication affecting functional end-to-end anastomosis following laparoscopic colectomy, physicians should consider blind loop syndrome in patients complaining of postoperative stool abnormalities.

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Surgical intervention is recommended for severe Clostridium difficile-associated disease (CDAD), and the mortality rate is high, at 24-80% in operated patients. An 82-year-old man developed diarrhea after treatment for community-acquired pneumonia with antibiotics. He was then diagnosed with pseudomembranous enteritis and was prescribed metronidazole, but the patient was admitted to our hospital because of severe abdominal pain and distension. Bloody bowel discharge was seen after hospitalization, white blood cell count was increased, and the patient met the criteria for SIRS with megacolon on computed tomography. Pseudomembranous enteritis was seriously worsening compared to the above, and we decided to perform emergency surgery. Left colectomy was performed and an artificial anus was prepared with transverse colon. Septic shock and Disseminated intravascular coagulation (DIC) developed transiently after surgery, but he recovered and achieved an excellent prognosis with some anti-DIC treatments.

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We report our experience with a rare case of spontaneous mesenteric hematoma, along with a discussion of some of the literature. A 56-year-old man visited our hospital in November 2014 complaining of sudden abdominal pain and vomiting. Visual inspection and palpation showed abdominal distension and tenderness of the entire lower abdomen. Contrast-enhanced computed tomography (CT) of the abdomen revealed a hematoma measuring about 10 cm in the sigmoid mesocolon, and signs of contrast extravasation were observed. Angiography showed signs of contrast extravasation from a vasa rectal of the sigmoid colon. Coil embolization was attempted, but proved difficult, thus surgery was performed. Laparoscopic observation showed collection of a large amount of blood in the abdominal cavity, and the sigmoid mesocolon was markedly swollen because of the hematoma. Identifying a bleeding point laparoscopically was difficult, so we converted to laparotomy. When the hematoma in the mesentery was removed, hemostasis by ligation was performed because active bleeding from the vas rectum was observed. The intestinal wall had thinned and succumbed to ischemia, so partial resection of the sigmoid colon and Hartmann's procedure were performed. Histopathological examination did not reveal vascular lesions or malignant findings, and spontaneous mesenteric hematoma was diagnosed.

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Here we report a case of ascending colon tumor in a patient with situs inversus totalis treated by laparoscopy-assisted colectomy. A 56-year-old woman was referred to our hospital for a positive fecal occult blood test. She was diagnosed with a laterally spreading tumor at the ascending colon. Chest radiography and computed tomography (CT) revealed situs inversus totalis. We performed a laparoscopy-assisted colectomy with no serious complications. The tumor was pathologically diagnosed as well differentiated adenocarcinoma, fTis(M), fN0, fH0, fM0, fP0, fStage 0. Preoperative three-dimensional CT findings provided useful information such as tumor location and its relationship with the feeding arteries that enabled us to perform laparoscopic surgery safely in a patient with situs inversus totalis.

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A 66-year-old woman visited our hospital because of right flank pain. Computed tomography (CT) revealed a cystic mass with some enhanced areas, located between the liver and ascending colon. As she had multiple liver cysts, the mass was suspected to be one of the liver cysts, with intracystic hemorrhage. Several days later, repeated CT revealed that the cystic mass had become smaller and closer to the ascending colon. The CT also revealed thickening of the wall of the transverse colon. Colonoscopy was performed, thereby an advanced cancer of the transverse colon was found. Right hemicolectomy was performed. The specimen showed a type 4 tumor, 33×30 mm in diameter, SE with depth of invasion, mainly with poorly differentiated adenocarcinoma. The cystic mass was revealed as to be an intramural hematoma, 35 mm in diameter, located from the subserosal space to the submucosal layer of the ascending colon. Cancer cells were also found in the subserosal space of the hematoma. The transverse colon cancer implanted to the ascending colon and thus might cause hemorrhage in the intramural space of the colon. Intramural hematoma of the colon is rare and mostly caused by trauma or bleeding. We report an extremely uncommon case of intramural hematoma associated with colon cancer.

