Aims : Postoperative nausea and vomiting (PONV) are unpleasant symptoms common in women undergoing breast cancer surgery. We investigated the risk factors and evaluated preventive measures associated with PONV following breast cancer surgery. Method : This retrospective observational study included 175 women with breast cancer who underwent breast cancer surgery. Based on the Apfel scoring system for PONV, these women were classified into a high- and low-risk group. Pharmacological prophylaxis was administered to 81 women in the “treatment group”. Results : The incidence of PONV was 27.7% (95% confidence interval [CI] 18.6-36.7%) in the non-treatment group and 9.9% (95% CI 3.4-16.4%) in the treatment group, and relative risk reduction was 64% (95% CI 25-83%). Multivariate analysis showed that pharmacological prophylaxis (odds ratio 0.15, 95% CI 0.06-0.39) and risk classification based on the Apfel score (odds ratio 6.4, 95% CI 1.7-24.1) were significant risk factors for PONV. Conclusion : The administration of pharmacological prophylaxis based on a pre-surgical scoring system was effective for the prevention of PONV.

Urachal remnant can repeatedly recur, where we must consider surgical resection. On the other hand, urachal remnant commonly affects juvenile people whose surgeries need to provide them both radical and cosmetic outcomes. In Japan, laparoscopic excision of the urachus aiming for a more cosmetic and less-invasive approach has been covered by the health insurance and becomes the standard surgical procedure. However, this procedure that uses three ports cannot be satisfactory from a cosmetic viewpoint. Recently, we have sometimes encountered reports on single incision laparoscopic site surgery for urachus excision seeking for further improved cosmetic outcomes. However, it is the current status that no procedures for umbilicus incision and umbilicoplasty have been standardized.

This paper introduces how we cope with contriving procedures for umbilicus incision as well as urachus excision in the single incision laparoscopic site surgery.

A 78-year-old man who had previous history of cerebral infarction and had been on oral antiplatelet regimen underwent operation for esophageal cancer. Before the operation, we substituted heparin for the antiplatelet drug. When heparin administration was resumed postoperatively, the platelet level abruptly dropped to 3.5 × 10⁴/μL and heparin-induced thrombocytopenia (HIT) was suspected. After we substituted argatroban hydrate for heparin, the dropped serum platelet level was gradually normalized. Thereafter he developed deep vein thrombosis (DVT) and pulmonary thromboembolism, for that an inferior vena cave filter was placed. After we confirmed the disappearance of DVT, argatroban hydrate was changed to edoxaban tosilate hydrate and the IVC filter was removed.

Although HIT is a rare disease, it can be associated with thromboembolism and is potentially lethal without giving appropriate therapies. Early diagnosis and treatment are mandatory. Attention should be paid to the disease when we use heparin.

We report a case of pancreatic metastasis of papillary thyroid carcinoma (PTC) that was resected via laparoscopic distal pancreatectomy (LDP). A 73-year-old woman underwent total thyroidectomy with radical neck-lymph-node resection for PTC. Multiple lung metastases appeared 5 years later and were controlled by thyroid-stimulating hormone suppression therapy. Tracheal metastasis was also treated via tracheal-wedge resection 7 years later. Computed tomography revealed a pancreatic-tail tumor, which was diagnosed as pancreatic metastasis of the PTC using endoscopic ultrasound-guided fine needle aspiration 14 years after the first surgery. Because the pancreatic metastasis grew expansively over a short term, we decided to perform surgery to improve her prognosis and quality of life. We performed LDP to remove the pancreatic metastasis. The postoperative course was uneventful, and she remains alive one year after the LDP. Radical resection could be safely performed via laparoscopic pancreatic surgery for pancreatic metastasis of thyroid cancer.

Phyllodes tumors in adolescents are rare and it is difficult to preoperatively distinguish them from fibroadenomas, especially juvenile fibroadenomas. So far, tumorectomy has been required for fibroadenomas, and wide local excision for phyllodes tumors. Recently, we have increasingly encountered reports describing that resection for phyllodes tumors do not require margins when the stumps are negative. An 11-year-old girl presented with a left breast lump of 7 cm in size. The features of imaging examinations and pathological findings led to a diagnosis of benign phyllodes tumor rather than juvenile fibroadenoma. Tumorectomy was performed, and the histopathological examination identified benign phyllodes tumor. In this case, we did not perform additional resection, because it was a benign phyllodes tumor and the surgical margin was negative. There have been no signs of recurrence as of 6.5 years after the operation. In the treatment of phyllodes tumors in adolescents, it is necessary to decide therapeutic policy in consideration of cosmetic outcome and functional preservation along with complete resection.

