Hirschsprung's disease and allied disorders present with functional intestinal obstruction in contrast to congenital conditions such as intestinal atresia, which typically manifest with features of mechanical obstruction. Hirschsprung's disease is characterized by the absence of intramural ganglion cells in the rectum and colon. Aganglionosis is restricted to the rectum and sigmoid colon in most patients, who can therefore be successfully treated with surgery, including resection of the dilated and aganglionic narrowed colonic segments with pull-through of the normoganglionic colon. However, an aganglionic segment that extends to the small bowel results in short bowel syndrome with poor outcomes in patients with total colonic aganglionosis. Patients with allied disorders show ganglion cells in the rectum ; however they tend to present with symptoms that mimic those of total colonic aganglionosis. Hypoganglionosis, megacystis microcolon intestinal hypoperistalsis syndrome, and chronic idiopathic intestinal pseudo-obstruction represent allied disorders of Hirschsprung's disease and are associated with poor outcomes. These patients can be treated with parenteral nutrition and appropriate intestinal decompression ; however, effective surgical treatment is unavailable. Long-term outcomes are poor, and most patients die of sepsis and liver failure. Studies are warranted to investigate the role of intestinal transplantation or novel stem-cell based therapeutic strategies.

To prevent postoperative pancreatic fistulas during suprapancreatic lymph node dissection in laparoscopic gastrectomy, we have adopted a surgical approach that avoids direct compression of the pancreas since January 2017. Between January 2011 and December 2018, 178 patients underwent laparoscopic gastrectomy with placement of an abdominal drain for gastric cancer at our institution. The patients were divided into two groups, with 124 patients in the compression group (until December 2016) and 54 patients in the non-compression group (since January 2017). The patients' background characteristics, clinicopathological factors, and surgical outcomes were then compared retrospectively. The drainage fluid amylase levels were lower in the non-compression group than in the compression group on postoperative day 1 ; in particular, they were significantly lower on postoperative day 3 (p=0.001). No patient developed postoperative pancreatic fistula (Clavien-Dindo Grade ≥2) in the non-compression group. A surgical approach to avoid direct compression of the pancreas in laparoscopic gastrectomy is a useful method to prevent postoperative pancreatic fistulas.

Primary neuroendocrine neoplasms (NEN) of the rectum are comparatively rare tumors, and there is scope for discussion of issues including indications for additional resection after endoscopic treatment and the risk of lymph node metastasis. A retrospective study of the clinicopathological characteristics, long-term treatment outcomes, and risk of lymph node metastasis of 21 cases of primary rectal NEN treated surgically in our hospital between January 2010 and April 2020 was conducted. Lymph node metastasis occurred in 6 cases (28.5%), but no patient developed recurrence. None of the six patients with only one of the risk factors of tumor diameter ≥ 10 mm, formation of a depression on the tumor surface, muscularis propria invasion, grade 2 or worse, lymphatic invasion, or venous invasion had lymph node metastasis, whereas it was present in 6 of 15 patients (67%) with two or more of these factors, and formation of a depression on the tumor surface was identified as the only risk factor with a tendency to significance. Additional surgery is not performed for some patients from the perspectives of avoiding stoma formation and surgical invasiveness. Patients at low risk of lymph node metastasis should be identified, and the lymph node metastasis rate should be more accurately assessed.

We report a rare case of Marine-Lenhart syndrome in a patient in whom a right thyroid nodule (associated with normal thyroid function) was transformed into a functional thyroid nodule (Plummer's disease) during treatment of Graves' disease. A 47-year-old euthyroid woman who was previously followed-up at our hospital and showed negative results on cytological evaluation of a right lobe thyroid nodule was referred with fatigue and palpitations during work. Blood tests revealed elevated serum levels of free tri-iodothyronine and thyroxine, low thyroid-stimulating hormone (TSH), and positive results for the TSH receptor antibody (TRAb). The oral administration of mercazole led to a negative serum TRAb titer ; however, continued oral administration of mercazole was necessary to maintain her euthyroid status. A thyroid scan with a technetium-99m scintigram revealed a diffusely enlarged gland with increased tracer uptake, particularly in the right thyroid lobe nodule ; therefore she was diagnosed with Marine-Lenhart syndrome. The right thyroid lobe nodule was a functional tumor and progressively increased in size ; therefore, we performed total thyroidectomy. Histopathological examination of the resected specimen showed an adenomatous nodule without evidence of malignancy.