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A 75-year-old woman with loss of appetite and nausea underwent lower endoscopy, revealing a type 2 lesion with half the circumference raised in the sigmoid colon. Sigmoid colon cancer was diagnosed. Preoperative three-dimensional computed tomographic angiography (3D-CTA) showed the presence of a horseshoe kidney and three extra renal arteries-in the left kidney from the left common iliac artery, in the right kidney from the right common iliac artery, and at the isthmus from 3 cm under the inferior mesenteric artery branch of the aorta. The preoperative diagnosis was clinical stage cT3 colon cancer (SS), Circ, type 2, cN0, cH0, cP0, cM0, cStage II, and laparoscopic sigmoid colectomy was performed. Consulting the images from preoperative angiography allowed safe performance of the surgical procedure. To prevent intraoperative misidentification, 3D-CTA needs to be implemented preoperatively to ascertain the precise positional relationships between the extra renal arteries and inferior mesenteric artery, and the kidney.

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A 54-year-old woman underwent laparoscopic high anterior resection for recto-sigmoidal cancer. Follow-up ultrasonography 2 years after surgery revealed a nodule on the inward side of a port-site wound of the former operation. It showed slight accumulation (standardized uptake value, 1.4) on combined positron emission tomography and computed tomography (PET-CT). The diagnosis was peritoneal metastasis at the port site. The nodule was resected by using laparotomy because no other lesions were found. Microscopic findings of the nodule showed an anisakiasis in the necrotic tissue with neutrophilic infiltration. Because extragastrointestinal anisakiasis is a rare disease and may have no symptoms, preoperative diagnosis is quite difficult. Clinicians should be attentive of this disease as a possible cause of nodule accidentally discovered on ultrasonography or PET-CT.

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A 72-year-old man was admitted to our hospital complaining of hematochezia. Colonoscopic examination revealed a cancer in the lower rectum. Computed tomography revealed para-aortic lymphadenopathy and stenosis of the left ureter. We performed loop colostomy to avoid intestinal obstruction. Postoperatively, leukocytosis continued without any evidence of infection. Serum levels of granulocyte-colony stimulating factor (G-CSF) were noted to be elevated (280 pg/ml). Immunohistochemical study showed positive staining for G-CSF in tumor cells of a metastatic lymph node. We determined that the cancer was producing G-CSF. We initiated chemotherapy (FOLFOX6 and bevacizumab), but his general condition deteriorated and he died 2 months after surgery.

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A 77-year-old man who visited neighboring hospital because of epigastric pain lasting from August 2010 was referred to our hospital with a suspected diagnosis of acute cholangitis in the same August. Blood analysis revealed no increases in hepatic function indicators and biliary enzyme levels, but showed inflammatory findings. Magnetic resonance cholangiopancreatography (MRCP) and abdominal contrast-enhanced CT scan showed slight dilatation of the intrahepatic bile duct and stricture of the common bile duct, but demonstrable tumor shadow was absent. Endoscopic retrograde cholangiopancreatography (ERCP) failed to visualize the gallbladder, suggesting the stricture of the common bile duct to be due to extramural compression. Three-dimensional integrating images using MD-CT and DIC-CT confirmed that the cystic artery compressed the common bile duct dorsad. Since a possibility of malignancy could not be ruled out completely for cholecystitis, cholecystectomy under laparotomy was performed in September 2010. Intraoperative findings were compatible with 3D integrating images. The histopathological diagnosis was chronic cholecystitis.
It is very rare that the cystic artery causes extrahepatic bile duct stricture like in this case, and no cases have been reported in which preoperative 3D-CT successfully diagnoses the disease. This case is thus reported here, with a review of the literature.

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A 77-year-old woman with a history of chronic hepatitis C with cirrhosis was referred to our hospital for surgical treatment of hepatocellular carcinoma. Laboratory data indicated fibrinolytic activated disseminated intravascular coagulation (DIC), and enhanced computed tomography revealed dissecting thoracoabdominal aortic aneurysm. We continued antifibrinolytic therapy with nafamostat mesilate in the perioperative period, using fibrin, fibrinogen degradation products and plasmin α2 plasmin inhibitor complex as indexes. During antifibrinolytic therapy, DIC improved and the postoperative course was uneventful.
We successfully and safely performed hepatectomy in a patient with fibrinolytic activated DIC with perioperative antifibrinolytic therapy.

