While hospitals that have introduced planning in collaboration with primary care providers to share the therapeutic process and common policies for medical treatment, a clinical pathway in a regional alliance for cancer has been established and used as a tool to provide safer and higher quality health care. The clinical pathway focuses on the top 5 cancers and has been used throughout the area of Fuchu and Fukuyama in the eastern part of Hiroshima Prefecture, where our hospital is situated. A paper-based clinical pathway for gastric cancer was introduced in April 2012 and has been used in pStage I patients who underwent surgery. The common network infrastructure promoted in Hiroshima Prefecture, called the Hiroshima Medical Network (HM Net), has been used to make the clinical pathway more convenient since April 2016, thus, enabling both, hospitals involved in planning and primary care physicians, to simultaneously manage patients. We are looking for ways to establish a new system for the computerized clinical pathway in the regional alliance that is more effective than the paper-based clinical pathway system. Here, we report the current status and challenges of our clinical pathway in a regional alliance with the HM Met.

The effects of hyperbaric oxygen (HBO) therapy were assessed in 28 patients with postoperative paralytic ileus and intestinal obstruction in our hospital from July 2012 to September 2015. Of the 28 patients, 21 (75%) improved, and the median number of days from starting HBO to eating was 7 days. Treatment was significantly more effective in cases treated without a decompression tube than in those treated with one (85.7% vs. 42.9%, p<0.05). There was no difference in response rate between paralytic ileus and intestinal obstruction. Of the 17 cases with paralytic ileus, the number of days from onset to starting HBO was significantly shorter in the effective group than in the ineffective group. Six cases (21%) had complications of HBO, inability to rest and middle ear pressure. We consider that HBO is safe and effective for patients with postoperative paralytic ileus and intestinal obstruction. In paralytic ileus, starting HBO early may be more effective.

A 30-year-old woman visited our ER complaining of general edema and acute epigastric pain. She was diagnosed as having diffuse peritonitis due to upper intestinal perforation, with congestive heart failure. Emergency laparotomy revealed a perforated duodenal ulcer, and peritoneal lavage with omental prombage was performed. Postoperatively, she developed severe tachycardia and hypertension. Blood examination revealed elevation of the WBC count, with elevated serum CRP and total bilirubin levels, and markedly reduced thyroid stimulating hormone levels. Based on these findings, she was suspected as having thyrotoxic crisis, and potassium iodide was administered via a nasogastric tube. As hemodynamic stability failed to be achieved despite intensive treatment at our hospital, the patient was transferred to a university hospital for further treatment. She was diagnosed as having thyrotoxic crisis accompanied by Basedow disease, and was provided intensive care for cardiovascular and respiratory failure. She was then transferred back to our hospital 18 days later, and then to a subsequent institution for rehabilitation 48 days after the primary operation. Thyrotoxic crisis can become fatal, unless proper and quick treatment is provided. Herein, we report a rare case of thyrotoxic crisis complicating untreated hyperthyroidism, associated with a perforated duodenal ulcer.

A 41-year-old woman had a breast mass in her left upper quadrant. Mammography revealed grouped, round-shaped microcalcification (category 3) in her left breast. A core needle biopsy was performed and diagnosed as an invasive ductal carcinoma in a fibroadenoma. We performed left partial mastectomy and sentinel lymph node biopsy. Pathological examination revealed an invasive ductal carcinoma that grew within a 15 × 15 × 5 mm fibroadenoma, which was an estrogen receptor-positive, progesterone receptor-positive, HER2-negative, and low (<10%) Ki 67 cancer. Postoperative radiotherapy was performed for her left breast, and she is currently receiving tamoxifen therapy. Breast cancer within a fibroadenoma is rare. This is the 17th case report in the Japanese literature. Thus, we report a case of invasive ductal carcinoma occurring in a fibroadenoma.

