In order to slow the down curb of the number of surgeons in Japan, we conducted a questionnaire survey to clarify the factors associated with the avoidance of surgery as a future profession for the medical students and interns. Questionnaires were sent anonymously to the young surgeons in all branches who attended annual special seminar of the Japan Surgical Association (JSA). Filled questionnaires recovered from a total of 210 young surgeons suggested that avoidance of surgery as a profession was related to work-life imbalances. The medical students and interns excluded surgery as a profession during the following period: 43% in medical school and 37% during the internship.

Ninety-five (43%) young surgeons themselves felt that there was insufficient work-life balance (WLB) in their places of work. Respondents reported that it was not easy to take maternity or paternity leave, or those for children's school ceremonies and events. Many of them reported that satisfactory changes for them in the work style reform have not been realized.

This study indicates that the poor WLB of surgeons is responsible for the avoidance of surgery as a profession. Accordingly, the establishment of a child-event holiday (CEH) system allowing them to utilize paid leave, and the promotion of work style reform, are recommended as strategies for reversing the decline in the number of young physicians and medical students who choose surgery.

As to the consideration for WLB of young surgeons, there was a discrepancy in the concept between young surgeons and the leadership (surveyed in 2016), indicating that a change in senior surgeon's perception might be a pressing need.

Tumors arising in the adrenal gland, retroperitoneum, or mediastinum may autonomically produce hormones. Missing the correct diagnosis may put the patient at risks of developing hemodynamic instability during the operation or postoperative adrenal insufficiency. Responsible surgeons need to be aware of such a rare disease and to prepare themselves for appropriate perioperative management.

Functioning tumors of the adrenal gland include pheochromocytoma, cortisol-producing neoplasm, and aldosterone-producing tumor. Neoplasms of paraganglia in the retroperitoneum or mediastinum producing noradrenaline are known as paragangliomas.

It is essential to give α-blockers preoperatively to control hypertension and restore circulatory volume in patients with pheochromocytoma/paraganglioma. Intra- and postoperative glucocorticoid administration for a long period of time is vital to prevent adrenal failure from various stresses in patients with Cushing's or subclinical Cushing's syndrome due to cortisone-producing tumors. The confirmatory tests to make the correct diagnosis and adrenal vein sampling to localize the lesion are keys to the successful management of patients with primary aldosteronism.

Surgeons who are unfamiliar with endocrinological care should consult with endocrine surgeons or endocrinologists.

Children with foreign bodies in the gastrointestinal tract diagnosed by chest or abdominal X-ray examinations were reviewed. Children under 16 years of age with foreign bodies in the gastrointestinal tract from January 2007 to December 2019 were investigated. Age, sex, position and type of foreign bodies, time from oral ingestion to X-ray examination, and treatments were examined. A total of 218 patients were reviewed. The foreign bodies were located in the esophagus, stomach, and intestines in 36, 143, and 39 cases, respectively. Types of foreign bodies in the esophagus were lithium batteries, coins, magnets, round foreign bodies, and others in 3, 14, 1, 5, and 13 cases, respectively. Treatments of foreign bodies in the esophagus were extractions or dropping to the stomach using a Foley catheter or endoscopic removal. Types of foreign bodies in the stomach were mainly round foreign bodies, coins, magnets, and button batteries in 42, 29, 19, and 19 cases, respectively. Foreign bodies in the stomach were treated by extraction using a magnet tube. All children with foreign bodies in the small and large bowel were observed without treatment. All children with foreign bodies recognized by X-ray examination were over the age of two years. An algorithm for the treatment of children with foreign bodies recognized by X-ray examination is presented.

The Lichtenstein method (herein after referred to as this method) for adult inguinal hernia is strongly recommended in global guidelines, but the number of cases is still small in Japan. Since 2010, we have continued this method of active nerve identification, pragmatic neurectomy, and the additional fixation of a self-adhesive mesh. Intraoperative nerve handling, additional fixation of a mesh, and treatment results were retrospectively examined in patients who underwent this method in our hospital during the five-year period from 2014 to 2018. As a result, the iliohypogastric, ilioinguinal, and genital branches of the genitofemoral nerve were identified in 73%, 69%, and 85% of the cases, respectively, and the iliohypogastric nerve was resected in 49% of the cases. Additional fixation of the mesh was performed in all cases. There were only two cases of complications associated with surgery, including one case of recurrence. No chronic pain was observed. In this method, good treatment results were obtained by active nerve identification, pragmatic neurectomy, and the additional fixation of a self-adhesive mesh.

