Li-Fraumeni syndrome (LFS) is an autosomal dominant disorder associated with various malignancies, including soft tissue sarcoma, osteosarcoma, leukemia, brain tumor, and breast, lung, adrenocortical, and gastrointestinal cancer. As radiation therapy in patients with LFS carries a potential risk of secondary carcinogenesis, treatment and surveillance must be carefully selected.

A 27-year-old woman who underwent surgery for right paratibial osteosarcoma aged 18 years old and for left upper mandibular chondrosarcoma aged 27 years old was referred to our department because follow-up computed tomography showed a nodule in her right breast. Needle biopsy revealed ductal carcinoma in situ (DCIS). We recommended genetic counseling and genetic examination because her past medical history matched the Chompret criteria. However, she was reluctant to undergo counseling, and genetic examination was not performed before surgery. We decided upon a treatment strategy under the assumption she had LFS. We performed right nipple-sparing mastectomy and sentinel lymph node biopsy followed by tissue expander insertion. The surgical specimen was a 16.7-cm high-grade DCIS. One and a half years after the operation, she decided to have the genetic examination, which indicated the likely pathogenic variant (NM1126114 (TP53) : c.476C>A : p.Ala159Asp, de novo) and she was diagnosed with LFS. We are currently following her using annual whole-body magnetic resonance imaging.

SAPHO syndrome is a disease associated with synovitis, acne vulgaris, palmar pustulosis, hyperostosis, and osteitis. These bone lesions require differentiation from bone metastasis in imaging studies. The disease has been suggested to have some correlation with inflammatory diseases. We report a case of SAPHO syndrome in which we had difficulties in differentiating it from bone metastasis of breast cancer. The patient was a 57-year-old woman who had a history of ulcerative colitis. In May 2014, she had been operated on for right breast cancer, when the resected specimen was diagnosed as papillary ductal carcinoma with the infiltrating diameter of 6 mm, pT1N0M0 and pStage I. She had been observed under postoperative hormone therapy. Starting in December 2016, she developed low back pain, and PET-CT and MRI scans disclosed lesions at the L1-5 and S1. Multiple bone metastases were suspected. On the same time, eczema affected her hands and foot and palmar pustulosis was diagnosed. Since the possibility of postoperative early recurrence of breast cancer was low and arthritis associated with palmar pustulosis was identified, SAPHO syndrome was suspected. Accordingly, we continued the same treatment and carefully followed her clinical course. MRI conducted one year later showed an improvement tendency of the bone lesions and she has been free from recurrence and aggravation, as of August 2018.

The accidental discovery of lobular carcinoma in situ (LCIS) of the breast is increasingly common, and how it should be handled may be a difficult question. A 44-year-old woman presented with pain in the left breast. Visual inspection and palpation did not identify any abnormality in either breast, and mammography only showed benign calcifications. On ultrasonography, however, a clearly demarcated lobular mass with a hyperechoic center was apparent in region D of the right breast. Fibroadenoma or LCIS was suspected from the results of needle biopsy, and tumorectomy was therefore performed. The histopathological diagnosis was fibroadenoma surrounded by LCIS and ductal carcinoma in situ (DCIS). Since both margins were positive, additional partial mastectomy was performed. The LCIS margin was partly positive, but rather than further surgery, breast-sparing radiotherapy was performed instead. The patient is currently taking tamoxifen citrate and remains under observation.

A 33-year-old asymptomatic man was referred to our hospital because of an abnormal shadow on a chest radiograph at a medical checkup. A chest computed tomography (CT) showed a smooth solid tumor of 11 cm in diameter extending from Th10 to L2, the level of the right renal artery and vein. A contrast-enhanced CT scan showed relatively poor enhancement effect. The tumor showed a homogeneous low signal intensity on T1-weighted magnetic resonance imaging (MRI) and partially high signal intensity on T2-weighted MRI. The patient was preoperatively diagnosed as having a neurogenic tumor and underwent thoracoscopic surgery using carbon dioxide (CO2) insufflation for tumor resection. Before surgery, we evaluated the artery of Adamkiewicz and prepared for possible postoperative chylothorax. The operation was initiated following CO2 insufflation into the thoracic cavity to ensure the surgical field, in a left lateral decubitus with four ports. Intrapleural pressure was maintained at 8 mmHg. A favorable operating field achieved in the posterior mediastinum allowed tumor resection by total thoracoscopic surgery. The operation time was 155 minutes, with minimal blood loss. The definitive histopathological diagnosis was ganglioneuroma. The patient developed right chylothorax on postoperative day two, which was successfully treated with conservative therapy, and on postoperative day 13, the patient was discharged. He has been doing well as of nine months after the operation.

