Purpose : In clinical breast imaging practice, breast ultrasonography (US) is essential, but US is operator-dependent and weak in objectivity. Automatic breast volume scanning is one of techniques that have been developed to overcome these US's weak points. The purpose of this study was to assess the detectability of breast cancer using the automated breast volume scanner (ABVS) in comparison with those using mammography and hand-held US.
Materials and Methods : We enrolled consecutive 30 patients with histopathologically confirmed breast cancer out of 324 patients who underwent mammography, ABVS and hand-held US. The detectability and assessment category of the lesions using ABVS were compared with those using mammography and the hand-held US.
Results : The histopathologic types of malignancy were invasive cancer (invasive ductal carcinoma, 19 ; invasive lobular carcinoma, one ; and mucinous carcinoma, one) in 21 patients, and ductal carcinoma in situ in nine patients. All the breast cancers were visualized and evaluated by both hand-held US and ABVS as Category 4 or higher lesions, whereas four lesions were interpreted as Category 1 or 2 on mammography.
Conclusion : The present study has indicated a possibility of ABVS to be a diagnostic procedure that is by no means inferior to hand-held US in detecting breast cancer.

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Background : It has been believed that there is some difference in underlying hepatic diseases of hepatocellular carcinoma (HCC) between Okinawa (our hospital) and the mainland of Japan. Hepatitis C virus (HCV)-related HCC represents 75% of all HCC in Japan. Negative virus markers for either hepatitis B virus (HBV) or HCV (nonBnonC) are recognized from 5 to 10%. The purpose of this study is to determine the distribution of underlying hepatic diseases of HCC in our hospital. Methods : A total of 114 patients diagnosed as having HCC from January 2001 to September 2010 were enrolled. The distribution of underlying hepatic diseases was examined. Results : HCV related HCC represented 33.3% of all HCC in our hospital. NonBnonC represents 50.9%. In the latter term (2006-2010), some cases of non-alcoholic steatohepatitis (NASH) were seen, while cases of HCV related HCC decreased. In the cases undergone hepatic resection, nonBnonC HCC cases represented 62.5%, including alcoholic liver disease related HCC cases that accounted for 29.2%. Conclusion : The distribution of underlying hepatic diseases of HCC patients in our hospital was different from that in the Mainland of Japan.

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Herein, we present 7 patients with diabetic mastopathy. All 7 patients were women, with durations of diabetes mellitus (DM) treatment ranging from 7 to 20 (average 16.6) years. Disease was bilateral in 5 cases, and unilateral in 2, for a total of 12 lesions. In all cases, examination revealed hard breast masses, but mammography revealed no abnormal findings. Ultrasonography of all lesions showed hypoechoic masses. Marked posterior acoustic shadowing was present in 10 lesions in 6 women. Magnetic resonance imaging (MRI) was performed for 9 lesions, of which 5 showed enhancement in the delayed phase, so malignancy could not be excluded. Core needle biopsies were performed for 11 lesions, in all cases yielding the diagnosis of mastopathy. We diagnosed all cases as having diabetic mastopathy based on their past history, physical examination and imaging. It is important that we ask patients presenting with breast lesions about their past history, especially DM, because this information is helpful for diagnosing diabetic mastopathy, in combination with MRI findings and the presence of bilateral masses.

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A rare case of paraneoplastic cerebellar degeneration caused by breast cancer is reported with a review of the literature. The patient was a 66-year-old female, whose first symptom was a floating sensation while walking. There were no abnormal findings on brain MRI or neck ultrasonography. Two weeks after her visit, She developed a walking disturbance, then became unable to eat because of severe nausea. She was referred to our hospital. Precise examination revealed no endocrinological or metabolic disease, infection or toxic symptoms. Brain neoplasms were also ruled out. However, right axillary lymph node swelling was detected on chest enhanced CT, indicating metastatic lymph nodes of right breast cancer. The walking difficulty seemed to have arisen from paraneoplastic cerebellar degeneration due to the right breast cancer. Total mastectomy with axillary dissection was performed. Anti-Yo antibody was found in her sera after surgery.

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A 67-year-old female underwent right hemicolectomy for an ascending colon cancer in 2007. Macroscopically, the tumor was type-2, and 5.5 cm in length. Histopathological examination revealed moderately differentiated tubular adenocarcinoma invading the subserosa with lymphnode metastases (pN2), lymphatic invasion (ly3), and venous invasion (v1). Twenty-five months after the operation, she had left-sided hemiparalysis. Magnetic resonance imaging of the brain revealed a ring enhanced lesion 19 mm in diameter in the right parietal lobe, which was diagnosed as a solitary brain metastasis, without any other systemic metastatic lesions. The brain tumor was surgically removed. The resected specimen was diagnosed as metastatic adenocarcinoma from the colon cancer because of the similar histological characteristics. After the craniotomy, she underwent whole brain radiation therapy of 40 Gy. She has survived 20 months so far without any further evidence of recurrence. Most patients with brain metastasis from colorectal cancer have multiple brain lesions and/or metastasis of other organs, and their prognosis is poor. However, there are some reported cases who had a solitary brain metastasis and survived a long time. The brain should be considered as one of the metastatic organs during recurrence surveillance.

