A case of a patient diagnosed with primary hyperparathyroidism who developed a hypercalcemic crisis as a result of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and who was treated with emergency removal of the enlarged gland is presented. An 80-year-old man was admitted for investigation of obstructive jaundice. On admission, his serum Calcium was high at 11.7 mg/dL (corrected value), but it had not been investigated in detail. ERCP was performed on the day of admission, and distal bile duct carcinoma was diagnosed on the basis of cytology. On Day 2, post-ERCP pancreatitis was complicated, and conservative therapy was initiated. The pancreatitis improved rapidly, but on Day 5, hypercalcemia rapidly worsened. The patient did not respond to conservative therapy, and his serum Ca rose up to 21.9 mg/dL (corrected value). Serum intact-PTH was 647 pg/mL, and ultrasound investigation showed that the left inferior parathyroid gland was enlarged to 13.4 × 15.1 × 9.6 mm. Hypercalcemic crisis due to primary hyperparathyroidism was diagnosed, and on Day 8, emergency surgery was performed to remove the enlarged gland. His serum intact-PTH normalized within 1 hour postoperatively, and by Day 12, serum Ca improved to 10.7 mg/dL (corrected value). After his recovery, curative surgery for the distal bile duct carcinoma was performed on Day 55, but on Day 178, the patient died of peritonitis carcinomatosa.

A 54-year-old woman with right breast cancer underwent right mastectomy with axillary lymph node dissection (level II dissection). She was diagnosed with invasive ductal carcinoma, solid type (ER (-), PgR (-), HER2 (0), MIB-1 labeling index > 90%, and T2N0M0, stage IIA). Her symptoms included vomiting and numbness/weakness in her bilateral upper extremity within 4 weeks after surgery. She was referred to the Department of Neurology to check for non-surgery-related causes. She was positive for anti-Zic4 antibody and was diagnosed with myelitis due to paraneoplastic neurologic syndrome. On admission, she was initiated on steroid pulse therapy. Her neurological symptoms gradually improved, and she was discharged approximately 1 month later. Her prednisolone dosage was gradually tapered until 10 months later. She underwent adjuvant chemotherapy 5 months after mastectomy, and no recurrence or metastasis was observed 1 year later. Paraneoplastic neurological syndrome requires prompt diagnosis and treatment. In patients showing unexplained postoperative neurological symptoms, the possibility of paraneoplastic neurological syndrome should be considered.

Solid papillary carcinoma (SPC) is a rare histological type of breast cancer, accounting for only one percent of all breast cancer, and it occurs primarily in women over 70 years of age. We report a case of breast SPC in a 40-year-old premenopausal woman. The patient came to our hospital for re-examination of a tumor in her left breast. On palpation, it was a 5 × 4 mm tumor. It was suspicious of malignancy on imaging, so we did a core needle biopsy on it. A diagnosis of invasive ductal carcinoma (IDC) with neuroendocrine features. We performed partial mastectomy of the patient's left breast and sentinel lymph node biopsy. The tumor was diagnosed as IDC, SPC with neuroendocrine differentiation and pT1a (2 mm) NOMO pStage I by histopathological analysis.

Superior mesenteric artery (SMA) syndrome is a disease resulting from compression of the third portion of the duodenum between the abdominal aorta and the SMA, and presenting with small bowel obstruction. Conservative treatment is the first-choice treatment strategy, but if it fails, surgical treatment is selected. There are several surgical approaches for SMA syndrome and duodenojejunostomy is one of the most common. In recent years, laparoscopic surgery has been performed because it is minimally invasive, and single-incision method is acquiring increasing interest. An 86-year-old man with SMA syndrome did not respond to conservative treatment and we performed single-incision laparoscopy-assisted duodenojejunostomy. By confirming the position of the third portion of duodenum by preoperative CT and opening the abdomen at the same level, it was possible to perform flexible operation under laparoscope and the anastomosis, which is the most important stage in this procedure, under direct vision. This approach is useful because it enables us to perform more secure and stable anastomosis than the conventional laparoscopic procedures due to the direct visualization.

