Primary hyperparathyroidism (PHPT) mainly occurs in middle-aged women, although it may occur in women of childbearing age. Treatment of PHPT is essential during pregnancy to avoid fetal complications including intrauterine growth retardation, neonatal tetany, or even fetal death. We report a case of PHPT in a woman who conceived while awaiting surgery and underwent surgery during the second trimester. A 34-year-old woman was diagnosed with hypercalcemia (serum calcium 10.7 mg/dL) during a medical checkup. She was diagnosed with PHPT based on an increased serum level of intact parathyroid hormone (i-PTH) and swelling of the left upper parathyroid gland on ultrasonography, and she was referred to our hospital for surgery. She was asymptomatic with only mild hypercalcemia and refused surgery. Therefore, we observed the patient without surgical intervention. Six years later, her serum calcium level was elevated to 11.2 mg/dL, and the parathyroid gland was enlarged. She was scheduled to undergo surgery ; however, she conceived (gestational age 6 weeks and 4 days) while awaiting surgery. We performed parathyroidectomy at a stable gestational age of 17 weeks. Histopathological examination of the resected specimen confirmed a diagnosis of parathyroid adenoma. Her serum i-PTH and calcium levels normalized postoperatively. She had a normal delivery with the birth of a healthy female neonate weighing 3,044 g, at the gestational age of 39 weeks and 6 days. The patient and neonate are doing well at the time of writing this report.

A 68-year-old woman visited our hospital with a left breast mass. Computed tomography (CT) revealed a left breast tumor, left axillary lymphadenopathy, and right breast tumor. She was diagnosed with synchronous bilateral breast cancer after needle biopsy. Laboratory tests revealed hypercalcemia (12.3 mg/dL), but PET-CT showed no bone metastasis or other distant metastasis. Therefore, we assessed PTHrP levels (18.8 pmol/L) and made the final diagnosis of breast cancer with humoral hypercalcemia of malignancy (HHM). After treatment for hypercalcemia, she underwent surgery for the breast cancers. Postoperatively, she had no elevation in serum calcium and PTHrP levels and had no recurrence for 6 months. Few cases of breast cancer with HHM have been reported. We believe that surgical treatment is a useful therapy for resectable breast cancer with HHM.

A 61-year-old woman was brought to the emergency room of our hospital with suspected retroperitoneal bleeding. Computed tomography (CT) showed a ruptured pancreaticoduodenal artery aneurysm and median arcuate ligament syndrome (MALS), and emergency interventional radiology (IVR) was performed the same day. Due to the risk of recurrent aneurysm formation and rupture, it was decided to perform arcuate ligament release, and the procedure was carried out in a hybrid operating room to assess perfusion and enable additional treatment following release of the ligament. The arcuate ligament was released, and decompression was achieved, but since some stenosis persisted, balloon dilatation was also performed. Postoperative CT showed that the stenosis of the celiac artery root and the dilatation of the arcade of the head of the pancreas had improved. Various different treatments for MALS have been reported, but treatment in a hybrid operating room, which enables real-time hemodynamic assessment, as well as the choice of other procedures such as balloon dilatation, is an effective option.

The supraclavicular approach is difficult to use in direct surgery for intrathoracic subclavian artery aneurysms, and the best approach and procedure to use must be determined individually in each case. We successfully treated an intrathoracic left subclavian artery aneurysm in a patient with chronic obstructive pulmonary disease by combining bilateral axillary bypass surgery with endovascular treatment. A 66-year-old man underwent a chest X-ray during a regular health check-up that identified an abnormal shadow, and computed tomography showed an intrathoracic left subclavian artery aneurysm adjacent to the origin of the left subclavian artery. Because the patient had chronic obstructive pulmonary disease, he was not capable of tolerating direct surgery, and he requested that a less invasive surgical procedure be used. Bilateral axillary bypass surgery was first performed, after which the aneurysm was closed with an Amplatzer Vascular Plug II on the distal side and a thoracic stent graft on the proximal side, and the origin of the left subclavian artery between them was embolized. This less invasive procedure may be an effective method of treating intrathoracic left subclavian artery aneurysms in high-risk patients.

