The patient was a woman 72-year-old who had been self-interrupted treatment for hypothyroidism for 5 years. She presented to the emergency department with abdominal pain and dyspnea and emergency surgery was performed with a diagnosis of gastrointestinal perforation. Intraoperative findings confirmed small bowel perforation due to strangulated bowel obstruction, and partial resection of the diseased small intestine was performed. Postoperatively, she developed type II respiratory failure and impaired consciousness on the Glasgow Coma Scale E2V4M5, leading to our strong suspicion of myxedema coma. The severity of her condition showed diurnal fluctuation, and due to the frequent occurrence of CO2 narcosis, invasive mechanical ventilation with tracheostomy was required and continued until postoperative day 44. On postoperative day 83, she was discharged home with home oxygen therapy. Myxedema coma is a highly fatal condition based on severe hypothyroidism, leading to circulatory and respiratory failure, or hypothermia. Perioperative onset is rare but can be a serious postoperative complication. We need to prevent those with poorly controlled hypothyroidism from developing myxedema coma in the perioperative period and should suspect myxedema coma when respiratory failure of unknown origin is detected.

Granulomatous mastitis is a relatively rare benign inflammatory disease that predominantly affects women of childbearing age. As the cause is unknown, there is no established treatment. Here, we report a case of granulomatous mastitis in an elderly woman that was unrelated to pregnancy or childbirth. An 89-year-old woman visited her doctor complaining of a right breast mass. She was referred to our department for further examination and treatment. Masses were palpated in areas, A and C, of the right breast, and mammography showed focal asymmetric density in R-UM/I, and R-U/O. Breast ultrasonography revealed two heterogeneous masses with isoechoic and hypoechoic mixture with well defined rough margins measuring 20 mm in diameter in inner upper quadrant and 10 mm in diameter in outer upper quadrant of the right mammary gland, respectively. Needle biopsies of both lesions revealed a centrilobular non-caseating epithelioid granuloma and inflammatory cell infiltration. Consequently, granulomatous mastitis was diagnosed. As no signs of infection, such as abscess formation, were observed, the patient was followed up without treatment, and the mass disappeared one year later.

Breast schwannoma is an extremely rare disease, accounting for only 0.2% of all benign breast tumors. Our case involved a 35-year-old man who presented with a left breast lump of which he had been aware for the last four years. Mammography revealed a round, circumscribed, and high-density lesion at the left 12 o'clock position, while ultrasonography identified a hypoechoic mass measuring 7 mm in diameter. The tumor was suspected to be a fibroadenoma, and the patient was observed. Two years later, the lesion increased to 13 mm, became tender, and showed erythema of the overlying skin. A core needle biopsy (CNB) suggested schwannoma and surgical excision was performed. Histopathologically, spindle cell proliferation, palisading nuclei, and Verocay bodies were observed. Immunohistochemical staining demonstrated positive for S-100 protein, leading to the diagnosis of breast schwannoma. There are no specific imaging findings for schwannomas. Histopathologic examination is believed to be useful for diagnosis, while distinguishing between benign and malignant lesions is often difficult. Therefore, surgical excision is appropriate for both diagnosis and treatment. There have been 56 reported cases of breast schwannoma, with only 9 cases in males, including this report. While breast lumps in males are rare, it is important to consider breast schwannoma as a differential diagnosis.

Although axillary lymph node dissection has been a standard therapy for axillary accessory breast cancer, sentinel lymph node biopsy is recently performed in some cases. We have experienced a case of HER2 positive axillary accessary breast cancer in which local partial excision with sentinel lymph node biopsy was performed after neoadjuvant chemotherapy to omit axillary lymph node dissection. The case involved a 61-year-old woman who was referred to our hospital because she had been aware of a right axillary tumor for 2 months. Close examination led to the diagnosis of accessory breast cancer (cT1N0M0 Stage I, HER2 positive) of the right axilla, and we performed neoadjuvant chemotherapy followed by local partial excision with sentinel lymph node biopsy. Intraoperative frozen section diagnosis was conveyed to us reporting metastasis negative, so that axillary lymph node dissection could be omitted. Pathological study demonstrated a 3-mm sized residual of invasive cancer component. Following the adjuvant systemic therapy with T-DM1, the patient has experienced no disease recurrence.