A 39-year-old man presented with epigastralgia and vomiting. We diagnosed the case as acute gastroenteritis and initiated conservative therapy, however, his symptoms became worse. An abdominal CT scan conducted on the 2^nd hospital day revealed a suspected diagnosis of perforation of Meckel's diverticulum associated with enterolith and so we performed an emergency operation. Laparoscopic observation of the peritoneal cavity showed collection of cloudy ascites and adhesions of the small intestine to the surrounding tissues. After dissection of the adhesions, the small bowel was mobilized outside of the body, when we confirmed a perforated diverticulum on the antimesenteric side of the small bowel locating about 100 cm proximal to the ileocecal valve. It appeared to be the Meckel's diverticulum. As the diverticulum was 4 cm in diameter and inflammation was also found to have infiltrated into the small intestine, we performed partial resection of the small intestine including the diverticulum. Histopathology revealed that ectopic tissues were absent in the diverticulum membrane but two enteroliths about 2 cm in diameter were present within the resected diverticulum. As a result of components analysis of the enteroliths, they were found to be calcium oxalate calculus Since perforated Meckel's diverticulum associated with true enteroliths has rarely been reported, we present our case with some bibliographic comments.

A 76-year-old man was admitted to our hospital with a chief complaint of abdominal pain. Computed tomography showed gastrointestinal perforation, so emergency surgery was performed. During the procedure, it was noted that there were two perforation points at the ileum, 50 cm from the ileocecal valve, and many ring-shaped white spots allover the small intestine. The ileocecal region, including the perforation, was resected and functional end-to-end anastomosis was performed. Pathological examination revealed amyloid deposits in the submucosal and proper muscle layers, and immunohistochemical staining showed AL amyloidosis. The patient was finally diagnosed with primary regional gastrointestinal amyloidosis. He was discharged 25 days after the emergency surgery without any complications in the postoperative clinical course. The perioperative mortality rate of gastrointestinal perforation due to amyloidosis is high because of immunodeficiency and organ dysfunction. Only four cases of perforation of the small intestine due to primary gastrointestinal amyloidosis have been reported in Japan, and these reports suggest that the condition might have a good prognosis due to the low incidence of anastomotic leakage.

Case 1 involved a 48-year-old man who had received three operations (once for intestinal invagination and twice for bowel obstruction) in his childhood. He developed enterocutaneous fistula (ECF) at operative scar in the right lower abdomen when he was 47 years old. Operation was scheduled after unsuccessful conservative therapy for 1.5 years. Laparotomy revealed ECF in a dilated blind loop that was formed with side-to-side anastomosis of the small intestine. Resection of the blind loop and end-to-end anastomosis were performed, and his postoperative course was uneventful. Case 2 involved a 65-year-old woman who had received three operations (for appendicitis, uterine myoma, and bowel obstruction). She developed ECF at median post-operative scar in the lower abdomen when she was 64 years old. Exploration in the former hospital was disengaged due to extensive adhesions. After the failure of conservative therapy in our hospital, 1 year from the onset of the disease, operation was performed. The operative findings and the surgical procedure in case 2 were similar to case 1. For the ECF patient with history of undergoing operation for bowel obstruction, blind loop syndrome should be considered in the differential diagnosis. Early operation should be applied for these patients because conservative therapy is often unsuccessful.

Strangulated intestinal obstruction accompanied by chylous ascites is extremely rare. We report two cases of this rare clinical condition.

Case 1 : A 98-year-old man with a history of surgery for rectal cancer and strangulated intestinal obstruction was transferred to our hospital as an emergency for evaluation of right-sided abdominal pain and vomiting. He underwent emergency laparotomy and was diagnosed with strangulated intestinal obstruction. We identified a band on the cranial umbilicus, and a segment of the small intestine measuring approximately 80 cm in length was strangulated. The lymph stands out as white vessels on the serous surface and mesentery of the strangulated intestinal tract, and we observed odorless, pinkish-white turbid ascites in the surrounding area.

Case 2 : An 89-year-old man visited our hospital for evaluation of nausea and poor food intake over several days prior to presentation. He underwent emergency laparotomy and was diagnosed with strangulated intestinal obstruction. The entire small intestine on the anal aspect extending from the Treitz ligament was twisted counterclockwise by about 360° and was strangulated. The mesentery appeared partly white in color with prominent lymphatic vessels, and we observed a large amount of odorless, yellowish-white turbid ascites. The affected intestinal segments did not appear necrotic in both patients ; therefore, the operation was completed without intestinal resection, and both patients showed an uneventful postoperative course.

