Choledocholithiasis is recognized as a complication after cholecystectomy. The objective of this study was to clarify whether cholangiectasis after cholecystectomy was a risk factor for choledocholithiasis. Subjects were 10 patients who had choledocholithiasis after cholecystectomy, (stone group), and 64 patients who did not have the complication for more than 3 years after cholecystectomy were served as control (control group). The common hepatic bile duct diameter was measured by CT or US before and after the operation and the measurements were compared between both groups. There was no significant difference in the diameter between both groups before the operation. The diameter of the common hepatic bile duct was measured before, one year and more than 3 years after cholecystectomy. The diameter became greater with time in both groups. Specifically, the mean diameter measured one year after the operation was 1.43±0.36 cm in the stone group, versus 0.80±0.19 cm in the control group, with a significant difference (p<0.01). All 7 patients whose diameters were more than 1.3 cm when one year had elapsed after the operation developed choledocholithiasis thereafter. It is considered that cholangiectasis after cholecystectomy is a risk factor for choledocholithiasis, and care must be exercised, if the diameter of the common hepatic bile duct is equal to or more than 1.3 cm after 1 year of the operation.

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[Objectives] About half the number of pancreatic endocrine tumors is malignant, but preoperative diagnosis of malignancy is difficult and thus we have been performing operations according to those for cancer. The purpose of this study is to examine whether the use of FDG-PET for pancreatic endocrine tumors can offer preoperative information about malignancy of the tumor. [Subjects and methods] A total of seven patients who underwent surgical resection for non-functioning pancreatic endocrine tumor at our Cancer Center from April 2006 to March 2009 were enrolled. Pattern of FDG-PET and malignancy of the tumor were studied. [Results] Abnormal uptake of FDG was demonstrated in three out of three patients with well differentiated endocrine tumor and in two out of four patients with well differentiated endocrine cancer. A study of correlations between the tumors and the maximum SUV disclosed that the median SUV max was 27.46 for well differentiated endocrine tumors, versus 3.57 for well differentiated endocrine cancers. As for correlation between the tumor diameter and the SUV max, the median SUV max was 2.02 in three patients with the tumor less than 20mm in diameter, versus 22.65 in four patients with the tumor more than 20mm in diameter. [Conclusion] Abnormal uptake of FDG might strongly relate to the tumor diameter compared to the malignancy of it. It is concluded that we could not identify the usefulness of FDG-PET in evaluating the malignancy of pancreatic endocrine tumors.

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A 40-year-old Filipino woman consulted our department because of a hard lump in her left breast. Physical, mammographic and ultrasonographic findings suggested malignancy. However, fine needle aspiration biopsy cytology showed only granulomatous cells. Excisional biopsy was performed. Histological examination showed a granulomatous lesion with caseation necrosis, a finding specific to tuberculosis. We ultimately diagnosed tuberculosis of the breast by PCR of the resected specimen.
Tuberculosis of the breast is a rare benign breast disease, but often mimicks breast carcinoma in both physical and imaging findings. We describe herein a rare case of tuberculosis of the breast with a review of the relevant literature.

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A 38-year-old female complained of left nipple erosion and a bloody nipple discharge of four years' duration. A red granulation-like tumor was found on top of the nipple. The tumor was soft, fragile, and bled easily. Breast contrast-enhanced MRI revealed a high intensity lesion in and right under the nipple. Histological examination of the excised biopsy specimens revealed adenoma of the nipple. Tumor extirpation along with the nipple was performed. On postoperative histology, an adenoma of the nipple was diagnosed. The patient has been free from local recurrence for 37 months since the operation.

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The case of a patient with secretory carcinoma of the right breast with ipsilateral accessory breast cancer for whom preoperative diagnosis was difficult is described. The patient was a 78-year-old woman whose chief complaint was a right axillary mass. A subcutaneous mass, 1.5 cm in diameter, that was elastic, hard, and movable was palpated in the right axilla near the upper arm. No clear masses were palpated in either breast. Although preoperative diagnostic imaging strongly suggested right breast cancer, fine needle aspiration cytology was suspicious of breast cancer, but not confirmed. Since axillary lymph node metastasis of right breast cancer was suspected, a right mastectomy with axillary lymph node dissection and right axillary tumor resection was performed in Janurary 2008. The final histopathological diagnosis was secretory carcinoma of the right breast and scirrhous carcinoma of the right axilla. In addition, the patient was diagnosed as having primary accessory breast cancer, because normal breast tissue and intraductal lesions were observed on the margin of the area of invasion by the axillary tumor. The patient is currently receiving exemestane and undergoing follow-up.

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A 9-year-old boy was admitted to the hospital because of persistent fever of 39°C or greater and left sided pleural effusion. On admission he developed left sided empyema which rapidly progressed and could not be controlled with chest tube drainage. We thus performed video-assisted thoracoscopic debridement and decortication via minithoracotomy.
Video-assisted thoracoscopic debridement and decortication via minithoracotomy is a safe and effective technique for acute empyema in pediatric patients. Childhood acute empyema tends to progress rapidly and we have difficulties in placing a thick chest tube due to the patient's physique. When the conservative treatment with chest tube drainage becomes ineffective, we should consider video-assisted thoracoscopic debridement and decortication via minithoracotomy as soon as possible.