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The patient was a 48-year-old woman who underwent segmental mastectomy and axillay lymph node dissection for right breast cancer at the age of 34, when the pathological diagnosis was noninvasive ductal carcinoma, TisN0M0 and Stage 0. Postoperative radiation therapy was performed, but chemotherapy as well as hormone therapy was not done. Thereafter no findings of recurrence had been seen for three years. She had received once-a-year mammography since the age of 44 until 48, when grouped multiform calcifications appeared and the fine-needle aspiration cytology resulted in Class V. Core needle biopsy at our center provided the diagnosis of invasive ductal carcinoma. No metastatic foci were identified other than the local recurrence. Right mastectomy was thus performed. The histopathological diagnosis was invasive ductal carcinoma (scirrhous carcinoma), and extended lymphatic invasion involving the skin was identified. The patient has been on postoperative chemotherapy (FEC+docetaxel) and postoperative hormone therapy (tamoxifen) and has been free from recurrence up to now.
The patient had lymphatic invasion of the skin without associating with inflammatory change of the skin that is considered as occult inflammatory breast recurrence.

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A 52-year-old woman was admitted to our hospital for right breast cancer. She had been followed for extreme tetralogy of Fallot Aortopulmonary shunt had been performed at age 21 years. Pulmonary circulation was maintained for the bypass and collateral perfusion from the aorta to pulmonary vessels. Right breast cancer was diagnosed as invasive ductal carcinoma, T1cN0M0 by fine needle biopsy, MRI, CT and bone scintigraphy. The NYHA classification of her cordiac condition was II. Blood gas analysis showed pH 7.36, PaO₂ 46 torr, PaCO₂ 46 torr and SpO₂ 75% on room air. Deciding the treatment plan was difficult due to her severe congenital heart disease. We decided to perform the operation based on the patient's performance status, her request and the anesthesiologist's advice. Mastectomy was performed under general anesthesia allowing spontaneous breathing to maintain the pulmonary circulation. She remains alive, without recurrence for more than one year to date since the operation. Long-term survival of cases with extreme tetralogy of Fallot is rare, and the Long-term this case with combined breast cancer is very rare.

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A 66-year-old woman was referred to our hospital with a palpable tumor measuring 2.5×3.2 cm in the CD area of the right breast. Ultrasonograpy revealed a low echoic lobulated mass with posterior echo enhancement. Mammography revealed a lobulated, high density mass with defined border and segmental extended linear calcification in the same area. The lobulated mass was diagnosed as malignant lymphoma by core needle biopsy. Under suspicion of a combination of breast cancer, we performed a partial breast resection with axillary dissection. Pathological examination revealed diffuse large B-cell lymphoma and ductal carcinoma in situ, in the same gland lobules. Postoperatively, after radiation to the remnant breast gland, she received CHOP therapy and hormone therapy. At present, she is alive without recurrence or metastasis 4 years postoperatively.

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A 72-year-old woman was referred to our hospital because of a large right breast tumor which had grown to 10 cm in diameter. Gross findings showed no dermal or papillary changes. The elastic hard tumor was minimally movable. Mammography revealed a well-circumscribed mass with extensive calcifications. The lesion showed peripheral hypointensity on T1-weighted MRI with central hyperintense areas, suggestive of hemorrhage and was suspected to have expanded to the intercostal muscle. An inadequate specimen was obtained on fine needle aspiration. Since malignancy could not be ruled out, tumor resection was performed. The tumor, expanding into the subcutaneous fat tissue, at 12 cm in diameter had arisen from a small part of the right fifth rib. The operation consisted of local resection of the tumor and reconstruction of the chest wall defect. Pathological analysis revealed grade I chondrosarcoma. We report this case because of its unusual appearance and our difficulties in differentiating it from a breast tumor.

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The patient was a 39-year-old man who was found to have a large shadow on chest X-rays taken during a routine health screening exam. The large mass occupied the right lower lung field. Chest CT findings demonstrated a large mass measuring 10 cm in diameter that compressed the right lung. The mass was diagnosed as a mediastinal cyst clinically, and surgery was performed to make a definitive diagnosis and to treat the patient. The large mass obstructed the visual field on video-assisted thoracic surgery. Therefore, the large cyst was deflated without leakage of the cystic contents using a pigtail catheter. On histopathology, there were no malignant cells in the excised cyst. The postoperative course was uneventful. This condition is rare. The authors describe the clinical findings of a large mediastinal cyst, together with a relevant literature review.

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The patient was a 68-year-old man who had an extended thymectomy for invasive thymoma associated with myasthenia gravis at the age of 51. Seventeen years later he was found to have multiple distant metastases located in the right thoracic wall, the mediastinal lymph nodes, bone tissue, lung tissue, adrenal tissue, and bilateral glutei. Despite radiation therapy to the sacrum and systemic chemotherapy, the patient died not having had a response to therapy. Based on the autopsy findings, multiple metastases combined with thymoma (Type B2, B3) and thymic carcinoma were diagnosed. We report this rare case and present the pathology of the primary, as well as each metastatic region.

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A 62-year-old woman was brought to the Emergency Department of our hospital with a 24-hour history of chest oppression and dyspnea.
A chest CT scan confirmed the presence of a huge coronary artery aneurysm beside the plumonary artery and cardiac tamponade. Emergency surgery was performed after cardiac catheterization.
Under cardiopulmonary bypass, the aneurysm was resected, and communication of the coronary artery aneurysm was closed with pledgetted sutures. The patient had an uneventful postoperative course and was discharged from the hospital 14 days after the operation.
Coronary artery fistula with aneurysm is rare. It is essential to resect the aneurysm and completely close the fistula in rupture case.

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A 30-year-old man was transported to our hospital with a diagnosis of iatrogenic hemopneumothorax after chest drainage. His chest X-ray showed massive right pleural fluid collection. Chest drainage revealed ongoing massive bleeding. Therefore, an emergency operation was carried out under a diagnosis of intercostal artery laceration or spontaneous hemopneumothorax. The bleeding point was a ruptured vessel between the parietal pleura and bulla at the apex of the lung. After improvement of complicating postoperative re-expansive pulmonary edema, the patient was discharged on the 7th postoperative day. Careful observation after chest drainage is necessary for early diagnosis and treatment of spontaneous hemopneumothorax.