A 68-year-old woman underwent partial mastectomy for right breast cancer (T2N0M0 Stage IIA). She developed sudden onset of dyspnea on exertion, 7 years postoperatively. This symptom gradually progressed, and the patient had difficulty moving, which necessitated a visit to our hospital. Contrast-enhanced chest computed tomography revealed no obvious organic disease. Echocardiography revealed right heart load, and lung perfusion scintigraphy revealed multiple wedge-shaped defects in the lung periphery bilaterally. Pulmonary artery aspiration cytology revealed atypical cells. Based on her medical history, clinical symptoms, and cytology findings, the patient was diagnosed with pulmonary tumor thrombotic microangiopathy (PTTM) associated with recurrent breast cancer. Anticoagulant therapy and cardiopulmonary management were continued ; however, the patient's general condition rapidly deteriorated, and she died on the fourth day after admission. PTTM results in rapidly progressive respiratory failure and is therefore associated with poor prognosis. Clinicians should consider PTTM in patients with cancer who develop sudden-onset dyspnea and right heart failure ; early diagnosis and prompt intervention are essential in such cases.

We report a case of breast cancer in which the size of the tumor shrank rapidly after discontinuation of hormone replacement therapy (HRT). The patient was a 52-year-old woman who noticed a mass in her left breast in March. Echography revealed a hypoechoic mass of 16 mm in size in the upper-inner quadrant of her left breast. The pathological diagnosis by core needle biopsy was invasive ductal carcinoma, ER(+ : 95%), PgR(+ : 80%), and HER2(1+). She continued placing an adhesive skin patch of estradiol and norethisterone for menopausal symptoms since she was 51 years old, but we told her to discontinue it in April. Breast echography just before surgery showed a significant reduction in tumor size from 16 mm to 8 mm. The interruption of HRT seemed to decrease the blood level of estradiol and in effect diminish the size of the tumor. It is clear that long-term HRT increases the risk of breast cancer tumorigenesis, and even short-term HRT, as in this case, may lead to latent tumor growth.

A 67-year-old woman, who presented with cough and hemoptysis, was followed up for three months, but the symptoms worsened. A chest computed tomography revealed a solid irregular mass measuring 37 mm in diameter in the lower lobe of the right lung. While a bronchoscopy at another hospital did not provide a definitive diagnosis, the mass was suspected as primary lung cancer. A repeat bronchoscopy at our hospital again failed to reveal the diagnosis and no specific bacteria were isolated. The lung lesion grew to the diameter of 42 mm by six months and a slight increase of the serum sialyl Lewis X-i antigen level was observed. Therefore, video-assisted thoracoscopic surgery was performed for diagnosis and treatment. Right lower lobectomy was performed and an intraoperative rapid diagnosis confirmed an inflammatory lesion. Subsequent histopathological examination revealed sulfur granules with mycelia arranged in a radiating pattern, suggestive of the diagnosis of pulmonary actinomycosis. There has been no recurrence for 18 months after the operation, despite no additional antibiotic therapy. It remains difficult to diagnose pulmonary actinomycosis by non-invasive examinations. Surgery should be adopted to differentiate lung cancer from an inflammatory mass, including pulmonary actinomycosis.