A 63-year-old man who had been aware of having exertional malaise for 6 months presented to a neighboring hospital because of dizziness occurred one month earlier. Anemia was identified and he was referred to our hospital for close exploration. As a result, pure red cell aplasia was diagnosed and blood transfusion was performed. A chest CT scan during the close exploration showed an anterior mediastinal tumor which was suspected to be a thymoma. Therapeutic guidelines for the patient were discussed in our hospital, and we decided to precede with surgery before initiating the medical treatment with immunosuppressors. At surgery, extended thymectomy through the median sternotomy was performed. The patient's postoperative course was uneventful. The histopathological diagnosis was type AB thymoma according to the WHO classification. Although he needed several times of blood transfusions due to anemia before the surgery, postoperative progression of anemia became gradual. Blood transfusion was conducted on the postoperative day 30 for progressing anemia and oral administration of cyclosporin was started. Thereafter, anemia improved, and he did not require additional blood transfusion. We present a case of a thymoma associated with pure red cell aplasia, together with a review of the relevant Japanese literature.

We report a female patient who had undergone extended thymectomy for a thymoma at 53 years of age. The tumor was histopathologically diagnosed as Type B3 + B2 thymoma according to the WHO classification. The patient received left hepatectomy for a liver tumor 9 years after the thymoma surgery. Although recurrent liver tumors were discovered 6 years after the liver resection, they disappeared by chemotherapy and radiation therapy. Two years after the liver recurrence, a gynecologist diagnosed her to have peritoneal dissemination of the thymoma (Type B3) by a biopsy, which was preoperatively suspected of a right ovarian tumor, but could not be resected due to abundant blood supply. We treated this disseminated tumor by radiotherapy and the tumor exhibited complete response. However, intraperitoneal tumors and a liver tumor newly appeared two years afterwards. Radiotherapy was very effective for those tumors, but new peritoneal and liver lesions persisted to grow. Multidrug chemotherapy was adopted and has been continued. More than 21 years or more than 12 years have elapsed after the thymoma surgery or after the resection of liver metastasis, respectively. There are few cases of liver metastases of a thymoma which were operated on and this is the only reported case of a thymoma of which peritoneally disseminated tumors were efficiently treated by radiotherapy. Multidisciplinary approach including surgical resection might contribute to long-term survival even for metastatic thymoma patient.

A 25-year-old woman in the northern region of South Sudan was shot on the roadside and transported to a hospital for treatment of gunshot wounds in the chest and abdominal regions. Laparotomy and left chest tube insertion were performed. The gunshot exit wound on the chest wall was closed. Thoracic empyema was noted on hospitalization day 10 ; drainage via the chest tube and continued antibiotic treatment did not produce improvement. After fenestration to the left chest on hospitalization day 17, the patient recovered and was discharged on hospitalization day 31. As the hospital and operating theater settings were not equipped with ventilators and only had oxygen of low concentration, it was difficult to decide whether fenestration should be performed or not. However, if normal drainage is insufficient, fenestration for thoracic empyema may be a valid option in low-resource settings.

