Since minimally invasive pancreatectomy requires advanced surgical techniques, it is important to ensure safety during the learning curve. Various introductory processes, such as a prospective registration system into the national clinical database, were established by surgical societies in Japan, and in 2020, national health insurance covered laparoscopic and robot-assisted pancreaticoduodenectomy with lymph node dissection procedures. In the surgical treatment of pancreatic cancer, preoperative and postoperative adjuvant treatments are extremely important to improve the prognosis. Therefore, minimally invasive pancreatectomy is expected to result in early postoperative recovery. However, the establishment of an educational system is an important issue. On the other hand, endoscopic surgery facilitates delicate dissection by showing the detailed anatomy with high-resolution images. Traditionally, Japanese surgeons have performed safe and curative surgery by understanding the anatomical structure. Therefore, the development of novel approaches for minimally invasive pancreatectomy while understanding the anatomy precisely is expected in the future.

Superior mesenteric artery (SMA) occlusion is rare, and the treatment results have not yet become favorable. The survival rate of SMA occlusion has improved due to the improvement of diagnostic and treatment techniques, but the mid- and long-term prognosis due to postoperative short bowel syndrome is still poor. The treatment options for SMA occlusion are surgery and intervention, but it is not clear which offers the greatest advantage. We examined the treatment strategies for SMA occlusion, and examined 14 cases that were managed in our hospital from 2012 to 2018. We conducted trial laparotomies in 8 cases (5 cases of thrombectomy and 3 cases of intestinal resection). At the time of thrombectomy, 2 patients underwent resection. Of the 5 patients who underwent percutaneous endovascular therapy (IVR), 2 patients did not undergo enterectomy. The survival rate was 86%. Massive enterectomy could be avoided in revascularized cases. It may be possible to avoid massive enterectomy by performing IVR or open thrombectomy, and it is thought that second-look surgery for the evaluation of delayed enteric ischemia after revascularization is beneficial.

Purpose : We investigated the short-term outcomes and safety of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair performed as day surgery.

Methods : We retrospectively investigated 1,408 patients with inguinal hernias who underwent TAPP at our clinic between November 2015 and December 2019.

Results : The mean operation time, anesthesia time, interval between the completion of surgery and discharge from the hospital, and pain score (Numerical rating scale) at discharge were 74.6 min, 103.5 min, 66.4 min, and 1.8, respectively. We observed 8 (0.6%), 101 (7.2%), and 74 (5.3%) cases of intraoperative, immediate postoperative, and postoperative complications, respectively. Notably, 1,405 (99.8%) patients returned home on the same day of the operation. One patient with anaphylactic shock and two patients with worsening asthma required hospitalization on the day of surgery. The operation was performed safely without any serious complications associated with it.

Conclusions : Day surgery is a safe, feasible, and useful option for TAPP inguinal hernia repair after building a team of medical care professionals who specialize in it.

Magnetic resonance imaging (MRI) of the breast is the most sensitive modality for the detection of breast cancer among current clinical imaging modalities such as mammography (MMG) and ultrasonography (US). We have detected lesions that were observed as abnormalities only on MRI alone (MRI-only visible lesions). In Europe and the United States, MRI-guided vacuum-assisted breast biopsy (MRI-guided VAB) is commonly used for evaluating such lesions. In Japan, MRI-guided VAB was included in the medical insurance coverage in April 2018. Accordingly, our facility established a system that can perform MRI-guided biopsy. We report the findings of the first evaluated case. The patient was a 61-year-old woman. She presented with bloody nipple discharge and was referred to our hospital. MRI-guided biopsy was performed because no target lesion could be identified for stereotactic-guided or ultrasound-guided biopsy. The biopsy result indicated a ductal carcinoma in situ (DCIS). Subsequently, surgical treatment was performed, and the final pathological result was still DCIS. MRI-guided biopsy is an effective diagnostic tool when MRI-detected lesions are observed without any lesions detected on either ultrasound or stereotactic-guided biopsy.

A 55-year-old woman with an abnormal finding on screening was referred to our hospital. Ultrasonography revealed a 10 mm irregularly shaped hypoechoic mass in the left breast. The result of aspiration biopsy cytology was positive, and the mass was suspected to be an invasive ductal carcinoma. Computed tomography revealed enlarged axillary lymph nodes, although no distant metastases were observed. We performed total mastectomy of the left breast and axillary lymph node dissection. Pathological findings indicated squamous cell carcinoma of the breast. Immunohistochemical staining revealed that the tumor was negative for estrogen and progesterone receptors, and positive for HER2. On postoperative examination, bone and para-aortic lymph node metastases were observed. The patient died 3 years after surgery. Thus, patients with HER2-positive breast squamous cell carcinoma should be carefully observed.