A 43-year-old man had been treated for smoking cessation with varenicline because he was aware of left chest pain and dyspnea with movement. When he came to our office for worsening of the symptoms and complained of severe dyspnea, a chest radiograph showed pneumothorax. A chest CT scan after chest drainage revealed a mass with a cavitary lesion and bulla in the left upper lobe. Air leak persisted even after the placement of a thoracic drain. There was no evidence of tuberculosis and mycosis. We diagnosed the case as secondary pneumothorax complicated by primary lung cancer and performed left upper lobectomy. Based on histological examinations, pleomorphic carcinoma (pT2bN2 cM0, Stage IIIA) was diagnosed. Although there are some case reports on pneumothorax due to cystic lesions adjacent to tumors and development of pneumothorax during chemotherapy containing a molecular target drug, secondary pneumothorax due to cavitary lung cancer is rare. We report a case of secondary pneumothorax due to ruptured cavitary pleomorphic carcinoma.

A 67-year-old man was found to have a 1.5-cm nodule in the right upper lobe of the lung at a medical checkup. A chest CT scan showed a solid lesion at the right S¹. Accordingly, we planned to conduct bronchoscopy. Bronchoscopy revealed right B¹⁺³ branching in the right upper lobe and B² branching from lateral side of the middle lobar bronchus of the right truncus intermedius. We could not diagnose the case based on bronchoscopy findings, and following thoracoscopic partial resection of the lung, pulmonary adenocarcinoma was diagnosed. Exploration of the whole body revealed no metastases to other organs, and the diagnosis of cT1bN0M0 stage 1A2 was made. Later right upper lobectomy and mediastinal lymph node dissection were performed. Incomplete lobulation was identified, but there was no anomalous branching of the pulmonary arteries and veins. We confirmed that a slightly thick B² had branched from the periphery of the truncus intermedius, and the bronchial stumps were closed by using a stapler. In treating lung cancer with anomalous branching of the bronchus, we are required careful attention at lung resection. We present our case with some bibliographical comments.

A 37-year-old man with no particular medical history presented with abdominal pain and vomiting on the day after overeating. Three days later, he was referred to our hospital because of suspicion of bowel obstruction. Physical examination revealed the remarkably distended abdomen and muscular defense at the upper right quadrant of abdomen. An abdominal CT scan showed significant dilatation from the stomach to the third part of duodenum and duodenal emphysema. Emergency laparotomy was performed with the diagnosis of acute gastric dilatation and duodenal necrosis. At laparotomy, the duodenum showed inflammation, but it was not necrotic. As a necrosis portion 5 cm in diameter was found at the upper body of the stomach, total gastrectomy was performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 17. Superior mesenteric artery syndrome can cause gastric necrosis due to the acute gastric dilatation. As the diagnosis is difficult, we should consider emergency laparotomy or follow up carefully.

A 42-year-old man was referred to our hospital for a submucosal tumor at the gastric fornix. On upper gastrointestinal endoscopy, an elevated lesion covered with normal mucosa was seen at the gastric fornix showing a positive cushion sign. Abdominal computed tomography showed an irregular exophytic cystic lesion at the greater curvature of the gastric fornix with no solid lesion within. The preoperative clinical diagnosis was cystic gastric submucosal tumor, and laparoscopic partial gastrectomy was performed for both therapy and diagnosis. The cystic lesion was similar to the surrounding gastric wall. The inner layer epithelium showed the features of stomach and lung on immunohistochemical examination, and the pathological diagnosis of the resected lesion was foregut duplication of the stomach. As the clinical diagnosis of foregut duplication of the stomach has not been established, surgical resection is the only way to make a definitive diagnosis. Since adult duplication of the stomach has malignant potential and the possibility of hemorrhage, surgical resection of the lesion should be considered as one of the treatment options, and laparoscopic surgery is a good choice.

A 67-year-old woman presented with recurrent bouts of abdominal distension and abdominal pain after the meal. An abdominal contrast-enhanced CT scan revealed a localized dilatation at the small intestine in the left upper quadrant of abdomen. Intestinal fluoroscopy demonstrated a cystic dilatation and retention of contrast material in the middle part of the small intestine. Double-balloon enteroscopy revealed dilatation of the lumen at the jejunum, but no obvious point of the obstruction was demonstrated. We performed laparoscopic-assisted partial resection of the small intestine with the preoperative diagnosis of jejunal diverticula. Based on histopathological findings, the lesion was diagnosed as jejunal duplication. Her postoperative course was uneventful and she was discharged from our hospital on the 5^th postoperative day. Abdominal distention and abdominal pain after the meal, of which she had complained before surgery, improved after the operation.

