Of 488 patients who underwent laparoscopic cholecystectomy in our hospital, postoperative biliary amylase levels were measured and cholangiography was performed in 271 who underwent C-tube placement to investigate the relationship between pancreaticobiliary maljunction and the level of biliary amylase. In all 4 maljunction patients in whom the pancreatic duct was constantly visualized, the biliary amylase level was ≥ 40,000 IU/L, whereas the median value for patients with high confluence in whom the pancreatic duct was intermittently visualized was 9,423 IU/L [7-205,900 IU/L]. In normal individuals, the median value is 10 IU/L [1-399,600 IU/L], and an investigation of the cut-off value for the biliary amylase level distinguishing between individuals with maljunction/high confluence and normal individuals based on the present results showed that the amylase value that maximized the area under the receiver-operating characteristic (ROC) curve was 6,698 IU/L (area under the ROC = 0.904). The clinical cut-off value for biliary amylase was set to 6,600 IU/L, and it was found that this cut-off value identified the presence of maljunction or high confluence with sensitivity of 85.7% and specificity of 94.2%. High confluence is known to be a lower risk factor for biliary cancer than maljunction, but there are no clear diagnostic criteria or an established treatment policy, and further investigations involving more patients are required.

An 88-year-old woman was being bathed at a daycare service when an employee noticed a mass in her left breast. Because the tumor was large and at risk of self-destruction, treatment was considered necessary to maintain activities of daily living (ADL). The patient had severe dementia and was unable to stay still, making it impossible to perform a biopsy while awake. A simple mastectomy for the joint purposes of diagnosis and treatment was therefore conducted under minimally invasive sedation. Histological investigation showed that the mass was a breast metastasis of primary brain (central nervous system) lymphoma, which had been diagnosed 1 year 8 months earlier and treated surgically. The mastectomy took only a short time, and the patient was discharged the following day, but she then developed a cerebral infarction that reduced her ADL. A single breast metastasis of central nervous system lymphoma is extremely rare, and this case is reported together with a discussion of the treatment policy for breast masses in older patients with severe dementia.

Lymph node metastasis from pulmonary typical carcinoid is rare. A 72-year-old man was pointed out a mass shadow with a screening cheat X-ray. A chest computed tomography (CT) showed a 3.1-cm lung tumor in the left lower lobe, which was suspected pulmonary carcinoid with bronchoscopy. Positron emission tomography (PET) revealed an abnormal FDG uptake in the tumor not but any other site. Although he was diagnosed with cT2aN0M0 : Stage IB lung cancer, he rejected surgery. Because the tumor was slightly enlarged during strict observation, he agreed to surgery and underwent left lower lobectomy and hilar and mediastinal lymph node dissection. Pathological findings showed tumor tissue with neither mitosis nor necrosis, tumor cells positive for chromogranin A and a metastatic hilar lymph node, leading to the diagnosis of typical carcinoid, pT2aN1M0 : Stage IIB. He had an uneventful postoperative recovery and was transferred to another institute for rehabilitation eight days after the surgery. We should carefully decide a surgical strategy based on the potential of pulmonary typical carcinoid to metastasize to lymph nodes.

The patient was a 49-year-old woman. She had breast cancer surgery and chemotherapy at the age of 41, and ovarian cancer surgery at the age of 43. At the time of her outpatient visit to the gynecology department of our hospital, an elevation of CA125 with time was observed, and a PET-CT scan showed an accumulation of FDG consistent with a tumor in the sternum. For diagnosis and treatment, partial resections of the sternal pedicle, part of the sternal body, and bilateral first, second and third rib cartilages were performed along with the tumor, and the chest wall defect was reconstructed using polypropylene mesh. The pathological findings revealed sternal metastasis of ovarian cancer. Breast and thyroid cancers are the most common malignant tumors with sternal metastasis, and multiple bone metastases are proved in most cases. Isolated sternal metastasis in ovarian cancer is rarely reported, but even in the case of distant metastasis, resection of a single tumor has been reported to prolong survival. In this study, we report a case of isolated sternal metastasis in which the extent of resection was determined by imaging, and after securing a sufficient surgical resection area, a sternal resection with chest wall reconstruction using polypropylene mesh was performed.

We experienced a patient who survived recurrence-free postoperative 8 years 10 months with radiation therapy for local recurrence of gastric cancer. In this study, we investigated the usefulness of the radiation therapy for local recurrence of gastric cancer and the cause of the local recurrence.

The patient was a 50 year-old man who had type 3 advanced gastric cancer with invasion to the celiac artery from metastatic lymph nodes.

Preoperative chemotherapy was effective to reduce the bulky lymph nodes which caused the celiac artery invasion. Then R0 operation (Appleby operation) was done. Histological examination of dissected specimen revealed R0 and stage III B, but perineural invasion (pn) and extranodal metastasis (en) were confirmed. After 3 months of the operation, local recurrence was recognized near the celiac artery. The local recurrence might be caused by pn and en. Radiation therapy was done. The patient survived 8 years and 10 months with no recurrence.

