[in Japanese]

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Pleomorphic carcinoma of the lung is a rare histologic type. It was proposed in the third edition of the 1999 WHO histologic classification of lung tumors. It is non-small cell lung carcinoma and at least more than 10% of the tumor comprises spindle and/or giant cells which are components of sarcoma. It is believed to carry poor prognosis. We made a study of 15 cases diagnosed as pleomorphic carcinoma of the lung among 389 cases operated on for lung cancer in our hospital between October 2007 and March 2014. The male-to-female ratio was 12 to three. The median age was 65 years, ranging from 54 to 83. Recurrence was noted in ten out of the 15 patients, and six of the ten patients died of this disease. The median time from the operation to the recurrence was 107 days, ranging from 17 to 301 days, in the ten recurrence patients. Nine out of the ten patients experienced recurrence within 6 months after the operation. Two patients have been disease-free for more than two years. One of them had locally advanced carcinoma, and in all two patients, lymph nodes have not been involved.
Although pleomorphic carcinoma of the lung is a tumor with poor prognosis, there are some cases in which even locally advanced pleomorphic carcinoma can be expected to have favorable prognosis as long as lymph node metastasis is negative.

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Background : The prognosis of patients with locally advanced or initially unresectable (so-called “initially resection-ineligible”) biliary tract carcinoma is poor, and the long-term survival can usually not be expected in unresected cases. Some reports revealed that salvage surgery following chemoradiation therapy might offer prolonged survival, however, the prognostic impact of salvage surgery is still under debate.
Methods : The patient background, preoperative therapy, perioperative results and R-status were evaluated in 3 cases of locally advanced or initially resection-ineligible biliary tract carcinoma treated by salvage surgeries between January 2011 and December 2012.
Results : The treatment protocol included combined gemcitabine plus CDDP or S1 therapy and irradiation (50.4 Gy) with daily S1 administration. The duration of the chemoradiation therapy ranged from 4 to 9 months. The treatment response was classified as stable disease or partial response (SD/PR) in all three cases, therefore, salvage surgery was scheduled. Histopathological examination revealed downstaging of the disease with R0 in all the cases.
Conclusions : Salvage surgery following definite chemoradiation therapy might offer improvement of the pathological outcome in patients with locally advanced or initially resection-ineligible biliary tract carcinoma.

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Mortality and morbidity following pancreaticoduodenectomy (PD) is attributed mainly to leakage of the pancreticoenteric anastomosis. Although many surgical techniques for pancreatic anastomosis have been reported, no gold-standard technique has been defined. Pancreaticogastrostomy (PG) with invagination method has been commonly used in our department. In some cases where the stomach is unusable for reconstruction, we have applied end-to-side pancreaticojejunostomy (PJ) using the basic concept of the PG with the invagination method, resulting in a good clinical course. After a case with second reconstruction by PJ for pancreatic leakage following PG showed good recovery, we have changed to using PJ after PD. We have experienced 12 cases of PJ with the end-to-side invagination method in the last 2 years, with none showing pancreatic leakage. This PJ technique is very simple with a low risk of leakage, and seems to offer a versatile reconstructive technique.

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Myeloid sarcoma, a mass-forming neoplasm composed of myeloid blasts, rarely arises from the breast. It can occur in a patient with concurrent acute myeloid leukemia (AML) or as a relapse of AML. A PET/CT scan of a 26-year-old woman who had been diagnosed as having AML at 21 years of age showed abnormal uptake in both breasts. The patient had experienced several relapses and remissions of AML despite having received umbilical cord blood transplantation, bone marrow transplantation and chemotherapy. She had also been diagnosed with subcutaneous myeloid sarcoma of the head. Ultrasonography showed that the masses in both her breasts were hypoechoic with indistinct margins. A diagnosis of myeloid sarcoma of both breasts was made following a core needle biopsy. The patient received radiotherapy for both breasts, after which PET/CT revealed disappearance of the abnormal uptake in both breasts. Because the clinical and radiological features of myeloid sarcoma of the breast are non-specific, a biopsy is necessary for the diagnosis.

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In recent years, breast-conserving therapy comprising partial mastectomy followed by irradiation has been established as the standard local therapy for breast cancer. We present our experience with a case of leiomyosarcoma developed 19 years after postoperative irradiation for right breast cancer, together with a review of the literature.
The case involved a 65-year-old woman complaining of a right subclavian tumor. There were previous histories of undergoing right breast-conserving operation, ipsilateral axillary lymph node dissection, irradiation for the remnant mammary gland in 1995 at another hospital. Thereafter she had been disease-free up to the end of a five-year follow-up period. One month earlier, she noticed a right subclavian tumor and presented to our hospital. An elastic soft tumor with the size of a tip of the small finger was felt right above the right second rib. Furthermore another two tumors with the size of a rice grain were palpated in the outside of the tumor. In order to perform treatment and biopsy, these tumors were resected under general anesthesia. Immunohistology revealed ASMA+, desmin+, and BCL2+. Leiomyosarcoma after irradiation was thus diagnosed.

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A 55-year-old woman became aware of a 6-cm mass in her left breast accompanied by skin edema and pleuroparietopexy and therefore visited our hospital. We diagnosed the mass as an infiltrating ductal carcinoma (triple negative) with metastasis to the axilla and parasternal lymph nodes (T4cN3bM0 Stage IIIc). As treatment, the patient received FEC 100×5 and docetaxel hydrate ×4 followed by left total mastectomy and axillary lymph node dissection. Histopathologically, the tumor measured 24 mm in diameter (pN0). Because prior to the onset of chemotherapy, we observed enlarged parasternal lymph nodes, we administered postoperative radiation therapy (50 Gy) to the thoracic wall and supraclavicular fossa. Six months after the radiation, the patient developed fever and dyspnea. A chest radiograph revealed infiltrative shadows in the left lung, and a chest computed tomography image showed multiple infiltrative shadows and ground glass-like shadowy images. On the basis of these findings, we diagnosed the patient with organized pneumonia after radiation therapy. We initiated steroid therapy, but additionally administered cyclosporine owing to three episodes of recurrence upon reducing the steroid dose. Thus, we encountered a case of organized pneumonia after breast cancer operation and radiation therapy, wherein it was necessary to administer an immunosuppressive agent, and report our findings herein.