Intestinal duplications are often detected in childhood and the site involved most frequently is the ileocecal region. Jejunal duplication that is diagnosed in adults is rare. We herein report a case which had been undiagnosed with jejunal duplication, until adultfood and was treated by laparoscopic-assisted small bowel resection. Although jejunal duplication is a rare entity, it may have a malignant potential. Laparoscopic resection should be considered if the patient is preoperatively diagnosed. As having jejunal diverticulum.

An 82-year-old woman presented with abdominal pain. Abdominal contrast-enhanced computed tomography (CT) done at another hospital to investigate the cause showed a cystic mass localized within the pelvic cavity. An intraperitoneal abscess due to gastrointestinal perforation was suspected, and she was transferred to our hospital for treatment. During surgery, rather than an intrapelvic abscess due to gastrointestinal perforation, it was found that the dilated small intestine had formed a massive cystic mass. Because this mass adhered tightly to the pelvic floor, as much of the small intestine as possible was resected. Immunostaining of the postoperative samples was CD3(+), CD4(-), CD5(-), CD7(+), CD8(+), CD20(-), CD56(-), and EBER in situ hybridization (-). Small to medium-sized atypical lymphoid cells were present throughout the entire thickness of the wall, and they showed comparatively monomorphic epitheliotropic proliferation and invasion in the mucosa, leading to a diagnosis of monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL). The patient was discharged on postoperative Day 13 and underwent chemotherapy after discharge. However, she developed progressive disease 10 months postoperatively and was switched to best supportive care. She died of the original condition 12 months postoperatively.

A 68-year-old man presented with appetite loss that had persisted for 1 week. A contrast-enhanced computed tomography scan showed a mesenteric abscess of 5.5 cm in diameter in the right lower abdomen. Diagnosis of Yersinia infection was suspected, and ceftriaxone sodium was subsequently administered. However, the abscess did not shrink ; therefore, we performed a resection of the abscess with ileum on the 6th hospital day. The pus culture revealed Yersinia enterocolitica. The patient was discharged on the 9th postoperative day. In case of mesenteric abscess formation due to Yersinia, surgical treatment may be able to reduce the length of hospital stay.

The patient was a 66-year-old man who underwent resection of malignant melanoma of the nasal cavity at the Department of Otolaryngology in our hospital in June 2018. After that, he had been followed up by the Department of Otolaryngology and Head and Neck Surgery in the neighboring university hospital. He had local recurrence in the posterior nares in February 2019 and underwent endoscopic sinus surgery. Then he was treated with immunotherapy, a total of 18 courses of nivolumab as postoperative adjuvant chemotherapy. Again, recurrence of retropharyngeal lymph nodes was confirmed in November 2019 and he was converted to another immunotherapy with pembrolizumab, a total of 2 courses, followed by proton beam therapy. Then, he was referred to the Department of Gastroenterology in our hospital in June 2020 for the examination of abdominal pain and progressive anemia which occurred a month earlier. Further examination revealed an ileal tumor about 100 cm proximal to the terminal ileum, which could not be reached by the preoperative endoscope. He was diagnosed preoperatively as having a malignant tumor of the small intestine, and laparoscopic partial ileal resection plus lymph node dissection was performed in July. Postoperative pathological diagnosis was metastatic small bowel tumor of malignant melanoma. The postoperative course was uneventful. Immunotherapy with pembrolizumab was resumed and is still sustained in an outpatient setting.

