Purpose : Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) has been recognized as an active treatment for peritoneal carcinomatosis of colorectal origin. However, the high rates of postoperative complication and recurrence remain to be solved. The purpose of this study was to clarify the feasibility and the clinical benefit of CRS+HIPEC.

Methods : The data of 11 patients who underwent CRS+HIPEC for peritoneal carcinomatosis of colorectal origin were retrieved. CRS was performed using peritonectomy procedures proposed by Sugarbaker, and HIPEC was administered using MMC and CDDP.

Results : The median value of the peritoneal cancer index (PCI), which represents the tumor burden of peritoneal carcinomatosis, was 14, and complete cytoreduction was achieved in all cases. Morbidity of grade ≥ 3 was observed as arrhythmia in one case, and there was no incidence of 90-day mortality. Early recurrence after adjuvant chemotherapy was observed in 7 cases. Median survival after the start of treatment was 26.4 months.

Conclusion : Our results showed that CRS+HIPEC was safe ; however, early recurrence was frequent. It was suggested that more precise patient selection was necessary by more accurate preoperative evaluation of PCI and chemosensitivity.

A 79-year-old woman was aware of a mass in her left breast and visited our hospital. On palpation, a 6 cm red tumor was observed in the left breast ABE area. She had previously undergone breast augmentation by silicone injection into both breasts. Ultrasonic examination revealed a slightly low-echoic, nonuniform mass image between the non-echo structures of silicone, and a core needle biopsy showed invasive carcinoma. MRI showed a contrast effect in the tumor and an axillary lymph node. Thoracoabdominal CT showed an enlarged tumor occupying the left breast with partial calcification. No distant metastasis was apparent. The patient underwent a total mastectomy with sentinel lymph node biopsy. Pathological analysis revealed a tumor in the silicone granuloma ; the tumor cells were similar to ones found in the needle biopsy. Silicone contamination was also found in the sentinel lymph node, but metastasis was not found. We experienced a breast cancer patient who had silicone granuloma after breast augmentation.

Case one was a 52-year-old woman with right-sided breast cancer. She underwent a partial mastectomy and sentinel lymph node biopsy. The pathological diagnosis was ductal carcinoma in situ. Case two was a cousin of case one ; she was a 45-year-old woman who underwent a total mastectomy, axillary lymph node dissection, and risk-reducing salpingo-oophorectomy for left-sided breast cancer. The pathological finding was papillotubular carcinoma. Due to a strong family history of breast cancer (seven breast cancer patients including bilateral breast cancer, multiple organ cancer, and young-onset breast cancer in four generations), case one and case two were suspected to have hereditary breast and ovarian cancer (HBOC). Genetic testing confirmed 5903delG in the BRCA2 gene. BRCA gene testing is useful in diagnosing HBOC ; in addition to determining the primary prevention of breast and ovarian cancers, and aiding selection of surgical or chemotherapy treatment.

A 70-year-old man who underwent computed tomography (CT) for persistent abdominal pain was found to have an abdominal aortic aneurysm, and he was referred to our hospital with suspected threatened rupture. CT showed an abdominal aortic aneurysm with a maximum short diameter of 60 mm below the renal artery, and the retroperitoneum around the aneurysm was thickened and contrast-enhanced (mantle sign). Blood tests showed elevated C-reactive protein, but procalcitonin was negative, and immunoglobulin G4 was not elevated. Blood culture was negative, and an inflammatory abdominal aortic aneurysm was diagnosed. Endovascular aortic repair was performed. The patient's postoperative course was uneventful and he was discharged on Day 6. Since hydronephrosis and similar comorbidities were not present, steroid treatment was not administered, and the patient was kept under observation. Six months after surgery, the inflammatory response (CRP) had decreased to 0.4 mg/dl, but there was no change in aneurysm diameter or retroperitoneal thickening. Follow-up without steroid treatment continued, and the thickening of the retroperitoneal wall eventually decreased one year postoperatively.

