Malperfusion of aortic branch vessels is a common, but catastrophic complication of acute aortic dissection associated with poor outcomes. Branch vessel obstruction causing organ malperfusion may be static, dynamic, or a combination of both. Patients with malperfusion are more likely to have an entry tear in the aortic arch and distal extension of dissection. Coronary, cerebral, and mesenteric malperfusion in particular increase the risk of death. Thus, treatment strategies that prioritize revascularization of the ischemic organ are important for such organ malperfusion. A therapeutic approach by an aortic team may facilitate early organ revascularization, leading to improved outcomes.

Locally advanced breast cancer often leads to ulcers that deteriorate the quality of life due to bleeding, exudate, malodor, and pain. Notably, there are no existing topical agents that can treat these symptoms and can be safely self-administered by patients. Therefore, we have developed and tested a original paste (Kishimoto paste ; K paste) that can be used safely and can simultaneously treat these symptoms.

We retrospectively examined the efficacy of K paste in 10 patients who used it between January, 2010 and January, 2020. At the initial visit, all the patients presented with ulcer exudate, nine had minor bleeding from the ulcer, eight had malodor associated with the ulcer, and seven had ulcer pain. The ulcer area was fully coated with K paste and subsequently covered with gauze.

There was an improvement or disappearance of symptoms and no side effects other than mild redness of the paste contact area were observed.

K paste was effective in treating various symptoms arising from skin ulcers associated with breast cancer. It is inexpensive and relatively safe to use without serious side effects. Hence, K paste has promising potential to treat patients with extensive breast cancer ulcers and associated symptoms that are difficult to control.

A 33-year-old Latin American woman, with a family history of breast cancer in her first cousin, initially presented with a lump in her right breast that had been present for 1 month. Ultrasonography revealed an 8-cm mass under the right nipple. The core needle biopsy performed by the previous doctor did not indicate malignancy. Due to the large size of the tumor, the patient was subsequently referred to our institution for surgical excision. Imaging showed a 75-mm tumor with numerous cystic lesions. Although the review of the specimen at our institution could not definitively rule out ductal carcinoma in situ, preoperative imaging did not provide any evidence of malignancy. The patient underwent tumor excision, and the pathological diagnosis was juvenile papillomatosis (JP). JP of the breast is a relatively rare disease and cases in the Asian population are rarely reported. Complete resection of the tumor is the first choice for the treatment of JP, and systemic treatment is generally not required. However, regular follow-up care is necessary because JP, especially in conjunction with a positive family history, might be a risk factor for developing breast cancer.

With the improvement in survival rate after kidney transplantation in Japan, the frequency of malignant neoplasms after kidney transplantation has increased.

Our hospital has a kidney disease center ; hence, many patients visit our hospital regularly after having undergone living donor kidney transplantation, and we have observed several cases of breast cancer after kidney transplantation.

We report two cases involving immediate breast reconstruction for breast cancer that developed after living kidney transplantation. Case 1 involves a 46-year-old woman who underwent bilateral mastectomy and primary two-stage reconstruction with implants for bilateral breast cancer. Case 2 involves a 42-year-old woman who underwent a right nipple sparing mastectomy for right breast cancer and primary one-stage and autologous tissue reconstruction with latissimus dorsi myocutaneous flap (LD flap).

In this report, we detail the perioperative management and literature review of these cases.

The patient was a 63-year-old woman. One year after surgery for transverse colon cancer, a chest CT scan showed a 1-cm nodule in the periphery of S1+2 of the left lung, and pulmonary metastasis was suspected. In addition, a mediastinal goiter, which had been followed up in another department, tended to increase in size and was accompanied by tracheal deviation. We admitted that the goiter should also be resected in terms of anesthesia and postoperative respiratory control for lung metastasis, and performed simultaneous operation. The operation was started by adding a median sternotomy to the collar incision of the neck. The mediastinal goiter was resected by dissection at the isthmus and the lower part of the right lobe. After that, right unilateral ventilation was performed with a bronchial blocker, and partial resection of the upper lobe was performed for a tumor in S1+2 of the left lung. A hoarseness was observed temporarily after the operation, but was relieved and she was discharged from the hospital. The pathological diagnosis was adenomatous goiter and lung metastasis of transverse colon cancer.

