[A Case of Adenocarcinoma of Duct of Luschka].

A 75-year-old man was transferred to our hospital with a diagnosis of acute cholecystitis. On next day, a laparoscopic cholecystectomy was performed. Histologic examination confirmed an adenocarcinoma arising from duct of Luschka. Patient underwent additional resection of the liver bed. No residual adenocarcinoma was seen in the surgical specimen. Adenocarcinoma of duct of Luschka is rare, but it is important during cholecystectomy to consider the presence of duct of Luschka, possibility of malignant disease and careful dissection of the gallbladder from its fossa staying close to the gallbladder wall.

[Repeat Hepatectomy for Primary Hepatic Neuroendocrine Carcinoma in the Remnant Liver Nine Years after the First Resection].

The patient was a 55-year-old man who had undergone extended right lobectomy of the liver with a diagnosis of primary hepatic carcinoid tumor. Nine years after the operation, enhanced abdominalCT revealed a tumor measuring 2.2 cm in the remnant liver. He was diagnosed with recurrence of primary hepatic neuroendocrine carcinoma and underwent partial hepatectomy. Pathologically, the tumor cells had round nuclei and formed trabecular patterns. Immunohistologically, the cells were positive for CD56, synaptophysin, and chromogranin A. The Ki-67 index was 6%, which was equivalent to Grade 2 in the WHO classification revised in 2010. Since there were no other lesions suspected to be the primary site other than in the liver, it was diagnosed as recurrence of the primary hepatic neuroendocrine carcinoma. Two years after the operation, he was diagnosed with recurrence of primary hepatic neuroendocrine carcinoma and underwent partialhepatectomy again.

[A Case of Abdominal Compartment Syndrome after Laparotomy for Peritonitis Caused by Colon Perforation Due to Gallbladder Carcinoma].

A70 -year-old man with a diagnosis of panperitonitis caused by colon perforation due to invasion of gallbladder cancer was transferred to our hospital. The next day, an emergency operation was performed. During laparotomy, the ascending colon was perforated; therefore, ileocecal resection was performed. Six hours after the operation, the stoma became ischemic with marked abdominal distention. The intra-abdominal pressure increased to 28 mmHg, and the patient was diagnosed as having abdominal compartment syndrome(ACS). He immediately underwent decompressive laparotomy at bedside. Multiple organ failure was avoided and he recovered, but he died of advanced gallbladder cancer 4 months after the surgery. This case suggests that immediate surgical decompressive laparotomy for ACS can prevent multiple organ failure.

[A Case Report of Bypass Surgery for a Perforated and Unresectable Gastric Cancer].

A 74-year-old man was admitted to a clinic because of epigastralgia in June 2018. He was referred to our hospital for further examination of right hydronephrosis. He was diagnosed as having type 2 gastric cancer in the middle gastric body and lesser curvature, with an upper gastric fiber, swollen para-aortic lymph node, and right hydronephrosis by using abdominal computed tomography. PET-CT revealed no hot spot in the para-aortic lymph node but revealed a hot spot in the lower small bowel. He was admitted to our hospital because of severe abdominal pain and appetite loss and underwent a reduction and palliative surgery for the unresectable gastric cancer. The omental cavity was perforated and penetrated into the retroperitoneum. He underwent esophageal jejunal bypass and intestinal fistula tube insertion in the stomach. He had a central vein port and was discharged from our hospital. He was able to eat during his short overnight stay at our hospital after the operation but died on postoperative day 30.

[Complete Obstruction of the Ascending Jejunal Limb due to Adhesion of the Y Loop after Total Gastrectomy].

A 43-year-woman who had undergone total gastrectomy for gastric cancer was admitted to our hospital because of lower abdominal pain 2 months after the operation. Abdominal computed tomography revealed an ascending jejunum dilation. Gastrointestinal endoscopy showed a complete obstruction in the ascending jejunum. A laparoscopic operation on the 14th hospital day revealed that the complete obstruction of the ascending jejunal limb was due to adhesion of the Y loop after total gastrectomy. She underwent division of the adhesion and was discharged on the 17th postoperative day.

[A Case of Port Site Recurrence of Gallbladder Carcinoma after Laparoscopic Cholecystectomy].