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The patient was a 76-year-old man who had been aware of a right axillary subcutaneous tumor since 40 years earlier. In May 2010, the tumor rapidly enlarged and formed ulcer. A biopsy of the lesion provided a diagnosis of invasive ductal carcinoma. He was referred to our department with a suspicion of male breast cancer. A CT scan showed swelling of the ipsilateral axillary and mediastinal lymph nodes. Any findings suggestive of metastasis from other organs were absent. In June 2010, we performed excision of the right axillary tumor, axillary lymph node dissection and reconstruction using a scapular flap. Histopathology confirmed malignant findings of proper mammary gland and discontinuing normal mammary tissue. Immunohistology revealed ER (-), PgR (-), and HER2 (3+). In October 2011 when the patient was under adjuvant chemotherapy, a nodule shadow appeared in the right lung and partial pneumonectomy was performed. The pathological diagnosis was metastatic breast cancer. In July 2013, multiple lung metastases appeared and the patient has been treated with chemotherapy. At present when 4 years and 5 months have elapsed after the operation, the patient can maintain the same activity of daily living (ADL) as he had before surgery due to the reconstruction.

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We report a case of male accessory breast cancer in the left anterior chest wall. A 65-year-old man was treated for a subcutaneous tumor in the left anterior chest wall at a neighborhood clinic. Histopathology of the resected tumor suggested a metastatic carcinoma with neuroendocrine differentiation, and the surgical margin was positive. Systemic examination at our hospital revealed no evidence of a primary malignancy in the skin tumor. Based on the tumor originating on the mammary ridge and some glands possibly suggestive of accessory breast tissue in the tumor, a final diagnosis of accessory breast cancer was made. Therefore, 5 months after the tumorectomy, resection of the residual tumor with axillary lymph node dissection was performed. Immunohistochemical staining demonstrated positive staining for ER and PgR, and negative staining for HER2. No axillary lymph node metastasis was found. Endocrine therapy with tamoxifen was started after the surgery and at present, 24 months since the reoperation, the patient shows no evidence of metastatic lesions. To the best of our knowledge, this is the first case of male accessory breast cancer originating in the left anterior chest wall.

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The patient underwent modified radical mastectomy (Auchincloss)+axillary lymph node dissection (Bt+Ax) for right breast cancer (T2N1M0=Stage IIB). Pathology revealed scirrhous carcinoma. The estrogen receptor (ER)/progesterone receptor (PgR)/HER2 was -/-/0, with n=2/35. Adjuvant chemotherapy with 5FU+epirubicin+cyclophosphamide (FEC) was thus performed. One year after the operation, a solitary tumor was detected at the right lung. Right partial pneumonectomy to differentiate from primary lung cancer disclosed the tumor to be metastasis of breast cancer (ER/PgR/HER2=-/-/1+). After the operation, the patient was given paclitaxel and S-1, and she has been drug free without having recurrence for more than five years.
Recurred breast cancers are commonly treated by drug therapy. In this case, surgical resection disclosed the diagnosis of metastatic breast cancer. It is considered that a cure can be a goal of surgical resection even for metastatic breast cancers if they are oligometastases. This paper deals with a rare case of a patient who survives more than 10 years after resection of lung metastasis of breast cancer.

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We encountered a case of post-operative graft infection where vacuum-assisted closure (VAC) therapy proved markedly effective and the graft was successfully salvaged. A 78-year-old man developed graft infection and perigraft abscess one year after left subclavian artery and bilateral common femoral artery bypass surgery, and he underwent an emergency incision drainage procedure. The abscess was present in the form of a tunnel along the graft, centered at a T-shaped branch of the graft in the left thoracoabdominal area. The wound was cleaned with a large amount of distilled water, and debrided as much as possible. The causative bacteria was MSSA. Symptoms were temporarily alleviated, but on day 5 after surgery, the infection recurred and VAC therapy was started immediately. The wound was incised, up to about 5 cm away from each anastomosis, along the graft leading from the left axillary area to the two thighs, and packed with sponge, then low-pressure sustained suction was applied. Fever, white blood cell count (WBC), and C-reactive protein (CRP) level were all alleviated and the leachate was greatly reduced, but MSSA continued to be detected from wound cultures. The wound incisions were thus expanded to the anastomoses, and VAC therapy was continued. On day 33, the sutures were successfully closed. More than 3 years have passed after surgery, and the bypasses have retained patency with out sign of recurrent infection.

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A 42-year-old man was admitted to our hospital because of abdominal pain, vomiting, and scrotal swelling. A computed tomography scan from abdomen to pelvis revealed unusual enteritis. We suspected a hereditary angioedema (HAE) based on the symptoms and the patient's past medical and family history. He had previously been diagnosed with this condition based on low levels of complement component 4 (C4) and complement factor 1 inhibitor (C1-INH) activity. HAE is a hereditary disease caused by a deficiency or a functional loss of C1-INH. It is characterized by paroxysmal episodes of edema involving the face, larynx, or bowels triggered by physical or psychological stress. Although HAE is rare, it should be considered as a differential diagnosis in patients with paroxysmal abdominal pain. We are reporting a case of HAE at our hospital with a review of the literature.

