[in Japanese]

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The case involved a 73-year-old woman complaining of bloody discharge from her right nipple for over twenty years. Smear cytology indicated that the nipple discharge was class III b. We diagnosed her with category 1 breast via mammography. Ultrasonography indicated a hypoechoic mass lesion, 10×3×4 mm in size, and mammary duct dilatation within the lateral region of E area of her right breast. MRI could not rule out a possibility of carcinoma spreading to the mammary ducts in AC area of the right breast. Duct lobular segmentectomy was performed for the diagnosis and therapy. Using indocyanine green (ICG) fluorescence for guidance, we identified the precise target segment requiring resection after injecting blue dye and ICG into the mammary ducts. Histopathological diagnosis indicated that the patient had invasive ductal carcinoma with a predominant intraductal component. Furthermore, the resected specimen was classified as T1, N0, M0, stage I, surgical margin-negative, ER-positive, and PgR-positive. She was treated postoperatively with radiation therapy and an oral aromatase inhibitor. The method described herein is safe and can be used to observe the target segment of the mammary duct lesion in real time.

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A 43-year-old woman was referred for evaluation of induration of her right breast. Right breast cancer (T2N3bM0, Stage IIIC, luminal B-like) was diagnosed, and primary systemic therapy (PST) with epirubicin + cyclophosphamide to docetaxel was administered. After PST, residual tumor with a hypoechoic area (ycT1N0M0, Stage I) was diagnosed. A partial right mastectomy and ipsilateral axillary lymph node dissection were performed.
However, the pathology report stated that the area assumed to be residual tumor was a fibroadenoma, and that the invasive ductal carcinoma had disappeared. Postoperatively, the patient underwent irradiation of the residual breast tissue and parasternal area, and she received adjuvant endocrine therapy. There has been no recurrence during follow-up for 3 years 8 months.
Needle biopsy after PST may prevent underestimation of the therapeutic effect of PST, thus enabling more minimal surgery.

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A 71-year-old man with left lower limb paralysis caused by poliomyelitis in childhood has used an axillary crutch. He complained of numbness in his left forearm. Computed tomography, revealed a left brachial artery aneurysm and acute brachial artery occlusion. He was referred to our department and underwent an urgent thrombectomy and bypass surgery. Axillary-brachial artery bypass grafting was performed using the great saphenous vein, and the aneurysm could be excluded. A year after the operation, the patient's upper arm remain well perfused. Most brachial artery aneurysms are attributable to trauma ; however, this patient developed the aneurysm secondary to the use of a crutch.

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An aortoduodenal fistula is a rare, severe complication after open abdominal aortic aneurysm repair. A case of an aortoduodenal fistula after open abdominal aortic aneurysm repair who was saved is reported. A 70-year-old man had undergone open abdominal aortic repair with a bifurcated graft 3 years ago. He complained of fever and lower back pain during the two weeks prior to his presentation. Vascular prosthesis infection was suspected based on these symptoms, and antibiotic therapy was initiated by the patient's previous physician. Melena and hematemesis developed a few days before, and the patient was transferred to our hospital. An aortoduodenal fistula was diagnosed on enhanced computed tomography, and emergency surgery was performed. The operative findings showed partial perforation of the anterior wall of the proximal anastomotic pseudoaneurysm into the duodenum. In situ prosthetic reconstruction, omental flap coverage of the graft, and primary suture closure of the defect of the duodenal wall were performed. The patient's postoperative course was uneventful, and he was discharged from hospital on foot postoperative day 44.