A 73-year-old man had undergone right nephrectomy for right renal cell carcinoma in 2001. In 2010, he underwent partial thyroidectomy of a thyroid metastasis while undergoing postoperative chemotherapy, and in 2012, a bone metastasis in the right 6th rib was resected. Progressive melena and anemia were observed in November 2017, and small intestinal metastasis of renal cell carcinoma was diagnosed by double-balloon enteroscopy in January 2018. Partial small intestinal resection was performed the following month. Computed tomography in 2018 also showed that a small nodular shadow in the lung that had been identified in 2011, but for which a definitive diagnosis had not been made, had grown and formed multiple nodules, and this was also considered to be a lung metastasis of renal cell carcinoma. Small intestinal metastasis of renal cell carcinoma is comparatively rare, but if progressive anemia appears and gastrointestinal bleeding is suspected, then detailed examinations should be carried out with small intestinal metastasis borne in mind. Lung metastasis often appears before small intestinal metastasis, and if lung metastasis occurs, then subsequent follow-up must include monitoring for small intestinal metastasis for a certain period. This case suggests that the early detection and proactive surgical treatment of small intestinal metastasis may help prolong survival.

A 54-year-old woman with HTLV-1 infection had developed progressive myeloparalysis and dysuria, and HTLV-1-associated myelopathy was diagnosed at the age of 32 years. She had been admitted to our hospital in 2019 and treated for severe constipation since then. She was admitted to our hospital for treatment of constipation in January 2020, and she was again referred to our hospital the following May for treatment of abdominal distension and difficulty defecating. Despite medical treatment, abdominal distension due to the accumulation of large intestinal gas as a result of difficulty in defecating and passing gas recurred while she was hospitalized, and she was referred to our department for surgical treatment. Secondary megacolon caused by HTLV-1-associated myelopathy was diagnosed, and total colectomy with colostomy formation was performed. The patient's postoperative course was uneventful, and she was able to control her bowel movements without the use of laxatives or antidiarrheal medication. Preoperatively, she had limited her food consumption out of concern that eating would cause constipation, but her appetite for food improved, and her food intake increased by 40%. Surgical treatment for secondary chronic megacolon causing chronic constipation due to HTLV-1-associated myelopathy improved the patient's quality of life. Surgical therapy may be one option for the treatment of constipation in this condition.

Lower digestive tract perforation after an upper gastrointestinal series with barium swallow is extremely rare. We encountered eight such cases at our institution between 2009 and 2019. The mean age of the patients was 63 years, and the mean period to perforation after barium swallow was 2 days. The perforation site was the sigmoid colon in six cases. Of these, a history of diverticulosis was present in three patients, and two regularly consumed laxatives.

Primary anastomosis was performed in five cases. The mean length of hospital stay was 29 days, although there were no mortalities, and all patients had favorable outcomes. We found some reports with similar results when we searched the Japan Medical Abstract Society database using the keywords “barium,” “lower digestive tract perforation,” and “colon perforation.” After performing a gastrointestinal series with barium swallow, it is necessary to look out for a perforation of the lower digestive tract in a patient presenting with severe abdominal pain with a medical history of digestive organic diseases or chronic constipation.

Situs inversus totalis (SIT) is a rare anatomic anomaly, occurring once in every 3000-5000 births in Japan. A 72-year-old woman with SIT visited our hospital for the investigation of fecal occult blood. Colonoscopy revealed a type-2 tumor in the ascending colon, and the preoperative diagnosis based on the 8^th UICC TNM classification was cT3N0M0 cStage IIA. We planned a laparoscopic right colectomy procedure with medial approach. The surgery was performed using five ports. The main surgeon stood between the patient's legs, while the assistants stood on the right side of the patient as opposed to the usual positioning where they stand on the left side. The operating time was 163 min. and the blood loss was 18 g. She was discharged on the 9^th postoperative day, without postoperative complications. Histopathological examination revealed moderately differentiated adenocarcinoma, pT4bN0M0 pStage IIC. Preoperative assessment of the anatomical position and vascular malformations, using three-dimensional computed tomography, was essential for our safe surgical intervention. Furthermore, our co-axial technique and positioning the surgeon between the patient's legs enabled us to perform the procedure in the same way as a normal right-sided colectomy with a medial approach.

