Since April 2020, BRCA1 and BRCA2 genetic tests have additionally covered by insurance for diagnosing hereditary breast and ovarian cancers (HBOC). This study was made to clarify the appropriateness of suggestive findings on which we rely to select a candidate for the testing. Subjects were all breast cancer patients undergone BRCA1/2 genetic tests to diagnose HBOC. Of these patients, we calculated the number of the tests by every inclusion criterion which is described in the guidebook for the HBOC treatment, and the carrying rates of inherited pathogenic variant (carrying rate) were also calculated. As a result, the number of tests performed for 10 years before the insurance coverage amounted to 600 cases, whilst in 2020 when the insurance coverage was approved, the number greatly increased to 126 cases for one year. The carrying rate in cases applicable to either of inclusion criteria was 13%. The carrying rates by inclusion criterion were 19.3% in triple-negative breast cancer patients at or before age 60 years ; 18.5% in those with more than two primary breast cancers ; 16.3% in those at or before age 45 years ; and 15.4% in those who had family history of breast or ovarian cancer within three-degree relatives, In patients who had three inclusion criteria, the carrying rate was as high as 70%. In conclusion, the carrying rate becomes higher when the candidate is applicable to more inclusion criteria, where information of the test result should be offered. With an increase in numbers of tests as well as carriers who inherit pathogenic variant, it would increasingly pose issues of performing risk-reducing mastectomy for the contralateral breast or following-up of pre-symptomatic pathogenic variant carriers.

Background : In recent years, the perioperative treatment of early-stage breast cancer has become personalized according to subtype, and large-scale clinical trials have suggested that axillary lymph node dissection can be avoided even when sentinel lymph node (SLN) metastasis is positive. There is also a tendency to avoid chemotherapy if there are only 1 or 2 lymph node metastases of luminal breast cancer. However, the number of lymph node metastases is an important factor in deciding on adjuvant therapy, and if non-SLN metastasis is present, then adjuvant therapy may be insufficient. In our hospital, we have been using intraoperative, one-step, nucleic acid amplification (OSNA) for SLN determination, but the total tumor load (TTL) of metastatic SLNs has been reported to predict non-SLN metastasis. Therefore, a retrospective study of the TTL of luminal breast cancer SLN and non-SLN metastases was conducted.

Methods : The study subjects were 83 patients with estrogen receptor-positive and human epidermal growth factor receptor-2-negative luminal breast cancer who underwent axillary lymph node detection after they were found to be SNL-positive by OSNA between May 2012 and June 2021. Non-SLN metastases were analyzed in two groups with a TTL cut-off value of 2.1 × 10⁴ copies/μL.

Results : Of the 83 patients, 11 were positive for non-SLN metastases, and the rate of non-SNL metastases was significantly higher in the high-TTL group (p=0.00854).

Conclusion : TTL may predict non-SLN metastases in luminal breast cancer.

We report a case of a 52-year-old woman with a history of hyperlipidemia who underwent partial mastectomy and axillary lymph node dissection for left breast cancer at the age of 45 years and was taking oral tamoxifen ([TAM] 20 mg/day). When 7 years and 3 months after the operation (or 6 years and 7 months after starting oral administration of TAM) had elapsed, she visited our Emergency Department with the complaints of abdominal pain and vomiting. A blood test showed an increased inflammatory response and a high triglyceride (TG) concentration of 2,670 mg/dL. She was admitted to our hospital with the diagnosis of acute pancreatitis associated with hypertriglyceridemia because she showed pancreatic enlargement and elevated peripancreatic fat tissue on computed tomography. We retrospectively found that serum TG concentrations tended to increase after the start of TAM treatment. TAM was discontinued with the onset of pancreatitis, and the serum TG concentration improved to the same as that before starting TAM. According to previous reports, acute pancreatitis due to TAM often occurs within 1 year from starting oral TAM administration, but it may develop even after a long period of time has passed since starting TAM like in this case.

