[Objectives] This study was made to clarify surgical outcomes of pancreaticoduodenectomy (PD) and postoperative long-term changes in nutritional indexes in elderly patients. [Subjects and methods] We enrolled a series of 100 patients undergone PD in our institution from 2009 to 2014. The subjects were divided into the elderly group comprising 20 patients of age 75 or over and the non-elderly group comprising 80 of age 74 or under. These two groups were compared for surgical outcomes and perioperative time-dependent changes in the total protein (TP), serum albumin (A1b), hemoglobin, number of lymphocytes, and Onodera's prognostic nutritional index (PNI). [Results] No statistically significant differences were noted in the surgical outcomes of PD between both groups. In the elderly group, significant decreases were noted in TP at postoperative 1 year, Alb at postoperative 3 months and one year, and PNI at postoperative one week and one year. A comparison between preoperative and postoperative 1 year values revealed no significant differences in TP, A1b, lymphocytes number, and PNI. [Conclusion] Surgical outcomes and postoperative changes in the nutritional indexes after PD in the elderly were almost comparable to those in non-elderly patients.

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Introduction : Hydrocele of the canal of Nuck may be a cause of inguinal swelling in females, and complications such as endometriosis and adenocarcinoma have been reported. Complete surgical excision is recommended. We report on our diagnosis and management of hydrocele of the canal of Nuck. Patients and methods : This study included 111 females who underwent surgery for inguinal swelling over the past 5 years at our hospital. Results : Canal of Nuck hydrocele was diagnosed in 19 of these 111 patients, and another 92 patients had inguinal hernia. Preoperative CT offered 84.2% sensitivity and 96.7% specificity. During laparoscopic inguinal hernia repair in patients in whom a canal of Nuck hydrocele could not be diagnosed by CT, the diagnosis was made by traction on the round ligament of the uterus. Histopathology showed endometriosis in 2 of the 19 patients with canal of Nuck hydrocele. Conclusion : Preoperative CT is useful for diagnosing canal of Nuck hydrocele but is not perfect. Surgery in women with inguinal swelling should be carefully selected, keeping in mind the possibility of canal of Nuck hydrocele.

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A 72-year-old man diagnosed with esophageal cancer, cT3N1M0, cStage III, underwent neoadjuvant chemoradiotherapy (NACRT) followed by subtotal esophagectomy by laparoscopy-right thoracotomy approach with 3-field lymph node dissection and retrosternal reconstruction. His postoperative course was uneventful and oral intake was resumed on the 7^th postoperative day. However, high fever and chill developed in the next early morning, and a blood culture yielded Acinetobacter species. The patient also developed DIC. Although no apparent source of infection could be identified, his general condition gradually improved with chemotherapy associated with treatments for DIC. Thereafter he did not have demonstrable complications and was discharged from our hospital on the 28^th postoperative day. Histopathology revealed disappearance of tumor cells by NACRT.
NACRT is considered to be an effective therapy, but particular attention should be paid to opportunistic infections due to weakened immune system during perioperative period, like in our case.

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Case 1 : The patient underwent total thyroidectomy with tracheal resection, followed by local recurrence. Radioactive iodine (RAI) (I¹³¹), external beam radiotherapy (EBRT) and sorafenib were administered ; however, the disease progressed, thus lenvatinib was prescribed. During the next three months, perforation of the trachea was detected and lenvatinib was withdrawn. One month later, the tracheal fistula closed naturally. Case 2 : The patient underwent total thyroidectomy, followed by local recurrence. EBRT and chemotherapy was administered but was ineffective. Lenvatinib was initiated and with in a week, skin perforation was observed, which was quickly resolved. Case 3 : The patient was diagnosed with papillary thyroid cancer and bone metastasis in C6 of the spine. The patient initially underwent EBRT, followed by total thyroidectomy. However, local recurrence with invasion to the esophagus was detected and stenosis of the esophagus worsened. Lenvatinib was initiated and within a week, perforation of the esophagus led to its discontinuation. The fistula closed naturally within three months.
The possibility of perforation should be noted in cases of invasive thyroid cancer in which lenvatinib is prescribed after EBRT ; however, perforation can be cured naturally following discontinuation.