Mediastinum goiter without subjective symptoms is indicated for surgery if it causes tracheal deviation, and the removal may be necessary for anesthesia and respiratory control when pulmonary resection is planned.

A 74-year-old man underwent right transthoracic esophagectomy with 3-field lymph node dissection and reconstruction using a gastric tube in posterior mediastinal route for esophageal cancer in September 2019. One year after surgery, he was brought into a local hospital for acute abdomen. Computed tomography (CT) showed prolapse of the small intestine into the right thoracic cavity. The patient was referred to our hospital with a diagnosis of postoperative diaphragmatic hernia through the esophageal hiatus. As abdominal pain was temporarily relieved, conservative therapy was performed. However, on the 12th day after admission, the patient had recurrent abdominal pain, and emergency surgery was performed because a hiatal hernia was suspected on a thoracoabdominal contrast-enhanced CT scan. After surgery, he had a surgical site infection (dehiscence) and required re-suture of the abdominal wall, but he was discharged on day 36 after re-suture. Esophageal hiatal hernia occurring in the reconstructive route after esophagectomy is relatively rare. The escape of the gastric conduit into the right thoracic cavity may result in a hiatal hernia. It was thought to be necessary for surgical treatment for postoperative hiatal hernia because it would not improve with conservative therapy.

An 83-year-old woman underwent distal gastrectomy (D2 dissection, Billroth I reconstruction) for gastric cancer and was discharged 15 days after surgery without complications. She was diagnosed with pT2 (MP) N3bM0, pStage III B and was receiving adjuvant chemotherapy with TS-1. On the 65th postoperative day, she suddenly developed hematemesis and melena. A contrast-enhanced CT scan revealed bleeding from a pseudoaneurysm in the gastroduodenal artery, and arterial embolization was performed. Bleeding due to rupture of a pseudoaneurysm after gastrectomy is rare, and most cases occur secondary to suture failure or pancreatic juice leakage within a month after surgery. On the other hand, there are some reports that heat generated by devices such as ultrasonic coagulator and incision causes vascular damage and pseudoaneurysm formation. Perioperative management and appropriate operation of the device are considered important, taking into account the possibility of ruptured pseudoaneurysm as a complication of gastrectomy.

A 64-year-old woman who had been dizzy for two months was rushed to our hospital due to vomiting and hematemesis. Upper endoscopy on admission showed scirrhous gastric cancer and an exposed aneurysm at the base of the ulcer. Abdominal contrast-enhanced computed tomography showed thickening of the gastric wall and an exposed, 7.5-mm, right gastroepiploic aneurysm in the stomach. Three days after admission, she developed hemorrhagic shock after vomiting a large amount of blood, and she underwent emergency surgery. At the time of laparotomy, there was no intraperitoneal bleeding ; all bleeding was limited to within the gastrointestinal tract. Therefore, she was diagnosed as having a ruptured right gastroepiploic aneurysm. After ligating the inflow and outflow vessel of the aneurysms, distal gastrectomy was performed. The resected specimen showed a ruptured vessel wall at the base of the gastric cancer ulcer. After discharge from the hospital on the 15th postoperative day she underwent chemotherapy, but she died of gastric cancer 11 months after the operation. Although patients with a right gastroepiploic aneurysm that ruptures in the gastrointestinal tract are extremely rare, such rupture can easily lead to shock ; therefore, prompt diagnosis and treatment are needed.

