Postgastrectomy syndrome, a clinical problem, often occurs after gastrectomy and disturbs a patient's daily life. A patient strongly wishes not only “recovering from the cancer” but also “being able to lead a daily life similar to the one before the surgery”. However, concerning the latter, sufficient efforts have not been made in reality. Most surgeons are devoted to “treating the cancer” by performing operations or chemotherapy ; thus, they do not have adequate time to respond to the postgastrectomy syndrome. Therefore, developing tools that can efficiently diagnose and cope with the problems of postgastrectomy disturbances is required, as well as establishing a medical transdisciplinary team in cooperation with the medical staff. Postgastrectomy syndrome has sometimes been difficult to precisely diagnose and treat as it presents various clinical features, and treatment has mostly been given based on the individual experiences of the surgeons. However, in future, it is essential to provide a means by which postgastrectomy syndrome can be systematically diagnosed and treated. The treatment can be divided into (1) prevention, (2) detection - evaluation - response, and (3) examination - diagnosis - treatment. The improvement of initial response is suggested to be particularly linked with the potential for a patient to lead a daily life similar to the one before the surgery and to contribute to the improvement of the quality of life.

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A 53-year-old woman with injury of the right precordium sustained by falling against her bicycle handlebar was admitted to our hospital. She was not on regular medication with antiplatelet drugs. A hematoma was detected in the right breast, which showed a tendency towards increase in size despite cooling and rest to the injured area. CT revealed extravasation of contrast medium into the right breast suggestive of massive hemorrhage. Interventional radiology (IVR) failed to accomplish hemostasis. Therefore, emergency surgery was performed and the source of bleeding was ligated. The postoperative course was uneventful and the patient was discharged 8 days after the surgery. There was no wound infection or scarring. The wound was also esthetically acceptable. Although IVR is considered to be effective against arterial bleeding in cases of blunt trauma, surgery may be much more effective in cases where the source of bleeding can be accessed with comparative ease.

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The patient was a 14-year-old girl who had become conscious of the difference between a part of the left nipple and breast cross section since 1.5 years before. She visited a nearby hospital and was suspected to have a tumor mass in the left breast. Thereafter, she was admitted to our hospital. On palpation, we felt an elastic and hard 5 cm mass in her left breast. We observed an apparently circumscribed mass with high density on the mammographic image and an 8-cm mass with a clear margin in the major axis on breast ultrasonography. The image of the tumor mass showed a mixed pattern accompanying a nipple-shaped solid part that protruded into the lumen. We suspected an intracystic tumor or papilloma on preoperative diagnosis. However, because we observed an outgrowth of fibrillary tissue into the cyst wall and both mammary gland tissue and fibrillary interstice in the solid part on histopathologic examination, the patient was given a final diagnosis of juvenile breast fibroadenoma. Upon satisfactory progress, the patient was discharged on the 5th hospital day, and no recurrence has been observed to date, i.e., 7 years after surgery.

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A 67-yearold woman noticed a growing tumor in her left axilla. After receiving an initial diagnosis of left axillary cancer, excision and axillary lymph node dissection were performed, and she was diagnosed with apocrine carcinoma. It was difficult to determine if the apocrine adenocarcinoma arose from the accessory breast or the skin. The tumor was positive for estrogen receptor and progesterone receptor. She was followed while receiving endocrine therapy for 5 years postoperatively. A neck tumor was detected 9 years after the surgery, and she was diagnosed with recurrent apocrine carcinoma. Local resection was performed, and hormone therapy was reinitiated.

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A 52-year-old woman presented with a palpable mass in the upper-outer quadrant of her left breast. Ultrasonography revealed a mass measuring 11×12×8 mm in size in the left breast. Core needle biopsy was performed, and immunohistochemical examination revealed positive staining for AE1/AE3, CAM 5.2, CK7, CD56 and synaptophysin. On the basis of the findings, we made the diagnosis of an invasive neuroendocrine carcinoma, possibly small cell carcinoma of the breast. The patient was treated by left mastectomy and axillary lymphadenectomy. Our final pathological diagnosis was primary small cell carcinoma of the breast. Small cell carcinoma of the breast is very rare. We report this case together with a review of the literature.

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Thyroid metastasis from breast cancer is rare. A 51-year-old woman presented to us with a mass in the neck. She had been diagnosed as having hormone-positive breast cancer at 45 years old, and been treated by mastectomy, followed by chemotherapy and hormone therapy. Two years 4 months after the surgery, cervical lymph node metastasis was detected, and PET-CT revealed multiple metastases in the lymph nodes and sternum ; she was treated with an LH-RH analogue. Two years 11months after this therapy, a thyroid metastasis from the breast cancer was detected. She was administered chemotherapy, however, because of the emergence of severe adverse effects and at her urging, the chemotherapy was discontinued. For achieving local control while the chemotherapy was suspended, left thyroid lobectomy was performed. After the surgery, the patient was started on hormone therapy with tamoxifen and an LH-RH analogue. Subsequently, PET-CT revealed the presence of a metastasis in the right thyroid lobe, and chemotherapy was resumed.

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A 77-year-old man complained of left leg weakness. Right internal carotid artery stenosis was diagnosed. Percutaneous catheterization of the right internal carotid artery was performed, and an arterial closure device (Angio-Seal^®) was used for the right femoral artery. An infected femoral pseudoaneurysm later developed at the puncture site.
Emergency surgery using great saphenous vein (GSV) graft interposition was performed. On the 21st postoperative day, the GSV graft ruptured due to infection. Repeat GSV graft interposition was performed immediately. On the fourth postoperative day, the old GSV graft ruptured again. A bypass graft procedure from the right iliac artery to the popliteal artery was performed through the right obturator foramen with a polytetrafluoroethylene graft.
The postoperative course was uneventful and the patient was discharged from the hospital two months after the first operation.