A 71-year-old man was brought to the emergency room with upper abdominal pain. On arrival, there was abdominal tenderness on palpation, mainly in the umbilical region. Contrast-enhanced computed tomography (CECT) showed a hypodense area extending from around the pancreas to the retroperitoneum. He was admitted with suspected acute pancreatitis, duodenal perforation, retroperitoneal tumor, or similar condition, but, after several hours, his vital signs deteriorated and he went into shock. Repeated CECT showed expansion of the hypodense area and pooling of contrast agent below the head of the pancreas. A ruptured inferior pancreaticoduodenal artery aneurysm was suspected, and emergency abdominal angiography was performed. A 10-mm aneurysm of the inferior pancreaticoduodenal artery was observed, and transcatheter arterial embolization (TAE) with a metal coil was carried out. Following TAE, a hematoma appeared that caused compression of the duodenum and stenotic symptoms, but these improved by conservative therapy with fasting and nasogastric tube placement, and the patient was discharged on postoperative Day 52. There have been no subsequent signs of recurrence.

We performed an emergency surgery for a case of delayed hemothorax and traumatic diaphragmatic hernia which developed 4 weeks after the patient had fallen.

A 70-year-old woman who had fallen at home and got a bruise on the left-sided chest visited a neighboring hospital on the next day and was diagnosed with multiple left rib fractures. She had been followed until 15^th day after the trauma when she was referred to our hospital because of an increasing tendency of pleural effusion. She underwent a thoracentesis with 550 ml of bloody discharge. As satisfied pulmonary expansion was regained with this procedure, we decided to follow her in the clinic. On the 28^th post-traumatic day, she presented to our hospital again because of cough and dyspnea. Large quantities of left pleural effusion were present. A contrast-enhanced CT scan confirmed aggravated left hemothorax associated with extravascular leakage around the left 9^th fractured rib. Then we performed emergency thoracoscopic removal of hematoma, and added an 8-cm small thoracotomy, through which we identified a one-cm hernia orifice at the diaphragm and the greater omentum protruding from the orifice. Traumatic diaphragmatic hernia was thus diagnosed. The greater omentum was reduced into the abdominal cavity and the diaphragmatic hernia was repaired. The postoperative course was uneventful and she was discharged from our hospital on the 11^th hospital day.

As with this case it is etiologically inferred that pieces of the fractured bone repeatedly contacted with the diaphragm with respiratory movements, leading to delayed diaphragmatic hernia.

A 65-year-old Japanese man, who had been on treatment for resistant massive ascites and hepatic encephalopathy due to alcoholic liver cirrhosis in our hospital, complained of dyspnea on exertion. Radiological findings and a thoracocentesis revealed massive right pleural effusion. Hepatic hydrothorax due to diaphragmatic fenestration was suspected, because massive hepatic ascites decreased following chest drainage, whereas diuretic and thoracic drainage did not improve thoracic effusion. From his clinical course, we determined that internal treatment could not control massive pleural effusion. Under general anesthesia, thoracoscopic surgery was performed after we obtained informed consent. Two tiny pores at the right hemidiaphragm were found, cut and sutured with a GIA stapler and covered with a polyglycolic acid (PGA) sheet. Post operative course was uneventful, and there had been no recurrence of hydrothorax for one year and eight months until his death due to cerebral hemorrhage.

A 29-year-old woman presented with a 3-year history of postprandial pain and a 2-day history of stomachache and nausea. Thoracoabdominal computed tomography revealed prolapse of the dilated stomach into the left thoracic cavity. Emergent laparotomy was performed several hours after hospitalization, because the patient was hemodynamically unstable in a state of shock. Intraoperatively, we observed that most of the stomach had prolapsed into the left thoracic cavity through a left-sided diaphragmatic hernia defect. Contaminated ascitic fluid and pleural effusion spread to the thoracic cavity through this stomach perforation. We removed the ischemic and perforated portions of the stomach and subsequently closed the gastric and diaphragmatic defects. We diagnosed the diaphragmatic defect as a Bochdalek hernia. The patient developed thoracic empyema, preperitoneal abscess, and surgical wound infection. However, these postoperative complications resolved following treatment, and she was discharged 31 days after admission. We report a case of Bochdalek hernia with gastric perforation along with a discussion of the relevant literature.

