Purpose : There have been no reports on lymphatic leakage from surgical wound after implantation of the central venous access port (CV port) system. The purpose of this study was to predict the onset of the lymphatic leakage as well as to grasp the actual situation. Methods : We enrolled a total of 160 patients who had the CV port system implanted in our department from April 2016 to August 2020. There were 80 patients who were implanted in the anterior thoracic region (anterior thoracic group) and another 80, implanted in the upper arm (upper arm group). They were retrospectively studied as to background factors, nutrition status, and complications. Results : Lymphatic leakage after CV port implantation was observed in no case from the anterior thoracic group, while in six (7.5%) cases from the upper arm group. Dividing the upper arm group patients into 6 patients who developed lymphatic leakage and the remaining 74 who did not, we comparatively analyzed clinical factors. As a result, a significantly higher average age and lower BMI and PNI levels were noted in patients with lymphatic leakage. Lymphatic leakage conservatively disappeared in all cases, but there was a case in which more than 2 months were needed to disappear. Conclusion : We must keep in mind that there is a possibility of developing postoperative lymphatic leakage in implantation of the CV port to the upper arm. Especially, patients who are elderly and in poor nutritional status would require more careful operations for the implantation.

Perforation of the lower digestive tract is an extreme emergency ; however, its penetration might be different. Conservative therapy or scheduled operations could be performed. We studied the methods of therapy used in 22 cases of penetration of the lower digestive tract in our hospital. There were 11 cases of colon diverticulitis, seven of colon cancer, one of small intestine diverticulitis, one of iatrogenic causes, one of foreign bodies, and one of unknown causes. Five conservative therapies, three emergency operations, and 14 scheduled operations were performed. Twelve laparoscopic surgeries and three colostomies were performed. If we could make a correct diagnosis clinically and by a CT scan, minimally invasive therapies could be chosen in cases of penetration of the lower gastrointestinal tract.

Acinic cell carcinoma (AcCC) of the breast is an extremely rare invasive ductal carcinoma that demonstrates similar morphological features to that of AcCC of the salivary gland, first reported in 1996.

A 68-year-old woman presented to our hospital with a palpable mass in the left breast. Physical examination revealed an irregular mass in the lateral upper quadrant of the left breast, measuring approximately 1 cm in diameter. The tumor was identified as invasive ductal carcinoma by core needle biopsy. Computed tomography showed no other findings in the whole body, including the salivary glands, which were suspected to be malignant. The patient underwent breast-conserving surgery with sentinel lymph node biopsy.

Histopathologically, the tumor cells with oval nuclei and basophilic cytoplasm showed an infiltrating microglandular growth pattern. Immunohistochemically, the tumor cells were positive for S-100, α1-antichymotrypsin, amylase, p53, CEA, EMA, and gross cystic disease fluid protein-15 and negative for mammaglobin, ER, PgR, and HER2. Based on the above results, a diagnosis of AcCC of the breast was made.

Although the patient refused to receive postoperative chemotherapy, there were no signs of recurrence for 4 years and 7 months after surgery.

Phyllodes tumors sometimes coexist with breast carcinoma. Here we report a case of invasive lobular carcinoma with a borderline phyllodes tumor in the ipsilateral breast. The case involved a 67-year-old woman who presented with a rapidly growing mass in the right breast, which had been recognized since half a year before the first visit. A dome-shaped tumor with 7 cm in diameter was observed in the CD area of the right breast. Ultrasound examination showed a round, well defined, hypo- to isoechoic tumor with heterogenous internal echoes. Core needle biopsy revealed a benign or borderline phyllodes tumor, so we performed right total mastectomy and level I lymph node dissection. On pathological diagnosis, invasive lobular carcinoma coexisted adjacent to the borderline phyllodes tumor of 9 cm in diameter. When a phyllodes tumor is accompanied by breast carcinoma, additional treatment according to the coexisting breast carcinoma is required. In this case, level I lymph node dissection was performed at the same time, and lymph node metastasis was found to be negative. We decided that additional surgery was not required. She has been on adjuvant endocrine therapy in the same manner as breast carcinomas.

