【Background and Purposes】Although patients who are expected to survive more than 2 months are considered to be candidates for palliative surgery, it is difficult to predict the prognosis of the end-stage patients. We examined the significance of the palliative prognostic index (PPI), prognostic nutritional index (PNI), modified Glasgow prognostic score (mGPS), and controlling nutritional status (CONUT) as 60-day prognostic indicators for patients undergoing palliative surgery.

【Patients and Methods】In a total of 94 patients who underwent palliative surgery, we compared the accuracy of the prognostic prediction of the postoperative 60-day survival rate in each prognostic index. A cut-off value was set for each index, and the patients were classified into two groups according to the index and statistically examined.

【Results】PPI, PNI, and CONUT were significantly correlated with the 60-day survival after palliative surgery. The 60-day survival rate was significantly better in patients with PPI ≦4 than in those with PPI >4. It was also significantly better in patients with the PNI >31.5 group than in those with PNI ≦31.5. Similarly, patients with the CONUT ≦7 group were significantly better than those with CONUT above 7. PPI is the best indicator for prognostic accuracy.

【Conclusions】PPI, PNI and CONUT can be good indicators to predict the 60-day survival in patients undergoing palliative surgery.

Unresectable recurrent gastric cancer with massive cancerous ascites has a poor prognosis because it is difficult to perform chemotherapy. The utility of modified cell-free and concentrated ascites re-infusion therapy (KM-CART) for pharmacotherapy and best supportive care is presented. KM-CART was performed for recurrent gastric cancer with massive cancerous ascites in 23 cases (58 times) between January 2017 and September 2019. KM-CART was performed in four cases before first-line chemotherapy, seven cases before second-line chemotherapy, five cases before third-line chemotherapy, and seven cases as best supportive care. The serum albumin level after KM-CART did not decrease from the pretreatment level, whereas the serum creatinine level decreased. Overall survival was 17 to 654 days. Even if patients had massive cancerous ascites at first-line therapy, KM-CART improved subjective symptoms and nutritional status, and chemotherapy could be continued. Overall survival could be extended with repeated KM-CART. KM-CART is useful for unresectable recurrent gastric cancer with cancerous ascites for both extending survival and best supportive care.

The development and spread of laparoscopic surgery in the field of abdominal surgery is remarkable, and the use of laparoscopic surgery as a standardized operative procedure is increasing annually. On these occasions, adhesions of the intestinal tract to the peritoneum associated with the previous laparotomy may hinder the laparoscopic approach. In our hospital, the evaluation and mapping of intraperitoneal adhesions using preoperative ultrasound examination have been performed in patients scheduled for laparoscopic surgery. We investigated a total of 615 patients in whom evaluation was possible among those scheduled for laparoscopic surgery from January 2014 to December 2018. The subjects were asked to slowly repeat deep abdominal breaths and we confirmed the respiratory movement of the abdominal organs. The ultrasonic diagnosis had a sensitivity of 51%, specificity of 95%, and diagnostic accuracy of 89%. If limited to the umbilical region for the insertion of a laparoscopic trocar, the sensitivity, specificity, and diagnostic accuracy rates were 84%, 99%, and 97%, respectively. We believe that this method can be widely applied to ensure safe surgeries by evaluating abdominal wall adhesions based on ultrasound examination findings.

Objective : In abdominal surgery, intestinal adhesions to the abdominal wall at the wound site are a risk factor for intestinal damage in future open abdominal surgery, and a range of different adhesion barriers are therefore used. In clinical practice, however, when open abdominal surgery is performed for some reason after laparoscopic surgery, it is not uncommon to find that there are no abdominal wall adhesions from the previous operation, despite the fact that no measures had been taken to prevent adhesions. Thus, surgical risk factors for adhesions to the abdominal wall at the wound site were investigated. Methods : Surgical factors associated with the presence of adhesions were investigated in patients with a history of abdominal surgery who underwent either planned or incidental repeated abdominal surgery. Results : Univariate analysis identified the volume of hemorrhage and surgical approach (open vs. laparoscopic) as significant risk factors for adhesions. On multivariate analysis, the only significant risk factor was the surgical approach, and there was no association with other risk factors, including the use of adhesion barriers. Conclusions : Open abdominal surgery increases the risk of intestinal adhesions to the abdominal wall at the wound site, and some sort of adhesion-prevention measures should be considered. However, the risk of intestinal damage in open abdominal surgery following previous laparoscopic surgery is low even if no particular measures were taken to prevent adhesions.