The patient was a 32-year-old woman. At age 24, the patient underwent right breast-conserving surgery along with sentinel lymph node biopsy, adjuvant chemotherapy (doxorubicin and cyclophosphamide, followed by paclitaxel), and postoperative radiotherapy. At age 32, she was diagnosed with metachronous contralateral multiple breast cancers and underwent left mastectomy plus axillary dissection and chemotherapy (doxorubicin and cyclophosphamide followed by paclitaxel). Multiple brain metastases were detected 1 month after adjuvant chemotherapy (10 months postoperatively). Genetic testing revealed a BRCA1 pathogenic variant, and treatment with olaparib (600 mg/day) was initiated. After 3 months of therapy, magnetic resonance imaging (MRI) showed a significant treatment response for multiple brain metastases (PR) ; however, a contrast effect along the brain surface was observed, and meningeal carcinomatosis was suspected. After 4 months of therapy, MRI showed a continuous response to brain metastases ; however, meningeal carcinomatosis progressed. Despite being treated with whole-brain irradiation and immunotherapy, the disease continued to progress, and the patient passed away 6 months after recurrence. Olaparib is indispensable for the treating breast cancer with BRCA1/2 pathogenic variant. It should be noted that there were differences in responses to intracranial lesions.

In December 2017, a 60-year-old woman was referred to our department from a nearby clinic with the chief complaint of a right breast mass that had been increasing in size for 6 months. Needle biopsy revealed invasive ductal carcinoma of the right breast, ER (-), PgR (-), HER2 score (3+). Systemic examination revealed right axillary lymph node and bone metastases, and trastuzumab + pertuzumab + docetaxel therapy was initiated in December 2017. The patient was switched to trastuzumab plus pertuzumab in May 2018 because of a clinical complete response (cCR) ; however, cerebellar metastasis appeared in December 2018. Radiotherapy for brain metastasis was successful ; however, the left ventricular ejection fraction (LVEF) decreased because of trastuzumab plus pertuzumab therapy. Thus, the patient was followed up without treatment from January 2019 to July 2019. After confirming LVEF recovery, anti-HER2 therapy was resumed from August 2019 to July 2020 ; however, the LVEF decreased again. The treatment has been suspended since July 2020. The patient had been in cCR for 5 years and 1 month after radiotherapy, and 3 years and 6 months after the treatment cessation.

Prosthetic valve endocarditis (PVE) and mediastinitis are serious clinical conditions with a high mortality rate. A rare case of PVE with a mediastinal abscess formation, in which a good outcome was obtained after a one-stage operation, is reported. The patient was admitted for evaluation of fever on day 191 after aortic valve replacement. Blood culture showed Methicillin-resistant Staphylococcus epidermidis. Transthoracic echocardiography showed vegetations on the leaflet and a perivalvular abscess, leading to the diagnosis of PVE. On computed tomography, an abscess cavity extending from the aortic root to the mediastinum, compressing the pulmonary artery, was seen. The patient had untreated dental caries and atopic dermatitis, which were considered the infection route. Aortic root replacement and one-stage omental flap transposition were performed on the fifth day of admission. Intraoperative and postoperative cultures did not identify any bacteria, and there was no infection recurrence. Three years have passed with no recurrence of infection.