A 65-year-old man presented to our department having noticed a mass beneath his right nipple 2-3 years previously. A mass around 2 cm in size was present immediately below the right nipple, and since invasive carcinoma (invasive lobular carcinoma) was suspected on needle biopsy, surgery was performed. Histological testing showed invasive, irregular proliferation of somewhat atypical cells with little cytoplasm. Although the nuclei of individual cells were of different sizes, the nuclear chromatin was comparatively consistent. Immunostaining results were negative for epithelial and lymphocyte markers, but positive for the mesenchymal markers of α-smooth muscle actin, vimentin, desmin, and CD34, leading to a diagnosis of myofibroblastoma. Myofibroblastoma is an extremely rare tumor arising from mammary stromal fibroblasts or myofibroblasts that is reportedly difficult to diagnose. Immunostaining is essential for its diagnosis. The differential diagnosis includes invasive lobular carcinoma and malignant phyllodes tumor, and this disease should be borne in mind when making a pathological diagnosis.

A 64-year-old woman presented with a rapidly growing mass in the left breast. Breast cancer was diagnosed on the basis of investigations including ultrasound and needle biopsy, and surgery was performed after preoperative chemotherapy. One month postoperatively, computed tomography showed local recurrence and lymph node, lung, and liver metastases. Because the patient had persistent fever and leukocytosis at one point, a liver abscess was suspected, and centesis was performed, but no bacteria were detected, and liver metastasis was diagnosed on the basis of cytology results. Procalcitonin was also low (0.61 ng/ml). Because the leukocytosis was prolonged, a granulocyte-colony stimulating factor (G-CSF)-producing tumor was suspected. Serum G-CSF was elevated at 54 pg/ml, and when surgical specimens were re-stained with anti-G-CSF antibodies, positive cells were observed, leading to a diagnosis of G-CSF-producing breast cancer. Chemotherapy had little effect, and the tumor rapidly metastasized and grew. The patient died five months postoperatively.

A 76-year-old woman diagnosed with carcinoma of the right breast underwent total mastectomy at the age of 68 years. Histopathological examination of the resected specimen revealed scirrhous carcinoma and the pathological stage was T2N1M0 Stage IIB, estrogen receptor (ER) (+), progesterone receptor (PgR) (+), human epidermal growth factor receptor 2 (HER2) (0). Therefore, she received adjuvant hormonal therapy for 5 years. During the 8^th postoperative year, a right adrenal gland tumor was identified by computed tomography with increasing levels of serum tumor markers. She underwent diagnostic and therapeutic laparoscopic right adrenalectomy. Histopathological examination of the specimen revealed an ER (-), PgR (-), HER2 (3+) tumor, which histopathologically differed from the primary tumor. Immunohistochemical examination revealed positive expression of gross cystic disease fluid protein-15 and mammaglobin, and the adrenal tumor was diagnosed as breast cancer metastases. The patient has shown no recurrence 2 years after the adrenalectomy.

Breast cancer often metastasizes to the adrenal glands as a component of systemic metastasis during the terminal stages of disease, and isolated metastases are rare.

We recommend surgical removal in these cases for different breast cancer of the treatment according to biology.

A 77-year-old man presented with of claudication of both legs. Since computed tomography (CT) showed a high occlusive lesion of the abdominal aorta, aorto-bilateral femoral artery bypass was performed. The patient's postoperative course was uncomplicated, and he was discharged home from the hospital. However, six months after the surgery, he visited a nearby hospital because of lower back pain and was transported by ambulance to our hospital due to a suspected iliopsoas muscle abscess on CT. He was diagnosed with a left retroperitoneal abscess with graft infection, and emergent laparoscopic abscess drainage and omental plombage were performed. Antimicrobial drugs were administered for a long time. Fortunately, he went home again and has been monitored without recurrence. Though most graft infections, which are refractory and may progress to systemic infection, need graft removal and revascularization, this patient achieved a successful outcome at one year without recurrent infection with laparoscopic abscess drainage and omental plombage.

Thoracic aortic injury due to a blunt trauma is a potentially fatal condition and we often have difficulties in saving lives of the patients. It is associated with multiple trauma at the same time in many cases, where therapeutic strategies would be important for the treatment of multiple traumatic lesions.

A 71-year-old man received a CT scanning for a blunt trauma by a fall and was diagnosed as having a pseudotumor due to thoracic aortic injury, bowel perforation, and hepatic injury. Under laparotomy, we performed a repair of the perforated intestine, followed by damage control surgery with gauze packing to control bleeding from the injured site of the liver. Thereafter, when hemostasis was confirmed, the injured aorta was treated by thoracic aortic stent grafting. On the 55^th postoperative day, the patient was transferred to another hospital for the purpose of rehabilitation. In this case, we treated the intraabdominal injury preferentially because the injury had dominated his general condition, and then the injured aorta could be treated less-invasively through a two-staged approach.

In treating multiple trauma extending from the chest to the abdomen, it is important accurately to grasp the severity of each injury. The use of a stent is beneficial for traumatic aortic injuries and we should use it for further extended indications.