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We report a rare case of delayed duodenal stenosis, which developed 2 weeks after transarterial embolization (TAE) to treat a ruptured aneurysm of the pancreaticoduodenal artery. A 62-year-old man underwent successful TAE for a ruptured pancreaticoduodenal aneurysm on day 1 of hospitalization. Oral intake was initiated on day 4 of hospitalization ; however, on day 14, he developed delayed duodenal stenosis for which conservative treatment was initiated. Follow-up imaging revealed marked reduction in the retroperitoneal hematoma, although symptoms caused by duodenal stenosis persisted, a laparotomy was performed on day 48 of hospitalization. Intraoperative findings showed extensive fibrotic sclerosis of the retroperitoneum around the duodenum with a small hematoma remnant. Removal of the retroperitoneal hematoma did not resolve the stenosis ; therefore, a gastrojejunostomy was performed. Delayed duodenal stenosis, as was observed in our patient, involving fibrotic sclerosis of the retroperitoneum, is often refractory to conservative treatment. Therefore, surgical treatment including gastrojejunostomy should be considered in such cases.

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A 73-year-old woman with previous history of chronic asthma presented to our clinic. A Chest radiograph showed a small nodular shadow in the right upper lung field. Chest computerized tomography (CT) scan showed a mass 40 mm in maximum diameter in the left lung S8 and a mass 13 mm in maximum diameter in the right lung S3. Positron emission tomography (PET)/CT showed high accumulation of 18F-fluorodeoxyglucose (FDG) in the lesion of the left lung while no accumulation of 18F-FDG in the lesion of the right lung. The tumor in the left lung had increased in size on chest CT scan taken two months later. Primary lung cancer was suspected and surgical treatment was planned. The tumor was suspected to be malignant intraoperatively using needle biopsy and we performed thoracoscopic left-lower-lobe resection. A fungal spawn was observed in a viscous liquid embolism. Pathological analysis indicated the presence of a large mass of acidophilic, necrotic material in the dilated bronchus. There was an epithelioid granuloma on the bronchus wall, and allergic bronchopulmonary aspergillosis (ABPA) was diagnosed. In ABPA, it is possible for 18F-FDG accumulation to be observed upon 18F-FDG-PET/CT analysis along with high CEA levels. Generally, differentiating between ABPA and malignant tumors is difficult. Therefore, patients with asthma who are diagnosed with a lung tumor using the aforementioned modalities merit additional testing to differentiate between ABPA and lung cancer.

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The patient was a 73-year-old woman who had been administered tocilizmab for multicentric Castleman's disease for about 10 years that led to a favorable control of the disease. She was pointed out having esophageal cancer at a medical checkup and was referred to our hospital for surgery. We performed thoracoscopic-assisted subtotal esophagectomy 19 days after the final day of tocilizumab regimen. She left the intensive care ward on the first postoperative day (POD), started to walk on the second POD, and resumed oral intake on the 14^th POD. Few episodes of high fever or increases in CRP level occurred after the second POD. Although the CRP level tended to be elevated since the 17^th POD, no findings suggestive of postoperative complications were seen. Administration of tocilizmab was resumed on the 22^nd POD and she was discharged on independent gait on the 28^th POD. During the tocilizmab withdrawal period employed in this case, the CRP level was scarcely elevated on blood analysis, even though it was analyzed immediately after the surgery. A possibility that the CRP level cannot be a determinant index of infectious postoperative complication appears to arise. We could safely resume administration of tocilizmab for the patient with Castleman's disease whose CRP level was elevated probably due to worsening of the disease after the surgery.

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The case of a patient with an elevated preoperative serum CA19-9 level of 533.0 U/ml who was diagnosed with a CA19-9-producing gastric cancer and diffuse cystic malformation (DCM) is reported. A 57-year-old man with an abnormal screening upper GI series (fluoroscopy) was referred for further evaluation. Upper GI endoscopy showed a type 4 lesion, and adenocarcinoma was diagnosed by biopsy. Surgery, including a total gastrectomy, D2 lymph node dissection, splenectomy, and cholecystectomy, was performed. The histopathologic diagnosis was pT3(se)N3H0M0, pStage III with DCM.
Immunostaining of the resected specimen was positive for CA19-9 in the cancer cell cytoplasm, and, based on normalization of the serum CA19-9 level two months after surgery, a CA19-9-producing gastric cancer was diagnosed. Several lymph node metastases were found, so adjuvant chemotherapy was started 20 days after surgery. Currently, at 60 months postoperatively, the patient is alive without recurrence.
CA19-9-producing gastric cancer is rare, with only 39 cases, including the present patient, reported in Japan. The coexistence of DCM in such cases has not been previously reported. This case is presented along with a discussion of the relevant literature.

