The patient is a 70-year-old woman who presented with a chief presentation of anal itching. Her previous physician diagnosed her with perianal extramammary Paget's disease, and she was referred to our hospital. Physical examination revealed a well-circumscribed red skin rash 6 cm in diameter centered on her anus. An anal skin biopsy showed adenocarcinoma, and immunostaining demonstrated CK7+,CK19+,CK20+,CDX2+, leading to the suspicion of pagetoid spread of anal adenocarcinoma. Lower gastrointestinal endoscopy revealed no obvious lesions; however, based on immunostaining results, she was diagnosed with small anal adenocarcinoma with Pagetoid spread. She underwent laparoscopic abdominoperineal rectal amputation(D1LD0)considering the circumferential circumference and possibility of a cure. A 1 cm margin of anal skin was removed, and pathological examination revealed an area filled with Paget cells in the duct near the transitional epithelium, which was considered the primary tumor and was diagnosed as anal adenocarcinoma(PE, pTisN0M0, pStage 0). The patient remains alive without recurrence for 6 months.

転移性膵腫瘍の切除例の報告は少なく,さらに骨肉腫を原発とするものは極めてまれである.我々は骨肉腫術後の異時性膵転移の1例を経験したので報告する.症例は55歳,男性.26年前に右下顎骨骨肉腫に対して原発巣切除が行われた.2年後,17年後に肺転移を認め,それぞれ切除,ラジオ波焼灼術,化学療法,放射線治療が行われ完全奏効が得られた.その後7年間は無再発で経過したが,定期検査で膵尾部に腫瘤影を認め当科紹介となった.CTで膵尾部に径53mmの淡く造影される腫瘤を認めた.超音波内視鏡では低~等エコーの分葉状の腫瘤であり,針生検で骨肉腫の転移と考えられた.PET-CTで同部位のみ異常集積を認め,単発の骨肉腫異時性膵転移と診断し膵体尾部切除術を行った.術後経過は良好で第10病日に退院した.骨肉腫の膵転移の報告は非常にまれであり,長期間無再発の後に膵転移再発していることとも含め示唆に富む症例と考えられた.

A 70s woman with a history of asthma and dyslipidemia underwent a robot-assisted abdominoperineal resection for rectal cancer. The ports were placed as per the method of Shizuoka Cancer Center and no intraoperative complications were observed. The colostomy was constructed in the left lower abdomen by the retroperitoneal route. The 12-mm port part was closed in 2 layers, the fascia and dermis, and the 8-mm port part was closed only in the dermis. The postoperative course was good; however, the patient vomited 10 days after surgery. Abdominal computed tomography revealed an incarcerated small intestine in the 8-mm port of the left abdomen, and it was diagnosed as port-site hernia incarceration. Emergency laparotomy hernia repair was performed on the day. A part of the 8-mm port was incised to 30-mm and the fascia dilatation to 30-mm was observed. The color tone of the incarcerated small intestine was good. Only adhesion peeling was performed, the small intestine was returned, and the fascia was closed. The postoperative course was uneventful and the patient was discharged 17 days after the second surgery. At the 1 year postoperative follow-up, recurrence of hernia or rectal cancer was not observed.

The recurrence of hepatocellular carcinoma(HCC)is primarily due to intrahepatic metastases. Additionally, extrahepatic HCC metastases most commonly occurs in the lungs, lymph nodes, adrenal glands, and bones. Systemic chemotherapy is the standard treatment for extrahepatic metastases. Although several reports on surgical resection of lymph node metastases (LNM) in patients with HCC have been published, its clinical benefits remain controversial. We report a case in which surgical resection of LNM was performed in a patient with HCC. The patient was a 74-year-old woman diagnosed with HCC and non-B non-C chronic hepatitis, for which she underwent a laparoscopic partial hepatectomy. The pathological diagnosis was St-A, 1.6×1.4 cm, confluent multinodular type, pT1N0M0, fStage Ⅰ. Nine months later, 2 LNM on the liver hilum were detected and managed with sorafenib. Sorafenib was discontinued after 2 months due to the development of Grade 3 hand-foot syndrome. Since no new lesions were detected on follow-up, lymph node resection was performed. The patient remains disease-free 4.5 years postoperatively.