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We report two squamous cell lung carcinoma cases which developed an abscess after transbronchial lung biopsy (TBLB). Case 1 : A 73-year-old man developed a fever and cough two days after TBLB. Antibiotic treatment was not effective ; a left lower lobectomy +ND1 was performed. Ipsilateral pneumonia occurred after the operation, but the patient improved. Case 2 : A 61-year-old man developed a fever two days after TBLB. Antibiotic treatment was not effective ; a right lower lobectomy +ND2a was performed. Bilateral pneumonia occurred after the operation ; the patient was put on a respirator and required another operation because of prolonged air leakage. TBLB in lung carcinoma patients carries the risk of abscess formation. It is important not to delay surgery so as to improve patient outcomes.

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The case involved a 59-year-old man who was seriously injured in a traffic accident at the age of 25 years and thereafter had been suffered from paralysis of the lower half of the body. At the age of 35 years, he was pointed out having left diaphragmatic hernia but had not received any treatment for it until 2003 when he was seen at the hospital because of upper abdominal pain. Left traumatic diaphragmatic hernia was diagnosed and the hernia orifice was directly sutured. He had been asymptomatic thereafter. In 2009, he was brought into our hospital by ambulance because of the sudden onset of chest pain and back pain.
Chest X rays showed bowels in the left pleural cavity, and CT scan showed the small intestine which escaped in the left pleural cavity, expansion of the small intestine and recurrence of diaphragmatic hernia.
We diagnosed the case as recurrent diaphragmatic hernia and strangulation ileus and performed emergency surgery. Upon laparotomy we confirmed a new hernia orifice on the outside of the last operation with the dilated small intestines, which had incarcerated in the thoracic cavity. We drew the small intestine necrotized in the range of approximately 150cm in the abdominal cavity, and performed partial excision of the small intestine. The hernia orifice was 3cm in size, but the direct choke was impossible. We closed the hernia orifice by using a flap created from transversus abdominis muscle. We report on our experience with a rare case of recurrence of traumatic diaphlagmatic hernia.

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We experienced a case of cervical esophageal transmural injury, successfully treated with simple closure of the injured site, transcervical vascular sheath mediastinal drainage and open paramedian tracheostomy with no contamination between the contaminated surgical wound and tracheostomy site. A 47-year-old man with schizophrenia swallowed a piece of a glass bottle. CT showed incarcerated glass in the cervical esophagus and deep cervical and mediastinal emphysema. He was transferred to our center because of cervical esophageal injury without respiratory or circulatory deterioration. In the operating room of our center, we found no glass in the esophagus and he underwent gastrotomy, removal of the piece of glass, and the gastrostomy with simple closure of the injured cervical esophagus and transcervical vascular sheath mediastinal drainage using an oblique cervical approach and open paramedian tracheostomy. We reached the posterior wall of the cervical esophagus via an incision on the anterior edge of the sternocleidomaastoid muscle, and inserted a tube drain for continuous aspiration along the cervical vascular sheath to the mediastinum. Finally, we performed an open paramedian tracheostomy as far from the surgical wound for esophageal surgery as possible. We confirmed oblique insertion of the tracheostomy tube by postoperative bronchofiberscopy and CT images. The tracheostomy tube was easily changed through the paramedian tracheo-cutaneous fistula.

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A 72-year-old man visited our hospital because of swallowing difficulty. Endoscopic examinations of the upper gastrointestinal tract indicated esophageal carcinoma, and esophageal resection was carried out. The final diagnosis was basaloid carcinoma, pT1b (SM3), ly1, v1, pN0, sM0 and Stage I. Liver metastasis was found four months after the operation, and complete response to hepatic arterial infusion chemotherapy was achieved. Fifteen months after the operation, small bowel obstruction developed. An abdominal CT scan revealed a tumor at the lower abdomen and emergency laparotomy was performed. We confirmed a tumor in the jejunum about 40 cm distal from the Treitz ligament which had invaded the ascending colon. Thus partial resection of the ileum and right colectomy were done. The pathological diagnosis was metastasis of basaloid carcinoma of the esophagus. He developed metastases to the lung and bores and died 40 months after the operation for esophageal carcinoma. This case of metastasis to the small intestine from basaloid carcinoma of the esophagus is the first report in the international literature.

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A 64-year-old man was referred to our hospital because of a neck tumor. Thoracic esophageal cancer with lymphatic metastasis to the neck was diagnosed, and he was given chemoradiotherapy. During therapy, the original lesion disappeared, but recurred 3 months later. Then, salvage surgery was undertaken and the postoperative course was satisfactory. However, 3 months later, he was transferred to our hospital again because of severe respiratory failure due to acute pneumonia. CT and bronchoscopy revealed a fistula between the right main bronchus and reconstructed gastric role. There was difficulty with mechanical respiration because of air leakage. Thus, we decided to emergently stent the right main bronchus. The fistula was closed temporarily by a metallic covered stent, but the next day the stent cover broke. Then, we changed to a silicon stent (Dumon stent), but the fistula could not be closed effectively. He required thoracotomy for fistula closure but he was judged to not be capable of tolerating surgery due to his poor general condition. Therefore, we created a jejunostomy under general anesthesia to improve his nutritional state. However, postoperatively his respiratory condition worsened rapidly and he died.