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A 46-year-old man admitted to our hospital with jaundice was found to have a tumor of the ampulla of Vater. A preoperative tumor biopsy showed nested, trabecular cells with an organoid appearance. Immunochemical findings showed that these cells were positive for chromogranin A, synaptophysin, and CD56. The Ki-67 index was over 90%. Ampullary neuroendocrine carcinoma was diagnosed, and the patient was treated by pancreaticoduodenectomy. Postoperative histological assessment revealed large cell neuroendocrine carcinoma (LCNEC) of the ampulla of Vater. The patient declined adjuvant chemotherapy, but he had to start chemotherapy with cisplatin and etoposide because multiple liver and lymph node metastases occurred three months after the surgery. After four courses of the chemotherapy, PD was assessed. His chemotherapy was thus changed to gemcitabine + S-1 (GS) as a second line. However, he was hospitalized because of cancerous peritonitis during four courses of GS, and he died of cancer 11 months after the surgery. LCNEC of the ampulla of Vater is extremely rare among ampullary tumors in the world, and its prognosis is poor.

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An 81-year-old woman with abdominal pain was brought by ambulance to our hospital. Abdominal contrast-enhanced computed tomography showed pneumatosis intestinalis and ascites. Non-occlusive mesenteric ischemia (NOMI) was suspected, and emergency surgery was performed. There was dark-red discoloration of the small intestine. Indocyanine green (ICG) fluorography to evaluate intestinal blood flow showed that mesenteric blood flow was maintained, but blood flow was absent in the discolored area of the intestinal wall. Intestinal necrosis associated with NOMI was diagnosed, and bowel resection was performed.
A single-stage anastomosis was avoided, and a second-look operation was performed the following day. Since ICG fluorography confirmed the absence of residual bowel ischemia, a small bowel anastomosis was performed. The patient was discharged home on postoperative day 17.
ICG fluorography is useful to accurately identify areas of necrosis during emergency surgery for NOMI and to evaluate any ischemia during second-look surgery. The utility of ICG fluorography to plan the treatment strategy in NOMI has rarely been reported. Therefore, this case is presented, and the relevant literature is discussed.

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A 29-year-old woman presented with abdominal pain. We diagnosed the case as intussusception due to small bowel tumors and performed emergency laparoscopic surgery with partial resection of the jejunum including the tumor. Histopathological findings showed that the tumors were hamartomatous polyps, and we made the diagnosis of Peutz-Jeghers syndrome. On the 50th postoperative day, she visited our emergency room complaining of abdominal pain. Computed tomography showed intussusception of the upper jejunum, and we performed an emergency laparoscopic operation. After reduction of intussusception, we found that the lead point was the anastomotic region of the previous surgery, and the intussusceptive bowel showed neither ischemia nor necrosis. We fixed the site of previous anastomosis to the left abdominal wall to prevent recurrence of intussusception. Postoperative double-balloon enteroscopy revealed no polyps in the upper jejunum. The patient had an uneventful recovery, and is doing well as of 4 years after the surgery, with no recurrence of intussusception or intestinal obstruction.
Intussusception of the end-to-end anastomotic region as the lead point is extremely rare ; we review and discuss the Japanese literature on this rare disease.

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An 86-year-old woman underwent anastomotic site resection with an ileostomy for recurrence of sigmoid colon cancer. Development of surgical site infection was observed following closure of the ileostomy. The patient's white blood cell count increased to 88,840 cells/μL despite wound drainage and the administration of antibiotics. Based on a high clinical suspicion of a hematological disorder, bone marrow aspiration was performed, which showed a normocellular marrow without evidences of abnormal cells. The patient was diagnosed with a leukemoid reaction, and the white blood cell count showed normalization along with improvement in the surgical site infection, following antibiotic treatment. A leukemoid reaction is a rare condition, which can be caused by infection, malignant tumors, or medications. A leukemoid reaction should be distinguished from leukemia or leukemia-related diseases. We report a case of a leukemoid reaction caused by surgical site infection after closure of an ileostomy.

