Objective : The purpose of this study was to clarify the outcomes and prognostic factors after palliative surgery in patients with malignant bowel obstruction due to peritoneal dissemination.

Methods : The clinical records of 58 patients were retrospectively reviewed, and clinical factors associated with a poor prognosis were evaluated. The clinical factors analyzed in this study were age, sex, performance status (PS), primary malignancy, resection of primary tumor, number of bowel obstructions, amount of ascites, grade of peritoneal metastasis, other distant metastasis, Glasgow Prognostic Score (GPS), Prognostic Nutrition Index, and Neutrophil/ Lymphocyte Ratio.

Results : Palliative surgery enabled 84.5% of the patients to resume solid diets and 89.7% of the patients to be discharged from the hospital. The complication rare was 31.0%, and the median survival time after palliative surgery was 5.1 months. Patients who received postoperative chemotherapy longer than 8 weeks showed a significantly better prognosis than patients who received best supportive care or postoperative chemotherapy shorter than 8 weeks. Multivariate analysis showed male (p<0.001), PS 3-4 (p=0.002), moderate/massive ascites (p<0.001), multiple bowel obstructions (p=0.001), and GPS of 2 (p=0.01) were independent factors related to a poor prognosis.

Conclusions : The outcomes of palliative surgery in our hospital were comparable to those of previous reports. Palliative surgery might be less indicated for patients with the factors associated with a poor prognosis.

The NeoSphere trial showed that pertuzumab combined with trastuzumab-based chemotherapy improved pCR rates in HER2-positive breast cancer. We retrospectively evaluated the safety and efficacy of pertuzumab combined with trastuzumab-based chemotherapy for neoadjuvant treatment in 17 patients with HER2-positive breast cancer between November 2015 and July 2019 in our institution. Four patients had operable, 12 patients had locally advanced, and 1 patient had inflammatory breast cancer. Eight patients were hormone-receptor-positive and HER2-positive. Nine patients were hormone-receptor-negative and HER2-positive. Seven patients (41%) underwent breast-conserving surgery. The overall pCR (ypT0/is) rate was 58.8%, and this outcome was almost the same as the TRYPHAENA trial. Our result showed that the regimens with pertuzumab for the neoadjuvant treatment were highly active, with acceptable tolerability.

Isolated superior mesenteric artery dissection (ISMAD) is rare, but the number of reports of ISMAD is increasing with the increase in CT scans. There are some options for treating ISMAD, including conservative treatments, intravascular treatments, and surgery, and so on. Moreover, there are some imaging classifications of ISMAD, but there is no consensus regarding which classification should be used.

A total of 20 patients (100% male ; mean age 56 years) diagnosed with ISMAD in our hospital from 2008 to 2019 were analyzed. The numbers of patients who underwent primary conservative, intravascular, and surgical treatments were 18 (90%), 1 (5%), and 1 (5%), respectively. The median follow-up period was 756 (interquartile range : 109-3845) days. The 20 patients were classified using five classifications : Sakamoto's classification, Zerbib's classification, Yun's classification, Luan's classification, and Li's classification. Yun's type I-IIb patients were managed conservatively, and of the two Yun's type III patients, one underwent intravascular treatment and the other surgical treatment. This shows that Yun's classification is the most useful for deciding which treatment to choose for ISMAD patients.

A 58-year-old woman underwent breast-conserving surgery with nipple areola resection and sentinel lymph node biopsy for Paget's disease (T1aN0M0, HER2 type) of the left breast. Postoperative radiation therapy (42.56Gy/16Fr) to the conserved left breast was performed. Five years after the primary surgery, she was diagnosed as to have an ipsilateral breast tumor recurrence with the size of 3 cm. Positron emission tomography showed contralateral axillary lymph node swelling and fine needle aspiration cytology confirmed metastasis of the adenocarcinoma. Lymphoscintigraphy showed accumulations in the bilateral axillary lymph nodes suggesting that the contralateral axillary lymph node was a regional lymph node of the conserved breast. She underwent resection of the conserved breast and bilateral axillary staging. Sentinel lymph node biopsy with combination of indocyanine green and isotope showed negative for the ipsilateral axillary lymph node and positive for the contralateral axillary lymph node. The Pathological diagnosis was HER2 type breast cancer recurrence and dual HER2 inhibitors, trastuzumab and pertuzumab, were administered as adjuvant chemotherapy. In patients with ipsilateral breast cancer recurrence, one should consider the possibility that contralateral axillary lymph nodes might become regional lymph nodes of the conserved breast.