We report a case of a 69-year-old female who was hospitalized with a crusted left areola and left nipple redness. The initial physical and imaging examinations indicated suspected left breast cancer. However, a skin biopsy of the left nipple was performed due to the presence of the crusted left nipple, which led to the diagnosis of Paget's disease of the breast. A left-sided mastectomy and sentinel lymph node biopsy were performed. The sentinel lymph nodes had no metastasis. Histopathologic examination confirmed the diagnosis as Paget's disease of the breast. The estrogen and progesterone receptors were negative, and the Her2 receptor was 3+. No postoperative adjuvant therapy was administered, and the patient has been regularly followed up without recurrence. The definitive diagnosis of Paget's disease of the breast in this case required time and a skin biopsy must be performed if nipple or areola lesions are found. Once a definitive diagnosis of Paget's disease of the breast is made, treatment should be performed in accordance with that of general breast cancer. The prognosis is determined by the presence or absence of invasion. Several characteristics of this disease are unclear, such as its mechanism of occurrence. In the General Rules for Clinical and Pathological Recording for Breast Cancer, the 18th Edition, Paget's disease with an interstitial invasion of 1 mm or more was classified as invasive carcinoma.

Accessory breast cancer is rare and primarily occurs in the axillary region. There have been very few reports of accessory breast cancer in the anterior chest wall. Here, we report a case of accessory breast cancer in the anterior chest wall.

A 56-year-old female was admitted to our hospital with a subcutaneous tumor in the right anterior chest wall (so-called milk line). A core needle biopsy revealed a pathological diagnosis of breast cancer. We suspected accessory breast cancer with no lymph node metastasis due to the diagnostic imaging findings. The patient underwent local wide resection and sentinel lymph node biopsy using the dyeing method. Although rapid pathological examination showed no metastasis in the sentinel lymph node, several hard lymph nodes were found in the right axillary region. Therefore, additional axillary lymph node dissection (level I) was performed. The histopathological findings showed scirrhous carcinoma of the accessory breast, and no axillary lymph nodes metastases were found. Immunohistochemical staining was positive for ER/PgR and negative for HER2. After surgery, 4 cycles of epirubicin-cyclophosphamide, along with an aromatase inhibitor, were performed as adjuvant therapy. There has been no evidence of recurrence in the 30 months after surgery.

A 68-year-old female presented with bleeding from her left nipple and a slowly enlarging mass in the same area. A physical examination revealed a 5-cm mass protruding from the left nipple, with associated erosion and hemorrhage. An incisional biopsy suggested spindle cell carcinoma. Positron emission tomography confirmed breast cancer of the left nipple. In addition, metastasis of the left axillary lymph nodes was suspected. The patient underwent left mastectomy with sentinel lymph node biopsy. An examination of the lymph nodes revealed evidence of metastasis, and an axillary lymph node biopsy was performed during the surgery. Histopathological examination revealed metaplastic carcinoma (spindle cell carcinoma) limited to the nipple (epithelial component : HER2 positive, sarcoma component : focally ER-positive). The patient received adjuvant anthracycline and taxane chemotherapy, as well as anti-HER2, and endocrine therapy postoperatively. The patient has not shown recurrence for over 2 and a half years.

An 82-year-old Japanese woman was diagnosed with right-sided breast cancer and hence underwent partial mastectomy and sentinel lymph node biopsy. Invasive ductal carcinoma was confirmed histologically, and it was estrogen and progesterone receptor-positive and HER2 negative. She was started on 1 mg of anastrozole (ANA) daily as adjuvant endocrine therapy. Nine months later, she experienced leg edema and symptoms of upper airway inflammation, followed by small purpura in both legs and lower abdominal pain. Skin biopsy revealed fibrinoid degeneration and infiltration of dermal vessels by neutrophils. Immunofluorescence staining revealed immunoglobulin A (IgA) and C3c deposits, consistent with IgA vasculitis. Skin lesions and elevated C-reactive protein levels resolved immediately after drug interruption. Tamoxifen was introduced alternatively, and she did not experience exacerbation of the vasculitis. She was continued on tamoxifen without recurrence.

We have encountered a case of exposure of a battery of a pacemaker implanted in the infraclavicular area that might be caused by exercise to reduce dizziness, and successfully dealt with it by minimally invasive alteration of the battery implantation with a use of an extending lead.