As for the cause of the local recurrence in this case, pn and en remnants were suspected. Radiation therapy was thus selected as a local therapy, leading to CR.

In local recurrence of gastric cancer, curative therapy can be done by irradiation.

A 50-year-old man presented with abdominal pain lasting for 2 week and was found to have superior mesenteric venous thrombosis and portal vein thrombosis on an abdominal contrast-enhanced CT scan. He was admitted to our hospital for the purpose of undergoing interventional radiology. On the next morning, his abdominal pain was aggravated, and an abdominal CT scan conducted again demonstrated an area enhanced poorly in the jejunum. He was referred to our department for emergency surgery. Intraoperative findings showed ischemic necrosis of the small bowel, that was inferred to be caused by circulatory disturbance due to congestion. Accordingly, we performed thrombectomy from the periphery of the superior mesenteric vein under laparotomy, followed by partial resection of the ischemic small bowel and creation of a small bowel stoma. Thereafter, strict antithrombotic and anticoagulant therapy was conducted, the small bowel stoma was closed on the 34^th postoperative day, and he was discharged on the 63^rd postoperative day. As he was proved to be lupus anticoagulant positive at the day of admission and at 12 weeks after admission, he was diagnosed with anti-phospholipid antibody syndrome.

Although we sometimes encounter a case of ischemic necrosis of the bowel caused by superior mesenteric venous thrombosis, it is rarely reported that thrombectomy during operation under laparotomy leads to bowel necrosis. We report our precious experience of the case, with a review of the literature.

The patient was a 46-year-old man who underwent total proctocolectomy and ileal J-pouch anal anastomosis (IPAA) for familial adenomatous polyposis (FAP) at the age of 16. After then, he had been followed up in our outpatient clinic until 10 years elapsed after the surgery. About thirty years after the surgery, he presented with general malaise and anemia. Colonoscopy showed multiple polyps and elevated lesions with ulcers in an ileal J-pouch. A biopsy from the elevated lesion revealed well-differentiated adenocarcinoma. Therefore, laparoscopic resection of the ileal J-pouch and the anus, and creation of ileostomy were performed. The pathological examination revealed multiple adenomas confined to the ileal pouch, type 2 advanced cancer, and two carcinomas in situ. Generally, after IPAA for FAP, surveillance of various organs including the jejunum and the ileum is important for a probable risk of carcinogenesis. As for ileal J-pouch, periodic surveillance using endoscopy is also essential.

A 70-year-old man presented with an intra-abdominal mass. A contrast-enhanced abdominal CT scan and contrast-enhanced abdominal MRI showed a faintly enhanced large mass measuring 5 cm in the longest diameter with a well-defined border in the left upper quadrant of abdomen. Pathologically and immunohistologically, the tumor was diagnosed as mesenteric fibromatosis. One year after the resection, a follow-up CT scan showed two well-circumscribed tumors ; one in the small bowel mesentery and the other, near the transverse colon. The tumors were suspected to be recurrences of mesenteric fibromatosis and were resected with a part of the jejunum and transverse colon, respectively. The pathological diagnosis was recurrence of mesenteric fibromatosis. One year and 10 months after the re-resection, the patient is alive without recurrence. We experienced a very rare case of a patient undergoing re-surgery for multiple recurrent mesenteric fibromatosis after resection of mesenteric fibromatosis which developed without history of familial adenomatous polyposis, surgery, or trauma.

A 76-year-old man presented complaining of hematochezia, and abdominal contrast-enhanced computed tomography (CT) showed extravasation within the appendix. On colonoscopy, blood was continuously oozing from the appendiceal orifice, and appendiceal hemorrhage was diagnosed. Endoscopic hemostasis was judged to not be feasible, and laparoscopic appendectomy was conducted on the same day. Histopathological investigations showed an appendiceal ulcer that was considered to be the source of the bleeding. The patient's postoperative course was uneventful ; his condition improved and he was discharged on postoperative Day 6. It is very rare for the appendix to be the source of bleeding in lower gastrointestinal hemorrhage. This case of appendiceal hemorrhage treated by laparoscopic appendectomy is reported along with a summary of other reported cases in Japan.

An 82-year-old man presented to our institution with a one-day history of abdominal pain and bloody stool. The abdomen was flat and right. Tenderness with peritoneal signs was present in all quadrants. Blood test findings revealed elevations in the white blood cell count and CRP. A plain CT scan of the abdomen showed significant wall thickening from the ileocecal area to the ascending colon with fat density elevation sign and free air. We diagnosed the case as colon perforation and performed emergency laparoscopic surgery. Observation of the peritoneal cavity revealed ischemia and gangrene of the cecum. We performed laparoscopic ileocecal resection on the same day. The postoperative course was uneventful. Isolated cecal necrosis appeared to be associated with the patient's history of arteriosclerosis. Isolated cecal necrosis should be considered in diagnosing right lower abdominal quadrant pain.