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A 52-year-old man complaining of appetite loss and abdominal distention was admitted to our hospital because of advanced carcinoma in the lower thoracic esophagus and a solitary giant tumor about 75mm in diameter around the lesser curvature of the stomach. Abdominal angiography showed displacement and narrowing of the splenic artery and vein due to the tumor. The most likely diagnosis was advanced esophageal cancer with solitary giant lymph node metastasis at the lesser curvature of the stomach. Right thoraco-laparotomic subtotal esophagectomy and resection of the giant abdominal tumor were performed by Appleby's procedure, followed by reconstruction of the esophagus using a gastric tube. The pathological diagnosis was poorly differentiated squamous cell carcinoma (type3, t3, ly1, v0, n2, 3.4×2.3 cm in diameter) with an abdominal lymph node metastasis about 90 mm in diameter. Eight days after the operation, major leakage of the anastomosis in the thoracic and right-sided pyothorax occurred. But the postoperative complications subsided eventually by conservative treatment with thoracic and gastrointestinal drainage. There has been no evidence of recurrence for 7 years after the operation. We report this case and a review of the relevant literature.

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We report a case of an unruptured aneurysm of the right gastroepiploic artery in a 56-year-old woman, who complained of constant abdominal pain. Abdominal CT showed an intramesenteric hematoma in the ventral side of the left kidney and an aneurysm of the right gastroepiploic artery. Since her abdominal pain had not improved, the hematoma was removed, and the unruptured aneurysm of the right gastroepiploic artery was resected laparoscopically. On pathology, the aneurysm was found to be caused by segmental arterial mediolysis. An aneurysm of the gastroepiploic artery is rare ; many of the cases are diagnosed after they rupture. However, recently the number of cases found incidentally on ultrasonography or abdominal CT is increasing. There are no recognized indications related to surgery for an aneurysm of the gastroepiploic artery. However, resection of the aneurysm laparoscopically is minimally invasive, safe, and therefore can be recommended.

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A 47-year-old woman was referred to our hospital because of a gastric submucosal tumor which had increased in size during a one-year observation period. The tumor (40 mm in diameter) was observed at the greater curvature of the middle part of the gastric body. Gastric schwannoma was preoperatively diagnosed by endoscopic ultrasound-guided fine needle aspiration biopsy. A laparoscopic partial gastrectomy was performed. Histopathological examination revealed spindle-shaped cells arranged in palisades. Mitotic figures were rare. The specimen was positive for S-100 protein, but negative for desmin, α-SMA, c-kit and CD34. Based on these findings, the tumor was diagnosed as a benign gastric scbwannoma. The postoperative course was uneventful. The patient remains alive without recurrence. Laparoscopic partial gastrecromy is thought to be an appropriate treatment for gastric schwannoma.

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A 68-year-old man was referred to our hospital with a diagnosis of gastric cancer. Gastrointestinal endoscopic examination showed a type3 tumor which had indiscrete border at the posterior wall of the gastric upper body. Abdominal CT scan showed swelling of multiple lymph nodes on the lesser curvature side and para-aortic lymph node swelling which appeared to be lymph nodes metastases, as well as a tumor about 2cm in size which appeared to be liver metastases in the S3 of liver. Therefore, we diagnosed the case as gastric cancer T2N3H1M0, StageIV. He was initially treated with 2 courses of TS-1+cisplatin. After the second course, abdominal CT scan showed remarkable shrinkage of lymph node swelling on the lesser curvature side, and disappearance of para-aortic lymph node swelling. We thus performed total gastrectomy+lymph node dissection (D3)+S3 partial hepatectomy. Histological findings showed no residual tumor cells in the primary gastric lesion and lymph nodes. The primary gastric lesion and lymph nodes were evaluated Grade3 as the effect of the preoperative chemotherapy. The patient has been recurrence-free as of 12 months after the operation.
It seems that neoadjuvant chemotherapy can provide improvement of the prognosis even for advanced gastric cancer.

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A 54-year-old man was admitted to our hospital with abdominal pain and vomiting. Abdominal CT scan showed retroperitoneal air and a low density area between the duodenum and the pancreatic head. Perforation of the duodenal diverticulum was diagnosed, and an emergency operation was performed. Laparotomy with a Kocher maneuver disclosed a retroperitoneal abscess behind the 2nd to 3rd portion of the duodenum ; however, there was no clear evidence of a diverticulum.
Retroperitoneal drainage was performed. After surgery, upper gastrointestinal imaging revealed a diverticulum on the 2nd portion of the duodenum. We report a case of a perforated duodenal diverticulum diagnosed by CT scan before surgery.

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A 63-year-old female presented with right upper quadrant pain. Computed tomography of the abdomen showed retroperitoneal gas on the dorsal aspect of the duodenum. Acute abdomen due to duodenal perforation was the most likely diagnosis and emergency laparotomy was performed. A perforated duodenal diverticulum was found in the descending portion of the duodenum. After the diverticulum was covered with the greater omentum, a tube was placed through the wall of the stomach to decompress the duodenum. Thereafter re-perforation occurred, but continuous drainage from the decompression tube of the duodenum was successful. Perforation of the duodenal diverticulum is a rare complication and we have great difficulties in diagnosis and treatment. It is important to select a reasonable surgical procedure considering possible postoperative complications.