A 40-year-old female was referred to our hospital complaining of blood-stained nipple discharge from her left breast. Mammography revealed segmental microcalcifications, and ultrasonography revealed extensive ductal dilatation in the upper region of the left breast. Contrast-enhanced magnetic resonance imaging revealed enhanced segmental lesions throughout the upper part of the left breast. Following vacuum-assisted biopsy of the lesions, the patient was diagnosed with ductal carcinoma in situ (DCIS). Preoperative labwork revealed elevated levels of serum cancer antigen 15-3 and the tumor markers NCC-ST439 and BCA225 ; however, further evaluation revealed no lesions other than the breast cancer. We performed a skin-sparing mastectomy with a sentinel lymph node biopsy and tissue expander insertion. Histopathological examination of the resected specimens confirmed the diagnosis of DCIS. Normalization of all tumor markers occurred three months postoperatively, and the patient showed no recurrence or metastases one year postoperatively. DCIS represents a very early stage of breast cancer ; therefore, elevated tumor markers are extremely rare in these cases.

We report a case of breast cancer-associated gene 1 (BRCA1)-related metachronous bilateral breast cancer, in which the second breast cancer was almost simultaneously treated with bilateral salpingo-oophorectomy with chemotherapy for ovarian cancer.

The patient had undergone surgery (Bp + Ax) for left breast cancer (TNBC) in 2002. Considering her family history, she underwent a genetic testing and was found to be a carrier of BRCA1 mutation. In 2017 she was found to have right breast cancer (TNBC). In addition, ovarian cancer was discovered almost at the same time. Treatment of ovarian cancer preceded that of breast cancer. We performed hysterectomy and bilateral salpingo-oophorectomy followed by 6 courses of weekly paclitaxel/carboplatin chemotherapy.

The breast cancer mass was reduced by the chemotherapy, and a complete pathological response was confirmed by total mastectomy. This is an interesting and suggestive case in which postoperative chemotherapy for BRCA1-related ovarian cancer also worked very successfully for BRCA1-related breast cancer.

Metastatic breast tumors are an uncommon disease. We present a 41-year-old lactating female with a metastatic breast tumor. A solitary well-circumscribed mass on her left breast appeared. The lesion resembled an atheroma or galactocele on ultrasonography and fine needle aspiration cytology (FNAC). She was later diagnosed with invasive ductal carcinoma by excisional biopsy. However, after a subsequent CT and MRI revealed a large mass in her lung squamous cell lung cancer with the EGFR deletion mutation (exon19del) her histological diagnosis of primary breast cancer needed re-evaluation. This case, whether double cancer or metastatic, further required immunohistochemical staining and EGFR mutation analysis. Finally, we determined that the breast tumor was metastatic disease from a primary lung cancer. When patients present without medical history or radiological information regarding a primary tumor site, some metastatic breast tumors might be wrongly diagnosed as primary breast cancer if only standard histological examination procedures are used.

A 71-year-old man underwent right lower lobectomy for right lower lung cancer and was discharged. On the 15th day after the surgery, he was urgently brought into our hospital due to impaired consciousness and respiratory failure. Bronchoscopic examination showed the bronchial stump to have completely opened. It was determined that the fistula could not be closed on one-stage operation, so after intervention of a nutritional support team and physiotherapists, fenestration was performed. As a result, 7 days after fenestration, a mechanical ventilator was no longer necessary, and walking training was started. Two months after the surgery, the bronchial stump was almost covered with surrounding tissues. The addition of 4 weeks' negative pressure wound therapy (NPWT) resulted in complete disappearance of the residual pleural cavity and wound epithelialization. The reasons for the successful closure of the fistula in a relatively short time after fenestration were that perioperative nutritional status was generally good, the volume of the remaining right upper and middle lobe was large, and the pleural cavity reduced as the empyema cleared. Perioperative active participation of each occupation was also important. NPWT was effective in reducing the residual pleural cavity.