Here, we have reported a case of a 45-year-old woman with primary breast cancer. She had a tumor measuring 6 cm in her right breast and a lymph node measuring 1 cm in her right axilla, both of which were palpable. Core needle biopsy revealed the following : invasive ductal carcinoma, nuclear grade 3, ER(-), PgR(-), HER2(1+), and Ki-67 : 85%. Imaging examination revealed no distant metastasis. The patient was diagnosed with cT3N1M0 cStage IIIA breast cancer and underwent a mastectomy after neoadjuvant chemotherapy. The histological therapeutic effect was grade 1a. One month after operation, local and axillary lymph node recurrence and multiple lung metastases were observed ; hence, eribulin treatment was initiated. At the end of the first course, hypercalcemia was observed (serum Ca level : 15.3 mg/dl) ; however, contrast-enhanced CT and PET-CT examination revealed no bone metastasis. Intact PTH levels were normal (5 pg/mL), while PTHrP levels were elevated (19.5 pmol/L) ; hence, we considered that the cause was humoral hypercalcemia of malignancy (HHM). Although the serum Ca level was normalized with bisphosphonate treatment, treatment for breast cancer could not be resumed because her disease progressed rapidly and her general condition worsened.

An 80-year-old woman with lung adenocarcinoma was receiving gefitinib therapy. After 2 years, follow-up computed tomography (CT) revealed free air and diffuse intramural air in the small intestine. There were no apparent findings suggestive of intestinal necrosis and gastrointestinal perforation. The patient's condition improved with conservative therapy, including withdrawal of gefitinib therapy. A follow-up CT after 10 days showed complete resolution of free air and diffuse intramural air in the small intestine. Recently, pneumatosis cystoides intestinalis caused by gefitinib has been reported. We believe that gefitinib might have induced pneumatosis cystoides intestinalis in this case.

In our hospital, nosocomial infection of coronavirus disease 2019 (COVID-19) occurred at the beginning of April 2020. In an early time of the nosocomial infection when the situation of the infection was still unclear, we performed total gastrectomy for a patient with gastric cancer and the patient was found to have COVID-19 infection after the operation. It was likely that the infection source might be another patient who stayed in the same sickroom around the surgery. The patient sometimes developed fever after surgery and pneumonia findings were demonstrated by a chest CT scan, so that the patient was suspected to be infected with COVID-19 virus. However, the patient had not been proved to have COVID-19 infection until the third PCR testing which certified COVID-19 virus positive. The patient's clinical course was favorable after the third PCR testing, possibly because administration of favipiravir might be helpful. The patient was discharged from our hospital on the 24^th postoperative day, or on the 9^th day after the third PCR testing. When we are compelled to perform surgery in hospitals where COVID-19 nosocomial infection has occurred, the patient should be managed in the single sickroom perioperatively.

A 79-year-old man was admitted with a complaint of an abnormality of the stomach on the right side. Abdominal computed tomography showed a submucosal tumor-like lesion that developed from the antrum of the stomach with pancreatic invasion. Endoscopic examination showed type 3 gastric cancer at the posterior wall of the gastric angle. Distal gastrectomy, body of the pancreas segmental resection, and combined submucosal tumor resection ablation were performed. Histologically, the advanced gastric cancer was diagnosed as moderately differentiated tubular adenocarcinoma. The submucosal tumor-like lesion showed similar histopathological findings. Thus, the submucosal tumor-like lesion was diagnosed as an intramural metastasis of the gastric cancer. A case in which it was difficult to preoperatively diagnose intramural metastasis of gastric cancer was presented.

The histopathology of adenocarcinoma with enteroblastic differentiation (ACED) is similar to gastrointestinal epithelium in the early embryonic period, and it is defined by positive expression of alpha-feto protein (AFP), Glypican3, or SALL4. Two cases of ACED are reported along with a review of the literature.

Case 1 : An 84-year-old man presented with an elevated AFP level and anorexia during hepatitis C treatment. He was diagnosed with a type 2 tumor of the gastric body and underwent distal gastrectomy. The histopathological findings showed moderate to poorly differentiated adenocarcinoma with a clear, rosette-like tubular structure, AFP+/SALL4+, which was diagnosed as ACED. The serum AFP level returned to the normal range seven months after surgery.