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The patient was a woman in her sixties who had received radiation therapy for cancer of uterine cervix 7 years earlier and had been suffering from diarrhea for these several years. The patient was seen at our emergency clinic because of a 5 hour-history of lower abdominal pain at the beginning of July 2010. An abdominal CT scan showed free air and ascites. A high density structure 1.5 cm in size was identified within the small intestine, but its relation with the perforation was obscure. Emergency operation was done with the most likely diagnosis of intestinal perforation and general peritonitis. When the lower abdomen was opened by midline incision, about 200 ml of cloudy ascites was observed and the ileum became white in color and hard resulting from the radiation therapy. A perforation was identified in the ileum about 15 cm distant from the ileocecal valve, and a 1.5-cm sized thin and hard material was palpated within the intestine at the same portion. Ilececal resection including the perforated portion was performed and functional end-to-end anastomosis was made at a grossly normal area. There was a piece of eggshell 1.5-cm in size in the perforated portion in the resected specimen. From this together with histopathologial findings, perforation of the small intestine caused by a piece of eggshell associated with radiation enteritis was finally diagnosed.
Small bowel perforation must be kept in mind as a possible late complication of radiation therapy, however, no cases of small bowel perforation caused by eggshell have been reported so far. This rare case is reported here, with a review of the literature.

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We present a six-year-old boy with HSP who was treated with steroids, factor 13 preparation, urinastatin, and steroid pulse therapy. However, the purpura, abdominal pain and melena gradually worsened, and renal dysfunction appeared. Steroid pulse therapy and steroid administration were repeated, and his symptoms and inspection values improved temporarily. However, abdominal pain recurred on the 24^th day after onset, and emergency surgery was necessitated by gastrointestinal perforation the next day. Necrosis and a punch at the ileum 90cm to 40cm from the Bauhin valve were observed. We excised this part and anastomosed the cut ends. Histopathological examination revealed little evidence of either an unusual thrombus or vasculiti of HSP. CMV inclusion was shown by HE staining. CMV was confirmed by immunohistochemistry. CMV antigenemia was positive, and CMV enteritis was proven to be the cause of the small-bowel perforation.

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We report a rare case of intestinal perforation associated with dialysis-related amyloidosis. A 61-year-old woman who had been receiving hemodialysis for 31 years required surgery for perforative peritonitis. A 1-cm perforation located in the ileum 20 cm proximal to the ileocecal junction was found. A partial resection of the ileum and an ileostomy were performed. On pathology, an amyloid deposit in a perivascular area of the submucosal layer was found ; Congo-red staining was positive. The patient was diagnosised as having dialysis-related amyloidosis. When panperitonitis is encountered in long-term hemodialysis patients, intestinal perforation due to dialysis-related amyloidosis should be considered in the differential diagnosis.

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This paper deals with a case of Crohn's disease (CD) in which an enterovesical fistula which had been formed 23 years earlier developed to be advanced cancer. The patient was a 52-year-old man who had been diagnosed as having CD including the small intestine and the colon at the age of 29. At the same time he was pointed out a vesicle fistula as well, but he refused surgery. Thereafter he had been treated with nutritional therapy and administration of 5-ASA preparation until recently (52 years of age) when he was found having a rectum-bladder-ileum fistula and hematurea. A biopsy of the cystic wall offered a diagnosis of mucinous adenocarcinoma. We thus performed ilectomy, Hartmann operation, sigmoid colostomy, and cystoprostatectomy with the diagnosis of enterovesical fistula caused by CD and carcinoma arisen from the fistula. It revealed that the terminal ileum, the bladder, and the rectum had formed a mass and communicated via the fistula. The histopathological diagnosis was also mucinous adenocarcinoma, and it was likely that the carcinoma arisen in the fistula invaded especially toward the bladder. After discharge from the hospital, he was treated with chemotherapy but died of cancer 6 months after the operation.
Although a risk of entailing carcinogenesis of internal fistula in CD patients is still unknown, we consider that surgery must actively be selected for internal fistula because there have been some cases in which cancer change of the fistula occurred like this case.

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A 68-year-old man developed a fever and abdominal pain. He was referred to the Department of Surgery from the Department of Internal Medicine due to a provisional diagnosis of an intra-abdominal tumor. The laboratory data showed anemia and a high C-reactive protein (CRP) level ; the abdominal CT scan showed an 8×7×5 cm-sized tumor and intra-abdominal fluid. No abnormal findings were found on endoscopy. The patient was operated on under a diagnosis of rupture of an intra-abdominal tumor. At surgery, about 300 ml of bloody ascites was found in the abdominal cavity and a protruding tumor in the ileum located about 180 cm from the terminal ileum. Some clots were attached to the tumor, and a small amount of hemorrhage was observed. Thus, the tumor was determined to be the bleeding source ; partial resection of the small intestine including the tumor was performed. On immunohistochemical staining, a positive reaction only to c-kit was noted. Intra-abdominal bleeding due to rupture of a gastrointestinal stromal tumor of the small intenstine was diagnosed. After the operation, the patient was treated with imatinib mesylate 400 mg/day. The patient is doing well, 3 years after surgery.

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The patient was a 76-year-old man. A follow-up CT scan after radiation therapy for laryngeal cancer revealed 2 slightly enhanced nodules in the small bowel mesentery, and a small bowel tumor was suspected in February 2009. Double balloon endoscopy and capsule endoscopy showed multiple small bowel carcinoid tumors. No tumors were discovered in other intestines by intraoperative endoscopy, and a 60cm-long ileum was resected with lymph node dissection. The resected specimen showed a total of 15 carcinoid tumors with the diameter of 2 ∼ 10mm and 2 lymph node metastases. He has been disease free, as of 14 months after the surgery. Small bowel carcinoid tumors often develop in multiple lesions, and so intraoperative endoscopy is useful for deciding resection range of the intestine.