A 75-year-old man was referred to our hospital with a diagnosis of thyroid carcinoma. CT revealed a tumor in the upper right lobe of the thyroid protruded in the anterior wall of the cervical trachea with bilateral multiple lymph nodes swelling. He underwent total thyroidectomy with excision of the upper trachea and bilateral modified neck dissection. His airway was primarily reconstructed by end-to-end anastomosis. He was ventilated for 7 days in the ICU and extubated on postoperative day (POD) 8. On POD 10, he developed subcutaneous emphysema of the neck extending to the chest. CT revealed a small anastomotic dehiscence and massive subcutaneous emphysema. Because he had no clinical symptoms except for subcutaneous emphysema, we compressed the skin of his neck where was considered at the anastomotic defect by a small triangular pillow made of gauze with tape to stop an air leakage. The subcutaneous emphysema was not extended afterwards and the gauze compression was removed on POD 19. After that he had an uneventful course and was discharged on POD 28. If the patient has no clinical symptoms, the compression of the skin considered at the small anastomotic dehiscence may be useful.

Chest injuries are classified into penetrating and blunt trauma. In Japan, penetrating thoracic trauma is infrequent, accounting for approximately 15% of all chest traumas. Most penetrating lung injuries do not require thoracotomy and are treated with a thoracic drain. We have experienced a case in which pulmonary tractotomy was useful for penetrating lung injury and a foreign body in the lung. A 30-year-old man had been operating an industrial press machine when a piece of metal flew out of it and embedded in the left thorax. Chest X-ray and CT scans revealed that metal fragments were retained in the lingular segment of the left lung and confirmed the diagnosis of penetrating lung injury due to a foreign body. A thoracotomy was performed to identify and treat the injury as well as to remove the foreign body. The entry hole of the metal piece was found in the upper left lobe, and a hard foreign body was palpable in the lingular segment. Stapled pulmonary tractotomy was successfully performed to ensure hemostasis and remove the foreign body. The patient had a good postoperative course and was discharged from our hospital without any complications on the 23^rd POD. Our experience suggests that pulmonary tractotomy is a useful technique for penetrating lung injury caused by a metal fragment.

A 59-year-old man was admitted to our hospital because of an abnormal shadow in the left hilum of lung on a plain chest X-ray film. Chest computed tomography revealed a tumorous shadow with fat density in the left upper bronchus, approximately 30 mm in diameter. The tumor was diagnosed as “lipoma” by bronchial biopsy. Because HRCT findings showed an extrabronchial growth of the tumor and an atelectasis of the left S3, a left upper lobectomy by complete video-assisted thoracoscopic surgery (VATS) was performed for complete resection. The pathological diagnosis was endobronchial liposarcoma with negative surgical stump. He was discharged on independent gait at postoperative day 7 without complications. The patient showed no evidence of recurrence 2 years after the operation.

Endobronchial lipoma is a rare entity and accounts for about 0.1% of all pulmonary tumors. As to endobronchial liposarcoma, we sometimes encounter case reports of it as metastasis from that arisen in other organs, but primary liposarcoma of the bronchus has extremely rarely reported. Further accumulation and sharing of such cases are expected to clarify the therapeutic guidelines and the prognosis.

An 80-year-old female was admitted to our hospital with complaints of chest pain and dysphagia. An upper gastrointestinal endoscopic examination showed an elevated tumor in the upper and middle-thoracic esophagus. Pathological findings of the biopsy specimens showed basaloid squamous cell carcinoma. Chest computed tomography showed increased esophageal wall thickness and regional lymph node metastases and she was diagnosed with stage III esophageal cancer (cT3N1M0). The patient received neoadjuvant chemotherapy twice (5-fluorouracil 600 mg/m², days 1-5 and nedaplatin 45 mg/m², day 1). After chemotherapy, the esophageal tumor decreased in size. This was considered a partial response and her disease was down-staged (CT-cT2N0M0 cStage II). The patient underwent thoracic esophagectomy in the prone position, laparoscopic gastric tube reconstruction through the retrosternal route, and esophagogastric anastomosis in the neck four weeks after neoadjuvant chemotherapy. Histological findings of the resected specimens were negative for tumor cells in the primary lesion of the thoracic esophagus. There was no lymphatic invasion, venous invasion, or lymph node metastasis. The tumor regression rate was 100%, considered a histological complete response : Grade 3. Combination chemotherapy with 5-FU and nedaplatin could be an option of neoadjuvant chemotherapy for advanced basaloid squamous cell carcinoma.