A man in his sixties who was a heavy smoker but had no remarkable histories presented to a neighboring hospital because of an about one-month history of right back pain. He was referred to our hospital because a chest X-ray film revealed an 8-cm tumor in the right upper lung field. Percutaneous needle biopsy suggested a diagnosis of poorly differentiated non-small-cell lung cancer. Imaging findings did not reveal lymph node nor distant metastases so that radical resection appeared to be possible. We performed right upper lobectomy + associated resection of chest wall, where the mediastinal lymph nodes were dissected up to ND2a-2. Histopathology showed that the tumor was composed of large spindle cells ; and the tumor cells were positive for CK AE1/3 and negative for TTF1, p63, synaptophysin, chromogranin A and calretinin D2-40 on immunostaining. The final diagnosis was spindle cell carcinoma, pT4N0M0. After the operation, we conducted 4 courses of adjuvant chemotherapy with carboplatin + paclitaxel. The patient has been free from recurrence, as of 2 years after the operation. Since there have been few cases of spindle cell carcinoma undergone surgical resection and treatment with adjuvant chemotherapy, we present our case together with some bibliographical comments.

A 72-year-old woman who had undergone endoscopic submucosal dissection (ESD) for esophageal cancer developed local recurrence half a year after ESD, and esophagostomy was performed. From the day after the operation, the drainage amount of the chest drain exceeded 1,000 ml/day, and the chest drainage changed to milky white in color. She was thus diagnosed with chylothorax. We started the treatment with octreotide and etilefrine, but no improvement was obtained. Furthermore because of nausea, which is an adverse side effect of octreotide, the administration of octreotide had to be withdrawn. Therefore, we decided to convert to surgical treatment and performed small laparotomy and laparoscopic-assisted trans-hiatal thoracic duct ligation. The volume of chylothorax remarkably decreased, and on the second day after re-operation, the amount of drainage was less than 500 ml/day. She was discharged on the 18th POD. Conservative treatment is often the first choice for initial treatment for chylothorax after surgery for esophagus cancer. If this is not effective, invasive treatments including surgical treatment are selected. Although re-operation is not minimally invasive, early intervention could reduce the hospital days and shorten the time to start oral intake. It should be important to select the proper treatment at an appropriate time.

A 72-year-old woman who presented with difficulty in oral ingestion was diagnosed with cancer of the lower thoracic esophagus <UICC7th-cT3N3M1(#104R), cStage IV>. We performed 2 courses of 5-fluorouracil + cisplatin (FP therapy) as neoadjuvant chemotherapy, followed by esophagectomy via right thoracotomy and three-field lymph node dissection. Histopathology revealed UICC 7^th-pT3N2M1(#104R) pStage IV, that appeared to suggest a high risk of recurrence. Consequently, additional radiation therapy (60 Gy) targetting #104R and #101R was conducted. PET-CT scan performed 7 months after the operation showed abnormally high accumulation of FDG to the posterior thoracic paraaortic lymph node. Recurrence of the esophageal cancer was considered, and we performed chemoradiation therapy (60 Gy + 2 courses of FP therapy). Thereafter 2 courses of weekly paclitaxel therapy were added. The patient has been free from any recurrence as of 61 months after the operation.

It is difficult to make therapeutic guidelines for recurrence to the posterior thoracic paraaortic lymph node after radical surgery for esophageal cancer. In treating this patient, we once considered to perform surgical resection, but our selection to employ multimodal therapy resulted in long-term survival. It might be beneficial for the treatment that the recurrence had involved a solitary lymph node.

A 42-year-old man tried suicide by taking a total of about 500 ml of the main ingredient and hardening agent of casting urethane resin. Six hours later, he presented to our hospital on independent gait. After our examination, he went back home because he lacked abdominal findings and we expected spontaneous excretion of the urethane resin from him. The day after tomorrow, he complained of abdominal pain and poor appetite. A hard tumor was palpated in the epigastric region. There was tenderness. X-ray and thoracic-abdominal-pelvic CT scan showed a honeycomb like low density foreign body occupied from the lower esophagus to the duodenal bulb. It was impossible to remove the hard foreign body by endoscope. To remove it, we performed emergency surgery. We cut the gastric wall, and identified the hardened urethane resin. To remove it from his stomach, we divided it into two parts by a hammer and a chisel, and removed from him. The urethane resin had casted from the lower esophagus to the duodenal bulb. Urethane resin is known widely as a casting material. We should be careful that some liquid materials may change to a solid by agitation in the body, demanding surgical removal.