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A 63-year-old man was brought to our hospital complaining of abdominal pain and nausea. He had a history of deep vein thrombosis of the lower extremities 16 years earlier. Contrast-enhanced CT showed thrombus in the superior mesenteric vein (SMV) extending to the portal vein, along with ascites and thickening of the jejunal wall. Because intestinal blood flow was likely to be intact, systemic urokinase and heparin were immediately administered. Laboratory examination on admission revealed protein C antigen deficiency with protein C activity reduction. The patient was diagnosed with SMV thrombosis caused by protein C deficiency. Although he was treated on a ventilator temporarily due to acute respiratory distress syndrome, the patient recovered from respiratory failure with intensive anticoagulant therapy under careful monitoring. The patient was discharged from hospital on the 28^th day after admission. He has been treated with oral warfarin as an outpatient without sign of recurrence. Immediate use of anticoagulants after diagnosis is likely to reduce the risk of surgical intervention and improve outcomes of SMV thrombosis.

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A 59-year-old man was diagnosed with infective endocarditis (IE) complicated by severe aortic regurgitation and vegetation on the mitral valve. Although antibiotic administration and treatment of periodontal disease controlled the IE, he went into shock due to rupture of a mycotic aneurysm of the superior mesenteric artery. Transarterial embolization (TAE) maintained hemostasis, but ischemia of the ileum was suspected 90 minutes after TAE. Both the ischemic event and the risk of worsening infection in the aneurysm led us to perform emergency surgery. Laparotomy revealed an ischemic ileum with a massive hematoma in the mesentery. The coils placed during TAE aided detection of the aneurysm. Partial ilectomy, including the aneurysm, was performed under stable hemodynamic conditions. The patient successfully underwent a Bentall procedure and mitral valvuloplasty 92 days after the preceding surgery. TAE could be a useful technique for both hemostasis and subsequent surgery in cases of ruptured mycotic aneurysm. However, the fact that TAE can develop complications such as ischemic events must be taken into consideration.

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A 40-year-old man who had a 22-year smoking habit (40 cigarettes per day) had been pointed out a bulla in the upper lobe of the right lung at annual examinations. The bulla tended to increase, but the clinical course had been observed because he was asymptomatic. A chest CT scan revealed that the bulla almost entirely occupied the upper lobe of the right lung or more than half of the thoracic cavity while it oppressed the middle and lower lobes. The patient presented to our hospital because of a one-week history of right chest pain. Following close exploration, right spontaneous pneumothorax was diagnosed, and right upper lobectomy of lung was performed on the next day. After the operation, the patient developed reexpasion pulmonary edema, prolonged pulmonary fistula, and impaired expansion of the remnant middle and lower lobes, but respiratory function improved.
Since no clear criteria for surgical indication for giant bullae have been established as yet, asymptomatic patients are often indicated clinical observation. In this case, the patient was indicated surgery because he presented with spontaneous pneumothorax, however, the observation resultantly allowed the bulla to grow larger. We had to resect extensive area of the lung that might affect his postoperative course. Periodic examinations and evaluation of the respiratory function and surgical therapy at an appropriate time are necessary for giant bullae.

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A 96-year-old woman was incidentally diagnosed with diaphragmatic hernia 4 years previously, but she had not been received any treatment because she was asymptomatic. She had bouts of vomiting after eating and visited a neighboring hospital. She was transferred to our hospital because conservative therapy by nasogastric tube insertion was ineffective. Endoscopic examination revealed stenosis of the gastric body. Abdominal CT scan showed the stomach, duodenum, omentum and transverse colon to have prolapsed in the right thoracic cavity and the diaphragmatic crura between the esophageal hiatus and the hernia orifice. From these findings, right parahiatal diaphragmatic hernia was diagnosed. Open surgery was performed and we reduced the herniated gastric body, duodenum, omentum and transverse colon to the abdominal cavity and sutured the hernia orifice. After the surgery, she was associated with reflux esophagitis (Los Angeles Classification B), but it subsided with conservative therapy. She was discharged on the 27^th postoperative day. No recurrence has occurred as of a year after the surgery.

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A 70-year-old woman visited a nearby clinic with a 1-week history of persistent left back pain. Chest X-ray indicated lifting of the left diaphragm and inflammatory response was also found to be elevated, so she was referred to our hospital for detailed examinations and medical attention. On presentation, blood tests showed a significantly increased inflammatory response, and imaging showed free air on the liver surface and a cavitary mass with a liquid surface under the left diaphragm. The possibility of gastrointestinal perforation was considered, but neither upper nor lower gastrointestinal endoscopy confirmed any perforations, and no findings suggesting any other infectious source were observed, so subphrenic abscess of unknown etiology was diagnosed. Percutaneous intraperitoneal drainage was performed and antibiotics were administered, with continued conservative treatment. Symptoms alleviated and she was discharged. Causes of subphrenic abscess could include gastrointestinal perforation, cholecystitis, or pancreatitis, but rarer causes have been reported, including ectopic Meckel's diverticulum and ectopic appendicitis. The present case was considered idiopathic, with unknown etiology, but medical attention needs to be provided with rare diseases in mind when a cause is being sought.

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A 61-year-old man was brought into our hospital by ambulance from another hospital because of dysphagia and hypoxemia. A chest CT scan showed an irregular-shaped aneurysm of the thoracic descending aorta which had oppressed the left bronchus and esophagus. The patient was admitted with a diagnosis of infectious aortic aneurysm, and on the next day he underwent endovascular stent grafting to repair the descending aortic aneurysm. Endoscopy conducted on the second postoperative day revealed ischemic change in the esophagus, but no leakage of contrast medium was demonstrated by esophagography. A CT scan on the 7^th postoperative day revealed extraesophageal gas image at the mediastinum. Esophagography also confirmed leakage of contrast medium into the mediastinum. Esophageal perforation was thus diagnosed and esophagectomy was performed by right thoracotomy on the 8^th postoperative day. The resected esophagus revealed necrotic defluxion of the wall extending through the full thickness of the esophagus. Esophageal reconstruction was done on the 49^th day after the esophagectomy. The esophageal reconstruction was made by anastomosing the total gastric tube to the remnant esophagus via ante-sternal route.