A 57-year-old female with hereditary spherocytosis (HS) presenting a mass in her left breast was referred to our hospital. She was diagnosed with left breast cancer cT2N0M0 cStage IIA. She underwent partial mastectomy and sentinel lymph node biopsy. One lymph node was positive for metastasis, and axillary lymph node dissection was performed. Pathological investigation revealed pT2N1M0 pStage IIB cancer. Radiation therapy, hormonal therapy, and adjuvant chemotherapy were scheduled.

After the first dose of chemotherapy, she was admitted to our hospital due to anemia and jaundice caused by the chemotherapy-induced hemolytic crisis ; hence, chemotherapy was canceled.

Computed tomography (CT) revealed multiple metastases of the spleen and the liver after 2 years post-operation. Splenectomy with partial hepatectomy was performed because of the possibility of using chemotherapy again. After several courses of hormonal therapy, the metastatic lesions continued to grow. Chemotherapy was re-challenged, and no hemolysis was observed because of splenectomy. Thus, she could continue with her treatment.

We suggest that splenectomy can enable patients with HS to undergo chemotherapy safely.

A 47-year-old woman had been treated for breast cancer at age 34 years (left partial mastectomy with sentinel node biopsy) and at age 44 years (right total mastectomy with sentinel node biopsy). In light of her history of cancer in both breasts, young onset, and family history, genetic screening was recommended. She underwent BRCA screening, which identified a BRCA1 pathogenic variant, and she was diagnosed with hereditary breast and ovarian cancer syndrome. She requested prophylactic surgery and underwent risk-reducing salpingo-oophorectomy in the Department of Women's Medicine. Mammography, breast ultrasound, and breast magnetic resonance imaging (MRI) all showed no lesion in the breast, and risk-reducing mastectomy of the remaining left breast was conducted. Postoperative pathological investigations showed a non-invasive ductal carcinoma [estrogen-receptor (ER)-positive], measuring 2 mm. The patient had been undergoing postoperative treatment with tamoxifen and luteinizing hormone-releasing hormone (LH-RH) agonist for the right breast cancer, but after the risk-reducing salpingo-oophorectomy, the hormonal agent was switched to anastrozole, and she currently remains under observation.

From April 2020, insurance coverage for hereditary breast and ovarian cancer (HBOC) medical care has been expanded, thus insuring for risk-reducing mastectomy. Some reports have suggested that risk-reducing surgery suppresses more than 90% of the onset of new breast cancer and improves the prognosis.

Here, we report the treatment of a patient with right breast cancer who underwent surgery for left breast cancer 30 years before. During the course of treatment, the patient was found to be BRCA2 positive and was diagnosed with HBOC syndrome. This was a suggestive case and is important to be reported.

A 68-year-old woman, who had been aware of a right breast tumor mass for eight years, was referred to our department because of gradual enlargement of the tumor. Magnetic resonance imaging (MRI) showed a bulky tumor measuring approximately 17 cm in the right breast with mostly fatty signals, and it contained a solid mass measuring approximately 8 cm. The mass showed a beak sign between the mass and the pectoralis major muscle, indicating that the tumor originated from the chest wall. Histological examination of the solid mass suggested a non-epithelial malignant tumor, and immunostaining was MDM2(+) and CDK4(+). No distant metastasis was found, and the patient was diagnosed as dedifferentiated liposarcoma of the pectoralis major muscle. A right mastectomy and dissection of the pectoralis major and minor muscles were performed with a preoperative diagnosis of dedifferentiated liposarcoma of the pectoralis major muscle. Pathological examination showed that the tumor was contiguous with the pectoralis major muscle, and a grayish-white nodule measuring 7 cm was located inside the adipose tissue tumor measuring 17 cm. The patient was diagnosed as having dedifferentiated liposarcoma arising from well-differentiated liposarcoma. No recurrence has been observed for twenty months after surgery.

Esophageal epiphrenic diverticulum is a rare condition and can be indicated surgery if it is associated with motor abnormalities of the esophagus and food regurgitation. Recently we have experienced a case of esophageal epiphrenic diverticulum in which the patient developed perforation of the esophageal diverticulum and acute mediastinitis which followed favorable clinical course after drainage followed by resection and reconstruction via a two-step approach.