The patient was an 86-year-old man who had been treated for pneumonia in the Department of Internal Medicine in our hospital. The condition of the illness was intractable, and cryptogenic organizing pneumonia was suspected. Corticosteroid treatment was started on the 22nd hospital day, then symptomatic remission was gained. However, intra-abdominal free air was observed by an X-ray examination on the 31st hospital day. An abdominal CT scan conducted on the same day revealed intra-mural gas in the wall of the stomach as well as intra-abdominal free air. Considering a possibility of an emergency surgery, the patient was consulted to our department. As he manifested neither abdominal symptoms nor aggravation of general condition, conservative treatment was initiated. An abdominal CT scan on day 5 after the onset showed vanishing of gastric intra-mural gas and reduction of intra-abdominal free air. A gastrointestinal endoscopy on the 6th day after the onset revealed erosive gastritis at the body of stomach, however, necrosis or ulceration of the gastric mucosa was not observed. Subsequently, the dietary restrictions were gradually loosened, and the patient left the acute care ward. Here we report a case of rare gastric emphysema that was especially uncommon for accompanying by intra-abdominal free air, and for being caused by a particular medicine.

Brain metastasis of gastric cancer is comparatively rare and has been reported to carry poor prognosis. Recently we have experienced three cases of brain metastasis after surgery for gastric cancer in which aggressive treatments were performed. The patients included one man and two women, with the median age at the surgery for gastric cancer of 61. As for the progression of gastric cancer, two patients had pStage IIIC gastric cancer and one had pStage IV with liver metastasis. The time from the surgery for gastric cancer to brain metastasis was more than 12 months in all three cases. The number of brain lesions was solitary in one case, or multiple in two cases. The treatments for the brain metastases included stereotactic radiation therapy in two cases and surgery in one case. All three patients died of cancer, including two of cerebral hernia associated with progression of the brain lesion and one of progression of a lung lesion. The surviving time after brain metastasis was 27 days, eight months, or nine months, respectively.

Contrary to our understanding that the prognosis after brain metastasis of gastric cancer is poor, comparatively long-term survival was gained in our three patients. Control of the brain lesion might be important, and hence we should aggressively consider and employ available treatments if it is treatable.

A 59-year-old woman was referred to our hospital because of lower abdominal pain. Contrast-enhanced computed tomography (CT) revealed a cystic mass with an 8-cm diameter and two solid masses with a 3-cm and 2-cm diameter in the lower abdomen. The solid masses exhibited contrast enhancement. A gastrointestinal series showed an enhanced cystic lesion in the pelvic cavity and it was suggested that the lesion communicated with the small intestine. We performed surgery under the suspected diagnosis of penetration of the gastrointestinal stromal tumor (GIST) into the intestinal lumen. Upon laparotomy, a 15-cm duplication of the alimentary tract was found on the opposite side of the mesentery, located 150 cm distal to the ligament of Treitz. Hard elastic nodules adjacent to the spherical duplication were palpable. The duplication of the alimentary tract and nodules were resected. On histopathologic examination, the nodules were diagnosed as ectopic pancreatic tissue.

Jejunal duplication associated with ectopic pancreatic tissue is very rare ; therefore, we present this case with a review of the literature.

The case of an 80-year-old man who required emergency surgery for jejunal necrosis caused by amyloidosis and nonocclusive mesenteric ischemia (NOMI) 6 days after cardiac cancer surgery is presented. In the second operation, the jejunum showed discontinuous patches of dark purple discoloration ; since the extent of resection could not be determined from the macroscopic findings alone, indocyanine green (ICG) fluorescence was used to assess intestinal viability, and an 85-cm portion of the jejunum was resected. The inner lumen of the resected specimen was stenotic due to amyloid deposition in the jejunal submucosal vessels, and this was attributed to comorbid amyloidosis and NOMI. Caution is required when treating NOMI because the extent of intestinal necrosis is frequently unclear, and unless appropriate resection is performed, there is a risk that extended bowel resection may lead to short bowel syndrome or postoperative necrosis of the remaining bowel. ICG fluorescence was useful for assessing the viability of slightly discolored bowel, but since it is not a quantitative method of evaluation, further investigations are required for the accurate diagnosis of ischemic bowel.