The case involved a 71-year-old woman who presented with dizziness and was implanted a pacemaker with the diagnosis of complete atrioventricular block. Five months later, she noticed exposure of the battery site by herself and was admitted to our hospital on an emergency basis. A possible contribution of infection or allergy was ruled out by various examinations after admission. Her dizziness had persisted after implantation of the pacemaker, for that she initiated exercise by her own decision referring a book sold commercially to reduce episodes of dizziness. We determined that this exercise for dizziness improvement might cause the exposure of the battery. We removed only the battery by sub-emergency operation. A new battery was implanted under the ipsilateral breast where is rich in subcutaneous fatty layer by using an extending lead.

There are some cases of exposure of the pacemaker battery due to movements or exercises of the ipsilateral upper limb or shoulder joint. Accordingly, we must observe the surgical wound at exercises in the management of the pacemaker after implantation.

We report a case of severe mitral regurgitation (MR) complicated by secundum atrial septal defect (ASD). A 45-year-old female was admitted to our hospital for orthopnea, dry cough, and leg edema. She was diagnosed with severe MR, severe tricuspid regurgitation (TR), pulmonary hypertension (65/42 mmHg), and ASD, which was 28 mm in size. Catheter examination revealed that the Qp/Qs was 6.35, and the L-R shunt ratio was 84.5%. The patient underwent mitral valve plasty and tricuspid annuloplasty, and pericardial patch-closure of the ASD. A chordal rupture of the anterior leaflet was discovered intraoperatively, and chordal reconstruction using artificial chordae was performed. In addition, mitral annuloplasty with CG future band and tricuspid annuloplasty using De Vega's procedure was performed.

The postoperative course was uneventful. Four years after the operation, the patient remains asymptomatic, and regular echocardiographic checkups have demonstrated no residual ASD, MR, and TR.

Zenker's diverticulum is a type of esophageal diverticulum and the prevalence is estimated to be about 0.1%. Herein, we report a rare case of Zenker's diverticulum that confined a foreign body mimicking esophageal perforation. The case involved an 84-year-old man who was suspected to have cervical esophageal perforation after accidental ingestion of a partial denture. His chief complaints were cervical pain and dysphagia lasting for a week after the accidental ingestion. A blood examination demonstrated elevated white blood cell count and C-reactive protein level, and a computed tomographic scan demonstrated the pressure of the partial denture's clasp outside the esophageal contour, suggesting esophageal perforation by the denture. The foreign body was safely removed endoscopically. The patient's vital signs were stable and therefore he was observed conservatively. Oral contrast study after a week revealed a Zenker's diverticulum without contrast leakage. We concluded that the foreign body, a partial denture with clasp, had entered the Zenker's diverticulum without causing esophageal perforation.

The current case suggests that the presence of a foreign body outside the contour of the digestive tract after accidental ingestion is not always due to perforation. Excessive surgical invasion can be avoided by keeping a possible existence of a Zenker's diverticulum and a foreign body confined there in mind, though it is uncommon.

A 79-year-old woman developed gastric mucosa-associated lymphoid tissue (MALT) lymphoma. She was Helicobacter pylori positive, and her condition was resistant to treatment. She had complete remission after radiotherapy and received follow-up treatment. She was admitted the next year with complaints of chest pain and diagnosed as upper gastrointestinal perforation. Conservative treatment did not improve her condition, and a surgical strategy was adopted. At surgery, a 20 × 20 mm perforated site was found on the middle posterior wall of the stomach, and a total gastrectomy was performed. No lymphoma cells were found on pathological examination. The patient had an uneventful course and was discharged on the 15th postoperative day. Although gastric perforation is rarely reported in patients who are in complete remission after radiation therapy for gastric MALT lymphoma, it should be kept in mind as a complication that also requires surgery.

Primary gastric mixed adenoneuroendocrine carcinoma (MANEC) is extremely rare. Case ① was a patient with a type 2 lesion in the anterior wall of the middle gastric corpus, and a liver tumor was identified during surgery. Gastrectomy and partial hepatectomy were performed. MANEC was diagnosed, and hepatic metastasis recurred rapidly. Case ② was a patient with an early-stage lesion that was removed by endoscopic submucosal dissection, followed by additional laparoscopic resection and lymph node dissection. MANEC is difficult to diagnose preoperatively, and its prognosis is worse than that of adenocarcinoma. However, there have been a few reports of good outcomes following its early discovery. Two cases of primary gastric MANEC treated by surgical resection are reported.