An 89-year-old woman was introduced to our hospital with symptoms of nausea and abdominal pain. She was performed laparoscopic Hartmann's operation for rectal cancer 4 years previously. The color of the stoma was not well slightly when the patient came to our hospital. An enhanced CT scan revealed a parastomal hernia without poor contrast area. Because the patient could not stop breathing during the examination, the images were poor, and we could not identify what the herniated digestive tract was. Therefore, the patient was admitted for follow-up. Because the symptoms did not improve and the stoma gradually became necrotic in 2 days after admission, we performed emergency operation. The content of the hernia was a jejunum 70-90 cm distal from Treitz's ligament with partial necrosis. The stoma was necrotic on the area distal from the hernia orifice. A partial resection of the jejunum, end-to-end jejuno-jejunostomy and end-transverse-colostomy (relocation) were performed. The cases of strangulated ileus and stoma necrosis due to parastomal hernia are very rare. We report on the case with a review of the literature.

A 39-year-old woman presented to our hospital with abdominal pain as the chief complaint. She had no history of abdominal surgery. A computed tomography scan revealed a mass lesion and suspected bleeding into the intestinal wall of the transverse colon, and emergency laparotomy was performed. Intraoperative findings revealed a solid mass in the splenic flexure and strong adhesions on the dorsal side of the stomach, tail of the pancreas, and hilum of the spleen. Partial resection of the stomach, tail of the pancreas, combined splenectomy, and partial resection of the colon were performed. Histopathological findings showed proliferation of spindle-shaped fibroblasts, and the image was diagnosed as a desmoid tumor. Hemorrhagic foci were observed in the tumor. Desmoid tumors that occur in patients with no history of abdominal surgery and are diagnosed by bleeding are rare. We report this unusual case together with a review of the available literature.

A 70-year-old man presented with abdominal pain and bloody stools. An abdominal computed tomography showed that the descending colon was invaginated. Intussusception resolved spontaneously, and a submucosal tumor-like lesion was found upon colonoscopic examination. We performed laparoscopic resection of the descending colon to rule out the possibility of malignancy and to prevent recurrence of intussusception. Grossly, the resected specimen revealed the presence of a 2.0×1.3×1.0 cm submucosal tumor-like lesion with a peduncle on the descending colon. Histopathological findings revealed proliferating fibrous connective tissue and small blood vessels with inflammatory cell infiltration. Neither recognizable malignant findings nor tumorous lesions were found. These findings led to the diagnosis of intussusception caused by an inflammatory fibroid polyp (IFP). He was discharged on the 7^th postoperative day.

IFP associated with intussusception of the colon is a rare condition. Here, we report such a case resected laparoscopically, along with a review of the literature.

A 57-year-old man presented with lower abdominal pain and fever. A thoracoabdominal computed tomography revealed a pulmonary abscess (S8), a liver abscess (S4) and wall thickening of the sigmoid colon. Colonoscopy revealed a type 2 tumor in the sigmoid colon. He was diagnosed as having sigmoid colon cancer, cT3N0M0 Stage IIa with the pulmonary abscess and the liver abscess. A puncture drainage of the liver abscess yielded α-streptococcus. His general condition was recovered by administration of an antibacterial agent and the percutaneous trans-hepatic abscess drainage (PTAD). Subsequently, we performed sigmoidectomy with D3 lymphadenectomy. The histopathological diagnosis was tub1, pT3N0M0 Stage IIa. He has been free from any recurrence of colon cancer and abscesses, as of 2 years after the operation.

Primary hepatic neuroendocrine tumors (PH-NETs) are rare, and preoperative diagnosis is often difficult. A 58-year-old woman was referred with a gourd-type tumor in liver S1/S4 on computed tomography (CT). The tumor had increased in size over the previous 6 years. CT showed a 7-cm-diameter tumor with a clear boundary in liver S1/S4, and the hepatic duct of the right posterior segment was slightly dilated. The patient was diagnosed with a primary malignant tumor of the liver with bile duct invasion and underwent left hepatectomy with extrahepatic bile duct resection. Tumor pathology showed cells with homogeneous nucleation with cord-alveolar structure and eosinophilic stroma. Immunostaining was negative for hepatocytes and positive for CD56 and synaptophysin. With a Ki67 index (MIB-1 index) of 5% and a cell division pattern of 3/10 on high-power field examination, the tumor was classified as NET-G2 based on the 2010 WHO classification. No primary lesions were found in any other organs, so the patient was diagnosed with a PH-NET. There has been no recurrence as of 41 weeks after surgery.