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A 55-year-old female presented with a 1-day history of abdominal pain, ever since she had been kicked in the abdomen by her husband, and was admitted to the hospital. Contrast-enhanced abdominal CT showed contrast leaking from the wall of the gallbladder into the lumen, and she was diagnosed as having intra-gallbladder bleeding resulting from blunt abdominal trauma. There was no evidence of rupture of the gallbladder or other injuries, therefore, she was managed non-operatively. Delayed cholecystitis occurred on the sixth hospital day and open cholecystectomy was performed. She was discharged six days later after an uneventful postoperative course. Intra-gallbladder bleeding without rupture caused by blunt abdominal trauma is a rare condition ; only a few cases have been reported, most of which were treated surgically. In some recent cases, non-operative therapy has been used, with good outcomes. However, as in the present case, delayed cholecystitis and biliary obstruction due to hematoma may occur. Resection must be considered in the event of delayed cholecystitis complicating the clinical course. Herein we report an extremely rare case of blunt traumatic intra-gallbladder bleeding not associated with rupture of the gallbladder.

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A 61-year-old man was emergently admitted to the hospital with a diagnosis of acute obstructive suppurative cholangitis. Endoscopic drainage was unsuccessful and percutaneous transhepatic cholangiodrinage (PTBD) was performed. Cholangiography revealed stricture of the distal bile duct and cytodiagnosis of bile juice revealed positive. Distal bile duct cancer was thus suspected and subtotal stomach-preserving pancreatoduodenectomy was performed. The stricture of the bile duct was histopathologically considered to be caused by hyperplasia of the bile duct epithelium, but in a part of the hyperplasia we confirmed findings suggestive of carcinoma in situ. There have been very few reports describing cancer change of hyperplasia of the bile duct epithelium in Japan. This might be a precious case suggesting the process in which bile duct carcinoma arises from hyperplasia of the bile duct epithelium.

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The patient was an 87-year-old man. Computed tomography (CT) performed 8 years prior revealed a cystic lesion 2 cm in size in a branching duct in the intraductal papillary mucinous neoplasm (IPMN) on the anterior surface of the pancreatic body. At this time, he was admitted for sudden upper abdominal pain. His laboratory data showed marked increases in white blood cell count and C-reacted protein level. Enhanced CT revealed a multilocular cystic lesion with a dirty fat sign at the pancreatic body and large amounts of ascites. We conducted an emergency operation under the diagnosis of peritonitis caused by rupture of the IPMN. Laparotomy findings indicated large amounts of dirty ascites and omental bursa with pus. Intraoperative ultrasonography revealed a 3-cm multilocular cystic lesion in the pancreatic body, connected to the omental bursa. Abdominal drainage and distal pancreatectomy were performed. The pathological diagnosis was noninvasive intraductal papillary mucinous carcinoma. As IPMN rupture is rare, we present this case along with a literature review.

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A 71-year-old man visited a referring physician with the chief complaint of abdominal pain, and was hospitalized with a diagnosis of obstructive pancreatitis due to tumor. When endoscopic retrograde cholangiopancreatography showed active bleeding from the papilla of Vater, he was referred to our hospital for detailed examination. Images showed a hypervascular mass measuring 30 mm in the pancreatic head. Anemia had progressed, and embolization was performed on the inferior pancreaticoduodenal artery. Suspecting pancreatic cancer, we performed pancreatoduodenectomy and D2 lymph node dissection. Macroscopic findings from the resected specimen showed a cystic mass measuring 4.2×2.3×2.0 cm. Upon histopathological examination, the background was found to comprise branch duct intraductal papillary mucinous neoplasm (IPMN). We observed papillary adenocarcinoma infiltrating the pancreatic duct and pancreatic parenchyma, as well as fibrosarcoma-like cells. Pancreatic carcinosarcoma occurring within branch duct IPMN was therefore diagnosed. We report our experience with a very rare case of pancreatic carcinosarcoma, and include a discussion of some of the literature.

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A 52-year-old woman who complained of epigastralgia, backache, and anorexia was referred to our hospital. Abdominal computed tomography revealed a 14-cm hypervascular, lobulated tumor in the whole pancreas. A filling defect suspected to be a tumor thrombus was observed in the splenic and omental veins. In addition, tumor infiltration into the superior mesenteric vein, left renal vein, and left adrenal gland was suspected. We made a diagnosis of pancreatic neuroendocrine tumor and performed total pancreatectomy with lymph node dissection. We also resected the portal vein, left adrenal gland, and left kidney. Pathohistological examination revealed that the tumor was an acinar cell carcinoma of the pancreas. The postoperative course was generally uneventful. Although no recurrence was found 14 months later, continuous careful follow-up was necessary.