An 85-year-old woman presented with left chest pain after she had fallen from her own bed. Chest X-ray showed left pneumothorax. Chest CT scan revealed left multiple rib fractures and intrapulmonary hematoma, and retention of small quantity of pleural effusion was also noted. She was thus admitted to our hospital to observe her clinical course. Chest X-ray conducted on the 2^nd hospital day showed no exacerbations of pneumothorax and pleural effusion, but on the 5^th hospital day, a blood analysis revealed slightly decreased hemoglobin level. Intrapulmonary hematoma improved on a chest contrast-enhanced CT scan, but the fractured rib end projected into the thoracic cavity and perforated into the left upper lobe. The left pleural effusion also increased and we diagnosed the case as delayed traumatic hemothorax. Since the fractured rib end was located adjacent to the left pulmonary artery, re-expansion of the lung might worsen the pulmonary perforation caused by fracture ends. We emergently performed thoracoscopic surgery. At the pulmonary perforated site due to fractured rib ends, the lung and wall side pleura were adhered. Without dissecting adhesions at the perforated site, we performed partial lung resection to achieve hemostasis. Dissection of adhesions of the perforated site after partial resection revealed that the 6^th rib fracture end had protruded into the thoracic cavity. So we made a mini-thoracotomy just above the fracture and performed partial resection of the rib and a stump plasty. After surgery a drain was removed on the 2^nd postoperative day and she was discharged on the 6^th postoperative day. As delayed traumatic hemothorax caused by fractured rib end is rare, we present our case with bibliographical comments.

The patient was a 68-year-old man. He was treated with antimicrobial chemotherapy for pulmonary nontuberculous mycobacterial (NTM) disease during the half year at the age of 57. He developed hemoptysis and underwent thoracoscopic resection of the right upper lobe at 58 years old. He refused to undergo postoperative chemotherapy. About one year later, a cyst with a membrane appeared just below the port site under the right scapula, and we excised it under local anesthesia. Pathologically, there were no specific changes in the cyst wall and thickened fibrous pleura was diagnosed. Ziehl-Neelsen staining and acid-fast bacillus culture of the fluid were negative, and we diagnosed the case as a chest wall hernia based on the clinical course. Eight years after excision of the cyst, the same area was found to be re-inflated. The lesion was more extensive than before. Under general anesthesia, we resected the cyst with a hard fibrous membrane completely. Thoracoscopic examination revealed no abnormalities in the pleura or thoracic cavity. Mycobacterium avium was detected in a cyst wall culture and PCR, we diagnosed the case as late-onset infected chest wall cyst. Although chest wall infection after thoracoscopic surgery for NTM is rare especially by slow-growing bacteria, it should be kept in mind, and we reaffirmed the importance of pre- and postoperative antibacterial chemotherapy.

The patient was a 69-year-old man. He presented to our hospital for a detailed evaluation of an abnormal mediastinal shadow seen on a plain chest X-ray taken during a medical check-up. A plane CT scan and contrast-enhanced MRI revealed a 4 cm defect in the right anterior part of the diaphragm and a greater omentum protruding into the mediastinum from the same area, leading to the diagnosis of diaphragmatic hernia. As the patient was asymptomatic, it was decided to perform an elective operation. The operation was performed laparoscopically with thoracoscopic observation of the right thoracic cavity. Intraoperatively a Morgagni hernia was diagnosed. The hernia sac was excised and the hernia orifice was closed by extracorporeal ligation and then augmented with a prosthesis. Although there have been many reports of laparoscopic surgery for diaphragmatic hernia in recent years, the number of cases with thoracoscopic observation is very small. In our case, the hernia sac was resected laparoscopically for the sake of cure, but thoracoscopic observation allowed us to assess the mediastinal emphysema, which is a problem with this technique, and to avoid the risk of damage to organs in the thoracic cavity or the mediastinum.

A 71-year-old woman underwent Hartmann's procedure for perforation of the sigmoid colon at the age of 48 years. Three months later, she developed a parastomal hernia. She presented with abdominal pain, leading to the diagnosis of gastrointestinal perforation caused by incarcerated parastomal hernia.