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We report a case of localized malignant pleural mesothelioma in a 69-year-old man who had a history of smoking and no history of asbestos exposure. An abnormal nodule in the left lung field was noted on a plain chest X-ray film. Chest CT showed an intrathoracic nodule on the left back pleura. PET-CT showed a hot lesion on the left pleural nodule, suggesting that the nodule was malignant. Therefore, video-assisted thoracic surgery was performed. On thoracoscopy, the nodule was found to arise from the parietal pleura and to adhere to the upper lobe of the lung ; there was no diffuse pleural spread. Since it was difficult to make a diagnosis based on intraoperative pathology the tumor and the pleura with the part of the upper lung were resected. On histopathology, tumor cell atypia, polymorphism, and mitosis were noted. Cytokeratin, EMA, and vimentin were positive, and CEA and CD34 were negative on immunohistchemical staining. Based on these findings, localized malignant pleural mesothelioma was diagnosed. As there was microscopic invasion of the pleural stump, postoperative radiotherapy was instituted. No signs of recurrence have been seen during 5 years of follow-up.

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A 65-year-old man was transferred to the hospital with sudden dyspnea. Bilateral pneumothorax was observed in the chest X-ray and CT scans, therefore bilateral thoracic cavity drainage was performed. There was a high-volume air leak which did not improve, so surgery was performed under PCPS support. On the left side, we ligated the adhesive bulla where the leak was observed. On the right side, even though the leak test was repeatedly performed, the responsible lesion could not be located. After the operation the PCPS was withdrawn in the operating room, but the air leak relapsed on the right side. Seven days later, surgery was performed on the right side. Because oxygenation was insufficient on the left-side requiring one-lung ventilation, surgery was performed under PCPS assist again. We ligated the basal bullae where the leak was observed, and the PCPS was withdrawn. In the present case, we believe that without the use of PCPS, it would not have been possible to save this patient.

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A 52-year-old woman was noted to have a mass in the left breast, and visited our hospital. A 30-mm tumor was found in the left breast, and diagnosed as invasive ductal breast carcinoma by biopsy. PET-CT showed FDG uptake in the left breast and axilla and a 9-mm nodule in the S10 of the left lung. The lung nodule showed no FDG uptake, but raised the suspicion of a metastatic lung tumor from the breast cancer. Thoracoscopic partial resection of the left lower lobe was performed for a definitive diagnosis and staging of the lung nodule. Histopathological examination showed cuboidal to polygonal cells with clear cytoplasm growing in a solid pattern. Immunohistochemical staining was positive for S-100 and negative for HMB-45, cytokeratin, and CD10. The morphological and immunohistochemical findings led to a diagnosis of benign clear cell tumor of the lung. This tumor is a relatively rare neoplasm. We report 32 such cases, including ours, in Japan.

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A 64-year-old woman, was asymptomatic but was found to have an elevated right diaphragm. A Morgagni hernia was diagnosed since the CT scan showed a prolapsing transverse colon and omentum in the right thorax on the right side of the sternum. A laparoscopic operation was planned, because of the risk of bowel incarceration. During surgery, the hernia sac contain was found to the transverse colon which was easily pulled into the abdomen. After dissection, of the round ligament of the liver, the size of the hernia orifice was found to be about 6 cm × 8 cm. Therefore, a repair with composite mesh without direct suture of the orifice was done. The composite mesh was suture to cover the hernia orifice without excising the sac. Operating time was 120 minutes, and there was little blood loss. The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day. Laparoscopic repair of a Morgagni hernia using a composite mesh is a safe procedure.

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Afferent loop obstruction associated with remnant gastric cancer is extremely rare, with only 7 cases reported to our knowledge in Japan. A 62-year-old man who underwent distal gastrectomy for a duodenal ulcer 37 years earlier, was admitted for nausea and vomiting. Laboratory studies revealed jaundice and hyperamylasemia and abdominal CT scans showed a fluid-filled dilated afferent loop and mass lesion near the gastrojejunostomy. Emergency upper gastrointestinal endoscopic examination showed type 3 gastric cancer at the gastrojejunostomy and the afferent limb was obstructed due to the cancer, so we could not insert the drainage tube into the afferent loop. We diagnosed afferent loop obstruction associated with remnant gastric cancer. Emergency surgery showed Billroth-II reconstruction by the retro-colic route in the primary operation, and an extremely dilated and dark red afferent loop. The tumor was found to have invaded the tail of the pancreas and the transverse mesocolon. Total gastrectomy and D2 lymph node dissection with resection of the tail of the pancreas and spleen was performed.

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We report a 49-year-old woman with multiple gastric cacinoids associated with type A gastritis. There were previous histories of pernicious anemia, Basedow disease, and anti-neutrophil cytoplasmic autoantibody (ANCA)-related angitis at the age of 28. In February 2010, she visited a hospital because of epigastric discomfort and was referred to our hospital for a suspected gastric tumor. Gastric endoscopy revealed remarkable atrophy spread widely from the gastric body to the fornix, and multiple small polyps 5mm in diameter in the fornix. These polyps were histologicaly diagnosed as gastric carcinoids. The serum gastrin level was found to be very high, 6406 pg/ml. The most likely diagnosis was multiple carcinoids and hypergastrinemia with type A gastritis, and we finally performed distal gastrectmy. On the next day the serum gastrin level dropped into a normal range. Seven months after the resection gastric endoscopy showed disappearance of carcinoid tumors at the upper body of the stomach.