Pulmonary carcinoid is a low-grade malignant tumor with neuroendocrine features. We report a resected case of postoperative liver metastases of pulmonary carcinoid. The patient was a 70-year-old man who had undergone lower-right pulmonary lobectomy and lymphadenectomy at another hospital after being diagnosed with pulmonary carcinoid nine years previously. Histopathological examination showed atypical carcinoid pT1N0M0 pStage IA. During postoperative follow-up observation, a tumor in the liver was confirmed by CT and the patient was referred to our hospital. Contrast-CT examination showed early deep-dyeing tumors of 25 mm in diameter in the segment VIII and 21 mm in the segment VI of the liver, and EOB-MRI examination revealed tumors showing a low signal in the hepatocyte phase of 25 mm and 4 mm in the segment VIII and 21 mm in the segment VI of the liver. Based on these findings, partial resection of segments VIII and VI of the liver was performed due to suspected liver metastases of the pulmonary carcinoid. The histopathological diagnosis was postoperative distant metastasis of the pulmonary carcinoid. As of 15 months after the surgery, the patient is alive with no recurrence. Pulmonary carcinoid has a record of recurring after a long-term interval, and sufficient follow-up observation would be necessary.

An 80-year-old man who had been receiving medical treatment as an outpatient after surgery for adenocarcinoma of the left upper lobe of lung was detected to have cystic wall thickening of the right apex of the lung by a chest CT scan 7 months earlier, and a 1.5-cm solid shadow in the same area by another chest CT scan one month earlier. Although definite diagnosis could not be obtained before surgery, laparoscopic partial resection of the right upper lobe was performed with a suspected diagnosis of lung cancer based on imaging findings. Histopathology revealed solid proliferation of highly atypical spindle-shaped cells and giant cells. Pulmonary pleomorphic carcinoma was diagnosed. Four months after the operation, he developed metastases to the right adrenal gland, the stomach, and lymph nodes of the lesser curvature of the stomach. We performed right adrenalectomy and distal gastrectomy with D2 lymph node dissection. The pathological diagnosis was metastases of pulmonary pleomorphic carcinoma. Retroperitoneal recurrence was detected three months after the second operation. Because of high PD-L1 expression was demonstrated in the specimen of the stomach, adrenal gland and lymphnodes, pembrolizumab administration was started and the metastatic lesion disappeared following 24 courses of the regimen. Pembrolizumab administration is sustained as of 28 months after the initial operation and the patient has been free from any recurrences.

A 65-year-old man was diagnosed with squamous cell carcinoma of the thoracic esophagus (LtAe, cT3N2M0, cStage III), and underwent two courses of preoperative chemotherapy (5-FU + CDDP), followed by subtotal esophagectomy under right thoracotomy and laparotomy, three-field lymph node dissection and posterior mediastinal reconstruction with a gastric tube. However, aspiration pneumonia was observed on the 8th postoperative day and antibiotics were administered. But on the 15th postoperative day, an abscess was found to have developed on the lower lobe of right lung. Conservative treatment with antibiotic administration, but clinical and imaging improvement was not obtained. Percutaneous puncture drainage was thus performed on the lung abscess on day 30. As a result, the symptoms and blood test gradually improved and he was discharged on the 78th postoperative day. Patients who develop a pulmonary abscess right after esophageal resection are extremely rare, and we herein report on our case with some literature considerations.

Recently, we have occasionally encountered reports on carcinoma arising from the Barrett's esophagus. But there were few reports about the process of developing cancer. Clinical cases of Barrett's esophageal carcinoma associated with systemic sclerosis (SS) have rarely been reported.

A 62-year-old female patient developed pulmonary embolism during hospitalization due to pneumonia. She was diagnosed with limited cutaneous systemic sclerosis because of the presence of centromere antibody, dermal sclerosis of the dorsum of hands, Raynaud phenomenon and dysphagia. Endoscopy to investigate the cause of prolonged dysphagia offered the diagnosis of esophageal carcinoma in the lower thoracic esophagus and abdominal esophagus. Biopsy revealed the pathological diagnosis of adenocarcinoma. She had been diagnosed as having gastroesophageal reflex disease and Barrett's esophagus. So, we diagnosed the case as Barrett's esophageal carcinoma and performed thoracoscopic esophagectomy. She remained to have dysphagia without recurrent nerve paralysis after the operation. The cause of her symptom was assessed by swallowing function test, which suggested gastrointestinal dysmotility due to SS. She was able to be discharged her home for about three months, but eventually she refused every medical practice including enteral nutrition and died on 288th postoperative day.

In this case, we could infer the development process of carcinoma in the Barrett's esophagus and keenly realized the seriousness of gastrointestinal dysmotility in the treatment of esophageal carcinoma with SS.

A 35-year-old woman presented with epigastric pain 4 years ago. Computed tomography revealed a tumor measuring 20 mm in size along the stomach. The tumor continued to grow, and she was admitted to our hospital for clinical examination. Imaging studies and histopathological examination of specimens obtained using endoscopic ultrasound-guided fine-needle aspiration could not establish a definitive diagnosis. Therefore, we performed laparoscopic tumor resection for histopathological diagnosis and treatment. During laparoscopy, the tumor was observed to be adherent to the stomach, and we performed partial gastrectomy using the laparoscopic and endoscopic cooperative surgery (LECS) approach. Finally, we diagnosed Castleman's disease (CD) in this patient. CD is a lymphoproliferative disease of unknown etiology, which occurs in 1-5 patients per 1 million per year. Reportedly, the incidence of intraperitoneal CD is 3.2%. We report a rare case of intraperitoneal CD diagnosed by LECS. Additionally, we have included a bibliographical description.