The patient was a 76-year-old man who underwent laparoscopic cholecystectomy with a diagnosis of cholecystolithiasis. Since the definite diagnosis of gallbladder carcinoma was made after the operation, he underwent additional resection. Four years later, he revisited the hospital complaining of painful swelling of the port site of his epigastrium. Magnetic resonance imaging of the abdomen revealed a mass 3.4 cm in diameter at the epigastrium. Thus, port site recurrence of gallbladder carcinoma was the suspected diagnosis. We resected the peritoneum, rectus abdominis muscle, and skin, as well as the tumor, and the abdominal wall was reconstructed using synthetic composite mesh. Histological examinations revealed recurrence of gallbladder carcinoma. Port site recurrence of gallbladder carcinoma is known to have a poor prognosis, but long survival can be expected in patients after complete resection of the metastatic lesion, if the recurrence develops more than a year after the initial operation.

[Internal Hernia after Distal Gastrectomy for Gastric Cancer Triggered by Retroperitoneal Recurrence].

A 77-year-male who had undergone distal gastrectomy with Roux-en-Y reconstruction received the tegafur/gimeracil/ oteracil adjuvant chemotherapy for about 1 year. 32 months after surgery, liver hilus lymph nodes and peritoneal recurrence were found. For obstructive jaundice, the metallic stent was implanted under double balloon-ERCP(DB-ERCP). He was treated 13 courses with SOX, preceded PTCD and re-implanted metallic stent for re-obstructive jaundice 52 months after the initial surgery. Although the jaundice was improved, he came to vomit after meal. Abdominal computed tomography revealed internal hernia. He had undergone the operation on the 8th hospital day. The hernial orifice was found in the mesentery defect due to peritoneal recurrence. He was able to eat after that operation but he was passed away POD-85 by the primary disease.

[A Case of Pancreatic Neuroendocrine Tumor with Necrolytic Migratory Erythema].

A 45-year-old man was admitted because of necrolytic migratory erythema. A computed tomographic scan of the abdomen revealed a 4.5cm mass in the tail of the pancreas. We performed distal pancreatectomy and splenectomy, and a definitive diagnosis of pancreatic neuroendocrine tumor(WHO class grade 2)was made histopathologically.

[A Case Report of Long-Term Survival after SOX Chemotherapy for Metastatic Ovarian Tumor of Gastric Cancer].

A 55-year-woman presented with abdominal fullness. An abdominal MRI disclosed ovarian and uterine tumors. Under the pathological diagnosis of Kruckenberg tumor, total hysterectomy and bilateral adenexectomy were performed. Gastrointestinal endoscopy disclosed type 3 on the greater curvature and anterior wall of the middle gastric body. The gastric cancer had a similar histology, which suggested the tumor origin and led to the diagnosis of c-stage IV. She received 6 courses of SOX chemotherapy. Staging laparoscopy revealed no peritoneal metastasis and negative cytodiagnosis of ascites. She underwent total gastrectomy with D2 lymphadenectomy. In May 2017, after S-1 chemotherapy, no metastasis to other organs was observed.

[A Case Report of Maintaining Continuous Ambulatory Peritoneal Dialysis after Total Gastrectomy for Perforated Gastric Cancer with ESD].

A 73-year-old man, receiving maintenance continuous ambulatory peritoneal dialysis(CAPD)was admitted to our hospital for chief complaining of heartburn. Gastrointestinal endoscopy disclosed 0- II a on the greater curvature of the upper gastric body. On further examination, the clinical diagnosis was defined as gastric cancer and c-stage I A(cT1aN0M0). The patient was recovered with conservative treatment from the perforated peritonitis after undergoing endoscopic submucosal dissection(ESD). Pathology revealed pT1b, INF b, UL(-), ly2, v0, pHM0, pVM0, for which he underwent total gastrectomy after changed to temporary hemodialysis(HD). On the 3rd postoperative day, blood examination showed WBC and CRP value of 16,100/mL and 20.282mg/dL, respectively. On the 6th postoperative day, nasal endoscopy revealed no anastomotic leakage and started oral take. The patient was discharged on the 20th postoperative day with changed to CAPD from the 7th postoperative day.

[Changes in Endocrine Function in Patients after Pancreatic Surgery].

We investigated glucose metabolism in patients who underwent pancreatoduodenectomy(PD), distal pancreatectomy (DP), and partial resection(PR). Fifteen patients(36%)were diabetic(HbA1c≥6.5%)before PD, 16(38%)were diabetic after PD, and 6(60%)were diabetic both before and after DP. The level of HbA1c was not significantly different preoperatively( PD: 7.5±2.7%, DP: 7.5±1.3%)vs postoperatively(PD: 6.7±1.1%, DP: 6.3±0.7%). These results suggest that pancreatic endocrine function was fairly preserved in patients who underwent pancreatic surgery.