We encountered a case of primary breast angiosarcoma. The patient was a 55-year-old woman who was referred to our hospital for a 3-cm palpable mass in the right breast C area. Ultrasonography showed a mixed mass of 2.2 cm in length with low echo and anecho in the same area. MRI showed a well-defined mass and a faint high-signal area surrounding the mass. Angiosarcoma was identified on needle biopsy, and mastectomy with extensive skin resection was performed. The pathological result was a moderately differentiated primary angiosarcoma. Macroscopically, the tumor was 4 cm in diameter ; however, there was infiltration in the areas surrounding the tumor. The patient has been without recurrence for 11 months post operation. Herein, we report a rare case of primary angiosarcoma of the breast with a literature review.

A case of malignant phyllodes tumor with multiple lung metastases is reported. The patient was a 39-year-old woman with a tumor that occupied the whole right breast and was ulcerated, with exudate, blood, and a foul odor. She was admitted immediately because of severe anemia and pain. Simple mastectomy and skin flap reconstruction were performed to control hemorrhage and pain. Tumor weight was 4 kg, and its maximum diameter was 36 cm. Pathological examination showed a malignant phyllodes tumor, with a Ki67 labeling index of 70%. About 2 months after the operation, local recurrence in the skin of the right breast was observed, and the lung metastasis increased rapidly in size. The patient died about 3 months after the operation.

A 64-year-old female patient had been followed up for a low echoic area in the right breast for 10 years. An intraductal lesion under the nipple was newly detected on ultrasound. As the diagnosis was difficult by fine needle aspiration biopsy and core needle biopsy, we performed excisional biopsy. Histologically, the funicular atypical cells proliferated with lymphocytic infiltration, and they were positive for CK and E-cadherin. We performed total mastectomy, and the patient was finally diagnosed with lymphoepithelioma-like carcinoma of the breast. The patient received adjuvant chemotherapy and endocrine therapy, and there has been no evidence of recurrence for 19 months after surgery.

A 67-year-old male was referred to the surgery/pathology department. The tumor in both of his mammary glands was examined. He was diagnosed with synchronous bilateral breast cancer using mammography, ultrasonography, breast magnetic resonance imaging scan, and core needle biopsy. Bilateral total mastectomy and sentinel lymph node biopsy were performed. Histopathological examination revealed invasive ductal carcinomas (no special type) in both breasts, pT1N0M0. These tumors were positive for estrogen and progesterone receptors and negative for HER2/neu, and the Ki67 score was less than 10%. His older brother was diagnosed with breast cancer ; thus, we performed genetic testing of BRCA1/2 ; however, no mutations were observed in the BRCA genes.

Herein, we report a case of therapy-related myelodysplastic syndrome in a female who received adjuvant chemotherapy for breast cancer.

An 82-year-old woman was diagnosed with stage I breast cancer and received a combination of epirubicin, cyclophosphamide, and letrozole. Laboratory investigations revealed pancytopenia and blast cells in a peripheral blood smear approximately 5 years after receiving adjuvant chemotherapy, and a bone marrow smear revealed myelodysplastic syndrome. Therapy-related myelodysplastic syndrome was primarily attributable to azacitidine administration in this patient. Therapy-related myeloproliferative neoplasm should be considered in patients receiving chemoradiation therapy.

Metastasis of breast cancer to the bile ducts is extremely rare. A 67-year-old woman underwent a total mastectomy with axillary lymph node dissection for left breast cancer (pT1c N2 M0), 19 years prior to presentation and received adjuvant chemotherapy and endocrine therapy for 5 years. However, chemotherapy was re-administered until recently for recurrent lymph node and bone metastases. The patient presented with liver dysfunction and jaundice. Radiological evaluation revealed a mass in the upper common bile duct. We performed left liver lobectomy and extraductal cholecystectomy to establish a definitive diagnosis and treat jaundice. Histopathological examination of the resected specimen revealed adenocarcinoma showing features similar to those of breast cancer. The aforementioned operation led to accurate diagnosis, and the patient was administered appropriate palliative treatment.

Empyema with fistula associated with rupture of cavities due to non-tuberculous mycobacteriosis (NTM) is intractable and often demands open window thoracotomy. Recently we have experienced a case of empyema with a fistula due to NTM, in which open window thoracotomy combined with bronchial embolization by using an endobronchial Watanabe spigot (EWS) made the negative pressure wound therapy possible, leading to successful control of the infection and relatively early spontaneous closure of the open window cavity. The case involved a 64-year-old man, who was referred to our hospital because of empyema with a fistula associated with a ruptured cavity due to NTM. A chest CT scan showed a cavity lesion which existed just under the visceral pleura to have penetrated the thoracic cavity. Bronchial embolization by using open window thoracotomy and EWS resulted in almost complete disappearance of air leakage soon after the operation. On the 80^th postoperative day when purification of the pleural cavity was attained, the VAC therapy was added. As a result, narrowing of the open window cavity, dilatation of the lung, and adhesion formation to the chest wall were gained. Without adding any closure procedure, the open window cavity spontaneously closed.