A 76-year-old man visited our hospital because of positive fecal occult blood and anemia in a screening test. He had no abnormal findings in upper or lower gastrointestinal endoscopy. Prior to further examination, he was admitted to the hospital for epigastric pain. Emergent enhanced abdominal CT showed acute cholecystitis and a tumor in the jejunum. After emergency cholecystectomy, he underwent elective surgery for a jejunal tumor. In the operative findings, the tumor was 5 cm in diameter, located at the jejunum 30 cm from Treitz's ligament toward the anal aspect, and the regional lymph nodes were enlarged. Pathological diagnosis of the enlarged lymph node during surgery revealed adenocarcinoma. Partial small bowel resection with lymph node dissection was done. The resected small bowel tumor showed ring-like narrowing. Histopathological diagnosis was mucinous carcinoma. Pathological staging was as follows : T3(SS), N2a(5/8), M0, and Stage III B (Eighth edition of UICC). He underwent adjuvant chemotherapy. At 18 months after surgery, he was doing well without recurrence. Mucinous carcinoma of the jejunum is a rare occurrence, accounting for 3.2%-7% of small intestinal adenocarcinomas. It has been previously reported that mucinous carcinoma of the jejunum rarely causes bowel obstruction with ring-like narrowing and involves relatively fewer numbers of lymph nodes. This case had different characteristics.

The most common non-obstetrical surgical emergencies complicating pregnancy are acute appendicitis, cholecystitis, and intestinal obstruction. With a recent technological development of operations using laparoscopy, the number of case reports of laparoscopic surgery during pregnancy has increased. We experienced three cases of laparoscopic surgeries for acute abdomen during pregnancy. Case 1 : A 34-year-old pregnant woman presented with right lower abdominal pain at 15 weeks of gestation. Strangulated intestinal obstruction was diagnosed with CT findings, and we performed laparoscopic intestinal adhesiotomy. Case 2 : A 38-year-old pregnant woman presented with right lower abdominal pain at 21 weeks of gestation. Acute appendicitis was diagnosed with ultrasound and MRI findings, and we performed laparoscopic appendectomy. Case 3 : A 23-year-old pregnant woman presented with epigastralgia at 25 weeks of gestation. Acute cholecystitis was diagnosed with ultrasound and MRI findings, and we performed laparoscopic cholecystectomy at 26 weeks of gestation. We report these three cases for a discussion in terms of diagnostic methods and surgical techniques including placement of port and choice of camera.

A 67-year-old man who was being treated for ulcerative colitis was admitted to our hospital because of abdominal distension. Computed tomography showed free air in the abdominal cavity. However, signs of peritonitis or ascites were absent. The physical examination only showed distension and mild tenderness without Blumberg's sign or muscle guarding. Conservative treatment, including antibiotics and abdominocentesis for deaeration, was carried out. Upper and lower gastrointestinal endoscopies demonstrated no perforation site. However, the patient was diagnosed with cytomegalovirus enteritis accompanied by ulcerative colitis and was treated with an anti viral agent. His post-admission course was uneventful. The patient re-started oral intake of solid food on day 4 and was discharged from our hospital on day 17 after treatment. Spontaneous pneumoperitoneum could be treated with conservative therapy when there are no signs of peritonitis and imaging examinations show free air in the abdominal cavity.

A 69-year-old male suffered from nausea and abdominal fullness. Our examination revealed descending colon cancer with stenosis. After decompression with a transanal drainage tube, laparoscopic resection of the descending colon was performed. After surgery, abdominal fullness and ileus developed, and an imaging study showed colonic dilation at the oral side of the anastomosis. Conservative treatment with an ileus tube had no effect, so surgery was performed 23 days postoperatively due to the possibility of adhesive obstruction. Since the small intestine, colon, and anastomosis were found to have no obstruction during surgery, an artificial anus was constructed on the dilated transverse colon. After reoperation, we suspected acute colonic pseudo-obstruction (ACPO) and started drug treatment. However, surgery was needed because cholecystitis occurred. After cholecystectomy, administration of drugs and pressure reduction improved ACPO. There are some reports of ACPO after laparotomy, but it is very rare after laparoscopic surgery. However, we believe that post-laparoscopic ACPO cases are becoming more common over time.