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A 75-year-old woman complaining of epigastric discomfort was performed upper gastrointestinal endoscopic examination and was found having stenosis at the pyloric part of stomach. No abnormalities were seen on the mucosal surface, but edematous stenosis was present at the pylorus. A biopsy revealed no malignant findings. An abdominal CT scan showed diffuse thickening of the gastric wall. The level of a tumor marker CA19-9 was as high as 735 U/ml. Although no definite diagnosis was gained, the patient was operated on for suspected malignancy, because no symptomatic remission was attained, the CA19-9 level was high and thickening of the gastric wall was demonstrated. The resected specimen included not thickening of the gastric wall but only hardening of the stenotic portion. Histopathologically no cancer was proved on the mucosal epithelia, and the diagnosis was made as submucosally invasive, well differentiated adenocarcinoma. Immunohistochemistry showed positive staining for CA19-9 and the elevated serum CA19-9 level was normalized after the operation. CA19-9-producing gastric cancer was thus diagnosed.
In the case of pyloric stenosis in which no abnormalities are seen on the mucosal surface and a biopsy provides no malignant findings, a possibility of cancer should be considered.

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A 65-year-old female was seen at the hospital because of epigastralgia and nausea. The patient had been followed up after undergoing laparoscopically assisted sigmoidectomy for sigmoid carcinoma at another hospital in August 1997. A follow-up CT scan revealed a tumor with 4cm in size, growing outside of the duodenum. But the patient denied more close examinations. Three years later, since she had nausea, dynamic CT scan was performed. The tumor had increased to be 8cm in size and there was bleeding inside of the tumor. After her symptoms disappeared with conservative therapy, she was referred to our hospital for operation. At that time, the tumor reduced to 4cm in size, and the duodenal mucosa was normal on gastroenterological fiberscopy. Perioperative diagnosis of carcinoid was made by cytology guided by endscopic ultrasonograpy of the submucosal cells. We performed pancreaticoduodenectomy with lymph node dissection in December 2008. Histopathology disclosed that tumors 7 mm and 5 mm in size which could not be identified before operation were found to be carcinoid tumors and that the 4×3×2.5 cm extramurally growing tumor of the duodenum which was diagnosed as carcinoid preoperatively was clarified to be lymph node metastasis of the carcinoid tumors. In this paper, we report a rare case of small carcinoid tumors of the duodenum, in which we could follow the solitary metastatic lymph node for four years. In a review of the literature, carcinoid tumors smaller than 10mm in size with a huge lymph node metastasis are very rare.

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A 40-year-old female was admitted for abdominal pain in April 2007, and was identified as having anemia. Examination was inconclusive, but sustained symptoms led to us to introduce scanning. The first result was Hb 7.9 ng/dl, and the tumor makers were normal. Endoscopy showed tumors surrounding the third portion of the duodenum. Biopsy result was Group V. CT showed a mass of 7×9 cm. The tumor was shaped mold which touched the pancreas, left kidney, superior mesenteric artery (SMA), and the aortic wall. There was a possibility of expansive growth tumor, so we performed an operation. The tumor was 7.2×5.7 cm, located at the third potion of the duodenum. There was a possibility of detachment, although invasion to the uncinate process of the pancreas was found, which required complete removal. Postoperatively she admitted frequent diarrhea, then improved and on postoperative day 31 became light headed leaving the hospital. Adjuvant chemotherapy was given for 12 months, after which lymph transition happened again.
Duodenal carcinomas are rare, and even when removed the transition recurrent high is rate. However, we expect to extend the lifetime by surgical treatmentar should consider the possibility of excision.

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Jejunal diverticulum is usually silent, but it rarely presents with massive melena. A Case of jejunal diverticulum with massive melena, of which bleeding site was locally diagnosed by preoperative abdominal enhanced CT, is reported.
A 65-year-old female complaining of recurrent bouts of massive melena was admitted to the hospital for severe anemia. Abdominal contrast enhanced CT on colonal view revealed leakage of contrast medium into a large diverticulum of the jejunum. Selective SMA angiogram could not reveal any bleeding point, and emergency operation was performed. A large cystic diverticulum about 4 cm in diameter, localized at a site of the jejunum about 30 cm distal to the ligament of Treitz, was resected with the part of the jejunum. It was found to be pseudo diverticulum lacking proper muscular layer. The postoperative course was uneventful. She was discharged 12 days after the surgery.
When we encounter the patient with overt ongoing bleeding of unknown origin, it is necessary to detect the bleeding site with abdominal enhanced CT as soon as possible and to consider the possibility of massive bleeding from a jejunal diverticulum.

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A case of allergic granulomatous angiitis (AGA) complicated by an ileal perforation is reported. A 58-year-old man, who had undergone treatment for Churg-Strauss syndrome, was treated with steroid pulse therapy for an acute exacerbation of multiple mononeuritis for one month. The steroid pulse therapy improved his symptoms and laboratory data. However, the patient presented with acute abdominal pain. Abdominal physical findings and computed tomography indicated a gastrointestinal perforation ; the patient underwent an emergency laparotomy. The intraoperative findings revealed an ileal perforation located 80 cm proximally to the ileocecal valve. A partial ileal resection was performed ; on histology, the perforation was found to be caused by active AGA. The postoperative course was uneventful, and low-dose steroid treatment was continued after surgery. The incidence of AGA is rare. Out of the 450 patients registered in Japan 54 cases are complicated by gastrointestinal perforation. We report a case of gastrointestinal perforation in a patient with AGA and discuss the prognosis of complicated AGA.