A 76-year-old woman was hospitalized because of epigastric pain and vomiting. Severe mixed type hiatal hernia with axial torsion was diagnosed on computed tomography and upper gastrointestinal (GI) series examinations. Therefore, laparoscopic repair was performed with Toupet fundoplication as anti-reflux surgery for severe hiatal hernia. One year and eight months after the initial surgery, she was hospitalized because of acute epigastralgia. Computed tomography showed esophageal hiatal hernia recurrence and a Morgagni hernia, and laparoscopic repair for the recurrent esophageal hiatal hernia was repeated, along with repair of the Morgagni hernia. Approximately 30 mm of the hernia orifice were found on the posterior surface of the sternum, and the greater omentum was impacted. The hernia orifice was closed by suture with mesh reinforcement. The esophageal hiatus opened wide and was closed again by suture. A Morgagni hernia is rare among diaphragmatic hernias, and there are few reports from Japan of a concomitant Morgagni foramen hernia and esophageal hiatal hernia. Thus, this case of Morgagni hernia that developed after mixed esophageal hiatal hernia recurrence is reported along with a review of the relevant literature.

A 67-year-old man was referred to our hospital for an elevated lesion at the middle thoracic esophagus detected by upper gastrointestinal examination in a medical check-up. Upper gastrointestinal endoscopy revealed an elastic-soft submucosal tumor-like lesion covered with smooth normal mucosa, 28 to 30 cm distant from the incisor teeth, and it stained with iodine. Fine needle biopsy showed it to be squamous cell carcinoma and he underwent radical esophagectomy (D2 dissection) with the diagnosis of esophageal cancer, Mt cType0-Is cT1bN0M0 cStage I. Histopathology demonstrated that the esophageal lesion was moderately differentiated squamous cell carcinoma extending into the deep submucosa and it displayed marked T-cell dominant lymphocytic infiltration and B-cell dominant lymphoid follicle formation in the tumor stroma. The Final diagnosis was moderately differentiated esophageal squamous cell carcinoma with lymphoid stroma.

It is reported that esophageal cancers presented as submucosal tumor-like lesions mostly have a highly malignant potential. Moderately differentiated squamous cell carcinoma with lymphoid stroma, like in this case, is rare among of them, and is believed to have good prognosis. Accordingly, pretherapeutic examinations are very important to decide on the treatment policy in terms of histologic type and mode of invasion.

A 75-year-old woman was diagnosed as having an upper gastric perforation, and emergency surgery was performed. The abdomen was full of food debris that had leaked from the stomach. A 6-cm perforation was found in the gastric wall, with no evidence of gastric ulcer. Suturing of the perforated gastric wall was performed, along with a gastrojejunostomy, since pyloric obstruction could not be ruled out on preoperative computed tomography. The patient's postoperative course was uneventful.

The patient was a 48-year-old man. Eight years earlier, he was referred to the department of enterology in our hospital because anemia was discovered at a medical check-up. At that time, the laboratory data were significant for anemia and hypoproteinemia. Endoscopic examination revealed numerous small and large easily-bleeding polyps in the stomach. The pathological findings revealed hyperplastic polyps, and the diagnosis was juvenile gastric polyposis (JGP). The patient had been followed until 3 months prior to visiting our hospital when his laboratory data revealed progression of anemia and hypoproteinemia. Surgical therapy was considered because the JGP had been resistant to conservative therapy and an abdominal CT scan showed irregular gastric wall suggestive of malignancy. We performed total gastrectomy and lymph node dissection, when we also found a large tumor at the fornix of stomach. The pathological diagnosis of the tumor was neuroendocrine carcinoma (NEC). The patient's postoperative course was uneventful, and his anemia and hypoproteinemia improved.

Juvenile polyposis (JP) is rare and is generally considered benign. However, JGP has recently been noted to have a high risk for malignant potential. We sometimes encounter JGP cases associated with adenocarcinoma, but non with NEC. This report describes a case of JGP associated with NEC, together with a review of the relevant literature.

