Among women with primary breast cancer of cTis/1/2, N0, having no preoperative chemotherapy, undergoing breast-conserving surgery and receiving whole breast irradiation and adjuvant systemic therapy, axillary lymph node dissection can be omitted for 1 or 2 sentinel lymph nodes metastasis cases. In our hospital, we omit the intraoperative frozen-section diagnosis of sentinel lymph node (SLN) in these cases. In this study, we compared for the operation time, hospitalization period, and number of reoperations between the omitted group and the control group.

In those criteria, the omitted group comprised 68 patients without the intraoperative frozen-section diagnosis from January 2018 to July 2019, and the control group comprised another 68 patients with the intraoperative frozen-section diagnosis from February 2017 to January 2018. We compared those groups.

As a result, the median operation time was 65 minutes (32-112) in the omitted group and 82 minutes (35-146) in the control group, with a statistically significant difference. There was no difference in the median hospitalization period of 2 days. There were no cases of reoperation.

Omitting the intraoperative frozen-section diagnosis significantly shortened the operation time, and no case of reoperation was observed.

In this study, we aimed to clarify the clinical features of gastric neuroendocrine neoplasms (NENs).

We retrospectively analyzed clinicopathological parameters and clinical outcomes of a total of 12 patients treated with the diagnosis of gastric NEN in Hokkaido University Hospital from November 2016 to April 2020.

Of the 12 patients with gastric NEN, ten had neuroendocrine tumor (NET) and two had neuroendocrine cancer (NEC). Of 10 NET patients, six had Rindi type I, two had Rindi type II, and two had Rindi type III. There were eight hypergastrinemia patients. As to treatments selected by the Rindi classification, type I patients underwent total gastrectomy (n=1), distal gastrectomy (n=1), partial resection (n=2), endoscopic dissection (n=1) and observation (n=1), and all six have been alive with no recurrence. One type II patient has been kept in observation for other diseases, and another one is undergoing a somatostain analog for unresectable liver metastases. The both type III patients underwent partial resection and proximal gastrectomy with no recurrence. One NEC patient died for sepsis and another one selected palliative therapy. In conclusion, we should decide the treatment of gastric NENs, which manifest in a variety of pathologic conditions, according to the Rindi classification.

Early diagnosis and treatment for acute appendicitis during pregnancy are important, because perforated appendicitis increases the risk of early delivery and fetal death. However, there is a limit to accurate diagnosis of acute appendicitis during pregnancy by ultrasound sonography (US). Computed tomography (CT) yields a high diagnostic rate and accuracy with suspected appendicitis, but radiation exposure to the fetus is deeply concerning. Useful preoperative imaging, operative morbidity, and fetal outcomes were investigated retrospectively in a total of 11 patients who underwent appendectomy during pregnancy from April 2012 to February 2021 in our hospital. The definite diagnosis of appendicitis was made by US in only two patients. All of the remaining nine patients were diagnosed as having appendicitis by CT. All patients underwent appendectomy. Perforation of the appendix was evident in one patient, and postoperative complications were seen in two patients. Neither early delivery nor fetal death related to acute appendicitis during pregnancy occurred in any of the patients. In conclusion, when US diagnosis is inconclusive for suspected appendicitis during pregnancy, CT examination should be considered, understanding both its risks and benefits.