A 40-year-old male patient with neurofibromatosis type 1 (NF1) underwent upper gastrointestinal series for epigastric discomfort and was diagnosed as having a 30-mm sized, gastrointestinal stromal tumor (GIST) with intraluminal growth pattern at the upper body of the stomach. A thoracoabdominal CT scan demonstrated no other lesions in our case, however, NF1-related GISTs often occur in the small intestine and prone to develop in multiple organs. Accordingly, it would be important for operative procedure not only to resect gastric GIST but also to confirm the absence of other lesions in the abdominal cavity. At surgery, we confirmed the absence of other lesions by close laparoscopic observation of the abdominal cavity, and then performed local gastric resection for gastric GIST by means of laparoscopic and endoscopic cooperative surgery (LECS). The postoperative course was uneventful and no recurrence has occurred as of 4 years after the operation.

It is very rare that NF1-related GIST occurs solitary in the stomach. If GIST of the stomach is detected in a NF1 patient, we must keep a possibility of the presence of other lesions in mind ; and even in a case in which preoperative imaging did not show any other lesions, we should actively perform intraoperative survey. As the procedure, laparoscopic observation may be useful in terms of minimal invasiveness.

A 34-year-old woman presented to a clinic with epigastralgia and was diagnosed with type 3 gastric cancer. Cystic lesions in both ovaries were detected preoperatively, which were diagnosed as benign tumors. There was no peritoneal dissemination in staging laparoscopy. After laparoscopic enucleation of the right ovarian tumor, open distal gastrectomy with D2 lymph node dissection was performed. Histopathology revealed stage IIB gastric cancer (por, T4a(se), Ly1a, V1a, N0, M0) and a mature cystic teratoma in the right ovary. After adjuvant chemotherapy, the right ovary began to grow, which appeared to be ovarian metastasis of gastric cancer or malignant conversion of the teratoma. Fourteen months after the gastric resection, bilateral oophorectomy was performed. Histopathology revealed the right ovarian tumor to be ovarian metastasis of gastric cancer, so-called “Krukenberg tumor”. She has been well without any recurrence for 5 years after gastrectomy or 4 years after oophorectomy. Although gastric cancer without accompanying lymph node metastasis nor peritoneal dissemination rarely metastasizes to the ovary, resection of the ovaries should be considered if they are growing in size. In addition, MRI may be useful in evaluating ovarian lesions which have existed there before the surgery during the follow-up.

Case 1 was a 70-year-old woman who presented with a complaint of shortness of breath due to anemia. Further investigations showed Type 2 advanced cancer in the gastric antrum. Computed tomography (CT) showed that not just the regional lymph nodes, but lymph nodes throughout the body were enlarged. Multiple lymph node metastases of gastric cancer were suspected, but rapid intraoperative pathological diagnosis of the paracolic lymph nodes resulted in a diagnosis of sarcoidosis, and open distal gastrectomy was performed. The final pathological diagnosis was pT2N0cM0 Stage IB, with all of the lymph nodes affected by sarcoidosis. Case 2 was a 75-year-old man who had been found to have anemia at a regular health check-up. Further investigation showed Type 0-IIa early gastric cancer in the gastric antrum. On thoracoabdominal CT, in addition to the gastric regional lymph nodes, the mediastinal lymph nodes were also enlarged. Preoperative whole-body magnetic resonance imaging (MRI) was considered negative for gastric cancer metastases, and laparoscopic distal gastrectomy (D2) was performed. The final pathological diagnosis was pT1bN0cM0 Stage IA, with sarcoidosis evident in the regional lymph nodes. In the event that multiple lymph node enlargement other than of the regional lymph nodes is seen in cases of gastric cancer, the treatment strategy must be decided with care, considering the possibility of the concomitant presence of sarcoidosis or another systemic disease.