Neurofibromatosis type 1 (NF1 ; von Recklinghausen's disease) is a condition characterized by multiple café-au-lait spots and neurofibromas. We present a case of NF1 associated with gastric cancer. The patient was a 71-year-old woman who began to develop skin coloring spots in childhood and neurofibromas in the skin in her twenties. She was pointed out anemia and was diagnosed as having a type 1 tumor on the posterior wall of antrum of the stomach by upper gastrointestinal endoscopy. She underwent endoscopic submucosal dissection for gastric cancer which was diagnosed as moderately differentiated adenocarcinoma. The pathological examination revealed invasion of small vessels and vertical stump, then she underwent distal gastrectomy.

It has been reported that NF1 is frequently associated with non-epithelial tumors including neurogenic tumors, but there are few reports that NF1 is associated with epithelial tumors.

A rare case of advanced gastric cancer that presented with a liver abscess is reported.

A 67-year-old woman was admitted to our hospital because of high fever. Abdominal computed tomography showed a liver abscess in the right hepatic lobe and wall thickening of the gastric antrum. Blood culture showed infection by Klebsiella pneumoniae, and she was treated with antibacterial drugs and percutaneous drainage of the liver abscess, after which the size of the liver abscess decreased. Klebsiella pneumoniae was cultured from the abscess. Upper gastrointestinal endoscopy showed an advanced gastric cancer with an ulcer on the antrum. After the abscess diminished, distal gastrectomy and D2 lymph node dissection were performed. Klebsiella pneumoniae was cultured from the cancer lesion. At 38 months after the operation, she has remained free from recurrence of the hepatic abscess and the gastric cancer.

In a case of liver abscess, it is important to as much as possible perform a complete gastrointestinal examination.

A 79-year-old man was found to have a type 3 lesion in the upper gastric body on upper gastrointestinal endoscopy during follow-up of atrophic gastritis. The biopsy showed moderately differentiated adenocarcinoma. Computed tomography showed no lymph node or distant metastases. Total gastrectomy and lymph node dissection were performed. The histopathological diagnosis was large cell endocrine carcinoma >>tub2, pT4a(SE), ly0, v3, pN0, Stage IIB. Immunohistochemistry showed positive staining for chromogranin A and synaptophysin. The patient's postoperative course was uneventful, and he was discharged from hospital on the 14th postoperative day. He received no postoperative chemotherapy and was free of relapse 1 year and 6 months after surgery.

A 76-year-old man was seen at a nearby clinic with a 2-week history of anorexia and vomiting. He came to our hospital because of a high CEA level. Abdominal computed tomography showed a tumor, 11 cm in diameter, centered on the dorsal aspect of the antral zone, and pancreatic invasion was suspected. Upper endoscopy showed that the tumor was mainly submucosal, and only necrotic tissue was found in the same site biopsy specimen. Colonoscopy showed rectal sigmoid carcinoma. It was decided to resect the stomach tumor because it was huge and obstructed. Pancreatoduodenectomy and colectomy were performed. The resected specimen showed large cell type gastric endocrine cell carcinoma with the findings of T3(SS)ly1v1N0, stage IIA. Three months after gastric surgery, anterior resection for rectal sigmoid carcinoma was performed with the findings of moderately differentiated tubular adenocarcinoma, T4(SS)ly1v1N0 in stage IIIa. Adjuvant chemotherapy with S1 was performed. Only one liver metastasis of rectal cancer occurred 1 year and 6 months after gastric surgery, so appropriate liver resection was performed. A rare case of simultaneous rectal cancer with gastric endocrine cell carcinoma was described.