Abdominal computed tomography (CT) showed prolapse of the stomach, small intestine, and colon into the hernia sac along with free air. Intraoperatively, the gastric body was found incarcerated at the hernia orifice, leading to perforation in the upper part of the gastric body. Although direct suture closure of the perforation site was performed, attempts to reduce the herniated organs into the abdominal cavity proved challenging. Additional small bowel resection was performed for volume reduction purposes, but reduction was deemed impossible. Consequently, the decision was made to release the hernia orifice and only reduce the incarceration.

Postoperatively, an intestinal skin fistula occurred. Despite weight management and subsequent creation of a small bowel stoma, definitive hernia repair could not be achieved. This case highlights the importance of not focusing on reducing herniated organs in cases of extensive parastomal hernia incarceration ; a judicious decision to only release the incarceration may be necessary.

We present a case of hypertrophic pyloric stenosis developed in an adult, diagnosed preoperatively and resected surgically. A 79-year-old man presented to our hospital with feeling of tightness and vomiting symptoms. For about one year prior to his visit, he had been followed by his previous doctor for reflux esophagitis, esophageal ulcers, and suspected lesions of esophageal cancer. Blood biochemistry tests revealed no abnormalities including tumor markers. Endoscopy of the upper gastrointestinal tract confirmed that the pyloric ring thickened around the entire circumference and looked like a cervix, the so-called cervix sign. Since there were no neoplastic lesions in the pylorus area by abdominal enhanced CT and there were no enlarged peripheral lymph nodes, distal gastrectomy was performed with the pre-operative diagnosis of hypertrophic pyloric stenosis in an adult. One year after surgery, he is still doing well. When patients present with repeated vomiting symptoms, reflux esophagitis, esophageal ulcers, and delayed gastric emptying, this disease should also be recalled as a differential diagnosis.

The patient was an 82-year-old woman who underwent endoscopy to determine the cause of anemia. A type 2 lesion was found on the posterior wall of the gastric curvature from the fundoplication area to the posterior wall of the hypogastric curvature, and it was diagnosed as adenocarcinoma by biopsy. She underwent total gastrectomy, distal pancreatectomy, and splenectomy. On histopathological examination, the lesion was SALL4-positive and AFP-negative, and a diagnosis of adenocarcinoma with enteroblastic differentiation was made. Considering her age, adjuvant chemotherapy was not administered. One year and two months after the surgery, metastases were found in the uterus, left obturator node, and peritoneum. One year and three months after the surgery, liver metastasis occurred, and the patient passed away one year and four months after the surgery.

Gastric adenocarcinoma with enteroblastic differentiation is very rare, and it is classified as a special type of malignant epithelial tumor. It is associated with a high rate of venous invasion, lymphatic invasion, and liver metastasis, and is considered to have an extremely poor prognosis. However, since the number of cases is small, and there is no established treatment strategy, further studies are needed.

A 73-year-old man who had been under observation at another hospital for type A gastritis was found to have elevated lesions in the stomach and referred to our hospital. Further investigations in the Department of Gastroenterology resulted in a diagnosis of neuroendocrine tumors (NETs) in the middle part of the gastric corpus, one measuring 4 mm in the anterior wall and another measuring 5 mm in the posterior wall. Endoscopic submucosal dissection (ESD) was performed. Histopathological examination showed that the lesion in the anterior wall was endocrine cell hyperplasia, whereas that in the posterior wall was a grade 1 NET. Upper gastrointestinal endoscopy seven months post-ESD showed ESD scars and a 5-mm elevated lesion at another location in the anterior wall of the middle part of the gastric corpus, which was diagnosed by biopsy as grade 1 NET. Mucosal reddening was also evident at locations other than the biopsy site. Theretore it was judged unlikely that medical treatment would be curative, and robot-assisted distal gastrectomy (D1+lymph node dissection) was performed. Histopathological examinations showed a total of four grade 1 NET lesions, and early gastric cancer (Sig, pT1a, pN0), 7 mm in size, was also present within the specimen. The patient's postoperative course was uneventful, with no complications. This case suggests that endoscopic diagnosis that bears in mind the possibility of early gastric cancer is important when performing gastrectomy for carcinoid lesions on a background of type A gastritis.