A 51-year-old female patient underwent a laparoscopic total gastrectomy and D2 lymphadenectomy with Roux-en-Y reconstruction for pT3N0M0 pStage II A gastric cancer. At postoperative month 13, she presented at the emergency department with an abrupt onset of abdominal pain and vomiting. An abdominal plain X-ray revealed a small amount of intestinal gas and intestinal dilatation. An abdominal computed tomography demonstrated a target sign in the jejunal limb near the Y anastomosis and dilatation of the oral side of the jejunal limb. A nasal tube was inserted for decompression and drained dark red fluid. Based on these findings, strangulated bowel obstruction with intussusception in the Y-anastomosis was diagnosed, and emergency surgery was performed on the same day. No evidence of recurrence was found intra-abdominally, and the jejunum on the anal side of the Y-anastomosis was retrogradely intussuscepted within the jejunum limb and partly within the Y-limb. As the invagination was unable to be repositioned using the Hutchinson technique, the invaginated area was resected, and the Y-anastomosis was re-reconstructed. There are few reports of similar retrograde intussusception after a total gastrectomy. Early diagnosis and early intervention should be considered for intussusception at the Y anastomosis after a gastrectomy.

An 83-year-old woman presented to a local clinic complaining of back pain and vomiting. She was referred to our hospital with suspected intestinal obstruction. Abdominal radiography showed intestinal obstruction, abdominal ultrasonography showed multiple concentric ring signs, and abdominal contrast-enhanced computed tomography (CT) showed a concentric layered intestinal canal in the left abdominal cavity. The patient was diagnosed as having intestinal obstruction due to intestinal accumulation, and emergency surgery was performed on the same day. Intraoperative findings showed small intestinal accumulation, and the oral side of the intestine was dilated. Manual repair was attempted, but it was difficult, so partial resection of the small intestine was performed. The surgical specimen showed adhesions of the mesentery and abscess accumulation encapsulated between the intestinal membranes. Histopathological examination showed anisakiasis worms, necrotic tissue, and granulomas in the mesentery at the site of intestinal accumulation. The surrounding intestinal wall was edematous, consistent with chronic anisakiasis. Anisakiasis of the small intestine is relatively rare, and a case of small intestinal accumulation due to abscess formation caused by an anisakiasis worm is reported along with some discussion of the literature.

A 22-year-old man presented with abdominal distention and abdominal pain. He was referred to our hospital for further treatment, because a contrast-enhanced computed tomography revealed a large intra-abdominal tumor of mesenteric origin that showed a rapid growth tendency with intra-tumorous hemorrhage and abscess formation. C-reactive protein was markedly elevated, and he was in a poor general condition with coagulopathy and severe nutritional disorder. We identified the tumor origin to be the ileocecal mesentery and judged that the tumor could be removed by semi-urgent ileocecal resection. A tumor 30 cm in size was found in the ileocecal mesentery, with invasion into the cecum and appendix. Based on histopathological findings, a diagnosis of desmoid fibromatosis was made. In this study, we experienced a case of resection of a giant mesenteric desmoid tumor that showed a rapid growth tendency with intratumoral abscess formation. Giant mesenteric desmoid tumors can be complicated by abscess formation, resulting in poor general condition, and it is important to perform surgery safely after thorough imaging evaluation to avoid missing the time when surgical resection is possible.

Intracorporeal anastomosis after laparoscopic colectomy has been introduced in recent years in Japan. We have also performed this procedure since 2020, but we have not fully shared the pitfalls of this procedure because it is a new method compared with extracorporeal anastomosis. The case of a 67-year-old man who developed an internal hernia on the 15^th postoperative day after laparoscopic right hemicolectomy for ascending colon cancer is presented. Preoperative computed tomography and intraoperative findings showed that the small intestine was incarcerated from the dorsal side to the ventral side through the mesenteric defect. Laparoscopic adhesiolysis was performed on the 5^th day after onset. After dissecting the adhesions and repositioning the small intestine, the mesenteric defect was closed with an omental patch. Closure of the mesenteric defect was then performed with non-absorbable suture thread as is our routine, because of which we have never had a case of internal hernia after laparoscopic colectomy. In some papers on laparoscopic gastrectomy that introduced intracorporeal anastomosis earlier, closure of Petersen's defect after Roux-en-Y reconstruction was recommended due to the risk of internal hernia. Our experience suggests that the mesenteric defect of reconstructed intestine needs to be closed after laparoscopic colectomy with intracorporeal anastomosis.