Two rare cases of ulcerative colitis (UC)-like gastroduodenitis that developed after total proctocolectomy are reported. Two women (Case 1 : 22-year-old and Case 2 : 29-year-old) had a 5-year and a 7-year history of left-sided UC, respectively. Both patients underwent total proctocolectomy with stapled ileal pouch anal anastomosis and covering ileostomy for intractable UC. Two months later, Case 1 had epigastralgia and nausea, and Case 2 had nausea and malaise. Upper gastrointestinal endoscopy showed UC-like gastroduodenitis in both cases. Although their symptoms initially improved with prednisolone treatment, they relapsed when the dose of prednisolone was tapered. Case 1 was successfully managed with repeat courses of prednisolone treatment. Nevertheless, Case 2 required therapy with mesalazine powder and granulocyte and monocyte adsorptive apheresis. Following these therapies, they finally achieved steroid-free remission of gastroduodenitis. UC-like gastroduodenitis is a rare clinical entity that is often persistent and intractable. Early diagnosis and treatment are essential to improve treatment outcomes.

A 43-year-old woman who was a resident of a facility for mentally retarded persons presented with anorexia/vomiting. As computerized tomography (CT) revealed foreign bodies in the stomach, she was admitted to the emergency department in our hospital. Upper gastrointestinal endoscopy revealed foreign bodies in the gastric and duodenal lumina, but they were too large to be removed. The duodenal lumen was finally emptied of the foreign bodies, and thereafter her clinical course had been observed. Subsequently, she underwent emergency surgery, because penetration and abscess formation in the mesenterium of the small intestine were suspected on CT. The foreign bodies in the stomach were removed via minilaparotomy at first. The gastric wall was then closed and the intraperitoneal cavity was examined by single-incisional laparoscopy, but there were no obvious detectable abnormalities. Intraoperative colonoscopic observation of the alimentary tract performed up to the ileum did not reveal any obvious abnormalities or presence of foreign bodies. Through an incision in the jejunum, retrograde observation of the duodenal and gastric lumina was made by intraoperative endoscopy. The site of penetration was located in the horizontal portion of the duodenum. After kocherization and derotation of the mesenterium of the small intestine, the duodenal descending to horizontal portion was examined. An inflammatory lesion was noted at the site of insertion of the mesenterium to the duodenal horizontal portion, and the site of perforation was confirmed upon ablation of the insertion. The perforation was closed by placing sutures, covered with an omental patch and decompressive duodenostomy. The postoperative course was uneventful, and the patient was discharged home in an improved condition.

A 75-year-old man who underwent robot-assisted prostatectomy for prostatic cancer 2 years previously presented to our emergency clinic because of the abrupt onset of right lower abdominal pain. An abdominal contrast-enhanced CT scan provided a diagnosis of strangulated bowel obstruction due to a right external iliac artery. Emergency laparotomy was thus performed. Intraoperative findings included that a small bowel had impacted in the interstice between the right external iliac artery which had exposed due to lymph node dissection at prostatectomy for prostatic cancer and the retroperitoneum. Manual reduction of the impacted bowel was difficult. So the impaction was reduced by collapsing the bowel while contents in the dilated and necrotized bowel were sucked up without injuring the right external iliac artery, and then we achieved partial small bowel resection. In order to prevent recurrence, the retroperitoneum was incised to cover the right external iliac artery. The patient's postoperative course was uneventful, and the patient was discharged from our hospital on the 11^th postoperative day. Few cases of strangulated bowel obstruction due to the external iliac artery have been reported. We present such a rare case with a review of the literature.