The patient was a 68-year-old man who presented with a sensation of food sticking in the throat. He was found to have an esophageal epiphrenic diverticulum and was scheduled to undergo surgery. However, subjective symptoms disappeared, and we selected to observe his clinical course according to his hope. During observation, perforation of the esophageal epiphrenic diverticulum and acute mediastinitis occurred so that emergent laparoscopic trans-hiatal mediastinal drainage was performed. After the mediastinitis was subsided, thoracoscopic subtotal esophagectomy was performed. After the surgery he developed suture failure, but it was conservatively resolved. He was discharged on 35^th postoperative day.

Esophageal epiphrenic diverticulum often presents with regurgitation and other symptoms, but these symptoms can improve spontaneously with enlargement of the diverticulum, leading to be a high risk of causing perforation. In the treatment of perforation of the esophageal diverticulum associated with acute mediastinitis, the surgery through a two-step approach was useful.

A 72-year-old man was found to have thickened wall of the gastric cardia and lymphadenopathy by computed tomography (CT) taken for the purpose of detailed examination of epigastric discomfort. Upper gastrointestinal endoscopy showed a subcircumferential type 3 tumor at the esophagogastric junction, and a biopsy examination revealed adenocarcinoma. No distant metastasis was found. We performed robot assisted esophagectomy with two field lymph node dissection, and gastric tube reconstruction via an anterior mediastinal approach. As a result of histopathological diagnosis, synaptophysin, chromogranin A, and CD 56 were positive, respectively. The diagnosis was established as neuroendocrine carcinoma (NEC). Of the dissected lymph nodes, metastases were observed in No. 1, No. 2, No. 9, No. 11p, No. 107 and No. 110. Postoperatively, pneumonia, right recurrent nerve palsy, and wound infection occurred, and the patient was discharged 38 days after the surgery. He has remained free of the disease at 2 months postoperatively. NEC of the esophagogastric junction is considered rare, and here we report our case and a review of the literature.

A 65-year-old man presented to the emergency department with primary complaints of abdominal distension and nausea that had started on the previous day. Plain abdominal computed tomography (CT) showed a gastric volvulus that was released by intubation. Esophagogastroduodenoscopy (EGD) was performed the following day, and multiple gastric ulcers were noted primarily in the gastric corpus. No gastric axial change was observed. On day 7 post-admission, the patient developed sudden abdominal pain and nausea reflex, which were associated with muscular defense. Contrast-enhanced abdominal CT revealed acute gastric dilatation and whirlpool signs in the epigastric blood vessels. Additionally, EGD showed exacerbated gastric ulcers and axial changes in the stomach. Therefore, he was diagnosed with acute gastric volvulus and the patient underwent emergency surgery. Intraoperative findings confirmed sigmoid volvulus, gastric volvulus, gastric volvulus release, and sigmoid fixation. In gastric volvulus, the possibility of gastric volvulus coexisting with sigmoid volvulus should be considered, particularly when conservative treatment is ineffective. Minimally invasive emergency surgery should also be performed.

The patient was a 64-year-old woman. For these several years she was on post-tracheostomy and gastrostomy nutrition due to multiple system atrophy. Two days before coming to our hospital, enteral tube feeding fluid flew out through her tracheostomy orifice after nutritional administration. She had fever and was admitted to our hospital with a suspected diagnosis of pneumonia. A CT scan showed intragastric emphysema and intra-abdominal free gas and mediastinal emphysema. She was conservatively treated because abdominal symptoms and findings suggestive of ischemia were absent. Seven days later, a CT scan showed that the findings had disappeared, and 9 days later, upper gastrointestinal endoscopy confirmed that there were no ischemic changes in the mucosa. Her nutrient administration was resumed. Seven days after the resumption, flowing out of the nutrient from the tracheostomy orifice flared up again, and a CT scan showed intramural emphysema and portal venous gas, but the patient again recovered with conservative treatment. Most cases of gastric emphysema have a good prognosis with conservative treatment. Intra-abdominal free gas, portal gas, and mediastinal emphysema are findings suggestive of gastrointestinal perforation or intestinal ischemia, but surgery may be avoided if no abdominal symptoms are present. It is important to make a judgment based not only on imaging findings but also on the patient's general condition and physical examination.