A postoperative pancreatic fistula (POPF) is a serious complication after gastrectomy. A case of a POPF after gastrectomy treated using endoscopic transgastric drainage is reported. A 67-year-old woman underwent laparoscopic-assisted distal gastrectomy. On the 4th postoperative day, she developed a high fever and back pain. A pancreatic fistula was diagnosed on computed tomography (CT). Conservative therapy was started and resulted in temporary relief of the inflammatory reaction, but her symptoms recurred repeatedly. An abdominal abscess due to a pancreatic fistula was diagnosed on CT on the 28th day after the start of conservative therapy. The patient was then considered to be a candidate for drainage. However, since there was no safe route for percutaneous puncture, endoscopic ultrasound (EUS)-guided transgastric drainage was performed. Her high temperature dropped rapidly, and CT confirmed a significant decrease in the retained fluid ; she was discharged from our hospital on the 18th postoperative day.

In cases in which conservative therapy is unsuccessful and percutaneous fine needle drainage is difficult for a POPF after gastrectomy, EUS-guided transgastric drainage may be one choice for treatment.

A 23-year-old Japanese woman presented with epigastralgia. Esophagogastroduodenoscopy showed a submucosal tumor with the size of about 25 mm in the gastric angle. An abdominal contrast-enhanced computerized tomography (CT) revealed a 35-mm hypo-dense mass with heterogeneous enhancement in the lower part of the gastric body and an about 16-mm mass in the gastric angle, which demonstrated similar enhancement to the pancreas. We suspected gastrointestinal stromal tumor (GIST), leiomyoma and ectopic pancreas, also known as heterotopic pancreas, for differential diagnoses. We performed open partial gastrectomy for each tumor because a possibility of GIST could not be ruled out. We diagnosed both tumors as ectopic pancreas in accordance with perioperative macroscopic findings. Both pathological diagnoses were ectopic pancreases. One existed between submucosa and muscularis propria in the gastric angle, and the other existed between muscularis propria and subserosa in the lower gastric body. We found that local pancreatitis had occurred repeatedly because the fibrosis with accumulation of histiocytes around some pancreatic ducts was detected. Epigastralgia which might be caused by local pancreatitis completely disappeared after the surgery. This is a rare case in which gastric ectopic pancreas in two locations presented with a clinical symptom.

A 32-year-old woman was pointed out having an abdominal tumor by an abdominal US on a health check. Upper gastrointestinal endoscopy showed an elevation in the posterior wall of the upper body of the stomach which was suspicious of a submucosal tumor of 30 mm in diameter. The specimen collected during endoscopic ultra sound-guided fine needle aspiration biopsy showed spindle cells. Abdominal MRI and CT scans revealed the tumor of 30 mm in diameter contacted with the posterior wall of the upper body of the stomach. We operated on the patient with a suspicion of an extraluminally growing GIST of the stomach. We found the tumor on the cranial side of the pancreas tail and the tumor did not have any connection to the stomach. The tumor was considered to be a retroperitoneal tumor. We excised the tumor without injuring the capsule. Histology showed the tumor to be composed of spindle cells. Immunostaining revealed CD34 (+) and c-kit (-). Genetic investigation showed no mutation on both c-kit and PDGFRA. Therefore, the tumor was diagnosed as solitary fibrous tumor (SFT). If a tumor suspicious of submucosal tumor of the stomach is found before operation, we have to consider a possibility that the tumor may be a SFT arising from the retroperitoneum.