A 66-year-old man who visited a neighboring hospital because of epigastric discomfort was referred to our hospital for a tumor in the right lower quadrant of abdomen detected by an abdominal echography. An abdominal CT scan demonstrated each one tumor with the longer diameter of approximately 4 cm in the upper body of the stomach and in the right lower quadrant, respectively. Esophagogastroduodenoscopy revealed a submucosal tumor at the greater curvature of the upper body of the stomach. As a result of endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB), gastrointestinal stromal tumor (GIST) of the stomach was diagnosed, for that we decided to resect laparoscopically. The right lower abdominal tumor was suspected to be a GIST of the small intestine, but we could not make the definite diagnosis. We thus performed laparoscopic surgery partly for tumor resection and partly for diagnostic treatment. The both tumors were successfully resected laparoscopically, and histopathologically synchronous GISTs of the stomach and ileum were diagnosed.

An 81-year-old man was diagnosed with type IV gastric cancer of the upper stomach. He visited our department for sudden abdominal pain 10 days after gastrography. A large amount of residual barium in the stomach and free air and leaked barium in the abdomen were confirmed on abdominal X-ray and computed tomography (CT) examinations. He was diagnosed with perforated peritonitis, and emergency surgery was performed. Intraoperatively, an approximately 5-cm perforation on the posterior wall from the fundus to the upper body and muddy residual barium in the stomach were noted, and the stomach cancer infiltrated from the entire lesser omentum to the hepatoduodenal ligament. Therefore, palliative gastrectomy, Roux-en-Y reconstruction, and peritoneal lavage and drainage were performed. Since the perforation was in a noncancerous area according to the pathology, decreased peristalsis with type IV gastric cancer accompanied by extensive infiltration from the lesser omentum to the hepatoduodenal ligament had induced compression necrosis due to the large amount of residual barium. There have been no previous reports of stomach perforation in a noncancerous area due to residual barium. For cases of type IV gastric cancer encompassing the entire stomach, it is necessary to observe sufficient barium excretion after gastrography.

A long-surviving case after surgical resection of a solitary lung metastasis from gastric cancer (GC) is reported. A 68-year-old woman had undergone total gastrectomy with splenectomy and D2 lymphadenectomy for GC. Gross examination of the resected specimen showed a type 2 tumor arising from the esophago-gastric junction. On pathological diagnosis and staging, the GC was a moderately-differentiated tubular adenocarcinoma a, pT2 (MP), int, INFβ, ly1, v0, N1, H0, P0, M0, stage IIB according to the Japanese classification systems (JCGC 14th edition). She was treated with S-1 adjuvant chemotherapy after surgery. Seven months after surgery, chest CT showed a mass lesion in the upper lobe of the right lung without other metastases. After an interval of 3 months, she underwent left upper lobectomy for the lung tumor. The pathological diagnosis of the resected specimen was a moderately-differentiated adenocarcinoma, and immunohistochemistry showed expression of CDX2, whereas CK7, CK20, and TTF-1 were not present ; it was thus considered a metastasis from GC. The patient's postoperative course was uneventful, and there were no signs of recurrence at 4 years after surgery. Pulmonary metastasectomy for GC can result in long-term survival for a highly selected group of patients with a solitary, isolated lesion.

The patient was a 60-year-old woman who was scheduled to undergo operation for early gastric cancer cT1b N0 M0 cStageIA (14^th Japanese Classification of Gastric Carcinoma). Preoperative multi detector-row computed tomography (MDCT) and 3D-CT angiography showed a vascular anomaly of Type V in Adachi's classification. Since it was diagnosed as early gastric cancer, laparoscopic distal gastrectomy with lymph node dissection was performed. The common hepatic artery and the splenic artery arising separately were confirmed at suprapancreatic lymph node dissection, and so D1+ lymph node dissection was safely performed by keeping the outer layer of each artery expose. In laparoscopic surgery, the branching pattern of the vessel cannot be confirmed easily during operation because of the lack of palpation and visual field expansion. In addition, laparoscopic surgery is more difficult than laparotomy in the operative technique itself. Consequently, it is important to recognize the branching pattern of the vessel and possible existence of vascular anomaly by preoperative CT, in performing suprapancreatic lymph node dissection safely.

A 72-year-old patient was diagnosed with advanced type 3 gastric cancer in the middle body of the stomach. Abdominal computed tomography (CT) showed a liver metastasis. The clinical stage was determined to be T3, N1, H1, M1(HEP), and Stage IV. The patient was referred complaining of sudden abdominal pain on day 13 of chemotherapy with S-1 plus oxaliplatin (SOX). Abdominal CT showed intra-abdominal free air and a defect of the gastric wall. Emergent total gastrectomy was performed. The defect of the gastric wall was observed in the ulceration of the gastric cancer. The pathological response was grade 3. The patient was discharged 17 days after surgery and continued the same chemotherapy. The liver metastasis shrank from 42 mm to 11 mm after 8 courses of chemotherapy, and metastasectomy was performed. The patient has survived 8 months after this metastasectomy (16 months from treatment start). The high antitumor effect of chemotherapy may lead to perforation of gastric cancer, and it is necessary to consider the treatment strategy taking into account the possibility of future conversion surgery if the gastric cancer perforates during chemotherapy.