An 85-year-old man underwent subtotal esophagectomy through right thoracotomy, with 3-field lymph node dissection, retrosternal route gastric tube reconstruction, and catheter jejunostomy with a diagnosis of thoracic esophageal cancer (Ut, cT2N0M0, cStage I). It was histologically diagnosed as carcinosarcoma and the tumor depth was pT1b-SM3. The resection margin and circumferential margin were negative of cancer. He was discharged 24 days after the surgery and had been followed as an outpatient. Although he did not have any symptoms, a metastatic lesion was found in the trachea by a follow-up CT scan conducted one year after the surgery. The cytology of sputum revealed squamous cell carcinoma and tracheal metastasis of esophageal cancer was strongly suspected. Only palliative radiation treatment was taken for the purpose of airway preserving, but then respiratory distress occurred, and he died 8 months after recurrence or one year and 8 months after the surgery. There are very few reports of tracheal metastasis after radical resection of esophageal cancer.

A 49-year-old woman was admitted to the hospital because of tarry stool and transient loss of consciousness. Esophagogastroduodenoscpy revealed a submucosal tumor with ulcer at the anterior wall of the middle position of the gastric body. Abdominal CT scan showed a mass 45 mm in diameter in the stomach. Gastrointestinal stromal tumor (GIST) of the stomach was suspected. Although surgical findings revealed the mass near the primary GIST was not likely to be lymph node (LN) metastasis, we performed LN dissection. Then we performed robotic assisted laparoscopic proximal gastrectomy with double-flap reconstruction for the primary gastric GIST. The tumor was 45×42×33mm in size. Immunohistochemically, tumor cells were positive for DOG-1 and CD34 and negative for c-kit and α-SMA. The mitotic figure was 3/50 HPF. The No.3a LN near the gastric GIST was diagnosed as LN metastasis. The patient remains alive without recurrence and any gastro-esophageal reflux symptoms as of 3 months after the operation. For now, there is no accepted standard treatment or management of GISTs with LN metastasis. Although lymphogenous metastasis of gastric GIST is rare, LN dissection may improve the prognosis. We present a case of gastric GIST with LN metastasis operated on by robotic assisted laparoscopic proximal gastrectomy.

A 63-year-old man was found to have an abscess in the dorsal stomach with a maximum diameter of 20 cm on computed tomography. Upper gastrointestinal endoscopy showed an elevated lesion in the posterior wall of the upper gastric corpus that was connected to the abscess by a fistula, and a submucosal tumor with abscess formation was diagnosed. The histopathological diagnosis was gastrointestinal stromal tumor (GIST), but the tumor and abscess were compressing the transverse colon, pancreatic tail, abdominal wall, and other organs, making total resection infeasible. A 7-Fr, 7-cm, double-pigtail stent was placed endoscopically in the abscess from the stomach via the fistula to create an internal fistula, and an 8.5-Fr transnasal drainage tube was also inserted to form an external fistula, draining the abscess to achieve decompression and infection control. The abscess decreased in size, enabling its complete removal by open total gastrectomy and partial transverse colectomy. The postoperative course was uneventful, and the patient was discharged on postoperative Day 13. Endoscopic drainage was an effective preoperative treatment in this case of gastric GIST with abscess formation.

A 69-year-old man was admitted to our hospital with a history of upper abdominal pain and anorexia. Upper gastrointestinal endoscopy revealed a tumor in the second portion of the duodenum. Biopsy revealed the diagnosis of undifferentiated pleomorphic sarcoma, and the patient was treated by subtotal stomach-preserving pancreatoduodenectomy. An abdominal CT performed 2.5 months after the surgery showed a local recurrence and liver metastases. Treatment was started with doxorubicin, however, the patient died 5.5 months after the operation. To the best of our knowledge, only 7 cases of duodenal undifferentiated pleomorphic sarcoma have been reported so far, including our case. This case is presented here, along with a discussion of the relevant literature.

A 74-year-old woman presented with a 3-month history of intermittent vomiting and abdominal distension. She was admitted to our hospital due to persistent abdominal pain. Abdominal CT showed free intraperitoneal gas and multiple enlarged mesenteric lymph nodes, with a fluid collection close to the extended jejunum. Emergency surgery was performed on the same day with a diagnosis of intestinal perforation due to malignant lymphoma. Histologic examination showed lymphoplasmacytic sclerosing mesenteritis with significant infiltration of IgG4-positive plasma cells. Her serum IgG4 level was 726 mg/dl. The findings of histological and serum studies were compatible with IgG4-related sclerosing mesenteritis. The patient was discharged without complications and started on steroid therapy as an outpatient. This relatively rare case is reported with a review of the literature.