We encountered a case of spindle cell carcinoma of the breast a rare type of breast cancer with early local recurrence after surgery and rapid outcomes. A 55-year-old woman presented to our hospital with a lump in her left breast ; pathological examination indicated a spindle cell carcinoma of the breast. Preoperative imaging revealed a 24-mm tumor in the left mammary gland and no axillary lymph node or distant metastasis. The patient underwent breast-conserving surgery and sentinel lymph node biopsy for the spindle cell carcinoma of the breast (cT2N0M0 cStage IIA). During postoperative adjuvant chemotherapy, we observed an increase in the size of the lumps in the left axilla as well as skin thickening of the entire left mammary gland. The patient was diagnosed with pathological recurrence on core needle biopsy. On the 64th postoperative day, left mastectomy with partial resection of the pectoralis muscle and axillary lymph node dissection were performed because the tumor showed chemotherapy resistance and no distant metastases were observed. Postoperative pathological examination revealed that the recurrent tumor had coalesced and reached a diameter of 85 mm. Two weeks after the reoperation, skin metastasis and lymph node metastasis were found. Subsequently, radiotherapy and some chemotherapy regimens were ineffective. Eventually, the patient died 6 months after the first operation.

We report a case of breast cancer with contralateral axillary lymph node metastasis from ipsilateral breast cancer after breast conserving surgery. The patient was a 57-year-old woman who had undergone right breast conserving surgery and axillary lymph node dissection for right breast cancer at the age of 46. She was diagnosed with ipsilateral breast cancer and contralateral axillary lymph node metastasis 11 years after the operation. Both of them were histologically consistent, but were different from the primary lesion at the age of 46. A preoperative lymphoscintigraphy revealed lymphatic drainage to the contralateral axillary node. The results meant that the contralateral axillary lymph node could be regarded as regional lymph node. Therefore, we diagnosed the ipsilateral breast cancer as a new primary breast cancer without distant metastasis and performed multidisciplinary treatment including surgical resection for a radical cure. Since contralateral axillary lymph node metastasis is usually distant metastasis, surgical resection is not recommended except for limited cases. In the case of ipsilateral breast cancer after breast conserving surgery and axillary lymph node dissection, contralateral axillary lymph node metastasis might be regarded as regional lymph node metastasis, and we should consider to perform multidisciplinary treatment including surgical resection for a radical cure.

We report a case of late recurrence of breast cancer with brain and small intestine metastases observed 17 years and 21 years after breast cancer surgery, respectively. A 71-year-old woman had undergone right mastectomy and axillary dissection 21 years ago for right breast cancer. The cancer was classified as luminal B (ER, 60% ; PgR, 60% ; HER2 score, 0 ; and Ki67, 20%) T1N1M0 stage 2A. Four courses of CMF therapy followed by tamoxifen were administered. Brain metastasis was detected 17 years after the breast cancer surgery. The brain tumor was resected, and other multiple lesions were treated with gamma knife radiosurgery. The pathology of the brain tumor was consistent with adenocarcinoma metastasis (ER, 80% ; PgR, 40% ; HER2 score, 0 ; and Ki67, 60%) and late recurrence of right breast cancer. Subsequently, the patient developed bowel obstruction 21 years after the surgery for right breast cancer. A tumor was found 50 cm from the ligament of Treitz ; hence, partial resection of the small intestine was performed. The pathological findings of the resected specimens were similar to those of the previously observed breast cancer cells (ER, 70% ; PgR, 10% ; HER2 FISH positive ; and Ki67, 10%-50%). There was no primary tumor, and the patient was diagnosed with intestinal obstruction due to metastasis of the previous right breast cancer. Currently, 2 years since the development of small intestine metastasis, the patient has been followed-up in our outpatient department on a regular basis.

A 49-year-old woman was referred to the emergency department with the chief complaint of recurrent vomiting. She had also noticed a left breast mass 8 months prior to the visit. The patient was diagnosed with left breast carcinoma, duodenal stenosis, and right urinary duct stenosis. Although distant metastasis of breast carcinoma to the peritoneum or retroperitoneum has been reported infrequently, it was difficult to elucidate the pathology of the duodenal and urinary duct stenosis based on the imaging findings in the current case. Exploratory laparotomy revealed tumor dissemination in the retroperitoneum and mesocolon, and the tumor was revealed to be an adenocarcinoma on frozen section analysis. As resection of tumor involving the duodenum was difficult, choledochojejunostomy and gastrojejunostomy were performed. After bypass surgery, the patient's nutritional status improved steadily, and she was diagnosed with advanced breast cancer with peritoneal and retroperitoneal metastases. Chemotherapy was administered, resulting in a partial response, followed by endocrine therapy combined with molecular targeted therapy.