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A 77-year-old man had a left lower lobectomy by video-assisted thoracoscopic surgery for left lung cancer about 8 months prior. On pathology a pleomorphic carcinoma (pT1N0M0 pStage IA) was finally diagnosed ; the patient was followed. He was admitted when he developed vomiting ; abdominal computed tomography (CT) revealed an intussusception of the small bowel. An intussusception due to a tumor of the small bowel was suspected and a laparotomy was performed. A 20-cm long jejunojejunal intussusception was found ; a tumor was found at the tip of the intussusception. A partial resection of the jejunum was performed. On pathology, the tumor was diagnosed as a metastasis of the pleomorphic carcinoma. The patient was discharged 10 days after the operation. Two months later, he complained of pain in the right groin area, pelvic CT showed a recurrence of the carcinoma in the right pelvic cavity that had invaded into the right piriform muscle and right internal obturator muscle. The tumor decreased in size with radiation therapy. Pleomorphic carcinoma of the lung is quite rare. This case is only the 3^rd case of intussusception due to small bowel metastasis reported in the English language and Japanese literature to date.

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A 57-year-old woman was admitted with right lower abdominal pain and fever. CT images showed a 5×4 cm irregular mass arising from the cecum and a right hydronephrosis. Colonoscopic examination showed a tumor, 15 mm in diameter, located at the orifice of the appendix. However, on pathology, no evidence of malignancy was found. A right hemicolectomy combined with a right nephrectomy and oophorectomy was performed, since it was thought that the tumor was an appendiceal cancer that had invaded the right ureter and right ovary. On pathology, only xanthogranulomatous change in the appendix was diagnosed. Although there are many reports of xanthogranulomatous change occurring in the gallbladder and kidneys, there are few reports of xanthogranulomatous change occurring in the appendix. Therefore, we report this case of xanthogranulomatous appendicitis that was difficult to differentiate from appendiceal cancer.

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We report a case of rectal perforation with transanal colon prolapse.
An 87-year-old woman was admitted for prolapse of the colon through the anus. Under a diagnosis of perforation of the rectum, the patient underwent emergency surgery. There was no contamination in the peritoneal cavity on laparotomy. The torn region was at the rectosigmoid located on the oral side from the peritoneal reflection and sigmoid colon prolaps to the anus occurred through this torn site. We conducted Hartmann's operation. Her postoperative course was good and she was discharged after rehabilitation.

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A 49-year-old woman was admitted to our hospital because of nausea, vomiting and abdominal distension. There was a past history of undergoing total hysterectomy for uterine myoma. Abdominal CT examination revealed an enhanced irregularly shaped mass lesion in the Rs-rectum and confirmed bowel obstruction. Barium enema and colonoscopy revealed stenosis of the rectum with a submusosal tumor. Thes, we performed a laparotomy. Operative findings were a tumor located in the rectum with severe adhesion to other adjacent organs and the pelvis. Low anterior resection with lymph node dissection was performed. The postoperative course was uneventful. The resected specimen revealed endometrial tissue with the stroma in the submucosal and muscular layers of the rectum. In addition, endometrial tissue involved in a metastatic pararectal lymph node (#251). These findings suggested that the tumor in our case might have malignant potential, like endometriosis-associated intestinal tumors (EAIT).

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A 69-year-old male was admitted to our hospital for abdominal pain and diarrhea, and subsequent laboratory examination revealed the presence of severe anemia. Gastrointestinal fiberscopy revealed a mass associated with a deep ulcer in the second portion of the duodenum which was subsequently diagnosed as adenocarcinoma on endoscopic guided biopsy. Upper gastrointestinal series revealed a fistula between the duodenum and the colon, and the patient was referred to our department for surgery. Pancreaticoduodenectomy and right hemicolectomy were subsequently performed. No foci of carcinoma metastasis were detected in the regional lymph nodes of the colon with an exception of the superior lymph node on the posterior surface of the pancreatic head in which small focus of adenocarcinoma metastasis was detected. There have been no clinical signs of recurrence and the patient is alive without disease as of 8 years and 10 months after the operation. Long-term survival of the patients may be feasible providing that en block resection including lymph node dissection is performed.

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A 80-year-old woman was diagnosed as having sigmoid colon cancer. She underwent an operation. Eight months after the operation, her general condition worsened. CT scan and colonoscopy done 1 year postoperatively revealed no metastasis or recurrence. However, tumor marker (CEA and CA19-9) levels were high. At about the same time, the patient developed diabetes mellitus (DM) for which she was treated. With DM treatment, the tumor marker levels returned to normal. It was suspected that the false-positive tumor marker levels were due to the presence of untreated DM.

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We report a case of rectal cancer with a recurrence in the anal canal 9 cm from the primary lesion. A 74-year-old man underwent a laparoscopic Hartmann operation for rectal cancer. Six months after the operation, he was seen in our hospital because of proctorrhagia ; a type 1 tumor, 12 mm in diameter, was observed on the dentate line in the anterior wall of the anal canal. On pathology, an adenocarcinoma was diagnosed. The remaining rectum and anus were resected. On histopathology, an adenocarcinoma located at the submucosal layer was observed ; no atypical epithelium was present around the tumor. The tumor was diagnosed as a metastasis of the primary rectal cancer via tumor implantation or intramural metastasis. Metastasis to the anal canal 9 cm from the primary lesion is thought to be rare. This case will have meticulous follow-up.