The patient was a 71-year-old man in whom left-sided pneumothorax was suspected due to a traffic injury, and a chest drain was inserted. However, subsequent chest computed tomography revealed left-sided hemopneumothorax and a bone fragment of the eighth rib that was detached toward the thoracic cavity. The free bone fragment had invaginated in the left lower lobe as it had moved anteriorly and posteriorly. Complete video-assisted thoracoscopic surgery (VATS) was thus planned to remove the bone fragment and perform rib plate fixation. The thoracic cavity was observed from the insertion site of the chest drain. A 2-cm bone fragment was found to have invaginated in the left lower lobe directly below the fracture site and was removed. Next, a 12-cm incision was made on the skin directly above the fracture site, and the fractured rib was fixed with a titanium plate (Matrix MANDIBLE^®). No air leakage was confirmed with complete VATS, Surgery was then completed. Thus, for traumatic rib fractures, a combination of removal of bone fragments using complete VATS and plate fixation enables intrathoracic manipulation with minimal skin incisions and minimally invasive rib fixation. This combination may be a useful therapeutic strategy for rib fractures associated with lung injury.

[Background] Post-thymectomy myasthenia gravis (PTMG) has been reported in patients who had no prior history of myasthenia gravis (MG) but developed symptoms of MG postoperatively.

Case 1 involved a 54-year-old woman whose preoperative anti-acetylcholine receptor (AchR) antibody was as high as 8.7 nmol/l. Thymectomy with right middle lobectomy was performed for a Type B1 thymoma, and the postoperative course was good. However, the thymoma recurred 2 years after the operation, and at the same time, drooping eyelids and dysphagia were observed, and MG was diagnosed. Symptoms improved with steroid pulse therapy and immunoadsorption therapy.

Case 2 involved a 76-year-old woman whose preoperative anti-AchR antibody was as high as 70 nmol/l. Thymectomy was performed for Type AB thymoma, but the body was weakened due to muscle weakness, malaise, dyspnea, and other symptoms. MG was diagnosed on the 32nd postoperative day, and symptoms improved after steroid pulse therapy and immunoadsorption therapy.

[Conclusion] Preoperative anti-AchR antibody was positive in both cases, and preoperative anti-AchR antibody-positive cases should be further noted due to the possible onset of PTMG.

We report a case of bilateral pneumothorax because of lung metastases that occurred during postoperative chemotherapy for spindle cell carcinoma of the breast. The patient was a 55-year-old woman who presented with an abnormal finding of her mammography when she was 52 years old. Repeated needle biopsies revealed no malignant findings until 54 years old when a needle biopsy showed breast spindle cell carcinoma (ER-, PR-, HER2-). Then she underwent total mastectomy, axillary lymph node dissection, and postoperative chemotherapy. During postoperative chemotherapy, she developed dyspnea and her chest X-ray film showed right pneumothorax. Although right pneumothorax was improved by chest drainage, left pneumothorax was also recognized on the 6th hospital day. On the 11th day, thoracoscopic bilateral partial lung resection was performed, because no remission was gained. The pathological diagnosis was lung metastases of breast spindle cell carcinoma.

Since bilateral pneumothorax was repeated two times at the same year, chest drainage and adhesion therapy were performed repeatedly. The patient died of aggravation of the disease at the age of 56.

Spindle cell carcinoma of the breast is a rare disease that is often difficult to diagnose, but if a breast tumor has a cystic tendency, we should consider spindle cell carcinoma as a possible diagnosis. When secondary pneumothorax due to lung metastasis occurs, pleurodesis may improve the patient's quality of life.

The patient was a 79-year-old man who presented to a neighboring hospital because of weight loss in November 2013. He was referred to the Department of Internal Medicine in our hospital with unknown cause in January 2014. Gastroscopy showed multiple II c lesions and he was referred to us with the diagnosis of moderately differentiated adenocarcinoma. A preoperative chest CT scan revealed an approximately 4.0 cm mass lesion in the lower lobe of the right lung and hilar lymph node swelling. From sputum cytology, PET-CT and chest CT findings, he was diagnosed as having early gastric cancer and primary lung cancer. At first, total gastrectomy was performed and moderately differentiated adenocarcinoma in stage I a was diagnosed. Then, right lower lobectomy was performed 6 weeks after gastrectomy by thoracoscopic surgery. Pathological examination showed moderately differentiated adenocarcinoma which was thought to be metastasis from gastric cancer. Twelve months after the surgery, the patient died of bilateral multiple lymph node recurrence and bilateral pleural effusion. We had great difficulties in differentiating synchronous lung metastasis of gastric cancer from primary lung cancer. Surgical resection for such cases should be indicated carefully.