An 82-year-old female patient with a history of primary biliary cholangitis was diagnosed with transverse colon cancer and underwent laparoscopic left hemicolectomy. One year later, image inspections detected tumors with a diameter of about 15 and 10 mm in segment 3 of the liver. The preoperative diagnosis was metachronous metastasis to the liver from transverse colon cancer. S3 subsegmentectomy was then performed. Histopathological findings revealed primary malignant lymphoma of the liver (diffuse large B-cell type). The postoperative course was uneventful, and she was discharged on postoperative day fourteen. R-CVP therapy as postoperative adjuvant chemotherapy was administered in 4 courses, and there has been no indication of recurrence 18 months after the surgery.

Although primary malignant lymphoma of the liver is difficult to diagnose, in the absence of extrahepatic lesions, liver resection serves both as a diagnostic method and the treatment. It is reported that the origin of the disease is related to chronic liver disease, autoimmune diseases, and so on. There are many unclear issues regarding its onset, mechanism, and histopathological characteristics.

Therefore, further studies are needed to establish a consensus.

An 82-year-old male patient was diagnosed with a tumorous lesion in the liver during a clinical observation for chronic hepatitis B. Abdominal MRI showed a lesion in segment 8 of the liver that was enhanced in the early phase and not clearly washed out. CT during arterial portography (CTAP) revealed an area in segment 8 where portal blood flow diminished. CT hepatic arteriography (CTHA) showed early enhancement but revealed no washout in the late phase. The preoperative diagnosis was atypical hepatocellular carcinoma (HCC), and the patient underwent partial hepatectomy. Based on histopathological and immunohistochemical findings, the tumor was diagnosed as cholangiolocellular carcinoma (CoCC). Four months after the resection, a lesion in segment 7 of the liver was detected. The preoperative diagnosis was recurrence of CoCC, and the patient underwent partial hepatectomy. Histologically, the tumor showed HCC.

Sometimes CoCC and HCC developed asynchronously.

The patient was a 49-year-old man. He underwent pancreaticoduodenectomy and para-aortic lymph node dissection for a pancreatic neuroendocrine tumor with para-aortic lymph node metastases. Seven years after the operation, the patient remains alive without recurrence. According to the guideline, resection of primary and metastatic lesions is indicated for pancreatic neuroendocrine tumors with resectable distant metastases, and prolongation of life expectancy can be expected. Multidisciplinary treatment is recommended. However, there are many reports of resection of metastatic lesions in the liver and few reports of resection of pancreatic neuroendocrine tumors with para-aortic lymph node metastasis, and its long-term prognosis is not clear. A case of a pancreatic neuroendocrine tumor with para-aortic lymph node metastases suggesting that prolonged survival may be obtained by curative resection is reported.

Glycerin enema, which is widely used in daily medical service, rarely causes critical complications. A 56-year-old man, who was planned to undergo laparoscopic subtotal esophagectomy for lower thoracic esophageal cancer, had glycerin enema for pretreatment for the operation. Just after that, he felt heavy pain at his anus and had a small amount of bleeding. But the symptoms improved soon, so he was brought into the operating room. After general anesthesia was induced, a small amount of red urine was recognized by a catheter insertion for withdrawing urine. Cystoscope showed only a small amount of red urine from bilateral ureteral opening. A 5-mm shallow wound was also found at the anus on anoscopy. The operation was performed as planned because the laboratory test showed no abnormalities and there was no abnormal pattern in his vital signs. There was no urinary output during the operation, and anuria persisted after the operation. Acute renal failure was diagnosed because the serum creatinine got worse gradually. Therefore, continuous hemodiafiltration (CHDF) and haptoglobin substitution therapy were started. CHDF was done for ten days after the operation, and intermittent hemodiafiltration was also done 5 times by 20^th day after the surgery. The renal function improved gradually afterward, and he was discharged from the hospital on the 27^th postoperative day. His renal function became normal in two months from the surgery.