A 64-year-old woman presented at a local clinic complaining of general malaise. Blood tests showed hepatic impairment, and she was referred to our hospital for further examination and treatment. Abdominal ultrasound conducted at an outpatient appointment to investigate the cause showed signs of hepatic congestion, and when echocardiography was performed, a large amount of circumferential pericardial effusion and reduced left ventricular ejection fraction were evident. Cardiac tamponade and right heart failure were diagnosed, and she was admitted as an emergency. Cytological examination of pericardial fluid collected by pericardiocentesis conducted during admission showed atypical cells, and carcinomatous cardiac tamponade was diagnosed. Thoracoabdominal contrast-enhanced computed tomography (CT) showed thickening of the wall of the transverse colon, enlargement of the para-aortic and mediastinal lymph nodes, and enlargement of the left adrenal gland. Thoracoabdominal magnetic resonance imaging (MRI) identified bone metastases in thoracic vertebra Th7 and lumbar vertebra L5. Lower gastrointestinal endoscopy showed circumferential Type 2 advanced cancer of the transverse colon, and cStage IV b transverse colon cancer was diagnosed based on these findings. This is an extremely rare case of the discovery of transverse colon cancer as a result of cardiac tamponade.

A 73-year-old male presented with melena and underwent a transrectal prostate biopsy under ultrasound guidance for a suspected diagnosis of prostate cancer. Six hours after the biopsy, a large amount of melena was observed, and it was difficult to stop the bleeding even with pressure. Then the patient was referred to our department on the same day due to a suspicion of rectal wall hemorrhage. On arterial phase CT, the contrast medium leaked into the rectum from rectal wall at the level of the seminal vesicle. A diagnosis of iatrogenic bleeding due to rectal wall injury was made, and an emergency operation was performed on the same day. Selective angiography of the superior rectal artery revealed leakage of the contrast medium into the rectum from the peripheral branch. Embolization with a gelatin sponge (Gelfoam^®) followed by coil embolization <Stryker Target XL (360°) ^®> was performed. After that, the disappearance of the leakage of the contrast agent was confirmed by contrast angiography. The postoperative course was favorable and the patient was discharged from the hospital on the 11th postoperative day. It is suggested that transcatheter arterial embolization is effective by selecting cases when clearly damaged blood vessels can be identified before surgery.

Case 1 was a 74-year-old woman with bowel obstruction due to invasion of peritoneal seeding into the ileostomy after total colectomy. A self-expandable metallic stent (SEMS) was placed, and the patient was discharged after 7 days. Case 2 was a 71-year-old man with bowel obstruction due to invasion of peritoneal seeding into the colostomy after the Hartmann procedure ; he underwent SEMS implantation and was discharged after 11 days. SEMS placement for cancerous stenosis of an ostomy can be performed minimally invasively, is very effective in improving the quality of life of terminally ill patients, and is considered a useful option.

Cholelithiasis is a rare complication of cholelithiasis. Although deirritation is necessary, there is no established opinion regarding closure of the internal biliary fistula. The patient, a 78-year-old woman, presented to our hospital with a chief complaint of vomiting. Computed tomography (CT) revealed a 30 mm-sized gallstone fitted into the small intestine and a cholecystoduodenal fistula. We performed an emergency small bowel lithotomy for a diagnosis of ileus due to gallstones, and decided to treat the cholecystoduodenal fistula conservatively in the hope that it would close spontaneously. Seven months after surgery, an upper gastrointestinal endoscopy revealed a residual fistula, for which the patient underwent laparoscopic resection using an automated suture device and cholecystectomy. Fistulectomy is recommended for internal biliary fistulas owing to the risk of retrograde cholangitis and biliary tumors. However, given the frequent occurrence of spontaneous closure of the fistula and the substantial increase in risk associated with performing a one-stage fistulectomy concurrently with ileus release surgery, a two-stage procedure is recommended. Additionally, the consideration of minimally invasive laparoscopic surgery is contingent upon the size of the fistula and the degree of inflammation. In cases where this approach is deemed appropriate, a two-stage laparoscopic cholecystoduodenal fistulectomy has proven to be beneficial.

