To clarify the imaging findings of gallbladder torsion, a retrospective review of the gallbladder torsion cases at our hospital was performed. The study included six patients over the five years from January 2017 to December 2022. All patients were female (median age, 88.5 [range, 75-91] years). The median period from onset to admission was 3.5 (range, 0-10) days. Computed tomography showed deviation of the gallbladder base in 5 patients and a high-density area in the neck of the gallbladder in 2 patients. All patients underwent magnetic resonance imaging (MRI). Magnetic resonance cholangiopancreatography (MRCP) showed V-shaped distortion of the extrahepatic bile ducts caused by cystic duct traction of the distorted gallbladder in 5 patients. It was thought that the cystic duct was twisted and the common bile duct was pulled at one point. The median period from admission to treatment was 0 (range, 0-2) days. Emergency laparoscopic cholecystectomy was performed in 5 patients, and percutaneous trans gallbladder drainage was done in the other. MRCP of gallbladder torsion has characteristic findings, which may lead to early diagnosis and treatment.

Obturator hernia is a relatively rare disease ; however, the incidences of obturator hernia are increasing with the recent aging population and advances in diagnostic imaging. In the past, it was generally recognized as a disease that required emergency laparotomy ; however, in recent reports, there has been an increased use of minimally invasive surgeries, such as laparoscopic and inguinal methods. Additionally, neither intestinal necrosis nor perforation are apparent ; therefore, elective surgery is performed after non-invasive reduction. At our hospital, when intestinal injury is not obvious, we first perform non-invasive reduction, hospitalize the patient for follow-up observation, and then perform anterior approach surgery under local and conduction anesthesia. Since 2010, we have reviewed 16 cases (18 lesions) of obturator hernia, and we discuss the treatment methods in this report.

The patient was a 51-year-old woman. A mass was palpated in the upper-outer region of the right breast, and mammography and ultrasonography showed ductal shadows in the same area. Since no definitive diagnosis was obtained by aspiration cytology, the patient was followed-up by observation. One year later, the mass had migrated to the upper-inner region of the right breast. A needle biopsy was performed for suspected parasitic disease, and surgical excision was performed, confirming plerocercoids of the genus Spirometra, leading to a definitive diagnosis of breast sparganosis. Recurrences were noted three years after the initial excision and 18 months after a subsequent excision, both in the ipsilateral breast. The etiology for recurrence was hypothesized to be migration of plerocercoids during the one-year interval between the initial medical examination and the surgical excision. Japanese reports of breast sparganosis are rare, with only 17 cases, including the present one, reported in Japan. Surgical excision should be considered immediately if breast sparganosis is suspected on imaging, because the plerocercoids may migrate over time, and complete excision may be difficult.

Mammary phyllodes tumor is one of relatively rare epithelial mixed tumors. It accounts for less than 1% of all mammary gland tumors, and juvenile tumors are extremely rare. It is difficult to distinguish it from fibroadenomas, especially from juvenile fibroadenomas. Therefore, it is difficult to determine the appropriate margin of resection at the time of surgery.

We experienced a case of a 13-year-old girl who was diagnosed with a borderline phyllodes tumor by postoperative pathology.

The patient was aware of a lump in her right breast. A needle biopsy revealed a fibroadenoma. However, the patient underwent lumpectomy because it tended to increase in size during observation suggestive of phyllodes tumor. Postoperative pathology revealed a diagnosis of borderline phyllodes tumor. The patient has been free from recurrence for 2 years after surgery.

Since there is no clear consensus on the margin of resection of phyllodes tumors, and many reports indicate that the margin does not correlate with the recurrence rate, it appears that additional resection is not necessary even with a diagnosis of phyllodes tumor. In breast surgery for juvenile patients, we should consider not only the cure but also the cosmetic benefits and preservation of future lactation function.

Breast cancer arising in a phyllodes tumor is relatively rare. Here, we report a case of a borderline malignant phyllodes tumor complicated with ductal carcinoma in situ in the epithelium. A rapidly growing 7-cm mass was found in the left breast of a 39-year-old woman. The preoperative diagnosis was borderline malignant phyllodes tumor. A total mastectomy was undertaken, based on the patient's request, and from the viewpoint of complete cure and esthetic outcome. Histopathological examination of the resected specimen revealed ductal carcinoma in situ (DCIS) with a maximum diameter of 12 mm within the phyllodes tumor. The resection margins were negative. Currently, the patient is being followed up without treatment. No recurrence has been observed 1 year after surgery. In this report, we detail our experience with the aforementioned case and also provide a literature review encompassing similar cases from Japan and overseas.