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A 42-year-old woman was admitted with a diagnosis of acute abdomen due to epigastralgia. Computed tomography (CT) showed intussusception of the ileum, which included a heterogenous eccentric fat density mass. Under the diagnosis of ileum-to-ileum intussusception, an operation was performed. During laparotomy, an invagination 40 cm oral to the terminal ileum was found. When the intussusception was relieved using Hutchinson's maneuver, an inverted diverticulum was found. A partial ileum resection was performed (including the Meckel's diverticulum). On pathology, small intestinal mucous membrane without gastric mucosa or pancreatic organization was noted. Meckel's diverticulum should be considered as one of the causes of adult intussusception.

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A 62-year-old woman, with renal failure and consciousness disturbance, underwent an operation for intestinal obstruction. However, no obstructive lesion was found. The cause of consciousness disturbance was found to be glyphosate poisoning. Toxic symptoms improved with medical therapy. One month later, radiological enteroclysis and CT showed intestinal intussusception. Decompression using an ileal tube was attempted, but was not successful. Therefore, the patient had surgery again. An intussusception of the small intestine, at 80 cm to 230 cm from the ligament of Treiz, was found. Between the serous surfaces of the entering and emerging wall of the intussusceptum, marked edema and adhesions were noted. We performed strictureplasty to the oral end after it had been shrunken as much as possible, and resected the anal end. She was discharged after surgery without recurrence of intussusception. To our knowledge, no other adult intussusception cases have been reported after glyphosate poisoning. Therefore, it must be extremely rare in Japan.

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A 55-year-old man who had caries teeth and a history of undergoing appendectomy was brought into our hospital by ambulance because of intersifying abdominal pain after he had a meal including boar meat. Abdominal CT scan showed some plate-like objects in the dilated small intestine. He was admitted with the diagnosis of food ileus. Another abdominal CT scan performed 12 hours after admission showed no improvement. Emergency laparotomy revealed lots of undigested residue of food, including pieces of cartilage, in the small intestine. In the diagnosis and decision-making for treatment of food ileus, we must give a careful patient interview to know contents of meals and his or her eating habit and bear in mind that surgery is often required.

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We report a strangulated ileus with chylous ascites. A 66-year-old woman was admitted to the hospital with abdominal pain. Abdominal computed tomography revealed an ascites and contrast defect of the small intestine. It was diagnosed as strangulated ileus and she underwent an emergency operation. The laparotomy revealed a chylous ascites, and strangulation of the small intestine caused by postoperative adhesion. Since intestinal blood flow improved following removal of the strangulation, intestinal resection was not performed. The ascites exhibited an elevated triglyceride level of 526 mg/dl, and Sudan-III stain-positive particles, which led to a diagnosis of chylous ascites. The patient was discharged on day 7 of hospitalization. Reports of strangulated ileus presenting with chylous ascites are rare and only 9 cases have been reported in Japan. Since the pressure in the lymphatic system is lower than that of the vascular system, the potential for occurrence of strangulated ileus presenting with chylous ascites was suggested as a result of the lymph flow being interrupted ; even in cases where the strangulation would not completely interrupt blood flow.

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An 89-year-old woman was seen at the hospital because of abdominal pain and bloody diarrhea. An abdominal enhanced CT scan revealed gas outside of the intestine mainly in the right lower quadrant of abdomen and distal end of the ileum, but obvious physical findings were lacked. Accordingly we performed laparoscopy for diagnosis. Laparoscopic study showed localized multiple minute cysts of gas collection in the subserosa, but findings suggestive of peritonitis and perforation were absent. We determined not to perform laparotomy but to observe the patient's clinical course conservatively. Her clinical course was uneventful and she was discharged from the hospital on the 5th hospital day. However, she was seen at the hospital again because of abdominal pain and diarrhea two weeks after discharge. An abdominal CT scan showed portal emphysema and pneumatosis intestinalis (PI). Based on a review of the literature, α-glcosidase inhibitor was the most likely etiology. Withdrawal of oral intake of α-glucosidase inhibitor yielded remission of PI. Thereafter the patient has been free from recurrence for about six months after withdrawal of oral α-glucosidase inhibitor.
So far only nine cases of PI caused by α-glucosidase inhibitor have been reported in Japan, among of which the condition associated with portal emphysema has been reported in as rare as two cases, including our case. It is hard to diagnose such a rare entity in an early time and hence diagnostic laparoscopic study is recommended that can avoid unnecessary exploratory laparotomy.

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We report a case of bleeding from the appendix caused by Dieulafoy's lesion. A 75-year-old man was admitted due to bloody stool and loss of consciousness. During emergency colonoscopy the colon the was filled with abundant old blood. Thus, we could not reach the ascending colon. Colonoscopy performed again after pretreatment showed bleeding from the appendix. Appendectomy was perfomed. Pathological study revealed an arterial abnormality of the appendix with neither diverticulum nor inflammation. We diagnosed it as a Dieulafoy's lesion. Dieulafoy's lesion of the appendix is a very rare cause of bleeding in the lower gastrointestinal tract, but needs to be considered.

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A 74-year-old man was seen at our hospital because of swelling over the right inguinal region. Abdominal enhanced CT scan demonstrated a right inguinal subcutaneous abscess. Incision and drainage for the abscess demonstrated fistula formation at the bottom of the abscess. After fistulography and colonoscopy, he was diagnosed as having a colocutaneous fistula between the ascending colon and the left inguinal region due to penetrated diverticulitis. Conservative therapy with tube drainage and irrigation was maintained for about three months. The inflammation regressed and the abscess cavity diminished in size, however, the fistula was not closed. We finally performed right colectomy. After the operation, the fistula was gradually closed and he was discharged from our hospital.
Our case demonstrates the difficulty of conservative therapy for fistula to the skin caused by colon diverticulitis. Early surgical treatment may be recommended for the intractable fistula after regression of local inflammation.