The case was a 61-year-old woman. She had repeated abdominal pain and vomiting since infancy, and sometimes developed acute renal failure and was hospitalized. Although intestinal malrotation was identified in her 20s, she had not had surgery. However, in recent years, she had been repeatedly admitted to and discharged from the Department of Gastroenterology at our hospital with the diagnosis of intestinal obstruction, and she was referred to the Department of Gastrointestinal Surgery. Preoperative investigation showed intestinal malrotation, which was classified as incomplete rotation type. She underwent elective laparoscopic surgery. The cord-like tissue in front of the duodenal-jejunal junction was dissected, and the 180-degree clockwise twist around the superior mesenteric artery of the small intestine was released (Ladd surgery). She had transient intestinal obstruction symptoms in the early postoperative period, but about 1 year has passed since then without relapse of the symptoms. When the reports of adult intestinal malrotation in Japan were collected, in the case of incomplete rotation type, the rate of symptoms was significantly higher with intestinal malrotation than with the non-rotation type. The rate of Ladd surgery, such as dissection of the Ladd ligament and release of axial twist, was also significantly higher.

A 36-year-old woman presented with a one-month history of watery diarrhea and periumbilical pain, and abdominal contrast-enhanced computed tomography (CT) showed wall thickening and intussusception at several sites in the small intestine. Bowel intussusception associated with multiple small bowel tumors was diagnosed, and emergency surgery was performed. Laparoscopic observation showed intussuscepted bowel with a black tumor as the presenting part, and a total of 5 tumors in the small intestine as a whole, including this one, were resected. The postoperative course was uneventful, and the patient was discharged on Day 8. Histopathological investigations led to a diagnosis of malignant melanoma, and since sacral, iliac, and multiple lung metastases were observed on PET-CT, chemotherapy with dacarbazine was started at another hospital. Primary gastrointestinal malignant melanoma is infrequent, accounting for 1.4%-1.8% of all malignant melanomas, and its primary occurrence in the small intestine is extremely rare. In the present case, systemic metastases were already present at the time of diagnosis, and the primary site was unknown, but the diagnosis of metastasis was considered appropriate. In most cases, the prognosis is hopeless, but it was considered that the laparoscopic total resection of tumors that may cause bowel intussusception, hematochezia or perforation, and the immediate postoperative start of chemotherapy were both extremely helpful.

A 41-year-old woman presented to the emergency clinic in our hospital because of a two-day history of intensifying epigastralgia, and she was diagnosed with intussusception caused by tumor of the transverse colon by an abdominal plain CT scan. As she had severe abdominal pain associated with peritoneal irritation symptoms, we peformed an emergency surgery. Operative findings showed the presence of intussusception caused by a tumor of the transverse colon. The colonic intussusception was easily reduced with Hutchinson's maneuver and no blood flow disturbance was seen in the colon. We performed partial resection of the transverse colon to excise the specimen and confirmed it to be submucosal tumor.

Consequently, we completed the surgery without performing additional lymph node dissection. The histopathological diagnosis was cystic lymphangioma. Her postoperative course was uneventful. She was discharged from our hospital on the 7^th postoperative day.

A 70-year-old man presented to our hospital with abdominal fullness. Severe stenosis of the sigmoid colon and a dilated colon were confirmed using abdominal computed tomography. The cause of the obstruction was unclear. Transverse colostomy was performed. Three months after the surgery, a colovesicocutaneous fistula formed. We considered colon cancer ; however, colonoscopy in our hospital showed several diverticula in the sigmoid colon and no malignancy. We diagnosed a colovesicocutaneous fistula secondary to sigmoid colon diverticulitis and performed high anterior resection and partial cystectomy with fistulotomy. The pathological diagnosis was diverticulosis, and there was no malignancy. We encountered a case of colovesicocutaneous fistula due to diverticulosis that required differentiation from cancer.