Low-grade adenosquamous carcinoma (LGASC) of the breast is a type of metaplastic carcinoma. Unlike other metaplastic carcinomas, LGASC exhibits a more favorable outcome. We present the case of a 43-year-old woman with a medical history of invasive ductal breast carcinoma 8 years before who was recently diagnosed as having a LGASC in the same breast and who underwent a surgical procedure. Simultaneously, on the other side of the breast, ductal carcinoma in situ was diagnosed and performed with mastectomy. Further therapy was not performed. BRCA1 mutation in association with LGASC has been reported. Thus, it may be important to consider the possibility of hereditary breast and ovarian cancer syndrome, and a surveillance program.

Breast cancer in the nipple is rare, and most cases are invasive ductal carcinoma. To our knowledge, invasive lobular carcinoma in the nipple has not been reported in Japan. Herein, we report a case of invasive lobular carcinoma in the nipple with skin invasion. A 62-year-old woman presented to our hospital with bleeding from the right nipple. Although an induration on the right nipple and areola was found on physical examination, mammography and ultrasonography did not reveal any tumor in her right breast. The exfoliative cytology of the areola was class II. Sixteen months after, her right nipple and areola were harder than on her first visit. Punch biopsy from her right nipple revealed invasive lobular carcinoma. Right mastectomy and right axially lymph nodes (level II) dissection were performed. Histological examination revealed an invasive lobular carcinoma in the right nipple and areola with skin invasion (T1 N1 M0 Stage IIA). The patient is currently alive, 1 year 3 months after surgery, without recurrence.

Pulmonary arteriovenous malformation (PAVM) is a pulmonary vascular anomaly. It is known that affected people can present with paradoxical brain embolism from right-to-left shunt. A 44-year-old woman with no significant family and medical histories presented to our hospital with the sudden onset of headache, dizziness, and aphasia. Magnetic resonance imaging and angiography of the head revealed acute ischemic stroke and occlusion of the right anterior inferior cerebellar artery. Thrombolytic therapy with recombinant tissue plasminogen activator and anticoagulant therapy with warfarin improved her neurological conditions rapidly. Contrast-enhanced transesophageal echocardiography revealed right-to-left shunt. Contrast-enhanced chest computed tomography revealed a PAVM in the segment 10 of the left lung peripherally. Radical resection of the PAVM was performed using video-assisted thoracoscopy (VATS). She was successfully treated without recurrence of the PAVM and stroke during 6 months after the operation. There are many articles reporting that coil embolization is the first choice of treatment for PAVM, but PAVM recurrence is a serious problem after coil embolization. Resection using VATS is a minimally invasive and more effective treatment for PAVMs, and thus could be a practical method for single and peripheral PAVMs. PAVM is an important differential diagnosis of cerebral infarction in younger patients.

An aortoesophageal fistula is a rare but fatal condition. There is no established treatment for the disease to date. We experienced two cases of aortoesophageal fistula successfully treated by endovascular stent-grafting. Case 1 involved a 69-year-old woman who was brought into our hospital by ambulance because of fever, back pain, and massive haematemesis. Case 2 involved a 67-year-old man who was brought into our hospital by ambulance because of dysphagia and massive haematemesis. In both cases, contrast-enhanced thoracic computed tomographic findings confirmed the diagnosis of descending aortoesophageal fistula. Urgent endovascular stent-graft placement was conducted on the day of hospitalization. After stent-graft placement, in case 1, we attempted primary closure of the esophageal fistula, its covering using a latissimus dorsi musculocutaneous flap and creation of jejunal fistula, but urgent esophagectomy was necessary 7 days later because of leakage of the closure site. Esophageal reconstruction was performed 2 months after esophagectomy as the second step approach. In case 2, we performed esophagectomy and esophageal reconstruction in a one-step approach. In both patients, 3-year follow-up studies revealed no signs of infection of the grafts.

Conclusion : Our experiences suggest that endovascular stent-graft placement is useful for bleeding control from aortoesophageal fistula and that esophagectomy followed by esophageal reconstruction provides good infection control.