A calcifying fibrous tumor (CFT) is a rare benign fibrous tumor. It is characterized by abundant hyalinized collagen and psammomatous calcification. CFT has sometimes required differentiation from gastrointestinal stromal tumor (GIST) because it may occur in the stomach. A 22-year-old woman underwent upper gastrointestinal endoscopy due to the presence of epigastric pain. A 15-mm elevated lesion was seen at the gastric fundus on upper gastrointestinal endoscopy. A mucosal cutting biopsy failed to provide a definite diagnosis ; therefore, a single-incision laparoscopic partial gastrectomy was conducted for the purpose of diagnosis and treatment. The pathological results showed chronic inflammatory cell infiltration with collagenous growth, psammomatous calcification, and lymphatic follicle formation. Based on the immunostaining results, CFT was diagnosed.

The patient's postoperative course was uneventful, and the patient was discharged on the 6th postoperative day. In this report, a very rare case of primary gastric CFT is presented along with a brief discussion of the literature.

A 66-year-old man was diagnosed with unresectable advanced gastric cancer (cT4bN3M1, cStage IVB) at presentation. After 12 courses of S-1 + oxaliplatin therapy and five courses of paclitaxel + ramucirumab therapy as second-line treatment, grade 3 peripheral neuropathy occurred ; thus, third-line treatment with nivolumab was initiated for 16 courses. By imaging studies, the primary lesion was remarkably reduced, and liver metastasis and peritoneal dissemination disappeared. Therefore, the therapeutic effect was judged as a partial response (PR). However, as PS had deteriorated, treatment continuation was deemed difficult. Upon re-evaluation 1 year after discontinuation of nivolumab, the PR was maintained, and staging laparoscopy was performed. In addition, conversion surgery was performed, as curative resection was possible. Total gastrectomy, splenectomy, D2 dissection, and Roux-en-Y reconstruction were performed, and the patient has survived for 15 months without recurrence. The effects of nivolumab on unresectable advanced gastric cancer may persist for a long time after treatment discontinuation. In cases of treatment interruption following the judgment of the therapeutic effect as PR, a continuous follow-up is important to not miss a chance for curative resection.

A 67-year-old woman was referred to our hospital because of hematemesis and disturbed consciousness following dialysis. Under the diagnosis of non-occlusive mesenteric ischemia (NOMI) with metabolic acidosis, we performed an emergency laparotomy. After one day of open abdominal management, necrosis of the small intestine, ascending colon, transverse colon, and duodenum was observed. The small intestine and colon were resected and the stump was made into an external fistula. Although the intubation tube was extubated on the second day after surgery, significant pancreatic fluid leakage was observed at the enterocutaneous fistula, and the operation was repeated on the 14^th day. A T-tube was inserted into the duodenal fistula because necrosis of the duodenal wall had progressed. The leakage of duodenal fluids was prevented by suturing between the abdominal wall and gastric wall. The patient was managed with dialysis and intravenous nutrition. However, she died of renal dysfunction 141 days after the surgery. Although NOMI is generally defined as discontinuous mesenteric necrosis in the small intestine, there are few reports of NOMI in the duodenum. This is a rare case of NOMI in which necrosis extended from the duodenum to the transverse colon.

A 93-year-old man was referred to our hospital due to abdominal pain. Computed tomography showed diffuse hemorrhagic ascites and a radiopaque, linear object in the small bowel with a small amount of air in the mesentery. Laboratory findings showed an increased inflammatory response and severe anemia. Acute peritonitis caused by fish bone perforation was diagnosed. On emergency laparotomy, a large amount of hemorrhagic ascites and blood clots were seen. After intraperitoneal lavage, a bleeding point with fish bone exposed outside the small intestinal wall was seen. The small bowel with a fish bone about 10 cm in length was resected. The patient was discharged on day 36 after surgery, although he had severe anemia postoperatively due to anastomotic bleeding. Gastrointestinal perforations caused by fish bones are reported to account for less than 1% of perforations, and fish bone perforation with intraperitoneal massive hemorrhage is very rare. Therefore, this case is presented along with the relevant literature.