[The Efficiency of Postoperative Endoscopy for Anastomotic Leakage after Total Gastrectomy].

An 81-year-old man underwent total gastrectomy with Roux-en-Y reconstruction for cardiac cancer in our department. He developed high fever on postoperative day 3, and pathological examination showed WBC and CRP level of 12,000/mL and 29.983mg/dL, respectively. A diagnosis of anastomotic leakage was confirmed using enhanced abdominal CT scanning that demonstrated free air around the esophagojejunalanastomosis after totalgastrectomy. The drainage tube was replaced by a 12 Fr sump tube because of leakage on postoperative day 10. Nasal endoscopy performed on postoperative day 13 revealed anastomotic leakage from the sump tube in the abdominal cavity. Endoscopy performed on postoperative day 20 confirmed the anastomotic leakage as a fistula that allowed air to leak into the abdominal cavity. On postoperative day 28, the sump tube was removed and oralintake was started. In conclusion, postoperative endoscopy might be usefulfor the assessment and drainage of anastomotic leakage.

[A Case Report of Difficult Esophagojejunal Anastomosis for Multiple Primary Cancer of Malignant Lymphoma and Gastric Cancer].

A 54-year-old man presented with cervical lymph node swelling and exhibited high levels of sIL-2R. Enhanced cervical, chest, and abdominal CT scanning demonstrated swelling of the cervical, hilar, axilla, and abdominal lymph nodes. The patient was diagnosed with malignant, non-Hodgkin's lymphoma, B-cell, follicular lymphoma using biopsy of the cervical lymph nodes. Gastrointestinal endoscopy revealed II c like advanced tumor in the upper gastric body and post-wall area. He was diagnosed with primary multiple cancer comprising malignant lymphoma and gastric cancer. It was difficult to elevate the jejunum for esophagojejunal anastomosis due to the giant abdominal lymph node swelling. The patient received 5 courses of combination R-CHOP chemotherapy for malignant lymphoma. The swollen lymph nodes considerably reduced in size after chemotherapy. Totalgastrectomy with reconstruction using the Roux-en-Y method was performed for gastric cancer. Histopathological findings revealed pT3(SS), pN0, pH0, pP0, pStage I B. The patient achieved complete remission following another course of chemotherapy and involved field radiation therapy. At present, he shows no signs of recurrence of primary multiple cancer.

[A Case of Gallbladder Carcinoma and Breast Cancer Associated with Pancreaticobiliary Maljunction].

We report a case of gallbladder cancer and right breast cancer associated with pancreaticobiliary maljunction.The patient was a 74-year-old woman who presented with abdominal pain due to cholecystitis.Abdominal CT detected a gallbladder tumor and right breast tumor.Enhanced CT and MRCP examination revealed gallbladder cancer and right breast cancer associated with pancreaticobiliary maljunction.We performed a gallbladder bed resection, bile duct resection, and right total mastectomy.The histopathological diagnosis of the gallbladder was moderately tubular adenocarcinoma and that of the breast tumor was scirrhous carcinoma.The patient remains recurrence-free 8 months after surgery.

[A Case of Adenosquamous Carcinoma of the Ascending Colon].

We report a case of adenosquamous carcinoma of the colon. A 70-year-old woman underwent a colonoscopic examination because of a positive fecal occult blood test. Colonoscopy demonstrated a type 2 tumor of the ascending colon, and a biopsy specimen showed poorly-moderately differentiated tubular adenocarcinoma. We performed a right hemicolectomy with D2 lymphadenectomy. The histopathology of the tumor demonstrated adenosquamous adenocarcinoma. Primary adenosquamous carcinoma of the colon is relatively rare and has a poor prognosis. Therefore, adenosquamous carcinoma of the colon may require strict follow-up.

[Difficulty in Preoperative Diagnosis of Residual Gastric Cancer after Distal Gastrectomy for Duodenal Ulcer].

A 67-year-old man underwent distal gastrectomy via the Billroth Ⅱ method (B-Ⅱ) for a duodenal ulcer. He presented with appetite loss and nausea in May 2014. Gastrointestinal endoscopy revealed wall thickness around gastrojejunostomy and the gastric mucosal fold. Biopsy and re-biopsy revealed a group 2 tumor. Laparotomy for diagnosis was performed because of stenosis and tumor progression. Intraoperative frozen section examination revealed adenocarcinoma in the lymph nodes of the jejunum. Residual gastrectomy with reconstruction using the Roux-en-Y method was performed for residual gastric cancer. Histopathological findings revealed pT4a, pN0, pM1 for the tumor in the lymph nodes of the jejunum, pStage Ⅳ. A distorted gastrojejunostomy site and the presence of anastomotic strictures are important for the rapid diagnosis of residual gastric cancer.