A 53-year-old man was referred to our facility from another regional hospital where he had been admitted 3 days earlier with a chief complaint of increasing intermittent epigastric pain for the previous 2 weeks. Computed tomography showed a hepatic artery aneurysm, 13 cm in diameter. His vital signs were stable, and surgery was performed. The aneurysm was located on the body of the pancreas. Its right lateral wall compressed and adhered to the common bile duct, and its posterior wall adhered to the portal vein. Its proximal end was at the bifurcation of the celiac artery to the splenic artery, and its distal end was connected to the right and left hepatic arteries. The celiac artery and proximal abdominal aorta were difficult to expose. Therefore, intra-aortic balloon occlusion was performed to control the blood flow to the aneurysm. The wall of the aneurysm was then incised, and the orifice of the common hepatic artery to the aneurysm was closed by suture, followed by saphenous vein grafting from the left gastric artery to the right and left hepatic arteries. The patient was discharged 12 days after surgery with recovery from jaundice. He has been well for 8 years since the operation.

Surgery for lung cancer in patients who have a cardiovascular anomaly can bring unexpected major hemorrhage or can disturb lymph node dissection. Recently we have performed video-assisted thoracic surgery (VATS) left upper lobectomy + ND2a-2 for cancer of the left upper lobe of lung in a patient who had a persistent left superior vena cava. The case involved a 64-year-old woman who was found having a 27 × 20 mm nodule shadow in the left S1 + 2 as well as a left superior vena cava on a chest CT scan. The accessory hemiazygos vein was found to have passed along the arch of the aorta, from the dorsal to the ventral aspect, to inflow into the left superior vena cava. We thus performed lymph node (#5) dissection while the accessory hemiazygos vein was taped up.

The persistent left superior vena cava is classified into three types according to Keith and that in our case is classified into one from the group (a) where the persistent left superior vena cava opens at the coronary sinus and surgery for it is unnecessary if any cardiac anomaly is absent. With preoperative CT scan to confirm that there was no communication between the left superior vena cava and the pulmonary vein and intraoperative careful identification of vessels, we could safely perform VATS left upper lobectomy.

We report a case of strangulated intestinal obstruction due to an idiopathic right diaphragmatic hernia in an adult whose hernia orifice was observed at the central tendon. An 89-year-old male presented to our emergency clinic because of abdominal pain and vomiting. There was no history of abdominal trauma. He had abdominal distention and slight tenderness in the epigastric region. Chest X-ray and computed tomography (CT) revealed prolapse of the small intestine and mesentery in the right thoracic cavity. Contrast CT revealed poor enhancement of the prolapsed organs. We diagnosed right diaphragmatic hernia with a strangulated intestinal obstruction. Emergency laparotomy confirmed an incarcerated ileum, with prolapse into the right thoracic cavity, just ventral to the right hepatic lobe. We reduced the herniated ileum and found a 3-cm hernia orifice at the right central tendon. The hernia orifice was sutured primarily and about 35 cm of necrotic ileum was resected. The patient was discharged on the 29th postoperative day. Subsequent hernia recurrence has not been observed.

Gastric duplications are rare digestive tract anomalies and usually occur from the greater curvature of the stomach. We report an uncommon case of a gastric duplication mimicking a retroperitoneal cyst, which could not be directly identified during laparotomy. A 10-year-old girl was referred to our institution with intermittent upper abdominal pain. MRI showed a cystic mass measuring 62 mm in diameter located between the left kidney and spleen. There seemed to be no communication with the surrounding organs. Serum levels of tumor markers of adrenal gland tumors were within normal range. Surgery was carried out for suspected left retroperitoneal cyst. The cyst did not exist in the retroperitoneal space, but developed on the gastric fundus. The cyst was excised without any injury to the gastric muscles. The cyst contained dense white fluid. Pathologically, the inner wall of the cyst was lined with gastric mucosa and ciliated columnar epithelium.