Complications of systemic sclerosis (SSc) include chronic intestinal pseudo-obstruction (CIP). When a patient has only a subtle skin lesion of SSc, it is very difficult to diagnose SSc that underlies CIP. We report a case of CIP associated with SSc induced by surgical stress, in which differentiation from postoperative paralytic ileus was so difficult.

A 71-year-old woman was admitted for adhesive small bowel obstruction. Although she responded to the conservative treatment, she underwent operation because of immediate recurrence after discharge. She underwent re-operation for suspected re-obstruction at the same location as before the 1^st operation. After the 2^nd operation, given the refractory paralytic ileus persisted, we searched underlying disease for suspected CIP. The findings of skin hardening that was localized in only the fingertips, Raynaud phenomenon, and positive anti-centromere antibody led to diagnose SSc. We then diagnosed the case as CIP with SSc because paralytic ileus had continued for more than 6 months after the operation. Surgical stress may induce CIP associated with SSc. The findings of skin hardening that was localized in only the fingertips and Raynaud phenomenon served to diagnose CIP associated with SSc.

A rare case of ileal duplication with diverticulitis is presented. A 62-year-old man presented with navel pain and was referred to our hospital. Abdominal computed tomography scan showed swelling of an appendix-like structure and an increased concentration of fat tissue surrounding the intestine. Blood biochemical examinations showed a high degree of inflammation. Based on the above, appendicitis or an appendiceal myxoma was suspected, and surgery was performed. Intraoperatively, intestinal-like tubular structures with inflammation with a blind end on the mesentery of the ileum were seen and resected as the suspected cause of the symptoms. The pathological findings of the resected intestinal canal structure showed intestinal mucosa and a muscular layer, and it was diagnosed as ileal duplication. In addition, a diverticulum was present in the duplicated intestinal tract, and inflammatory cell infiltration was found around the diverticulum, leading to a diagnosis of diverticulitis occurring in the duplicated intestinal tract.

A 22-year-woman with ovarian cystoma and asthma presented with upper abdominal pain. Physical examination revealed a temperature of 38°C. Computed tomography revealed appendicitis and a cystic mass in the pouch of Douglas. Preoperative diagnosis was difficult, and laparoscopic appendectomy was performed. Laparotomy revealed that the cystic mass in the pouch of Douglas was connected with the ileum. The cystic mass was tentatively diagnosed as duplication of the alimentary tract, and we performed resection of a segment of the small bowel. Histopathological examination of the resected specimen revealed that the mass represented a duplicated alimentary tract segment with ciliated and stratified squamous epithelium and resembled bronchial tissue.

A 66-year-old man admitted to a hospital with abdominal distention and bloody stools was found having a lesion with remarkable wall thickening in the ileocecal region on CT. Following a colonoscopy and a biopsy, the diagnosis of primary intestinal Burkitt lymphoma in Stage II2 (Lugano classification for staging of lymphomas) was made. He was referred to the Department of Hematological Medicine in our hospital R-EPOCH therapy was performed, but small bowel obstruction developed after the end of 4 courses. Decompression treatment using an ileus tube gave a temporary improvement, however, he developed an abrupt onset of right lower abdominal pain. Further CT scan revealed ascites and free air around the ileocecal area, suggesting perforating peritonitis that required surgical intervention. We performed an emergency operation with the diagnosis of perforating peritonitis. The chemotherapy was resumed on postoperative-day 43. The postoperative course then proceeded uneventfully, and he remains currently under observation. Gastrointestinal malignant lymphoma is sometimes reported in cases requiring emergency surgery involving intussusception, bowel obstruction, gastrointestinal perforation, and others. Information sharing between internal-medicine and surgery is recommended, by keeping a possible need for emergency surgery in mind.

A 69-year-old man was admitted to the hospital with the complaint of epigastric pain. Abdominal CT revealed a tumor in the ileum, and PET/CT showed high uptake in the tumor and mesenteric lymph nodes. Laparoscopy-assisted surgery was performed. The tumor in Meckel's diverticulum was resected with the diverticulum. The intraoperative diagnosis based on frozen-section examination was adenocarcinoma of Meckel's diverticulum. Segmental resection of the ileum with lymph node dissection was performed. The patient received postoperative adjuvant chemotherapy with mFOLFOX6 for 6 months and is currently alive, 30 months after the surgery, without recurrence.