Although laparoscopic liver resection is widely accepted as a minimally invasive surgical approach for Hepatocellular Carcinoma (HCC), repeat laparoscopic hepatectomy has not been widely adopted due to its technical difficulties. Therefore, it has been limited to highly selected patients. A 75-year-old man was admitted to our hospital with a diagnosis of HCC and underwent open central bisectionectomy. One year after surgery, abdominal Computed Tomography (CT) revealed a mass measuring 10 mm in diameter on the cut liver surface of Segment 7 (S7). Our preoperative diagnosis was recurrent HCC and the patient underwent repeat laparoscopic S7 partial hepatectomy. There was no sign of recurrence 10 months after hepatectomy. Repeat laparoscopic hepatectomy for recurrent HCC in S7 after open hepatectomy is an especially challenging, but suitable and safe procedure for selected patients. We report a case of repeat laparoscopic S7 partial hepatectomy for recurrent HCC after open central bisectionectomy.

Early laparoscopic cholecystectomy (LC) after gallbladder drainage is recommended in cases with acute cholecystitis (AC); however, the safety of LC after gallbladder drainage is still controversial, and it is not clear whether the drainage contributes to prevent bile leakage during operative procedure. A single institutional retrospective cohort study was performed to assess the safety of LC after gallbladder drainage as well as the frequency of bile leakage during LC. Twenty-four patients that had gallbladder drainage (Drainage group) and 67 patients that had early LC (Early LC group) were treated for AC. Charlson comorbidity index was significantly higher in the Drainage group ( P = 0.015). Early LC group had a shorter operative time than Drainage group ( P = 0.020) and tend to have less bile leakage rate than Drainage group. In cases when the initial treatment was started within a day after the onset of symptom, no bile leakage was observed in either group. LC after gallbladder drainage can be performed safely; however, it does not reduce the bile leakage rate. Early laparoscopic cholecystectomy with immediate admission as possible might help to prevent the postoperative bile leakage.

Background: Anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target area have been established as essential methods for curative treatment of hepatocellular carcinoma (HCC) and have subsequently been applied to other malignancies. However, laparoscopic anatomical liver resection (LALR) procedures are very difficult to reproduce, and the confirmation of demarcation of the hepatic segment on a monitor is also challenging. Recently, indocyanine green (ICG) fluorescence imaging has been used to identify hepatic tumors and segmental boundaries during hepatectomy. Herein, we describe LALR using ICG fluorescence imaging. Methods: Three patients underwent pure LALR using ICG fluorescence imaging at our institute. One patient underwent anatomical partial liver resection for HCC, another underwent segmentectomy 3 for metastatic liver cancer, and the third underwent right anterior sectionectomy for HCC. To visualize hepatic perfusion and the demarcation line by negative staining using an optical imaging system, 2.5 mg ICG was injected intravenously during surgery following clamping or closure of the proximal Glissonean pedicles. Results: For all three cases, ICG fluorescent imaging clearly delineated the demarcation lines and allowed identification of intersegmental planes to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. This allowed surgeons to recognize the direction and guide the transection of the liver parenchyma when performing LALR. Conclusion: LALR using ICG fluorescence imaging is a feasible procedure for resection of the tumor-bearing hepatic region and facilitates visualization of the demarcation line and identification of the boundaries of the hepatic sections. (C) 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V.

リンパ管腫は通常，小児に発生するまれなリンパ管奇形であり，成人例での報告は少ない．今回，新規発生から増大経過を観察し，腹腔鏡下手術で切除した成人脾リンパ管腫の1例を経験したため報告する．症例は73歳の女性で，約2年前のCTでは脾臓に病変を認めなかったが，他疾患精査のCTで脾臓に19 mm大の単房性囊胞性病変を認めた．その後3年5か月間経過観察していたが，50 mm大の多房性囊胞性病変へと増大を認めたため，腹腔鏡下脾臓摘出術を施行した．標本の割面で大小さまざまな多房性囊胞性病変を認め，囊胞の内容物は淡黄色の液体であった．病理組織検査では囊胞壁は1層の扁平な内皮で覆われており，内腔に好酸性の液体貯留が散見された．内皮細胞の免疫組織学的検査ではCD34が陰性，D2-40がごく一部で弱陽性であり，CD31，Prox-1が陽性であったことから，リンパ管腫と診断した．

Gallbladder metastasis from breast cancer, especially from ductal carcinoma, is rare. Herein, we report a rare case of gallbladder metastasis from ductal carcinoma of the breast that was diagnosed after laparoscopic cholecystectomy (LC) for acute cholecystitis. A 78-year-old woman presented with right upper abdominal tenderness and positive Murphy’s sign during chemotherapy for advanced multiple metastases of the breast cancer. Abdominal ultrasonography and computed tomography showed a slightly thickened gallbladder wall and two calculi. After a diagnosis of acute calculous cholecystitis was established, LC was performed. Pathological examination revealed poorly differentiated adenocarcinoma infiltrating the submucosal and subserosal layer over the entire gallbladder, and a lymph node metastasis in the gallbladder neck. Immunohistochemical examination revealed that the tumor cells tested positive for estrogen receptor and negative for progesterone receptor, which was consistent with primary breast cancer. The patient was uneventfully discharged without abdominal pain 7 days later. Although she subsequently underwent several chemotherapies, she died 16 months later. In conclusion, gallbladder metastasis should be considered in patients with multiple metastatic breast cancer who present with signs or symptoms of cholecystitis. Moreover, LC should be considered to relieve the symptoms of cholecystitis for improved prognosis, even in a patient with multiple metastases.