AL amyloidosis associated with ileocecal intussusception is a rare condition. One such case is reported along with a literature review. A 91-year-old man was admitted to our hospital with complaints of general malaise and right lower abdominal pain. Abdominal computed tomography showed a target sign around the ascending colon. Colonoscopic examination showed an elevated lesion at the ileocecal region, which invaginated into the ascending colon. The biopsy results suggested amyloidosis, but the possibility of malignancy could not be ruled out, and surgery was selected to relieve the intestinal obstruction. A laparoscopic right hemicolectomy was performed. A camera port was inserted in the umbilical region, for a total of five ports. A small 4.0-cm incision was made at the umbilical region, and reconstruction was performed by functional end-to-end anastomosis. Grossly, the resected specimen showed tumor-like thickening, 4.0 cm in diameter, from the ileum to Bauhin's valve. Histopathological findings showed amyloid deposition in the submucosa, leading to the diagnosis of amyloidosis. The amyloid was immunohistochemically typed AL. The patient was discharged on postoperative day 9.

A 45-year-old man had previously undergone two laparotomies at other hospitals. Since then, he had frequently developed intestinal obstruction and had been treated conservatively. Abdominal computed tomography at the onset of intestinal obstruction showed marked dilatation of the intestinal tract on the oral side from the anastomosis of the small intestine, and many flattened foreign bodies were observed inside the anastomosis. Laparoscopy showed that the small intestinal anastomosis adhered to the abdominal wall and served as the starting point of the intestinal obstruction. The adhesions were removed, and the small intestine including the anastomosis was partially resected. The anastomosis was found to show saccular dilatation on the oral side with scar stenosis, and many stones were found inside the anastomosis. These stones were the true enteroliths made of deoxycholic acid. The patient had a good postoperative course and was discharged on the sixth postoperative day.

In this case, the intestinal fluid stagnated due to saccular dilatation at the functional end-to-end anastomosis resulting from postoperative anastomotic stenosis, and true enteroliths were considered to have formed. Reports of true enteroliths caused by gastrointestinal anastomosis are rare, and this case is reported along with a review of the literature.

An 18-year-old Japanese man was presented with an acute abdomen, secondary to the right lower abdominal pain and vomiting. Abdominal computed tomography revealed a 6-cm-diameter tumor with fat concentration and intestinal obstruction caused by the volvulus of the small intestine. Although the volvulus resolved spontaneously, semi-emergency laparotomy was performed because of concerns regarding its recurrence. The tumor was located in the mesentery of the small intestine and was in extensive contact with the intestinal wall. Surgery was performed to resect the tumor along with some portion of the small intestine. The histopathological diagnosis revealed lipoma consisting of mature adipocytes. Mesenteric lipoma is a rare solid primary tumor that develops in the mesentery and accounts for approximately 2% of all mesenteric tumors. The indications for surgery in acute abdomen cases in young patients mostly include inflammatory diseases, such as appendicitis and gynecological inflammatory diseases. Thus, it is important to consider the possibility of an organic disease as a cause of an acute abdomen.

Pneumatosis cystoides intestinalis (PCI) is a disease that causes multiple air-containing cysts in the mucosa and submucosa of the intestine. Although abdominal free air and portal emphysema may be present, there are cases with no specific abnormalities : they lack abdominal symptoms and have no abnormal laboratory findings. In this case, a woman came to the hospital with the chief complaint of rectal prolapse. She had no obvious abdominal symptoms, but the chest X-ray incidentally showed abdominal free air under the diaphragm. Computed tomography of the abdomen showed abdominal free air (intestinal emphysema). However, she had no abdominal symptoms, and there was no inflammatory reaction on blood tests, so she was treated conservatively. The patient then underwent elective laparoscopic rectal fixation for rectal prolapse. Intraoperatively, multiple cysts were found on the mesenteric side of the ileum ; they were partially resected and histologically diagnosed as PCI. In this case, intestinal gas leaked into the intestinal wall and the abdominal cavity due to increased intestinal pressure caused by rectal prolapse. The intra-abdominal free gas improved after rectal prolapse surgery, supporting the hypothesis that the obstruction was caused by rectal prolapse. There are no reports of PCI associated with rectal prolapse, and this case is therefore reported and discussed.