A 28-year-old man without remarkable medical history was admitted to our hospital with acute abdominal pain and bloody stools. Abdominal computed tomography showed the patient's ileum to have invaginated into the ascending colon at where multiple gaseous cysts were confirmed. The patient was considered to be a candidate for emergency surgery, on account of having bowel ischemic symptoms. During surgery, some small palpable elastic-soft tumors were found in the cecum, so we performed ileocecal resection because a possibility of malignancy could not be ruled out. Grossly the resected specimen revealed the presence of multiple polyps on the cecum mucosa. Histopathological findings showed severe edema and cysts of variable sizes in the submucosal area, in addition to bleeding and congestion in the lamina propria mucosae area. These findings led to the diagnosis of intussusception caused by pneumatosis cystoides intestinalis (PCI).

PCI is a disease characterized by the presence of multiple gaseous cysts beneath the serosa and mucosa in the intestinal wall, and the etiology has been unclear. PCI associated with intussusception is a rare condition. Here we report a case along with a review of the literature.

A 56-year-old woman presented to our hospital because of a pancreatic tumor detected by an abdominal ultrasonography at a health exam. The hypoechoic tumor was 17mm in size, and closely contacted to the pancreas and small intestine. On a contrast-enhanced CT scan, it was revealed as a hypervascular tumor adjacent to the bowel wall and pancreas parenchyma. Primary mesenteric tumor, especially, gastrointestinal stromal tumor or neuroendocrine tumor (NET) was suspected. Laparoscopic tumor resection was performed (the operative time was 174 min and the operative blood loss was 10mL).

At least in laparoscopic findings, the tumor was adjacent to the ligament of Treitz and had no anatomical continuity with the surrounding organs. The resected specimen showed the character of primary mesenteric NET. On immunostaining, tumor cells were positive for chromogranin A, synaptophysin, and CD56, and the MIB-1 index was 8.4%. These findings were compatible with NET G2.

Primary mesenteric NET is extremely rare. Several case reports are known and most of them were treated by open surgery. So far, there is no case of primary mesenteric NET resected by pure laparoscopic procedure. Considering the advantage of laparoscopic surgery, it might be a suitable way to treat.

Four years previously, the patient had undergone colonoscopy in our institution during which over 100 polyps were identified, and after genetic screening, non-concentrated familial adenomatous polyposis (FAP) due to a nonsense mutation in the APC gene was diagnosed. The patient refused surgery and remained under observation while undergoing regular yearly endoscopy to remove the polyps. The patient subsequently presented with right lower abdominal pain that had persisted for 2 days. Appendicitis was suspected on the basis of blood tests and abdominal computed tomography, and the decision was made to perform emergency surgery that day. Because appendiceal cancer could not be excluded, an open appendectomy was performed, and since intraoperative rapid pathological testing resulted in a diagnosis of mucinous carcinoma of the appendix, ileocecal resection and lymph node dissection were also performed. The case of a patient with FAP who developed primary appendiceal cancer, a rare occurrence, is reported along with a short discussion of the literature.

A 72-year-old man came to our hospital because of right lower abdominal pain. Abdominal computerized tomography (CT) scan revealed ileocecal lymph node enlargement, but otherwise we could not find apparent primary lesion. The lymph node tended to enlarge with time. Positron emission tomography (PET)-CT scan also suggested a malignancy at the same site. Thus, we diagnosed the case as unknown primary cancer with ileocecal lymph node metastasis. He underwent laparoscopic ileocecal resection. Histopathologically, adenocarcinoma containing mucinous adenocarcinoma with metastasis to the resected lymph nodes was confirmed, but no primary cancer was found in the resected intestinal specimen. Immunohistochemistry revealed the nodes to be positive for caudal-related homeobox transcription factor (CDX) 2, but negative for cytokeratin (CK) 7 and CK 20. Furthermore, immunohistochemical stainings of mucin (MUC) 1, 2, AC and 6 for mucinous adenocarcinoma were positive. We thus suspected digestive tract cancer, hepatobiliary and pancreatic cancer, or a urological tumor. Even after the operation, the primary cancer was still unknown by capsule endoscopy, magnetic resonance cholangiopancreatography (MRCP), magnetic resonance imaging (MRI) and cystoscopy. Follow-up observation without adjuvant chemotherapy was provided. The p53 antibody levels which had elevated before surgery were immediately normalized after the surgery. Although three years have passed since the surgery, no recurrence has been detected. In this case, long-term survival could be achieved with surgery alone. It is so rare that further accumulation of clinical cases, including our case, would be needed.