A 60-year-old woman with unresectable advanced gastric cancer and pyloric stenosis was treated by chemotherapy S-1 + CDDP (SP therapy). She was then admitted to our hospital with severe diarrhea and vomiting. Abdominal dynamic computed tomography (CT) revealed widespread pneumatosis cystoides intestinalis (PCI) accompanied by hepatic portal venous gas (HPVG). Abdominal distention was observed ; however, only abdominal tenderness was noted. She underwent both gastric tube decompression and antibiotic administration. Day 12 after admission, both PCI and HPVG dramatically disappeared on abdominal CT. On day 35, gastrojejunostomy was performed for the pyloric stenosis. No recurrence of PCI was observed during the second course of SP therapy. In cases of PCI with HPVG or free air in the abdominal cavity, emergency laparotomy should be considered for suspected gastrointestinal perforation or intestinal necrosis. In the present case, we successful treated the patient with severe PCI and HPVG conservatively since the abdominal findings were mild and the inflammatory response was moderate.

Postoperative enterocutaneous fistula (ECF) is a rare and serious complication which is difficult to manage for surgeons. We report a case of intractable ECF treated with a rectus abdominis musculocutaneous flap. A 68-year-old man who had undergone distal gastrectomy with Billroth II reconstruction was diagnosed with cholecystitis combined with choledocholithiasis. He underwent open cholecystectomy one month after endoscopic sphincterotomy and lithotripsy. Operative findings showed severe intraperitoneal adhesions. The small intestine injured due to dissection of adhesions was repaired during the procedure. On the next day, reoperation was performed for peritonitis with sepsis due to the duodenal perforation. He was managed with intensive treatment for sepsis successfully. However, on the postoperative day 12, wound dehiscence of the incision with spillage of intestinal contents occurred. Although conservative treatment was continued for 100 days, we decided to perform a surgical intervention considering that the high-output ECF would not close spontaneously. We closed the anterior wall of the fistula by extra-peritoneal manner using the pedicled vertical rectus abdominis musculocutaneous flap. The patient was discharged 3 weeks after the operation. To treat ECF, the closure with musculocutaneous flap may be a choice of treatment in cases in which re-laparotomy cannot be indicated due to potentially severe adhesion.

A 53-year-old male patient with a history of undergoing laparoscopic proximal gastrectomy for gastric cancer six months before presented to our hospital with a 4-day history of severe upper abdominal pain and nausea. Contrast-enhanced computed tomography (CT) of the abdomen revealed a whirl sign and a poorly enhanced distended small bowel. Strangulated bowel obstruction was diagnosed, and emergency laparoscopy was performed. An accumulation of chylous ascites was observed in the entire abdomen. The small intestine was incarcerated in a small hole formed by adhesions between the small intestine and its root while it was twisting, demonstrating intestinal torsion and an incarcerated internal hernia. The strangulated small bowel mesentery became edematous, with a prominently extended lymph duct, and a whitish surface. After the torsion was released by avulsion, the color of the small intestine was immediately normalized, obviating the need for small bowel resection. The postoperative course was uneventful, and the patient was discharged on postoperative day 10.

Few patients with volvulus of the small intestine have chylous ascites as an ancillary manifestation. The case of a patient with primary volvulus of the small intestine who presented with bowel obstruction and chylous ascites is presented. A 69-year-old man developed sudden upper abdominal pain and was brought to hospital by ambulance. The whirl sign was evident on abdominal contrast-enhanced computed tomography, and arterial perfusion in the mesentery proper was preserved, perfusion in the superior mesenteric vein was interrupted, and there was widespread congestion in the mesentery proper. Ascites was also present, and since impaired perfusion of the intestinal tract due to volvulus of the small intestine could not be excluded, emergency laparoscopic surgery was conducted. Observation of the peritoneal cavity showed no small intestinal volvulus, which had spontaneously resolved, but the mesentery of the upper small intestine was white and edematous, and chylous ascites was present. There were no signs of irreversible intestinal ischemia, and the procedure was concluded as purely observational laparoscopy. In impaired intestinal perfusion with chylous ascites, ischemia is generally mild, and intestinal resection is often not required. Laparoscopic surgery is thus a good choice for this condition.

A 32-year-old woman at 27 weeks and 5 days of pregnancy was brought into our hospital by ambulance because of epigastralgia and vomiting. Since midgut volvulus was suspected by an abdominal pain CT scan, we performed an emergency operation in the presence of a neonatologist and a gynecologist. We identified that the Treitz ligament had not been formed and that the small intestine, cecum, and ascending colon were twisted clockwise by 360 degrees around the superior mesenteric artery. We diagnosed the case as midgut volvulus associated with malrotation and reduced the volvulus. Ischemic change of the intestine was so mild that bowel resection was unnecessary. Although a temporary uterine contraction was noted, her postoperative course was uneventful and she was discharged from our hospital on the 9^thpostoperative day. Midgut volvulus occurring during pregnancy has rarely been reported and this case is the second report in Japan. We present here that both mother and her baby were successfully treated with favorable prognosis.