Adenocarcinoma of Meckel's diverticulum is extremely rare and preoperative diagnosis is very difficult due to the anatomical characteristics of this region. Laparoscopy-assisted surgery is useful for the diagnosis and resection of adenocarcinoma of Meckel's diverticulum.

Endosalpingiosis is defined as ectopic fallopian tube epithelium. We report a case of ileocecal endosalpingiosis presented with repeated episodes of intestinal obstruction. The patient was a 42-year-old woman who had undergone laparoscopic-assisted uterine myomectomy and left paraovarian cystectomy. After that, she was hospitalized three times with the diagnosis of intestinal obstruction and she visited our department.

Preoperative examination revealed a narrowing in the ileocecal area and we performed laparoscopic ileocecal resection because a possibility of adhesion or malignant tumor could not be ruled out. Surgical findings revealed an induration in the ileocecum. Histopathological findings showed endosalpingiosis with ectopic ovarian tube epithelium in the ileocecal wall. We think this case is extremely rare, because the patient was symptomatic and this endosalpingiosis was located at the ileocecum.

An 89-year-old woman was admitted to our hospital with a complaint of left lower abdominal pain. Abdominal computed tomography revealed a heterogeneous enhanced tumor measuring 50 × 40 mm in diameter in the abdominal wall of the left lower quadrant. The patient had a past history of laparoscopic right colectomy for ascending colon cancer (Stage I), which was performed 6 years ago. A port site recurrence of rectal cancer after surgery was suspected due to a history of cancer and thus the tumor was resected. Histologically, the tumor comprised spindle cells with high inflammatory cell infiltration. The tumor cells were immunohistochemically negative for cytokeratin, c-kit, S-100, and ALK. The tumor was finally diagnosed as inflammatory pseudotumor. The patient has experienced no recurrence one year after surgery.

An 88-year-old woman visited the hospital with bloody stool. Hematological investigation showed anemia, and colonoscopy revealed a type 1 tumor in the sigmoid colon. Abdominal CT detected intussusception with a mass in the sigmoid colon. Endoscopic pneumatic reduction was not successful in reducing the intussusception. We performed open sigmoid colon resection. Macroscopic examination revealed a large type 1 tumor of size 10×5×3 cm in the sigmoid colon. Pathological examination showed spindle-shaped atypical cells in the tumor. There was hyperplasia with a complex sequence. Immunostaining showed c-kit-negative, CD-34-negative, α-SMA-positive, and caldesmon-positive areas, and the patient was diagnosed with sigmoid colon leiomyosarcoma. The postoperative course was good. No adjuvant chemotherapy was administered, and the patient has been free of leiomyosarcoma recurrence 9 months after the operation.

A 71-year-old man presented with a tumor in the left lower quadrant of abdomen was diagnosed with sigmoid colon cancer, and he was also pointed out having a 47-mm tumor at the lesser curvature of the stomach by a CT scan for the purpose of close exploration. Gastrointestinal stromal tumor (GIST) of the stomach was suspected and laparoscopic sigmoidectomy and tumor extirpation were performed. The tumor was situated between the left gastric artery and the lesser curvature of the stomach, and no contract with the gastric wall was seen. Histopathologically the tumor was composed of irregularly arranged and proliferated spindle-shaped cells. Immunohistostaining revealed the tumor cells to be positive for c-kit and CD34 and negative for S-100 protein and αSMA. The mitotic count was less than 5 per 50 high power fields. The Ki-67 positive rate was 2 - 3 %. From these findings, it was diagnosed as GIST of the lesser omentum in the low-risk group in accordance with the modified Fletcher classification. His postoperative course was uneventful. Following adjuvant chemotherapy for sigmoid colon carcer, he has been followed in our clinic. Although extragastrointestinal GISTs are rare, we need select appropriate operative procedures by baring a possible recurrence of GIST in mind in performing surgery.