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A 65-year-old man who had taken aspirin for two years with the diagnosis of essential thrombocythemia was reported that his fecal occult blood test was positive. Colonoscopy showed cecal cancer. He was reffered to our hospital and performed laparoscopic assisted iliocecal resection after withdrawal of aspirin. The postoperative course was uneventful. Aspirin was resumed on the postoperative day 7 after percutaneous injection of enoxaparin sodium. Twelve months after the operation the patient is doing well without sign of recurrence and his platelet count has been controlled at the level of 80∼100×10⁴/μl. So far only one another case of essential thrombocythemia with cecal cancer has been reported, and this case which appears to be very rare is presented here.

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The patient was a 56-year-old woman undergone transverse colectomy, omentectomy, radical hysterectomy, and bilateral ovariectomy for transverse colon cancer with bilateral ovarian metastases in August 2004. The histological diagnosis was si (omentum), n3, ly1, v2, m1 (bilateral ovaries) and Stage IV, based on the Japanese classification of colon cancer. Positron emission tomography (PET) performed 2 years and 7 months after the first operation showed recurrence at the Douglas' pouch, and we performed local excision. Afterwards she developed recurrence two more times at the peritoneum during the next 1 year and 4 months. We performed local excision for each recurrence. The pathological findings in reoperations demonstrated metastasis from the transverse colon cancer. Her serum carcinoembryonic antigen (CEA) level rose to unusual value at each recurrence, and was normalized after each excision. There has been no recurrence for 6 years and 2 months since the first operation, or 2 years and 2 months after the last operation. We report herein a case of resected metachronous peritoneal recurrence of transverse colon cancer, occurred three times in 4 years. This case appears to be interesting interms of a mode of cancer recurrence.

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Obstructive colitis is a non-specific inflammatory disease in which erosions, ulcers, and other lesions occur proximal to obstructive lesions in the colon. Because it is an obstructive lesion, preoperative diagnosis is considered difficult. In the present paper, a patient with sigmoid colon cancer complicated by obstructive colitis for whom preoperative diagnosis was difficult is reported. The patient was a 64-year-old man who was transferred to our hospital and placed on mechanical ventilation after developing septic shock during hospitalization at another hospital for constipation, abdominal pain, and severe anemia. General investigations showed no clear disease other than sigmoid colon cancer accompanied by stenosis to an extent that allowed passing of an endoscope. Surgery was performed on day 60 of the hospitalization following emergency admission, when the patient was deemed fit to undergo surgery. Because the intraoperative findings suggested obstructive colitis up to the serous surface of the middle of the transverse colon, an extended left hemicolectomy was performed up to that area. The pathological results were SE, N1 (1/58), H0, M0, P0, f stage IIIa. Obstructive colitis was observed extensively on the proximal side of the cancer, and intranuclear inclusion bodies were seen at the ulcer site. Cytomegalovirus infection was considered a cause of the increase in severity.

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A 44-year-old man was found to have a tumor (38×44 mm) between the prostate and the rectum (Rb) on MRI. The origin was unknown, but on pathology of a transrectal biopsy, a gastrointestinal stromal tumor (GIST) was diagnosed. Barium enema and colonoscopy did not show a tumor in the rectum. The tumor was resected via the perineal approach because it was localized anterior to the rectum and adhesion or invasion to the prostate was suspected. The incision was made from one mid-ischial tuberosity to the other with the apex 1.5 cm above the anus, just anterior to the mucocutaneous pigmentation line. After dissecting between the external rectal sphincter and the rectum, and transecting the rectourethral muscle, the tumor was found to be a growth outside the rectal wall which had adhered to the prostate.
On pathology, the tumor was diagnosed as a rectal GIST.

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A 66-year-old woman was admitted to our hospital because of constipation and difficulty in defecating. She underwent abdominoperineal resection and lymphnode dissection following a diagnosis of poorly differentiated adenocarcinoma. A resected specimen contained two tumors and each tumor was separated. Histopathological examinations of both tumors diagnosed basaloid carcinoma. Basaloid carcinoma is an uncommon neoplasm of the anal canal, and the incidence of this tumor is reported to be 1.6 % of all anal canal neoplasms in Japan. Only two cases were reported with multiple lesions. Recently, this tumor has been reported to respond well to chemoradiation therapy, therefore it is important to diagnose precisely before treatments.

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Anorectal malignant melanoma is a rare and aggressive disease. We report a case diagnosed at an early stage which required an abdominoperineal resection with sentinel lymph node biopsy and postoperative immunochemotherapy. A 67-year-old woman with diverticulitis was found on follow-up colonoscopy to have a black lesion in the anorectum. Biopsies were taken of the lesion, which pathology confirmed to be malignant melanoma. She underwent an abdominoperineal resection and sentinel lymph node biopsy which demonstrated no metastasis based on intraoperative pathology ; thus, an inguinal lymph node dissection was avoided. After the operation, five cycles of DAV-Feron (dacarbazine, nimustine hydrochloride, vincristine sulfate, interferon β) therapy was given. The patient remains disease free.

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Brief summary : Hepatoblastomas in children are rare and rupture of the tumor is lethal. A 22-month-old boy fell down the ground to be bruised the abdomen. He went into shock and was brought into a hospital by ambulance. Hemorrhagic shock due to rupture of a liver tumor was diagnosed by abdominal ultrasonography and abdominal enhanced CT scan. After initial treatment, his vital signs were stable and he was transferred to our hospital. Arriving at the ICU, his vital signs were still stable and abdominal enhanced CT scan at our hospital did not show any increase of abdominal hematoma due to the rupture and extravasation from the tumor. No invasive examinations nor treatments including transcatheter arterial embolization were performed. The level of AFP was strikingly high, 324,770 ng/ml, and he was diagnosed as having hepatoblastoma. After 2 courses of preoperative systemic chemotherapy by a pediatrician, the size of the tumor was reduced and right hepatectomy was performed. He received postoperative systemic chemotherapy and there has been no evidence of tumor recurrence for 1 year after the curative resection.