The case involved a 19-year-old woman who had been diagnosed with X-linked dominant hypophosphatemic rickets at the age of one year, and then treatment with activated vitamin D3 derivative and phosphorus preparation was started. Five years before, the high serum Ca and the elevated parathyroid hormone (PTH)-intact levels were noted, and she was referred to our hospital with the diagnosis of tertiary hyperparathyroidism. At surgery, we removed the left superior parathyroid gland which was the swollen gland, that disclosed another lesion suggestive of the left inferior parathyroid gland in the tail side. We resected both lesions and diagnosed them as the parathyroid glans in accordance with intraoperative frozen section diagnosis. The two glands were diagnosed as hyperplasia of the parathyroid gland. After the operation, the elevated serum Ca and PTH-intact levels dropped within normal ranges. A long-term administration of phosphorus preparations can cause hyperparathyroidism during a long course of the treatment. The pathologic condition where the parathyroid gland keeps the autonomy and irreversibly secretes excessive PTH is called tertiary hyperparathyroidism. The therapies for the condition include parathyroidectomy. Although the condition is often associated with hyperplasia of several glands, our patient could be cured by removal of the swollen gland by one-side exploration. We need to consider the patient's background factors, to employ surgical indication carefully, and to search for appropriate surgical procedure.

The patient was a 38-year-old woman who had been diagnosed with Prader-Willi syndrome (PWS) in infancy. A screening ultrasonography showed a nodular lesion in the right lobe of the thyroid gland, and the patient was referred to our department for further examination and treatment. As a result of a thorough examination, its lesion was strongly suspected to be malignant, and we decided to perform surgery. Because of a delay in mental development, the patient sometimes became agitated, and it was difficult to induce general anesthesia. The patient underwent surgery to remove the right lobe and isthmus of the thyroid gland, followed by additional cervical lymph node dissection due to the diagnosis of papillary thyroid cancer by intraoperative diagnosis. Preoperative CT scan showed no enlarged cervical lymph nodes, but nine microscopic metastatic lymph nodes were found. As of two years and nine months after the surgery, no apparent recurrence has been observed. There are very few reports of malignant neoplasms in PWS patients, and this is the first report of papillary thyroid carcinoma with PWS in Japan.

Phyllodes tumors of the breast are rare, accounting for 0.3-0.9% of primary breast tumors, of which up to 16-30% are malignant.

A 47-year-old woman underwent right mastectomy, latissimus dorsi myocutaneous flap, and split-thickness skin graft for a 35-cm tumor in the right breast. The resected specimen weighed 7.9 kg ; the postoperative pathological diagnosis was a borderline phyllodes tumor. Six months postoperatively, contrast-enhanced computed tomography showed a mass shadow in the lung. Thoracoscopic partial resection of the left lung was then performed for establishing a diagnosis and initiating treatment. Upon specimen reevaluation at the time of metastasis, its features were found to be consistent with those of malignant phyllodes tumors, hence the revision of the diagnosis. Subsequently, rapidly growing tumors developed in the right atrium and paranasal sinuses and were clinically evaluated as systemic metastases of the malignant phyllodes tumor. We present a rare case of a phyllodes tumor metastasizing to the nasal cavity.

To conclude, this was reported as a rare case of a giant phyllodes tumor of the breast with pulmonary, atrial, and nasal metastases.

Nipple-sparing mastectomy (NSM) has increasingly been employed as a procedure that provides an excellent cosmetic benefit. However, it generally presupposes breast reconstruction. Herein, we report four patients with breast cancer who underwent NSM with omission of primary breast reconstruction between August 2008 and November 2010. Their mean age was 52 years, and their mammograms revealed calcification and extensive foci. A peri-areolar with lateral extension incision was performed in all the patients, whereas intraoperative frozen section diagnosis of the surgical margin on the nipple side was performed in three patients. The final pathological diagnosis was invasive ductal carcinoma in two patients and ductal carcinoma in situ (DCIS) in the other two patients. The margin on the nipple side of two of the four patients were also found to be histologically positive. Postoperative complications, including nipple necrosis and infection, were not observed. The postoperative level of satisfaction was high in all the patients, since they did not feel a sense of breast loss. There was one case of nipple recurrence during a follow-up period of ≥10 years, which resolved with local resection without relapse. Therefore, NSM without primary breast reconstruction can be a treatment option for selected cases, including extensive DCIS.