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Treatment for claudication due to peripheral artery disease is characterized by lower perioperative morbidity and better long-term patency because limb survival is acceptable. A 77-year-old man had severe claudication and extensive calcified lesions of the abdominal aorta, bilateral common iliac artery, right common femoral artery, and right popliteal artery. Combined endovascular treatment with stenting from the abdominal aorta to the left common iliac artery and crossover bypass of the left external iliac artery to the right common femoral artery were performed. The clinical symptoms improved and the postoperative course was uneventful.

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Syphilis is a known cause of aortic aneurysm. We report a case in which we were unable to diagnose syphilitic aortic aneurysm before surgery in a 71-year-old male. Computed tomography identified a large ascending aneurysm with a maximum diameter of 60 mm. The serum rapid plasma reagin (RPR) test was positive at 2.6 R.U. and the fixed Treponema pallidum Latex Agglutination (TPLA) test was positive at 2,387 U/ml. However, the fusiform aneurysm was diagnosed as an atherosclerotic aneurysm before surgery. We performed aortic hemi-arch replacement and right brachiocephalic artery/left common carotid artery reconstructive surgery. However, the aortic aneurysm was strongly adherent to the surrounding tissues, and thickening of the aortic arch wall was observed. Pathological findings showed infiltration of plasma cells around the feeding artery in the media of the aortic aneurysm wall, and we postoperatively diagnosed a syphilitic aortic aneurysm. On postoperative day 8, we started oral administeration of amoxicillin 1,000 mg per day for 2 weeks.
The patient did well after surgery, and was discharged on postoperative day 13. The RPR became negative and the TPLA was 1,542 U/ml at postoperative month 18. Today, a syphilitic aortic aneurysm is extremely rare, and may be incorrectly diagnosed before surgery unless consciously considered.

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We report three cases of lung metastses from pancreatic cancer performed lung resection. The first case involved a 73-year-old woman. She underwent right wedge resection for three lung metastases 2 years 2 months after the surgical resection of pancreatic carcinoma, followed by left lower lung wedge resection and left lower lobectomy for lung metastases, 4 years 2 months and 5 years 9 months after the resection of pancreatic cancer, respectively. In the course of her treatment, she maintained on chemotherapy (gemcitabine : 57 courses). The patient has been alive without tumor relapse as of 7 years 8 months after the initial pancreatic resection. The second case involved a 76-year-old man. He underwent right wedge resection for three lung metastases 1 year 8 months after the surgical resection of pancreatic carcinoma, followed by left lower lung wedge resection for lung metastasis 2 years 1 month after the resection of pancreatic cancer. In the course of his treatment, he maintained on chemotherapy (gemcitabine : 32 courses). The patient has been alive without tumor relapse as of 2 years 11 months after the initial pancreatic resection. The third case involved a 71-year-old woman. She underwent bilateral wedge resections for three lung metastases (right : one, left : two) on a two-step approach 2 years after the surgical resection of pancreatic carcinoma. In the course of her treatment, she maintained on chemotherapy (gemcitabine : 48 courses). The patient has been alive without tumor relapse as of 3 years 2 months after the initial pancreatic resection. Aggressive pulmonary resection and the maintained chemotherapy may contribute to improvement of prognosis.

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A 61-year-old woman was referred to our hospital because of dyspnea, wheezing, and tachycardia. Computed tomography revealed a giant hiatal hernia with protrusion of the stomach, duodenal bulb, transverse colon, ileum, and pancreatic tail through the hiatus. The hernia contents were believed to have caused symptoms due to lung and heart compression. She underwent a radical laparoscopic operation involving repair of the hiatal hernia using polytetrafluorethylene mesh and Nissen fundoplication. The postoperative course was uneventful, and the symptoms improved. We report this case of giant hiatal hernia causing heart failure.

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Esophageal submucosal tumors (SMTs) including schwannoma are rare and we have great difficulties in diagnosing them preoperatively in many cases. The usefulness of thoracoscopic esophagectomy in the prone position has been demonstrated in these days, but there are very few reports of left thoracoscopic resection of esophageal tumors. We describe a case of an esophageal schwannoma performed left thoracoscopic resection in the prone position. A 65-year-old woman complaining of epigastric pain was found to have a 6-cm esophageal SMT on esophagogastroduodenoscopy. A chest CT scan revealed a 55 × 38 mm tumor with the homogeneous center on the left wall of the mid-to-lower thoracic esophagus. The tumor was diagnosed with schwannoma by a fine needle aspiration biopsy under endoscopic ultrasonography (EUS-FNAB) and immunohistochemistry. She underwent left thoracoscopic enucleation of the tumor in the prone position, because the tumor was localized in the left wall of mid-to-lower esophagus. The operative time was 207 min and the operative blood loss was 3 g. The postoperative course was uneventful and she was discharged on the 8^th postoperative day. Because preoperative diagnosis decides operative methods for esophageal SMTs, we should carry out EUS-FNAB which ensures a high correct diagnosing rate. Left thoracoscopic approach in the prone position is beneficial for enucleation of SMTs locating in the left side of the esophageal wall below the aortic arch.

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We report a rare case of an 8-year-old boy with lymphatic malformation derived from the stomach that was resected by single port laparoscopic surgery. He came to our hospital because of upper abdominal pain and fever. Blood biochemical study revealed elevated inflammatory reaction. An abdominal contrast-enhanced CT scan showed a pedunculated multilocular cystic mass (12.4×7.8cm) occurred from the lesser curvature of his stomach.
MRI showed low signal in T1 weighted images and high in T2 in the mass, indicating that the mass contained fluid components. From these studies, we diagnosed this mass as lymphatic malformation derived from the stomach or lesser omentum.
We performed single port laparoscopic surgery one month after successful conservative treatment with antibiotics. During the operation, we observed that the pedunculated cystic mass connected to the lesser curvature of the stomach through the dorsal aspect of the stomach. and The mass was too large to be taken out via the umbilical incision of the port sight. Aspiration of the fluid components using S.A.N.D. balloon^® enabled to take out the mass. We excised it completely with partial wedge resection of the stomach without rupture. Histopathological diagnosis was lymphatic malformation derived from subserosa of the stomach. He was discharged from the hospital with no complications 7 days after the operation.
This case is presented here, together with a review of the literature and some devices in operative procedures.