The patient was a 55-year-old man who had been experiencing recurrent abdominal pain. He presented to the emergency department with abdominal pain that had started 6 hours earlier. Computed tomography (CT) showed multiple fat-density lesions within the intestinal tract and free air. Intraoperatively, a perforation was identified in the dilated segment of the bowel, necessitating a small bowel resection. Gross examination of the resected specimen showed multiple pedunculated tumors within the intestinal tract, and a perforation was identified in the mucosa at the base of the tumor. Microscopically, adipose tissue proliferation was observed within the submucosal layer. Based on these findings, intestinal perforation secondary to small bowel lipomatosis was diagnosed. The patient had an uneventful postoperative course, with no recurrence of abdominal pain noted over the subsequent 2 years.

Small bowel lipomatosis is a rare condition, with most cases presenting as intestinal intussus-ception. To the best of our knowledge, this is the first reported case of small bowel lipomatosis presenting with perforation in Japan.

A 70-year-old man was referred to our hospital for surgical treatment of recurrent appendicitis in September 2022. Colonoscopy and computed tomography (CT) were conducted as pre-operative examinations. Colonoscopy did not show any mucosal disorders, and there were no malignant findings in the biopsy specimen from the appendiceal orifice. CT of the abdomen showed localized wall thickening of the appendix. This was also seen on CT in 2021 and 2022 when he was diagnosed with appendicitis, but it was not seen before 2021. Laparoscopic appendectomy was performed in November 2022. A localized mass region was observed in the body of the appendix during surgery. Macroscopic examination showed a white nodular lesion in the body of the appendix. On microscopic examination, spindle-cell proliferation with prominent eosinophilic infiltration was identified within the submucosa. Immunohistochemical stains showed that the spindle-shaped cells were positive for CD34 and negative for desmin, c-kit, EMA, and S100P. Based on these findings, an inflammatory fibroid polyp (IFP) on the appendix was diagnosed. An IFP on the appendix is a rare benign tumor, and its cause is unclear. We suggest that resection is an appropriate treatment for an IFP on the appendix because it could cause appendicitis.

A 63-year-old man presented with a positive fecal occult blood test and was diagnosed with ascending colon cancer after a detailed examination. The patient had a history of thrombocytopenia incidentally detected at the age of 61. His blood test was positive for anti-cardiolipin and β2-glycoprotein-I complex, and antiphospholipid antibody syndrome was diagnosed. His preoperative coagulation tests showed absence of abnormalities, and antithrombotic therapy was not administered at surgery. However, due to a preoperative platelet count of approximately 50,000, he underwent high-dose intravenous immunoglobulin (IVIG) therapy and platelet transfusion to increase the platelet counts. followed by laparoscopic ileocolic resection. The perioperative period proceeded without hemorrhagic complications. Here, we report a case of ascending colon cancer accompanied by thrombocytopenia associated with antiphospholipid antibody syndrome, in which the perioperative period was successfully managed with high-dose IVIG therapy and platelet transfusion, with considerations from the literature.

An 83-year-old man was admitted to our hospital due to massive rectal bleeding. He had undergone Hartmann's procedure three years earlier at another hospital for sigmoid volvulus. A significant increase in inflammatory markers and worsening renal function were observed on the third day of admission. Emergency colonoscopy from the anus showed extensive necrosis in the remaining rectal mucosa. He was diagnosed as having severe ischemic proctitis, and emergency surgery was performed. Intraoperatively, no necrosis was observed on the serosal surface, and the inferior mesenteric vessels preserved in the previous surgery were intact. The remaining rectum was mobilized as far as possible towards the anal side and resected in the lower rectum as close to the anus as possible. Postoperatively, disruption of the rectal stump caused a pelvic abscess, which improved with transanal drainage. The patient was transferred to another facility on the 31st postoperative day.