A 76-year-old man who underwent subtotal esophagectomy and anastomosis of the stomach to the cervical esophagus via posterior mediastinal route for esophageal cancer elsewhere 4 years previously was referred to our hospital for the purpose of clinical observation of a colonic adenoma. When he came home after colonoscopy, he developed abdominal pain. An abdominal CT scan revealed left diaphragmatic hernia involving the transverse colon as the hernia content. As no apparent ischemic changes were seen in the prolapsed intestine, he was emergently admitted to our hospital to follow the clinical course conservatively. Since his intestinal obstruction was of minor degree, oral ingestion was started and he was temporally discharged. However, the prolapsed transverse colon was not spontaneously repositioned and intermittent bouts of abdominal pain persisted. We electively performed open repair of the diaphragmatic hernia. During surgery, the transverse colon was manually reduced into the abdominal cavity and the hernia opening was repaired by using mesh. His postoperative course was uneventful and he was discharged on the 8^th postoperative day. He is doing well without recurrence as of 8 months after surgery. We report a case of left diaphragmatic hernia presented with colonoscopy after surgery for esophageal cancer.

A case of incarcerated esophageal hiatal hernia after laparoscopic total gastrectomy (LTG) is reported. The patient was a 79-year-old man who underwent LTG for type 3 advanced gastric cancer. During dissection of the peri-esophageal area, the left thoracic cavity was opened with a 10-mm hole on the left dorsal pleura. On the third postoperative day, he had abdominal pain and decreased SpO₂. Abdominal computed tomography showed a dilated small intestine prolapsing into the left thoracic space. He was diagnosed with an incarcerated esophageal hiatal hernia, and emergency laparotomy was performed. The protrusion of the intestines was reduced into the abdominal cavity, and there were no necrotic findings. The hernial orifice was occluded by suturing the diaphragm and esophageal hiatus. The esophago-jejunal anastomosis was fixed to the anterior wall of the esophageal hiatus and the closure site of the diaphragm. Postoperatively, anastomotic leakage at the esophago jejunostomy was observed, but the patient was successfully treated with drainage and nutritional management, and he was discharged 54 days after re-operation. No recurrence of either the gastric cancer or the hiatal hernia has been observed one year after the procedure. If intraoperative pleural injury is suspected during surgery, repair or intestinal fixation should be considered.

A 58-year-old man presented with a sensation of food sticking in his throat and was referred to our hospital with a diagnosis of thoracic esophageal cancer. The preoperative diagnosis was thoracic esophageal cancer, Mt, cT3N1M0, Stage III (The 11 th Edition of Japanese Classification of the Esophageal Cancer). Preoperative CT scan showed an air density along the right posterior side of the trachea in close proximity to an enlarged lymph node (No.106recR), and association of a tracheal diverticulum was suspected. After two courses of neoadjuvant chemotherapy, thoracoscopic esophagectomy, two-field lymph node dissection, gastric tube reconstruction via posterior mediastinal route, and tracheal diverticulum resection were performed. During the operation, the cystic tracheal diverticulum was found to be connected to the right wall of the trachea and adjacent to the enlarged lymph node (No.106recR). At lymph node dissection, it was possible to clip and safely resect the tracheal diverticulum thoracoscopically. He was discharged from our hospital on the 10th postoperative day. Mediastinal lymph node dissection is crucial in treating esophageal cancer, and perforation of an esophageal diverticulum can cause serious complications. Resection of the diverticulum should be considered when a tracheal diverticulum and lymph nodes are adjacent like in this case.

A 71-year-old man presented to our hospital with anemia, with a Hb level of 6.9 mg/dl pointed out at another hospital. A CT scanning and upper GI endoscopy revealed a type 3 tumor with hepatic invasion at the gastric antrum, and he was diagnosed with highly advanced gastric cancer, cT4b (HEP) N0M0, cStage IVA. We planned to conduct chemotherapy, and performed 6 courses of FOLFOX regimen as the primary treatment and 7 courses of ramucirumab + nab-PTX regimen as the secondary treatment, leading to the therapeutic result as progressive disease (PD). After 11 courses of nivolumab as the tertiary treatment, the local tumor and hepatic invasion significantly reduced in size and any tumor cells were not pointed out at a biopsy. We determined that the radical operation might be possible and performed surgery 20 months after the first diagnosis. Final histopathological diagnosis did not reveal tumor cells, so that we rated the therapeutic result as pathological complete response (pCR). As of 14 months after the surgery, he has been free from recurrence. We report the case of advanced gastric cancer in which the patient could follow a very beneficial clinical course, together with a review of the literature.