A 63-year-old man presented to our hospital because of an abnormal shadow in a chest radiograph at a medical examination. A chest CT scan showed a nodule of ϕ13 mm in the periphery of the lower right lobe. A chest MRI was performed, because a follow-up chest CT scan revealed the tumor to have grown to 18 mm in diameter, and mucus-producing adenocarcinoma was suspected. On the chest MRI, adenoid cystic carcinoma was suspected and surgery was performed. It was difficult to diagnose by intraoperative cytology, and the possibility of lung malignancy could not be ruled out. Therefore, intraoperative pathological diagnosis was performed, and adenoid cystic carcinoma, was diagnosed. Video-assisted thoracoscopic right lower lobectomy was performed. Adenoid cystic carcinoma arisen in the peripheral lung is very rare. In this case, a mucus producing tumor was suspected by chest CT and adenoid cystic carcinoma, by chest MRI. We report this case of adenoid cystic carcinoma in the peripheral lung for which MRI was useful for diagnosis.

An 83-year-old man was found having a nodule in the left lower lobe of the lung during the examination of appetite loss. Computed tomography (CT)-guided lung biopsy revealed non-small cell carcinoma, and the clinical stage was IIIB from PET-CT findings. Pre-treatment examination showed leukocytopenia (the WBC count of 1,200/μL) and coagulation disorder (the PT-INR of 5.16 and the APTT of 107 seconds). He was diagnosed with systemic lupus erythematosus (SLE) with increases of antinuclear antibody to 5,120 times and anti-DNA antibody to 9.9 IU/ml. No clinical symptoms of SLE such as butterfly rush, arthralgia, renal impairment were observed. Coagulation disorder was relieved with Vitamin K, but leukocytopenia was not improved despite steroid treatment. A chest CT scan one month after the treatment revealed a growth of the lung tumor and reduction of mediastinal lymph nodes, therefore we performed partial resection of left lower lobe of the lung. The pathological diagnosis was combined large cell neuroendocrine carcinoma. After the resection of the tumor, leukocytopenia was improved, and we stopped steroid medication. Neither lung cancer nor systemic lupus erythematosus recurred, but four months after the surgery he was found at home with the state of cardiopulmonary arrest. This case may suggest that SLE can be a paraneoplastic syndrome of lung cancer.

A 57-year-old woman with a medical history of undergoing Stanford type B acute aortic dissection 11 months before presented with hematemesis. A computed tomography (CT) scan revealed an aortic arch aneurysm, and she was diagnosed with aortoesophageal fistula (AEF). Then, thoracic endovascular aortic repair (TEVAR) was emergently performed, and it was successful in gaining stable hemodynamics. After the infection subsided, we performed three-staged esophageal reconstruction for a radical cure. She became able to eat, and she was discharged home from our hospital. In addition to bleeding due to fistula between the aorta and the esophagus, infection of the aortic wall is the main symptom of AEF. Esophagectomy, removal of infected arterial tissue, and revascularization with artificial blood vessel are necessary as radical treatments. There are reports describing that the post-operative mortality rate is 3.1% and the in-hospital mortality rate is 18.8%. AEF is still a disease with a not-so-high lifesaving rate. We report a case of AEF treated with three-staged esophageal reconstruction to reduce surgical invasion after TEVAR along with some literature reviews.

A 68-year-old woman had a screening for stomach cancer and was found having a gastric submucosal tumor with a central depression in the upper body in May 2018. She was referred to our hospital for further examination and was diagnosed with synovial sarcoma by an endoscopic biopsy. PET-CT examination demonstrated an abnormally high uptake of FDG in the stomach. No other abnormal uptake indicating metastasis, was observed. Therefore, we diagnosed her case as primary gastric synovial sarcoma and decided to conduct laparoscopic partial gastrectomy. We performed intraoperative endoscopy to identify the location of the tumor, followed by partial gastrectomy with a 2-cm margin of excision and nearby lymph node sampling. The resected specimen showed a tumor with the major axis of 9 mm, ill defined, and mainly positioned in the submucosa, in which bundled growth of spindle-shaped tumor cells was observed. Tumor cells were positive for cytokeratin, EMA, and bcl-2 by immunohistochemical examination. And we observed split signal by the FISH method using the SS18 probe. No other lesions were found, and the patient was diagnosed with primary gastric synovial sarcoma. No local or distant recurrence has occurred as of two years and 6 months after the operation. Primary gastric synovial sarcoma is a very uncommon neoplasia.