A 73-year-old man diagnosed as having ileus who presented with nausea and vomiting was referred to our hospital. Abdominal contrast-enhanced computed tomography revealed a thickening of the small intestinal wall, swelling of surrounding mesenteric lymph nodes, and multiple liver metastases. Double-balloon endoscopy revealed a type 2 total circumference lesion in the jejunum, on the immediate anal side from the Treitz ligament, and laparotomy was performed. The primary tumor, which was 70 mm in diameter, was located in the ileum, 20 cm from the Treitz ligament on the anal side, and liver metastasis and numerous disseminated nodules were confirmed in the peritoneal cavity. We performed partial intestinal resection and obtained biopsies of samples from the hepatic and peritoneal nodules. The histopathological diagnosis was mucinous adenocarcinoma in all the specimens. Postoperative chemotherapy with S-1 + CDDP was started. Treatment response was judged as partial response on CT examination at 6 months and as complete response at 36 months after the surgery. From the 45th month after surgery, treatment was continued with S-1 alone. Thereafter, chemotherapy was terminated 78 months after the operation without findings of recurrence. Currently, 10 years have passed since the surgery, without apparent findings of recurrence.

The patient was a 76-year-old woman who was admitted to the emergency department with a 2-week history of abdominal distension, loss of appetite, and fever. She had been hospitalized twice for bowel obstruction, which had been treated conservatively, in the previous two years. The patient had been undergoing periodic decompression with a transanal drainage tube inserted by the family for a year. Abdominal CT showed marked dilation of the large bowel from the transverse colon to the rectum, with no evidence of mechanical obstruction. Despite four sessions of endoscopic decompression, the abdominal distension continued to recur. The patient was diagnosed as having chronic idiopathic colonic pseudo-obstruction (CICP) and scheduled for surgery. Hand-assisted laparoscopic colectomy (HALS) of the large bowel, from the transverse colon to the sigmoid colon, and end-transverse colostomy was performed. The postoperative course was uneventful. CICP is rare and only four cases treated by laparoscopic surgery have been reported. HALS is useful for cases that show marked bowel dilatation.

A 40-year-old man was referred to our hospital with right upper quadrant abdominal pain and a palpable tumor in the right abdomen. Serum CRP was elevated and abdominal CT revealed a 13-cm clearly demarcated tumor with a low-density area on the anal side of the ascending colon. The abdominal pain failed to resolve with conservative therapy. Therefore, we performed emergent right hemi-colectomy. Histopathological examination of the resected specimen revealed the diagnosis of undifferentiated pleomorphic sarcoma (UPS). It has been reported that UPS arising from the colonic mesentery has a poor prognosis, but little is known about the prognosis or standard therapy of this condition. Recently, long-term survival of a case of UPS who underwent radical surgery was reported. Therefore, it is important for complete resection to be performed in patients with UPS ; we have reported our case with a review of the literature.

Serious complications associated with oral intake of calcium polystyrene sulfate (CPS) include intestinal perforations and intestinal necrosis probably caused by constipation. We herein report, along with a review of the literature, on two cases of sigmoid colon perforation and panperitonitis occurred during oral intake of CPS for chronic kidney disease (CKD) and hyperkalemia in our institution. Patient 1 was an 87-year-old woman who was taking CPS for CKD and hyperkalemia and visited our hospital because of abdominal distention and hypogastric pain. Panperitonitis was diagnosed, and Hartmann's operation was carried out. We observed multiple ulcers with perforation in the sigmoid colon and CPS crystals on the ulcer floor. Although sepsis and DIC occurred following the surgery and required multidisciplinary therapy, she was discharged home with remission. Patient 2 was an 86-year-old woman taking CPS for CKD and hyperkalemia. She visited our hospital because of emesis and hypogastric pain. Sigmoid colon perforation and panperitonitis were diagnosed, and Hartmann's operation was carried out. There were CPS crystals in the perforated region of the sigmoid colon, which were thought to be the cause of the perforation. Although the peritonitis could be controlled, ARDS occurred following the surgery and she died due to the progression of respiratory failure. It is necessary to take notice of evacuation control for renal dysfunction patients with oral intake of CPS.