A 72-year-old woman presented with tarry stool and left lower-quadrant pain. An abdominal contrast-enhanced CT scan revealed multiple diverticula arisen in the sigmoid colon ; from where an area of hyper absorption continuously extended to the left uterine adnexa ; and an area of low absorption and extraintestinal gas were associated in the inner part. We diagnosed the case as penetration of the sigmoid colon to the uterine adnexa secondary to diverticulitis, with abscess formation, and initiated conservative therapy. However, a CT scan showed persisting extraintestinal gas and abscess formation, and so partial sigmoidectomy and resection of the left uterine adnexa were performed. Histopathology revealed rupture of pseudodiverticulum and infiltration of inflammatory cells mainly in the subserous structure of the sigmoid colon ; and there were abscess formation composed of accumulation of neutrophiles and foreign-body type multinucleated giant cells in the left ovary. Her postoperative course was uneventful and she was discharged from our hospital on the 16^th postoperative day.

We have experienced a case of sigmoid diverticulitis penetrating the left uterine adnexa to cause an ovarian abscess. Since the case is considered very rare, we present the case together with some bibliographic comments.

There are many surgical reports of rectal cancer invading the surrounding organs such as the vagina, uterus, bladder, and sacrum, but we have found no previous reports of surgery for rectal cancer in a patient with external genital malformation in Japan. A 50-year-old woman with sex chromosome abnormalities and external genital malformation presented with a type 2 tumor with vaginal invasion in the lower rectum. The tumor was large and had extensive invasion, so the patient underwent neoadjuvant chemotherapy followed by radical surgery. When deciding on the surgical procedures, consideration was given to the urinary and sexual functions because she had the external genital malformation and hypoplastic internal genitalia. With careful preoperative examination and investigation, we were able to safely perform laparoscopic rectal resection with resection of the posterior wall of the vagina in a woman with external genital malformation. Since rectal cancer with vaginal invasion in women with external genital malformations is rare, we report this case with some discussion.

The patient was a 37-year-old woman who was found to have a 42-mm mass in the liver S6 in a CT scan for preoperative scrutiny of breast cancer. Although there was a possibility of liver metastasis from breast cancer, it was difficult to make a definitive diagnosis by imaging tests, so a percutaneous transhepatic tumor biopsy was performed. As a result of the biopsy, epithelioid hemangioendothelioma (EHE) was suspected, and a laparoscopic partial hepatic S6 resection was performed after breast cancer surgery. No postoperative complications occurred, and the patient was discharged on 9th postoperative day. Follow-up studies conducted so far revealed no recurrence of EHE. Since this is a rare case of laparoscopic resection of hepatic EHE, we report this case with some literature discussion.

A 72-year-old man was diagnosed with aplastic anemia in his thirties and thereafter had received a periodic blood transfusion. A liver mass in the lateral segment was incidentally pointed out by a plain computed tomography (CT). Contrast-enhanced CT could not be performed due to his allergy to contrast media. He was diagnosed with hepatocellular carcinoma (HCC) by a liver biopsy. In this case, we considered the surgical risk to be extremely high due to severe pancytopenia. This patient could not be a candidate for radiofrequency ablation and hepatic artery embolization because the maximum tumor diameter was 3.0 cm and he was allergic to contrast media. After discussions with hematology and gastroenterology professions, we decided to perform laparoscopic lateral hepatectomy after a planned platelet transfusion. The patient was discharged home from the hospital after the surgery without major complications. The patient has had good postoperative course with no evidence of recurrence as of 16 months after the operation. The patients with HCC with aplastic anemia can pose some perioperative problems such as anemia, bleeding tendency, and susceptibility to infection. However, they can be treated by appropriate perioperative management in cooperation with related departments and reduction of the bleeding risk by selecting laparoscopic hepatectomy.

A 19-year-old woman developed epigastric pain in the 24th week of gestation with twins, and since magnetic resonance imaging (MRI) showed a massive cyst in the hepatic hilum and an enlarged gallbladder, she was referred to our hospital. Magnetic resonance cholangiopancreatography (MRCP) showed that the massive cyst was the common bile duct. Pancreatography was also obtained by bile duct contrast during endoscopic retrograde cholangiopancreatography (ERCP), and a Pancreaticobiliary maljunction was identified. From these findings, Todani type Ia congenital biliary dilatation, with localized dilatation of the extrahepatic bile duct, and a pancreaticobiliary maljunction was diagnosed.