魚骨により消化管穿孔をきたすことがあると知られているが，魚骨の迷入により肝膿瘍をきたした症例は稀である．症例は，74歳の男性．発熱，呼吸苦を主訴に救急受診した．2週間前に魚骨を飲み込んだ自覚があった．腹部CT検査，腹部超音波検査で肝内に魚骨を疑う異物および肝膿瘍を認めた．ショックを伴う全身状態の悪化を認めたため，緊急で経皮的膿瘍ドレナージ術を施行した．翌日に開腹肝内異物除去術，膿瘍ドレナージ術を施行した．術中超音波検査で膿瘍内に音響陰影を伴う線状高エコーを認めた．膿瘍ドレナージを行ったところ，肝内に完全に埋没した魚骨を認め，摘出した．消化管の穿孔・穿通部位は明らかではなかった．術後21日目に軽快退院した．魚骨の迷入により肝膿瘍をきたした稀な症例を経験した．保存的加療やPTADのみでは再燃・増悪例も報告されており，全身状態が安定した状態で，可及的速やかに魚骨の除去を検討すべきである．

Background: Many surgical techniques have been developed to treat inguinal hernia. In recent years, the laparoscopic transabdominal preperitoneal (TAPP) approach has been widely performed to repair inguinal hernia. Giant inguinal hernia (GIH) is an extremely rare disease that is a challenge for general surgeons. GIH appears when patients neglect the treatment for many years and it is defined as an inguinal hernia that extends below the midpoint of inner thigh in standing position. According to previous publications, the Lichtenstein tension-free hernioplasty is recommended to repair GIH. In this article, we describe consecutive four cases of GIH repaired via the TAPP approach. Methods: From April 2015 to March 2017, 200 patients underwent hernioplasty against inguinal hernia at our hospital. Inguinal hernias were treated via the TAPP approach in principle. We performed hernioplasty via the TAPP approach in all 4 patients (2%) who met the definition of Type 1 GIH. Demographic information, maximum diameter of hernia sac, hernia orifice size, and surgical data were obtained. Results: The mean operative time was 135 min. No intraoperative complications were encountered. All patients could walk from postoperative day 1 and were discharged home early, but they all had scrotal seromas. Three patients did not need puncture or drainage, but one of them required puncture. All seromas disappeared within 6 months. There was no recurrence in the 8- to 24-month follow-up. Conclusion: The TAPP approach is a feasible, safe therapeutic option that may reduce wound size and pain following surgical treatment of Type 1 GIH. (C) 2018 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V.

A 78-year-old woman was found to have gallbladder wall thickening on ultrasonography during a routine health check-up and was referred to our clinic. On contrast-enhanced endoscopic ultrasonography, a papillary lesion measuring 14mm was detected in the fundus, which showed a heterogeneous enhancement at the early phase. She underwent cholecystectomy and gallbladder bed resection. Histological examination revealed that the tumor consisted of mucinous atypical cells, regularly arranged in a high-papillary architecture with delicate fibrovascular cores, which led to the diagnosis of intracholecystic papillary neoplasm of the gallbladder.

Omental abscess due to a spilled gallstone is extremely rare after laparoscopic cholecystectomy. Herein, we report a 68-year-old man who presented with left upper abdominal pain after laparoscopic cholecystectomy for gangrenous cholecystitis. Seven months prior to admission, gallbladder perforation with spillage of pigment gallstones and bile occurred during laparoscopic cholecystectomy. The spilled gallstones were retrieved through vigorous peritoneal lavage. Abdominal computed tomography showed a 3 × 2.5 cm intra-abdominal heterogeneous mass, suspected to be an omental abscess, and ascites around the spleen. Exploratory laparoscopy revealed an inflammatory mass within the greater omentum. Laparoscopic partial omentectomy and abscess drainage were performed, and a small black pigment gallstone was unexpectedly found in the whitish abscess fluid. Abscess fluid culture results were positive for extended-spectrum β-lactamase-producing Escherichia coli and Streptococcus salivarius, which were previously detected in the gangrenous gallbladder abscess. The histopathological diagnosis was abscess in the greater omentum. Postoperative course was uneventful, and the patient was discharged 13 days later. In conclusion, we report a successful case of laparoscopic management of an omental abscess due to a spilled gallstone after LC. It is important to attempt to retrieve spilled gallstones during LC because they may occasionally result in serious complications.