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A 53-year-old woman presented to our hospital with a 2-year history of dysphagia. A barium esophagogram showed a filling defect and a gastrointestinal endoscopy revealed a soft and smooth faced submucosal mass in the cervical esophagus. Contrast-enhanced chest CT scan revealed a cystic mass without enhancement effect in the cervical esophagus. FDG-PET showed no abnormal uptake of FDG. The mass was surgically excised by cervical esophagotomy. The resected specimen showed a multilocular cyst that measured 64 by 22 mm containing viscous fluid and was histophathologically diagnosed as a retention cyst of the esophageal gland. Esophageal cyst is rare and its incidence is reported to be one of 8,200 cases by an autopsy study. Esophageal cysts are predominantly congenital cysts such as duplication and bronchogenic cysts, and acquired cysts or esophageal retention cysts are extremely rare. This is only the 9th case of esophageal retention cyst. We present a case report and literature review.

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A 31-year-old Brazilian man was admitted to our hospital because of dysphagia. Upper gastrointestinal endoscopy revealed a giant intraluminal tumor covered with normal esophageal epithelium. CT demonstrated that a giant tumor had occupied from the cervical esophagus to the lower thoracic esophagus, and the pedicle of the tumor originated from the cervical esophagus. A 3D-CT demonstrated that a branch of the bilateral superior thyroidal arteries was a feeder of the tumor. A diagnosis of a giant fibrovascular polyp was made and an operation was performed. Through a left cervical approach, a longitudinal esophagotomy, 6 cm in length, was performed, and the entire polyp was removed through the esophagotomy. The tumor measured 27 cm in length. Pathologically, it was diagnosed as a benign fibrovascular polyp composed of a mixture of adipose tissue, fibrous tissue and vascular structures. No recurrence has occurred, as of 6 months after the operation. This tumor in this patient was the largest in the domestic reports so far. Cervical approach is considered as a proper surgical treatment even for such a giant fibrovascular polyp.

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A 38-year-old female complaining of dysphagia was admitted to our hospital for treatment of an esophageal submucosal tumor. Esophagogastroduodenoscopy revealed a submucosal tumor in the cervico-thoracic esophagus. Pathological examination of the biopsy specimens showed interlacing bundles of pleomorphic spindle cells with numerous mitoses. Most of the spindle cells reacted strongly with antibody to Ki-67. Esophageal leiomyosarcoma was most likely, and larynx-preserving total esophagectomy and reconstruction using a gastric tube and a free jejunum graft with micro-vascular anastomosis through the retrosternal route were performed with a thoracoscopic surgery. Immunohistochemistry of the resected specimen revealed positivity for desmin and α-SMA and negativity for c-kit, CD34, S-100 protein, and keratin. The tumor was diagnosed as leiomyosarcoma histologically. The patient became to be able to eat most foods without aspiration, and has shown no signs of recurrence for six months after the surgery. We herein describe a case of a cervico-thoracic esophageal leiomyosarcoma in which radical operation was performed with a thoracoscopic surgery and in which the larynx function could be kept intact by a joint operation with head and neck surgery and plastic surgery.

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Hyperammonemia is a rare but serious adverse event of fluorouracil (5-FU). Although there are some cases of hyperammonemia in patients with colorectal cancer, it has rarely been reported in patients with esophageal cancer. We report two cases of hyperammonemia with disturbance of consciousness during FP therapy for esophageal cancer. Case 1 : A 58-year-old man was diagnosed with Stage IV esophageal cancer in the esophagogastric junction zone and had been treated with chemoradiation. During the fourth course of FP therapy, he suddenly presented with disturbance of consciousness on treatment day 5. Through laboratory data and radiographic examination, hyperammonemia (493μg/dl) was found. Case 2 : A 71-year-old man who underwent subtotal esophagectomy for thoracic esophageal cancer started postoperative FP therapy. He presented with the sudden onset of consciousness disturbance on treatment day 6. Blood tests showed hyperammonemia (361μg/dl). In both cases, patients were treated with rehydration and branched-chain amino acid solutions, resulting in gradual improvement of the symptoms. We should be aware that 5-FU may cause hyperammonemia and resultant disturbance of consciousness during FP therapy.

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A 75-year-old man with esophageal cancer underwent subtotal esophagectomy with gastric tube reconstruction and three-field lymph node dissection after two courses of docetaxel, cisplatin, and 5-fluorouracil (DCF) chemotherapy. Recurrence developed in his mediastinal lymph nodes one and a half years post operation. The patient was re-admitted for additional DCF treatment and enteral nutritional support. A high fever exceeding 39°C with an inflammatory reaction developed six days after starting naso-gastric tube feeding. A computed tomography (CT) scan revealed portal venous gas and submucosal emphysema in the reconstructed gastric tube, and emphysematous gastritis was suspected. The feeding tube was removed and antibiotic treatment started. One week after starting treatment, the gastric tube emphysema and portal venous gas resolved along with improvements in the inflammatory signs. To our knowledge, this is the first report of emphysematous gastritis developing in the reconstructed gastric tube after esophagectomy. Early diagnosis and treatment appears to be crucial for this critical disease.

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We report a rare case of esophageal hiatal hernia with incarcerated transverse colon after spontaneous reduction of an upside-down stomach. An 83-year-old woman visited our hospital with vomiting and anorexia. Computed tomography and upper gastrointestinal series showed an upside-down stomach and esophageal hiatal hernia with incarcerated transverse colon. Nasogastric tube insertion and conservative management were successful. Three years later, her upside-down stomach had reduced spontaneously, but the transverse colon remained incarcerated. She underwent laparoscopic repair of the hiatal hernia and Toupet fundoplication. The postoperative course was uneventful. As of 3 months after surgery, she remains in good condition without recurrence.