A 63-year-old man underwent computed tomography for the investigation of upper rectal carcinoma that also showed a contrast-enhanced, irregularly shaped cystic mass of longest diameter 70 mm containing calcifications in the mesentery. The differential diagnoses were lymphangioma and gastrointestinal stromal tumor, and cystectomy was performed at the same time as rectal carcinoma surgery. The cyst formed an irregularly shaped mass in the mesentery proper, 130 cm on the oral side of the terminal ileum, and was not continuous with the small intestine. Total resection was easily performed, with perfusion of the vessels of the mesentery proper well preserved. The resected cyst measured 80 mm × 45 mm × 25 mm, and its interior included areas containing a yellow mucinous substance and others containing a clear serous substance. Pathological examination showed columnar epithelium with mucus in the cyst wall, and mesenteric mucinous cystadenocarcinoma was diagnosed. Mesenteric cysts are comparatively rare, and signs of malignancy are extremely uncommon. A case of asymptomatic mucinous cystadenocarcinoma arising in the mesentery proper that was discovered accidentally prior to upper rectal carcinoma surgery is reported.

A 61-year-old woman was admitted to our hospital because of left abdominal flank pain and fever. Computed tomography (CT) showed a 10-cm solid tumor between the descending colon and the transverse colon. Left colectomy was done, and the pathological findings led to a diagnosis of poorly differentiated adenocarcinoma.

However, immunostaining of the tumor was positive for cytokeratin (CK) 7 and negative for CK20, which suggested the possibility of metastasis from another organ to the colon. Despite several further investigations after the operation, the primary lesion was not detected. Three and a half years after the operation, PET-CT showed abnormal FDG uptakes in the right adrenal gland and left ovary. Because of the elevation of CA72-4, the left ovary was diagnosed as a primary cancer, and the right adrenal gland was thought to be a metastatic tumor from an unknown origin, similar to the previous colon tumor. Right adrenalectomy and bilateral salpingo-oophorectomy were done. Based on the immunohistochemical findings for CK20, CK7, and PAX8, the final histological diagnosis was metastases from left fallopian tube carcinoma to the colon heterochronously and right adrenal gland synchronously.

A 93-year-old female was admitted to our hospital with fever and anorexia. She was diagnosed with a fever of unknown origin by computed tomography (CT) and treated with antibiotics. On the 6th day, E. coli was detected in the blood culture, and enhanced CT revealed a splenic abscess with an invasion of colon cancer and tumor thrombosis in the splenic vein. Therefore, splenectomy, partial colectomy, distal pancreatectomy, and colostomy were performed. Histological examination revealed that the splenic abscess had developed as a direct invasion of the colon cancer, and tumor thrombosis was extended from the spleen to splenic vein. The postoperative course was uneventful. Here, we report a rare case of a splenic abscess with an invasion of colon cancer and tumor thrombosis in the splenic vein and have reviewed previous case reports.

An 84-year-old man who had been taking calcium polystyrene sulfonate (CPS) for diabetic renal failure and hyperkalemia presented to our emergency clinic because of left lower quadrant abdominal pain. An abdominal CT scan revealed free air around the sigmoid colon. We performed an emergency operation with a diagnosis of panperitonitis due to perforation of the sigmoid colon. Intraoperative findings revealed perforation with the size of a tip of the thumb in the sigmoid colon, from where hard stools exposed. Accordingly, we performed Hartmann's operation. He developed abdominal pain again on the 6^th postoperative day, and re-perforation at the peduncle of the stoma was diagnosed from CT findings. Relaparotomy disclosed reperforation of the colon at 10 cm proximal to the stoma. We resected the colon from the stoma to the reperforation and created a colostomy. Histopathology revealed precipitation of basophilic polygonal crystalline foreign materials associated with inflammatory cell infiltration at the perforated site, strongly suggesting coating with CPS.

Colorectal perforation in patients who are taking oral CPS can be fatal due to general disorder associating with chronic renal failure. In order to avoid repeated perforation, we are required surgical devices such as aggressive removal of hard stools and larger penetrating part through the abdominal wall.