Hyperammonemia is a rare, serious adverse drug reaction to 5-FU. There have been a few reports of its occurrence in patients with colorectal carcinoma, but very few in patients with esophageal carcinoma. We herein report a case of a patient who developed disturbance of consciousness due to hyperammonemia during the administration of neoadjuvant chemotherapy with 5-FU and cisplatin (FP therapy) for esophageal carcinoma is presented.

A 67-year-old man had experienced a feeling of obstruction while swallowing and vomiting for three months, and he was diagnosed with squamous cell carcinoma of the esophagus at his previous hospital. This was diagnosed as LtAe, 70×30 mm², type 3, SCC, cT3, cN3, cM0, cStage III, and it was decided to administer preoperative chemotherapy with FP therapy (5-FU days 1-5, CDDP day 1). Early on day 3 after starting treatment, the patient became drowsy. His level of consciousness subsequently decreased to JCSIII-200. Blood tests showed an elevated blood ammonia level (132 μg/dl), and the disturbance of consciousness was considered to be caused by 5-FU-induced hyperammonemia. 5-FU was discontinued, and branched-chain amino acid infusion were administered. The patient's level of consciousness then improved rapidly. For the second course, the 5-FU dose was decreased by 50%, and oral lactulose and branched-chain amino acid infusion were administered to enable chemotherapy to continue. Thoracoscopic subtotal esophagectomy and gastric tube reconstruction were performed, but tracheal invasion by metastatic lymph nodes (numbers 106tbL and 106recL) was observed, followed by an R2 resection. Enteral nutrition was started on postoperative day 1, and the patient started eating on postoperative day 7 and was discharged on postoperative day 19. In this case, the hyperammonemia may have been triggered by anemia, hypoalbuminemia, and skeletal muscle loss.

Corrosive gastritis is induced by oral ingestion of tissue-damaging agents and has various consequences, ranging from mucosal erosion to cicatricial stenosis. While there are reports that conservative treatment was effective, surgical treatment is required in souce cases. A case of antral stenosis after corrosive gastritis induced by intentional ingestion of laundry detergent that was treated surgically is presented. The patient was a 45-year-old woman who presented with coffee ground emesis. Esophagogastroduodenoscopy showed acute gastritis. She was discovered to have ingested a weakly alkaline detergent with the intention of self-harm. She was transferred to our hospital for treatment of corrosive gastritis. Although the inflammatory changes in the gastric corpus were improved by conservative treatment, severe stenosis was identified in the pyloric antrum. Therefore, laparoscopic stomach-partitioning gastrojejunostomy with Braun enteroenterostomy was performed on day 43 post-injury. Laparoscopic bypass surgery is an effective treatment option in patients with cicatricial stenosis caused by corrosive gastritis that is refractory to conservative treatment.

A 61-year-old man presented with a 10-day history of jaundice and general malaise. He had undergone total gastrectomy in our hospital for pT4aN1 stage IIIA gastric carcinoma five years previously, and after postoperative adjuvant chemotherapy, no recurrence had occurred. Blood tests showed elevated transaminase levels and obstructive jaundice, and contrast-enhanced computed tomography showed stenosis of the lower bile duct and a 30-mm tumorous lesion in the duodenal bulb that exhibited a gradually increasing contrast effect. The preoperative differential diagnoses included primary duodenal tumor and recurrence at the duodenal resection margin. Because no other metastatic lesions were seen, pancreaticoduodenectomy was performed following percutaneous transhepatic biliary drainage. The tumor was located in the duodenal bulb, from where it was invading the bile duct side. Reconstruction was carried out by Imanaga's method, and the patient's postoperative course was uneventful. Histopathologically, the tumor was a primarily submucosal, poorly differentiated adenocarcinoma, and since its histology differed from that of the previous gastric carcinoma, it was considered to be a primary duodenal tumor. Investigation of the duodenum after total gastrectomy is often difficult, and careful observation is required. A primary duodenal tumor following total gastrectomy is rare, and such a case is reported along with a discussion of the literature.

We report a case of massive small bowel bleeding caused by cytomegalovirus (CMV) enteritis requiring an operation. A 57-year-old man who had been under treatment with CHOP for human immunodeficiency virus (HIV)- related malignant non-Hodgkin lymphoma was admitted to our hospital for severe hypotension and melena. Gastrointestinal hemorrhage was suspected. A contrast-enhanced abdominal CT scan revealed extravascular leakage of contrast medium in the proximal jejunum. Angiography demonstrated active bleeding from the branch of the first jejunal artery. Jejunal bleeding was diagnosed and he underwent interventional radiology therapy (IVR) twice, however, hemorrhage persisted. Emergency surgery was indicated. The bleeding site was easily identified by a hematoma on the serosal surface of the jejunum. Partial resection of the jejunum by 20 cm in length including the lesion was performed. Histological examination of the resected jejunum showed severe mucosal ulcerations with loss of villi. The presence of CMV in the jejunum was demonstrated by an immunohistochemical study. CMV enteritis requiring surgery is rare. CMV enteritis should be considered as a possible cause of bleeding when dealing with immunocompromised patients.