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Case 1 : A 63-year-old man presented at our hospital with a gastric abnormality. Gastroscopy revealed antral stenosis on the basis of a reddish irregular protruded lesion, which was determined to be adenocarcinoma by biopsy. The lesion was diagnosed to be a type 3 advanced gastric caner, and distal gastrectomy was performed. The resected specimen showed a reddish slight depressed lesion, 45 × 35 mm, in the gastric antrum. Histopathological examination revealed mucosal well-differentiated adenocarcinoma associated with diffuse submucosal heterotopic gastric glands (SHGG).
Case 2 : A 74-year-old man presented at our hospital for examination of a gastric abnormality. Gastroscopy revealed three small slightly depressed lesions in the upper gastric body, gastric angle, and lower gastric body. All these lesions were diagnosed to be early gastric cancer (0-II c), and endoscopic submucosal dissection was performed.
Histopathologically, the lesions were revealed to be mucosal or submucosal adenocarcinoma associated with cystic dilatation of SHGG. Total gastrectomy was performed. The cut surfaces of the resected specimens showed a large number of small submucosal cysts in the gastric body, and these were pathologically diagnosed as SHGG. It should be taken into consideration that early gastric cancer associated with diffuse SHGG can masquerade as advanced cancer and often develop multifocally.

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We describe a case of a 63-year-old man who consulted our hospital for paralysis of his left side. He was diagnosed with a metastatic brain tumor from lung cancer (Stage IV). Systemic chemotherapy was started after radiation therapy for the metastatic brain tumor. Tarry stool and progressive anemia were observed on the second day after beginning chemotherapy. An upper gastrointestinal endoscopy showed a 3-cm submucosal tumor at the greater curvature of the stomach fornix. Histopathological examination showed poorly differentiated adenocarcinoma and a metastatic tumor of the stomach suspected to originate from lung cancer based on immunohistochemical examination. We performed laparoscopic and endoscopic cooperative surgery (LECS) for the metastatic gastric tumor. This is, to our knowledge, the first case report of metastatic tumor of the stomach successfully treated with LECS under correct diagnosis in Japan.

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A 29-year-old man was brought into the emergency room 18 hours after he received an injury to the abdomen with a physical assault. He was in a state of shock and presented muscular defense in the entire abdomen upon arrival. Abdominal and pelvic CT scans suggested a rupture in the duodenum. A subsequent emergency operation revealed a rupture encircling half of the circumference at the pancreatic face of the second and third portions of the duodenum. In addition, the duodenum around the ruptured site appeared to be severely damaged with suspicion of ischemic change. We thus avoided treating with simple closure or serosal patch using the jejunum. After localizing the ampulla of Vater from the inside of the lumen, which was away from the injury, we performed a partial resection of the affected duodenum with jejunal Roux-en-Y reconstruction. Since Roux-en-Y reconstruction offers less physical tension and requires no mobilization of the duodenum, we believe that it is a safe and feasible way of reconstruction particularly in the case of extensive injury where end-to-end anastomosis is not feasible.

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The patient, a 54-year-old woman, was admitted to a nearby doctor with epigastric pain. She was diagnosed with cholecystitis, and referred to our hospital under the diagnosis of acute cholecystitis. Abdominal CT showed high-density nodules in the gallbladder and duodenum. Endoscopic study showed a protruding lesion in the first portion of the duodenum. Endoscopic ultrasonography showed a hyperechoic lesion with an acoustic shadow in the duodenal wall, suggesting an aberrant stone in the duodenal wall. Under the diagnosis of gallstone cholecystitis and stone in the duodenal wall with cholecyst-oduodenal fistula, cholecystectomy and enucleation of the aberrant stone were performed. Operative observations showed no fistula between the gallbladder and duodenum. Postoperative analysis of stone components revealed little difference between the aberrant stone and gallstones. We also thought that the gallstone had passed through the common bile duct and impacted into the duodenal wall, where it became covered by duodenal mucosa. We report herein a quite rare case of aberrant gallstone in the duodenal wall.

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We encountered two cases of duodenal obstruction accompanying hematoma after pancreatic aneurysm rupture, and report them here with a discussion of the literature. Both patients visited with a chief complaint of abdominal pain, were diagnosed with rupture of a visceral artery aneurysm on computed tomography, and showed aneurysm in the pancreatic artery on angiography. One case was followed-up and one case underwent embolization, but both cases followed a favorable course. However, after discharge, abdominal pain and vomiting appeared, and duodenal obstruction was diagnosed in each case. Both improved with conservative treatment, and later followed a favorable course. Pancreatic aneurysm rupture can in some cases be followed by duodenal obstruction accompanying hematoma, and follow-up is thus regarded as necessary.

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Herein, we report a case of Ehlers-Danlos syndrome (EDS) presenting with multiple small intestine diverticula, possibly caused by adhesive small bowel obstruction, after vascular surgery. A man in his 50s underwent a surgical procedure for inferior vena cava filter deviation. One week after the operation, abdominal CT showed dilated small bowel segments and free air in the abdomen : gastrointestinal perforation was suspected and emergency surgery was performed. During the operation, a small intestinal stenosis was found in an adherent part of the intestine under the last operative wound. As a result of the stenosis, the proximal side of the small intestine was dilated, with the formation of multiple diverticula. One of the diverticula penetrated the mesentery, causing inflammation. Small intestinal resection and anastomosis were risky because of the weakness of the tissue associated with EDS. Adhesiolysis for the small bowel obstruction and decompression of the small intestine with an ileus tube were performed. EDS type IV is characterized by a decrease in type III collagen, which reduces the tissue tolerance to pressure of tissues. In this case, the intestinal tissue expanded with the formation of multiple diverticula, presumably because of the poor tolerance to pressure associated with the lack of type III collagen.

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An 86-year-old man with a history of hemodialysis and diabetes mellitus was admitted to our hospital for sudden abdominal pain. Abdominal computed tomography (CT) revealed free air and wall thickening in part of the small intestine, while chest CT showed many small nodules in the bilateral lungs, suggestive of bronchial pneumonia. Emergency laparotomy revealed a perforation site, 1 mm in diameter, in the small intestine as well as many small white nodules on the mesenterium. Under a tentative diagnosis of idiopathic perforation, partial resection of the small intestine was performed. Histopathological examination showed tuberculosis of the intestine ; polymerase chain reaction (PCR) tests of patient sputum samples were also positive for Mycobacterium tuberculosis DNA. Based on these findings, the patient was also diagnosed with secondary intestinal tuberculosis leading to perforation. Although perforation caused by intestinal tuberculosis is rare, it should be included in differential diagnosis for intestinal perforation, especially in immunity-impaired patients, even if it is not considered a typical tuberculosis finding.