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A 53-year-old woman was diagnosed with recurrent gastric gastrointestinal stromal tumor (GIST) with peritoneal dissemination and was admitted to our hospital for abdominal pain on day 136 of imatinib therapy. We performed urgent surgery under a diagnosis of hemoperitoneum from GIST. We resected a ruptured peritoneal dissemination that was causing bleeding. After surgery, she was followed-up without imatinib therapy. Two years later, peritoneal dissemination revealed exacerbation. We therefore performed reintroduction of imatinib therapy. However, she was admitted to our hospital in hemorrhagic shock on day 26 of imatinib therapy. We performed urgent surgery again due to ruptured peritoneal dissemination of GIST. Intraoperative findings revealed the ruptured GIST involved the transverse mesocolon. We performed transverse colectomy including the ruptured GIST.
Imatinib is a standard medication for recurrent GIST. Hemoperitoneum due to tumor rupture is an infrequent adverse event following imatinib therapy. We present a case and review the literature.

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An 89-year-old man was admitted to our hospital because of abdominal pain. An abdominal CT scan demonstrated free air along the mesorectum. Emergency surgery was performed with a suspicion of large bowel perforation. During the operation, however, multiple diverticula were revealed on the mesenteric side throughout the small bowel, with perforation of a diverticulum and abscess formation 180 cm proximal to the ileocecal valve. The diverticulum and the abscess on the adjacent ileum were resected. The histopathological diagnosis was perforation of the true diverticulum. Perforation or penetration of an ileal diverticulum is rare, and difficult to diagnose. Once this type of perforation occurs, delayed diagnosis carries a fatal prognosis. Emergency surgery in an early stage should be considered when this is suspected. Our case in which multiple true diverticula affected the entire small bowel and perforation of a true diverticulum required emergency operation appears to be very rare.

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A 16-year-old man was brought into our hospital by ambulance because of the abrupt onset of massive anal bleeding. An abdominal contrast-enhanced CT scan showed arterial bleeding from the small intestine and an angiography revealed bleeding from the ileal artery. Vascular embolization and coiling achieved hemostasis. We performed single-balloon enteroscopy and video capsule endoscopy to localize the source of the bleeding several days later. A submucosal aneurysm of the small intestine was suspected by video capsule endoscopy. We decided to conduct an elective surgery. A single incisional laparoscopic assisted partial jejunectomy was performed for the purpose of diagnosis and hemostasis. The pathological diagnosis was a ruptured submucosal aneurysm. His postoperative course was uneventful and he was discharged on the 7^th postoperative day. Small bowel hemorrhage has been reported to account for about 2-5% of all cases of gastrointestinal bleeding. Ruptured small bowel aneurysm is extremely rare. We often have difficulties in making preoperative diagnosis of small bowel hemorrhage but in this case the comcomitant use of angiography, single-balloon enteroscopy and video capsule endoscopy was useful for diagnosis of bleeding site. We resultantly performed less invasive surgery.

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A 46-year-old man complaining of abdominal distension and massive bloody bowel discharges was brought into our facility by ambulance. On admission, the patient's consciousness was alert and had no fever or symptoms of shock. Blood test showed no signs suggestive of hemolysis. Abdominal ultrasonography showed significant enteric dilatation, edema of the intestinal wall, and collection of ascites. The patient went into cardiopulmonary arrest just before the end of the X-ray examination, but we were able to resuscitate. An abdominal contrast-enhanced CT scan showed extensive intestinal necrosis with portal venous gas, leading to urgent laparotomy. The entire intestine significantly dilated and an ileum by about-one meter in length became necrotic, though ascites was yellow and transparent. We performed partial ileum resection, but the patient underwent cardiac arrest again by the end of the operation. While performing cardiopulmonary resuscitation, we started percutaneous cardio-pulmonary support and endotoxin adsorption therapy by polimyxin B immobilized fiber column direct hemoperfusion in the ICU. Although we continued intensive care, the patient died approximately seven and a half hour after admission. The resected ileum contained widespread pseudomembranous hemorrhagic enteritis and the ileal necrosis had extended to the full thickness of the intestine. The histopathological diagnosis was made as Clostridium perfringens infection on immunostaining. We report the case with a review of 24 domestic cases of the disease which rapidly followed a fatal course after admission.

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We report a case of loop ileostomy prolapse in an 89-year-old woman with a history of unresectable sigmoid colon cancer. The patient was admitted to our hospital with severe abdominal pain during the follow-up period. An initial examination revealed intestinal prolapse of the afferent limb of a loop ileostomy, resulting in strangulation and obstruction, which was not relieved by manual reduction. We used the stapled Altemeier operation for loop stoma prolapse. This technique involves a simple operation, which includes a circumferential incision through the full thickness of the outer and inner cylinder of the prolapsed limb, followed by stapled prolapse resection without incising the abdominal wall. The postoperative course was uneventful and the patient showed no early recurrence of prolapse. This procedure is useful as an optional surgical treatment for cases of loop ileostomy prolapse because of its decreased invasiveness compared to open exploration. We present a case of loop ileostomy prolapse successfully treated with the stapled Altemeier operation, and provide a review of the current literature on this topic.

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A 76-year-old woman was introduced to our hospital for detailed inspection and treatment for an abdominal mass detected incidentally by a CT scan for a medical checkup. A lobulated share mass, 4cm in size and enhanced by a contrast medium, was detected inside of the mesentery of small inetestine on an abdominal CT scan in our hospital. Abdominal MRI revealed high signal intensity of the mass on diffusion weighted image. Laparotomy was carried out with a preoperative diagnosis of malignant lymphoma or GIST. The mass detected by CT and MRI was an enlarged mesenteric lymph node belonging to the small bowel. A constricted tumor was also identified in the small bowel. Small bowel resection with lymphadenectomy was carried out. The tumors were diagnosed as a neuroendocrine tumor of the small bowel and its lymph node metastasis. The histopathological diagnosis was neuroendocrine tumor (G2), pT3 (SS), pN1, ly2, v3 and Stage IIIb. When we encounter a mass in the mesentery on imagings like in our case, not only malignant lymphoma or GIST but also lymph node metastasis of neuroendocrine tumor should be included in the differential diagnosis. Radical operation including lymph node dissection appears desirable if distant metastasis is absent.