We report two cases of breast cancer metastasis to the skull base with different clinical courses. Case 1 was observed in a 72-year-old woman who was diagnosed with right breast cancer (cT4bN0M1, OSS, Stage IV) accompanied by cranial neuropathy of nerves VIII, IX, and XII due to skull base metastasis. A marked improvement was observed in the cranial nerve symptoms after radiotherapy to the left skull base (39 Gy in 13 fractions). Case 2 was observed in a 67-year-old woman who was diagnosed with right breast cancer (cT4bN3aM1, PUL, Stage IV) accompanied by cranial neuropathy of nerves VIII, IX, X, and XII due to skull base metastasis. The patient was scheduled to start chemotherapy but was admitted with the chief complaints of headache, dizziness, and dyspnea. Owing to progressive dysphagia, the patient was unable to eat and was transferred to another hospital for palliative care. Accordingly, the early detection and therapeutic intervention of cranial nerve symptoms due to bone metastasis of breast cancer may prevent the deterioration of the patients' quality of life (QOL).

von Recklinghausen's disease is an autosomal dominant hereditary disease characterized by multiple skin tumors and abnormal pigmentation. Vascular lesions are rarely complicated with this disease, but such cases can be fatal. We encountered two cases of massive bleeding caused by spontaneous arterial rupture. Case 1 : A 57-year-old woman diagnosed with right hemothorax underwent surgery the day after admission. The first intercostal artery was suspected to be ruptured, and we stopped bleeding by using fibrin tissue adhesives. A neurofibroma near the artery was also confirmed, but arterial invasion was not evident. Case 2 : A 55-year-old woman was brought to our emergency department in a state of vital shock. She experienced cardiopulmonary arrest after hemorrhagic shock caused by rupture of the left lumbar artery. Intervascular treatment was performed immediately after the recovery of circulation, but the patient died of disseminated intravascular coagulation. Both patients had been diagnosed with von Recklinghausen's disease.

Thus, immediate surgical intervention is required if a patient with von Recklinghausen's disease experiences massive bleeding caused by arterial rupture.

The case was a 66-year-old woman who visited our hospital complaining of both epigastric and right hypochondriac pain from the day before. Her skin had yellowed, and she was in septic state with severe inflammatory response, impaired consciousness, and a decreased blood pressure. Computed tomography revealed a highly swollen gallbladder, with part of the liver and hepatic flexion of the colon in the right thoracic cavity. Passive atelectasis in the lower lobe of the right lung, pleural effusion, common bile duct stones, dilation of the intrahepatic bile duct, and the enlargement and leftward displacement of the left hepatic lobe were also observed. Our diagnosis was acute cholecystitis and cholangitis in a right-sided Bochdalek hernia. We excluded emergency surgery since the hernia portion of the liver and blood supply to the colon were not impaired, and the colon was not obstructed. Nevertheless, percutaneous transhepatic cholangial drainage was performed on the same day via the left hepatic lobe to cure cholangitis. The inflammation of the gallbladder and the bile duct quickly disappeared, and ingestion was possible again. After endoscopic lithotomy of the common bile duct stones, Bochdalek hernia repair and cholecystectomy were performed simultaneously on the 58th day after treatment. The postoperative course was good, and the patient was discharged on the 11th day after surgery.

A 55-year-old man presented to our hospital with abnormal radiological findings in the upper gastrointestinal (UGI) tract. A double contrast UGI series and an endoscopy showed an entire circumferential, multinodular, irregular, and elevated lesion at the proximal pyloric region. A computed tomography showed entire circumferential wall thickening, a protruding lesion at the pylorus, and a dilated stomach. Although an endoscopic biopsy of the lesion showed gastric adenoma, our provisional diagnosis was pyloric stenosis due to gastric carcinoma, Distal gastrectomy with lymph node dissection was performed. Histopathological examination of the resected specimen revealed hypertrophy of the proper muscle layer of the pyloric ring (9 mm in thickness) and submucosal fibrosis ; the nodular elevated lesion was consistent with gastric adenoma and gastritis cystica profunda (GCP). Coexistence of hypertrophy of the pyloric muscle and GCP should be taken into consideration in cases of pyloric stenosis without biopsy diagnosis of gastric cancer.