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Toxic shock syndrome (TSS) is a rare but life-threatening condition caused by toxins produced by the Staphylococcus species of organisms.
Diagnosis of postoperative TSS is often challenging because patients may present with generalized systemic symptoms and rarely show signs of local wound infection.
A 70-year-old woman with history of undergoing bilateral mastectomies for breast cancer presented with diarrhea, vomiting, and high fever. She developed a diffuse rash on the upper part of her body the following day. She rapidly developed hypotension, renal failure, and disseminated intravascular coagulation leading to a clinical suspicion of septic shock. Although her wound was clean, we opened the surgical wound and observed no abscess formation. A small amount of serous discharge was sent for culture analysis, which revealed methicillin-sensitive Staphylococcus aureus infection, and the toxic shock syndrome toxin antigen was positive. Antibiotics and intravenous immunoglobulin were administered, and on day 6, we performed surgical debridement of the wound. The patient gradually recovered and was discharged a month postoperatively.

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Adenomyoepithelioma (AME) is a benign tumor characterized by biphasic proliferation of both epithelial and myoepithelial cells, and in some cases can become malignant. We report 2 cases of malignant AME of the breast.
Case 1 was a 68-year-old woman. A tumor was located in the right breast, measuring 14 mm in diameter. The tumor appeared as a lobulated mass. Core needle biopsy revealed both AME and ductal carcinoma, suggesting a coexistence between both lesions. Partial resection was performed. Microscopically, the epithelial cells of the AME had become malignant and we diagnosed the tumor as an AME with ductal carcinoma in situ (DCIS).
Case 2 was an 81-year-old woman with a tumor located in the right breast, measuring 35 mm in diameter. The tumor appeared as an irregularly-shaped mass. Core needle biopsy revealed a malignant AME ; a malignant phyllodes tumor was also suspected. A mastectomy with axillary lymph node dissection was performed. Microscopically, the myoepithelial cells of the AME had become malignant. Three months after the operation, radiology showed multiple lung, liver and bone metastases, and the patient subsequently died 6 months later.
AME is difficult to diagnose by core needle biopsy and the prognosis of malignant AME is very poor. Surgical biopsy should be performed for definitive diagnosis. It is important to resect the tumor before it starts growing.

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We report an extremely rare and suggestive case of metachronous bilateral breast cancer associated with neurofibromatosis type1 (NF1) and complete visceral inversion (situs inversus totalis). Metachronous left breast cancer occurred 10 years after right breast cancer which was non-palpable carcinoma detected by screening examinations. She had an identical twin who also developed breast cancer. It was suggestive that twin sisters from a family with NF1 had breast cancer NF1 also called von Recklinghausen disease is an autosomal dominant hereditary disease characterized by multiple café au lait spots, axillary and inguinal freckling and multiple cutaneous neurofibromas. It is caused by mutations in the NF1 gene which is located on chromosome 17q. Recently NF1 is recognized as one of the hereditary cancer predisposition syndromes. Therefore, recognition of this syndrome has significant importance of cancer screening.

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A 63-year-old woman was brought into our hospital by ambulance because of vomiting after dinner and subsequent chest and back pain. A chest CT scan revealed left pneumothorax with pleural effusion and periaortic mediastinal emphysema. Esophagogram showed extravasation of contrast medium from the esophagus into the thoracic cavity. Spontaneous esophageal rupture was diagnosed. The patient was a candidate for surgery, but she refused to undergo surgery which entailed a possibility of blood transfusion owing to her religious reason. Accordingly after complete fasting and administration of antibiotics, we inserted an elemental diet tube equipped with vaccum lumen as well as two thoracic drains under thoracoscopy. Her general condition was unstable, but intrathoracic lavage and tube feeding were performed. Esophagography conducted on the 48^th hospital day confirmed disappearance of leakage of contrast medium. Oral intake was resumed and she was discharged from our hospital on the 81^st hospital day.
Spontaneous rupture of the esophagus with thoracic perforation is associated with high mortality and requires emergency surgery as a rule. However, appropriate intrathoracic drainage and enteral nutrition using an elemental diet tube equipped with vaccum lumen could be a choice of therapy.