A 78-year-old woman with abdominal pain visited our hospital. A contrast-enhanced CT scan revealed wall thickening of the gastric body, with bulky lymph nodes but no ascites. Gastrointestinal endoscopy revealed a type 3 tumor in the gastric antrum (adenocarcinoma, tub2, HER2 positive). On the basis of these findings diagnosed as cStage III, we decided to perform a distal gastrectomy. However, the patient underwent gastrojejunostomy because the gastric cancer had invaded the head of the pancreas. The cancer was intraoperatively diagnosed as stage IV gastric cancer. The patient underwent XP plus trastuzumab therapy. However, because of Grade 3 side effects during the first course, chemotherapy had to be interrupted. Thus, we started SOX plus trastuzumab therapy for 4 alternating courses. After therapy, the patient underwent distal gastrectomy, as the primary tumor size and number of lymph nodes had significantly decreased compared to those previously. Pathological analysis showed no tumor cells in the resected specimen, including the lymph nodes. The histological grade was determined as Grade 3. At present, 6 months after radical resection, the patient remains free from recurrence. Combination therapy with SOX plus trastuzumab for HER2-positive gastric cancer could be one of the initial treatment options after which conversion surgery may be expected.

A 67-year-old man underwent open distal gastrectomy with Roux-en-Y reconstruction for advanced gastric cancer after neoadjuvant chemotherapy. Lymph node recurrence was observed, and he was started on nivolumab as tertiary treatment. Six months later, he noticed loss of appetite and general fatigue, and one month later, he had multiple arthralgias in his extremities. Nine months after the start of nivolumab therapy, he was urgently hospitalized for malnutrition, general fatigue, and multiple arthralgias. After further examination, he was diagnosed with having isolated adrenocorticotropic hormone (ACTH) deficiency and polyarthritis due to an immune-related adverse event (irAE). After a single intravenous infusion of hydrocortisone and oral administration of prednisolone, his symptoms improved. He has now discontinued nivolumab therapy, but recurrent sites are maintaining a complete response. Although the diagnosis and treatment of irAEs are important in immune checkpoint inhibitor therapy, it is sometimes difficult to distinguish them from postgastrectomy syndrome.

A 76-year-old man who had been treated for ureteral stones and urinary tract infection in a local hospital was urgently transferred to our institution because his general condition became worse due to septic shock and multiple organ failure. On the 9th hospital day, a tarry stool was observed. Upper gastrointestinal endoscopy showed gastric ulcer without active bleeding. On the eleventh day, he went into hemorrhagic shock due to massive blood loss, and a colonoscopy was performed. Despite the presence of an ulcerous lesion at the terminal ileum, any site of active bleeding could not be identified. No extravasation could be detected by an enhanced CT scan. After that, intermittent bleeding continued, and he went into a state of shock again on the 14th hospital day Emergency surgery was thus performed. Operative findings showed no obvious abnormalities on the serosal side of the small intestine. When an endoscope was inserted from the incision site of the terminal end of the ileum, arterial hemorrhage was observed in the intestinal wall 110 cm proximal from the incision, and it was treated with coagulation. There was no apparent ulceration at the lesion, suggesting a Dieulafoy's ulcer. One year after the operation, no rebleeding occurred, and the colostomy was closed.

A 65-year-old man presented with fever and abdominal distention and was referred to our department for further investigation. There was evidence of inflammation, with a white blood cell count of 25,400/mm³ and C-reactive protein of 20.29 mg/dl, and abdominal computed tomography showed a 20-cm-diameter cystic mass with an air-fluid level in the upper abdomen. Exploratory laparotomy was performed for the purpose of diagnosis and treatment. The jejunum was subcircumferentially ruptured and opened into the lumen of the mass, and partial jejunectomy was performed, including resection of the mass. As much of the wall of the mass was removed as possible, but widespread adhesions to the transverse mesocolon meant that it had to be left in place. Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) was diagnosed on histopathological examination. The patient's postoperative course was uneventful, and the patient started chemotherapy at another hospital, but he developed multiple brain metastases and died of the underlying disease on postoperative Day 197. Enteropathy-associated T-cell lymphoma II was renamed MEITL in the 2016 revisions to the World Health Organization classification. A case of MEITL that formed a giant intraperitoneal mass, 20 cm in diameter, is reported.