Acute renal failure as a serious complication of glycerin enema has not been fully understood because it occurs infrequently. We medical professions should acknowledge this possibility.

A 71-year-old man presented with a one-week history of persistent loss of appetite and vomiting. An abdominal computed tomography (CT) scan revealed a right renal cyst (measuring 14 × 13 cm) that had compressed the descending portion of the duodenum, as well as marked gastric dilation. As a result, the patient was diagnosed with duodenal obstruction caused by a giant renal cyst. Percutaneous cyst drainage and sclerotherapy consisting of intracystic injection of 200 mg minocycline hydrochloride (MINO) were performed. Subsequent abdominal CT scan performed on hospital day 7 revealed marked shrinkage of the cyst and amelioration of the compression to the descending portion of the duodenum. There was no recurrence of the intestinal obstruction after completion of the treatment, and the patient was discharged from our hospital on postoperative day 10. Patients with renal cysts are often asymptomatic and are therefore rarely treated, but treatment may be considered in symptomatic patients. Moreover, intestinal obstruction is extremely rare among symptomatic patients, and such cases have rarely been reported to date. Here, we report a case of duodenal obstruction due to a giant renal cyst that was successfully treated by percutaneous cyst drainage and sclerotherapy.

A 71-year-old woman, who had histories of undergoing surgeries for multiple cancers including endometrial cancer 14 years previously, for multiple early gastric cancer 1.5 years and for lung cancer one year previously, had been followed in our clinic. A CT scan conducted recently revealed an enlargement of a peritoneal nodule which had been there since the diagnosis of gastric cancer and a newly appeared liver tumor. Accordingly, the patient first presented to our department for consulting about further treatment guidelines. Imaging studies such as MRI and FDG-PET scans disclosed no other lesions, however, we had difficulties in making definite diagnosis whether the peritoneal nodule and the liver tumor were derived from the same disease, or whether they were metastatic lesions or not. We thus obtained informed consent from the patient and performed surgical resections of both the lesions for the diagnosis and treatment. Histopathology revealed that the lesions were metastatic recurrence of endometrial cancer.

It is extremely rare that endometrial cancer metastasizes or recurs after elapsing more than 10 years following surgery for the primary lesion. We, however, should not stick to a long lapse after surgery for the primary malignancy and keep the possibility of recurrence in mind. Literature review is also presented.

An 83-year-old man presenting with fever and swelling of the right thoracolumbar region was admitted to the department of internal medicine in our hospital. Intramuscular abscess was suspected by a computed tomography (CT) scan and he was referred to our department of surgery. After an aspiration drainage and administration of antibacterial agents, his symptoms improved but recurred 3 weeks later. We performed percutaneous drainage of the abscess. As a fish bone in the abscess was demonstrated retrospectively on CT, we removed it under spinal anesthesia. His postoperative course was uneventful. A colonoscopic examination revealed multiple diverticula in the ascending colon and localized edematous mucosa with an inflammatory polyp like lesion in the hepatic flexure. We considered that the ingested fish bone had passed through the colonic wall, migrated to the retroperitoneum further under right thoracolumbar fascia, and developed abscess. There are some cases in which a fish bone penetrated the gastrointestinal tract, but it is rare that a fish bone reached the dorsal muscle.

A 49-year-old man presented to our hospital with lower abdominal pain. Abdominal ultrasound and computed tomography showed a cystic tumor approximately 10 cm in size in the pelvic area.

T-2 weighted magnetic resonance imaging showed that the outer margin of the capsule of the mass was low, and the intertumoral area generally had a high density. Although a chronic expanding hematoma (CEH) was suspected, the possibility of a retroperitoneal tumor could not be ruled out. We performed laparoscopic surgery to excise the mass, and the patient was diagnosed with CEH by pathological examination. CEH is defined as a hematoma that develops following surgery or injury and slowly expands without natural resorption ; however, the patient had no history of these events. Most previous reports have demonstrated that CEH is generally present in the soft tissue and thoracic cavity, and only a few cases of CEH in the abdominal cavity have been reported. Herein, we report our experience of a rare intraabdominal CEH case treated with laparoscopic surgery, together with a literature review.