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Here we describe a case of a 76-year-old man with a spermatic cord abscess. The patient was admitted to our hospital for the further examination of fatigue. Laboratory tests showed leukocytosis (12,030/μL) and an elevated C reactive protein level (16.6 mg/dL). Contrast-enhanced computed tomography (CT) demonstrated an encapsulated fluid collection 6×3 cm in diameter with peripheral enhancement in the right hemipelvis suggestive of an intrapelvic abscess. CT performed 2 months earlier revealed a dilated and enhanced right ductus deferens, and we retrospectively suspected deferentitis. According to these findings, we diagnosed the patient with a spermatic cord abscess and initiated conservative therapy with antibiotics. However, the patient did not respond to the antibiotics and open surgical drainage of the abscess was performed on the 4^th hospital day. On the 18^th hospital day (14^th postoperative day), white blood cell count and C reactive protein level were elevated again ; however, both gradually declined without the administration of antibiotics. The patient was discharged on the 27^th hospital day (23^th postoperative day). Here we report a very rare case of spermatic cord abscess.

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We report a case of mixed-type retroperitoneal liposarcoma consisting of three different histological types. A 58-year-old man was admitted to our hospital with the chief complaint of abdominal distension. Computed tomography (CT) and positron emission tomography (PET)-CT revealed a giant tumor occupying almost the entire abdominal cavity. Retroperitoneal liposarcoma was suspected and surgical resection was performed. The tumor was 30 × 20 × 15 cm in size and weighed 4,100 g. The pathological diagnosis was mixed-type retroperitoneal liposarcoma, consisting of well-differentiated, myxoid, and pleomorphic types in almost equal proportions. The present case was studied because of the rarity of retroperitoneal liposarcoma comprising three different histological types.

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We report a rare case of transmesocolonic hernia in the mesentery of the transverse colon. A 92-year-old woman, with no history of abdominal surgery, was urgently transferred to our hospital due to abdominal pain and vomiting. Abdominal CT scan revealed an expanded intestine prolapsed in the mediastinum which had compressed the heart. The mesentery of the prolapsed intestine showed edematous change so that the prolapsed intestine was considered to be strangulated by the esophageal hiatus. Small intestine gastrographin contrast examination revealed complete obstruction at about 20 cm distal to the Treitz ligament. We diagnosed the case as internal hernia and performed emergency operation. An oval defect approximately 3 cm in diameter in the mesentery of the transverse colon was found. A part of the jejunum was incarcerated into the defect and the incarcerated intestine was prolapsing through the esophageal hiatus. The incarcerated intestine was released, when no ischemic change was seen. No intestinal resection was needed. The closure of the transmesocolonic hernia was carried out. Esophageal hiatus was 6 cm in diameter and had no relation to the obstruction of the intestine. Postoperative course was uneventful. Transmesocolonic hernia is a comparatively uncommon internal hernia and we sometimes encounter clinical reports in the literature. This case is very rare because an incarcerated intestine was prolapsing through the esophageal hiatus.

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A 63-year-old man underwent laparoscopic transabdominal preperitoneal (TAPP) repair of a right inguinal hernia in August 2013. He returned to the clinic in October 2013 with bulging in the right inguinal region. Computed tomography revealed abscess formation at the surgical site, and postoperative infection was diagnosed. With no response to conservative treatment, surgery was performed in November 2013. The abscess was approached from the inguinal region, and the abscess cavity was exposed for removal of necrotic tissue and washing. The mesh was not removed, as it was not in contact with the abscess cavity. After surgery, continuous washing was performed through a drainage tube placed at the surgical site, but the abscess did not resolve. Laparoscopic mesh removal was subsequently performed in January 2014. The mesh was found to be firmly adhered to the surrounding tissue and extra effort was needed for removal. Wound infection resolved rapidly after surgery and no relapse of hernia has since been noted. Details of this rare case of post-TAPP mesh infection that was successfully treated by laparoscopic mesh removal are reported and accompanied by a review of the literature.

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