The patient was an 88-year-old-man who had been under treatment with pembrolizumab, an immune checkpoint inhibitor, for Stage IVA lung adenocarcinoma elsewhere. After 6 courses of the treatment, he noticed bloody stools and diarrhea. So he received colonoscopy, and ulcer was pointed out in the rectosigmoid. He was diagnosed with drug-induced colitis. Prednisolone resulted in symptomatic remission, but he developed severe abdominal pain with rebound tenderness on the 31^st day after the initiation of the drug regimen. CT examination showed free air in the peritoneal cavity, and he was brought into our hospital by ambulance with a suspected diagnosis of gastrointestinal perforation. An emergency colonoscopy revealed a deep ulcer in the rectosigmoid. Perforation of the same site was strongly suspected, and an emergency operation was performed. As the perforated part was like a pinhole and there was no leakage of feces, we sutured the perforated part without rectal resection. Immune checkpoint inhibitors are effective for various advanced cancers such as malignant melanoma, non-small cell lung cancer and renal cell carcinoma. On the other hand, they cause immune related adverse events (irAE) to various organs, and colitis and diarrhea are typical ones. We report a case of colon perforation during the treatment with an immune checkpoint inhibitor, despite an improvement with steroid therapy.

Rectal paraganglioma is very rare and has not ever been reported in Japan. This time, we treated functional paraganglioma arisen in the rectum. A 60-year-old woman with bloody stool and right lower abdominal pain visited a neighboring hospital. A colonoscopy pointed out a rectal tumor, and she was referred to our hospital for the purpose of close exploration and treatment. The tumor was diagnosed with rectal paraganglioma by a biopsy. We performed low anterior resection of rectum. From 2 years and 5 months after the surgery, she had recurrences twice in the paraaortic lymph nodes, and on each occasion we performed paraaortic lymph nodes dissection. Thereafter, further lymph nodes metastasis occurred, and she died 6 years after the initial surgery. Because rectal paraganglioma is a very rare disease, we should consider treatment strategies carefully.

A 54-year-old female patient was admitted to our hospital with a history of feeling a swelling at the vaginal introitus. Colonoscopy showed a submucosal tumor measuring 60 mm in diameter in the lower rectum, above the anal canal. Aspiration biopsy was positive for c-kit and CD34, and the tumor was diagnosed as a gastrointestinal stromal tumor of the rectum. Computed tomography revealed a tumor measuring 10 cm in diameter between the vagina and the lower rectum. There was no evidence of either lymph node or distant metastasis. Although preoperative imatinib mesylate therapy was considered, surgical resection was selected, because immunohistochemical examination of a biopsy specimen revealed an Exon-9 KIT mutation. Therefore, abdominoperineal resection with resection of the posterior wall of the vagina was performed. The defect in the vaginal wall was reconstructed using a gluteal fold flap by plastic surgeons. The patient did not receive adjuvant therapy, but remains alive 18 months after the operation with no evidence of recurrence.

Herein, we describe a case of pure laparoscopic Spiegel's lobectomy performed for a colorectal liver metastasis in the caudate lobe. The patient was an 81-year-old female, who had undergone open colectomy with D3 lymph node dissection for sigmoid colon cancer (T4aN2M0 Stage IIIB) at the age of 80. Nine months after the surgery, her tumor marker level was slightly elevated and CT revealed a mass measuring 18 mm in diameter in the caudate lobe of the liver (Spiegel's lobe). A diagnosis of liver metastasis from sigmoid colon cancer was confirmed, liver resection was scheduled, and pure laparoscopic Spiegel's lobectomy was performed. The operative time was 207 minutes and the operative blood loss was 100 ml. Although isolated caudate lobectomy is a highly difficult surgery because of the anatomical characteristics of the caudate lobe, the magnified caudal view offered by laparoscopy enables safe dissection of the Glissonian pedicles and short hepatic veins during pure laparoscopic Spiegel's lobectomy. Pure laparoscopic Spiegel's lobectomy is a feasible surgical procedure, involving maximal use of the advantages of laparoscopic surgery.

A 68-year-old man underwent-left-hemihepatectomy for a 17-cm-sized hepatocellular carcinoma in the medial segment. Then, 1 year and 4 months after the first operation, he visited a local doctor with dyspnea, and a 3-cm-diameter tumor was found in the right ventricle that was suspected to be metastasis from hepatocellular carcinoma. Because he had symptoms of cardiac failure that could cause sudden death, he underwent tumor excision and tricuspid valve replacement. He was discharged from the hospital 15 days after surgery with an uneventful course. The excised tumor was confirmed to be metastasis from hepatocellular carcinoma. Multiple recurrences were observed in the lumbar spine, lung, and cardiophrenic angle 3 months after the second surgery. He was treated with the molecular target agent sorafenib. However, it was discontinued due to side effects such as interstitial pneumonia. Since then, he has received palliative treatment. He is still alive without cardiac failure 1 year and 1 month after the second surgery. If patients have symptoms of cardiac failure after liver resection for hepatocellular carcinoma, the possibility of cardiac metastasis should be considered. There is no established standard therapy for isolated metastasis of hepatocellular carcinoma in the ventricle.