An 80-year-old man with performance status (PS) 0 who presented with hyperthermia, abdominal pain, and abnormal liver function following a blood examination was diagnosed with type 3 gastric cancer and obstructive cholangitis caused by giant tumor thrombus in the portal vein with obstruction. Biopsy of the gastric tumor yielded a diagnosis of papillary adenocarcinoma with HER2-positive expression. After treatment of cholangitis, he received combination chemotherapy with capecitabine, oxaliplatin, and trastuzumab. After 13 cycles of chemotherapy, the primary tumor was markedly reduced in size, and the portal vein tumor thrombus disappeared. Therefore, total gastrectomy with D2 lymph node dissection as conversion surgery was performed. Operation time was 317 minutes, and blood loss was 324 ml. He was discharged on postoperative day 30 with no complications. S-1 was administered as adjuvant chemotherapy. He is alive without evidence of recurrence 30 months after surgery.

A 74-year-old woman presented to our hospital for close examination of a gradually enlarging gastric submucosal tumor which had been pointed out elsewhere 5 years previously. An esophagogastroduodenoscopy revealed a 20-mm submucosal tumor-like lesion associating with a shallow ulcer at its top in the greater curvature of the pyloric antral zone. The lesion was diagnosed as gastric adenocarcinoma by a biopsy. Using endoscopic ultrasonography, it was diagnosed as submucosal carcinoma mainly located in the third layer. There were no lymph node nor distant metastases. We thus performed laparoscopic distal gastrectomy with the diagnosis of cT1b, cN0, cM0 and cStage I. Histopathology confirmed about 80 % of atypical cells to be composed of adenocarcinoma component and about 20%, neuroendocrine carcinoma component. We diagnosed the case as collision tumor composed of adenocarcinoma and neuroendocrine carcinoma, pT1b2, pN0. She has been alive without recurrence, as of 16 months after the operation. This is the first case report of collision tumor with a gastric submucosal tumor-like morphology in Japan. In treating submucosal tumor-like gastric cancer, we should carefully diagnose and treat it by keeping a possible existence of collision tumor in mind.

The patient was a 54-year-old woman who had undergone laparoscopic distal gastrectomy and Roux-en-Y reconstruction (D1 dissection) for gastric cancer 9 years previously in another hospital. After that, she was getting to be aware of intermittent abdominal pain frequently. When she was admitted to our hospital, she had severe abdominal pain in the left lower quadrant of abdomen, without peritoneal signs. An elastic-soft mass with tenderness was felt there. A contrast enhanced abdominal CT scan showed “multiple concentric ring sign” in the small bowel near the Roux-en-Y anastomotic site. Therefore, we diagnosed the case as strangulation and performed emergency laparotomy. We found that the jejunum had retrogradely invaginated into the anastomotic site and the site dilated. We resected the expansion site after manual repositioning and reconstructed the anastomosis. She was discharged from our hospital 5 days after the operation. In post-gastrectomy patients, bowel overload is an extremely rare complication, accounting for 0.07 - 2.1% of all complications. We should be aware of this rare and ill-defined complication and try not to lose the chance of its early diagnosis and treatment.

A 52-year-old woman visited a local physician complaining mainly of abdominal pain and vomiting in September 2013 and was referred to our hospital for suspected ileus. Computed tomography revealed multiple lipomas in the small bowel and ileocecal intussusception caused by lipomas. A detailed examination resulted in the diagnosis of intestinal lipomatosis.