A 50-year-old man presented with a sudden-onset left abdominal pain. Contrast-enhanced abdominal computed tomography (CT) revealed a 15-cm mass on the pancreatic body and a large amount of ascites. Intra-abdominal hemorrhage due to rupture of the mass was suspected. As anemia was mild, we examined him for elective surgery. His diagnosis was gastroesophageal junction cancer with lymph node metastasis rupture and para-aortic lymph node metastasis. Surgical therapy was performed in advance, instead of chemotherapy, which might cause tumor lysis syndrome and another hemorrhage. Postoperative chemotherapy is ongoing. Although gastrointestinal bleeding due to gastric cancer is frequently encountered, intraperitoneal hemorrhage due to gastric cancer is quite rare, with only 4 cases reported in which metastasized lymph nodes were enlarged and ruptured. Emergent surgery was selected in 2 cases ; one patient died about one and a half months after the operation due to complications. Sometimes, an expanded surgery to resect a huge metastatic lymph node is necessary. As it is risky to perform an emergent and expanded surgery, careful judgment of timing and procedure is needed.

A 73-year-old man who was admitted to our hospital to investigate the cause of anemia was diagnosed with gastric adenocarcinoma through a biopsy of a tumor at the lesser curvature of the gastric body using gastroscopy. Abdominal computed tomography (CT) scan showed bulky metastatic lymph nodes at the lesser curvature of the stomach with no evidence of distant metastasis. He received two courses of combined neoadjuvant chemotherapy with S-1 plus cisplatin. The bulky lymph nodes were reduced remarkably, and he underwent total gastrectomy and cholecystectomy. The pathological diagnosis was gastric endocrine cell carcinoma, ypT3(SS), ypN0, M0, ypStage IIA. According to the treatment guideline for small cell lung cancer, two courses of adjuvant chemotherapy with irinotecan plus cisplatin were added. He also received S-1 orally due to elevation of a tumor marker 6 months after the surgery. The tumor marker levels fell to the normal range. The patient remains alive without recurrence as of 21 months after the diagnosis. Gastric endocrine carcinoma is rare, so that no effective therapy has been established and the prognosis is poor. Multidisciplinary therapy including pre- and post-operative chemotherapy was considered to be effective in this case.

A 57-year-old woman with a 1-week history of abdominal pain was admitted to the Department of Internal Medicine at our hospital. Upper gastrointestinal endoscopy showed multiple ring-shaped ulcers in the second and third portion of the duodenum. The biopsy showed vasculitis. Coagulation factor XIII was also decreased. These findings suggested ulcers due to IgA vasculitis, and corticosteroid treatment was started. On admission day 12, abdominal pain increased, and computed tomography showed free air and fluid collection in the abdominal cavity, and the wall of the distal duodenum and proximal jejunum was markedly thickened. Emergency surgery was performed for perforation of the duodenal ulcer with associated peritonitis. There were perforated sites in the fourth portion of the duodenum and the proximal jejunum. In addition to simple closure for the perforated sites, a retrograde duodenal drainage tube and an antegrade jejunal tube were inserted. Anastomotic leakage was not observed postoperatively. On the 68th postoperative day, duodenojejunal anastomosis was performed for the stenosis of the perforated site in the proximal jejunum. The patient was discharged on the 119th postoperative day.

A 91-year-old woman presented to our hospital with vomiting and abdominal pains. Her white blood cell count was as high as 15,480/μl. There was only mild tenderness in the abdomen. Radiologic imaging confirmed three signs including pneumatosis cystoides intestinalis, abdominal free air, and portal venous gas, while apparent bowel ischemia was absent. She was thus monitored over time with gastric tube decompression. Contrast-enhanced CT scan 48 hours after her admission demonstrated that the portal venous gas had disappeared and the abdominal free air decreased. However, bowel ischemia prompted emergent enterectomy. She was discharged 24 days after the operation.

We must remain alert for a possibility that the small bowel which is intact at the diagnosis despite the presence of three signs can become necrotic.