A 68-year-old woman with constipation visited her local doctor. Abdominal X-ray and colonoscopy showed obstruction due to a tumor at the rectosigmoid junction. She was referred and admitted to our hospital for treatment. After decompression with a transanal ileus tube, she was diagnosed as having rectal colon cancer. At laparotomy, the tumor had invaded the ileum at three sites, and high anterior resection with D3 lymph node dissection, combined partial ileal resection, and ileostomy were performed. Fistulas were found in each location of ileal invasion in the resected specimen. The final diagnosis was rectal sigmoid cancer [pT4b(ileum)N1aM0 pStage IIIc]. She received adjuvant chemotherapy for 6 months, and 1 year has passed since surgery without recurrence. Formation of fistulas between colorectal cancer and the small intestine is relatively rare, and furthermore, the finding of multiple fistulas at the same time is extremely rare. A case of rectosigmoid cancer with three ileal fistulas is reported along with a review of the relevant literature.

The patient was an 82-year-old man who underwent laparoscopic sigmoidectomy for sigmoid colon cancer. Reconstruction was performed with a functional end-to-end anastomosis. The patient's postoperative course was good, and he was discharged on the 8th postoperative day. From one year and three months after the operation, dilation of the anastomotic site was seen on computed tomography (CT). Three years and 7 months after the operation, he visited our hospital for constipation and abdominal bloating. Blind loop syndrome was diagnosed due to the marked dilation of the anastomotic site on CT. Because his symptoms did not improve with conservative treatment, laparoscopic resection of the anastomotic site with reconstruction by double-stapling technique anastomosis was performed. Blind loop syndrome at a functional end-to-end anastomosis is a rare postoperative complication. However, patients with symptoms of intestinal obstruction should be treated surgically.

A 49-year-old woman diagnosed with neurofibromatosis type 1 (NF1) was admitted with bowel obstruction due to a large, rapidly growing pelvic tumor. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a tumor 250 mm in diameter in the mesentery of the rectum. Posterior pelvic exenteration was performed, and the tumor (300 × 250 × 250 mm, 2,370 g) was resected. On histopathological examination, S-100 was diffusely positive, and both C-kit and CD34 were negative. Thus, the patient was diagnosed with epithelioid malignant peripheral nerve sheath tumor (eMPNST) derived from the mesentery of the rectum. Three months after surgery, multiple recurrent tumors were found in the abdominal cavity, and she died six months after surgery. MPNST is a relatively rare tumor that accounts for 5% to 10% of malignant soft tissue tumors. However, it rarely occurs in the mesentery, and there have been few reports. In this report, a case of eMPNST derived from the mesentery of the rectum is described.

It is known that liver abscess can occur in relation to the treatment for hepatocellular carcinoma (HCC). However, simultaneous occurrence of HCC and liver abscess before initiation of the treatment is as rare as 13 domestic cases, where we often have difficulties in diagnosis. Recently we have experienced a case of HCC associated with an extrahepatic growth type monostotic liver abscess. The patient was a 77-year-old woman who was referred to our hospital for a purpose of treatment for chronic hepatitis C. When she was first seen, an abdominal CT scan revealed a tumor distally protruding from the lateral segment of the liver associating with low-density inner part. Several days later she was admitted to our hospital because of epigastralgia and high fever. Symptomatic remission was gained by antibiotic therapy and the tumor reduced in size on imaging. A liver abscess was thus suspected, but an associating hepatic malignant tumor was also likely because an enhanced solid part was left. Following left lobectomy of the liver, the histopathological diagnosis was HCC associated with liver abscess. We present our case together with a review of the literature.

The patient was a 57-year-old man, who had been indicated having thickening of the gallbladder wall at medical check-ups from 2012. But he had been followed up because he was asymptomatic and had no abnormality on blood examination until July 2018 when we recommended him diagnostic treatment for liver dysfunction. We performed laparoscopic cholecystectomy in August 2018. During operation, we examined his gallbladder which seemed normal in appearance and found that the funicular structure attached to the inside of the cystic structure which seemed like the gallbladder. And only the funicular structure connected with the common bile duct. We suspected that the funicular structure might connect to the cystic structure, because a muddy bile collection was observed between the space of these two structures. Morphologically, we considered that this case might be of double gallbladder. However, the perfect construction of the gallbladder wall was seen in the junction of the cystic structure and the funicular structure, histopathologically ; and the cystic structure was composed of serosa and sub-serosa. In addition, multiplied or failed Rokitansky-Aschoff sinuses which perforated the muscularis propria, were observed in the funicular structure. We thus considered that this case is of gallbladder wall dissection, triggered by adenomyomatosis.

