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To perform complete mesocolic excision with central vessel ligation, it is important to recognize the vessel anomaly and the location of the tumor. For left-sided colon cancer, the variations in the course of the left colic artery and accessary middle colic artery must be recognized preoperatively. Here, we describe our experience with a 57-year-old man who was diagnosed with sigmoid colon cancer with complicated inter-mesenteric connections between the inferior mesenteric artery (IMA) and superior mesenteric artery (SMA), possibly due to median arcuate ligament syndrome. We performed laparoscopic sigmoidectomy with low ligation of the IMA to preserve the extremely enlarged left colic artery. The total operative time was 155 minutes, and the estimated total blood loss was 10 mL. The patient was discharged on postoperative day 9 without any postoperative complications. For patients with vascular anomalies in the left-sided mesocolon, preoperatively ruling out SMA stenosis by using angiography and 3-D CT might be important.

Background The safety and feasibility of laparoscopic colectomy for T4 colorectal cancer remain controversial. We believe that setting a “Goal” that will guide the surgeons in returning from the deep layer could be the key to safe en bloc resection of neighboring organs. For descending colon cancer, the cranial-first approach makes it possible to clearly visualize the pancreas and origin of the transverse mesocolon, leading to safe splenic flexure mobilization and complete mesocolic excision, which is the strongest advantage of this approach. Case presentation A 75-year-old woman was diagnosed with T4 descending colon cancer invading the Gerota’s fascia. We performed laparoscopic left colectomy using the cranial-first approach to set a “Goal” at the inferior border of the pancreas for safe resection of the Gerota’s fascia. The total operative time was 233 min, and the estimated blood loss was 98 ml. She was discharged after surgery without postoperative complications. Pathological findings revealed the invasion into the Gerota’s fascia, and the resection margin was negative for cancer. Conclusions The cranial-first approach of laparoscopic left colectomy appears to be safe and feasible and could be a promising method for selected patients with T4 descending colon cancer invading the Gerota’s fascia.

Background Subtotal cholecystectomy is an effective surgical method to decrease the risk of complications for gallbladders that are difficult to remove. However, there is a risk for postoperative refractory bile leakage through the gallbladder stump. Here, we report a new management technique involving the use of argon plasma coagulation (APC) to stop bile leakage after a subtotal cholecystectomy. Case presentation A 74-year-old man was referred to our hospital for abdominal pain and fever. Contrast-enhanced computed tomography of the abdomen showed fluid collection, such as an abscess, surrounding the gallbladder and hepatic flexure colon. The patient was diagnosed with colonic perforative peritonitis, and he underwent emergency surgery. On laparotomy, the abscess was observed outside of the hepatic flexure colon and gallbladder necrosis was detected. The neck of the gallbladder and the area close to the hepatoduodenal ligament was severely inflamed prohibiting dissection. The hepatic flexure colon was part of the abscess wall, and resection was needed. A subtotal cholecystectomy and right hemicolectomy confirmed peritonitis caused by cholecystic perforation. The mucous membrane of the gallbladder neck that remained was necrotic or detached. Therefore, the stump of the gallbladder was closed by primary sutures without cauterization of the mucosa. On postoperative day 6, bile leakage from the gallbladder stump was revealed. Percutaneous and endoscopic retrograde cholangiography drainage were performed. However, the liquid, which seemed to be secreted from the mucosa of the remnant gallbladder, was continuously obtained. We used APC to cauterize the gallbladder mucosa through the fistula of the abdominal drainage tube. Bile leakage and mucus discharge were improved after three rounds of APC cauterization. Conclusions APC effectively treated refractory bile leakage from a gallbladder stump after subtotal cholecystectomy for severe cholecystitis.

The feasibility and safety of laparoscopic surgery for locally advanced colorectal cancer remain controversial due to the high rate of incomplete resection and conversion to open surgery. Especially for T4 colorectal cancer, laparoscopic techniques are still demanding mainly because of the difficulty in distinguishing between inflammation and tumor involvement, which often lead surgeons to do overtreatment in surgery. We believe laparoscopic magnified and multidirectional approach might be useful for pathologically complete resection and minimizing an unnecessary extended surgery for these cases. A 49-year-old man was diagnosed with locally advanced T4 sigmoid colon cancer invading the urinary bladder and ureter. We performed laparoscopic anterior resection with en bloc resection of the urinary bladder and the left ureter. Total operative time was 462 min, and the estimated blood loss was 50 ml. This patient was discharged on the 28th day after surgery without any ostomies and urinary functional disorders. The magnified view by laparoscopic techniques from multiple directions would enable surgeons to set surgical landmarks for another approach, which is the key for safe and feasible laparoscopic surgery in patients with locally advanced T4 colorectal cancer.

The objective of this study was to evaluate the benefits of wound protectors (WPs) in preventing incisional surgical site infection (I-SSI) in open elective digestive surgery using data from a large-scale, multi-institutional cohort study. Patients who had elective digestive surgery for malignant neoplasms between November 2009 and February 2011 were included. The protective value of WPs against I-SSI was evaluated. A total of 3201 patients were analyzed. A WP was used in 1022 patients (32%). The incident rate of I-SSI (not including organ/space SSI) was 9%. In the univariate and the multivariate analyses for perioperative risk factors for I-SSI, the use of WP was an independent favorable factor that reduced the incidence of I-SSI (odds ratio 0.73, 95% confidence interval 0.55–0.98. P = 0.038). The subgroup forest plot analyses revealed that WP reduced the risk of I-SSI only in patients aged 74 years or younger, males, non-obese patients (body mass index