Although colon cancer incarcerated in an inguinal hernia is a rare situation, it needs urgent care due to the high risk of perforation and necrosis. A case of a sigmoid colon cancer incarcerated in a left inguinal hernia treated with laparoscopic surgery is presented. A 75-year-old man with a 20-year history of a left inguinal hernia was referred to our facility for positive fecal occult blood. Examination showed two sigmoid colon adenocarcinoma lesions incarcerated in the inguinal hernia, and surgery was planned. Laparoscopic sigmoid colon resection was performed due to mass incarceration using the anterior inguinal hernia surgical site for extraction. Iliopubic tract repair was subsequently performed. No postoperative complications occurred, and at present there is no evidence of recurrence of either the cancer or the hernia.

An inflammatory pseudotumor (IPT) is a clearly demarcated mass lesion characterized by inflammatory histology. Recent findings indicate that IPT may include true neoplastic lesions that recur and metastasize. These have been differentiated as inflammatory myofibroblastic tumors (IMT). IMTs share similar histological features with IPTs but are distinguished by the presence of ALK gene rearrangement in approximately half of the cases. Despite this, no method has been established to clearly differentiate between the two. Here, we report a case involving a right inguinal mass that was initially diagnosed as an IPT based on pathological examination following surgical resection. Immunostaining was ALK negative, suggesting a high probability of IPT. However, it was challenging to definitively rule out IMT ; hence, we continued to follow up with the patient through periodic imaging.

Reduction en masse of a hernia is a rare condition where a prolapsed organ is retracted into the preperitoneal space while remaining trapped within the hernia sac. This complication has been documented following the reduction of incarcerated inguinal or femoral hernias. Obturator hernias themselves are uncommon, and cases of reduction en masse within this type of hernia have yet to be reported. We present a case of a patient with a reduced en masse of obturator hernia. An 85-year-old woman diagnosed with a left incarcerated obturator hernia via computed tomography (CT) underwent ultrasound-guided reduction and was subsequently hospitalized. On the third hospital day, she developed intestinal obstruction necessitating exploratory laparotomy due to a lack of improvement. Intraoperatively, the herniated small intestine was found to be reduced into the preperitoneal cavity through the obturator foramen, remaining incarcerated within the hernia sac, consistent with a diagnosis of reduction en masse. The surgical approach included small bowel resection, inversion and ligation of the hernia sac, followed by laparoscopic radical hernia repair at a later date. Retrospective CT imaging of post-reduction identified a preperitoneal hernial sac sign, a characteristic finding of reduction en masse. Our case highlights the potential for incarcerated obturator hernias to undergo reduction en masse after initial reduction. Therefore, post-reduction CT imaging is crucial to confirm the absence of this life-threatening complication.

A 64-year-old male patient underwent right eyeball enucleation for right choroidal malignant melanoma in 2008. He had no recurrence and the follow-up was already completed, but a pelvic mass was noted on a preoperative CT scan for percutaneous angioplasty for arteriosclerosis obliterans of the left lower extremity in December 2021. The tumor was suspected to be a submucosal tumor of the small intestine or sigmoid colon, and since it was less than 3 cm in diameter, the patient was followed up for observation. A CT scan conducted in April 2022 showed an increasing tendency of the tumor and intratumoral hemorrhage and surgical resection was performed for diagnosis and treatment. The tumor was black and adherent to the sigmoid colon and bladder, and multiple black masses were observed on the liver surface. The colon and bladder were partially resected in combination, and histopathological examination revealed a diagnosis of metastatic malignant melanoma of the sigmoid colon. The liver mass was later diagnosed as hepatic metastasis of malignant melanoma by EOB-MRI.

We report this case because choroidal malignant melanoma itself is a rare disease, and this is a rare case of metastasis after the completion of follow-up after surgery of the primary tumor.