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A 55-year-old man was admitted to our hospital with a history of recurrent bowel obstruction. Imaging examinations, including PET-CT, failed to reveal any evidence of malignancy, and laparoscopic surgery was performed to identify and treat the cause of the obstruction. During the operation, we detected a tumor-like protuberance from the ileum, approximately 50 cm proximal to the ileocecal junction, and peritoneal nodules. Partial resection of the ileum and excisional biopsy of the peritoneal nodules were performed under a presumed diagnosis of carcinoma of Meckel's diverticulum and peritoneal metastases. Histopathological examination of the resected ileum and peritoneal nodules revealed well-to moderately differentiated adenocarcinoma, but no ectopic tissue. Postoperatively, the patient failed to respond satisfactorily to chemotherapy, and eventually died of peritonitis carcinomatosa at 16 months after the surgery. The prognosis of carcinoma of Meckel's diverticulum is poor, as the diagnosis is often made only at an advanced stage due to the diagnostic limitations of imaging studies for this cancer. We report a case of Carcinoma of Meckel's diverticulum with a review of literature.

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A 48-year-old woman was admitted to our hospital complaining of abdominal pain. Acute appendicitis was suspected from the physical examination findings, and abdominal CT and USG showed a swollen appendix with a tumor in the proximal portion of the organ. We made the diagnosis of appendiceal neoplasm with acute appendicitis, and scheduled radical operation after initial conservative treatment to control the symptoms. Colonoscopy showed a submucosal tumor of the vermiform appendix. Histological examination of a biopsy specimen revealed only mucosal inflammatory changes, however, an appendiceal carcinoma could not be ruled out. We performed laparoscopic-assisted ileocecal resection with lymph node dissection. The appendiceal tumor in the resected specimen was 2.0 cm in diameter, and histopathology revealed the tumor to be composed of spindle-shaped cells. Immunohistochemistry showed positive staining for S-100 protein, consistent with the diagnosis of appendiceal schwannoma. In most cases, appendiceal neoplasms are found accidentally and tend to be confused with acute appendicitis. Appendiceal schwannoma is rare and preoperative confirmation of the diagnosis is difficult. In cases where surgery is scheduled, it is often difficult to decide the resection area. Therefore, it is desirable to conduct further examination after the symptoms of acute appendicitis improve, in order to determine the appropriate surgical procedure.

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A 66-year-old man whose stools were positive for occult blood was detected to have a bulging lesion with a concave at the sigmoid colon by colonoscopy. A biopsy of the lesion offered a diagnosis of mucinous carcinoma. A bulging like submucosal tumor was revealed near the orifice of the appendix, for which no biopsy was performed. An abdominal CT scan showed a 7×4 cm sized cystic tumor adjacent to the sigmoid colon and cecum. Sigmoid colon invasion of appendiceal mucinous carcinoma was preoperatively diagnosed, and we performed ileocecal resection with D3 lymph node dissection, and partial resection of the ileum and sigmoid colon. Adjuvant chemotherapy with mFOLFOX6 was conducted, however, one year 6 months later, he developed abdominal paraaortic lymph node recurrence. Thereafter the patient has maintained on chemotherapy with bevacizumab + capecitabine for more than one year.
In a review of the relevant literature, only three cases of appendiceal carcinoma with invasion to the sigmoid colon have been reported, including only one case diagnosed preoperatively.

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Fistulas developing secondary to anastomotic leakage after resection of the lower intestine often require re-operation, and sometimes, even a colostomy. We report the case of a patient who underwent a right hemicolectomy and developed a non-healing fistula secondary to anastomotic leakage ; the patient was successfully treated using the Over-the-Scope Clip (OTSC^®) System. The patient was a 77-year-old man who underwent right hemicolectomy and partial hepatic resection for advanced ascending colon cancer with hepatic metastasis. The postoperative CT showed an intra-abdominal abscess, and percutaneous drainage was performed. A barium study showed the formation of a fistula between the anastomotic site and the abscess. The OTSC^® System was used to treat the fistula on day 90 postoperatively, and the fistula was completely closed. Until now, 16 months since the surgery, the patient has shown no evidence of recurrence of the colon cancer or intra-abdominal abscess. The OTSC^® System appears to be useful for the treatment of non-healing fistulas occurring secondary to anastomotic leakage.