A 70-year-old man was admitted to our hospital with a 2-week history of fever and abdominal pain. He was treated with antimicrobial agents for 11 days, but the fever and elevated inflammatory response persisted, and since colonic necrosis was evident, emergency surgery was performed. Because intermittent ischemic changes were present from the middle part of the descending colon to the sigmoid colon, the proximal side of the descending colon was transected, and a stoma was created. Histopathological examination showed fibrinoid necrosis in medium-sized and small blood vessels, and ischemic colorectal necrosis due to polyarteritis nodosa (PAN) was diagnosed. Ten days postoperatively, the drainage fluid appeared stool-like, and when the abdomen was re-opened, intermittent intestinal necrosis was present from the jejunum to the proximal side of the stoma. The entire small intestine and colon were therefore removed. Exacerbation of vasculitis was diagnosed on the basis of histological findings, and multimodal therapy was provided. However, the patient repeatedly developed fistulas of the duodenal stump and sepsis and died on postoperative day 110.

There are no specific findings of the gastrointestinal lesions of PAN, but this disease has a high mortality rate, and it is necessary to include vasculitis in the differential diagnosis, start medical treatment at an early stage, and perform surgery in patients who are resistant to treatment.

A 79-year-old woman with right lower quadrant abdominal pain was admitted to our hospital. Abdominal contrast-enhanced computed tomography showed a 70-mm tumor in the ascending colon and peritoneal dissemination in the vicinity, with suspected invasion into the inferior leg of the duodenum. Colonoscopy showed a tumor of three-quarters of the circumference in the ascending colon, but a confirmed diagnosis was not obtained on biopsy. Right hemicolectomy with concomitant resection of the duodenum, jejuno-duodenal anastomosis, and resection of peritoneal dissemination were performed for the ascending colon tumor with peritoneal dissemination. Histopathological examination showed diffuse growth of short spindle-shaped cells with large heterozygous nuclei. On immunostaining, only vimentin was positive. The final diagnosis was undifferentiated pleomorphic sarcoma of the ascending colon. Computed tomography 3 months after surgery showed recurrent peritoneal dissemination. The patient died only 5 months after the initial operation. Undifferentiated pleomorphic sarcoma is prevalent in extremity soft tissues. Since undifferentiated pleomorphic sarcoma of the colon is rare, with only 27 cases, including the present patient, reported in the past, this case is reported along with a review of the relevant literature.

A 77-year-old woman presented with malaise and abdominal pain. Preoperative investigations showed a type 2 lesion in the ascending colon, with marked enlargement of the paracolic and intermediate lymph nodes. Ascending colon cancer with lymph node metastases was diagnosed, and resection was performed. On pathological examination, the lesion in the ascending colon was highly differentiated adenocarcinoma, but no lymph node metastasis was identified. The enlarged lymph nodes showed no sign of malignancy but contained regularly arrayed hyperplastic lymph follicles, with a large amount of plasma cell infiltration between the follicles. Plasma cell localized Castleman's disease was diagnosed. Castleman's disease is a lymphoproliferative disease of unknown origin. It commonly occurs in the chest and the head and neck region, and it only rarely arises in the mesentery. Only a few cases of its occurrence together with colorectal cancer have been reported in Japan. A case of Castleman's disease in regional lymph nodes of colorectal cancer that was difficult to distinguish from lymph node metastasis is reported.

In colorectal cancer, neuroendocrine carcinoma (NEC) is a relatively rare histologic type. It is histologically classified as small-cell NEC (SCNEC) and large-cell NEC (LCNEC). The case of a patient with ascending colon LCNEC who underwent curative surgery and chemotherapy for postoperative early recurrence is presented. A 77-year-old man presented with anorexia. He was diagnosed with ascending colon cancer T4aN2M0, Stage IIIC (UICC-TNM 7th) and underwent right hemicolectomy (D3). The pathological diagnosis was LCNEC T4aN1aM0, Stage IIIB (UICC-TNM 7th). No postoperative chemotherapy was given. Two months later, lymph node recurrence and multiple liver metastases developed. CDDP plus CPT-11 therapy for small cell lung cancer was then given. The lesions did not increase for a while, but then they gradually got worse. The patient died 16 months after surgery.

A 71-year-old woman presented with shortness of breath and unsteadiness, her blood tests showed anemia, and she was then seen at our hospital. Abdominal computed tomography showed a mass with a maximum diameter of about 5 cm in the ascending colon and regional lymph node enlargement, but there were no signs of distant metastases or peritoneal dissemination. Lower gastrointestinal endoscopy showed a circumferential type 2 lesion in the ascending colon, which was histologically diagnosed as moderately differentiated adenocarcinoma. Cancer of the ascending colon with regional lymph node metastasis was therefore diagnosed, and open ileocecal resection was planned. Intraoperatively, in addition to the main lesion in the ascending colon, tumors were also found at six different locations in the small intestine, between 20 cm and 120 cm from the proximal side of the terminal ileum, and two parts of the small intestine were also resected. On gross observation, the resected small intestinal tumors comprised four type 2 tumors located mainly in the muscularis layer and two submucosal tumors. Histopathologically, the ascending colon cancer was highly differentiated adenocarcinoma [T3(A), N0, ly1, v2], and the small intestinal tumors were all adenocarcinomas with similar characteristics. Ascending colon cancer with multiple small intestinal metastases in six locations was diagnosed.