Intestinal lipomatosis is a relatively rare condition, comprising primarily numerous intestinal lipomas. Surgical therapies for intestinal lipomatosis include partial, local, and ileocecal resections. In our case, the two segments that were laparoscopically resected included 1) a causative lesion in the terminal ileum identified using preoperative small bowel endoscopy and 2) a segment on the oral side where multiple lipomas were found to aggregate. However, concerns about potential reintussusception due to residual lipomas and the risk of short bowel syndrome due to bowel resection made it difficult to determine the best extent of resection. As of now (2021), residual lipomas were observed with no recurrence of ileus.

Laparoscopic appendectomy for acute appendicitis in pregnant women has been commonly reported in Japan, but reports of single-incision laparoscopic appendectomy (SILA) are still limited. We encountered two cases of acute appendicitis in pregnant women who underwent SILA. Case 1 was a 23-year-old woman completing 23 weeks of pregnancy, and Case 2 was a 33-year-old woman completing 15 weeks pregnant. Both patients complained of abdominal pain and were diagnosed with acute appendicitis following CT examination. Thereafter, the patients urgently underwent SILA. The postoperative course was good without complications, and both patients experienced a normal delivery. Laparoscopic appendectomy for pregnant women is minimally invasive ; however, devising the port arrangement according to the position of the uterine fundus to avoid interference with the uterus during surgery is necessary. When the uterine fundus does not rise to the umbilicus height, SILA is suitable for acute appendicitis in pregnant women because it can be approached only from the umbilicus.

A 77-year-old woman presented with epigastric pain. Computed tomography showed an irregular cecal mass, ileocecal lymphadenopathy, and small intestinal dilation. Colonoscopy showed an irregular ulcerative tumor in the cecum and ascending colon, and a subsequent biopsy specimen revealed it to be moderately differentiated tubular adenocarcinoma. She was diagnosed with intestinal obstruction secondary to cecal cancer (cT3N2M0, cStage III) and underwent right hemicolectomy. The resected specimen was an irregular ulcerative tumor (11 × 10 cm). Histopathological evaluation showed well-differentiated tubular adenocarcinoma (tub1) in the mucosa and submucosa at the tumor periphery, while the central, muscular, and subserosal components of the lesion were identified as neuroendocrine carcinoma (NEC). In view of the fact that the tub1 and NEC components each occupied > 30% of the tumor (pT3, INFc, ly1b, v1b, N2a [metastatic NEC], Stage IIIb), the lesion was diagnosed as MiNEN, mixed adenocarcinoma-NEC. She received postoperative adjuvant chemotherapy with carboplatin and irinotecan ; however, 8 months postoperatively, she developed multiple liver metastases with hepatic hilar lymphadenopathy and died 11 months postoperatively. Although colorectal mixed adenocarcinoma-NEC is rare, case accumulation and development of effective chemotherapy are needed to improve its prognosis.

A 66-year-old man was found to have a giant abdominal tumor on abdominal computed tomography (CT), and he underwent tumor resection. Histological examination of the resected specimen showed that the tumor was composed of spindle cells. Immunostaining was CD34(+) and STAT6(+). Therefore, the tumor was diagnosed as an extrapleural solitary fibrous tumor (EPSFT).

Six years later, abdominal ultrasound (US) showed a tumor in the liver. Recurrence of EPSFT was suspected, and subsegmentectomy of the liver was performed. The histopathological findings closely resembled the findings of the previously resected tumor ; therefore, recurrence of EPSFT was diagnosed. EPSFT is relatively rare, and moreover, there are few reports of liver metastasis of EPSFT. In this case, the original tumor was very large, and thus it was thought that there was a high potential for malignancy. Accordingly, the patient was followed for a long period of time, and recurrence of EPSFT was identified. This rare case of recurrence of EPSFT in the liver is reported along with a review of the literature.