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A 52-year-old man, diagnosed with obstructive sigmoid colon cancer with liver and lung metastases, underwent a sigmoidectomy. After the operation, he received FOLFOX + panitumumab therapy. A follow-up computed tomography scan after 8 cycles of treatment revealed intraperitoneal free air, retroperitoneal free air, vertical emphysema, and diffuse intramural air in the ascending and transverse colon. However, the abdominal examination was unremarkable, and there was no evidence of intestinal necrosis or peritonitis. Therefore, we diagnosed the patient with pneumatosis cystoides interstinalis (PCI). We treated him without surgery, and gradually the peumatosis coli and emphysema decreased. After the treatment of PCI, he received chemotherapy without panitumumab, and PCI did not recur. Recently, PCI caused by cetuximab has been reported. However, cases of PCI caused by panitumumab are rare. We report this case of PCI occurring during panitumumab therapy, along with a review of the literature.

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A 31-year-old man with Coffin-Lowry syndrome from childhood visited our hospital due to fever for a month and anal pain from the day before. He was diagnosed with a perianal abscess, and incisional drainage was performed. After a week of drainage, he complained of abdominal pain and was found on pelvic CT to have a perianorectal abscess from the pelvirectal pouch to subcutaneous tissue, so a drainage tube was inserted into the cavity of the abscess. Repeated fistulography after tube insertion showed a communication with the sigmoid colon, and a gastrografin enema showed multiple diverticula in the sigmoid colon. Since he was finally diagnosed with a perianorectal abscess due to diverticulitis of the sigmoid colon, a sigmoidectomy was performed three months later after his first visit. During surgery, the sigmoid colon adhered to the right side of the rectovesical pouch, and a fistula between the pelvic space and the retroperitoneal space was confirmed at this location. A rare case of a perianorectal abscess caused by sigmoid colon diverticulitis was described. This case is important because it suggests a potential relationship between Coffin-Lowry syndrome and diverticular disease.

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A 79-year-old-man who was diagnosed as having hepatocellular carcinoma underwent laparoscopic partial liver resection. However, dense adhesions in the upper abdominal cavity and bleeding from the liver cutting surface made the surgery difficult. After induction of pneumoperitoneum, the EtCO₂ level in this patient persisted at around 50 mm Hg. At around 5 hours after the start of CO₂ insufflation to produce pneumoperitoneum, the blood pressure of the patient suddenly dropped to 50 mm Hg and the EtCO₂ level decreased to 28 mm Hg. Results of arterial blood gas analysis performed at this time revealed a pH of 7.253 and PaCO₂ of 56.8 mm Hg. Based on the discrepancy between the PaCO₂ and EtCO₂, the patient was diagnosed as having pneumoperitoneum-induced gas embolism. Therefore, the surgical approach was changed to the conventional open approach. Following conversion to the open approach, hemostasis was achieved at the liver cutting surface, the blood pressure rapidly recovered, and the surgery was completed without any further events. The postoperative course was also uneventful and the patient was discharged on postoperative day 12. The need for careful monitoring for preventing severe gas embolism in patients undergoing laparoscopic resection cannot be overemphasized, especially in the event of unexpectedly prolonged surgery or excessive bleeding.