Percutaneous transhepatic biliary drainage (PTBD) was done are cesarean section was planned after 37weeks' gestation, when the fetuses could be safely delivered, followed by dilated bile duct resection with reconstruction after the mother's recovery. However, the twins showed fetal growth restriction and were delivered at 27 weeks by emergency cesarean section, and expected operation were conducted 6 weeks later. The patient's postoperative course was uneventful, and she was discharged on postoperative Day 7.

A 56-year-old man presented with epigastric pain. A computed tomography (CT) demonstrated a highly enhanced nodular lesion about 10 mm in diameter in the middle of extrahepatic bile duct. We diagnosed him with extrahepatic bile duct carcinoma and performed bile duct resection and choledochojejunostomy. Histopathological examination showed a G1 clear cell neuroendocrine tumor (clear cell NET) in the deep part with co-existent adenocarcinoma of the bile duct in the surface part. Since the each component accounted for more than 30% of the tumor, the final diagnosis was mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) with a mixed G1 clear cell NET and adenocarcinoma. Although partial invasion to the surrounding fatty tissue was seen, no horizontal extension was present and surgical margins were negative on both liver and duodenal sides. Radical resection could be done. In a literature review, there were a few reports of MiNEN composed of NET G1 and adenocarcinoma, however, co-existent G1 clear cell NET and adenocarcinoma in the bile duct is very rare.

Jaundice is a typical first symptom of duodenal papillary carcinoma and there has been no previously reported case of duodenal stenosis as its initial manifestation. Here the rare case of a patient with duodenal papillary carcinoma who presented with duodenal stenosis is reported. A 57-year-old woman was referred to our hospital with vomiting, and routine examination showed no evidence of malignancy. However, she came back and was eventually admitted with complete duodenal obstruction. Abdominal contrast-enhanced computed tomography (CT) showed thickening of the duodenal submucosa and stenosis of its descending portion. The bile duct and main pancreatic duct were not dilated. Malignancy was not definitively diagnosed, gastrojejunal bypass was performed for the duodenal obstruction. Two months after surgery, however, she was readmitted with obstructive jaundice. Multiple biopsies and bile cytology still showed no evidence of malignancy, but since the possibiliry of a malignant tumor could not be excluded, subtotal stomach-preserving pancreatoduodenectomy was performed. Postoperative histopathological diagnosis revealed highly differentiated adenocarcinoma located mainly in the ampullary bile duct, and from the findings of the immunostaining results, ampullary cholangiocarcinoma was diagnosed.

A 53-year-old man was diagnosed with intrapapillary mucinous neoplasms at the pancreas head concomitant with circumportal pancreas and celiac artery stenosis. Pancreatic juice cytology showed class IV, and subtotal stomach-preserving pancreaticoduodenectomy was performed. Intraoperatively, the median arcuate ligament around the celiac artery was divided, and we confirmed that the blood flow from the celiac artery to the hepatic artery was preserved by clamping of the pancreatic arcade. The main pancreatic duct passed posterior to the portal vein. In considering reconstruction, the pancreas was first transected at the distal side of the circumportal pancreas, and subsequently divided again above the portal vein. This procedure made it possible to execute the usual pancreatojejunostomy. The diagnosis was intraductal papillary mucinous adenocarcinoma of pancreas. Postoperatively, pancreatic fistula developed but improved with conservative management. When pancreaticoduodenectomy is performed, it is important to recognize anatomical variants such as circumportal pancreas and celiac artery stenosis preoperatively and to consider appropriate reconstruction procedure to prevent postoperative complications.

In recent years, various names have been used for cystic lesions that cannot be classified as pancreatic cystic lesions, such as mucinous cystic neoplasm and intraductal papillary mucinous neoplasm (IPMN). At the Baltimore consensus meeting held in 2014, the name simple mucinous cyst was proposed for cystic lesions of 1 cm or more covered with simple squamous epithelium without ovarian-like stroma. The case was a 74-year-old man who had been followed up with cystic lesions in the body and tail of the pancreas since 2012. The cyst diameter increased gradually, with nodular wall thickening inside the cyst. Therefore, he was referred to our department for the purpose of surgical treatment. Distal pancreatectomy with splenectomy was performed for a preoperative diagnosis of branch-type IPMN. Histopathological findings showed no ovarian-like stroma or papillary growth of epithelium, and the columnar epithelium was poorly atypical. The case was diagnosed as a recently reported simple mucinous cyst.