Erythropoietic protoporphyria (EPP) is a rare inherited disorder of heme synthesis. We report a case of acute appendicitis in a 21-year-old female patient with EPP. She was diagnosed with EPP in early childhood ; it was associated with photosensitivity of the skin and a high risk of causing visceral damage. Thereafter she had been followed up. Recently she presented with upper abdominal pain and was diagnosed with acute appendicitis. Following conservative treatment for several days, she was admitted to our hospital for the purpose of undergoing surgery. In the perioperative period, we performed light wavelength measurements to avoid the wavelength that might cause phototoxic reactions. During appendectomy under laparotomy, we covered surgical lights and headlights with a special film to prevent the harmful wavelength causing photosensitivity. After the surgery, no emerging complications happened. She was discharged on the third hospital day. Meticulous perioperative management using a special film ensured a safe surgery for the patient with EPP.

A 59-year-old man was admitted to our hospital with persistent abdominal pain and vomiting. The patient reported usual defecation the day before. The patient's vital signs were normal. Abdominal distention was detected but without peritoneal signs. Blood examination revealed renal dysfunction and a severe inflammatory reaction. An abdominal computed tomography (CT) scan revealed a small intestinal ileus, possibly caused by an obstruction in the upper right abdomen. Pneumatosis intestinalis and portal vein gas were also noted. However, there was no ascites. An intestinal tube was successfully inserted, and intravenous fluids therapy improved renal function and reduced inflammation. Despite defecation and flatus, abdominal distention persisted, and the patient underwent surgery. An internal hernia was observed in the paracolic gutter of the ascending colon. The partial obstruction was released. There was no necrosis, and bowel resection was not required. This is a rare case of an internal hernia with pneumatosis intestinalis and portal vein gas.

Patient 1 was an 85-year-old woman who had presented at another hospital complaining of loss of appetite. Based on computed tomography (CT), ascending colon carcinoma with multiple liver metastases was diagnosed. Preoperative contrast-enhanced CT also showed a horseshoe kidney, but a duplicate ureter was not evident, and the courses of the ovarian artery and vein were not anomalous. Laparoscopic right hemicolectomy and D3 lymph node dissection were performed. Because the right renal pelvic ureter ran on the ventrolateral side of the horseshoe kidney, the mesocolon and renal pelvic ureter were somewhat difficult to detach via the medial approach. Patient 2 was an 80-year-old man whose tumor markers were found to be high at a regular health checkup, and he was diagnosed with ascending colon carcinoma on further investigation. Preoperative contrast-enhanced CT showed a horseshoe kidney, but there was no duplicate ureter, and the courses of the testicular artery and vein were not anomalous. Laparoscopic right hemicolectomy, D3 lymph node dissection, and combined resection of the right testicular artery and vein were performed. The course of the right ureter was more medial than its usual course, running along the ventral side of the isthmus of the horseshoe kidney. There has been no previous report of right colon cancer with a concomitant horseshoe kidney, and these cases are reported with a short discussion of the literature on points to note with respect to the ureteral course during surgery.

A 71-year-old woman presented with vomiting. She had not bowel movement for a week An abdominal plain CT scan showed a volvulus of the transverse colon. After an unsuccessful attempt at endoscopic repair, emergency surgery was performed. Upon operation, intestinal malrotation was identified to be non-rotation type. There was no Ladd's band and the transverse colon banded to the sigmoid colon and jejunum. The torsion twisting counterclockwise by 360 degrees was released. Although she had not bloody ascites nor ischemic change in the intestine, she underwent right hemijejunostomy to prevent recurrence. This adult case of intestinal malrotation causing midgut volvulus with non-specific bands is reported due to its rarity in the Japanese literature.