Lymph node metastasis of gastrointestinal stromal tumor (GIST) is rare. A case of a patient with primary GIST of the stomach who developed lymph node metastasis is presented. A 68-year-old man was referred to our department after a submucosal tumor in the upper gastric corpus was identified on upper gastrointestinal endoscopy at a local clinic. Fine needle aspiration was conducted at our hospital, and GIST of the stomach was diagnosed. Abdominal contrast-enhanced computed tomography showed both the tumor and enlarged lesser curvature lymph nodes. Surgery was performed for the GIST of the stomach. During open surgery, signs indicative of lymph node metastasis were observed, and total gastrectomy and D2 lymph node dissection were therefore performed. Pathological testing showed that the tumor measured 40 × 30 mm with mitotic figures (63/50 high-power fields), and the patient was therefore classed as high risk according to Fletcher's risk classification. Postoperative adjuvant chemotherapy with imatinib mesylate was started, but after 1 month of oral treatment, the patient developed general malaise and discontinued is subsequent use. There have been no signs of recurrence to date. Because lymph node metastasis of GIST almost never occurs, lymph node dissection is usually of no value, and local resection without lymph node dissection is normally performed. However, lymph node dissection should be considered in cases of GIST with lymph node metastasis to ensure complete resection.

A 78-year-old man presented to another hospital with epigastric discomfort. Gastric cancer was diagnosed by upper gastrointestinal endoscopy, and he was referred to our department for surgery. A type 3 lesion was present in the pyloric antrum, which was diagnosed as adenocarcinoma (tub2) by biopsy. Since the diagnosis was advanced cancer of the pyloric antrum, distal gastrectomy (DG) was scheduled, but because the patient had previously undergone open left hemicolectomy and distal pancreatectomy with splenectomy (DP) for perforated descending colon cancer with direct invasion of the tail of the pancreas, during which the splenic artery and the short gastric arteries had been transected, ischemia of the remnant stomach was a concern. Intraoperatively, indocyanine green (ICG) fluorography was performed after the blood vessels had been divided to confirm perfusion of the remnant stomach, after which distal gastrectomy was completed. A Grade A pancreatic fistula developed postoperatively, but there were no other major issues, and the patient was discharged on postoperative day 11. Since perfusion of the remnant stomach after DG is normally supplemented from the branches of the splenic artery, patients such as the present one who have previously undergone DP are at risk of necrosis of the remnant stomach. The case of a patient with cancer of the pyloric antrum for whom total gastrectomy was avoided by the use of ICG fluorography is presented, together with a short discussion of the literature.

A 69-year-old woman underwent laparoscopic local gastric resection for a gastric submucosal tumor in July 2014. Histopathologically, the tumor was composed of a proliferation of spindle-shaped cells, and the tumor was 30 mm in size with a mitotic index of 7 to 8 of 50 high-power fields. Immunohistochemically, the tumor cells were positive for c-kit and CD34. The tumor was diagnosed as a gastric GIST, intermediate risk. Abdominal computed tomography (CT) showed a liver metastasis, 95 mm in diameter, in segment 4 in November 2016. Imatinib mesylate treatment (400 mg/day) was started. However, the patient developed several side effects such as CTCAE grade 3 anorexia and grade 2 mouth ulcers. After 6 months of treatment, the tumor volume decreased to 85 mm in diameter and showed a partial response to imatinib treatment. A left hepatic lobectomy was performed in May 2017. The tumor was replaced by a translucent gelatinous substance. Immunohistochemically, some viable GIST cells that were positive for c-kit and CD34 remained. Thus, the liver tumor was diagnosed as a metastasis of gastric GIST that responded to imatinib treatment. The patient remains alive with no recurrence 3 years after R0 resection.

A 25-year-old woman who had been followed up for a several-year history of vomiting and abdominal pain was referred to our department because of worsening symptoms for these 7 months. Esophagogastroduodenoscopy (EGD) showed severe stenosis of the duodenum between the descending part and the bulb. So, she was diagnosed as having post-pyloric stenosis due to duodenal ulcer. Potassium-competitive acid blocker (P-CAB) had no effects, so that laparoscopic selective proximal vagotomy (LSPV), Toupet fundoplication and Jaboulay gastroduodenostomy were performed. She was discharged on the postoperative day nine, however, abdominal distention and vomiting were noted two months after the operation. EGD showed anastomotic stenosis and ulcer. We judged oral administration of proton pump inhibitor (PPI) might be ineffective for her, and a double dose of PPI was administered intravenously. The anastomotic stenosis was improved by endoscopic balloon dilatations, and then she resumed meals and took a double dose of P-CAB orally. Since she became pregnant, a double dose of P-CAB was reduced to a normal dose considering the effects on the fetus. We report a case of juvenile intractable duodenal ulcer with duodenal stenosis treated with LSPV and Jaboulay gastroduodenostomy, followed by anastomotic ulcer and stenosis.