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A 75-year-old woman presented to our hospital complaining of intermittent abdominal pain. Blood examination revealed anemia, and contrast-enhanced abdominal CT revealed a tumor measuring 9×4 cm in diameter in the small intestinal lumen causing dilatation of the proximal segment of the small intestine. The patient was diagnosed as having small bowel obstruction caused by a tumor, and laparotomy was performed. Intraoperatively, we visualized a small intestinal tumor growing into the lumen without exposure at the serosa, therefore, resection of the small intestinal segment bearing the tumor was performed. On histopathological examination, the tumor was found to be composed of spindle cells arranged in sweeping fascicles. We diagnosed the tumor as a malignant peripheral nerve sheath tumor of the small intestine. A year and five months after the operation, recurrence of the malignant peripheral nerve sheath tumor was suspected in the patient on the basis of worsening of her anemia. We performed a second laparotomy and resected a small intestinal tumor and tumor of the mesentery. Histopathology revealed recurrence of the tumor in the small intestine and peritoneal dissemination. A search of the current literature revealed few reports of cases of malignant peripheral nerve sheath tumor of the small intestine.

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Case 1 : A 42-year-old woman with neurofibromatosis type 1 (NF1) was admitted to the hospital for close exploration of anal bleeding. Endoscopic study showed a submucosal tumor and an elevated lesion just distal to the tumor in the small intestine. Bleeding from the jejunal mass was diagnosed. Partial resection of small intestine was performed, when a nodule at the small bowel mesentery was detected and removed. The resected specimen had two tumors which were diagnosed as gastrointestinal stromal tumor (GIST) and neuroendocrine tumor (NET), respectively. The mesenteric nodule was GIST as well.
Case 2 : A 73-year-old woman with NF1 visited our hospital for further examination of hypertension, and small bowel masses were detected on an abdominal CT scan. Capsule endoscopy revealed a tumor in the duodenum and three tumors in the small intestine. Laparoscopic-assisted partial resection of small intestine was performed. The duodenal mass was not resected because the patient's general condition was poor. The resected intestine had three tumors. Two of those were diagnosed as GIST and the remaining one was diagnosed as NET.
Although clinical cases of NF1 combining with either GIST or NET are sometimes reported, both diseases occurred concomitantly in those patients are very rare. We thus report our two cases of NF1 with both GIST and NET of the small intestine, with some bibliographic comments.

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A 70-year-old man with bloody bowel discharge resulting in severe anemia was referred to our hospital. Abdominal CT and endoscopic examination revealed a hemorrhagic tumor 3 cm in diameter in the jejunum. Partial resection of the jejunum was performed both as a cure for bowel bleeding and to diagnose the tumor. The resected specimen showed a submucosal tumor measuring 9.5×4.5×4.0 cm projecting into the lumen. Histologically, the tumor comprised spindle cells showing patternless growth and a hemangiopericytoma pattern. Immunohistochemically, tumor cells were positive for bcl-2 and CD99. According to these findings, the tumor was diagnosed as solitary fibrous tumor. The patient showed recurrence in the superior mesenteric plexus, L5 lumbar vertebra, left suprarenal gland, and piriformis muscle 3 months after the operation, and died 5 months postoperatively due to multiple-organ failure. This is a rare case in which SFT of the intestine caused a malignant outcome.

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A 56-year-old man visited our hospital with the chief complaint of gradually intensifying right lower quadrant abdominal pain. The abdomen was flat and soft, but there was tenderness in the right lower quadrant. Abdominal computed tomography showed a swollen appendix up to 8 mm in diameter with grape-like “multiple diverticula. The patient was diagnosed as having acute appendicitis with appendiceal diverticulosis, and underwent appendectomy. Multiple diverticula were detected in the enlarged appendix, but no perforation and abscess were found. Pathological examination indicated multiple true diverticula with muscle layer and infiltration of chronic inflammatory cells mainly composed of lymphocytes and plasmacytes at the body of appendix and diverticula. Histopathological diagnosis was appendicitis with true diverticulitis of the appendix.
Diverticulosis of the appendix is a relatively rare entity. The majority are pseudodiverticula and true diverticula are very rare. We present a case of true diverticulosis of the appendix diagnosed preoperatively, with a review of the literature.

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A 63-year-old male with a diagnosis of Ra, cT3, N1, M0, cStage IIIa rectal cancer underwent laparoscopic lower anterior resection. The stomach, small intestine, and colon were found to be enlarged during surgery. Although defecation and flatus were present after surgery, the large intestine was markedly enlarged from the descending to the ascending colon and the small intestine contained gas, suggesting postoperative intestinal paresis. In spite of some intestinal pressure relief through a transnasal ileus tube, complications of translocation of Pseudomonas aeruginosa from the enlarged intestine, septic shock, and disseminated intravascular coagulation (DIC) developed on the 20th postoperative day. We were able to treat the DIC by advancing the transanal ileus tube to lower the pressure in the enlarged intestine and achieve whole body control. An endoscopic examination and computed tomography revealed no evidence of inadequate suturing or an obstruction point ; there was no blood flow disorder, enteritis, or other evidence of infection ; therefore, an acute colonic pseudo-obstruction following abdominal surgery was diagnosed.
Although reports on postoperative acute colonic pseudo-obstruction are not novel, this case is unusual in that the problem followed a laparoscopic procedure and was accompanied by septic shock.