The patient was a 64-year-old woman who underwent right hemicolectomy for double cancer of the cecum and ascending colon ; it was diagnosed as pT4a(SE)N1M0 Stage IIIa. After adjuvant chemotherapy, she had been followed without recurrence until a tumor of the small intestine was detected by an abdominal/pelvic CT scan 51 months after the colectomy. Small bowel metastasis or primary tumor of the small intestine was suspected, and we performed partial resection of the small intestine. Intraoperative findings disclosed a 10×35 mm ridging lesion encircling the whole circumference of the bowel at 210 cm proximal to the anastomosed site at the previous operation. There was no gross infiltration into the serous surface. Histopathological survey demonstrated the lesion to be solitary hematogenous metastasis of colon cancer, because a clearly demarcated tumor composed of tubular and mucous adenocarcinoma which was similar to the specimen of resected colon cancer was identified. According to her hope, adjuvant chemotherapy was not added. The patient has been relapse-free as of 30 months after the operation. Hematogenous metastasis of colon cancer to the small intestine is rare and there are few reports on the treatments and prognosis. In the recent 30 years in Japan, only 15 patients with hematogenous colon cancer metastasis to the small intestine who underwent surgical resection are reported. Including ours, 13 patients were reported to have been relapse-free, two had recurrence and one died of cancer progression 71 months after the second surgery. Although the relapse-free survival periods are reported to be from nine to 120 months after bowel resection, five patients had earned five years or longer survival. Throughout relatively extended survival period of them, even though the treatment strategy has not statistically established, surgical treatment would improve the prognosis of patients with solitary metastasis of colon cancer to the small intestine.

A 57-year-old woman was referred to our hospital with right lower quadrant abdominal pain lasting for 3 days. She had undergone laparoscopic appendectomy elsewhere 7 months before her presentation. Her fever was 37.5°C. Her white blood cell (WBC) count was 9,500/μl, and the C-reactive protein (CRP) level was 12.3mg/dl. Antibiotic therapy was ineffective. An abdominal contrast-enhanced computed tomography (CT) scan revealed luminal structure at the caudal part and a high density area suggestive of staple at the apical part of the cecum. We thus diagnosed this case as stump appendicitis and emergency surgery was performed. An inflamed 10-mm appendiceal stump was identified. Laparoscopic cecal partial resection was performed. A histological examination showed phlegmonous appendicitis. The patient was discharged 7 days after the operation.

A 72-year-old man with chronic renal failure caused by underlying diabetic nephropathy and a single kidney (after right kidney removal) was being monitored in the Department of Nephrology. For hyperkalemia associated with these conditions, he was taking calcium polystyrene sulfonate (CPS) regularly. The patient noticed that his stool was black and contained blood, and abdominal computed tomography (CT) showed a mass lesion at the tip of the appendix. Abdominal contrast ultrasonography showed a saccular dilatation at the tip of the appendix with a multilocular structure with contrast enhancement of the mucosa. There was no significant uptake in the appendix on positron-emission tomography CT (PET-CT). Myxoma of the appendix was therefore diagnosed, and ileocecal resection was performed. Histopathological examination showed yellow granulomatous changes with CPS crystal deposition in the appendix. This is believed to be the first Japanese report of appendicitis of this histological type. The possibility of CPS-induced yellow granuloma appendicitis should be considered in the diagnosis and treatment of patients taking oral CPS, and it is important to obtain detailed medical and drug histories.

A 38-year-old male was urgently admitted to our department with an incarcerated left inguinal hernia. Reduction was unsuccessful, and emergency surgery was performed the day after admission. The surgery was performed laparoscopically, but because it was difficult to manage the incarcerated omentum, we converted to an inguinal incisional approach. About two years later, the patient had a positive fecal occult blood test, and fiberoptic colonic endoscopy was performed at our hospital. The endoscopy showed a structure that seemed to be part of a Kugel patch in the sigmoid colon. There were no subjective symptoms or abnormal blood tests. However, we assumed that changes due to chronic inflammation would probably cause problems later. Therefore, we performed curative surgery with laparoscopic assistance. Initial laparoscopic observation confirmed adhesions between the left inguinal bed and sigmoid colon. We peeled away the adhesions at the top and bottom of the patch, and then performed open sigmoidectomy, including peeling of the prosthesis from the inguinal bed. We then reconstructed the digestive tract using end-to-end anastomosis. Despite our concerns, no infections occurred in the wound or inguinal bed, and the patient was discharged 12 days after the operation. More than 1 year has passed since the surgery without problems. As only a few cases of gastrointestinal perforation caused by a Kugel Patch have been reported, this appears to be an extremely rare case. Surgical management should take into consideration the possibility of serious complications, regardless of the type of procedure or prosthesis.