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A 66-year-old woman was admitted because of an abdominal mass with systemic inflammatory response syndrome. We decided to perform emergent resection surgery to confirm the diagnosis and provide treatment as appropriate. As the tumor was located in the root of the jejunal mesentery, we performed partial jejunectomy with the tumor. Pathological examination revealed that the tumor was an anaplastic large cell lymphoma that was anaplastic lymphoma kinase-negative. After the operation, the patient's general condition improved and the laboratory data promptly returned to normal. Three months after the surgery, hilar lymph node, abdominal lymph node, inguinal lymph node metastases, as also lung metastasis appeared. Chemotherapy with eight cycles of CHOP was administered, and at present, four years later, the patient is still doing well.

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We report a case of neurofibromatosis type 1 (NF1) with colonic and small intestinal cancer. The patient was an 80-year-old female with NF1 who presented with the chief complaint of bloody bowel discharge. Abdominal CT revealed wall thickening of the sigmoid colon and small intestine with contrast enhancement, and bleeding from the colon or small intestine was suspected. Colonoscopy revealed a mass lesion and stenosis 25 cm from the anal verge. The following day, emergency surgery was performed to control the bleeding. Intraoperatively, the bladder, ileum, both ovaries, and uterus were adherent, with abscess formation. Also, we found a perforation proximal to the tumor in the sigmoid colon and multiple mass lesions in a 60-cm segment of the small intestine about 200 cm proximal to the Bauhin's valve. Hartmann's operation was performed with resection of the involved segment of the small intestine. Histopathological examination revealed multiple neurofibromata in the jejunum, and an adenocarcinoma with well-differentiated and moderately differentiated components in the sigmoid colon. There have been previous reports of NF1 patients with gastrointestinal carcinoma, and NF1 patients should be examined carefully with special attention paid to the possible presence of tumors in the gastrointestinal tract.

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A man in his 50s presented with lower right abdominal pain from about 4 pm on the day of consultation at our hospital. Because symptoms rapidly worsened, he was transported by ambulance to our hospital. Physical findings on arrival showed tenderness and rebound pain in the lower right abdomen. Blood test findings revealed no abnormalities other than an elevated white blood cell count (20,500/mm³). Plain CT examination of the abdomen showed that the appendix was filled with fecaliths, with mild edema of the appendiceal wall and very mild swelling to 7 mm. Because we could not rule out the possibility of early appendicitis and in light of the intensity of lower right abdominal pain, same-day emergency surgery was performed. When the inside of the peritoneum was observed laparoscopically, the cecum was sallow and necrosis was suspected. Ileocecal resection was performed to remove the necrotic intestine, and functional end-to-end anastomosis was performed. Histological examination of the resected specimen showed necrotic findings, but no clear thrombus was evident in the blood vessels, including those of the mesenterium. A small range of gangrenous ischemic colitis was implicated as one possible cause of the cecal necrosis, due in part to the patient's history of arteriosclerotic disease.

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A 61-year-old woman was admitted to a local hospital with a few days' history of persistent lower right abdominal pain. She was diagnosed as having acute appendicitis and treated conservatively with antibiotics, however, her symptoms did not improve. Then, based on the findings of abdominal ultrasonography, she was suspected as having an ileocecal abscess and was referred to our hospital. Physical examination revealed local signs of peritoneal irritation in the right iliac fossa and a hard, fist-sized mass, which was tender to palpation, was palpable. The white blood cell count and serum C-reactive protein levels were elevated. Abdominal CT showed an ileocecal abscess. Appendicitis with abscess formation was suspected based on detailed examination, and emergency surgery was scheduled. During the surgery, we observed a mass in the ileocecal region, and mucus with pus was present when the mass was removed.
Since a malignant lesion was suspected, ileocecal resection with D2 lymph node dissection was performed. The resected specimen showed an abscess in the ileocecum on the serosal side, with the appendix identified along the abscess wall. However, the mucosal surface was intact. The lesion was finally diagnosed by histopathology as a sessile serrated adenoma/polyp of the appendix. We report a rare case of appendiceal SSA/P.

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A 63-year-old woman who began to vomit from the next day of barium meal study of the upper digestive tract at a medical checkup presented to our hospital on the second day after the barium study. An abdominal CT scan showed leakage of barium into the abdominal cavity, and perforation of the sigmoid colon was suspected. Blood analysis revealed abnormally high level of inflammatory reaction and impaired renal function. Emergency operation was performed with a diagnosis of sigmoid colon perforation. Laparotomy demonstrated perforation of the sigmoid colon, and Hartmann's operation was performed. The patient's early postoperative course was uneventful, but she developed high fever on and after the 16^th postoperative day. Blood analysis revealed strong inflammation. Despite administration of antibacterial agents, her inflammation persisted. Another abdominal CT scan revealed barium remnant in the abdominal cavity. Peritonitis caused by barium remnant was diagnosed and steroid therapy with prednisolone was started that resulted in prompt relief. The stoma was closed 5 months after the operation and no abnormalities have been seen at present. Barium peritonitis is an extremely rare and serious disease. We present a favorable outcome of steroid therapy for barium peritonitis caused by sigmoid colon perforation in which postoperative inflammatory reaction persistently existed.