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A 70-year-old woman visited our hospital complaining of worsening dysphagia. She underwent left mastectomy for left breast cancer (Stage IIb) 10 years previously and was given oral anastrozole as adjuvant hormonal therapy for 7 years after completion of adjuvant chemotherapy. She had been on retreatment by hormonal therapy for left supraclaviclar lymph node recurrence detected 9 years postoperatively. Upper gastrointestinal endoscopy revealed stenosis encircling the entire circumference of the middle thoracic esophagus without mucosal change and the endoscope could not pass through beyond this point. No malignant findings were detected in the biopsy tissue and treatments with balloon dilatation catheter and stent placement were difficult. As positron emission tomography (PET) examination showed limited bone and lymph node metastases, video-assisted thoracoscopic subtotal esophagectomy (VATS-E) was carried out with intent to make the precise diagnosis and to ameliorate dysphagia. The pathological diagnosis was esophageal metastasis of breast cancer. Minor anastomotic leakage occurred but healed with conservative management. She was discharged on day 30 after the operation. Over the following eight months, her oral intake gradually recovered and she is treated with chemotherapy. Chemotherapy is generally chosen for treatment of esophageal metastasis from breast cancer, but VATS-E is a potential option for achieving symptomatic amelioration.

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Introduction : Although afferent loop syndrome associated with gastric cancer often requires surgical treatment, it remains unclear whether invasive procedures are appropriate for terminal cancer patients. Case : A 57-year-old man had undergone Roux-en Y reconstruction for distal gastrectomy. Multiple peritoneal dissemination nodules were observed and the histopathological diagnosis was poorly differentiated Stage IV adenocarcinoma. During postoperative chemotherapy, the patient developed a complicated malignant bowel obstruction. A segmental resection of small intestine with a concomitant colostomy did not improve the symptoms ; therefore, the treatment goal was shifted to palliative care for better quality of life. However, stiffness and pain in the lower back with high fever occurred subsequently. As a blood test and abdominal computed tomography (CT) indicated afferent loop syndrome, we performed a percutaneous transhepatic biliary drainage. A catheter tip was also successfully inserted into the duodenum to reduce the pressure of the afferent loop. Subsequently, the back pain improved. The patient was discharged from hospital and began to receive home care services. Conclusion : Our experience suggests that decompression of afferent loop syndrome through percutaneous transhepatic biliary drainage is a promising option for the treatment of afferent loop obstruction due to peritoneal dissemination, even in terminal patients.

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The patients were a 63-year-old and 61-year-old male siblings with familial adenomatous polyposis (FAP). During follow-up after subtotal colectomy, both were diagnosed as having early gastric cancer with multiple adenomas in the pyloric antrum ; distal gastrectomy, and not endoscopic excision, was performed owing to the presence of the cancer lesion. The disease was classified as pT1a (M)N0M0, pStage IA. There are only 19 reported cases of gastric cancer associated with FAP in Japan. Ten out of 15 mucosal or submucosal invasive lesions were operatively resected in the foregoing reports. Although malignant transformation of multiple adenomas is known, H. pylori infection was considered as the predisposing factor for the malignancy in our cases. It is important to screen FAP patients for H. pylori infection and carefully decide the surgical procedure for early gastric cancer in patients with FAP.

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The patient was a 94-year-old woman who had been referred to our hospital because of anemia. Abdominal CT showed a solid tumor, 50 mm in diameter, in the duodenal bulb. Upper gastrointestinal endoscopy showed transpyloric prolapse of a type 1 gastric cancer. Her diagnosis was gastric cancer prolapsing into the duodenal bulb. Distal gastrectomy was performed, and the resected specimen was a type 1 tumor, 60 × 50 mm in size, located in the pyloric ring. Histopathological examination showed tub2 > tub1, pT2 (MP), int, INFb, ly2, v2, pN0, pPM0, pDM0, and pStage IB. Gastric tumors prolapsing into the duodenal bulb are usually early gastric cancers, while advanced gastric cancer is reportedly rare. It is possible that the tumor diameter and the presence of ball valve syndrome provided an indication for the preoperative evaluation of depth of invasion in this case.