A 52-year-old woman presented to the emergency department of our hospital with a chief complaint of abdominal pain. Computed tomography (CT) showed discontinuity of the transverse colon wall. A transverse colectomy and functional end-to-end anastomosis were performed with construction of a diverting ileostomy for transverse colonic perforation. Pathological findings of the resected specimen showed no causative factor for the perforation on hematoxylin and eosin staining. After closure of the ileostomy, she was discharged on postoperative day 31. One week after discharge, she presented to our emergency department again with abdominal pain. CT showed free air around the sigmoid colon. Hartmann's procedure was performed for sigmoid colon perforation. The pathological findings of the resected specimen were the same as previously. She was discharged on postoperative day 34. Ten weeks after discharge, she presented to our Emergency Department once again with abdominal pain. CT showed extraluminal feces around the ascending colon. A right hemicolectomy and ileostomy were performed for ascending colonic perforation. The pathological findings of the resected specimen showed diffuse amyloid deposits in the wall of the colon on direct fast scarlet stain, and the previous two resected specimens showed the same findings. The final diagnosis of the cause of these colonic perforations was intestinal amyloidosis.

An 82-year-old woman who had been taking anticoagulants for pulmonary thromboembolism developed mesosigmoid hematoma. We started conservative treatment, however, penetration of diverticulum happened to mesosigmoid hematoma with the sudden onset of abdominal pain on hospital day 3. We performed an emergency Hartmann's operation and drainage. Her mesosigmoid had ruptured by hematoma and the peritoneal cavity was contaminated with stool. We also identified the penetration of pseudodiverticulum to mesosigmoid hematoma. Histopathological findings showed that the intramural colon hematoma was present at penetrated pseudodiverticulum and suggested that pseudodiverticulum penetration might be caused by ischemia or rupture. The postoperative course was uneventful and she was discharged on 42nd day after the surgery. Non-traumatic mesenteric hematoma is relatively rare and no case of pseudodiverticulum penetration to hematoma has been reported during the conservative therapy for it. We should perform early operation when mesenteric hematoma was found in a colonic segment with multiple diverticulum.

A 62-year-old man was admitted to our hospital complaining of bloody stools and was diagnosed as having rectal cancer. He underwent laparoscopic low anterior rectal resection. A follow up CT scan at 1 year after the operation detected no sign of recurrence. Another CT scan at 1.5 years detected soft tissue images on the dorsal side of the anastomosis and around the right ureters. PET-CT scan showed the abnormal fluorodeoxyglucose accumulation on the soft tissue. Disseminated recurrence of rectal cancer was suspected and systemic chemotherapy was scheduled. However, the elevated level of serum IgG4 suggested a possibility of IgG4 associated disease. The pathological specimen of the lesion obtained by CT-guided biopsy showed fibrous tissue and infiltration of lymphocytes, although in which the proportion of IgG4 positive cells was slight. As presence of malignant cells suggestive of metastasis was not proven, we continued with observation. Steroid therapy had been initiated and the soft tissue diminished. Some cases of IgG4 related disease may be misdiagnosed as malignant tumors or their recurrence, and extended surgery or chemotherapy may be performed. When an image diagnosis suggested recurrence of a malignant tumor, it is important to take IgG4 related disease into consideration as one of differential diagnosis.

A 62-year-old man stabbed himself in his neck and chest with a kitchen knife with suicidal intent. He was transferred to our hospital, and a pericardial effusion and perihepatic fluid were observed on contrast-enhanced computed tomography (CT), and an arterio-portal shunt (AP shunt) was strongly suspected. Emergency surgery was performed. Fortunately, the right ventricle was only shallowly lacerated, and there was no active hemorrhage. In addition, the liver had a 2-cm-deep stab wound, but there was no active hemorrhage. A TachoSil fibrin sealant patch was used to stop these local bleeding areas. Immediately after surgery, emergency transarterial embolization was performed for the A3 branch of the hepatic artery using N-butyle-2-cyanoacrylate (NBCA), and absence of the AP shunt was confirmed. He progressed well and was transferred to a psychiatric hospital 10 days after surgery. The timing of intervention for an AP shunt associated with hepatic injury has not yet been clarified. A case of chest penetrating trauma with an AP shunt is described, and the timing of intervention for an AP shunt with hepatic injury is discussed in terms of liver microcirculation.