A 66-year-old man presented to the emergency clinic in our hospital for bloody discharge and prolapse of unidentified chord-like soft tissue from the anus following a bowel movement. Upon arrival at our hospital, shock signs were positive. The surface of the object protruding from the anus included fat, suggestive of a part of intestinal serosa. An abdominal CT scan indicated perihepatic fluid, intramesenteric extravasation of enhancement material and intussusception of the sigmoid colon into the rectal lumen without free intra-abdominal air. An emergency surgery was performed due to hemorrhagic shock and sigmoid colon prolapse with rectal perforation. During the operation, we observed a large amount of bloody ascites, mesenteric shear of the sigmoid colon with active bleeding and a tear through all layers of the anterior wall of rectum on the peritoneal reflex measuring 5 cm in length. We performed simple closure of the rectal perforation and sigmoid colostomy due to concerns of leakage under shock condition. The postoperative course was uneventful, and the patient was discharged on day 17 of hospital stay. Rectal perforation with intestinal tract evisceration through the anus has usually good prognoses due to minimum intraperitoneal contamination and early detection. However, in cases of rectal prolapse of the colon without perineal looseness, such as in this case, patients might suffer hemorrhagic shock due to mesenteric shearing.

The patient was a 67-year-old man. In 2017, he underwent sigmoid colostomy with double orifices for treating obstructive lower advanced rectal cancer. After preoperative chemoradiation therapy, low anterior resection of the rectum, D3 lymph node dissection, and diverting ileostomy were performed. The postoperative pathological diagnoses were ypT3, ypN0, ycM0, and ypStage II. Postoperative adjuvant chemotherapy with UFT/LV was administered for 6 months. In 2019, computed tomography revealed two masses shadow, on the inferior surface of the liver and caudal to the mid-gastric region, indicating multiple peritoneal dissemination recurrence. A total of 21 courses of FOLFOX plus panitumumab were administered, while the mass continued to shrink for approximately 14 months. No other new lesions developed, and with informed consent, closure of the ileostomy and peritoneal dissemination resection were performed in 2021. Postoperative pathological examination revealed that what was considered a peritoneal dissemination on the inferior surface of the liver was a desmoid tumor primary to the ligamentum teres hepatis. There are few reports of desmoid tumors occurring after surgery for colorectal cancer or primary desmoid tumors of the ligamentum teres hepatis, and it is extremely difficult to differentiate them from postoperative cancer recurrence.

A 68-year-old woman underwent tumorectomy of a solitary fibrous tumor (SFT) of the brain at another hospital, followed 9 years later by left lobectomy for lung metastasis. Multiple liver metastases subsequently appeared, and she was referred to our department for transarterial embolization and radiofrequency ablation. In a follow-up computed tomography (CT) scan 14 years after the original brain tumor surgery, a 3-cm mass was observed on the left side of the rectum. Recurrence was also evident in the brain and lung, but since the rectal tumor was growing at a faster rate than the other lesions, it was decided to remove it laparoscopically to avoid the risk of rectal obstruction. Intraoperatively, the tumor was found to be located entirely within the mesorectum, and it was successfully removed with a sufficient margin without rectal resection. Histopathological testing confirmed that it was an SFT metastatic lesion. SFT was previously reported to be a mesenchymal tumor arising from the pleura, but in recent years, its occurrence in all parts of the body has been reported. However, there has been no previous reported case of a mesorectal metastatic lesion of a primary tumor in another organ or of the resection of a metastatic lesion within the mesorectum. The treatment of a patient with a mesorectal metastasis of a primary SFT of the brain that was laparoscopically resected is reported.