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A 79-year-old man was admitted with the chief complaint of bloody bowel discharge. Hemorrhage was not present at the time of admission, but recurred on the 4th hospital day. Urgent colonoscopy (CF) demonstratd hemorrhage in an ascending colon diverticulum We could not achieve complete hemostasis using CF, so we performed urgent angiography. We identified the site of active hemorrhage, and performed selective transarterial embolization (TAE) using NBCA (N-butyl-2-cyanoacrylate). After TAE, we planned to perform colectomy including the embolized segment, and monitored the patient's course. Since he had no further abdominal symptoms, we performed elective surgery 4 days after TAE. At surgery, we found a full-thickness, circular necrotic focus in the ascending colon. We conducted right hemicolectomy to include multiple diverticula including the necrotic focus. The wound site became infected after surgery, but improved with the discharge of pus. We report a case in which asymptomatic colonic necrosis spontaneously resolved after selective TAE for colonic diverticular hemorrhage.

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Urachal anomalies are rare abnormalities resulting from incomplete closure of the urachus during fetal development. Transverse colo-urachal-cutaneous fistula is an uncommon complication of urachal remnant. We report a case of laparoscopic resection of a transverse-urachal fistula in an adult with cecal cancer. A 56-year-old woman was admitted to hospital with an abscess around the umbilicus. Abdominal CT revealed a mass extending from the umbilicus to the lower abdomen, and incidentally revealed cecal cancer. During antibiotic treatment, the abscess ruptured from the navel. No colon diverticula were identified with barium enema examination. The transverse colo-urachal-cutaneous fistula was detected through fistulography. The patient was thus diagnosed with cecal cancer and urachal remnant with fistula to the transverse colon. Laparoscopic resection was successfully performed using 5 ports and a small midline incision. The postoperative course was favorable. This is the first report of a unique case of transverse colo-urachal fistula in an adult woman with cecal cancer.

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This is a report of our experience with a rare case of isolated right external iliac lymph node recurrence following surgery for ascending colon cancer. The patient was a 73-year-old woman who was diagnosed with ascending colon cancer and underwent a laparoscopic-assisted right hemicolectomy in April 2012. The patient was treated with UFT/LV as postoperative adjuvant chemotherapy, but isolated right external iliac lymph node metastases and lung metastases were noted 4 months later. Her treatment was changed to mFOLFOX6+bevacizumab (7 courses). After 4 months, the lung metastatic lesions had shrunk, but para-aortic lymph node metastases had developed. Eight months after the initial surgery, the isolated right external iliac lymph nodes and para-aortic lymph nodes were dissected. Pathological analysis led to a diagnosis of lymph node recurrence of ascending colon cancer. Recurrence was observed in multiple para-aortic lymph nodes 2 months after the surgery to treat recurrence. The patient was treated with FOLFIRI+bevacizumab as postoperative chemotherapy, and the patient passed away 30 months after the initial surgery. This case was considered to be of interest because local lymphatic flow was likely affected, as there was metastasis to the retroperitoneal lymph nodes and extensive colon cancer invasion with cecal involvement and severe lymph duct invasion.

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Meningeal carcinomatosis is a disease in which cancer cells diffusely spread to the leptomeninges. It is also called meningitis carcinomatosa. Only few cases of meningeal carcinomatosis arising from colorectal cancer have been reported so far. The case involved a 38-year-old man who was diagnosed with signet-ring cell carcinoma of the transverse colon following close exploration of intestinal obstruction and was operated on. The patient also had peritoneal dissemination and then adjuvant chemotherapy was performed. About eight months later, however, he developed severe headache and was diagnosed as having meningeal carcinomatosis by cytodiagnosis of cerebrospinal fluid. Since his general condition had been unstable, we could not give anticancer therapy. Creation of medullary-peritoneal shunt could provide an about one-week home care period, but he died about one month after the onset of headache.
Once meningeal carcinomatosis occurs, it can often be intractable and carries poor prognosis. Although meningeal carcinomatosis rarely arises from colorectal cancer, the frequency has been reported to be relatively high if the pathological type is poorly differentiated cancer or signet-ring cell carcinoma. In treating signet-ring cell carcinoma of the large intestine, we should keep a possibility of the disease in mind and early diagnosis and treatment are critical if the patient presents with neurological symptoms.

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A 77-year-old woman complaining of lower abdominal pain was referred to our hospital following unsuccessful treatment with antimicrobial agents. On admission, there was tenderness in the lower abdomen but muscle guarding was absent. The WBC count was 21,900/μl and the CRP level was 20.58mg/dl, showing elevated inflammatory response. An abdominal contrast-enhanced CT scan showed multiple diverticula and surrounding low density areas in the sigmoid colon. Intraabdominal abscess due to sigmoid colon diverticulitis was diagnosed. We performed operation because no symptomatic remission was gained. Upon laparotomy, we confirmed that the sigmoid colon was firmly adhered to the uterine and left adnexa and the uterine had swollen. Compression of the uterine produced defluxion of pus between the sigmoid colon and the uterine. Accordingly association of pyometra was determined, and sigmoidectomy, hysterectomy and left adnexectomy were performed. Histopathological study revealed an abscess cavity and the left adnexa with severe inflammation between the sigmoid colon and the uterine ; but it did not reveal colouterine fistula. From these findings, it is etiologically considered that intraabdominal abscess formation occurred due to sigmoid diverticulitis, followed by formation of the pyometra via the fallopian tube. Here we present a case of diverticulitis of the sigmoid colon associated with pyometra.

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We report a case of hemolytic renal dysfunction caused by rectal injury resulting from glycerin enema. The patient was a 58-year-old woman who was scheduled to undergo laparoscopic cholecystectomy because of the diagnosis of gallstone. On the day of surgery, she had anal pain and a small amount of anal bleeding after preoperative administration of glycerin enema. Nevertheless, the surgery was performed on schedule. During the surgery, hematuria was observed and urine output was low. After the surgery, hematuria continued and blood examination revealed hemolysis. The urine output was almost nil. On the day after the surgery, blood examination and computed tomography revealed acute renal failure and rectal perforation. Based on the patient's progress after the preoperative administration of glycerin enema, we made a diagnosis of hemolytic renal dysfunction caused by rectal injury resulting from glycerin enema. Thus, on the day after the surgery, hemodialysis was initiated to treat renal dysfunction and haptoglobin was administered to prevent the risk associated with hemolysis. Rectal perforation was treated conservatively. Hence, the patient recovered from both the renal dysfunction and rectal perforation. She was discharged on day 28 after the operation.