A 58-year-old woman was diagnosed with sigmoid colon cancer and underwent high anterior resection. Her postoperative oral intake was good, but frequent vomiting developed on Day 8. Abdominal computed tomography showed that a branch of the superior mesenteric artery (SMA) was sharply flexed, and the horizontal limb of the duodenum was compressed, with fluid retention in the stomach and duodenum. SMA syndrome was diagnosed. The patient improved after conservative treatment comprising decompression via a nasogastric tube and intravenous nutrition. SMA syndrome following left colorectal cancer surgery is believed to occur when the angle of the SMA branch becomes sharply flexed and compresses the duodenum due to tension generated by the caudal traction of the mesentery during anastomosis. It should be borne in mind as a cause of early postoperative ileus following left colorectal cancer surgery, and if a diagnosis of SMA syndrome is confirmed, then conservative treatment is the first choice.

We report a case of an 82-year-old woman who underwent sigmoid colectomy for sigmoid colon cancer in December 2013. Computed tomography (CT) was performed in December 2015 because carcinoembryonic antigen (CEA) levels showed a mild increase to 5.4 ng/ml ; however, no recurrence was found. Positron emission tomography (PET)/CT was performed in May 2016 at the patient's request and no abnormal accumulation was seen. In January 2018, CEA levels increased to 9.3 ng/ml ; therefore, CT was performed in February 2018, but there was no sign of recurrence. However, CEA levels increased further to 10.3 ng/ml and PET/CT was performed again. The PET/CT detected a small nodule with intense fluorodeoxyglucose uptake (maximum standardized uptake value 4.3) on the ventral side of the left common iliac artery and recurrence of peritoneal dissemination was suspected. As all CT images obtained after surgery for sigmoid colon cancer showed a small nodule with a major axis of approximately 9 mm in the same area, it was considered that the small nodule had changed from PET/CT negative to positive. Tumor removal was performed in April 2018 post-diagnosis and treatment. Histopathological examination of the resected specimens showed no malignant findings, and abscess and inflammatory granulation formed around the suture. Therefore, it was diagnosed as foreign body granuloma.

The patient was a 69-year-old woman who had undergone laparoscopic low anterior resection for rectal cancer at the age of 66. Pathological findings revealed T3N0M0 Stage IIA and no adjuvant chemotherapy was conducted. Two years and seven months after the surgery, she presented to our hospital because of irregular vaginal bleeding, and a 3 cm-sized tumor that was adjacent to the external urethral opening was detected. Histopathologically the tumor was diagnosed as vaginal metastasis of rectal cancer. After confirming the absence of lymph node or other distant metastases by CT and MRI, we performed R0 resection of the tumor together with distal part of the urethra and cystostomy. The surgical margin was negative. We performed urethroplasty three months and removed vesical fistula four months after the surgery. She has been free from local recurrence or distant metastasis as of 1 year and 4 months after the surgery without adjuvant chemotherapy.

Although vaginal metastasis of colorectal cancer is rare and it frequently requires multivisceral resection due to anatomical reasons, long-term survival may be expected if R0 resection can be achieved.

We performed pure laparoscopic caudate lobectomy for a case of giant hepatic hemangioma. A 56-year-old woman was referred to our hospital complaining of epigastric distress after intake of meals, appetite loss and weight loss, and was diagnosed as having a giant hepatic hemangioma measuring 10 cm in diameter in the caudate lobe with extrahepatic extension, that could not be successfully treated by transarterial embolization. Therefore, we performed pure laparoscopic caudate lobectomy using Pringle's maneuver for the giant hepatic hemangioma. The postoperative clinical course was uneventful and the patient was discharged from our hospital on postoperative day 7. Pringle's maneuver for laparoscopic hepatectomy is effective for hemangioma reduction, as it causes inflow occlusion during the hepatectomy.