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Gallbladder duplication is a rare congenital biliary anomaly. We report a case of gallbladder duplication, that was resected laparoscopically. A 43-year-old female was admitted with a complaint of epigastric pain. Acute cholecystitis was suspected form the laboratory data. ERCP and MRCP revealed Boyden H, Gross B type gallbladder duplication with gallstones. Since extensive examinations had been conducted before surgery, we were able to perform laparoscopic cholecystectomy. This case demonstrated the importance of imaging examinations, such as MRCP or ERCP, for classifying subtypes preoperatively. We discuss laparoscopic cholecystectomy for gallbladder duplication by reviewing the literature.

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We report a case of gallbladder metastasis from renal cell carcinoma. A 64-year-old man underwent radical left nephrectomy for renal cell carcinoma 7 years ago. One year ago, multiple lung metastases and right adrenal gland metastasis were found, and he was treated with IFN-alpha. About one year after he started IFN-alpha, a follow-up abdominal computed tomography showed a tumor in the fundus of the gallbladder. The multiple lung metastases and right adrenal gland metastasis showed a partial response, thus, an open simple cholecystectomy was performed. Histologically, the tumor was 3 cm, and classified as clear cell carcinoma, and was considered to be a metastasis from the primary renal cell carcinoma. We have reported this case because it appears to be an interesting and uncommon disease.

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Splenic hamartoma is a comparatively rare entity. Recently we encountered a case of a splenic tumor with an increasing tendency in a patient who had been followed after surgery for colon cancer. It was hard to differentiate from metastatic splenic tumor, so that splenectomy was performed and splenic hamartoma was resultantly diagnosed. The patient was a man in his sixties. A follow-up abdominal CT scan performed two years after the operation for colon cancer revealed a 10-mm diameter tumor with the strongly enhanced margin and the scarcely enhanced center in the spleen. MRI showed iso-intensity on T1-weighted images and slightly high signal intensity on T2-weighed images. In a course of six months, the tumor enlarged to be 20 mm in diameter. Splenectomy was performed with a suspicion of metastatic splenic tumor. The histopathological diagnosis was splenic hamartoma.
Splenic hamartoma lacks specific imaging findings and preoperative diagnosis is difficult. It might be important to perform surgery to gain the definite diagnosis, especially for a splenic tumor with a tendency to enlarge or that suggestive of malignant splenic tumor.

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We report a rare case of retroperitoneal solitary fibrous tumor associated with hypoglycemia. A 71-year-old man was aware of abdominal distension for two years before admission. He was admitted urgently to our hospital with severe hypoglycemia. A large mass was palpable filling the entire abdomen. Abdominal CT scan revealed a large mass occupying the entire abdominal cavity. We diagnosed this lesion as having arisen from the retroperitoneal space. The tumor was completely resected with severing of the feeding vessels from the right testicular artery. The resected specimen was an encapsulated elastic hard mass 31×27×16 cm in size and weighing 7.0kg. The cut surface of the specimen was white with focal necrosis. Histologically, the tumor showed a patternless proliferation of spindle cells with irregularly arranged collagen bundles in the stroma. On immunohistochemistry, the tumor cells were diffusely positive for Vimentin, CD 34 and Bcl-2. The final diagnosis was a retroperitoneal solitary fibrous tumor.

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We present a case with a giant retroperitoneal liposarcoma during pregnancy with 4 year survival after resection. A 30-year-old pregnant female at 12-weeks gestation was referred with a left-sided retroperitoneal tumor. Magnetic Resonance Imaging (MRI) showed a 30cm multilocular tumor along the left iliopsoas muscle. The tumor was resected using a retroperitoneal approach at 13-weeks gestation with meticulous intraoperative fetal monitoring, and revealed a low-grade myxoid liposarcoma on histopathological examination. She delivered a normal baby at 37-weeks gestation by cesarean section and was found to have no local recurrence at that time. Although she had a local recurrence 18 months after resection, the recurrent tumors were controlled by radiotherapy more for than 24 months and were resected 4 years after the fist resection because of re-growth. A retroperitoneal liposarcoma during pregnancy is extremely rare and is thought to carry a poor prognosis. This report emphasizes the importance of timing as well as the possibility of continuing the pregnancy, which requires a multidisciplinary team approach to achieve a successful outcome for the patient and her child.

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We herein report a case of mucinous cystadenoma of the retroperitoneum successfully removed by laparoscopy. A 45-year-old woman was admitted with a complaint of left back pain associated with re-growth of a retroperitoneal cystic mass, which had been treated by ethanol injection twice since she was 33 years old. Computed tomography and magnetic resonance imaging demonstrated a well demarcated 13.5 cm×9.5 cm cystic mass, in the left retroperitoneum. Under a diagnosis of benign retroperitoneal tumor, laparoscopic resection was performed. To minimize the size of the tumor, as much of its fluid content as possible was aspirated via a trocar, which was then closed using a MINI LOOP RETRACTOR^TM, thereby preventing spillage of the tumor content. This facilitated full mobilization of the tumor, allowing it to be removed successfully. The histopathological diagnosis was mucinous cystadenoma. The patient has been well, without evidence of tumor recurrence, for 17 months since surgery.