An 84-year-old man presented with anemia and was diagnosed with transverse colon cancer. A tumor invaded the second part of the duodenum with a fistula formation, and tumor thrombus to the superior mesenteric vein via the gastrocolic trunk of Henle were observed by preoperative imaging diagnosis. Intraoperative findings showed no peritoneal dissemination or liver metastasis, so we judged that R0 resection was possible, and performed right hemicolectomy and subtotal stomach-preserving pancreatoduodenectomy with combined resection and reconstruction of the superior mesenteric vein. Pathological findings were pT4b (duodenum), pN0, pStage IIc, R0, CurA. The patient is currently alive without recurrence as of 9 months after the surgery. Even for locally advanced colorectal cancer with invasion to other organs or tumor thrombus, a good prognosis can be expected if R0 resection is performed, so it is necessary to consider the optimal surgical procedures according to tumor extension.

Electrolyte depletion syndrome (EDS) is characterized by a consciousness disorder and electrolyte imbalance due to frequent diarrhea associated with villous tumors of the rectum. We report a very rare case of EDS with acute renal failure and hyperammonemia that was successfully treated with continuous hemodiafiltration (CHDF) and laparoscopic surgery. A 68-year-old woman presenting a history of liver cirrhosis was presented to our hospital with the chief complaint of a consciousness disorder. Blood examination showed hyperammonemia, decreased renal function, and electrolyte imbalance, which were resolved by hemodialysis within a few days. A huge villous tumor measuring 160 mm × 150 mm was detected using abdominal computed tomography and colonoscopy. Histological examination using biopsy revealed villous adenoma. Hypokalemia is frequently observed, even after CHDF. We performed a laparoscopic Hartmann's operation after the treatment of hypokalemia. The pathological diagnosis revealed well-differentiated tubular adenocarcinoma in the villous adenoma. The postoperative course was uneventful, with no symptoms of EDS. She recovered, within a follow-up period of 24 months. EDS should be considered when frequent diarrhea or consciousness disorder accompanies rectal villous tumors, and appropriate examination and treatment are essential.

A 73-year-old woman undergoing chemotherapy for colorectal cancer with peritoneal dissemination developed small bowel obstruction due to a worsening of peritoneal dissemination. Partial resection of the jejunum and loop ileostomy were performed, however, 2 months after the surgery, stoma prolapse occurred. As manual reduction was ineffective, emergency surgery was performed. The operative technique was based on the Altemeier method for rectal prolapse. The patient underwent resection of the prolapsed intestine from the stoma side without making a skin incision, and the reconstruction was performed with an automated anastomotic device. The postoperative course was unremarkable. The patient was discharged on the postoperative day 12 and was able to resume outpatient chemotherapy from the postoperative day 20. This technique is considered a promising option for stomal prolapse because it does not require intraperitoneal manipulation, is minimally invasive and relatively simple, and does not cause any changes in postoperative stoma care.

Pancreatic intraductal oncocytic papillary neoplasm (IOPN) has been classified as one of the pre-cancerous lesions, placing as same category with IPMN, in the General Rules for the Study of Pancreatic Cancer (seventh edition). We have experienced a case of IOPN in an asymptomatic 47-year-old woman treated surgically. A cystic lesion at the head of the pancreas was noted by an abdominal ultrasonic examination at a medical checkup one year earlier and we diagnosed it as a branched ductal intraductal papillary mucinous neoplasm (IPMN). The following year, we observed an enlargement of the mural nodule, which was corresponded to high-risk stigmata, and we performed subtotal stomach-preserving pancreatoduodenectomy (SSPPD). Histopathological findings showed cystic branched pancreatic ducts and papillary growth of tumor cells having oval-shaped nuclei in the pancreatic head. Immunohistochemical staining was positive for MUC5AC, partially for MUC1, and negative for MUC2. We finally diagnosed the lesion as IOPN, based on the morphological picture. Her postoperative course was uneventful and she was discharged 14 days after the operation. Although IOPN is a disease with a relatively good prognosis, strict follow-up is necessary because there are some cases of distant metastasis regardless of localized lesions.