A 59-year-old man underwent abdominoperineal resection and lateral pelvic lymph node dissection with resection of the left external iliac vein after chemoradiography for rectal cancer with bulky lymph node metastasis. The pathological diagnosis was ypStage IIIb, and adjuvant chemotherapy was conducted. Two years after the surgery, an abdominal computed tomography revealed a nodule just below the abdominal wall. Slight accumulation of FDG (standardized uptake value, 1.7) to the nodule was demonstrated on the combined positron emission tomography and computed tomography (PET-CT). The nodule was suspected to be dissemination metastasis. As no other metastases were confirmed, laparoscopic resection for the nodule was performed. During surgery, a white nodule was identified in the greater omentum which was histopathologically found to be a foreign body granuloma due to an anisakis larva. He was diagnosed with extra gastrointestinal anisakiasis.

Preoperative diagnosis of this disease is very difficult because it is rare and may be asymptomatic. We must be attentive to this rare disease as a differential diagnosis of an intra-abdominal nodule after operation for advanced rectal cancer.

Malignant transformation arising in intestinal endometriosis is extremely rare, and there is no report of simultaneous resection of intestinal endometrial adenocarcinoma with metastasis. We report a case of rectal endometrial adenocarcinoma with liver metastasis. The patient was a 53-year-old-woman. A tumorous lesion suspected of liver metastasis was observed in S6 and S8 on computed tomography for screening after a breast cancer surgery. Since adenocarcinoma was detected in a liver biopsy specimen, we performed colonoscopy and detected a type 1 tumor pathologically diagnosed as adenocarcinoma in the rectum. As a result of immunohistological staining, the hepatic lesions were not confirmed as metastases of breast cancer, and the possibility that the hepatic lesions were not liver metastasis of rectal cancer was also considered. However, high anterior resection and partial hepatic resection of S6 and S8 were performed after fully explaining the possibility. On histopathological examination, the patient was diagnosed with serous adenocarcinoma in rectal endometriosis with liver metastasis. Paclitaxel + carboplatin therapy was administered as adjuvant therapy, and the patient has survived without recurrence for 6 months.

A 61-year-old woman was diagnosed with a cystic hepatic tumor in the S4 segment of the liver during her treatment for a gastric ulcer. Computed tomography revealed a cystic tumor measuring 16 mm in diameter with internal septal and cyst-in-cyst formations. Despite the diagnosis of a mucinous cystic neoplasm (MCN) of the liver, she opted against surgical intervention at the time. After a 3-year follow-up, the tumor had grown to 29 mm in diameter with thickening of the internal septal formation ; laparoscopic left hepatectomy was then performed. Macroscopic findings showed a multilocular cystic tumor that contained mucinous material. Pathological evaluation of the hepatic MCN confirmed the presence of an ovarian-type stroma. She was discharged from the hospital 13 days after the surgery without any postoperative complications.

Hepatic MCN is a rare type of cystic tumor of the liver, which presents with a good prognosis if complete resection is performed. In conclusion, low-grade malignancies, such as hepatic MCN, are good indications for laparoscopic surgery.

We report a rare case of pancreaticobiliary maljunction without biliary dilatation following traumatic gallbladder injury in a 38-year-old man who presented with abdominal pain and vomiting after being kicked during karate. We diagnosed gallbladder injury based on computed tomography, and he underwent laparoscopic cholecystectomy. Intraoperative cholangiography revealed pancreaticobiliary maljunction without bilary dilatation at the junction. Histopathological examination of the gallbladder mucosa revealed intraepithelial neoplasia BillN-1, 2. After his condition improved, we performed resection of extrahepatic bile ducts with intrahepatic cholangiojejunostomy to prevent cholangiocarcinoma. At the time of writing this report, he is alive without evidence of cholangiocarcinoma.

An 86-year-old man was referred to our hospital with the diagnosis of an intra-abdominal abscess. He underwent laparoscopic cholecystectomy for cholelithiasis at our hospital 2 years prior to his current presentation. Abdominal computed tomography (CT) revealed a low-density mass in the posterolateral sub-hepatic space, and we performed laparoscopic drainage of the abscess. Intraoperatively, purulent material was removed, and a single black gallstone was retrieved followed by copious irrigation of the surgical field. The patient was discharged on the 5^th postoperative day after an uneventful postoperative course. Abdominal CT performed a month after discharge revealed a recurrent abscess, which had gradually increased in size and measured 5 cm in diameter. He underwent percutaneous drainage of the abscess and was discharged 2 weeks after the procedure. No recurrence was observed 6 months after being discharged following the second procedure. Complete retrieval of lost gallstones laparoscopically is difficult and may cause recurrent intra-abdominal abscesses.

An 86-year-old-man, who visited another hospital because of anorexia, was diagnosed as having duodenal cancer based on upper gastrointestinal endoscopy and referred to our hospital. Subtotal stomach-preserving pancreaticoduodenectomy was performed, and the histopathological diagnosis was primary adenocarcinoma of the minor duodenal papilla (Stage IIA : Japanese Classification of Biliary Cancer 2013). Invasive tubular adenocarcinoma was mainly located in the minor duodenal papilla and invaded the pancreatic parenchyma. A non-invasive component was observed in the accessory pancreatic duct. The patient has been followed up after the operation for one and a half years, he has not developed recurrence, and he remains alive.