A case of early-stage duodenal bulb cancer is presented. The patient was an asymptomatic 64-year-old man. He was referred to our hospital because of elevated tumor marker levels, a protruding lesion in the duodenal bulb detected on gastric endoscopy, and a small nodular shadow of the right lung on computed tomography. The histological diagnosis of the biopsy of the duodenal lesion was suspicion of cancer. The right lung nodular shadow seemed to be primary lung cancer. After discussion with respiratory physicians and surgeons, laparoscopic limited distal gastrectomy was performed first. The pathological examination showed gastric-type adenocarcinoma invading to the submucosa with no lymph node metastasis. The appropriate surgical procedure for duodenal bulb cancer has been the subject of debate. For patients with advanced duodenal cancer, pancreaticoduodenectomy is often performed. However, considering the burden on the patients and the complications following extended surgery, limited surgery might be feasible for early-stage cancer.

A 57-year-old man was referred for abdominal pain. CT showed calcifications, 25 mm in size, in the lower abdomen. Meckel's diverticulitis with enteroliths was suspected. Emergency laparoscopic surgery was performed due to poor contrast of the intestinal wall, suspected ischemic changes, and increasing abdominal pain. Bloody ascites was seen in the pelvis, and a Meckel's diverticulum was located to the anti-mesenteric side, 80 cm oral from the terminal ileum. The wound was extended to 4 cm. The Meckel's diverticulum was excised, and ectopic mucosa was present in the diverticulum. Meckel's diverticulitis with true enteroliths is very rare. This case is reported together with a brief review of the literature.

A 44-year-old woman without a history of abdominal surgery presented with persistent abdominal pain and vomiting. An abdominal CT scan showed a closed loop of the small intestine at the dorsal aspect of the sigmoid mesocolon without ischemic change. We diagnosed her as having bowel obstruction by an internal hernia. After treatment with a long tube for 3 days, her ileus had been persisted. We performed laparoscopic surgery and confirmed intersigmoid hernia with an incarcerated small intestine. The small intestine was reduced laparoscopically by incising the hernia orifice approximately 2 cm in diameter without resection of the intestine approximately 7 cm in length. To prevent the hernia recurrence, we incised and mobilized the anatomical attachment of the sigmoid colon from the hernia orifice to the Monks' white line laparoscopically. The postoperative course was uneventful, and she was discharged on the 5th postoperative day. Intersigmoid hernia is a rare and less acknowledged disease and has rarely been diagnosed before surgery. We report a case of intersigmoid hernia treated with laparoscopic surgery.

A 59-year-old man was admitted to our hospital because of traumatic subarachnoid hemorrhage and thoracic spine fracture due to a fall injury. Two days after the operation for thoracic spine fracture, he developed high grade fever and severe watery diarrhea. Colonoscopy revealed irregular ulcers covered with white exudate in the entire colon. Detection of Trophozoites of Entamoeba histolytica from a biopsy specimen led to a diagnosis of amebic colitis. The symptoms improved after administration of metronidazole. Follow-up colonoscopy conducted 6 months later showed severe cicatricial stricture completely encircling the ascending colon. He also suffered from abdominal distension, and laparoscopic ileocecal resection was performed. We report a rare case of refractory cicatricial colonic stricture after amebic colitis that required surgery.

A 69-year-old man visited a hospital with lower abdominal pain. Abdominal computed tomography (CT) showed an intussusception in the ileocecal region, and the symptoms improved with conservative management. A subsequent CT scan showed a 35-mm, low-absorption mass in the ascending colon. Because the symptom recurred repeatedly, the patient was referred to our hospital for surgical resection. Colonoscopy showed a 30-mm, yellow submucosal tumor with a smooth surface, broad base, and normal mucosa on the ileocecal anal side, and it was diagnosed as an ascending colon lipoma. Laparoscopic ileocecal resection was performed, because the edge of the tumor was not clear. An excised specimen showed a yellowish submucosal tumor that bulged 34 × 24 mm on the upper lip of the ileocecal valve. Histopathological examination showed mature adipose tissue at the lesion, and no mitotic figures or cellular atypia. The tumor was diagnosed as lipohyperplasia of the ileocecum, because of the unclear border between the terminal ileum and the submucosal adipose tissue, the inclusion of the intrinsic muscle layer in some adipose tissue, and the lack of film formation. A case of intussusception caused by ileocecal lipohyperplasia is reported.

A 70-year-old woman with chronic renal failure was admitted to our hospital because of left lower abdominal pain and vomiting. She was diagnosed as having ischemic colitis and hospitalized for conservative medical treatment. However, her symptoms exacerbated on the same day, and necrotic ischemic colitis was suspected on computed tomography (CT) and colonoscopy. Sub-total colectomy was performed. Ischemic areas were initially seen from the descending colon to the transverse colon. However, the blood flow of the cecum and ascending colon was poor on real-time indocyanine green fluorescence imaging. The patient was discharged from hospital without any complications. Necrotic ischemic colitis is rare, and multiple organ failure can occur. Early diagnosis and surgical treatment are necessary to prevent a poor outcome. Blood flow evaluation was performed by real-time indocyanine green fluorescence imaging, which was useful for determining the range of resection.