An 86-year-old woman presented with bilateral edema of the lower extremities. Abdominal CT revealed marked swelling of the para-aortic lymph nodes and wall thickening of the sigmoid colon, however, no obstruction of the inferior vena cava was observed. Thus, the lower extremity edema was diagnosed as lymphedema. Colonoscopy revealed a type 2 tumor resembling a submucosal tumor in the sigmoid colon. Biopsy examination revealed micropapillary carcinoma, however, the microscopic appearance of the tumor was different from that of typical colorectal cancer. Accordingly, the tumor was suspected as invasive ovarian cancer or primary peritoneal cancer. Sigmoidectomy was conducted for the purpose of preventing obstruction of the colon and therapeutic diagnosis. Macroscopic examination during the operation indicated that the tumor arose from the sigmoid colon. Histopathologic examination revealed that the tumor was an invasive micropapillary carcinoma originating from the colonic mucosa. Herein, we report a case of invasive micropapillary carcinoma of the sigmoid colon that was associated with rather different clinical features and biological characteristics from those of typical colorectal cancer.

A 71-year-old man who developed cardiac arrest (initial rhythm : ventricular fibrillation) underwent cardiopulmonary resuscitation (CPR) performed by emergency medical paramedics and regained spontaneous circulation approximately 29 minutes after collapse. Emergency coronary angiography revealed a normal coronary artery, and the administration of anticoagulant and antiplatelet drugs was initiated. A plain thoracoabdominal computed tomography (CT) scan on ICU admission revealed no findings suggestive of organ injury. However, 9 hours after admission, his hemodynamic state suddenly worsened and an echography revealed fluid retention in the abdomen. An enhanced CT scan showed intra-abdominal hemorrhage and liver injury with extravasation of contrast medium. Transcatheter arterial embolization was performed with the diagnosis of liver injury complicated with chest compression, his hemodynamic state became stable, and he was transferred to another hospital on hospital day 17 without neurogenic disorder. Liver injury complicated with chest compression is rare, but diagnosis is difficult at the patient's first visit and occasionally late and sudden worsening of hemodynamic state can occur that demands urgent hemostasis. When hemodynamics becomes unstable with a decrease of hemoglobin value, enhanced CT should be performed early considering a possibility of liver injury complicated with chest compression.

A 37-year-old woman who underwent emergency cesarean section for a progressive severe hypertensive disorder of pregnancy with dichorionic diamniotic twins was referred to our department. She was diagnosed as having partial HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome because of severe elevations of liver enzyme levels. Computed tomography for postoperative intraabdominal hemorrhage showed hepatic rupture and a massive subcapsular liver hematoma associated with a right-sided round ligament. Hemostasis for active arterial bleeding by transcatheter arterial embolization (TAE) rescued the patient, but the right liver infarcted. Therefore, she underwent resection of the right lateral sector and dorsal part of the right paramedian sector of the liver 10 days after the TAE procedure. The sequential strategy of emergency TAE and elective hepatectomy with a rare anatomical anomaly to manage hepatic rupture associated with a severe peripartum complication is reported.

An 88-year-old woman presented to our hospital because of abdominal pain and underwent emergency operation with a diagnosis of septic shock due to panperitonitis. Perforation of the gallbladder was diagnosed based on intraoperative findings, and cholecystectomy and abdominal drainage were performed. A cyst which was confirmed to be at the porta hepatis of the right lobe of liver by preoperative CT scan gradually enlarged after the operation. The cyst was accompanied by dilatation of the peripheral bile duct, but she was asymptomatic. We had followed his clinical course until 61^st postoperative day, when he suddenly developed high fever with chill and trepidation. We diagnosed the case as cholangitis and infected hepatic cyst from CT findings, and on the same day, performed ultrasonic-guided percutaneous transhepatic abscess drainage. Since white purulent discharge amounted to 35 ml and E. coli was isolated from cultures of the blood and content fluid of the cyst, the cyst was determined to be the source of infection. Administration of antibiotics and drainage resulted in symptomatic remission, so that the drain was removed on the 38^th day after initiation of the drainage. Thereafter no further enlargement of the cyst has occurred. Hepatic cysts follow an asymptomatic course in most cases, however, if the cyst tends to enlarge, we must keep a possibility of causing infectious hepatic cyst in mind.