症例は48歳，男性．大腸癌検診にて便鮮血陽性を指摘され，当院を受診した．下部消化管内視鏡検査にて上行結腸に2型病変を認めた．術前の生検では高分化から中分化型管状腺癌の診断であり，腹腔鏡補助下右半結腸切除術を施行した．切除標本の病理組織学的検査では，腺癌と神経内分泌細胞癌が混在していた．腫瘍内の各々の占拠範囲は30％以上を占めており，mixed adenoneuroendocrine carcinoma（以下MANECと略記）と診断した．術後補助化学療法としてCDDP+etoposide（VP-16）を4コース施行し，術後30カ月無再発生存を継続している．大腸MANECの2年以上の無再発生存例はまれであり，文献的考察を加えて報告する．

We report a rare case of complete spontaneous necrosis with residual intrahepatic metastasis of hepatocellular carcinoma in viable status. A 59-year-old man followed because of alcoholic liver dysfunction was referred to our hospital for liver tumor. Abdominal MRI and CT showed tumor with 1.5cm diameter in segment 8 of the liver, and hepatocellular carcinoma was diagnosed. Segmentectomy 8 was performed. In the resected specimen, the nodule had clear border recognized as hepatocellular carcinoma. Histopathological findings showed that the nodule with clear border was replaced granulation tissue and had no viable cancer cell. Another lesion of mod-erately differentiated hepatocellular carcinoma with 0.2 cm diameter was indicated near the nodule unconnect-edly. These findings suggested that viable intrahepatic metastatic lesion just remained although the primary nodule became spontaneous necrosis.

EUS-FNAで膵腺房細胞癌(ACC)と診断し得た2例について,その組織像を中心に報告する.2例とも70歳代男性で,腫瘍径はそれぞれ95mm,56mmであった.いずれも発見時に肝転移が認められた.EUS-FNAで得られた腫瘍組織は,類円形核,好酸性胞体を持つ異型細胞の充実性から腺房様増殖からなり,ACCと神経内分泌腫瘍(NET)が鑑別となった.免疫染色では種々の程度にsynaptophysinなどの神経内分泌マーカーが陽性となり,ACCとNETとの鑑別を要したが,いずれの症例もBCL10がびまん性かつ強く発現しており,腺房細胞癌と診断し得た.BCL10はACCに特異性の高いマーカーとして近年同定され,Trypsinを含めた既知のマーカーよりも発現がびまん性かつ強いことが多く,EUS-FNAを含めた微小検体でのACCの診断に有用であると思われる.

Endoscopic retrograde cholangio-pancreatography (ERCP) is one of the most technically challenging procedures in therapeutic endoscopy; difficulties in biliary cannulation and post-ERCP pancreatitis are still significant problems. Deep cannulation of Vater's papilla may fail in up to 5% of cases; selective biliary cannulation reportedly fails in 15–35% of cases, even in experienced hands; repeated and prolonged attempts at cannulation increase the risk of post-procedure pancreatitis. Therefore, cannulation technique plays a pivotal role in successful cannulation and occurrence of post-procedure pancreatitis.This review presents and discusses the techniques that can be used for achieving biliary cannulation after an initial failure and for minimizing the risk of pancreatitis, including guide wire assisted technique, needle knife precutting, trans-pancreatic sphincterotomy, and pancreatic stenting.

今回われわれは,indocyanine green 15分血中停滞率(ICG R15)が74.9%と異常高値を示したがChild-Pugh分類ではAであったため,ICG排泄異常症と診断した肝細胞癌(HCC)症例を経験した.症例は66歳,男性.右肩痛を主訴に近隣医院を受診しCT検査で肝右葉に巨大腫瘤が認められ当院に紹介となった.腹部CT・MRI検査で肝S5-7-8に最大径11.5cmの巨大な腫瘤像を,またS6に1.3cmの腫瘤像を認めた.肝動脈化学塞栓療法後,横隔膜の合併切除を伴う右肝切除術を施行し,術後19日目に退院となった.ICG R15のみ異常高値を示す体質性ICG排泄異常症を背景とするHCC症例では治療方針に苦慮するが,広範囲切除であっても安易に手術選択肢を排除せず,総合的に肝機能の評価を行い手術加療の可能性を検討する必要があるものと考える.