A 72-year-old man was admitted to our hospital with obstructive jaundice. Abdominal imaging showed a tumor located in the anterior segment and hilum of the liver. The tumor invaded the main portal trunk and the horizontal portion of the left portal vein. Bile cytology obtained from a biliary drainage tube showed nuclear molding, suggesting neuroendocrine carcinoma (NEC). After right portal vein embolization, resection of the right and caudate lobes was performed with portal reconstruction of the anastomosis between the main portal trunk and the horizontal portion of the left portal vein. On histological examination, the resected hepatic tumor, measuring 29 × 22 mm², showed rosette formation, and immunostaining was positive for neuroendocrine markers including chromogranin A, confirming the diagnosis of primary hepatic NEC. In addition, the Ki-67 positive rate was 47% (>20%), and staining was positive for p53, consistent with poorly differentiated NEC. Therefore, postoperative chemotherapy with cisplatin and etoposide or irinotecan was given. He showed a partial response to chemotherapy, but the tumor recurred, and the patient died 395 days after the operation. In this case, bile cytology was useful for preoperative diagnosis, and the intensive surgical procedure combined with postoperative chemotherapy provided some survival benefit.

Spontaneous perforation of the bile duct can be associated with congenital biliary dilatation in childhood, and is rare in adults. On the other hand, spontaneous cystic duct perforation has been reported in only a few cases to date. A 63-year-old woman was referred to our hospital complaining of right lower abdominal pain, and abdominal CT revealed localized ascites. At first, we started the patient on treatment for acute pancreatitis, based on the finding of elevated serum amylase levels. However, thereafter, because of the increasing abdominal ascites and unclear findings on the abdominal CT of acute pancreatitis, we performed exploratory laparoscopy. The laparoscopic exploration revealed intraperitoneal bile and a necrotic area in the hepatoduodenal ligament. The surgery was converted to laparotomy, and cholecystectomy and extrahepatic bile duct resection, including the necrotic part, and hepaticojejunostomy were performed. Finally, we found that the necrotic part was in the cystic duct, with a low junction of the common bile duct (intra- pancreatic junction). The patient had an uneventful postoperative course and was discharged after the surgery. Histopathology of the resected specimen indicated acute inflammatory cell infiltration of mainly the serosal side at the perforated part of the cystic duct, and the possibility of diverticulitis in the area and exterior influences such as pancreatitis was considered.

A 94-year-old male patient was diagnosed as having choledocholithiasis and cholecystolithiasis, with dilatation of the common bile duct and gallbladder. At first, we tried PTGBD, as we considered that ERCP would be difficult in this patient because of the surgically altered anatomy. However, we could not insert the tube. Then, we performed a mini-laparotomic cholecystostomy. As the jaundice was successfully controlled, we performed elective endoscopic lithotripsy and laparoscopic cholecystostomy.

Endoscopic biliary drainage is the treatment of first choice for patients needing biliary drainage. Percutaneous transhepatic biliary drainage becomes necessary when endoscopic biliary drainage cannot be accomplished. On the other hand, surgical biliary drainage is rarely required. When both endoscopic biliary drainage and percutaneous transhepatic biliary drainage prove impossible, cholecystostomy could be an effective alternative that may be worth considering.

A 79-year-old woman receiving treatment for hypertension presented with epigastric pain. Abdominal contrast-enhanced computed tomography showed a cholecystic tumor and a retroperitoneal tumor, and she was admitted for further investigation and treatment. The retroperitoneal tumor was suspected to be a lymph node metastasis, but magnetic resonance imaging showed cholecystic carcinoma and a comorbid paraganglioma. On functional diagnosis, blood and urine tests showed elevated catecholamines, confirming the diagnosis, and single-stage surgery was performed. After radical cholecystectomy, the paraganglioma was removed, but it was located on the posterior surface of the inferior vena cava and had numerous feeding vessels that made it difficult to detach, and abnormal hypertension occurred at one point during the surgery. Because this condition of the patient was predicted by preoperative diagnosis, the anesthetist was able to make the appropriate decisions, and the surgery was performed safely. Paraganglioma rarely occurs in combination with gastrointestinal cancer ; it must be carefully differentiated from other conditions such as lymph node metastasis, and advance preparation for difficulties during surgery are important. Since malignancy is also a possibility, its course needs carefully longterm follow up.