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We report a case of gastric cancer that metastasized from ovarian cancer. A-69-year-old woman had undergone total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic lymphadenectomy for ovarian cancer following neoadjuvant chemotherapy. Two years and 5 months after the operation, she was admitted to our hospital with abdominal pain. Gastroscopy revealed a type 2 tumor and a biopsy was performed. Histology showed that the tumor was a serous adenocarcinoma similar to the primary ovarian cancer, which led to a diagnosis of metastatic gastric cancer originating from the ovarian cancer. Computed tomography (CT) scan showed that the tumor had directly invaded the pancreatic body ; thickening of the lower third of the stomach wall and swelling of the abdominal para-aortic lymph nodes (PAN) were also identified. According to the ovarian cancer treatment guidelines (2015), we planned a secondary debulking surgery. After chemotherapy, the pancreatic invasion disappeared. Distal gastrectomy, D2 lymphadenectomy and PAN lymphadenectomy were performed. The postoperative course was uneventful and the patient has remained free of disease since the operation.

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A 66-year-old man was admitted to our hospital with abdominal pain. Conservative treatment was administered according to a diagnosis of acute aggravation of chronic pancreatitis. In response to continued hyper-cancer antigen (CA)19-9 hematopoiesis, we performed a computed tomography (CT) and found a tumor showing contrast enhancement in the duodenal bulb. Esophagogastroduodenoscopy (EGD) showed that the tumor exceeded 10 mm in size ; therefore, distal gastrectomy (D2) and partial duodenectomy were performed. There was no lymph node metastasis upon postoperative pathological examination. Tumor diameter, invasion depth, and presence or absence of mitotic images are important factors for predicting metastatic risk in duodenal neuroendocrine tumors ; however, the optimal treatment strategy and operative techniques remain unknown.

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A 40-year-old woman with a chief complaint of hematuria was evaluated in the urology department at our hospital. An intraperitoneal cystic mass was found, and she was referred to our department. Abdominal computed tomography showed a 50-mm cystic mass in the dorsal ascending colon. Surgical resection for diagnosis was planned, and ileocecal resection was performed. Histopathology revealed metastatic adenocarcinoma involving the ascending colon, but further evaluation including FDG-PET failed to identify the primary lesion.
Primary ovarian lesion was suspected, so bilateral ovariectomy was performed. However, no evidence of ovarian malignancy was identified, so unknown primary cancer was diagnosed. No postoperative chemotherapy was given, on the request of the patient, and the patient was followed-up. As of 9 months after resection of metastatic adenocarcinoma, no recurrence or primary lesion has been found, and the patient is continuing outpatient follow-up.
Lymph node metastases from cancer of unknown primary are common, but cystic metastases to the colon from unknown primary cancer have not previously been reported in Japan. We report this case of unknown primary cancer with cystic metastases to the ascending colon.

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A 77 year old female patient presented to us with a history of abdominal pain and a palpable abdominal mass. Further examination revealed transverse colon cancer with extramural progression and multiple liver metastases. Accordingly, transverse colectomy was performed. Histopathological examination of the resected specimen revealed poorly differentiated adenocarcinoma with CK7^-/CK20⁺. Despite treatment with three courses of mFOLFOX6 and bevacizumab following the colectomy, the patient died of progression of the liver metastases and the development of peritonitis carcinomatosa. This case report gives details about the very rarely encountered poorly differentiated adenocarcinoma of the transverse colon with extramural progression.