A 53-year-old man with a history of childhood epilepsy and mental retardation presented to a hospital because of nausea and vomiting. He was diagnosed with intestinal obstruction and treated conservatively by the previous doctor for two days, but his condition became worse and he was referred to our hospital for more detailed examinations. Abdominal plain radiography showed a dilated large intestine and an air fluid level. Contrast-enhanced abdominal computed tomography scan showed remarkable intestinal dilatation ascites, and a whirl sign which suggests intestinal torsion, in the right lower quadrant of abdomen. Intestinal obstruction caused by volvulus was diagnosed and a laparotomy was performed. Intraoperative observation showed a markedly dilated colon with caecal and sigmoid volvulus, and we performed subtotal colectomy. After the surgery, paralytic ileus was prolonged. He was discharged from our hospital approximately three months after the surgery. Intestinal volvulus is a condition in which the intestinal tract is twisted with the mesentery. Intestinal volvulus usually occurs at a single site, and it is rare that multiple torsions occur simultaneously. We report a very rare case of intestinal obstruction due to synchronous caecal and sigmoid volvulus.

A 63-year-old woman presented to our hospital due to sigmoid colon cancer detected by a colonoscopy. The tumor was 0-Isp lesion measuring 20 mm in diameter. Endoscopic submucosal dissection was planned and the glycerol with epinephrine and indigocarmine was locally injected just under the tumor. However, the non-lifting sign was seen and the patient was considered to be a candidate for surgery. Therefore, laparoscope assisted sigmoid colectomy with lymph node dissection was performed. The resected specimen only showed ulcer scar and tumorous lesion was absent. Histological examination revealed no cancer cells. The mechanism of spontaneous regression of the tumor in our case was speculated that separation between the normal and cancer tissues due to the injection, and the ischemic change due to vasoconstriction effect of epinephrine resulted in necrosis, sloughing ulcer and scar formation of cancer cells.

We must keep in mind that preoperative endoscopic treatment like in our case can lead to spontaneous regression of the tumor.

An 81-year-old male was found to have a right inguinal hernia with sigmoid colon cancer within the hernia, and surgery was scheduled. However, a right common iliac aneurysm was found on preoperative testing, and aneurysm treatment was prioritized. On day 2 after stenting, the patient developed inguinal distention, abdominal pain, and vomiting, and computed tomography showed perforation of the incarcerated colon inside the hernia sac. Emergency surgery was performed through an inguinal incision. The incarcerated sigmoid colon was perforated, and the hernia sac was filled with intestinal fluid. To reduce the invasiveness of surgery, Hartmann's procedure was performed though an incision in the inguinal region, and the inguinal hernia was repaired using the Bassini method. This type of inguinal hernia incarceration rarely occurs in patients with colorectal cancer and/or perforation. As this patient was elderly and in poor general condition, an incision was only made in the inguinal region, and a sigmoidostomy was performed instead of anastomosis. His subsequent progress was relatively favorable.

A 56-year-old man presented with perineal discomfort and was found to have an anal tumor. He was diagnosed with a gastrointestinal stromal tumor (GIST) based on the biopsy specimens. Computed tomography (CT) and magnetic resonance imaging (MRI) showed an extramural tumor approximately 6 cm in diameter in the anterior wall of the lower rectum (Rb-P) displacing the urethra ventrally. Imatinib mesylate as neoadjuvant chemotherapy was administered to reduce tumor size, and radical surgery was planned six months later. The tumor was resected by the perineal approach because the tumor was located close enough to the perineum to be palpable through the perineal skin. The patient's postoperative course was uneventful, and the patient was discharged 13 days after the operation. This perineal approach for GIST is one option for minimally invasive surgery instead of invasive surgery requiring intersphincteric resection and abdominoperineal resection. We expect that a future study will provide further evaluation of the perineal approach for lower rectal tumors.