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A 64-year-old man presented with a chief complaint of lower right abdominal pain. Abdominal ultrasonography and contrast-enhanced CT showed a hepatic mass with a diameter of 3 cm in contact with the diaphragm. Lower gastrointestinal endoscopy revealed cancer progression in the sigmoid colon, and he was preoperatively diagnosed with simultaneous liver metastasis. Laparotomy revealed the principal site of the mass was in the diaphragm, being fed from the right inferior phrenic artery. The mass was firmly attached to the liver, and the patient underwent a complicating partial diaphragm resection, sigmoid colectomy, and D3 lymph node dissection. Immunostaining of the diaphragm mass showed negative results for carcinoembryonic antigen (CEA), hepatocytes, and thyroid transcription factor (TTF)-1, but positive findings for cytokeratin 5/6 (CK5/6), epithelial membrane antigen (EMA), D-2-40, and calretinin, and the patient was ultimately diagnosed with peritoneal mesothelioma. Localized peritoneal mesothelioma is a hypervascular tumor, and identification of feeding vessels with contrast angiography or CT angiography is regarded as an auxiliary method of diagnosis. This case suggests the possibility that serum CA125 levels and CA125 immunostaining might offer auxiliary diagnostic methods or indicators of recurrence.

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The patient was in her forties who had admitted to the hospital with bloody stool and buttock pain, and was diagnosed as having lower rectal cancer. Laparoscopic super low anterior resection was performed with lateral lymph node dissection. Two days after the surgery, the patient developed fever, abdominal pain, and the ascitic fluid from the drainage tube turned fecoid. Emergent surgery was performed for wound dehiscence, followed by transverse colostomy and lavage. Four days after the emergency operation, the fluid from the drainage tube turned bloody. Contrast-enhanced CT revealed an intrapelvic pseudoaneurysm, and emergency angiography and embolization were performed. After the embolization, the patient recovered and was discharged from the hospital on day 40 after the first operation. In cases of wound dehiscence after rectal surgery with lateral lymph node dissection, attention should be paid to the possible presence of an infectious pseudoaneurysm.

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Herein, we present and review a case of hypercarbia associated with ventilation difficulty and severe subcutaneous emphysema during laparoscopic low anterior resection to treat rectal cancer. An octogenarian with a diagnosis of advanced rectal cancer had been scheduled for laparoscopic low anterior resection. Hypercarbia was noticed 3h after the start of the operation and was associated with ventilation difficulty and subcutaneous emphysema from the anterior chest wall. A chest radiography showed no pneumothorax. However, massive subcutaneous emphysema was detected from the bilateral axilla to the neck. We stopped the laparoscopic procedure and reduced insufflation pressure from 10 mmHg to 8 mmHg. Thereafter, the ventilation disorder was improved, and we were able to continue the laparoscopic procedure without hypercarbia. The postoperative course was good, without further hypercarbia. Although subcutaneous emphysema is a common complication of laparoscopic surgery, ventilation difficulty combined with severe subcutaneous emphysema is rare. In this case, we believe that the reason for such a rare occurrence was that the patient presented with several risk factors for subcutaneous emphysema, such as age, and weakness in the subcutaneous tissue. Therefore, in such high-risk cases, it is important to cooperate with the anesthetist to ensure early detection and prevention of a fatal event.

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A 74-year-old woman had undergone hepatectomy for a ruptured hepatocellular carcinoma (HCC) six years previously, and upper gastrointestinal endoscopy showed gastric submucosal tumor with no symptoms. The tumor was 2.1×1.7 cm in size. According to the endoscopic excisional needle biopsy, the preoperative diagnosis was gastrointestinal stromal tumor (GIST), epithelioid type, on the basis of KIT negativity and discovered on GIST-1 positivity on immunohistochemical staining. Conversely, the pathological diagnosis was considered to be peritoneal metastasis of HCC. Although peritoneal metastasis of HCC is rare, accounting for only 0.32% of all cases of HCC recurrence, the pattern of metastasis could be solitary or tardive. Early diagnosis of peritoneal metastasis is rare and difficult. We present this case with a review of the literature.

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A 90-year-old man was admitted to our hospital for treatment of a huge hepatocellular carcinoma (HCC). He had undergone aortic valve replacement 2 years earlier at another hospital. Abdominal contrast-enhanced computed tomography and Gd-EOB-DTPA magnetic resonance imaging revealed a huge hypervascular tumor with a diameter of 12 cm in liver segment 4. Laboratory data were as follows : aspartate aminotransferase, 37 IU/l ; alanine aminotransferase, 21 IU/l ; hepatitis B surface antigen-negative ; hepatitis B core antibody-negative ; hepatitis C virus antibody-negative ; α-fetoprotein, 5.7 ng/ml ; protein induced by vitamin K absence or antagonist-II (PIVKA-II), 220,000 mAU/ml ; and indocyanine green test R15, 16%. With a diagnosis of non-B, non-C HCC, transcatheter arterial chemo-embolization (TACE) was performed to reduce tumor size. However, tumor size and PIVKA-II level did not decrease. To prevent rupture of the huge HCC, extended lateral segmentectomy of the liver with middle hepatic vein tumor embolectomy was performed after immunonutrition and respiratory exercise. The histological diagnosis was moderately differentiated HCC (pT3, Stage III). Postoperative course was uneventful and he was discharged on the 20th postoperative day. Hepatic resection can be performed even in extremely elderly patients in good general physical condition with appropriate perioperative management.

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We report herein the case of a patient with primary biliary cirrhosis (PBC) with hepatocellular carcinoma (HCC) who underwent anatomical hepatectomy. A 74-year-old man with PBC was found to have a 3.4-cm liver tumor close to the right hepatic vein in segment 7 on follow-up CT study. HCC was diagnosed and extended right posterior sectionectomy involving the right hepatic vein was performed. The technical difficulty of transection of the hepatic parenchyma with PBC seemed comparable to that in cases of other causes of liver cirrhosis, and no particular perioperative complications were encountered. Histological study revealed moderately differentiated HCC and Scheuer grade IV PBC. Even in the case of PBC, hepatectomy can be safely performed according to the indications on the basis of cancer progression and hepatic functional reserve, as in other etiologies of liver disease.