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A 77-year-old man visited our hospital with abdominal pain. A chest CT scan revealed a 7-cm diameter mass in the right lung and an abdominal CT scan showed intussusception with a tumor in the lead in the sigmoid colon. We diagnosed the case as intussusception of the sigmoid colon and metastatic cancer of the lung, and performed sigmoid colectomy and biopsy of the lung tumor. The resected specimen was a type I tumor sized 45×45×40 mm in dimension. Immunohistochemical analysis yielded positive results for cytokeratin (CK) 7 and thyroid transcription factor-1(TTF-1), and a negative result for CK20. Intussusception caused by colonic metastasis of lung cancer was finally diagnosed. As intussusception caused by colonic metastasis of lung cancer is rare, we present our case with a review of the literature.

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A 69-year-old man visited the hospital with a 2-day history of abdominal pain and a large mass in the left lower abdominal quadrant. Abdominal CT revealed a large mass of the descending colon with telescoping of the colonic segment into the distal colon ; the patient was diagnosed as having intussusception and referred for surgery. We decided to perform elective surgery as there was no sign of intestinal obstruction, and performed MRI before the operation. The preoperative diagnosis was a 12-cm sized tumor of the descending colon with intussusception ; the possibility of malignancy could not be ruled out.
A left hemicolectomy with lymphnodectomy (D3) was performed. During the operation and after the resection, the intussusception persisted. The tumor was finally diagnosed, based on histopathology and immunohistochemistry, as a leiomyosarcoma. The postoperative course was uneventful and the patient has shown no signs of recurrence over the two years since the operation.

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A 64-year-old man was presented with abdominal distension and poor appetite was diagnosed as having colonic obstruction associated with anatomical anomaly of the intestine by close exploration. An expandable metallic stent was placed under colonoscopy. A tumor completely encircling the sigmoid colon was found. It was histologically diagnosed as well differentiated adenocarcinoma. A CT angiography identified that the inferior mesenteric artery (IMA) had branched from the median of the abdominal aorta and pursued the bilateral symmetry course against the usual run. Laparoscopic resection was electively performed. During the surgery, another tumor was detected at the terminal ileum. Ileocecal excision was added and the pathology showed the tumor to be primary cancer of the small bowel.
Sometimes we encounter case reports on gastrointestinal cancer associated with intestinal malrotation. However, our case is extremely rare in terms of its anatomical characteristics that the IMA pursued the bilateral symmetry course and the colon from the descending to the sigmoid colon was located in the right side of the abdomen, as well as of synchronous double cancer involving the sigmoid colon and the small bowel. We thus present our case.

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A 90-year-old woman who had undergone Miles' operation for rectal cancer 23 years earlier was hospitalized for dementia and disuse syndrome ; while at hospital, she developed fever of unidentified cause and frequent leakage of feces from her ostomy pouch. She was referred to our hospital for treatment. We found a fistula around the stoma. Abdominal CT revealed a subcutaneous abscess around the stoma and stomal stenosis. We performed a seton procedure. A gastrointestinal barium series revealed the absence of any diverticula in the sigmoid colon. Therefore, we made the diagnosis of idiopathic stomal fistula. Although we dilated the stoma after the operation, the fecal fistula failed to improve. The patient continued to have frequent leakage of feces from the ostomy pouch. We changed the pouch to a one-piece ostomy system every 2-3 days and the problems resolved. She was transferred to her earlier hospital on the 28th postoperative day. While the abscess cavity was becoming smaller, the seton loop cut through the skin inside the loop and the fistula became an excretory duct. While under observation for that process, she has had no stomal troubles during the 10 months since the operation.
We report this case in which the seton procedure in a very elderly patient whose activities of daily living had deteriorated because of idiopathic stomal fistula resulted in avoidance of reconstruction of colostomy.