We report a case of hepatic abscess caused by a fish bone penetrating the gastric wall. A 41-year-old man presented with a 2-week history of low-grade fever and upper abdominal pain. Abdominal USG and CT showed strong internal needle-like echoes, and abscess, respectively, in the lateral segment of the liver, and the patient was started on antibiotics. Since the hepatic abscess was regarded as being secondary to a foreign body, that is, a fish bone that had penetrated through the stomach, laparoscopic removal of the fish bone was performed. Simultaneously, we used intraoperative USG in order to locate the fish bone and confirm the remnants. The postoperative course was good. When the general condition is stable after conservative therapy, an elective laparoscopic approach can be chosen to remove a foreign body. While laparoscopy surgery is less invasive and provides magnified viewing, intraoperative palpation is difficult. Alternatively, intraoperative USG may be a useful option for checking foreign objects accurately.

A patient with a Klebsiella pneumoniae-induced liver abscess who developed sepsis despite antibiotics and percutaneous transhepatic abscess drainage (PTAD), who was successfully cured by semi-emergency right lobectomy on Day 35 after the start of conservative treatment, is presented. There are still cases of patients such as the present one who require surgical treatment after failing to respond to a range of conservative therapies. The decision on surgical indications for pyogenic liver abscess is a difficult one, and its characteristics on diagnostic imaging (such as multiple abscesses, large size, seclusion by septa, a thick capsule, and the concomitant presence of biliary duct lesions), its properies (high viscosity), and the causative pathogen must all be taken into account. Hepatectomy is an effective method of treatment that enables rapid recovery in patients who do not respond to conservative therapy, and it should be considered as one option for the treatment of pyogenic liver abscess.

A 16-year-old woman with no history of using contraceptives or anabolic steroids presented to a local hospital with epigastralgia. Although abdominal USG revealed a hepatic lesion measuring 3 cm in diameter, the patient refused further investigation. After one year, the lesion increased to 5 cm in diameter. She was referred to our hospital for further study, and based on the findings of dynamic contrast-enhanced CT, the lesion was suspected as a hepatocellular adenoma. Laparoscopic partial hepatectomy was performed, and the lesion was finally diagnosed by histopathology as an unclassified hepatocellular adenoma. There has been no sign of recurrence until date, 2 years since the surgery. We have presented the case here, as pathologically proven unclassified hepatocellular adenoma is extremely rare.

The patient was a 42-year-old man. He vomited blood and was transported urgently to a nearby hospital in June 2014. Hemostatic treatment with upper gastrointestinal endoscopy (UGE) was conducted. On contrast-enhanced computed tomography (CT), pancreatic tumor, splenomegaly, dilation of the splenic vein, and gastric varices were found. A diagnosis of bleeding from a gastric varix caused by left portal hypertension due to tumor invasion to the splenic vein and tumor embolism was made. He was referred to our hospital for scrutiny and treatment purposes. The tumor showed an unevenly high absorption in the arterial phase and mild low absorption in the venous phase of the contrast-enhanced CT. No increase in pancreatic hormone level was observed by blood biochemical examination. The UGE in our hospital revealed gastric varices and submucosal tumor-like elevation in the posterior wall of the gastric upper body. By endoscopic ultrasonography-guided fine-needle aspiration, a cytological diagnosis of Class V tumor and a histological diagnosis of pancreatic neuroendocrine tumor (PNET) were made. Therefore, distal pancreatectomy, splenectomy, cholecystectomy, total gastrectomy, and partial colon resection were performed. PNETs incidentally found because of hematemesis are extremely rare. The authors report the present case with some considerations of the morphological mechanism that caused the portal hypertension.

Primary splenic tumors, including cysts, hemangiomas, lymphangiomas, hamartomas, malignant lymphomas, metastatic tumors, and angiosarcomas, are uncommon. We report a case of a 25-cm large splenic cavernous hemangioma, which is the largest reported hemangioma to date in Japan, treated by laparoscopic splenectomy after selective splenic artery embolization.