A 40-year-old woman visited a neighboring hospital because of lower abdominal pain developed after barium gastrography. An abdominal X-ray film showed an enlargement of the almost entire colon due to filled barium and a colonoscopy revealed a stenosis completely encircling the sigmoid colon. She was diagnosed as having large bowel obstruction caused by suspected sigmoid colon cancer and was referred to our hospital. Since a transanal decompression tube could not be placed due to severe stenosis, laparoscopic surgery was planned on the next day. As a result, laparoscopic sigmoidectomy and double-barreled ileostomy were performed for the mass in the sigmoid colon. The patient had an uneventful postoperative course and was discharged on day 11 after the surgery. The mass of the sigmoid colon was histopathologically diagnosed as intestinal endometriosis and the hormone therapy is currently ongoing. We report a case of sigmoid colon endometriosis presented with bowel obstruction after barium gastrography.

A 76-year-old man presented with stomachache, fever and appetite loss lasting for 7 days. Abdominal plain CT scan performed elsewhere showed a mass in the sigmoid colon with free air and ascites. He was brought into our hospital with a diagnosis of acute peritonitis associated with perforation of a sigmoid colon tumor. Emergency operation was performed on the same day. Operative findings included a fist-sized tumor in the sigmoid colon associated with intermesenteric penetration, but intestinal contents did not leak out intraperitonealy. Hartmann surgery plus D2 dissection was performed with an intraoperative diagnosis of cancer of the sigmoid colon. The final histopathological diagnosis was large cell endocrine cell carcinoma, pT4a(SE), INFb, Ly0, Vac, BD3, Pn1a, pN0, pStage IIb (Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma Third English Edition). Reoperation was performed on postoperative day (POD) 3 because of contaminated ascites from drain, and abdominal irrigation was performed. He left the hospital on POD 25. He refused adjuvant chemotherapy. Thereafter he has been followed up by home care clinic. Intramesenteric penetration of the sigmoid colon by endocrine cell carcinoma has rarely been reported in the Japanese literature.

A 14-year-old boy was seen at our hospital because of right lower quadrant abdominal pain and high fever. Abdominal contrast-enhanced CT scan demonstrated large quantities of ascites, swelling of the appendix, and well-thickened sigmoid colonic wall with nodular calcification. Emergency operation was performed with a suspected diagnosis of generalized peritonitis caused by perforated appendicitis. Based on intraoperative findings, there were large volumes of serous ascites, and numerous disseminated nodules were found in the whole abdominal cavity. The main sigmoid colon tumor had invaded the pelvic wall diffusely. The appendix had swollen, but there were no perforations. We performed appendectomy and transverse colostomy. The histopathological diagnosis was mucinous adenocarcinoma-signet ring cell carcinoma. Despite 14 courses of adjuvant chemotherapy with FOLFOX + bevacizumab and three courses with FOLFIRI + bevacizumab, the patient died of peritonitis carcinomatosa 350 days after the operation. Colon cancer extremely rarely affects children. To date, only 29 cases have been reported in Japan since 1983. We consider that colon cancer should not be excluded from differential diagnoses even in children.

A 44-year-old man presenting with general fatigue, pain in the buttocks, necrosis in the left hip, and protrusion of malignant neoplasm from the anus was found to have rectal cancer with severe local invasion and gas image on CT. Fournier's gangrene caused by rectal cancer was diagnosed and we emergently performed surgical debridement and colostomy. Following the operation, we performed local therapy using the negative pressure wound therapy with instillation and dwelling (NPWTi-d) for the perineal wound which had become a widespread tissue defect accompanied by infection. In three weeks, we could conduct split-thickness skin grafting and from the 65^th postoperative day neoadjuvant chemotherapy was started. The tumor showed a reduction in size, so that we determined radical resection to be possible. Total pelvic exenteration along with the coccygeal bone was performed. The perineal wound was closed by using a right dufourmenta l flap. Histopathology indicated R0 resection.

In treating Fournier's gangrene caused by rectal cancer, the time until starting oncological intervention directly determines the prognosis of the patient. Here we report a case of Fournier's gangrene with rectal cancer where the introduction of NPWTi-d led to early completion of the wound therapy followed by early start of oncological therapy.