A 41-year-old woman was diagnosed with ulcerative colitis (UC) in 1988 and was receiving maintenance therapy at a local clinic. In 2016, her symptoms deteriorated, and she was referred to our hospital to start steroid treatment. Lower gastrointestinal endoscopy showed a circumferential Type 3 tumor in the upper rectum. UC-related rectal cancer (colitic cancer) was diagnosed, and laparoscopic total colectomy, ileoanal anastomosis, and ileostomy formation were performed. The histopathological diagnosis was rectal signet-ring cell carcinoma, pT3(SS)N2bM1a(LYM), pStage IVa. Postoperatively, 12 courses of mFOLFOX6 were administered, but computed tomography 1 year postoperatively showed enlargement of the left ovary and ileal mesenteric lymph nodes. Laparoscopic bilateral adnexectomy and ileoanal resection were performed, and bilateral ovarian and ileal mesenteric lymph node metastases of rectal signet-ring cell carcinoma were diagnosed. Postoperative chemotherapy was administered, but peritoneal dissemination recurred 16 months after the second surgery, and the patient died of the underlying disease 39 months after the initial operation.

A patient with accessory liver discovered during preoperative investigations for ascending colon cancer that was difficult to distinguish from a hepatic portal lymph node is presented. A 73-year-old woman was scheduled to undergo surgery for ascending colon cancer (T1bN0). A 9-mm, contrast-enhanced, nodular shadow in the hepatic portal region was observed on preoperative abdominal contrast-enhanced computed tomography (CT), and hepatic portal lymph node metastasis could not be excluded. Laparoscopic-assisted right hemicolectomy for the ascending colon cancer was scheduled, and it was decided that, if hepatic portal lymph node metastasis was suspected from intraoperative findings, then the lymph node would be submitted for rapid intraoperative pathological diagnosis. Intraoperatively, a brown nodule, 10 mm in size, was observed to be attached to the serosal surface of the body of the gallbladder. There was no continuity with the liver parenchyma, but since it was in communication with the medial segment of the liver and the gall bladder via vascular channels, it was diagnosed as an accessory liver and excised. The histopathological findings were not inconsistent with liver parenchyma, and there were no signs of malignancy or other atypical findings. An accessory liver is a rare condition, with only around 100 reported cases in Japan. This case is reported and compared with the other Japanese reported cases, with a short discussion of the literature.

A multicystic biliary hamartoma (MCBH) is an extremely rare multifocal cystic lesion of the liver. In this report, a case of MCBH treated by left medial sectionectomy is presented. The patient was a 36-year-old man who was referred to our hospital because of a hepatic tumor that was incidentally identified during an episode of acute enteritis. Contrast-enhanced computed tomography (CT) showed a 45×35 mm² multifocal cystic lesion with a cluster of cysts ranging from several to 17 mm in size at segment 4 of the liver. Intraductal papillary neoplasm of the bile duct could not be ruled out, and left medial sectionectomy was performed. The pathological findings showed that the cyst wall was covered by a single layer of columnar epithelium without nuclear atypia. The periphery of the cyst showed fibrous connective tissue containing peribiliary accessory glands and blood vessels, and the lumen of the cyst contained a bile-like fluid accumulation. The final diagnosis was MCBH. The patient had no postoperative complications and was discharged on the 8th postoperative day. The patient is alive without recurrence 3 years and 10 months after surgery.

Several cases of gallbladder bleeding with anticoagulation therapy have been documented, but cases involving gallbladder carcinoma are rare. We herein present a case of gallbladder carcinoma with bleeding after the commencement of anticoagulant therapy. An 84-year-old male patient with dysarthria disorder and right hemiplegia was admitted on an emergency basis. He had been receiving anticoagulation therapy for treating a cardiogenic cerebral infarction. On hospital day 3, he began experiencing abdominal pain. Abdominal computed tomography revealed findings suggestive of gallbladder hemorrhage. A laparoscopic cholecystectomy was performed but was converted to open surgery because of severe hemorrhage. Gallbladder carcinoma (T1b) and positive margins of the cystic duct were histopathologically confirmed. Extrahepatic bile duct resection, hepaticojejunostomy, and regional lymph node dissection were additionally performed. The patient was discharged on hospital day 58 with no postoperative complications.