A 31-year-old woman was diagnosed as having a splenic tumor by abdominal ultrasonography at another hospital 2 years and 5 months previously and was under observation. She was referred to our hospital because of nausea. We diagnosed a 25-cm large splenic cavernous hemangioma. Selective splenic artery embolization was performed on the day before surgery to avoid intraoperative hemorrhage and decrease the spleen size. Her abdominal pain was managed using continuous epidural anesthesia and oral analgesics. She underwent laparoscopic splenectomy after manipulation of the splenic artery and vein at the splenic hilum. Her postoperative course was uneventful, and she was discharged 9 days postoperatively. Laparoscopic splenectomy using the internal approach technique and selective splenic artery embolization are useful procedures for the management of large splenic tumors.

A 62-year-old woman complaining of right lower abdominal pain was pointed out having an intraabdominal mass lesion by ultrasonography (US) examination at the home doctor's clinic and was referred to our hospital. There was previous history of undergoing left adnexectomy for mature cystic teratoma elsewhere 13 years earlier. Abdominal US examination revealed an oval shaped cystic lesion of 6 cm in diameter in the right lower quadrant of abdomen. Enhanced abdominal CT scan revealed that the oval-shaped cystic lesion with clear margin was composed of calcified capsular structure surrounded by-fat tissue with no infiltration into the adjacent organs, and a solid lesion was also found in this cystic lesion. MRI imaging demonstrated that the content of this cystic lesion mainly consisted of fat tissue. These findings were compatible with mature cystic teratoma. Thus, we diagnosed this lesion as mature cystic teratoma covered with the greater omentum clinically and performed surgical resection. Histopathology revealed that the cystic capsule was mainly composed of fibrous stromal structure with remarkable calcification with no epithelial spreads. This lesion did not include neoplastic growth nor atypical nuclear changes. The ovarian tissue components were seen in this cystic capsular structure. The hair and bone structures were also found in the solid lesion included in the cystic lesion. These findings suggested this lesion to be a cystic teratoma derived from the left ovary, which might be implanted into and covered with the greater omentum. Her postoperative course was uneventful, and she was discharged from our hospital on the fourth post-operative day.

Low grade fibromyxoid sarcoma (LGFMS) is a rare soft-tissue tumor showing such malignant clinical features as a high metastasizing potential and sometimes long interval between tumor presentation and metastasis. We report a recent case of intrapelvic LGFMS.

A 43-year-old man presented to our hospital because of abnormal bowel movement. An abdominal contrast-enhanced CT scan revealed an about 11-cm tumorous lesion on the pelvic surface of sacrum. Preoperative transrectal needling biopsy failed to make the definite diagnosis. We performed the tumor extirpation through the transsacral and transabdominal approach by keeping the dissected margins, followed by low anterior resection of rectum. Histopathology disclosed the tumor to be concomitantly composed of fibrous and myxoma-like components. Immunostaining showed MUC4 positive. Accordingly, LGFMS was diagnosed. The patient's postoperative course was uneventful, and no recurrence has occurred as of 3 years after the operation.

Although presacral LGFMS is extremely rare, it must be kept in mind as a possible differential diagnosis and a long-term follow-up is mandatory because it takes a long time until metastasis.

A 45-year-old woman had developed strangulated bowel obstruction after a Cesarean section 12 years earlier ; this had been treated by small intestinal resection and colostomy, and the stoma was later closed. Eight years earlier, she had undergone hernia repair (simple closure) for an abdominal incisional hernia at the stoma closure site, and five years earlier, the abdominal incisional hernia recurred. She presented to our department with recent pain. Computed tomography showed hernia orifices with diameters of 15 mm and 30 mm in the right flank. The patient had been diagnosed with dermatomyositis 18 years previously and was taking oral prednisolone 10 mg, and consequent tissue fragility and central obesity meant that there was a high risk of further recurrence if simple closure was again performed. Since the patient was also an immunocompromised host, the use of mesh may have been problematic in light of the high difficulty of treating a surgical site infection. It was therefore decided to close the hernia orifice by turning over the anterior rectus abdominis sheath and repair the hernia with an autologous fascia lata graft. In the presence of tissue fragility, patients with recurrent abdominal incisional hernia are at high risk of further recurrence. Choosing a suitable surgical procedure taking into account patient attributes may reduce the rate of recurrence.