A 71-year-old man who had been on dialysis for polycystic kidney disease for 20 years and was taking kayexalate was admitted to our hospital because of sudden lower abdominal pain. Computed tomography showed free air in the peritoneal cavity. He was diagnosed with gastrointestinal perforation and underwent emergency surgery. The perforation site was found in the rectum, and Hartmann's operation was performed. The pathological findings showed basophilic crystalline materials around the perforated site and rectal cancer on the side opposite the perforation. He was discharged 43 days after the operation. Since polystyrene sulfonate may contribute to gastrointestinal perforation, the risk of gastrointestinal perforation, such as of a diverticulum, should be recognized before surgery and bowel movements should be strictly controlled.

The case involved a 74-year-old woman with low rectal cancer. She had undergone radical hysterectomy and total cystectomy with bilateral lateral lymph node dissection and ileal conduit for cervical and bladder cancers, respectively. We performed laparoscopic intersphincteric resection using the pull through procedure with delayed coloanal anastomosis, because it was difficult to create a diverting stoma for firm adhesions at the ileum and the transverse colon in operative findings, and because she had a feeling of rejection to double stomas. She was discharged 15 days after the initial operation with no complications.

Delayed coloanal anastomosis using the pull through procedure has recently attracted attention in Western countries as a technique for avoiding anastomotic leakage without a diverting stoma. We report the case of low rectal cancer avoiding double stomas by using the pull through procedure.

A 72-year-old woman had undergone low anterior resection for rectal carcinoma in September 2010. In July 2013, a metastasis in the left lung was resected, after which she underwent postoperative chemotherapy. In June 2019, a thyroid tumor showed rapid growth causing airway stenosis that resulted in dyspnea, and total thyroidectomy and tracheostomy were performed to secure the airway. Since the patient's postoperative quality of life (QOL) was greatly improved, she was able to be cared for at home, albeit for a short time, since she died 4 months after surgery. The histopathological diagnosis was thyroid metastasis of rectal carcinoma. This is a rare condition, and in most cases the metastasis is microscopic, causing clinically significant signs only very rarely. In the present case, total thyroidectomy and tracheostomy greatly improved the QOL of the patient in whom rapid growth of a thyroid metastasis of rectal carcinoma had caused airway stenosis. It may be of value to consider surgical treatment of airway stenosis due to metastatic thyroid cancer after assessment of the patient's general condition and metastasis to other organs, in order to improve QOL.

A rare case of a tailgut cyst occurring in the ischiorectal fossa is reported. A 74-year-old woman underwent abdomino-pelvic computed tomography before laparoscopic resection for cholecystitis, which incidentally showed a 40-mm mass lesion in the pelvis. Magnetic resonance imaging showed a multilocular cystic lesion in the ischiorectal fossa, with high signal intensity on T2-weighted imaging. Based on a diagnosis of a tailgut cyst, she underwent tumor resection by a posterior approach after cholecystectomy. Intraoperatively, the cystic lesion was removed en bloc without visualization of its contents. Histopathologically, the cystic lesion was diagnosed as a tailgut cyst without malignancy, and the surgical margin was negative. She is now doing well without any recurrence 13 months after treatment.

We report a case of resection of liver tumor considered to have developed from metastases of pancreatic gastrinoma 13 years after primary resection. The patient was a 76-year-old man who had undergone pancreatectomy and splenectomy for a neuroendocrine tumor of the pancreas tail in August 2005. The tumor was diagnosed as gastrinoma (WHO Classification 2017 PanNET G2). Three years after the first operation, the patient developed liver metastasis and underwent partial resection of the liver (S4). It was also diagnosed as gastrinoma (PanNET G1). Ten years after the second operation, the patient presenting with abrupt onset of lower abdominal pain was admitted to our hospital. Gastroendoscopy showed multiple ulcers in the second part of duodenum. Abdominal plain computed tomography showed low-concentrated masses. The low-concentrated tumors were diagnosed as multiple liver metastases of the pancreas gastrinoma, and partial resections of the liver S2, S3, S5, and S8 were performed. The resected tumors were diagnosed as metastases from pancreas gastrinoma (NET G1). Immunohistochemical analysis showed that the tumor cells were positive for maker of gastrin. Two years after the last operation, the duodenal ulcers improved. The patient remains well without any evidence of the recurrence.

This case appears to be of rare in which recurrence occurred more than 10 years after the primary resection.

With the recent ageing population the treatment of acute cholecystitis is expected to increase in patients with a gastrostomy. However, laparoscopic treatments in such cases are avoided due to the difficulty of placing ports and ensuring the surgical field. We report our surgical outcomes of laparoscopic cholecystectomy for acute cholecystitis in three patients with a gastrostomy. The mean age of them was 78.3 years old. They comprised two males and one female and stayed in a hospital or a nursing home. One case was of acalculous cholecystitis and two were of calculous cholecystitis treated with PTGBD preoperatively. Laparoscopic cholecystectomy with usual 4-port method was successfully completed without receiving influence of gastrostomy in all cases. The mean operation time, intraoperative blood loss and postoperative hospital stay were 143.3 min, 33.3 ml and 4.7 days, respectively. There were no intraoperative accidents and postoperative complications. Their postoperative courses were uneventful and they regained generally the same conditions as before. Laparoscopic cholecystectomy is safely performed for acute cholecystitis in patients with a gastrostomy.