A solitary extramedullary plasmacytoma (EMP) is a rare from of plasmacytoma and is often located in the upper and lower aerodigestive and gastrointestinal tract. We report a rare case involving a solitary EMP that occurred from the spleen. A 76-year-old man with indications of solitary EMP based on routine abdominal ultrasonography was referred to our department from a previous medical department. He did not exhibit any symptoms, and blood test results revealed no increase in tumor markers. Computed tomography revealed a well-defined splenic tumor, 46 mm in diameter. After various examinations, he underwent splenectomy because the possibility of malignant lymphoma could not be discounted. The resected spleen, weighing 130 g, contained a solid mass measuring 52 mm × 40 mm. Histopathologically, the tumor had plasmacystic monoclonal growth. There were no tumors in other organs except the spleen, and on postoperative examination, there was no evidence of bone lesions and urinary Bence Jones protein. Thus, we confirmed the diagnosis of solitary EMP of the spleen. After the surgery, he continues to be followed-up without undergoing additional chemotherapy, and there has been no recurrence 20 months post-surgery.

A 28-year-old woman was referred to our hospital because of an elevated serum testosterone level and amenorrhea. No features suggesting Cushing's syndrome were observed. Her clitoris was slightly swollen. Her serum levels of testosterone and dehydroepiandrosterone sulfate (DHEA-S) were abnormally elevated. No abnormality in pituitary function was identified. A 9-cm, well-bordered, large, round, left adrenal tumor with heterogeneous enhancement was revealed using contrast-enhanced abdominal computed tomography. No lymph node swelling or lung or liver metastasis was observed. A diagnosis of testosterone-producing left adrenocortical carcinoma was confirmed. Laparotomy revealed a clear-bordered, hypervascular tumor originating from the left adrenal gland without invasion into the surrounding organs. A 380-g tumor could be excised easily with the left adrenal gland. On the cut surface, the tumor was reddish-brown with a dark-red central portion. Histopathological examination revealed atypical tumor cells with palisade arrangement and large irregular nuclei. The tumor fulfilled 8 of the 9 Weiss criteria, and a diagnosis of adrenocortical carcinoma (T2N0M0) was confirmed. The postoperative course was uneventful, and she was discharged on the seventh postoperative day. Her testosterone and DHEA-S decreased to normal levels, and menstruation resumed. No sign of recurrence was observed and adjuvant therapy was not required for 16 months.

A 41-year-old woman was admitted with abdominal pain and vomiting. Abdominal computed tomography revealed small intestinal obstruction with caliber change observed on the dorsal aspect of the uterus ; however, a definitive diagnosis could not be established. The obstruction persisted despite drainage using a long intestinal tube, necessitating single-incision laparoscopic surgery. Intraoperatively, the lower half of the small intestine was observed to be incarcerated on the right side of the pouch of Douglas. The defect was closed using suture ligature after releasing the obstruction and confirming bowel integrity. The patient was discharged on the 10^th postoperative day following an uneventful postoperative course. Few reports have described internal hernia through a peritoneal defect in the pouch of Douglas. This is the first report to describe such a case of a patient treated with single-incision laparoscopic surgery. Single-incision laparoscopic surgery is minimally invasive and excellent in deformation and a potentially useful treatment strategy.

A 36-year-old Japanese man presented to the emergency department of our hospital with sudden epigastric pain after elaborate toilet cleaning. Initial computed tomography (CT) did not reveal any evidence suggesting the underlying cause of pain. However, his pain worsened, and contrast-enhanced CT performed 9 hours later revealed the small intestine had herniated into the omental bursa through a defect between the portal vein and the inferior vena cava, and we diagnosed herniation through the foramen of Winslow (HFW). Laparoscopic surgery was performed 21 hours after the onset of symptoms. The invaginated small intestine showed prominent congestion ; however, the color improved following reduction, which obviated the need for intestinal resection. He was discharged 9 days later following an uneventful recovery. HFW is a rare internal hernia ; however, it can be diagnosed preoperatively on CT. In most cases, decompression using an ileus tube is challenging, and we recommend that immediate surgery be performed as first-line treatment after diagnosis. In this case, we could follow the time course of the development of HFW on CT. We conclude that the patient's posture and elevated abdominal pressure (during toilet cleaning) contributed to the serious presentation in this case.

An 83-year-old woman presented to our hospital with a mass and pain in her bilateral lumbar area. Computed tomography revealed an abdominal wall defect and herniation of prolapsed colon in the same area leading to a diagnosis of idiopathic bilateral superior lumbar hernia. Laparoscopic retroperitoneal hernia repair was performed using a Versatex^TM mesh. The patient was discharged on the 3^rd postoperative day without complications. No adverse events including recurrence and/or pain were observed at postoperative follow-up. We recommend a retroperitoneal approach as a suitable approach to treat lumbar hernia to surrounding organ injury.