Case 2 : A 76-year-old man showed a CEA increase during follow-up after hepatocellular carcinoma surgery. He was diagnosed with type 3 gastric cancer and underwent total gastrectomy. The diagnosis of ACED was confirmed on histopathology : SALL4+ columnar cells with clear endoplasmic reticulum similar to fetal gastrointestinal epithelium. He has survived more than half a year and is currently undergoing adjuvant chemotherapy.

A 72-year-old man visited our hospital because of epigastric pain. Computed tomography (CT) showed a slight amount of free air in the upper abdomen, but the epigastric pain tended to improve, and conservative treatment was started. The free air then disappeared on CT. Adenocarcinoma of the lower stomach was diagnosed by biopsy examination under gastroscopy, and perforated gastric cancer was thought to be the cause of the free air. In addition, adenocarcinoma of the lower rectum was diagnosed by biopsy examination under colonoscopy. The preoperative serum CA19-9 level was elevated at 5,525 U/ml. Distal gastrectomy, partial hepatectomy, and low anterior resection were performed. The postoperative serum CA19-9 level decreased to 488 U/ml. On immunohistochemistry, gastric cancer cells stained strongly positive for CA19-9. Based on the above, a CA19-9-producing gastric cancer was diagnosed. In addition, rectal cancer cells stained weakly positive for CA19-9.

There have been 45 reported cases of CA19-9-producing gastric cancers, including the present case, but there have been no reports of simultaneous CA19-9-producing gastric and rectal cancers, and this case is reported along with a review of the relevant literature.

Duodenal gastrointestinal stromal tumors (GISTs) are relatively rare, and the optimal surgical strategy in such cases remains unclear. Various techniques have been described for limited resection of duodenal GISTs, depending on the site and size of the tumor, and the developmental morphology. We herein report a 70-year-old man who presented with a tumorous lesion near the pancreas by an abdominal ultrasonography at a medical checkup. It was diagnosed as a GIST showing an extramural growth, involving the first portion of the duodenum by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). We employed a laparoscopic surgical technique using a retrieval bag, with which we covered the tumor, and applied tension to it to enable a safe and easy tumor resection at its base with an automatic suture device. Histopathological findings showed a low-risk GIST with a negative surgical margin. This report highlights that a use of a retrieval bag from beginning of the resection facilitates easy laparoscopic partial resection of extramural duodenal GISTs without injuring the pseudocapsule of the tumor.

A 44-year-old man who had an inborn bowel habit comprising several diarrheas with abdominal distention a day presented with a three-day history of intensifying abdominal pain and abdominal distention. On physical examination, there were spontaneous pain and tenderness in the entire abdomen with the strongest point in the lower abdomen. A blood analysis showed a rise of inflammatory reaction and an abdominal CT scan revealed small bowel mesenteric gas image and abscess formation. Consequently, emergency operation was performed with the diagnosis of perforation of the small intestine. Furthermore, the cecum was found to be in the right upper quadrant of abdomen, for that we acknowledged the presence of intestinal malrotation before surgery. Intraoperative findings included that a small intestine which appeared to be the perforated site had formed a mass and, in the proximal bowel, there were a small intestine associating with white sclerosed stricture and twisting, and multiple diverticula. We thus resected a jejunum by 150 cm in length. Histopathological studies revealed several true diverticula, some of which had abscess formation in their peripheries. From these findings, we diagnosed the case as panperitonitis due to perforation of the jejunal diverticula. Small bowel diverticulosis is a rare entity. Among of them, true diverticula infrequently occur but carry a high mortality. When we encounter a case of peritonitis in which we have great difficulties in diagnosing before surgery, it is important to consider the entity in a differential diagnosis.

A rare case of jejunal mesenteric lymphangioma involving the pancreas in a 60-year-old man is reported. A cystic lesion about 9 cm in diameter was detected by abdominal ultrasonography in the patient at the onset of colonic diverticulitis. The patient was referred to our hospital for further examination. Follow-up was initiated, since lymphangioma was suspected. Six years later, a medical check-up showed a tumor mass greater than 11 cm in diameter, and the patient was again referred to our hospital. Abdominal computed tomography showed a multilocular tumor in the right side of the abdomen. Considering the possibility that the mass might have been malignant, laparotomy was performed. The tumor was found in the mesentery of the jejunum and involved the uncinate process of the pancreas. Therefore, tumor removal with partial resection of the pancreas was performed using an automatic suturing device. The final pathological diagnosis was lymphangioma of the jejunal mesentery involving the pancreas, which is rarely observed in adults. The findings of the present case are discussed in the context of the relevant literature.