A 75-year-old man with complaints of dimmed vision, abdominal pain, and dyspnea was transferred to our hospital. Computed tomography revealed multiple hepatic and splenic tumors and hemorrhagic ascites. Intraabdominal hemorrhage caused by the rupture of either of the tumors was suspected. Because his blood pressure was well maintained through fluid replacement and transfusion, we performed splenectomy and lateral segmentectomy of the liver the next day. After pathological examination, the patient was diagnosed with primary splenic angiosarcoma and multiple liver metastases. Intraabdominal hemorrhages on the 32nd and 34th postoperative days were managed using transcatheter arterial embolization. Following a detailed explanation and informed consent, chemotherapy with paclitaxel was initiated ; however, it was discontinued after the first cycle owing to the progression of liver metastasis. The patient died on the 106th day following complications due to disseminated intravascular coagulopathy. Primary splenic angiosarcoma is extremely rare and has a poor prognosis. The mean survival time after an intraabdominal hemorrhage has been reported to be approximately 4.4 months. The treatment for this disease has not yet been established. Herein, we report this case along with a review of the literature.

A 52-year-old man who had undergone mesh hernioplasty for a right inguinal hernia 10 years ago presented with a complaint of right inguinal region discomfort for 2 weeks. At the initial examination, a 5-cm bulge was found in the right inguinal region, which easily reduced in the supine position. Computed tomography in the prone position showed that the bladder prolapsed inside an inferior epigastric vessel. A right inguinal bladder hernia was diagnosed, and the transabdominal preperitoneal approach procedure (TAPP) was planned. However, no hernial orifice was found on the abdominal wall. Therefore, an extraperitoneal bladder hernia was diagnosed, and the procedure was quickly changed to the totally extraperitoneal approach procedure (TEP). A mesh was placed to cover the 1-cm hernia orifice. The patient's postoperative course was uneventful. This case showed that the TEP procedure is more helpful for extraperitoneal bladder hernia in identifying the hernial orifice and avoiding bladder injury.

Intra-abdominal candidiasis (IAC) is a rare postoperative complication with a poor prognosis. We report a case of surgical drainage of multiple intra-abdominal abscesses after emergency surgery for peritonitis secondary to a perforated duodenal ulcer. A 65-year-old man with peritonitis and septic shock due to a perforated duodenal ulcer underwent emergency laparotomy. Postoperatively, although the patient recovered from septic shock, fever and CRP re-elevation were observed on the sixth postoperative day. Since Candida albicans was identified in the infectious ascites collected during surgery, an antifungal agent was administered. Symptoms such as fever did not improve 10 days after surgery. Abdominal contrast-enhanced CT showed numerous intra-abdominal abscesses. Hence, surgical drainage was performed. Postoperatively, intestinal fluids flowed out of the perforated duodenal ulcer. The antifungal agent was continued for 28 days, during which the IAC improved. Surgical drainage is essential for the treatment of IAC after emergency surgery. However, relaparotomy is highly risky, and further studies on the appropriate timing and indications are required.

A 79-year-old man was diagnosed with advanced gastric cancer and underwent total gastrectomy with D2 lymphadenectomy and Roux-en-Y reconstruction. Pancreatic fistula on postoperative day 5 and duodenal stump leakage on postoperative day 9 occurred. These complications were improved with conservative treatment, however, septic shock due to catheter infection occurred on postoperative day 25. The central venous catheter (CVC) was immediately removed, and antibiotic treatment was started. Low back pain appeared 32 days after the surgery and gradually worsened. Lumber MRI on 49 days after the surgery led to a diagnosis of pyogenic spondylitis. He was treated with conservative therapy with antibiotics and rest and was discharged 96 days after the surgery without any neurological sequelae. There are some patients who require CVC during the perioperative period of gastric cancer. If low back pain appears after CVC infection, early diagnosis and intervention should be performed with the complication of pyogenic spondylitis in mind. Further studies about perioperative management without CVC or preventing clinical conditions that require long-term treatment with CVC are necessary.