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A 64-year-old man presented with fever and right upper abdominal quadrant pain was referred to our hospital. Blood analysis revealed increased inflammatory reaction and an abdominal CT scan showed a 50-mm low density area with irregular margin in the posterior segment of liver. He was emergently admitted with a suspected diagnosis of hepatic abscess. Percutaneous transhepatic biliary drainage performed on the next day did not aspirate purulent fluid but only blood. Furthermore histopathology of a fine needle biopsy specimen revealed atypical cells suggestive of malignancy. A possibility of a tumor derived from the vessel was also suspected. Despite sustained chemotherapy after admission, high fever and increased inflammatory reaction persisted and the hepatic function gradually deteriorated. We considered that hepatic resection was only one therapy for the hepatic lesion if it was malignant, and performed posterior segmentectomy of liver and cholecystectomy on the 22^nd hospital day. However, the operation did not result in curative resection. Although fever and abdominal pain temporarily relieved after the operation, he died on the 25^th postoperative day. The histopathological diagnosis was hepatic angiosarcoma with concomitant existence of multinucleated osteoclast-like giant cells.
As our case is the first report describing that hepatic angiosarcoma coexisted with osteoclast-like giant cells in Japan, we present our case together with a review of the literature.

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The patient was a 65-year-old man who underwent low anterior resection of the rectum with D3 lymph node dissection for rectal cancer and synchronous hepatic metastasis 2 years and 5 months earlier. The histopathological diagnosis was SS, N1, M1a (HEP), and chemotherapy with CapeOX regimen was started. The therapeutic effect of PR was attained. One year and 7 months earlier, he underwent the first stage of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), comprising S3 segmentectomy, ligation of the right branch of portal vein and hepatic resection, followed by the second stage of ALPPS (right lobectomy). He experienced hepatic metastases in three sites one year and 2 months earlier when he had been on adjuvant chemotherapy (UFT/LV). We thus started capecitabine + Bmab administration. Since no new lesions appeared and the chemotherapy had to be withdrawn due to hand-foot syndrome, laparoscopic partial hepatectomy for three metastatic lesions was performed. He has been doing well, as of 11 months after the last operation.
Hepatic metastasis of colorectal cancer can recur after surgery, so that we have to pay consideration to the possibility of rehepatectomy. This case where we were able to perform laparoscopic hepatectomy after ALPPS is presented here with a review of the literature.

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An 81-year-old man was admitted to our hospital because of abdominal pain. Abdominal CT showed calculus of the common bile duct and a fluid collection under the left diaphragm. On the same day, the patient underwent emergency surgery. The intraperitoneal space was filled with bile and ascites. The surface of the liver showed a pinhole and a bile fistula. Intrahepatic bile duct rupture was diagnosed, and partial hepatectomy, cholecystectomy, and choledocholithotomy were performed, with placement of a T-tube. The patient's postoperative course was favorable, resulting in discharge 25 days after surgery. Bile peritonitis due to spontaneous bile duct rupture is rare. Among such cases, intrahepatic bile duct rupture is even rarer and has almost never been reported. Though this disease is very rare, it should be included in the differential diagnosis of bile peritonitis.

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An 83-year-old woman was brought into our hospital because of dyspnea and thoracoabdominal pain. Initially, she was suspected to have gallbladder carcinoma with hemorrhage by physical/blood biochemical findings, abdominal CT and MRI scans. As bleeding stopped spontaneously and she was elderly and had dementia, we decided to follow her clinical course.
Thereafter she had recurrent bouts of pain of the thoracoabdominal region and tarry stool. Another abdominal CT scan revealed hemobilia and an aneurysm of the cystic artery. We assessed that the bleeding might be originated from the aneurysm of the cystic artery. After embolization of the cystic artery for the aneurysm, laparoscopic cholecystectomy was carried out. Histologically, the gallbladder was diagnosed to develop xanthogranulomatous cholecystitis, and the aneurysm of the cystic artery was pseudoaneurysm.
We performed laparoscopic cholecystectomy safely for aneurysm of the cystic artery following arterial embolization.