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A 76-year-old woman who had been admitted to another hospital for two months after fainting was detected to have a mass in her rectum during a computed tomographic scan, and she was referred to our hospital for further examination and treatment. A submucosal tumor of the rectum and enlarged lymph nodes were revealed by close exploration and rectal carcinoid combined with nodal metastases was suspected. She underwent low anterior resection of the rectum and D3 lymph node dissection. The pathological diagnosis was node-negative benign rectal schwannoma. Schwannoma is rare, especially in the large intestine. As it is very difficult to diagnose this disease preoperatively, tumor resection with lymph node dissection should be considered, if malignant schwannoma is suspected before operation.

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A woman in her sixties underwent right lateral and para aortic lymph node dissection due to postoperative lymph node metastasis from rectal cancer. Postoperatively, she experienced some episodes of small bowel obstruction due to postoperative lymphocele in the right obturator lymph node area. We considered fenestration of the lymphocele would be difficult because of adhesions in the pelvis, and performed drainage and sclerotherapy with OK-432. This approach was effective, the amount of drainage from the catheter decreased over time and the lymphocele eventually collapsed. Operations with retroperitoneal procedures may cause postoperative lymphocele. As lateral lymph node dissection procedures become common, demand for sclerotherapy will increase. Further investigations of OK-432 sclerotherapy are needed to evaluate safety and effectiveness.

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A 67-year-old man and a 62-year-old man were diagnosed with multiple rectal neuro-endocrine tumors from endoscopic examination. In Case 1, laparoscopic intersphincteric resection and colo-anal anastomosis were performed. In Case 2, laparoscopic super-low anterior resection was performed. Histopathologically, the tumor in Case 1 was confined to the submucosal layer, and showed lymphatic invasion. Case 2 showed venous vessel invasion and lymph node metastasis. Multiple rectal neuro-endocrine tumors are rare, and standard treatments have thus not been defined. Furthermore, according to some reports of neuro-endocrine tumors, the probability of lymph node metastasis is very high. We therefore consider that surgical resection with lymph node dissection should be performed.

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A woman in her eighties presenting with anal pain was referred to our hospital. Physical examinations revealed a hard rectal tumor protruding through the anus. Abdominal CT and MRI scans showed a huge tumor from the rectum to the anus accompanying by a pelvic lymph node enlargement. Although definitive preoperative diagnosis was not obtained, poorly differentiated malignant tumor was suspected because a biopsy of the tumor showed more than 90% of Ki-67 index. An abdominoperitoneal resection was performed. On histopathological examinations, the most of the tumor cells were immunohistochemically positive for neuroendocrine markers. The tumor was diagnosed as neuroendocrine carcinoma (NEC). Because the tumor cells were strongly positive for somatostatin receptor (SSTR) type 2 (SSTR2) and she was not be a candidate for general chemotherapy, we introduced i.m. administrations of octreotide LAR (30 mg) every 4 weeks. Despite extremely high Ki-67 index, she remains relapse-free for 2 years after the surgery. We recommend an application of octreotide as an adjuvant therapy for SSTR-positive NEC, when standard chemotherapy is not feasible as in the present case.

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A 65-year-old man presented with constipation and anal pain. Colonoscopy revealed advanced rectal cancer and he was referred to our hospital. Abdominal computed tomography scan showed a primary tumor which infiltrated into the prostate and levator ani muscles, perirectal abscess formation, and lateral lymph node swelling. He developed bowel obstruction due to the tumor during examination and emergency double barrel sigmoid colostomy was performed. After treating the abscess with broad spectrum antibiotics, chemoradiotherapy (500mgUFT/75mgLV and radiation at a total of 50.4Gy) was administered. The primary tumor showed a significant reduction in size and pelvic exenteration was performed. Adhesion ileus occurred postoperatively was conservatively treated and the patient was discharged on the 51st postoperative day. Histopathological examination showed no residual tumor cells in the primary lesion or regional lymph nodes. The effect of the preoperative chemoradiotherapy was rated as Grade 3, with a pathological complete response (pCR). The patient remains free of disease two years after the surgery without adjuvant treatment. Preoperative chemoradiotherapy is a viable treatment option for patients with advanced rectal cancer with abscess formation, if the abscess is managed appropriately.

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One of the most severe complications after laparoscopic unroofing for liver cysts is the formation of a biliary fistula caused by bile duct injury. Recently, intraoperative indocyanine green fluorescent cholangiography has been used to delineate the biliary tree and detect tumors during hepatobiliary surgery. We report a case of laparoscopic unroofing which was performed successfully using intraoperative indocyanine green fluorescent cholangiography. A female patient in her eighties with a liver cyst was admitted to our hospital due to right abdominal distension. Abdominal CT revealed a giant liver cyst causing right hydronephrosis ; therefore, laparoscopic unroofing was planned. During the operation, the large liver cyst containing clear cystic fluid was visualized with the laparoscope. Then, laparoscopic unroofing was performed without bile duct injury under the guidance of intraoperative indocyanine green fluorescent cholangiography. Indocyanine green fluorescent cholangiography is a simple and useful technique to avoid biliary injury during laparoscopic unroofing of liver cysts.

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A 62-year-old man who had received puncture, drainage and injection of ethanol for several times for multiple liver cysts which tended to enlarge at previous hospital developed infection of the treated cysts that acquired resistance against medical treatment. He was thus referred to our hospital. When he was first seen at our hospital, a drainage tube had been placed in the infected liver cyst in the hepatic right lobe, small quantities of bloody discharge persisted, and skin damage was associated. Right lobectomy of the liver was performed with a diagnosis of infected liver cyst and the drainage tube could be removed. The postoperative course was uneventful and he was discharged from our hospital. The wall of the infected hepatic cyst was white and thickened, and a intramural solid component was present. Histopathological studies revealed adenocarcinoma within the cyst and along the fistula. It has rarely been reported that polycystic liver disease is associated with a malignant neoplasm, but a possibility of the association must be kept in mind when an infected liver cyst is intractable for a long time.