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A 66-year-old woman had visited a nearby clinic with frequent hiccupping one month earlier. Gastric distension was noted on abdominal X-ray, and she was referred to our hospital with suspected pyloric stenosis. No abnormal findings other than abdominal bloating were apparent. Upper gastrointestinal endoscopy showed severe stenosis in the pylorus and a submucosal tumor-like protrusion at the center of the posterior wall. Biopsy identified a Group 1 mass, but invasion into the duodenal bulb was suspected on abdominal ultrasonography. Submucosal tumor-like gastric cancer could not be ruled out, and she underwent surgery for the purposes of definitive diagnosis and treatment of the obstruction. After distal gastrectomy conforming to treatment for gastric cancer with accompanying duodenal invasion, lymph nodes D2+No.12b/p, 13a, and 14v were dissected. Malignant transformation of an aberrant pancreas was diagnosed from histopathological examination. Lymph node metastasis was observed at No. 5, 6, 8a, and 13a.
General findings were pT3, pN2, sH0, sP0, pCY0, pM1, fStage IV. This case suggests that when gastric submucosal tumor is diagnosed, differential diagnosis should include primary adenocarcinoma of aberrant pancreas in the stomach, although this is rare, and a surgical procedure that takes lymph node metastasis into account should be considered.

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A 14-year-old boy had a past medical history of splenectomy for trauma at 2 years old. Because of intermittent abdominal pain and vomiting, he was taken to the emergency room. Contrast-enhanced CT showed beak sign as a sign of small bowel obstruction, and laparotomy was therefore performed. A small mass was incarcerated within a loop consisting of an adherent band. The band and mass were excised. Histopathological examination showed splenic tissue. Small bowel obstruction was triggered by splenosis. If a patient with a history of splenic injury or splenectomy complains of abdominal symptoms, splenosis must always be considered as a differential diagnosis.

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A 44-year-old woman visited our hospital because of a 1.5 year history of severe abdominal distension. When she was first seen, her upper half of the body showed remarkable emaciation and the abdomen was seriously bulging. An abdominal CT scan showed a giant tumor occupying almost the entire abdominal cavity. She was operated on under a diagnosis of retroperitoneal liposarcoma. At laparotomy, the tumor had displaced abdominal organs such as the small intestine, colon, liver, and stomach, and it surrounded the pancreatic body and tail. We radically resected the tumor with the spleen and pancreatic tail. The resected tumor was 63 × 41cm in diameter and weighed 24.5kg. The histopathological diagnosis was well-differentiated liposarcoma. Recurrence was detected in the peripancreatic retroperitonium and the surface of the liver 6 months after the first surgery, and the tumors were resected. Three months later, another abdominal CT scan revealed multiple recurrences in the liver and we started systemic chemotherapy. The multiple recurrences progressed and the patient died 2 years and 7 months after the first surgery. Here we report the case of a giant retroperitoneal liposarcoma exceeding 20kg in weight, and discuss the contiguous organ resection and the systemic chemotherapy.

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Necrotizing fasciitis is a serious and often fatal necrotizing soft tissue infection. It is important to make the correct diagnosis and rapidly debride the affected area. We recently treated a 79 year-old woman with necrotizing fasciitis associated with an incarcerated groin hernia, who presented with appetite loss. Physical examination showed a soft tissue bulge with skin necrosis in the right inguinal area. A computed tomography (CT) scan showed gas at the level of the fascia and prolapse of the small intestine. She was diagnosed with necrotizing fasciitis associated with an incarcerated inguinal hernia. Debridement, hernia repair, and resection of the small intestine were performed. Debridement was performed twice more after the first operation. Despite this aggressive surgical management, the patient died on the sixth day after the operation (POD6). Early debridement and multimodal therapy are important for treatment of patients with necrotizing fasciitis.

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A 67-year-old man was admitted for abdominoperineal resection with lateral lymph node dissection for rectal cancer. The final diagnosis was rectal carcinoma, Rb, type2, moderately differentiated tubular adenocarcinoma, MP, N1 (1/28), M0, cStage IIIa (post-therapeutic). Twelve months after the operation, bulging of the perineum appeared and gradually enlarged with discomfort. Computed tomography showed the small intestine was eventrating the subcutis of the perineum over the pelvic floor. Repair of the perineal hernia with artificial mesh was performed under laparotomy. Almost all perineal hernias occur after abdominoperineal resection and total pelvic exenteration. A transabdominal approach has the advantage of a good view of the pelvic floor and stable technique for mesh repair.

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A 79-year-old woman who underwent abdominoperineal resection for rectal cancer 18 years earlier had been noted to have abdominal incisional hernia and parastomal hernia in her postoperative course. In May 2014, she presented to our emergency clinic because of the abrupt onset of abdominal pain. An abdominal contrast-enhanced CT scan revealed an abdominal incisional hernia in the midline of abdomen in which a prolapsed intestine became slightly thickened. Furthermore another prolapsed intestine was found in the vicinity of the stoma that was diagnosed as incarcerated hernia. Since maneuver reduction of the herniated intestine was possible and any ischemic change was seen in the involved intestines, hernia repair was scheduled later. Employing laparoscopic surgery, we repaired these hernias at the same time by using Parietex^TM Optimized Composite Mesh. No recurrence has occurred after the surgery.

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A 51-year-old man with a tattoo covering large parts of his body underwent a lower anterior resection. Intraoperatively, he suddenly developed low blood pressure, tachycardia, and facial flush. Anaphylactic shock was suspected, and the operation was stopped. Intravenous injection of epinephrine and other medications improved the patient's general condition and stabilized his vital signs. A postoperative examination revealed high serum levels of latex-specific type E immunoglobulin. Therefore, this event was very likely caused by a latex allergy. A reoperation performed with latex-free equipment was completed without complications. Several case reports have described latex as a cause of intraoperative anaphylaxis. Generally, the patients underwent frequent medical interventions or worked in the medical field or in manufacturing. These populations come frequently in contact with rubber gloves and are therefore at high risk of latex allergy. In our case, the patient did not belong to any high-risk group. This suggests that he was sensitized to latex during the application of his extensive tattoo.

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