A 78-year-old woman was presented to the hospital with a chief complaint of consciousness disturbance. The patient was hospitalized for dehydration and cognitive decline treatment. Neurological symptoms of microscopic polyangiitis were diagnosed as the cause of cognitive decline, and steroid pulse therapy was performed. During the steroid reduction course, extensive subcutaneous emphysema was observed mainly on the left side of the chest, extending from the left neck to the lower left abdomen. The only physical finding was extensive subcutaneous emphysema without abdominal symptoms. Computed tomography showed a large amount of emphysema mainly on the left lateral side of the chest, which was connected to the left neck and left pelvic retroperitoneum. No free intraperitoneal air was observed, but small air bubbles were suspected in the mesosigmoid. Based on the findings, mesosigmoid penetration was suspected, and an emergency exploratory laparotomy was performed. Based on the intraoperative findings, the patient was diagnosed with mesosigmoid penetration, and Hartmann's operation was performed. Histopathological findings indicated diverticulum perforation. We report a case of mesosigmoid penetration without evidence of peritonitis, which was discovered due to extensive subcutaneous emphysema.

An 83-year-old man tested positive for fecal occult blood and underwent lower gastrointestinal endoscopy, which led to a diagnosis of T1bN0M0 cStage I descending colon cancer. He had previously undergone endovascular aortic repair (EVAR) for an abdominal aortic aneurysm (AAA) at another hospital. Abdominal and pelvic contrast-enhanced computed tomography (CT) showed a large AAA, measuring 50 mm × 45 mm, in the center of the abdominal cavity, but no endoleak was evident. Given the possibility of AAA rupture or stent graft displacement as a result of contact with forceps from the right-side port that might occur during multiport laparoscopic surgery, as well as the restrictions on forceps operation imposed by the AAA, single-port laparoscopic surgery was conducted. Access was obtained via the umbilicus, at the peak height of the abdomen, which enabled the operation to be conducted safely without displacement of the AAA by the forceps. Cases of laparoscopic surgery for colorectal cancer when an AAA is present are expected to increase in the future, and single-port surgery is an option that enables the risks described above to be avoided. This case is reported together with a discussion of the literature on the value of this technique.

Right hepatic lobe hypoplasia is a rare abnormality, and congenital hepatic lobe hypoplasia is the primary cause, with stenosis and portal vein and bile duct obstructions being secondary causes. Hepatic lobe hypoplasia is often associated with gallbladder malposition, which can lead to torsion and compression of the gallbladder duct, causing biliary stasis and cholelithiasis. Laparoscopic cholecystectomy for cholelithiasis has not been recommended in such cases because of the difficulty approaching the gallbladder. A 72-year-old man with recurrent cholecystitis was referred to our hospital for surgical treatment. Preoperative computed tomography (CT) showed severe atrophy of the right hepatic lobe and dorsally deviated position of the gallbladder in the abdominal cavity. Furthermore, due to the compensatory hypertrophy of the left hepatic lobe, difficulty in maintaining the surgical field was anticipated. Based on the preoperative blood tests and CT, it was thought that the severe atrophy of the right hepatic lobe was caused by congenital hypoplasia. In the present case, laparoscopic cholecystectomy was performed safely with the patient in the left lateral tilt position to secure a clear view of the surgical field. There were no complications after surgery.

A 51-year-old female presented to our hospital with complaints of appetite loss and abdominal pain. Computed tomography (CT) revealed a 16-cm cystic tumor with portal vein thrombosis. Additionally, endoscopic ultrasound-guided biopsy showed acinar cell carcinoma with positive Bcl-2 staining. We chose gemcitabine-S1 (GS) therapy for initial treatment. However, the patient's symptoms became worse during the first course. Thus, the patient underwent semi-emergent pancreatoduodenectomy and portal vein resection. The resected tumor was diagnosed as pancreatic acinar cell adenocarcinoma by histopathology. The postoperative course was uneventful without any adverse events. After discharge, recurrence of peritoneal dissemination was observed before adjuvant chemotherapy. Therefore, the patient was administered FOLFILINOX following four courses of GS therapy. However, the patient died after 14 months postoperatively. This case shows that in patients with pancreatic acinar cell carcinoma, chemotherapeutic response indicates prognosis.

A 52-year-old man consulted his doctor with complaints of lower abdominal pain for 1 year. Blood and urine analyses showed urinary occult blood but no anemia or elevated tumor markers. Computed tomography and magnetic resonance imaging revealed a 75 × 62 mm retroperitoneal tumor with no metastasis. The tumor was in contact with the left common iliac artery and the left ureter was compressed, resulting in hydronephrosis. The patient was referred to our hospital after the placement of a left ureteral stent. Biopsy was difficult due to tumor localization ; therefore, retroperitoneal tumor resection was performed. Histopathology revealed a pleomorphic rhabdomyosarcoma. There was a localized recurrence after 3 years. We performed tumor resection and postoperative radiation therapy at 50 Gy. The clinical course was favorable, with no recurrence or metastasis for 6 years since the first surgery.