We report a case of a 57-year-old man who visited our hospital with a complaint of repeated abdominal pain for approximately 2 months. After close examination, the patient was diagnosed with acute pancreatitis of the pancreatic body and tail due to pancreatic arteriovenous malformation. Although the symptoms improved with conservative treatment, pancreatitis worsened after resuming meals ; therefore, distal pancreatectomy, including resection of the arteriovenous malformation, was performed. Histopathologically, abnormal blood vessels with uneven wall thickening, a common finding in pancreatic arteriovenous malformation, were noted. Fibrosis and liponecrosis were observed around it, and ischemia due to blood stealing of the pancreatic arteriovenous malformation was considered the primary cause of pancreatitis. The recurrence of pancreatitis did not occur after surgery. In recent years, the incidence of diagnosed pancreatic arteriovenous malformation has increased due to the spread and progress of various imaging tests ; however, treatment reports via surgical resection in cases with acute pancreatitis are rare. We report a case of successful surgical treatment for pancreatic arteriovenous malformation with acute pancreatitis along with a review of the literature.

A 74-year-old man with borderline resectable pancreatic cancer was referred to our hospital. Enhanced computed tomography showed a 45-mm mass in the pancreatic body that invaded the celiac axis, splenic artery, and splenic vein.

Poorly to moderately differentiated adenocarcinoma was pathologically diagnosed by endoscopic ultrasound-guided fine needle aspiration. Distal pancreatectomy with celiac axis resection was performed after neoadjuvant chemotherapy using gemcitabine and nab-paclitaxel followed by S-1. Despite the preoperative diagnosis as partial response, the histopathological findings showed fibrous changes with an Evans classification of grade 4, which meant pathological complete response. The patient has been alive without recurrence for 18 months after R0 surgery.

A 25-year-old woman presented with left abdominal pain and was diagnosed with pancytopenia resulting from a wandering spleen and splenomegaly. On subsequent follow-up, her abdominal pain improved. Thirteen years after her first admission, she then presented with subcutaneous bleeding and hematuria and was diagnosed with severe thrombocytopenia (0.1×10⁴/mm³) caused by immune thrombocytopenic purpura (ITP) combined with splenomegaly. Since the platelet count did not improve sufficiently with medical treatment, laparoscopic splenectomy was performed. The patient's postoperative course was uneventful, and the platelet count increased gradually. Thrombocytopenia has not recurred 6 months after surgery. A rare case of ITP with a wandering spleen and splenomegaly is reported.

A 32-year-old man presented to the emergency department with complaints of acute onset epigastric pain and nausea. Abdominal computed tomography (CT) showed displacement of dilated and fluid-filled small intestine into the omental bursa. The patient was diagnosed as having small intestinal strangulation due to an internal hernia, and emergency laparoscopic surgery was performed. Laparoscopy showed herniated small intestine through the defect of the greater omentum into the omental bursa. After reduction of the small intestinal strangulation, the omental defect was repaired. No intestinal resection was needed. The patient's postoperative course was uneventful, and the patient was discharged on the 5th postoperative day. Multidetector CT (MD-CT) is useful for the preoperative diagnosis of a transomental hernia, though it remains difficult. Laparoscopic surgery is thought to be very effective for the treatment of transomental hernia.

A 66-year-old man underwent robot-assisted laparoscopic radical prostatectomy for prostate cancer, at which time left transverse testicular ectopia was observed. This time, it was introduced for the purpose of radical surgery for right inguinal hernia. A hand-fist-sized swelling was observed from the right inguinal region to the scrotum, but it could be easily returned. Abdominal CT showed two testes in the right scrotum. Intraoperative findings revealed a huge hernia sac and two bundles of vas deferens, testicular arteries, and veins in the spermatic cord. The hernia was repaired using a mesh after sufficient exfoliation. The postoperative course was uneventful and the patient was discharged on the second postoperative day. We report an extremely rare case of inguinal hernia associated with transverse testicular ectopia in an adult.