A 30-year-old woman was admitted to our hospital complaining of exacerbation of intermittent abdominal pain lasting for one month and nausea. Abdominal CT showed intestinal intussusception invading the hepatic flexure of the ascending colon. Since the intussusception was difficult to reduce endoscopically, laparoscopic-assisted surgery was performed. After reduction by the Hutchinson technique, a tumor was found at the ileum, 70 cm oral from Bauhin's valve. Partial intestinal resection was performed, and the specimen contained brownish granular tumor, diagnosed as a cystic lymphangioma of the ileum on pathological examination. Laparoscopic surgery is preferable in adult intussusception because one can easily search for the responsible lesion. Although lymphangioma of the small intestine is rare, it should be considered as a possible cause of intussusception.

A 51-year-old woman who was referred to our hospital for the purpose of close exploration of anemia and fatigue was found having a tumor lesion locating from the lower jejunum to upper ileum and encircling three-fourths of the circumference of the bowel by an enteroscopy. We decided to treat her surgically with a suspected diagnosis of malignant lymphoma or gastrointestinal stromal tumor (GIST). During surgery, we identified a 12-cm tumor in the small intestine and performed segmental resection of the involved intestine with bowel anastomosis. Her postoperative course was uneventful and she was discharged from our hospital on the 7^th postoperative day. Histopathology revealed the lesion to have continued from the proper muscular layer, where the disarrayed tumor cells were seen. On immunostaining, the tumor cells were positive for α-SMA and negative for S-100, CD34, and c-kit. Leiomyosarcoma was thus diagnosed. A follow-up CT scan after discharge revealed hepatic metastasis so that laparoscopic partial hepatectomy was performed. The histopathological diagnosis was hepatic metastasis of small bowel leiomyosarcoma. Thereafter the patient developed retroperitoneal metastasis and was treated with chemotherapy, however, she passed away 2 years and 8 months after the initial operation. Small bowel leiomyosarcoma is rare, extremely highly malignant, and needs careful attention clinically.

Leiomyosarcoma arisen in the mesentery is rare. We report an extremely rare case of primary leiomyosarcoma of the mesentery which ruptured and resultantly caused hemorrhagic shock.

A 79-year-old man was brought into our emergency clinic by ambulance because of 4-day history of abdominal pain and vomiting. When he arrived at our hospital, the blood pressure was 72/49 mmHg, and the abdomen was distended, board-like and hard. An infant's head-sized tumor was palpated in the right lateral abdomen. A contrast-enhanced abdominal CT scan revealed an ill-defined tumorous lesion with the longer diameter of 23 cm and massive ascites. Hemorrhagic shock due to the ruptured intraperitoneal tumor was diagnosed and an emergency operation was performed. Intraoperative findings included that the tumor which had invaded from the ileocecum to the ascending colon existed in the mesentery, ruptured at the anterior wall, and was associated with massive clots. As the mesentery including the tumor could be mobilized at the anterior surface of the retroperitoneal fascia, we determined the tumor to have arisen in the mesentery and performed ileocecal resection. Histopathology confirmed proliferation of spindle-shaped cells. Combined with immunostaining outcomes, we diagnosed the tumor as primary leiomyosarcoma. Despite careful follow-up, he developed recurrence 11 months and died 13 months after the operation.

A 46-year-old woman visited our emergency clinic with the chief complaint of abdominal pain. Abdominal contrast-enhanced computed tomography showed intestinal intussusception from the cecum to the ascending colon. Tumorous lesion was suspected as a cause of the intussusception. Emergency laparoscopic surgery using three ports was performed. The intussusception was manually reduced on the outside of the body. Although no definitive diagnosis was obtained, a possibility of a malignant tumor could not be ruled out. Therefore, laparoscopic ileocecal resection with lymph node dissection was performed. The patient had an uncomplicated postoperative course and was discharged 7 days after the surgery. Endometriosis of the cecum was diagnosed on pathology. The patient has been on hormonal therapy to prevent recurrence. Adult intussusception is a relatively rare condition and is usually caused by organic lesions, such as tumors or inflammation. Cecal endometriosis manifesting intussusception is a rare illness. We report a patient with cecal endometriosis presented with intussusception and was treated by laparoscopic-assisted ileocecal resection, with the literature review.