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The case involved a 79-year-old man who underwent low anterior resection for rectal cancer in May 2001, and partial resection of the lung for recurrent lung metastases in February 2004, March 2004 and June 2005, followed by adjuvant chemotherapy. The plasma CEA level began to be elevated in October 2005. He had been followed carefully until June 2008 when he was admitted to the hospital because left upper abdominal pain developed. Abdominal CT scan showed a mass in the pancreas tail. Metastatic pancreatic cancer was diagnosed and we perfomed disatal pancreatectomy, splenectomy and partial gastrectomy.
The 2-cm tumor was shown histologically to be well differentiated adenocarcinoma, which was identical to the rectal cancer and metastatic foci in the lung and was negative for cytokeratin 7 and positive for cytokeratin 20. Accordingly metastasis to the pancreas from rectal cancer was diagnosed.
Although metastasis to the pancreas from colorectal cancer is rare, several cases have shown that multi organ metastasis during the course of the disease usually carries a poor prognosis. We present this case with a review of other 27 cases reported in the literature.

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A 76-year-old man was admitted to our hospital for constipation and lower abdominal pain. Colonoscopic examination revealed rectal cancer (pathological examination of a biopsy specimen revealed moderately differentiated adenocarcinoma). Although he had multiple liver and lung metastases, the rectum was mostly obstructed due to rectal cancer, and we performed laparoscopic anterior resection and lymph node dissection (D2). Before starting chemotherapy, lumbago and coxalgia appeared, and blood examinations revealed disseminated intravascular coagulation syndrome (DIC). Detailed examinations revealed disseminated carcinomatosis of bone marrow. He died on the 26^th day after the onset of DIC.
Dissminated carcinomatosis of bone marrow with rectal cancer is rare. If therapy for DIC is not effective, the prognosis is very poor. There are some cases surviving with chemotherapy for this disease. Therefore, it is necessary to consider the treatment for this disease with accumulation of more case reports.

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A 77-year-old woman developed epigastric pain. She was diagnosed as having cholecystolithiasis at other clinic and referred to our hospital for surgery. We electively performed a laparoscopic cholecystectomy. An enlarged lymph node was found by the gallbladder neck and was also resected. On pathology, Langhans giant cells, a granuloma consisting of epithelioid cells with caseation necrosis were found in the lymph node, and tuberculous lymphadenitis was diagnosed. On chest and abdominal CT, no abnormalities were found ; tubercle bacillus was not identified in the sputum. A 4-drug antituberculous regimen (isoniazid, rifampicin, ethambutol, and pyrazinamide) was given postoperatively.

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We report a case of laparoscopic cholecystectomy in a patient with situs inversus totalis. A 65-year-old man was admitted to hospital because of symptomatic multiple gallstones. Abdominal ultrasonography and computed tomography (CT) confirmed the diagnosis of cholecystolithiasis, as well as situs inversus totalis with the liver and the gallbladder located on the left side. Three dimensional CT did not visualize the gallbladder. A cholecystectomy was performed laproscopically. A 12-mm trocar was inserted through an infra-umbilical incision. Two 5-mm trocars were placed in the upper midline and the left anterior axillary line, respectively. A 12-mm trocar was inserted 7 cm below in the left subcostal midclavicular line to maintain an appropriate distance from the upper midline trocar. The laparoscopic cholecystectomy was carried out without any complications. The postoperative course was uneventful, and the patient was discharged on the second postoperative day. A double-handed technique, in particular involving left-hand manipulation is crucial when doing a laparoscopic cholecystectomy in a patient with situs inversus totalis.

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A 61-year-old woman was diagnosed, 8 years prior, as having a solitary hepatic cyst with septum formation on abdominal echography. During the previous 8-year period, the patient was followed by echography ; no particular changes were noted. However, she developed abdominal distention. Computed tomography (CT) revealed a solitary multilocular cyst with papillary proliferation in segment S3 of the liver. Endoscopic retrograde cholangiopancreatography revealed an abundance of mucin in the intrahepatic bile duct. The diagnosis based on cytology was adenocarcinoma. A left hepatic lobectomy with lymph node dissection was performed ; on pathology was a diagnosis of a pancreatobiliary type of intraductal papillary neoplasm of the bile duct (IPNB) was made. The differential diagnosis of a suspected solitary hepatic cyst should include IPNB. Patients with a solitary hepatic cyst should have appropriate follow-up care so that surgery can be performed in a timely manner if necessary.

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We report a 61-year-old Japanese male with a cholangiolocellular carcinoma. Abdominal enhanced computed tomography demonstrated an S7-liver tumor, about 45 mm in maximal diameter. CT examinations showed enhancement in the peripheral area in the early phase and prolonged enhancement in the delayed phase. The lesion was depicted as a hypoechoic nodule by ultrasonography. The tumor was seen as a hypointense nodule in the hepatobiliary phase of Gadoxetic acid disodium-enhanced liver magnetic resonance imaging. Upon confirmation of the diagnosis of intrahepatic cholangiolocellular carcinoma, S7 segmentectomy of the liver was performed. Microscopically, the tumor was composed of dense proliferation of small irregular tubules with fibrous stroma. Immunohistochemistry showed the carcinoma cells to be positive for EMA, NCAM, CK-7 and CK-19, EMA was strongly positive on the luminal surfaces of tubules. These findings are typical characteristics of cholangiolocellular carcinoma.