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A 64-year-old man with cholangiocarcinoma near the porta hepatis underwent resection of the left hepatic lobe, caudate lobe, and extrahepatic bile duct. No postoperative complications occurred, and he was discharged home on day 13 after surgery. However, on day 27, he developed abdominal pain and was brought by ambulance to our hospital. Melena and shock occurred later that day, emergency angiography was performed, and rupture of a proper hepatic artery pseudoaneurysm was diagnosed. Other than the hepatic artery, no arterial collaterals to the residual liver were identified, so coil embolization of the proper hepatic artery was performed for hemostasis.
To ensure arterial blood flow to the residual liver immediately after embolization, anastomosis of the ileocolic vessels and arterioportal shunting were performed. There were no further postoperative complications, and after arterial collaterals to the residual liver were confirmed on day 64, the ileocolic artery was coil embolized.
Monitoring of possible complications such as portal hypertension is of course necessary. However, combined embolization and arterioportal shunting for rupture of a postoperative hepatic artery pseudoaneurysm after hepatectomy is an effective treatment strategy to prevent postoperative ischemic liver failure.

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The patient was an 85-year-old man who was admitted with vomiting and hematemesis caused by acute gastroenteritis and esophageal ulcer. During treatment, he developed biliary pseudolithiasis caused by ceftriaxone, necessitating laparoscopic cholecystectomy. Infrared spectroscopic examination of the gallbladder sludge revealed it to be consistent with ceftriaxone pseudolithiasis.

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A 67-year-old female patient presented with a hepatic tumor in the lateral segment of the liver with an extrahepatic tumor in the left upper quadrant of the abdomen, as detected on screening ultrasonography. Her serum alpha-fetoprotein (AFP) level was elevated to 16,500 ng/ml. The diagnosis was hepatocellular carcinoma with extra hepatic growth, and a left lateral sectionectomy with resection to the extrahepatic tumor and spleen and a left lung partial resection were performed. Regarding pathological findings, the majority of the intrahepatic tumors were cholangiocellular carcinoma with Hering tube-like structures. Immunohistochemical staining revealed that the tumor cells were cytokeratin 19-positive. Some AFP-positive cells were also observed. Pathological examination of the extrahepatic tumor showed moderately differentiated hepatocellular carcinoma with AFP- and cytokeratin 19-positive cells. Six months after the surgery, a recurrent tumor was confirmed in segment 6. Pathological findings of the recurrent tumor showed moderately differentiated hepatocellular carcinoma.

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A 71-year-old man who had frequent bouts of unconsciousness since around May 2014 was emergently admitted to our hospital because of hypoglycemic attack, and was diagnosed as having a malignant insulinoma, a neuroendocrine tumor, of the pancreatic tail with multiple hepatic metastases. Radical resection was impossible. Control of the blood glucose level with diazoxide had to be discontinued by thrombocytopenia, an adverse side effect of diazoxide. Since internal treatment failed to control the blood glucose, we performed a debulking surgery of the primary lesion and hepatic metastases including the maximum metastatic nest in the S6, for blood glucose level control. Histopathologically the pancreatic tail tumor showed findings compatible with insulinoma. The Ki-67 index was as high as 41%. The hepatic metastatic lesions also showed similar findings. After the operation he did not develop hypoglycemic attack and was discharged from our hospital to home. After discharge, the tumor remnant began to increase in size and he had recurrence of hypoglycemic attack, so that treatment with sunitinib was started. His intensive treatment favorably controlled the blood glucose level and he was maintained on the treatment in the clinic, however, he developed hepatic encephalopathy associated with exacerbation of the primary disease and passed away.

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A 71-year-old female patient who was referred to our hospital due to jaundice and gastric outlet obstruction was diagnosed with cancer of the pancreatic head T4N1M0 and underwent endoscopic placement of duodenal stents (22×100mm and 22×60mm metallic stent) and a biliary stent (10×60mm covered stent) for obstructive lesions. After the stent placement, the patient underwent chemotherapy with gemsitabin + S-1. Abdominal CT scan after three courses of the chemotherapy revealed tumor shrinkage and migration of duodenal and biliary stents. The biliary stent was dislocated into the duodenum, which was removed endoscopically and replaced. The duodenal stent was dislocated into the small intestine, which could not be removed by endoscope. We decided to follow up the migrated stent in expectation of spontaneous excretion. Twelve days from the CT scanning, the patient had small bowel obstruction caused by the migrated stent so that she required emergency operation with partial small bowel resection. The duodenal stent had perforated the wall of the upper ileum.
We present a rare case of stent migration necessitating surgical intervention with a review of the literature.