A woman was referred to our hospital for evaluation of thrombocytopenia (platelet count 24,000/μl). She had no history of thrombotic events or morbidity in pregnancy. Idiopathic thrombocytopenic purpura (ITP) was diagnosed after ruling out other potential causes of thrombocytopenia. She showed a prolonged activated partial thromboplastin time (APTT) and elevated serum levels of lupus anticoagulant (LA) and was considered an asymptomatic antiphospholipid antibody carrier (aaPL carrier). Since her thrombocytopenia was considered refractory to standard treatment for ITP, splenectomy was performed 17 months after its diagnosis. Eight days after splenectomy, the platelet count increased up to the normal range. Heparinization to prevent thrombosis due to the aaPL carrier state was performed throughout the perioperative period. One month after splenectomy, antiplatelet therapy using aspirin was started because of high D-dimer value. Twenty-three months after splenectomy, the APTT and LA levels improved to the normal range. In the present case, the improvement of the LA level and the platelet count accomplished were supposed to be which would adjust a common immunological imbalance between ITP and the aaPL carrier state.

The patient was a 19-year-old woman. She had developed an inguinal swelling on the left associated with pain two years prior to this admission, but the symptoms had improved spontaneously. The symptoms recurred and the patient visited our department whith a history of pain for six days. Physical examination revealed a tender mass in the left inguinal region. Abdominal ultrasonography and computed tomography revealed an incarcerated inguinal hernia of the ovary. Manual reduction was difficult, and emergency laparoscopic radical hernia repair was performed. Intraoperative findings showed that the ovary was incarcerated in the left internal inguinal ring, so the peritoneum around the internal inguinal ring was dissected to relieve the incarceration. The patient was diagnosed with a sliding hernia of the ovary, the peritoneal incision was repaired, and the internal inguinal ring was sutured. Laparoscopic surgery can accurately diagnose, reduce, and repair the hernia orifice, and it is considered to be a useful and safe treatment, especially considering the fertility issues associated with sliding hernia of the ovary in adolescents and young women.

This is a case of an 83-year-old man with a history of hypertension and type 2 diabetes mellitus who presented with right-sided back pain that had been persisting for 10 days before visiting the primary clinic. At the clinic, a hard mass was found in the thoracolumbar area, and exploratory puncture showed no purulent components. Cefcapene pivoxil hydrochloride hydrate was administered for 7 days, but the pain did not improve ; hence, he was transferred to our hospital. We observed a 60-mm hard, reddish mass ; the patient had a normal white blood cell count and C-reactive protein level and an elevated HbA1c value (8.2%). Ultrasonography, computed tomography, and magnetic resonance imaging showed an irregular lesion located from the subcutaneous layer to the peritoneum, suggesting both a malignant tumor and abscess. Percutaneous drainage was performed, and actinomycosis was diagnosed using biopsy specimens obtained from the mass wall and pus. Amoxicillin/clavulanic acid was administered for 6 months since the day of drainage. Therefore, clinicians should consider the possibility of actinomycosis in cases of a chronic suppurative lesion.

Myxofibrosarcoma (MFS), one of the soft tissue tumors, occurs frequently in the limbs. Herein, we report a rare case of MFS that arose from the abdominal wall. The patient was an 89-year-old man referred to our department due to a swelling in his left inguinal region. Radiological image examinations revealed that he had an unequally contrast-enhanced mass of approximately 6 cm in diameter beneath the left side of the rectus abdominis muscle. The plan was to surgically resect the mass, and the preoperative diagnosis was an abdominal desmoid tumor. Perioperatively, an elastic soft multinodular mass was found located between the anterior and posterior sheaths of the rectus abdominis muscle. The tumor was anchored firmly to the pubic bone ; thus, it was resected along with part of the pubic periosteum. The cut surface of the resected tumor looked lobulated, and it consisted of mucous components separated by fibrous tissues. Microscopic analysis revealed proliferating histiocyte-like cells with severe atypia in the tumor, leading to a final diagnosis of MFS. In the Japanese literature, only five cases of MFS arising from the abdominal wall have been reported, and in this case, it was difficult to make the precise diagnosis of MFS before surgery.