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Hepatectomy with reconstruction of the hepatic vein using a patch graft is useful if the functional liver volume is not sufficient. We report the usefulness of this patch graft reconstruction in two cases of liver metastasis from rectal cancer involving the root of the middle hepatic vein (MHV).
Case 1 involved a 66-year-old man who had rectal cancer with concomitant liver metastasis in the segment IV, whose root of the MHV had been involved by the tumor. Considering liver impairment due to neoadjuvant chemotherapy, we performed left lobectomy with reconstruction of the MHV using an umbilical portion patch graft. An abdominal CT scan performed 7 months after the operation confirmed the patent MHV.
Case 2 involved a 75-year-old man who had rectal cancer with concomitant liver multiple metastases, whose root of the MHV had been involved by the tumor manly locating in segment II/III. We confirmed his functional liver volume to be insufficient and performed extended left lateral segmentectomy with the MHV and reconstruction of the MHV using an umbilical vein patch graft. We did partial resections for other tumors. An abdominal CT scan performed 8 months after the operation confirmed good blood flow through the MHV.
Reconstruction of the hepatic vein in hepatic resection for hepatic metastasis of colorectal cancer involving the root of the MHV is useful to maintain the functional liver volume as well as the radicalness of the treatment.

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Two patients with an aberrant right hepatic artery (ARHA) arising from the gastroduodenal artery (GDA) underwent pancreaticoduodenectomy (PD) for cholangiocarcinoma.
Case 1. A 66-year-old man who presented to our hospital with back pain. Case 2. A 62-year-old man who presented to our hospital with jaundice. In both patients, contrast-enhanced CT showed a mass in the distal bile duct, and 3-dimensional CT demonstrated an ARHA arising from the GDA. Both patients were treated by PD with preservation of the ARHA. Histopathology revealed R0 resection in both patients. The clinical stage was T1N0M0 (stage IA) in one patient, and T2N0M0 (stage IB) in the other patient. Dumping syndrome and grade B pancreatic fistula were encountered as the postoperative complications. Absence of recurrence was confirmed at follow-up performed at 29 months in one patient and at 13 months in the other. Careful preoperative imaging is necessary prior to PD in patients with an ARHA, and some caution is needed to preserve the ARHA during the surgery.

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A 60-year-old man who developed a bruise in the upper abdomen after he fell against an iron fence was admitted to our hospital. Abdominal CT scan showed injury of the head of the pancreas. Endoscopic retrograde pancreatography (ERP) showed no contrast medium leakage from the main pancreatic duct. We selected conservative treatment with an endoscopic nasopancreatic drainage (ENPD) tube placed in the main pancreatic duct. ENPD contrast examination on the second day showed contrast medium leakage from the main pancreatic duct at the pancreatic head. We diagnosed type IIIb pancreatic trauma, however, continued conservative treatment as the general condition of the patient was improving. The ENPD was exchanged for an endoscopic retrograde pancreatic drainage (ERPD) tube on the 25th day. The patient was discharged on the 36th day with the ERPD tube in place. The ERPD tube was removed after three months from the injury. A medical follow-up at 13 months revealed disappearance and absence of recurrence of the bruise.
Surgical treatment may be avoided in some case with type IIIb pancreatic trauma by instituting pancreatic drainage. It is necessary to accumulate further evidence to establish a standard therapeutic strategy for type IIIb pancreatic trauma.

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A 44-year-old man was referred to our hospital complaining of right hypochondralgia in June 2007. He had been diagnosed as to have cholelithiasis at a neighboring hospital since 2003, but he was asymptomatic. Laboratory data showed mild endocrine and exocrine dysfunction of the pancreas, though hepatic and biliary enzymes and tumor markers were in normal ranges. Imaging examinations (CT, MRI, ERCP and angiography) showed gallbladder, common bile duct and pancreatic stones, accompanied by pancreaticobiliary maljunction, and visualized a tumor image with stricture at the inferior bile duct. MRI showed the fatty replacement of the pancreatic body and tail. Angiography visualized the dorsal pancreatic artery. Laparotomy was performed with a suspicion of an intraductal tumor at the distal common bile duct (CBD). Intraoperative cholangioscopy and histological examination showed no malignancy. The CBD stones and pancreatic stones were removed without performing pancreatic resection. Choledochojejunostomy and pancreatic duct drainage were performed following CBD resection. Endocrine and exocrine functions of the pancreas were restored after the operation. The patient has been free from abdominal symptoms as of 8 years after the operation.

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The patient was 73-year-old woman who had no particular disease history. In August 2013, a bilateral pneumonia-like shadow was noted on chest radiography, and based on expectoration culture test and chest computed tomography (CT) findings, nontuberculous mycobacteriosis was suspected. Follow-up examination with contrast enhanced abdominal CT revealed a lymph node-like tumor with poor enhancement that were connected from the interior margin of the left renal vein to the pelvic cavity, around the left edge of the abdominal aorta. We suspected malignant lymphoma, and performed abdominal biopsy. Pathological findings confirmed solitary neurofibroma. Then, the retroperitoneal tumor was resected. Any tumor infiltration into surrounding organ was not observed nor remained macroscopically. Pathological findings indicated no malignancy. The patient made satisfactory progress, and no recurrence has been observed thus far.
Retroperitoneal solitary neurofibroma not associated with neurofibromatosis Type-1 is rare. We presented a case of the solitary neurofibroma originated in the retroperitoneal cavity, and review of the literature.