Sporadic intra-abdominal desmoid tumors are rare. We treated a patient with a sporadic desmoid tumor which originated in the appendiceal mesentery. A 58-year-old man was shown to have a tumor adjacent to the appendix on a follow-up computed tomography after gastric cancer surgery. Tumor cells could not be collected by a biopsy during a colonoscopy and surgery was performed with a pre-operative diagnosis of an appendiceal tumor. A tumor with serosal white changes behind the cecum and appendix was identified and a laparoscopic ileocecal resection with D3 dissection was performed. The histopathologic examination was consistent with a desmoid tumor. The tumor was presumed to have originated in the appendiceal mesentery based on pre-operative imaging and intra-operative findings. Most intra-abdominal desmoid tumors have been reported to originate in the small intestine mesentery, but very few in the appendiceal mesentery. The basic treatment for a desmoid tumor is complete surgical resection. Even after complete resection, there is a risk of local recurrence, thus regular postoperative follow-up is required.

A 51-year-old man had been aware of a right inguinal hernia for several years, but he let it untreated because it was easily reduced. He fell into a waterway and bruised the base of the right foot. Abdominal pain was intensified, so he visited a nearby medical institution. Contrast-enhanced computed tomography revealed intraperitoneal free air. He was brought into our hospital by ambulance and emergency surgery was performed on the same day. At surgery, we confirmed that the abdominal cavity had been contaminated with stool juice, the greater omentum incarcerated in the right inguinal hernia, and a perforation of about 1 cm in size was found in the transverse colon. The inner inguinal ring was crimped from the abdominal cavity and the operation was completed. Five months after the operation, a right inguinal hernia repair using an artificial mesh was performed with an anterior approach. As traumatic rupture of the transverse colon within the inguinal hernia is very rare, this case is presented together with a review of the literature.

Fish bone is the most frequent cause of all foreign bodies inducing gastrointestinal perforation in Japan. Emergency surgery is often needed when the lower bowel is involved. Here we report two cases of sigmoid colon perforation due to a fish bone. One patient was surgically and the other was endoscopically treated.

Case 1 : A 96-year-old woman presented with fever and reduced consciousness. Abdominal findings were difficult to evaluate due to dementia, but no muscular defense was observed. CT revealed perforation of the sigmoid colon by a fish bone and an emergency surgery was performed. The fish bone had perforated the sigmoid colon and the surroundings were covered with the scar tissue. The perforated sigmoid colon was resected and a surgical stoma was created.

Case 2 : A 73-year-old man presented with one-day history of pain in the left lower quadrant of the abdomen. Physical examination revealed tenderness to palpation without peritoneal signs. An abdominal CT scan identified a liner high-density structure in the mesentery of the sigmoid colon, and a fish bone was removed using colonoscopy on the next day because his general condition was stable.

An 81-year-old woman who had previously been diagnosed with situs inversus totalis was referred to our hospital for a positive fecal occult blood. She was diagnosed with sigmoid colon cancer by total colonoscopy. Chest x-ray and chest and abdominal computed tomography (CT) showed situs inversus totalis. We performed laparoscopic sigmoidectomy. No bowel malrotation or vascular malformations were observed.

She was discharged from the hospital seven days after the surgery without any perioperative complications. The tumor was histopathologically diagnosed as pT2, N0, M0, stage I. Although attention to intraoperative disorientation is necessary for surgery in situs inversus totalis, laparoscopic surgery can be performed safely with enough recognition of the anatomical position using a left-right mirror image.

A 41-year-old woman underwent laparoscopic low anterior resection for rectal cancer. Seven days after surgery, she underwent ileostomy due to anastomotic leakage and an abdominal abscess. Twenty-five days after surgery, she was transferred to our hospital because her abdominal infection was uncontrollable. She had a fever and a high level of inflammatory markers. Vancomycin was given to treat the methicillin-resistant Staphylococcus aureus that was cultivated from her abdominal drains, and she recovered. However, 37 days after surgery, she again developed a fever. Forty-two days after surgery, bone marrow aspiration showed hemophagocytic syndrome (HPS), and she underwent steroid therapy. Seventy-two days after surgery, she was transferred to the rehabilitation hospital because her HPS had improved. The HPS after gastrointestinal surgery was related to the surgical site infection. There are some case reports of fatal HPS related to gastrointestinal surgery ; therefore, it is important to make a diagnosis and start drug therapy such as steroid therapy as soon as possible.