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An abdominal tumor was detected in a 45-year-old woman when she underwent an abdominal ultrasonic examination for a health check. Imaging modalities revealed an approximately 7-cm retroperitoneal mass close to the aorta and inferior vena cava. Following diagnosis of a retroperitoneal functional paraganglioma, laparoscopic resection was performed after an α-blocker was administered preoperatively. Intraoperatively, blood pressure was controlled with a continuous arterial pressure line, central venous catheter, and Swan-Ganz catheter. No significant hypertension occurred. With a magnified view and an increased horizontal field of view, laparoscopic resection is minimally invasive, safe, and feasible in select patients with functional retroperitoneal paraganglioma.

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A 59-year-old man was referred to our hospital because of left-sided inguinal pain. He was diagnosed with an incarcerated inguinal hernia, which was manually reduced. Several hours after the reduction, he returned to our hospital with abdominal pain and vomiting. No herniation was observed in the inguinal region. Abdominal computed tomography revealed a round mass containing a part of the small intestine and fluid close to the left inguinal region. He was diagnosed with bowel obstruction secondary to reduction en masse (REM) of an inguinal hernia and underwent emergency surgery. We utilized a front approach from the groin. He showed evidence of co-existence of indirect and direct hernia, and we performed hernia repair using a Modified Kugel Patch^®. We performed laparoscopy to examine the abdominal cavity because we were not able to confirm the presence of REM in the operative field using the anterior approach. The thickened peritoneum served as the hernial orifice and strangulated the small intestine. Intestinal blood flow improved as soon as we loosened the hernial orifice ; thus, the small intestine could be preserved. After surgery, the patient was discharged following an uneventful course. We propose that a laparoscopic composite operation facilitates detailed examination and is useful in patients presenting with REM.

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A 10-year-old girl was admitted to our hospital with abdominal pain. Computed tomography (CT) showed acute appendicitis, necessitating emergency laparoscopic appendectomy. A gangrenous appendix and purulent ascites were observed in the intraperitoneal space during laparoscopy, suggesting perforated appendicitis. The appendix was resected at its root. The right outer inguinal ring was slightly enlarged. The patient's postoperative course was uneventful ; however, on postoperative day 7, the patient had right inguinal pain. CT showed an abscess in the right inguinal canal. It was postulated that purulent ascites due to perforated appendicitis tracked into the right inguinal canal, leading to an abscess. Percutaneous aspiration of the abscess was performed, and approximately 1.5 ml of purulent discharge was drained. Antibiotics were continued, and the symptoms improved. The patient was discharged on postoperative day 9. Although there are reports of abscess formation in a hernia sac after panperitonitis and surgery for perforated appendicitis, most occurred in elderly patients. As seen in the present case, young people can also develop a hernia sac abscess after intraperitoneal infection, thus emphasizing the need to remain alert during the postoperative course.

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The patient was a 78-year-old man with previous histories of rectal cancer, gastric cancer, bladder cancer, lung cancer, and transverse colon cancer. He was hospitalized with melena. We performed colonic endoscopic examination, and detected two tumor lesions, an I s type lesion and a type 2 lesion situating 5 cm and 20 cm apart from the artificial anus, respectively. A biopsy of the later lesion revealed adenocarcinoma. We performed left hemicolectomy with lymph node dissection. Double cancer of the descending colon was diagnosed via pathological examination. No recurrence has been observed 1 year after the operation. Furthermore, we confirmed that seborrheic keratosis affecting the ventral aspect of trunk rapidly increased in number before operation for gastric cancer. We thus assessed that he had the sign of Leser-Trélat (LT).
The sign of LT is defined as sudden appearance and rapid increase in number of seborrheic keratosis with pruritus. Especially, it should be noted that the syndrome is frequently associated with gastric cancer. We experienced the case of asynchronous septuple cancer with the sign of LT.

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