An 87-year-old man underwent resection of a cutaneous malignant melanoma in March 2016. Metastases subsequently appeared in the right inguinal, paraaortic, and right axillary lymph nodes and the brain. The brain metastasis was treated with gamma knife therapy, followed by treatment with pembrolizumab. This multimodal treatment successfully controlled the lymph node and brain metastases, but computed tomography (CT) scanning in August 2018 showed an elevated lesion in the gallbladder. This gallbladder tumor was enlarged on a CT scan in October, and gallbladder metastasis or gallbladder cancer was diagnosed. Because the lesions at other sites remained under control with pembrolizumab, the possibility of gallbladder cancer could not be excluded, and it was decided to resect the tumor. The surgical procedure used was liver bed resection with 12b lymph node dissection. Pathological examination confirmed gallbladder metastasis of malignant melanoma. There has been no subsequent recurrence 14 months postoperatively. Multiorgan metastasis of malignant melanoma is considered to have a poor prognosis, but it may be improved by the complete surgical resection of sites where the disease cannot be controlled by immune checkpoint inhibitors.

A 77-year-old woman undergoing preoperative examination for distal bile duct cancer was seen in our Emergency Department with chief complaints of fever, chills, and vision loss in the left eye. She was diagnosed with a liver abscess after being admitted to our institution. At the Department of Ophthalmology, she was diagnosed with uveitis, iritis, and vitreous opacity and treated with antibiotics. Two days after admission, swelling and pain in the left eye had worsened. It was diagnosed as metastatic endophthalmitis and treated with enucleation of the left eyeball on day 7. Since the patient's condition improved with antibiotics, she underwent subtotal stomach-preserving pancreatoduodenectomy on day 29. Postoperatively, there was a biochemical leak based on the International Study Group of Pancreatic Fistula criteria. She was discharged on postoperative day 25 after conservative treatment. Metastatic endophthalmitis is a rare disease caused by blood-borne fungal or bacterial metastasis into the eye from infected foci of other organs, and its prognosis is extremely poor compared to exogenous endophthalmitis. A case of metastatic endophthalmitis secondary to a bacterial liver abscess before surgery for cholangiocarcinoma, which led to enucleation of the eyeball, as well as bile duct carcinoma treated with radical resection, is reported.

A 77-year-old man presented with dysarthria and left upper limb paralysis was referred to our hospital with a diagnosis of Trousseau's syndrome due to carcinoma of the pancreatic tail. His pancreatic carcinoma had invaded the other organs and the CA19-9 level was abnormally high. Latent peritoneal dissemination was considered likely and we performed neoadjuvant chemotherapy with GEM + nab-PTX. As a result, the CA19-9 level was significantly reduced, and the tumor diameter had shrunk by 30%. We performed distal pancreatectomy, partial gastrectomy, and partial colectomy. Adjuvant chemotherapy with S-1 was carried out. Although lymph node recurrence occurred 10 months after the operation, re-administration of GEM + nab-PTX resulted in disappearance of the lymph node recurrence. He has been on chemotherapy as of one year and 4 months after the operation.

Trousseau's syndrome signifies hypercoagulability associated with any malignant disease or disseminated intravascular coagulation (DIC) associated with migratory thrombophlebitis. In Japan, it is often signified as a condition where cerebral infarction has occurred due to hypercoagulability associated with a malignant tumor. Cases of malignant disease associated with Trousseau's syndrome are often to be of advanced and the prognosis is resultantly poor. However, by achieving successful control of the malignancy with neoadjuvant chemotherapy, we can resect the tumor like in our case, and we here present our case as a notable one.