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We report two patients with intractable postoperative chylous ascites that was successfully treated with octreotide. The first case was a 49-year-old male who underwent pancreaticoduodenectomy. Fasting temporarily improved his ascites, however, the patient deteriorated with oral intake. Furthermore, insufficient drainage of ascitic fluid led to abdominal bloating. The subcutaneous administration of octreotide (200μg/day, twice daily) decreased the amount of fluid that was drained and relieved the abdominal bloating ; the drainage tube was removed 20 days after the start of octreotide treatment. The second patient was a 77-year-old female who had a resection of a perforated transverse colon cancer. A minimum of 1,000mL/day of chylous ascitic, fluid was produced when the patient was tube fed. The chyle disappeared and the amount of fluid that was drained dramatically decreased the day after subcutaneous administration of octreotide (200μg/day, twice daily) was started. The drainage tube was removed 12 days after the start of octreotide treatment. Octreotide appears to be an effective treatment for intractable chylous ascites.

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An 85-year-old woman with two enterocutaneous fistulae in the right upper and lower abdomen and a mesh infection in the upper abdomen required the modified components separation method for a large fascial defect. After the resection of the enterocutaneous fistulae and the infected mesh, a large fascial defect (12 cm in diameter) was observed. First, the aponeurosis of the external oblique muscle was transected longitudinally. Next, the anterior rectus sheath was transected longitudinally, was mobilized to medially, and then sutured. Though the operative wound was partially ischemic after the operation, the ischemia improved with conservative treatment. There has been no recurrence during 18 months of follow-up. The modified components separation method for a large fascial defect appears to be effective in contaminated cases.

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An 80-year-old man who had received appendectomy was seen at the hospital because of abdominal pain and nausea. An abdominal x-ray film taken when he was first seen revealed air-fluid level formation, but an abdominal CT scan failed to identify the origin of the intestinal obstruction. He was admitted with a diagnosis of adhesive intestinal obstruction that had come to the fifth admission in this year. Symptomatic remission was gained by conservative therapy, but laparoscopic-assisted surgery to reduce the obstruction was performed because he had repeatedly been affected by the condition. At surgery, dissection of adhesions between the abdominal wall and the ileum disclosed a narrowing intestine about 10 cm in length extending in the ileum with thickening of the mesentery, where was 30 cm proximal to the ileocecum and was thus determined to be the origin of the obstruction. Subsequently the ileum was pulled out from a small laparoscopic wound to outside of the body, and partial resection of the small intestine was performed. Histopathological examinations showed minor degree of inflammation of the ileum mucosa and structures like ducts in the pancreatic tissue in the small bowel mesentery, suggesting the presence of an ectopic pancreas. It was type III according to the Heinrich's classification. The final diagnosis was small vowel stenosis caused by ectopic pancreas in the small bowel mesentery. The patient has been free from intestinal obstruction as of 6 months after discharge.

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An 82-year-old man was treated by antibiotics because of right lower abdominal pain. The symptoms did not improved ; he was diagnosed as having a gastrointestinal perforation on abdominal contrast-enhanced CT. A localized peritonitis with an intraperitoneal abscess caused by small intestinal diverticulitis was diagnosed ; emergency surgery was done.
Many diverticula were found on the mesenteric side of the jejunum, and a mesenteric abscess was suspected. Thus, a partial jejunectomy was done. Since on histology no intestinal mucosa was seen in the diverticulum wall, an intraperitoneal abscess caused by small intestinal false diverticulitis was diagnosed. According to previous reports, diverticula of the small intestine are rather rare, and in many cases a false diverticulum is present in the jejunum. Our review of the 41 papers indicates that perforation or penetration of a false diverticulum of the small intestine occurred in 36 cases. The diverticulum was reported to have been located in the jejunum in 31 cases and in the ileum in 10 cases. Small intestine diverticula were most commonly found close to the ileum.

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A 60-year-old man visited a nearby hospital with a 3-month history of back pain. Abdominal ultrasonography revealed a 9-cm mass in the peritoneal cavity, and the patient was referred to our hospital. On first examination, a movable mass was palpable in the abdomen. Blood examination revealed an elevated white blood cell count of 35,600/mm³. An abdominal computed tomography (CT) showed a mass measuring 9×6×7 cm in the mesentery, but no abnormalities were detected in the bone marrow biopsy. Hence, a diagnosis of reactive leukocytosis associated with an intraperitoneal tumor was made. Open surgical biopsy led to a diagnosis of inflammatory myofibroblastic tumor (IMT). Judging that there was no effective treatment other than resection, we surgically removed the tumor. The final histopathological diagnosis was inflammatory malignant fibrous histiocytoma (MFH). Documented cases of mesenteric MFH are rare. Herein, we report a case of MFH that was originally identified as IMT by surgical biopsy, but finally diagnosed as MFH by postoperative reassessment, and we also discuss the relevant literature.

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A 72-year-old man seen at the center because of a right inguinal bulging was diagnosed as having a right inguinal hernia and underwent a hernia repair through the anterior approach. However, no hernia sac was seen, and fatty tissue prolapsed from the internal inguinal ring was identified. Abdominal enhanced CT scan performed after the operation revealed a 15×10 cm tumor, almost of which showed the concentration of fat, in the lower abdomen. Liposarcoma was likely. Reoperation was done and the tumor was removed under laparotomy. The tumor was found to be well differentiated liposarcoma arisen from the upper part of the pubic bone.
So far there have been ten reported cases of liposarcoma enlarged to the abdominal cavity and presented with an inguinal bulging. All the ten cases were of liposarcoma arisen from the retroperutoneum, and this case is the first report of liposarcoma which had arisen from the upper part of the pubic bone and presented with an inguinal bulging. Although it is rare that liposarcoma grown into the abdominal cavity presents with an inguinal bulging, if we notice some abnormalities in the hardness and/or reduction of such a bulging, close exploration of the abdomen is required considering a possible enlargement of liposarcoma to the abdominal cavity.

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