A 71-year-old man presented to a local hospital with a complaint of heartburn. Upper gastrointestinal endoscopy showed type 3 gastric cancer, and computed tomography showed multiple large para-aortic lymph nodes from the celiac artery to bilateral common iliac arteries. He was diagnosed with gastric cancer cT4, N+, M1 (LYM), cStage IVB. After 4 courses of S-1+CDDP therapy, which was effective, he underwent surgery. Total gastrectomy, para-aortic lymph node dissection, and cholecystectomy were performed. Para-aortic lymph node dissection was extended from the celiac artery to bilateral common iliac arteries, where metastases were suspected. Pathological examination showed moderately differentiated tubular adenocarcinoma, ypT1b2, N0, M0, ypStage IA. The para-aortic lymph nodes were in a state of complete response, and the treatment efficacy was Grade 2a. The patient was given postoperative adjuvant chemotherapy with S-1 and has survived 15 months postoperatively without recurrence. The outcome in this case suggests that patients with extensive para-aortic lymph node metastases may be eligible for surgical resection after chemotherapy, and that R0 resection may lead to long-term survival.

Seven cases of gastric perforation that were diagnosed with gastric cancer only after surgery was performed following conservative treatment for the perforation are presented. All patients were under 80 years old, had only mild comorbidities, and pain control was achieved with medication. In our hospital from 1991 to 2011, 13 cases were admitted for perforated gastric cancer, of which seven cases (53.8%) underwent conservative treatment for the acute phase of perforation. All seven cases achieved natural closure, and elective surgery was performed. Six cases underwent radical surgery, of which five survived over 5 years (stage IIA 1 case, stage IIB 1 case, stage IIIA 4 cases, based on the Japanese Classification of Gastric Carcinoma 15 Edition). In one case, because of extensive invasion of the cancer, it was unresectable, and the patient died of cancer within a year (stage IVA). To summarize, all cases that underwent radical surgery electively after conservative treatment for perforated gastric cancer had a good prognosis. For cases of perforated gastric cancer, conservative therapy is an option as the primary treatment under certain circumstances.

A 69-year-old woman who had undergone laparotomy for uterine cancer at another hospital 8 years prior presented to our emergency room with a slow-onset of abdominal pain. A contrast-enhanced CT scan of the abdomen revealed that the distal ileum was constricted by the right external iliac artery, forming a closed loop, and emergency surgery was performed based on the diagnosis of strangulated bowel obstruction. Laparoscopic observation revealed bloody ascites and an ileum which changed to dark red in color in the right lower abdomen. Due to difficulty in manipulating the intestinal tract, the patient was transferred to an open laparotomy. Upon laparotomy, it was observed that the right external iliac artery had been free due to the previous surgery and the ileum was fitted into the gap between the retroperitoneum and the ileum, which was strangulated and the right external iliac artery was severerly stretched. The strangulation was released through iliotomy and the right external iliac artery was preserved. The gap was covered with a retroperitoneal flap to prevent recurrence. Strangulated bowel obstruction caused by a blood vessel is rare. This case report presents a rare instance of strangulated bowel obstruction caused by the external iliac artery 8 years after laparotomy for uterine cancer.

We have experienced three cases of widespread pneumatosis cystoides intestinalis treated conservatively. Case 1 : A 73-year-old woman who had been on oral steroid therapy for polymyalgia rheumatica presented to our hospital with vomiting and abdominal pain. The lactic acid and inflammatory reaction levels were high and an abdominal CT scan showed ascites, and emphysema in the duodenum and small intestine. We thus performed staging laparoscopy for a suspicion of bowel ischemia that revealed no ischemic changes. Her illness was conservatively relieved without performing bowel resection. Case 2 : An 84-year-old man presented with abdominal pain during the hormone therapy for prostate cancer. He had increased inflammatory reaction and a CT scan showed small bowel emphysema, intraabdominal free air and ascites. We performed staging laparoscopy with a suspected diagnosis of bowel ischemia. There were no ischemic changes and his illness was relieved by conservative therapy. Case 3 : A 49-year-old man presented with emphysema in the colon, intraabdominal free air and ascites on CT during chemotherapy and steroid therapy for tongue cancer, however, no noteworthy findings were seen in the abdomen on physical examination and his general condition was favorable. We decided to select conservative therapy. His illness was relieved by oxygen therapy. Here we present our algorism for depicting clinical approach to widespread pneumatosis cystoides intestinalis.

The patient was a 49-year-old man with no previous medical history. He was referred to our hospital because he was found to have pneumatosis cystoides intestinalis on computed tomography (CT) and colonoscopy. CT at our hospital showed intussusception associated with pneumatosis cystoides intestinalis in the hepatic flexure, and the intussusception was relieved with colonoscopy. The patient had repeated right upper quadrant pain, which suggested the possibility of repeated intussusception, and laparoscopic right hemicolectomy was performed.