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Polysplenia syndrome is a very rare congenital disease complicated by variable combinations of thoracic and abdominal anomalies. We report a case of common bile duct cancer with polysplenia syndrome.
The patient was a 48-year-old woman admitted to our hospital for management of common bile duct cancer and duodenal stenosis. Subtotal stomach-preserving pancreaticoduodenectomy was performed.
Preduodenal portal vein, congenital absence of the pancreatic tail, and polysplenia were noted at operation. Moreover, inspection after the operation revealed absence of the hepatic portion of the inferior vena cava with azygos continuation and a dilated azygos vein.
Post operatively, infectious thrombosis developed due to infection of the central venous catheter of the right femoral vein, and antibiotic and anticoagulant therapes were administered. Pathologically, early common bile duct cancer associated with pancreatobiliary anomaly was diagnosed.

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A 42-year-old woman was emergently admitted to the hospital because of epigastralgia lasting for a day. We confirmed peritoneal irritation sign on the upper abdomen during the first examination. Furthermore, abdominal CT scan showed a heterogeneous tumor with partial calcification and ascites in the pelvis. We performed laparotomy with a suspected diagnosis of dissemination of a malignant tumor or a submucosal tumor of the stomach, or an intraperitoneal abscess with panperionitis. Intraoperative findings revealed a palpable tumor on the greater curvature of the stomach in contact with the pyloric ring. The tumor was 10 cm in diameter with an edematous appearance and indistinctive margin which firmly adhered to the stomach. Thus, we removed the tumor with a part of the stomach. Pathological examination showed the heterotopic pancreas with exocrine glands and ducts and the islets of Langerhans. The final diagnosis was heterotopic pancreas of Heinrich type I.

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The patient was a 68-year-old woman who received transcatheter arterial chemoembolization (TACE) for multiple metastatic lesions in the liver originated from endocrine carcinoma of the pancreatic body and tail in September 2002. Because a favorable locoregional tumor control in the liver had been achieved, the patient underwent distal pancreatectomy for the primary pancreatic lesion 3 months after the TACE. After distal pancreatectomy, the patient additionally received 3 further TACEs for the treatment of tumor relapses in the liver. A rapidly growing tumor in the left chest wall, which was diagnosed as a metastatic lesion of pancreatic endocrine carcinoma by fine needle aspiration biopsy, was identified and resected including the 3rd, 4th and 5th ribs in July 2009. The patient remains alive as of 96 months after the initial diagnosis of pancreatic endocrine carcinoma with multiple liver metastases.
This case report serves to emphasize that aggressive multimodal treatment for pancreatic endocrine carcinoma potentially offers a long-term survival even in cases with concurrent distant metastases. Although the chest wall metastasis is considered as a rare form of metastasis arising from pancreatic endocrine carcinoma, this unusual metastatic disease also needs to be kept in mind from the viewpoint of long-term follow up for the patient with pancreatic endocrine carcinoma.

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The patient was a 78-year-old woman who was found having a 3-cm sized tumor at the pancreas head which was diagnosed as an intraductal papillary mucinous neoplasm (IPMN) of branch ducts in April 2003. Thereafter she had been followed in the clinic until May 2006, when she was admitted to the hospital because of lower abdominal pain and slight fever. An abdominal CT scan showed enlargement of the tumor and developement of a solid lesion in the cyst. ERCP revealed moniliform dilatation of the main pancreatic duct and a filling defect in the cyst which seemed to be a solid component. Intraductal ultrasonography showed a solid tumor in the cyst, and a biopsy of the tumor indicated IPMN with moderate dysplasia. Five days after ERCP, the patient developed obstructive jaundice, so that an ERBD tube was placed. After relief of obstructive jaundice, pancreatoduodenectomy was performed. Postoperatively a fistula about 1cm in diameter between a cyst and the common bile duct was disclosed in the sargical specimen. Histopathological study showed no tumor cells at the fistula.
It is known that IPMN can sometimes penetrate the adjacent organs. This paper presents a case of IPMN of the pancreas which formed a pancreatic cyst and a common bile duct fistula and developed obstructive jaundice.

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An internal hernia via a defect in the broad ligament of the uterus is extremely rare. A resection of the intestine during an open procedure is performed in most cases because of the difficulty in making a pre-operative diagnosis. We present a patient that was diagnosed as having an internal hernia via a defect in the broad ligament of the uterus on computed tomography (CT) and was subsequently treated successfully laparoscopically.
The patient was a 47-year-old female. She was admitted to our hospital due to abdominal pain and vomiting. Conservative therapy with a naso-intestinal tube was not effective. Imaging following the introduction of contrast from the tube into the small intestine revealed a stricture in the small intestine at the base of the pelvic cavity. CT showed a stricture in the small bowel caused by the supportive tissue on the right side of the uterus. Given a diagnosis of an internal hernia via a defect in the broad ligament of the uterus, a laparoscopic hernia reduction was successfully performed. The postoperative course was uneventful, and the patient was discharged five days after the operation.

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A 33-year-old man had been diagnosed with congenital antithrombin (AT)-III deficiency as a grade-schooler. He was admitted to another hospital for pulmonary embolism and deep vein thrombosis in January 2009. Anticoagulant therapy with warfarin was discontinued in August 2009 because of poor compliance. In November 2009, he was admitted to our hospital because of abdominal pain. Enhanced computed tomography (CT) showed segmental infarction of the ileum as welll as thrombosis of the superior mesenteric, portal and splenic veins. AT-III activity was low at 46% of normal. An emergency laparotomy was performed, and segmental intestinal infarction was detected. We resected the necrotic intestine and constructed an ileostomy. He was administered anticoagulant therapy comprised of AT-III, heparin and warfarin. The ileostomy was closed 3 months after the operation. No venous thrombosis was observed during the post-operative course of anticoagulant therapy with warfarin. In cases of acute superior mesenteric vein thrombosis associated with congenital AT-III deficiency, early surgical treatment and anticoagulant therapy are the most important treatments.