A case of rectal adenocarcinoma with heterotopic ossification and peritoneal dissemination is presented. The patient was a 67-year-old woman complaining of abdominal pain. Computed tomography and sigmoidoscopy showed rectal cancer. A low anterior resection and proctostomy were then performed. The pathological diagnosis of the resected rectal specimen was well-differentiated adenocarcinoma with ossification. Moreover, peritoneal dissemination was discovered near the tumor. The patient received chemotherapy using a combination of tegafur/gimeracil/oteracil potassium and oxaliplatin and was disease-free without any recurrence one year after surgery. Colorectal cancer with heterotopic ossification occurs in less than 0.4% of all colorectal cancer cases, and it is commonly known to be a low-malignant colorectal tumor with no tendency for vascular invasion, resulting in a slow-growing tumor with a good prognosis. However, some previous studies have found that distant metastases could occur in rectal adenocarcinoma with heterotopic ossification. The findings in the present case suggest that rectal adenocarcinoma with heterotopic ossification is not always a low-malignant cancer and needs careful follow-up.

We report a case of an 86-year-old man with a tumor arising from a colostomy site which had created 35 years previously when rectal amputation was done for rectal cancer. The patient visited our hospital complaining of exacerbating melena. Biopsy revealed mucinous adenocarcinoma and surgical resection of the tumor was performed. Pathological examination revealed mucinous adenocarcinoma invading the surrounding skin. His postoperative course was uneventful. Carcinoma arising from a colostomy site is rare. It can invade the subcutaneous structure in some cases. Radical surgical resection seems to contribute to favorable outcomes. Surgical resection is important.

A 41-year-old woman was admitted to our hospital with an anal tumor. Rectal examination showed a hard tumor on the anal skin at the 5 o'clock position. On anal ultrasonography, a hypoechoic lesion that was not continuous with the anal canal was seen at the 5 o'clock position. Elastography showed a hard tumor with features that were clearly different from the surrounding tissues. Malignancy could not be ruled out ; therefore, the tumor was resected. Histopathological examination of the resected specimen showed clusters of large cells with abundant cytoplasm, and these cells were positive for S-100 on immunohistochemical examination. Based on these findings, the diagnosis was a granular cell tumor.

Anal granulomas are extremely rare. These lesions are reportedly nonmalignant and may develop as infiltrative lesions. Treatment includes excision with preservation of anal function. It is important to precisely delineate the relationship between the tumor and the surrounding organs preoperatively because these lesions may involve the internal anal sphincter, and injury to the sphincter can cause complications. Preoperative anal ultrasonography, which was performed in the present case, is a simple procedure that produces a local magnifying effect and offers good spatial resolution.

A 69-year-old man was referred to our department for resection of a growing mass in S4 of the liver. The results of a biopsy conducted at his previous hospital showed non-alcoholic steatohepatitis with no liver dysfunction. HBs antigen and HCV antibody tests were both negative, and the levels of the tumor markers CEA, CA19-9, AFP, and PIVKA II were within normal limits. Abdominal ultrasound showed a hypoechoic mass in the left lobe of the liver, and computed tomography and magnetic resonance imaging showed that, although the tumor was ischemic, its interior was penetrated by blood vessels. Malignant lymphoma of the liver or cholangiocarcinoma was diagnosed, and hepatectomy was performed. Immunostaining resulted in a diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma of the liver. The patient is currently recurrence-free 9 months postoperatively.

MALT lymphoma of the liver is a comparatively rare disease about which much remains unknown, including its etiology and treatment strategy. A case of its resection is presented.

A 73-year-old man was admitted to our hospital complaining of lower abdominal pain and fever and was diagnosed with cholecystitis. On the fourth day of hospitalization, the abdominal pain and blood tests worsened. Abdominal CT showed emphysematous changes in the gallbladder wall and in the gallbladder, and percutaneous transhepatic gallbladder drainage (PTGBD) was performed to improve his symptoms. Elective laparoscopic cholecystectomy was then performed 9 days after PTGBD. Severe inflammation and adhesions to surroundings tissues were observed. The gallbladder was excised carefully, leaving part of the inflamed gallbladder wall in the liver. The patient recovered after surgery with mild pneumonia and was discharged 10 days after the operation. This case was classified as moderate acute cholecystitis according to TG18 and needed to be considered for early or elective surgery based on surgical risk factors and the success of initial treatment. In this case, elective surgery after PTGBD was selected based on surgical risk factors and other factors. Emphysematous cholecystitis has a higher risk of necrosis and perforation during its course than normal cholecystitis, but if strict follow-up and careful surgery after PTGBD ensure safety, laparoscopic cholecystectomy after PTGBD for emphysematous cholecystitis seems to result in no major problems.