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An 88-year-old woman presented to the emergency department of our hospital with symptoms of ileus. Computed tomography revealed a left obturator hernia with small intestinal incarceration. We performed manual reduction under ultrasound guidance, followed by elective laparoscopic surgery. The second patient was a 77-year-old woman who presented to our hospital with a chief complaint of stomach ache. Computed tomography revealed a right obturator hernia with small intestinal incarceration. We performed elective laparoscopic surgery after manual reduction under ultrasound guidance. Laparoscopy revealed a bilateral obturator hernia ; hence, we performed bilateral repair with Paritex ProGrip^TM Mesh (Covidien). The postoperative course was good, and at 1-year follow-up, there was no sign of recurrence. An obturator hernia without strangulation can be treated with elective laparoscopic surgery after manual reduction, and hernia repair with self-gripping mesh is effective in preventing injury to the obturator nerve and corona mortis.

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We encountered a case in which the small intestine was embedded in the peritoneal defect after totally extraperitoneal (TEP) inguinal hernia repair, causing ileus. An 84-year-old male underwent TEP right inguinal hernia repair. He developed ileus on postoperative day 3. Computed tomography revealed intestinal prolapse into the preperitoneal cavity, and we inserted an ileus tube for decompression. On postoperative day 4, he complained of abdominal pain, and had no symptom improvement. Thus, we performed a reoperation. Laparoscopic peritoneal inspection showed that the small intestine was embedded in the preperitoneal cavity at the peritoneal defect, and partially impeded blood flow was observed. The peritoneal defect was enlarged to approximately 5 cm, and we closed the peritoneum with sutures to finish the operation. The peritoneal defect was initially about 1 cm in size. When there is a risk of intestinal prolapse into the preperitoneal cavity, closure with sutures is necessary if a peritoneal defect is observed in advance.

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A 42-year-old woman visited our hospital because of a left inguinal tumor. The tumor was elastic and soft with poor mobility on palpation. Since we could not rule out a possibility of malignancy, imaging studies were performed. An abdominal computed tomography (CT) scan showed a low-density mass 6 cm in diameter with fat-like density in the left inguinal region. Magnetic resonance imaging (MRI) showed a high intensity mass, which had cord-like strucuture, on T1/T2-weighted images. From these findings, liposarcoma was strongly suspected. Since the tumor showed an enlarging tendency, tumorectomy was performed with some surgical margin including the left round ligament and the skin. Histopathological examination showed intricate mixtures of mature adipose tissue and bland smooth muscle with no cellular atypia. The pathological diagnosis was myolipoma. Myolipoma of the soft tissue is rare. We present this case with a review of the literature.

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A 68-year-old man who presented to the emergency room with complaints of fever and right lower quadrant abdominal pain was diagnosed with ascending colon diverticulitis. Two days later, he came to our department with increasing right groin pain and swelling. On examination, we identified a painful mass in the right groin that was irreducible and erythematous. The laboratory data revealed leukocytosis and high C-reactive protein level. Enhanced abdominal computed tomography showed a suspicion of intestinal prolapse in the right groin. A diagnosis of right incarcerated inguinal hernia was made and emergency surgery was performed. On diagnostic laparoscopy, we identified a small hernia orifice in the right femoral area, but no abdominal organ was prolapsed. A small amount of turbid fluid was drained from the femoral hernia orifice. We performed high ligation of the hernia sac, and repaired the hernia with a mesh plug via the anterior approach. A thickened peritoneal membrane with inflammation and neutrophil infiltration was observed on pathological examination ; thus, we diagnosed a femoral hernia abscess caused by ascending colon diverticulitis.

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A 79-year-old woman who received an antithrombotic agent for a chronic myeloproliferative disorder complained of abdominal pain and nausea from the previous day and was admitted to our hospital. Abdominal computed tomography showed a giant hematoma expanding from the lower rectus abdominis muscle into the pelvic retroperitoneum. Emergency surgery was performed with the diagnosis of intraabdominal bleeding, gradual worsening of anemia, and decreasing blood pressure. Bleeding from a ruptured left inferior epigastric artery was found, and a rectus sheath hematoma expanding into the pelvis was diagnosed. The artery was ligated and the hematoma was removed. The patient was discharged and had no serious postoperative complications, except for hemorrhagic gastric ulceration. Recognition of the factors predisposing to such a hematoma in aging patients and those receiving antithrombotic therapy is important.

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We report three patients diagnosed with Burkitt lymphoma after emergent surgery. Case 1 involved a 54-year-old man who was referred to our hospital for back pain, lower abdominal pain, and oliguria. Symptoms worsened within 1 week. Emergency surgery was performed. The intestinal wall appeared thickened overall and a tumor was identified in the terminal ileum. The tumor was resected and ileostomy was carried out. Burkitt lymphoma was diagnosed on pathological examination. Chemotherapy was performed and the patient showed complete response. Case 2 involved a 72-year-old woman who came to our hospital with fever and backache. She showed multiple tumors with ulceration in the stomach on gastrointestinal endoscopy. Because stopping bleeding from the gastric tumor was difficult, she underwent emergency gastrectomy. She was diagnosed with Burkitt lymphoma by pathological examination and received chemotherapy. However, she died 30 days after surgery because of bone marrow invasion. Case 3 involved an 82-year-old man who was referred to our hospital with a 1-week history of abdominal pain and distension. He underwent emergency surgery under a diagnosis of appendicitis. The tip of the swollen appendix adhered to a tumor of the omentum, so appendectomy including the omentum was performed. He was diagnosed with Burkitt lymphoma, received chemotherapy, and achieved complete response.

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Screening CT for a 44-year-old man who had been treated for myotonic dystrophy (MD) revealed abnormal wall thickening in the stomach and ascending colon. Upper gastrointestinal endoscopy revealed a type 0—IIc early gastric cancer in the anterior wall of the lesser curvature of the stomach. Colonoscopy revealed a type 1 colon cancer in the ascending colon. We performed laparoscopic distal gastrectomy and laparoscopic right colectomy at the same time. Anesthesia was maintained with total intravenous anesthesia. Postoperatively, no complications were identified, and he was discharged on postoperative day 10. We present a rare case of a patient with MD who was successfully treated with one-stage laparoscopic resection for gastric cancer and colon cancer.

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