[Two Cases of Small Bowel Obstruction Due to Postoperative Adhesions Treated with Laparoscopic Adhesiolysis].

We occasionally require surgical treatment for postoperative adhesion ileus. One patient had adhesion ileus 14 times in 14 years after distal gastrectomy and Billroth-Ⅰreconstruction for gastric cancer. He underwent laparoscopic adhesiolysis for a small bowel obstruction that adhered to the entire surface. Another patient experienced adhesion ileus 7 times in 1.5 years after distal gastrectomy and Billroth-Ⅰreconstruction for gastric cancer. He underwent laparoscopic adhesiolysis for a small bowel obstruction adhering to the scar and the retroperitoneum. After laparoscopic treatment, he underwent an open operation for ischemic colitis but no small bowel obstruction was found. Laparoscopic adhesiolysis was found to be useful in both cases.

[A Case of Gastrointestinal Stromal Tumor of the Stomach after Pancreatoduodenectomy].

We report a case of gastrointestinal stromal tumor of the stomach 17 years after pancreatoduodenectomy(PD). The patient was an 83-year-old man who had undergone PD for chronic pancreatitis at 65 years of age. Gastric endoscopy revealed a 2.5-cm gastric submucosal tumor on the lesser curvature of the stomach, which was the gastrojejunostomy site. As the gross appearance of the tumor showed ulceration at the top of the tumor, the patient underwent total gastrectomy and Roux-en-Y reconstruction. Histopathological examination demonstrated that the tumor was a GIST of the stomach. Currently, 5 years after surgery, no recurrence has been observed. Therefore, postsurgical care for a malignant disease may require a strict follow-up for a long time.

[Two Patients with Recurrence of Hepatocellular Carcinoma after Liver Resection Who Achieved Long-Term Stable Disease with Small Doses of Sorafenib Therapy].

Case 1: A6 4-year-old man with hepatocellular carcinoma (HCC) had received local therapy repeatedly for 20 years. In 2012, he underwent hepatic right lobectomy for recurrence of HCC. Multiple recurrences were found in the hepatic remnant, and transcatheter arterial chemoembolization (TACE) was performed. Considering his condition, a small dose of sorafenib (200 mg per day) was administered. He complained of general fatigue, so we prolonged the administration interval (200 mg every other day). Thereafter, compliance improved and long-term stable disease (long SD), for more than 6 months, long SD was achieved. Case 2: A7 5-year-old man with HCC was treated by TACE repeatedly for multiple recurrences after liver resection (segment 6). In 2008, metastases to the thoracic vertebra and left rib were treated by radiation therapy and radiofrequency ablation, respectively. Subsequently, sorafenib (400 mg per day) was administered. We reduced the dose of sorafenib to less than 400 mg per day because of diarrhea, hypertension, and general fatigue. Thereafter, long SD was achieved despite the small dose of sorafenib. We report here 2 cases of HCC where we achieved long SD in spite of treating with a small dose of sorafenib.

Superior mesenteric artery syndrome after ileal pouch-anal anastomosis for colon cancer associated with ulcerative colitis: report of a case.

Superior mesenteric artery syndrome (SMAS) after a surgical operation is very rare. We experienced an extremely rare case of ileal pouch-anal anastomosis with subsequent development of SMAS requiring duodenojejunostomy. A 74-year-old Asian woman underwent total colectomy, ileal pouch-anal anastomosis (J-pouch), covering ileostomy, splenectomy, and distal pancreatectomy for treatment of descending colon cancer associated with ulcerative colitis. She complained of abdominal discomfort and vomiting 17 days postoperatively. Computed tomography (CT) revealed fluid collection at the pancreatic stump. We diagnosed a pancreatic fistula and performed CT-guided drainage. SMAS was thereafter diagnosed by contrast-enhanced CT, which revealed a narrow aortomesenteric angle of 36° and short aortomesenteric distance of 2 mm. The SMAS did not respond to conservative therapy. Finally, we performed duodenojejunostomy. This case illustrates that ileal pouch-anal anastomosis might induce relative stretching of the superior mesenteric artery and flatten it against the aorta, resulting in SMAS.