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A 44-year-old woman with sudden-onset severe abdominal pain was brought to our hospital by ambulance. Computed tomography (CT) scan showed coupled cystic lesions presenting as a 70 mm unilocular cystic lesion in the pancreatic tail, and a 95 mm unilocular cystic lesion in the stomach wall. Endoscopic ultrasound showed a unilocular anechoic cystic lesion with a thick wall in the pancreatic tail, which communicated with a multilocular cystic lesion in the stomach wall. Fine needle aspiration identified bloody fluid in the stomach cyst. Amylase and carcinoembryonic antigen (CEA) levels were elevated in the fluid. We diagnosed mucinous cystic neoplasm of the pancreatic tail perforating into the stomach wall with hemorrhage. Distal pancreatectomy with resection of the cystic lesion in the stomach wall was performed. The histopathological diagnosis was mucinous cyst adenoma of the pancreas with ovarian-like stroma. Analysis of the fluid showed that the amylase level was high in both lesions, suggesting that the mucinous cyst adenoma had communicated with the pancreatic duct and enlarged, before perforating the stomach wall.

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The patient was a 74-year-old woman who had undergone subtotal stomach-preserving pancreatoduodenectomy for invasive ductal carcinoma. After undergoing postoperative adjuvant Titanium silicate (TS-1) chemotherapy for 6 months, she was followed up at an outpatient clinic, and cancer antigen (CA) 19-9 was found to be elevated during a regular examination 18 months post-surgery. A contrast-enhanced abdominal computed tomography (CT) scan revealed a low-density area in the pancreas body ; thus, the patient was diagnosed with residual pancreatic cancer and underwent completion pancreatectomy. Pathological examination revealed the tumor as an adenosquamous carcinoma, which was subsequently diagnosed as a metachronous pancreatic cancer based on the fact that the histological diagnosis of the initial and residual cancer differed from one another, and because both pancreatic margins were negative. This is the second reported case of residual pancreatic adenosquamous carcinoma cancer in Japan. Invasive ductal carcinoma is associated with poor prognosis ; however, recently there have been several reports of residual pancreatic resection for metachronous pancreatic cancer. During follow up after surgery for pancreatic cancer, it is extremely important to consider both postoperative recurrence as well as potential development of metachronous pancreatic cancer.

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A 69-year-old man was referred to our department due to frequent urination, computed tomography (CT) revealed a huge pelvic mass pressuring the bladder and prostate to the right with no signs of direct invasion. No diagnosis was possible with imaging studies alone. En-bloc resection was deemed possible ; therefore, no biopsy was performed preoperatively. Surgery revealed a tumor mainly in the peritoneum and retroperitoneum extending deep into the right inguinal canal. The extracted tumor was 26 cm in diameter and weighed 2030 g. The tumor consisted of a mixture of multi-cystic jelly and solid components. Pathologically, the tumor consisted of spindle cells showing a “patternless pattern”. Immunohistochemical staining showed positive expression for cluster of differentiation (CD) 34, CD99, B-cell lymphoma 2 (Bcl-2), and signal transducer and activator of transcription 6 (STAT6). A final diagnosis of solitary fibrous tumor (SFT) was confirmed.
We report a rare case of SFT that presented with an obscure symptom, i.e., frequent urination.

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Identification of the site of origin and qualitative diagnosis of giant tumors occupying the pelvic cavity is difficult. We report a case of a giant leiomyoma originating from the pelvic retroperitoneum. The patient was a 26-year-old woman who was examined by a local doctor for complaints of nausea and diarrhea. A pelvic mass was identified on abdominal ultrasound, and she was referred to our hospital. A giant mass occupying the pelvic cavity was revealed by various imaging modalities ; however, no infiltration of the surrounding tissue was identified. Findings on the cranial and caudal sides of the tumor differed. Aggressive angiomyxoma was suspected preoperatively, and surgery was performed to remove the pelvic tumor, which was attached only to the retroperitoneal pelvic floor. The site was dissected and a giant tumor—25.5 cm in diameter—was removed. The results of histopathological and immunohistological tests led to a diagnosis of leiomyoma with myxoid degeneration. Herein, we present this case together with a review of the literature.