A 78-year-old man was undergoing treatment with sorafenib for hepatocellular carcinoma with vascular invasion, tumor thrombi in the portal vein and inferior vena cava, and multiple lymph node metastases. Having complained of loss of appetite and back pain for the previous two days, he was diagnosed with hemorrhagic cholecystitis and underwent emergency laparoscopic cholecystectomy. The neck of the resected gallbladder contained a tumor projecting into the lumen, which was considered to have caused obstruction, inflammation, and hemorrhage. The patient was also taking anti-platelet medication, which may have contributed to the bleeding. Pathological examination of the gallbladder tumor identified it as a metastasis of hepatocellular carcinoma. The patient's postoperative recovery was uneventful, and he was quickly able to resume treatment for the hepatocellular carcinoma. Gallbladder metastasis of hepatocellular carcinoma is infrequent, and a rare case in which this was combined with hemorrhagic cholecystitis requiring emergency treatment is reported.

A 64-year-old man presented with jaundice and fatigue. An abdominal contrast-enhanced CT scan showed a 25-mm space occupying lesion with poor enhancement effect at the lower extrahepatic bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) revealed stricture. Biopsy of the bile duct revealed non-epithelial atypical cells. We performed subtotal stomach-preserving pancreatoduodenectomy with a diagnosis of malignant tumor arisen in the bile duct. The histopathological diagnosis was carcinosarcoma of the extrahepatic bile duct.

Carcinosarcoma of the extrahepatic bile duct is rare and only 32 Japanese or English case reports have been decribed so far. In this paper we compared carcinosarcoma of the extrahepatic bile duct and carcinoma of the bile duct, together with a review of the literature. Computed to bile duct carcinoma, carcinosarcoma of the extrahepatic bile duct appears to be difficult to differentiate from the other before treatment, based on the age of the onset of the disease, gender, symptoms, blood biochemical analysis, and imaging findings. The prognosis of carcinosarcoma of the extrahepatic bile duct is poor compared to the other. The standardization of the diagnosis and treatments for the carcinosarcoma is desired with further accumulation of clinical cases.

A 66-year-old woman was admitted to our hospital because of epigastric pain and underwent esophagogastroduodenoscopy. She was pointed out to have a neoplastic lesion of the duodenum. Biopsy taken from the tumor showed squamous cell carcinoma. Abdominal contrast-enhanced CT scan showed a tumorous lesion in the gallbladder with invasion into the adjacent organs. She was diagnosed with gallbladder cancer cT4aN0M0 stage IV A and underwent surgery. Intraoperative findings showed that the tumor mainly located in the gallbladder had invaded the transverse colon, liver bed, and duodenum. Subtotal stomach-preserving pancreatoduodenectomy, partial resection of segment 4 and 5 of the liver, right hemicolectomy and lymph node dissection were performed. Adenocarcinoma components were absent and the histopathological diagnosis was squamous cell carcinoma of the gallbladder. She did not receive adjuvant chemotherapy and has been followed up without recurrence. The histological type of gallbladder cancer is predominantly adenocarcinoma, and squamous cell carcinoma is rare. Here we report a case of squamous cell carcinoma of the gallbladder.

The case involved a 56-year-old woman who had undergone tumor resection for malignant melanoma of the right upper jaw in 2014, followed by tumor resection and INF-β local therapy twice for postoperative local recurrences. A CT scan conducted in February 2018 showed a tumor at the uncus of the pancreas. Pancreatic metastasis was suspected, but otherwise no distant metastases were identified by PET that revealed no abnormal accumulations of FDG to anywhere. We thus considered the tumor to be resectable and planned to perform pancreaticoduodenectomy (PD). Laparotomy disclosed two nodules on the surface of the liver S4 when no other dissemination nor metastasis was confirmed. We determined that macroscopic radical resection could be attained and performed partial hepatectomy and PD. The histopathological diagnosis was pancreatic and hepatic metastases of malignant melanoma.

It is believed that prognosis of pancreatic metastasis of malignant melanoma is poor, however, the efficacy of anti PD-1 antibody has recently been reported. There are some reports describing that combination of surgery and chemotherapy yielded long-term survivals. In this case, chemotherapy was introduced after surgery and the patient is still alive at present when 2 years have elapsed after the operation. Even the patient has metastases to the pancreas and the liver like in this case, resection followed by chemotherapy can result in improvement of prognosis, if complete resection can be expected.

A-64-year-old man presented with an enlarged left adrenal mass during follow-up and was referred to our department to undergo surgical resection. Enhanced abdominal computed tomography revealed a 50-mm tumor without a pancreatic body or tail. A diagnosis of left adrenal tumor with pancreatic body and tail deficiencies was made and laparoscopic surgery was planned. A laparoscopic transabdominal anterior approach was chosen because the reflux disorder of the splenic vessels could not be denied on the basis of the pancreatic parenchyma deficiency during splenic mobilization when a retroperitoneal laparoscopic resection was planned. The intraoperative findings revealed that the identification or resection of the tumor was relatively stress-free. Thus, the transabdominal anterior approach can be considered an appropriate resection method for patients with relatively large left adrenal tumors with pancreatic body and tail deficiencies.