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Primary leiomyosarcoma of the mesentery is relative rare. To date, 9 cases with this disease diagnosed immunohistologically, including our present case, have been reported in Japan. We describe an immunohistologically diagnosed case of primary leiomyosarcoma of the small intestinal mesentery recently encountered at our facility. The patient was a male in his 70s. In June 2009, he visited the Department of Internal Medicine of our hospital, with a chief complaint of abdominal flatulence. A giant mass was palpable in the hypogastric region. Abdominal CT scans revealed a mass approximately 120 mm in size within the pelvis. Based on test results, a non-epithelial malignant tumor of retroperitoneal or mesenteric origin was suspected and the patient underwent surgical tumor resection. The tumor was found to have developed in the small intestinal mesentery, with subsequent invasion of the small bowel and urinary bladder. Histopathologically, spindle cells with intensely eosinophilic cytoplasm formed a complex array of bundles. The tumor cells were immunohistologically shown to be α-SMA and desmin positive and tested negative for c-kit, CD34 and S-100, thus allowing a diagnosis of leiomyosarcoma.

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A 60-year-old female with a tumor suspected to be a retroperitoneal fibrosarcoma underwent tumorectomy with left nephrectomy and left adrenal ectomy in October of 1988. CT scan showed local recurrence in the retroperitoneal space in November of 2003. Therefore, the tumor was removed with the spleen and transverse colon. The patient complained of dysphagia in May of 2008. CT scan showed that the tumor had spread from the retroperitoneal space to the mediastinum. We resected the tumor through a thoracoabdominal approach. The pathological diagnosis was a dedifferentiated liposarcoma. Retroperitoneal tumors have a variety of histopathological features. As a stem cell becomes differentiated, the retroperitoneal tumor may show a number of histological features. As there is little evidence of the effectiveness of various adjuvant treatments, such as chemotherapy and radiotherapy, aggressive resection should be carried out. We present a rare case with dedifferentiated retroperitoneal liposarcoma. This patient survived long-term with multiple resections.

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A 51-year-old woman was admitted to our hospital for detailed examination and medical treatment of a left inguinal bulge. On palpation, a 4cm in diameter, elastic soft and movable mass was felt in the left inguinal region. Abdominal computed tomography showed a heterogenous, sharply demarcated iso-dense area. Although a definite diagnosis could not be made preoperatively, we performed surgery. Intraoperative findings revealed a hematoma-like tumor in the left inguinal canal. The tumor adhered to the left round ligament of the uterus. The resected specimen had a smooth surface. The tumor was grayish-white and solid. Immunohistochemical staining was positive for HMB-45 and actin. A diagnosis of perivascular epithelioid cell tumor was confirmed. The patient's postoperative course was uneventful. She was discharged on the 2nd postoperative day. Ten months after the operation, to date no recurrence has been observed. We present this case with a review of the literature.

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The case of a 59-year-old man who had been diagnosed with right inguinal hernia and had frequently experienced protrusion in the right inguinal area but managed to reduce the hernia by himself each time is described. In late October, 2008, the patient manually reduced another hernia in the right inguinal area, but he subsequently developed abdominal pain that gradually worsened. Therefore, he visited a local physician the next day, was diagnosed as having ileus, and was referred to our hospital. On examination, no protrusion was observed in the right inguinal area, and although spontaneous pain and tenderness were present in the lower abdomen, no peritoneal irritation was seen. Abdominal plain X-ray showed dilation of the small intestine, and abdominal CT showed dilation of the intestinal tract in the right lower quadrant, but no prolapse of organs outside the abdominal wall in the right inguinal area was observed. The patient was treated conservatively, but since the ileus appeared to worsen on abdominal plain X-ray the next day, conditions such as internal hernia and strangulation by bands were suspected, and emergency laparotomy was performed. Examination of the abdominal cavity revealed a hernia sac that invaginated into the abdominal cavity side in the right inguinal area, in which the small intestine was incarcerated. This is a rare type of incarceration called reduction en masse.

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A 78-year-old man was referred to the hospital because of epigastralgia. Gastric endoscopy revealed an elevated lesion at the upper portion and another elevated lesion at the antrum of the stomach, of which biopsies indicated poorly differentiated adenocarcinoma and well differentiated adenocarcinoma at the upper portion and at the antrum, respectively. The depth of tumor invasion was determined to be shallower than MP in both lesions. An abdominal CT scan revealed no metastases to the other sites as well as lymph nodes, but did the presence of gallstone. Multiple gastric cancer and gallbladder stone were diagnosed, and laparoscopic-assisted total gastrectomy, D2 dissection, and cholecystectomy were performed. Histopathological diagnosis of the lesion at the upper portion of the stomach was small cell carcinoma of the stomach because the tumor cells were positive for CD56, synaptophysin, and chromogranin A ; and that of the antrum lesion was well differentiated adenocarcinoma. The gallbladder lesion was well differentiated adenocarcinoma. His postoperative course was uneventful and he was discharged from the hospital on the 23rd day after the operation.
Small cell carcinomas of the stomach reportedly account for about 0.06%-0.2% of all gastric cancers. Furthermore, multiple occurrence of this malignancy has been reported in only eight cases, including those of multiple cancers in the same organ. The prognosis of such patients might be determined by the progress of small cell carcinoma of the stomach, though influence of the associated malignancy could not be neglected.

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