A 22-year-old woman at 20 weeks of gestation visited our hospital complaining of intense epigastric pain. She had no peritoneal signs, and her laboratory data were within normal limits. Computed tomography and magnetic resonance imaging without contrast showed a large upper abdominal mass of unidentifiable origin. Her intense abdominal pain negatively affected her pregnancy. She underwent an emergent exploratory laparotomy at 20 weeks of gestation. A tumor was identified at the body of the pancreas and diagnosed as a pancreatic cystic neoplasm. Distal pancreatectomy preserving the spleen and splenic vessels was performed. The patient's postoperative clinical course was uneventful. The specimen was diagnosed as a solid pseudopapillary neoplasm (SPN) expressing progesterone receptors on immunohistochemical staining. She delivered a healthy male baby spontaneously at 37 weeks of gestation. A rare case of an SPN diagnosed during pregnancy is presented.

A 51-year-old woman underwent a craniotomy for intracranial hemangiopericytoma (HPC). Ten years later, a follow-up abdominal computed tomography scan showed contrast-enhancing tumors in the head and tail of the pancreas. Metastatic pancreatic tumors from intracranial HPC were suspected, but pancreatic neuroendocrine tumors remained in the differential diagnosis. Endoscopic ultrasound-guided fine-needle aspiration samples were taken from the tumor in the tail of the pancreas. The histology was consistent with metastatic HPC. Subtotal stomach-preserving pancreatoduodenectomy and caudal pancreatectomy were performed to remove the tumors. Histopathologically, these tumors showed morphological similarities to the intracranial tumor and intranuclear STAT6 positivity, confirming that both tumors in the head and tail of the pancreas were metastases of the intracranial HPC.

It is often difficult to diagnose desmoid tumor because of the lack of specific imaging studies. A 45-year-old man underwent laparoscopy-assisted distal gastrectomy for gastric cancer M0II c, cT1N0M0, cStage IA. The postoperative diagnosis was gastric cancer M, Ant, adenocarcinoma, por and sig>tub2, pT1b1, ly2, v0, N2(3/29), M0, R0-pStage II A, so he was given S-1 8 cycle as postoperative adjuvant chemotherapy. There was a mass measuring 15 mm near the blind end of the Roux-Y jejunum as observed on the CT scan 3.5 years after the operation. However, on the CT scan 2.5 years after the operation, the same mass was 5 mm. As the mass grew slowly, we concluded that the mass was not dissemination recurrence, and we carried out surgery to remove the mass as well as staging laparoscopy. The mass was covered by the greater omentum, and there was no infiltration to the nearby structures. The patient was diagnosed with intra-abdominal desmoid tumor by pathological examination, and there were no cancer cells. He was alive and free of relapse 20 months after surgery.

A 57-year-old woman was diagnosed with a linea alba hernia 10 years ago. She had no prior complaints other than abdominal swelling. She visited our hospital with upper abdominal swelling and pain. A CT scan showed a linea alba hernia with impaction of the round ligament of the liver. We were unable to reduce the hernia, so we performed emergency surgery. She underwent laparotomy and hernia orifice repair with direct sutures. The postoperative course was uneventful. Linea alba hernias are rare and difficult to diagnose. In this study, we report our experience of emergency surgery for a linea alba hernia, which we diagnosed preoperatively.

A 66-year-old woman suddenly developed intermittent right calf claudication following a 100-m walk, and she consulted a doctor two weeks later. Angiography showed bilateral persistent sciatic arteries (PSAs) and occlusion of the right PSA. Echography of the lower limbs showed fresh thrombi, and she was referred to our hospital, where an emergency thrombectomy was performed. However, since it was difficult to completely remove the thrombi in the central femoral neck because of arterial stenosis, percutaneous balloon angioplasty was performed at the same time. Seven days after the thrombectomy, the right PSA was again occluded, so a right femoropopliteal bypass was performed. After surgery, the patient's intermittent right calf claudication disappeared. Thirteen days later, she was able to walk and was discharged from hospital. Her acute occlusion and stenosis of PSAs were successfully treated with thrombectomy and right femoropopliteal bypass.