An 18-year-old man presented with pains from the epigastric region to the lower right abdomen. An abdominal contrast enhanced computed tomography revealed a huge tumor measuring 150 × 70 mm extending from the right lower quadrant of abdomen to the pelvic cavity that obtained blood flow from the superior mesenteric artery. We suspected the tumor to have derived from the ileocecal intestine or mesentery and performed surgery for the purpose of diagnostic treatment. Upon laparotomy, there was a moderate degree of bloody ascites. The tumor firmly adhered to the peritoneum, the bladder, and the ileum of approximately 30 cm in length, and it was removed by combined resection with the ileum. His postoperative course was uneventful and he was discharged on 8^th postoperative day. Histopathologically the tumor was diagnosed as Ewing's sarcoma/peripheral primitive neuroectodermal tumor (ES/pPNET) derived from the ileal mesentery. Although the tumor itself could be resected, intraoperative ascites cytology found tumor cells ; thus, the patient was referred to a higher-level medical institution to receive adjuvant chemotherapy in consideration of possible intra-abdominal micrometastasis. Fifteen months after the operation, the patient has not experienced any macroscopic recurrence. Here we report a case of ES/pPNET originating from the mesentery, because it is a very rare disease.

A 68-year-old man with a history of multiple bilateral renal cysts presented to our hospital with complaints of abdominal pain and distention. Physical examination revealed abdominal distension and tenderness in the right lower quadrant. Abdominal computed tomography revealed multiple bilateral renal cysts, a 6-cm fecal stone in the transverse colon, and distention of the proximal colon. Blood tests revealed a remarkable inflammatory reaction. Obstructive colitis due to fecal stones in the transverse colon was diagnosed, and emergency surgery was performed. Necrosis of the distended colon was noticed intraoperatively, and right hemicolectomy was performed. The patient was discharged on postoperative day 11 with no significant postoperative complications. Obstructive colitis caused by fecal stones formed in the transverse colon is very rare. Emergency surgery should be considered when blood tests reveal a remarkable inflammatory response in patients with fecal bowel obstruction.

A 43-year-old woman presented with the abrupt onset of severe abdominal pain and diarrhea. When she arrived at our hospital by ambulance, she was in a state of shock and the Hb level was 10.7 g/dl, showing anemia. An abdominal enhanced CT scan revealed a moniliform deformity at the left branch of the middle colic artery, and giant hematoma formation and ascites from the transverse mesocolon to the omental bursa. We suspected that intraabdominal hemorrhage associated with rupture of the left branch of the middle colic artery might occur and employed emergency operation. After laparoscopic surgical removal of the hematoma, the ruptured vessel branching from the left branch of the middle colic artery was treated by clipping hemostasis. The postoperative course was uneventful, and the patient was discharged from our hospital on 15^th postoperative day. An abdominal angiography after the surgery revealed moniliform deformities and multiple aneurysms not only in the left branch of the middle colic artery but also in the splenic, left colic, and sigmoid arteries. According to the clinical diagnostic criteria advocated by Uchiyama and his coworkers, we diagnosed the case as segmental arterial mediolysis (SAM). SAM is a comparatively rare entity causing intraabdominal hemorrhage due to rupture of the abdominal artery. So far only few cases of SAM performed laparoscopic surgery have been reported. From our experience with laparoscopic surgery for SAM which resulted in favorable postoperative course, we consider that laparoscopic surgery might be beneficial for SAM.

This case pertains to a 71-year-old woman who had undergone ventriculoperitoneal (V-P) shunt placement at the age of 58 years due to postoperative hydrocephalus. At the age of 63 years, the patient had undergone transverse colectomy (D3) for transverse colon cancer, but the V-P shunt was not displaced. The pathological diagnosis was pT4N2M0 stage IIIb. Eight years after surgery, a mass in the lower right abdomen was observed. Abdominal computed tomography revealed a tumor at the same area that was penetrated by the V-P shunt tube. A biopsy of the mass revealed recurrence of colon cancer. Hence, neoadjuvant chemotherapy was administered, which reduced the size of the tumor. There were no other metastatic or recurrent lesions ; thus, we resected the abdominal wall tumor containing the V-P shunt tube. A V-P shunt revision was performed. The resected specimen showed that the shunt tube penetrated the tumor. The pathological diagnosis was colon cancer metastasis. A possible cause of recurrence was implantation of cancer cells along the tube. Here, we have reported a rare case of recurrence of colorectal cancer at the abdominal wall containing a V-P shunt tube. To the best of our knowledge, no such cases have been reported in the literature.