A case of laparoscopic low anterior resection for rectal cancer associated with Leriche syndrome is described along with a review of the literature. The patient was a 74-year-old woman whose chief complaint was positive fecal occult blood. She was diagnosed as having rectal cancer by lower gastrointestinal endoscopy and was found to have cT3cN1bM0, cStage IIIb. Preoperative contrast-enhanced computed tomography and 3D-angiography showed Leriche syndrome, but the patient was asymptomatic, and imaging studies suggested blood supply to the lower limbs and intra-abdominal organs from collateral vessels. Since it was possible to confirm a collateral blood channel from the iliolumbar artery to the internal iliac artery region, it was decided to perform rectal resection by dissecting the superior rectal artery and S1 artery, followed by anastomotic reconstruction. Intraoperative evaluation of blood flow using indocyanine green (ICG) fluorescence was performed. The patient had no perioperative complications and was discharged from the hospital on the 13th postoperative day. By performing preoperative and intraoperative blood flow assessments, it was possible to perform the operation without revascularization.

An 80-year-old woman presented to her previous doctor complaining of fever and chills. Abdominal computed tomography (CT) showed a 20-mm-long, linear foreign body from the lesser omentum into the liver, which was suspected to be a migrated fish bone. Antibiotic therapy was started, and the patient was referred to our hospital for drainage. Elective drainage was planned after the inflammation subsided. The inflammation flared up after it had subsided, and CT showed an abscess in the lesser omentum ; a linear shadow suggestive of a fish bone was observed inside it and the liver abscess. Laparoscopic drainage of the abscess and foreign body removal with endoscopy were performed. Intraoperative endoscopy confirmed that the mucosal surface of the gastrointestinal tract was maintained. The patient's postoperative course was good, and the abscesses disappeared. Even for intra-abdominal abscesses caused by fish bones, which are difficult to detect intraoperatively, laparoscopic surgery combined with intraoperative endoscopy made it possible to safely perform drainage and remove the foreign body while confirming the positional relationships of the mucosal surface on the gastrointestinal tract, the abscess, and the foreign body.

Acute superior mesenteric artery (SMA) embolism has a high mortality rate and is often difficult to treat. We report two consecutive successfully treated cases of SMA embolism. In both cases, after thrombus removal under open abdominal manipulation, open abdominal management (OAM) was performed to determine whether blood flow was impaired. The following day, the abdomen was closed after confirming that the intestinal color was good.

Case 1 was a 90-year-old woman who had sudden abdominal pain and called for an ambulance. An electrocardiogram showed atrial fibrillation.

Contrast-enhanced computed tomography showed SMA occlusion. An abdominal angiogram was performed and a thrombus retrieval attempted, but it was challenging. The patient had persistent abdominal pain and elevated lactate levels ; therefore, open thrombectomy was performed using a 3Fr Fogarty catheter. The operation time was 3 h and 31 min. The abdomen was closed the following day after OAM, and the patient was discharged from the hospital 20 d post-surgery.

Case 2 was an 85-year-old woman who was transported to another hospital due to sudden abdominal pain and diagnosed with SMA embolism.

She was transferred to our hospital, underwent open thrombectomy and OAM, and discharged 11 d after the operation.

This report is on a 69-year-old male with neurofibromatosis type 1, chronic obstructive pulmonary disease, and a history of previous surgeries for duodenal perforation and multiple small intestinal tumors. Although he was diagnosed with an abdominal incisional hernia at another hospital, owing to his low lung function, surgery was deemed inappropriate. However, he strongly desired surgery and sought consultation at our hospital. On physical examination, the hernia protrusion was the size of an adult head, and based on computed tomography findings, it was diagnosed as a loss of domain (LOD) hernia. Progressive preoperative pneumoperitoneum (PPP) was performed, followed by hernia repair. The surgical procedures involved bilateral transversus abdominis muscle release and partial anterior component separation, followed by retromuscular mesh repair. Postoperatively, he required ventilator support for 1 week ; however, he had a favorable recovery and was discharged after 32 days of hospitalization. PPP was considered a valuable treatment method for LOD hernia.

A hernia prolapsing from the sciatic foramen is referred to as a sciatic hernia and is considered rare among pelvic hernias. Herein, in an 83-year-old woman, a right greater sciatic foramen hernia was incidentally detected through a follow-up computer tomography (CT) performed after gastric cancer surgery. However, as the patient had been asymptomatic and wished to avoid further surgery, she had been placed on follow-up for 18 months. Considering her age and the risk of intestinal incarceration, we proposed surgery, to which she agree ; thus, elective surgery was performed. Laparoscopy revealed a hernia portal measuring approximately 2 cm in the greater sciatic foramen, which was diagnosed intraoperatively as a greater sciatic foramen hernia. The preperitoneal space was dissected and a mesh was placed. The postoperative course was uneventful, and the patient was discharged on the second postoperative day. Reports of elective laparoscopic hernia surgery are limited. Therefore, we report on this case, along with a review of the literature.