In this report, we present a review of the literature concerning a rare case of cholecystitis with sludge and a cyst located in the wall of the gallbladder neck. The patient was a 78-year-old man who visited our hospital due to mild upper abdominal pain after breakfast. Laboratory findings revealed elevated levels of hepatobiliary enzymes (T-Bil 1.5 mg/dl, AST 63U/L, ALT 47U/L) and CRP (1.39 mg/dl). Abdominal ultrasonography demonstrated a thickened gallbladder wall, bile sludge in the gallbladder, and a cystic area in the wall of its neck, suspected to be a Rokitansky-Aschoff sinus. CT scan demonstrated mild wall thickening and enlargement of the swallen gallbladder. Subsequently, laparoscopic cholecystectomy was performed under the diagnosis of acute cholecystitis with gallbladder sludge and adenomyomatosis. Upon opening the resected gallbladder, a mucus-containing cyst less than 10 mm in diameter was found in the wall of its neck. Histopathological examination revealed it to be a dilation of an encapsulated glandular duct with no malignant findings. Gallbladder cysts are rare, and only 17 cases, including ours, have been reported in Japan. Nevertheless, in view of the possibility of cancer development, it is important to follow up patients closely for cyst expansion and not overlook the timing for surgery.

A 74-year-old man presented to our hospital for a detailed examination to evaluate abnormal liver function detected by a medical checkup. He had a history of extracorporeal shock wave lithotripsy (ESWL) for right urolithiasis 26 years ago. Abdominal computed tomography revealed a mass lesion adjacent to the cecal wall and enlarged lymph nodes around the root of the ileocolic artery and vein. Colonoscopy revealed no abnormalities in the cecal mucosa. Laparoscopic ileocecal resection with regional lymph node dissection was performed for a definite diagnosis and further treatment. An additional resection was performed because of suspected invasion of the mass lesion to the testicular artery and vein, which was found intraoperatively. The operation was completed with an ileocecal resection and functional end-to-end anastomosis. The macroscopic findings of the mass showed that it was 25 × 20 mm in size and had a cystic lesion filled with old blood components. Histological findings of the mass lesion have a damaged three-layered structure of the testicular artery wall, therefore, the mass lesion was determined to be a pseudoaneurysm. On the other hand, the lesion suspected to be a lymph node metastasis was diagnosed as a schwannoma. So far, only few cases of pseudoaneurysm suspected to be caused by ESWL have been few reported. The postoperative course was uneventful, and the patient was discharged 8th days after operation.

The patient was an 82-year-old man, who was initially diagnosed with incarceration of the right inguinal hernia due to difficulty in moving, and subsequently transferred to our hospital. A manually irreducible giant inguinal hernia was found, and emergency surgery was performed because necrosis could not be ruled out on CT. Surgery was initiated using the inguinal method. However, a lower incision was made for observation of the whole bowel, resulting in that intestinal necrosis was found at two sites. The first loop was intraperitoneal ileum approximately 20cm long located 10cm from the ileocecal valve, and the second ileal loop was 80cm long in the hernia sac located 70cm from the terminal ileum. Each necrotic loop underwent resection and anastomosis. After a favorable postoperative course, the patient was transferred to another hospital on the 23rd day of illness.

Maydl's hernia is a very rare condition in which multiple intestinal loops prolapse into the hernia. This condition can occur in patients with a giant inguinal hernia and may result in necrosis of the intraperitoneal intestine between the incarcerate loops, as well as of the intestine in the hernia sac. Therefore, this treatment requires careful decision-making with surgery in mind.