An 82-year-old woman with advanced sigmoid colon cancer and rectal cancer underwent laparoscopic Hartmann's surgery. She developed stomal varices due to portal hypertension caused by type C liver cirrhosis four months after the colostomy. She was found to be severely anemic and underwent sclerotherapy by direct puncture twice. We performed sclerotherapy by puncturing the varices directly under ultrasound guidance and obtained a suitable hemostatic effect using an original cylindrical instrument and a balloon to block blood flow. Upon autopsy, pathological findings of stomal varices after sclerotherapy were noted.

An 83-year-old man underwent surgery for malignant lymphoma extending from the third portion of the duodenum to the upper jejunum. Tumor intestinal resection and gastrointestinal reconstruction were performed. Postoperative pancreatic fistula occurred as a complication, and a large amount of blood leaked out through the drain on the 9^th postoperative day. Emergency angiography was performed, and pseudoaneurysm formation was suspected in the arterial arcade of the pancreatic head. Coil embolization was difficult, and there were no active bleeding sites. Therefore, conservative treatment with a hemostatic infusion was performed. A large amount of bloody drainage from the drain was observed again on the 15^th postoperative day. Therefore, angiography was performed again, and pseudoaneurysm formation was more clearly observed this time. The pancreatic head artery arcade, including the pseudoaneurysm, was selectively embolized using N-butyl-2-cyanoacrylate (NBCA), and no rebleeding was observed thereafter.

This patient was elderly and had experienced two episodes of bleeding from a pseudoaneurysm, and his general condition was poor. Hemostasis by reoperation was risky due to the complication of a pancreatic fistula. Hemostasis with NBCA could be a promising treatment option for patients with poor general conditions in which coil embolization is difficult.

A case of late-onset pancreatic fistula that was related to pancreas divisum after distal pancreatectomy (DP), which was treated with trans-minor papilla and transgastric stenting, is presented. A 72-year-old woman underwent DP for cancer of the tail of the pancreas. Abdominal computed tomography showed a pancreatic pseudocyst due to a late-onset postoperative pancreatic fistula at the pancreatic stump 6 months after surgery. Endoscopic ultrasound-guided transgastric drainage was performed. The pancreas divisum was then diagnosed by endoscopic retrograde cholangiopancreatography. Considering the pancreatic fistula caused by the pancreas divisum, the patient underwent endoscopic minor papillotomy and pancreatic stenting. Following this procedure, the pancreatic pseudocyst disappeared. When pancreas divisum is diagnosed, endoscopic minor papillotomy should be considered to prevent a late-onset pancreatic fistula.

A 60-year-old woman was diagnosed with locally advanced non-resectable pancreatic cancer due to superior mesenteric vein (SMV) involvement. Invasion with SMV narrowing was detected on the peripheral side of the middle colic vein (MCV) and inferior mesenteric vein (IMV), and collateral circulation to the MCV and IMV developed. Since no collateral vein was detected during the operation, pancreaticoduodenectomy was performed without SMV reconstruction. After the operation, the patient developed chylorrhea and was discharged from hospital 34 days after surgery. A rare case of pancreaticoduodenectomy without SMV reconstruction is presented along with a review of the literature.

A 34-year-old woman presented with a bulge in the right groin that developed repeatedly for the past ten years. On presentation, a mildly tender cord-like structure was palpable in the right groin. On abdominal ultrasound, a 28-mm cystic mass was seen in the right groin. Based on the repeated change in symptoms, endometriosis with a hydrocele of the canal of Nuck was suspected, and this was diagnosed by magnetic resonance imaging during menstruation. The mass was excised via an inguinal incision, and histopathological testing confirmed the presence of endometrial and stromal components within the hydrocele. Because the patient wanted to have children, postoperative drug therapy was not administered, and as of 3 months postoperatively, there has been no recurrence.