A 64-year-old woman underwent follow-up CT after surgical treatment of sigmoid colon cancer, and a mass with a diameter of 10 mm was found in the S2 region of the liver and diagnosed as metastatic liver cancer. Laparoscopic partial resection of liver S2 was performed, and intraoperative indocyanine green (ICG) fluorescence also showed different fluorescent sites aside from the tumor, which was resected for diagnosis. On pathological examination, microscopic tumor embolism of adenocarcinoma was found in the bile duct inside Glisson's sheath, which was diagnosed as metastasis of sigmoid colon cancer. The patient's postoperative course was good, without any complications, and she was discharged on the 4th postoperative day.

Previous reports suggested that intraoperative ICG fluorescence is effective not only for the primary lesion, but also for metastatic liver cancer to identify the tumor. On the other hand, when the mass not recognized before surgery is fluorescent, its significance is controversial. In the present case, microscopic tumor embolism with liver metastasis of colon cancer, which could not be detected on preoperative examination, was identified by intraoperative ICG fluorescence. This case is reported along with a review of the relevant literature.

A 61-year-old man was referred to our hospital for abdominal pain and vomiting. Contrast-enhanced CT showed a huge hematoma in the 2nd portion of the duodenum and a 40-mm hypervascular mass in the pancreatic head. We made the diagnosis of pancreatic head cancer with a huge duodenal hematoma, and performed pancreatoduodenectomy, combined with superior mesenteric vein resection and partial resection of the transverse colon. Intramural duodenal hematoma is a rare disease. In most cases, intramural duodenal hematomas are reported to be caused by blunt abdominal trauma, and there are only a few reports of intramural duodenal hematoma caused by pancreatic cancer. Herein, we report a case of pancreatic cancer with an intramural duodenal hematoma that was treated by surgery.

An 81-year-old man with moderate obstructive pulmonary impairment as co-morbid was diagnosed as having an about 20 mm tumor of the pancreatic body on an abdominal CT scan. Previous histories included right nephrectomy with interferon therapy for renal cell carcinoma, followed by right pulmonary partial resection for lung metastasis which occurred 2 years after the nephrectomy. This time, when 5 years had elapsed after the nephrectomy, the tumor located in the pancreas body was found by a follow-up CT scan. The tumor was diagnosed as pancreatic metastasis from the previously resected renal cancer because of the similarity of CT-enhanced pattern of the pancreatic tumor to the resected renal one. Other organ metastases were absent. Therefore, we performed laparoscopic distal pancreatectomy. Microscopically, the tumor was diagnosed as clear cell carcinoma which was identical to the previously resected renal tumor. He was discharged on 10th postoperative day without morbidities and is alive without recurrence as of 3 years after the third operation. Pancreatic metastasis of renal cell carcinoma occurs late in many cases, and surgical resection is reported to improve the long-term outcome. Laparoscopic approach that can provide radical therapy may be useful for elderly patients with pancreatic metastasis from renal cancer whose pulmonary function is deteriorated.

A 74-year-old woman with a 1-month history of fatigability was referred to our hospital after diagnostic imaging revealed splenomegaly and splenic tumors. Her laboratory data showed thrombocytopenia. Abdominal computed tomography and magnetic resonance imaging revealed splenomegaly and multiple splenic tumors ; however, definitive diagnosis could not be established. We performed splenectomy to definitively diagnose and treat her condition. Histopathological findings showed diffuse proliferation of large atypical cells with abundant eosinophilic cytoplasm and large pleomorphic nuclei. Immunohistochemical examination showed cells that stained positive for CD68 and CD163 and negative for CD1a, langerin, and CD34. Therefore, we diagnosed this patient with histiocytic sarcoma of the spleen. Her platelet count promptly increased postoperatively ; however, thrombocytopenia recurred 23 days after surgery. Unfortunately, the focus of recurrence could not be detected by further examination. Her general condition worsened, and she was treated palliatively. The patient died 4 months postoperatively.