Case 1 : A 41-year-old woman presented with abdominal pain. MRI scan of the abdomen revealed a soft tissue mass in the pelvic cavity and abdominoperineal resection for the tumor was performed. The histopathological diagnosis was aggressive angiomyxoma (AAM). Case 2 : A 36-year-old woman patient presented to the Department of Gynecology in our hospital because of uterine bleeding. MRI scan revealed a myoma of the uterus and a soft tissue mass in the pelvic cavity. We performed enucleatic myomectomy + tumorectomy. The histopathological diagnosis was AAM. Case 3 : A 64-year-old woman patient presented with a tumor protruding from the anus at defecation. Based on CT findings, it was diagnosed as a condition where a pelvic soft tissue tumor had directly invaded the rectum and exposed from the anus. We performed tumorectomy + partial resection of the rectum. The histopathological diagnosis was AAM.

AAM is a rare mesenchymal tumor which often affects the genital organs, perineum, and pelvis in women of reproductive age. Our experiences with three cases of AAM are presented here, together with a review of the literature.

Tailgut cysts are rare and derived from the remnants of the embryonic tailgut. Occasionally these cysts becomes malignant. We experienced a case of a tailgut cyst with adenocarcinoma with prolonged patient survival after surgery. The patient was a 29-year-old female who presented with complaints of swelling in the right buttock. CT and MRI revealed a cystic lesion of 130 mm in the presacral space with a solid mass inside. Preoperatively we suspected a tailgut cyst with a malignant tumor inside ; thus, surgery was indicated. The surgery involved a tumorectomy with a parasacral incision in the jack-knife position. Histopathologically, she was diagnosed with tubular adenocarcinoma of the papillary gland that remained inside the cyst. The patient was discharged on the sixteenth postoperative day. Seven years and 4 months have passed since the surgery with no recurrence. Locally advanced and metastatic cases of tailgut cysts with malignant tumors are usually associated with a poor prognosis. However, the long-term postoperative prognosis may be better when the adenocarcinoma remains inside the cyst, as with our case. However, appropriate follow-up can be challenging since enlargement of tailgut cyst occurs extremely slowly.

An 84-year-old female, with no history of abdominal surgery, presented with complaints of abdominal pain and nausea. Computed tomography (CT) revealed a dilated small intestine with an internal hernia pointed cranially beyond the transverse colon. Thus, an internal hernia involving the transverse mesocolon was suspected and emergency laparotomy surgery was performed. The small intestine within the hernial sac was incarcerated into the omental bursa through the defect of the transverse mesocolon. No ischemic changes were detected in the incarcerated intestine. Transmesocolonic hernias are rare, and only represent 12.2% of all mesocolonic hernias. Transmesocolonic hernias are classified into two types : one type which involves the bilateral transverse mesocolon, and another which involves the unilateral transverse mesocolon. This case was classified as the latter type. Today, a few reports indicate that multi-detector row computed tomography (MDCT) enables diagnosis of transmesocolonic hernias. Using MDCT, we could diagnose the transmesocolonic hernia preoperatively.

A 92-year-old woman who had undergone open left femoral shaft fracture reduction complained of leg pain on the same side immediately following the procedure. The lower leg was pale and cold, and the peripheral artery was impalpable and inaudible on Doppler. Occlusion of the left superficial femoral artery was diagnosed on contrast-enhanced computed tomography, and emergency surgery was performed. Intraoperatively, intimal dissection in the superficial femoral artery due to damage in the area of the fracture and open reduction surgery was evident, together with occlusion due to what was regarded as secondary thrombus formation. Thrombectomy and intimal fixation did not provide good recanalization to the periphery, and a left superficial femoral artery-popliteal artery bypass was performed using a blood vessel prosthesis. There were no postoperative complications such as reperfusion injury, and the leg was salvaged. Intimal damage to the superficial femoral artery may occur as a complication of femoral shaft fractures in older patients, and even if the original injury is nonobstructive, the progression of dissection and thrombus formation in the perioperative period after orthopedic surgery may cause secondary vascular occlusion leading to acute lower limb ischemia. Accurate evaluation of physical findings over time and perioperative management with an awareness of the possibility of vascular injury as a complication are both vital.