A 93-year-old woman was admitted to our hospital to treat aggravation of chronic heart failure caused by severe aortic stenosis (AS). She had refused transcatheter aortic valve implantation (TAVI) and received drug therapy. She developed right upper abdominal pain 7 days after admission, and enhanced computed tomography showed gallbladder body necrosis due to torsion. In consultation with cardiologists and anesthesiologists, balloon aortic valvuloplasty (BAV) was performed for severe AS under general anesthesia to reduce the risk of perioperative mortality. Since BAV decreased the maximum pressure gradient between the left ventricle and aorta from 154 to 86 mmHg, subsequent open cholecystectomy was performed uneventfully. She was discharged 26 days after the operation without any complications.

The patient was a 33-year-old woman with unremarkable past medical history and family history. Abdominal ultrasonography during a routine medical checkup revealed a mass measuring 1 cm in diameter in the pancreatic body. The patient was asymptomatic, and her laboratory tests revealed normal levels of endocrine hormones and normal parathyroid function. Abdominal endoscopic ultrasound revealed 6 tumors varying in diameter from 2-20 mm in the body to the tail of the pancreas. The patient was diagnosed as having multiple non-functional pancreatic neuroendocrine tumors (pNET) and treated by distal pancreatectomy. The histopathological diagnosis was multiple NETs, G2, with lymph node metastasis. The patient remained relapse-free until our follow-up at 19 months. Herein, we report a rare case of sporadic multiple non-functional pNET, with a review of the literature.

A 28-year-old woman was referred to our hospital following the identification of an abdominal foreign body on radiographic examination performed at another hospital. She was asymptomatic and could not attribute the foreign body to any specific cause. Computed tomography revealed a small high-density object close to the inferior margin of the liver. Laparoscopic surgery was performed, and we identified a foreign body fused with the omentum. We carefully removed the foreign body, along with a portion of the peripheral omentum, without breaking the object. No foreign material remained in the surgical field ; this was confirmed fluoroscopically. The foreign body was a metallic needle. Urgent removal of foreign bodies is warranted because metallic objects may undergo corrosion and/or cause injury to abdominal organs. A small portion of the peripheral tissues into which the foreign body is lodged should be removed intraoperatively to prevent breakage of the object.

A 69-year-old woman was diagnosed with an intra-abdominal foreign body on abdominal radiography performed at a previous hospital and was referred to our department for further management. Computed tomography revealed a linear foreign body in the vesico-uterine pouch. Single-incision laparoscopic surgery was performed to remove the foreign body to avoid the risk of injury to the gastrointestinal tract. Intraoperatively, the foreign body was identified in the extraperitoneal space and was easily removed after cutting the peritoneal surface. We conclude that single-incision laparoscopic surgery is a useful minimally invasive approach for removal of extraperitoneal foreign bodies.

A 76-year-old man who had been suffering from diarrhea symptom visited a neighboring hospital because the symptom became pronounced for these 3 months. Colonoscopy revealed each one tumor growing circumferentially and almost completely encircling the rectum and the sigmoid colon, respectively. Biopsies of the tumors resulted in comparatively well differentiated adenocarcinoma. The patient was referred to our hospital for the purpose of exploration and treatment. Despite absence of apparent distant metastases on imaging studies, irregular-shaped wall-thickening images with strong enhancement effect were also confirmed in the transverse and the descending colon. We thus performed partial resection of the transverse colon and abdominoperineal resection including extensive left-sided colon. Histopathology revealed that the all tumors arisen from the four sites were of type 3, and tubular adenocarcinoma reaching the subserosa (except the rectal tumor which had exceeded the proper muscle layer). They were mainly composed of well differentiated adenocarcinoma.

We have experienced a case of simultaneous quadruple advanced cancer of the colon and the rectum, Although the definite diagnosis could not be made preoperatively, the case was of multiple cancer synchronously associated with early esophageal cancer. The patient follows a relatively favorable postoperative course. We present the case with some bibliographical comments.