A 68-year-old man was transported to our hospital with sudden onset of left-sided abdominal pain that occurred at bedtime. Upon admission, he showed abdominal distention and upper abdominal tenderness, without any evidence of trauma. Abdominal computed tomography revealed accumulation of perisplenic high-density fluid. Emergency laparotomy was performed, and he underwent splenectomy for a diagnosis of atraumatic splenic rupture. Intraoperative findings included extensive coagulation and splenic rupture extending from the serous surface to the parenchyma. Based on histopathological examination of the excised specimen, bone marrow examination, peripheral blood tests, and urinalysis, he was diagnosed with multiple myeloma. Atraumatic splenic rupture secondary to malignant hematological disorder is rare. We could not confirm domestic reports of splenic rupture caused by multiple myeloma in the literature. We report this rare case along with bibliographic comments.

A 51-year-old woman was admitted to our hospital for the evaluation of a retroperitoneal solid tumor measuring 6 cm in size. The right-sided periadrenal tumor was incidentally identified on abdominal computed tomography performed during medical examination for another disease. The tumor was located on the dorsal aspect of the inferior vena cava and the right renal vein. Magnetic resonance imaging showed a well-defined tumor boundary that separated it from the right adrenal gland. Serum levels of cancer antigens (CEA and CA 19-9) and all 3 fractions of blood catecholamines were within reference range. Endoscopic ultrasound-guided fine-needle aspiration was performed, and the tumor was diagnosed as a retroperitoneal schwannoma. Based on the aforementioned findings, we performed 5-port laparoscopic surgery. We carefully dissected the soft adhesions between the tumor and the inferior vena cava and performed lysis of the strong fibrotic adhesions between the tumor and the right border of the vertebral body. Subsequently, we resected the tumor, including the adjacent portion of the right adrenal gland. The operation time was 256 min, and the estimated intraoperative blood loss was 250 g. No postoperative complications occurred, and the patient was discharged 7 days postoperatively.

A 48 year-old man was referred to our hospital because of a huge pelvic tumor. His past medical history included hypertension. Laboratory findings were unremarkable, and an abdominal computed tomography (CT) scan showed a huge “well-demarcated” pelvic mass measured 20 cm in size. Neither distant metastases nor involvement of other organs were seen. Needle biopsy was performed to make the histopathological diagnosis. Then a solitary fibrous tumor (SFT) was diagnosed. An angiography revealed that the tumor was fed only by the inferior mesenteric artery. So we performed resection of the tumor with the patient in the Jack-knife position via the transsacral followed by abdominal approach. The rectum associated with part of the sigmoid colon was dissected at the anal side of the tumor, and the tumor was exfoliated from the pelvic wall through transsacral approach prior to abdominal resection. The duration of the operation was 8 hours and 5 minutes, and blood loss was 1,135ml.

Even huge SFTs like in our case can safely be removed by operation preceded by the transsacral approach that certify the operative vision and space.

We present a case of strangulated small bowel obstruction in an 80-year-old man who underwent left inguinal hernia repair in March 2017 using the transabdominal preperitoneal (TAPP) approach. No complications were reported after TAPP repair, and he was discharged after postoperative day 2. He returned 1 year and 5 months later with left-sided lower abdominal pain. Computed tomography revealed strangulated small bowel obstruction that necessitated emergency surgery. Strangulated small bowel obstruction was caused by adhesions observed at the site of peritoneal sutures, and no other adhesions were identified. Resection of the strangulated bowel segment and adhesiolysis were performed, and an adhesion barrier was applied to the suture site. Notably, adhesions at the site of peritoneal sutures may occasionally cause small bowel obstruction. It is recommended that an adhesion barrier be applied to the site of peritoneal closure.