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We treated a 73-year-old man who reported history of having undergone a Bentall operation for aortic dissection and stent grafting for a thoracoabdominal aortic aneurysm. He had been administered warfarin potassium for his history of atrial fibrillation. He presented to our hospital with a right inguinal swelling, which was diagnosed as a right inguinal hernia, The Lichtenstein procedure was performed under general anesthesia after preoperative heparinization. Heparin administration was resumed the day after surgery. He developed a marked superior to subcutaneous swelling the wound site 2 days postoperatively. Hematological findings showed a drop in his hemoglobin level and platelet count. Contrast-enhanced computed tomography revealed a rectus sheath hematoma and leakage of contrast medium. Because conservative treatment was considered difficult, we performed angiography, which revealed hemorrhage from the right-sided deep circumflex iliac artery, and arterial embolization with N-buty1 cyanoacrylate-lipiodol was performed. Subsequently, anticoagulant therapy was resumed, and no additional hemorrhage was reported during the 8-month postoperative follow-up. Although the development of rectus sheath hematomas following inguinal hernia surgery is rare, we report a patient in whom hemostasis could be achieved using interventional radiology.

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An 83-year-old man was evaluated for right inguinal bulging that he had first noticed during childhood. Examination showed a bulge the size of a small child's head extending from the right inguinal region to the thigh. A left inguinal bulge the size of a fist was also noted. Abdominal computed tomography showed ileal, right colon, and omental protrusion into the right inguinal hernia ; and bladder protrusion into the left inguinal hernia. Nonreducible giant inguinal hernias were diagnosed, and single-incision laparoscopic totally extraperitoneal repair (SIL-TEP) was used to repair bilateral hernias.
Early postoperative seroma was noted, but improved with conservative management. The patient has shown a good postoperative course over 9 months without hernia recurrence. SIL-TEP : 1) is aesthetically superior ; 2) permits safe reduction of hernial contents and treatment of the hernial sac ; and 3) enables wide extraperitoneal dissection for sufficiently large mesh placement. We believe that SIL-TEP may become the surgical procedure of choice for nonreducible giant inguinal hernia.

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A 63-year-old man with left inguinal bulging that had remained untreated for 6 years was evaluated for difficulty in urination associated with hernia enlargement. Physical examination revealed protrusion of a left hernial sac that reached to the knee with the patient standing. The hernia could not be manually reduced. Computed tomography showed protrusion of the small intestine, ascending colon, and sigmoid colon. Surgery was started using a laparoscopic approach, but the hernia was not reducible due to adhesions between the incarcerated bowel and hernia sac, so surgery was converted to an anterior approach. After hernia reduction, the peritoneal cavity was explored laparoscopically. No disruption in blood supply to the bowel was noted, and surgery was completed.
Postoperatively, abdominal compartment syndrome (ACS) was suspected, so the patient was intubated and managed in the intensive care unit (ICU). Mechanical ventilation was required for 4 days because of cardiorespiratory failure associated with ACS, but even after extubation, weaning from noninvasive positive pressure ventilation was difficult. The patient was transferred out of the ICU on postoperative day 11, and was discharged home on postoperative day 24.
This patient with giant inguinal hernia experienced postoperative ACS that could not be avoided even with combined laparoscopy and open surgery. The surgical procedure and perioperative management in such patients must be carefully planned.

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A 57-year-old man was evaluated for a chief complaint of right inguinal swelling. Computed tomography (CT) showed a 34×26 mm mass consistent with an enlarged inguinal lymph node. Excisional biopsy of the lymph node was performed, and histopathological examination showed findings of neuroendocrine carcinoma. However, a systemic search including endoscopy and positron emission tomography-CT found no evidence of a primary lesion. Immunohistochemistry (IHC) showed positive results for neuroendocrine tumor markers, including CD56, synaptophysin, and chromogranin A ; negative results for CK7 ; and positive results for CK20. Merkel cell carcinoma was suspected. Further treatment included lymph node irradiation and follow-up observation.
Merkel cell carcinoma is a rare skin tumor most often found in Caucasian males and shows poor prognosis. This patient underwent systemic evaluation for lymph node metastases originally considered to arise from neuroendocrine tumor with an unknown primary site. However, IHC suggested primary Merkel cell carcinoma involving a lymph node as the most likely diagnosis.

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