A 90-year-old man was transported by ambulance to our hospital with fever and right hypochondrium pain. Abdominal computed tomography showed acute cholecystitis with stones. We performed cholecystectomy after a diagnosis of acute calculous cholecystitis. A bile culture test performed with a sample collected during surgery, revealed Campylobacter jejuni monoinfection, which was identified as the cause of cholecystitis. The patient had a history of antibiotic treatment for enteritis of the ascending colon after the consumption of raw fish 25 days before presentation. The infection may have been caused by the secretion of C. jejuni into the bile via the portal vein secondary to bacterial translocation during enteritis. The patient's condition improved, and he was discharged from the hospital 7 days after surgery.

Enteritis caused by C. jejuni is common ; however, cholecystitis caused by C. jejuni is rare. Only 13 cases have been reported worldwide. Here, we have reported a case of cholecystitis caused by C. jejuni, performed a literature review, and evaluated the bile culture test results of 699 cases from our hospital.

A 73-year-old woman who was treated for liver cirrhosis at a previous hospital developed back pain and underwent abdominal ultrasonography, which revealed a pancreatic head tumor. Computed tomography and magnetic resonance imaging revealed a pancreatic head tumor with invasion of the superior mesenteric vein. The tumor was diagnosed as locally advanced pancreatic cancer, cT3N0M0, cStage II A. At the initial visit, the patient's liver disease was categorized as Child-Pugh class A, although the platelet count was low at 6.5 × 10⁴/μL ; therefore, we performed laparoscopic splenectomy. She showed rapid elevation in her platelet count postoperatively, after which we administered two courses of gemcitabine combined with S-1 as neoadjuvant chemotherapy. Four months later, we performed subtotal stomach-preserving pancreatoduodenectomy following adjuvant chemotherapy. In cases with complicating liver cirrhosis that require perioperative chemotherapy, splenectomy may offer an effective auxiliary means for administrating chemotherapy safely.

A 68-year-old woman presented with left-sided back pain. Based on computed tomography findings, she was diagnosed with a tumor (20 mm) in the vicinity of the left renal vein. Six months later, the tumor had increased in size to 28 mm. We performed endoscopic ultrasound -guided fine-needle aspiration biopsy and suspected leiomyosarcoma. We performed laparoscopic tumor resection ; however, tumor invasion of the left renal vein necessitated conversion to laparotomy, and we performed resection of the tumor together with the left renal vein. We could preserve the left kidney by preserving blood flow to the left ovarian vein. Histopathological examination of the resected specimen showed features compatible with leiomyosarcoma originating from the left renal vein. Immunohistochemical evaluation revealed tumor cells with immunopositivity for α-smooth muscle actin, caldesmon, and desmin. The patient's postoperative course was uneventful without any renal dysfunction.

A 79-year-old woman with abdominal pain was diagnosed with bowel obstruction and admitted to another hospital. However, the patient was later referred to our hospital for treatment because her symptoms persisted without improvement. Despite further examination, the precise cause was unknown. We suspected adhesive small bowel obstruction ; however, the details of obstruction were unclear owing to her history of hysterectomy. Non-surgical treatment with an intestinal tube was ineffective. Hence, emergency open abdominal surgery was performed on the sixth day of admission. The small intestine was incarcerated in a hernial orifice adjacent to the right side of the rectum ; therefore, the patient was diagnosed with pararectal hernia. The strangulated internal hernia was released, and the necrotic portion was resected. Since pararectal hernia is an exceptionally rare type of internal hernia, it was difficult to establish the diagnosis and treatment preoperatively. Pararectal hernia is one of the most difficult conditions to diagnose. In our case, differential diagnosis was extremely challenging. Therefore, the decision to perform emergency surgery was made after a long period of deliberation. Here, we have presented a case of pararectal hernia and reviewed the relevant literature available.

An 84-year-old man was admitted to a local clinic for bulging of the right inguinal region. The patient was diagnosed with right inguinal hernia and referred to our hospital. On palpation of the right scrotum, the right testis could not be identified. Computed tomography (CT) revealed a small solid mass, considered the right testis, within a right inguinal hernia. Hence, the patient was diagnosed with right inguinal hernia with cryptorchidism and operation was performed. The hernia sac was protruding through the right internal inguinal ring and was between the external oblique muscle and subcutaneous fat layer instead of extending down into the inguinal canal. The small right testis was found in the hernia sac. Based on these intraoperative findings, the patient was diagnosed with interparietal hernia with cryptorchidism. Orchidectomy was performed owing to the possibility of testicular cancer in addition to hernioplasty (Marcy method).

Inguinal hernia with cryptorchidism in adults is rare. Additionally, interparietal inguinal hernia is considered a rare variant of inguinal hernia. To our knowledge, this is the first case report of interparietal inguinal hernia associated with cryptorchidism in an adult in Japan.