Case 1 : A 78-year-old woman was transferred to our hospital on an emergency basis, with a diagnosis of gallstone pancreatitis. One day after admission, she developed abdominal compartment syndrome (ACS) and required emergency laparotomy for decompression. On postoperative day 14, cholecystectomy and abdominal wall closure using bipedicle flaps, made by shifting bilateral strips of skin were performed, and the abdomen was closed. Case 2 : A 39-year-old Russian man was transferred urgently to our hospital with a diagnosis of severe acute pancreatitis. He developed ACS the day after admission and required emergency laparotomy for decompression. Fifty-two days after the operation, the abdominal wall was closed in the same manner as the former case.

Abdominal closure after open abdominal management for ACS is sometimes difficult if the abdominal wall dehiscence is large ; however, this technique makes it possible to close the abdominal wall.

A 38-year-old woman had been suffering from exudation and pain from the hypogastrium several times a year from childhood. When she first presented to our hospital, a midline fistula of the abdominal skin was observed at 7 cm below the umbilicus. No infectious signs were revealed. Computed tomography revealed a cutaneous fistula extending toward the pubic bone and connected with the median umbilical ligament. Laparoscopic excision of the fistula was carried out in consideration of related residual disease. The median umbilical ligament diverged toward ventral skin and connected with the fistula. Histopathological examination in the lumen demonstrated that epithelium at the deep fistula was urothelial epithelium covered with the smooth muscle, and changed to stratified squamous epithelium around the opening of the fistula. Her postoperative course was uneventful and she has been free from recurrence as of one year after the operation.

A 23-year-old man complaining of left scrotal pain and swelling was transferred to our hospital. Computed tomography and ultrasonography revealed a left inguinal hernia, the content of which was suspected to be greater omentum with a solid mass. Testicular torsion was also suspected, for which we performed emergent surgery. In the scrotum, we found a large omental tumor causing the acute scrotum. We resected the tumor and repaired the hernia. The testis was preserved. A histopathological examination revealed an intra-abdominal desmoid tumor possibly arising from the greater omentum.

Here we reported a rare case of omental desmoid tumor revealed by acute scrotum.

The patient was a 22-year-old man who presented at a local hospital with a 2-week history of right abdominal pain and fever. He was prescribed antibiotics, but his symptoms did not improve. Therefore, he was referred to our hospital. Abdominal contrast-enhanced computed tomography (CT) showed a low-density area measuring 65 mm long and images of retroperitoneal gas collection ; hence, he was diagnosed with a retroperitoneal abscess. There was no underlying disease that was likely to cause abscesses, such as a urinary tract infection, appendicitis, diverticulitis, or pancreatitis. Therefore, the condition was diagnosed as a primary retroperitoneal abscess for which percutaneous drainage was performed under ultrasound guidance. Antibiotic treatment was administered, drainage was performed, and on hospital day 8, CT showed that the abscess cavity had disappeared. The drain was removed on hospital day 10, and the patient was discharged home on hospital day 13. Primary retroperitoneal abscesses that develop in young individuals without underlying diseases are rare. Here we report our experience with a case of primary retroperitoneal abscess that was cured using percutaneous drainage.

Here we report a case of intestinal obstruction due to an incarcerated superior lumbar hernia treated with laparoscopic reduction and repair. A 95-year-old woman visited a nearby clinic with abdominal pain, was diagnosed with intestinal obstruction, and was referred to our hospital. A 10-cm bulge was found on the left dorsal lumbar area and the patient was diagnosed with an intestinal obstruction due to an incarcerated left superior lumbar hernia containing the descending colon on abdominal computed tomography. As manual reduction was ineffective, surgery was selected. Laparoscopic surgery was performed using a three-port intraperitoneal approach with the patient in the right semi-lateral decubitus position under general anesthesia. The descending colon was mobilized and pulled, and the herniated viscus was reduced into the abdominal cavity with external manual compression. The surgery was performed as follows : the hernia orifice was confirmed circumferentially, additional about 3 cm of the circumference was detached, and a circular mesh was placed and fixed using the double crown method. Superior lumbar hernia is rare and reports of laparoscopic surgery are scarce. Despite some reports of intraperitoneal and extraperitoneal approaches, the suitable operative procedure has yet to be determined. Here we report this case and a review of the relevant literature.