症例は50歳の男性で，35歳時，常染色体優性遺伝性多発性嚢胞腎（autosomal dominant polycystic kidney disease；以下，ADPKDと略記）と診断され，48歳より高血圧と全身湿疹の症状が出現し加療されていた．家族歴は父が死亡（慢性腎不全あるも詳細不明）．今回，腹痛で受診し，上部消化管造影および内視鏡検査でスキルス胃癌と診断し，胃全摘出術を施行した．最終診断は印環細胞癌を含む低分化腺癌，UML，4型，pT3（SE），pN0，sH0，pP1，pCY1，sM0，stageIVであった．術後12日目に退院し，化学療法を施行しつつ，術後1年3か月生存中である．ADPKDと腫瘍の関連はin vitroで，原因遺伝子産物であるpolycystin-1とpolycystin-2の影響が報告されているが，臨床的には賛否両論で，胃癌に関しての報告はない．今回，日本病理剖検輯報（2002年～2006年の5年間）による剖検例で検討すると，胃癌に関しては非分化型が多かったが，関連は不明であった．

症例は61歳の男性. 平成11年6月右下腹部痛を主訴に近医より当院紹介受診した. 右下腹部に有痛性の腫瘤を触知し急性虫垂炎の術前診断にて同日虫垂切除術を施行した. 病理組織学的には悪性リンパ腫 (diffuse large cell type) であった.腫大した体表リンパ節は触知せず術前の胸部単純X線写真, 他の消化管精査, 腹部CTにても異常所見認めず, 虫垂原発悪性リンパ腫と診断された. 術後化学療法追加した.虫垂原発悪性リンパ腫の本邦報告例は自験例を含め32例で, 文献的考察を含め報告する.

症例は46歳男性, 2年前の人間ドックで膵腫瘤を指摘されたが放置,平成9年1月当院受診し精査となる. USにて膵体部に2.0×1.9cmの低エコーで内部に石灰化を伴う腫瘤を認めた. CTでは周囲が膵と等吸収域,内部低吸収域で一部に石灰化を伴う腫瘤を認めた.リンパ節腫脹は認められなかった. ERCPでは主膵管のわずかな圧排像を示す以外は所見無く,腹部血管造影において明らかな栄養血管や腫瘍濃染像は認められなかった.悪性腫瘍も否定できないため,平成9年7月17日,膵体尾部脾合併切除術を施行.病理組織学的検査では,腺房細胞癌であった. 経過良好で術後2年の現在再発は認めていない.以上,比較的まれな膵腺房細胞癌の1例を経験したので,免疫組織所見と電顕所見を加え報告する.

A 50-year-old woman was admitted to the hospital because of an abnormal shadow detected incidentally by a routine chest X-ray, examination 4 years previously, when she was asymptomatic. The tumor gradually increased in size in those years. After admission, a partial resection of the lung including the tumor was performed. The tumor was attached to the visceral pleura of right lower lobe by a pedicle. Pathologically the tumor was solitary fibrous tumor of the pleura (localized fibrous mesothelioma). The histogenesis of solitary fibrous tumor is still controversial, but the mesencymal origin is preferred on the basis of immunohistochemical findings including CD34 positivity. In this case tumor cells also demonstrated positive for CD34.

A 60-year-old man who had had transarterial embolization six times for multiple hepatocellular carcinoma received seventh transarterial embolization at the hospital. Procedures included that 4mg of smankus was dissolved in 10ml of lipiodol, and 5. 3, and 1ml of the solustion were infused into the right inferior dia-phragmatic artery and right posterior intracostal artery (between the 9th and 10th) which fed the tumor. The patient complained of numbness and pain of the bilateral lower extremities immediately after the infusion. On the next day the patient manifested symptoms of transverse lesion of spinal cord which did not recover hereafter. Magnetic resonance imaging revealed an infarction image at the level of Th 9/10. Reevaluation of an angiography which was taken before surgery showed spinal artery branched from the 9th posterior intercostal artery. Thus, it was thought that lipiodol flew into the spinal artery through intracostal artery causing spinal infarction.

血管腫との鑑別が困難であった乳腺血管肉腫を経験した.症例は24歳女性で,左乳房腫瘤を主訴に来院,左乳房BD領域に5.0×6.Ocmの弾性軟な腫瘤を認め乳腺部分切除を施行し,病理組織学的診断は血管腫であった. 3回の局所再発をきたしたが手術にて摘出された.初回,再手術時の病理組織学検査で,乳腺血管腫と診断されたが,臨床経過より血管肉腫が強く疑われたので,抗Ki-67抗体を用いた細胞増殖能の評価を試みた.自験例が血管肉腫に匹敵する高い細胞増殖能を持つ事を確認でき,血管肉腫と判断し補助療法としてインターロイキン2製剤の投与を行った.初回手術後約3年2カ月で肺・肝・左第7肋骨転移をきたし,再発部の病理組織学的所見は低分化型血管肉腫像を呈していた.初回手術後4年3カ月にて転移性肝腫瘍破裂にて死亡した.

Two cases of acute abdomen in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) are reported. Case 1: A 48-year-old man complained of an abdominal pain followed by a cloudy dialysate return. With a clinical and ultrasonographic diagnosis of appendiceal abscess, an appendectomy and drainage of the abscess were performed. Case 2: A 63-year-old man presented with an abdominal pain and a melena. The dialysate return was cloudy, in which S. epidermidis was isolated. Colonoscopy showed longitudinal ulcers in the splenic flexure and a diagnosis of ischemic colitis was made. Neither clinical nor radiographic finding was diagnostic of the perforation, and the patient was treated conservatively. He died of a sudden septic shock on the 11th hospital day. The autopsy revealed perforated ischemic coloitis. Diagnosis of acute peritonitis due to perforation is difficult in patients on CAPD due to the daily peritoneal lavage. Our experience suggests that early surgical treatment is necessary when perforation is possibly suspicious.