This case involved a 68-year-old woman who had undergone pancreatoduodenectomy for an intraductal papillary mucinous neoplasm (IPMN) in the head of the pancreas. On histopathological examination, the diagnosis was invasive intraductal papillary mucinous carcinoma (IPMC), pT1N0M0, pStage I. The intraductal papillary mucinous adenoma was widely observed in the branched pancreatic duct of the resected specimen. The patient received S-1 as adjuvant chemotherapy. Five years after surgery, enhanced abdominal CT and MRI showed a 35-mm-sized mass lesion in the residual pancreas. FDG-PET showed strong FDG uptake in the mass, but there was no evidence of metastasis. Total residual pancreatectomy was then performed. Histopathological examination showed that the tumor was composed of adenocarcinoma and squamous cell carcinoma. Proliferation of atypical cells considered to be IPMC was observed in the expanded main pancreatic duct, and transition to both adenocarcinoma and squamous cell carcinoma was observed. The tumor was therefore diagnosed as IPMN-derived adenosquamous carcinoma (ASC). Only six cases of IPMN-derived pancreatic ASC have been reported, and the present case is the first report of pancreatic ASC in the residual pancreas after IPMC resection.

A 70-year-old man with known HIV infection presented with abdominal pain and wobble with no history of trauma. He was admitted for further evaluation of atraumatic splenic rupture as a tentative diagnosis based on computed tomography (CT) findings. Imaging tests showed multiple hematomas in the spleen, as well as a suspected splenic aneurysm. Because the splenic rupture was accompanied by HIV infection, open splenectomy was performed to clarify the cause of splenic rupture and prevent rebleeding. Intraoperative findings showed hemorrhagic ascites, a 5-cm ruptured hematoma on the splenic surface, and multiple non-ruptured hematomas in the spleen. Pathological examination showed no evidence of infectious diseases, such as tuberculosis, or neoplastic lesions. An aneurysm caused by HIV-associated vasculopathy had been considered ; however, no evidence of aneurysms or vasculopathy in the intima was observed. There have been few reports of splenic rupture in patients with HIV infection ; however, it should be noted that HIV infection can play an etiological role in atraumatic splenic rupture when HIV infection is present with splenomegaly, tuberculosis, neoplastic disease, or HIV-associated vasculopathy.

The case involved a 38-year-old man who had undergone appendectomy for appendicitis at the age of 10. When he was 30 years old, he was referred to our hospital because of a 36-mm tumor in the right lower quadrant of abdomen detected by an abdominal ultrasonography at a medical checkup, however, he withdrew from our ambulatory treatment by his own judgement. Recently he was referred to our hospital again because the right lower abdominal tumor showed an increasing tendency in size. An abdominal ultrasonography demonstrated a 71-mm tumor with smooth margin and calcification in the inner part. An abdominal contrast-enhanced CT scan showed an enhanced tumor wall with a high density area in the center. Since the tumor tended to enlarge and a patient interview strongly suggested textiloma caused by retained surgical gauze, we decided to employ surgical treatment. We performed laparoscopic excision of the tumor and identified the tumor to have adhered with the greater omentum and abdominal wall in the vicinity of the right lower abdominal ileocecum. Laparoscopic dissection of the adhesions was performed to remove the tumor. We identified surgical gauze from the inside of the removed specimen and made the diagnosis of textiloma. Here we report a case of textiloma caused by retained surgical gauze which was removed laparoscopically, together with some bibliographical comments.

An 86-year-old woman was hospitalized due to abdominal pain and vomiting. She had a scar from a previous uterine myomectomy in her lower abdomen, with abdominal mass occurring at the scar. Abdominal contrast-enhanced computed tomography revealed a 2-cm-diameter incisional abdominal hernia, with small intestine and bladder incarceration. Both the small intestine and bladder had poor contrast effects, especially the bladder intramural gas ; therefore, she was diagnosed with ischemia and necrosis. Emergency surgery was performed. After releasing the incarcerated small intestine and bladder by opening the hernial orifice, both of them were inviable and thus resection was required. Incarcerated bladder due to incisional abdominal hernia and necrosis rarely occurs ; hence, it is difficult to diagnose. However, in our case, it was diagnosed preoperatively. Therefore, the operative method appropriate for the patient should be considered considering the bladder incarceration and necrosis, when the organ incarcerates the incisional lower abdominal hernia.