Abstract : A retrospective study was conducted to decide the indication for pylorus-preserving gastrectomies (PPG). We enrolled consecutive 2173 patients who were treated with distal gastrectomy or total gastrectomy along with lymphadenectomy more than D1 as radical operation for gastric cancer. The incidence of peripyloric lymph node metastasis was evaluated with reference to the depth of invasion, tumor size, and the tumor-pylorus ring distance. The positive rate of lymph node metastasis decreased in proportion to the tumor-pylorus ring distance. On the other hand, the rate increased in proportion to the tumor depth. Among pT1 cases with > 5 cm tumor-pylorus ring distance, peripyloric lymph node metastasis was detected in only 5 cases, which had >= 2 cm tumor size and pSM invasion. Then we set the clinical indication of PPG for cM and cSM (tumor diameter < 2 cm) with > 5 cm pylorus-tumor distance. In a re-evaluation made based on this indication criteria, there was only one (0.2%) case of positive lymph nodes out of 424 PPG indicated cases, however, this was unordinary case with bone metastases 4 years after operation regardless of D2 lymph node dissection. In conclusion, cM or cSM (< 2 cm) gastric cancer situated more than 5 cm distant from the pylorus ring can be a candidate for PPG.

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Purpose : The aim of this study was to assess the effect of reduced port surgery on cosmetic satisfaction with laparoscopic cholecystectomy (LC).
Methods : Our department has 3 procedures for LC : conventional LC (CLC), needlescopic cholecystectomy (NC), and single-incision LC with an additional small port (TANKO+1). DAS59 questionnaires were sent postoperatively to 151 patients who had undergone any LC procedure between November 2009 and June 2013, and responses were analyzed.
Results : A total of 111 responses (74%) were sent back. DAS59 results following CLC, NC, and TANKO+1 were 19.5, 20.9, and 19.7, respectively, indicating that all procedures were associated with adequate satisfaction. Detailed assessment of patients' complaints revealed that larger wound sizes were associated with more significant complaints related to cosmesis or postoperative pain. There were no complaints from those with a 3.5-mm wound.
Conclusion : Any advantages of reduced port surgery to cosmetic satisfaction were not found in patients who had undergone LC. However, results suggested that wound size might correlate with cosmetic satisfaction and postoperative pain.

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Intra-operative cytological assessment of the surgical margin is considered a useful method for accurate lumpectomy. However, a false-positive diagnosis can occur in some cases. False-positive cases of intraoperative scrape cytology performed at our hospital were evaluated. The subjects were taken from 271 cases of breast cancer that underwent breast-conserving therapy from January 2007 to June 2013. Of these, 17 cases (7%) were diagnosed as malignant and 7 (2.9%) were considered false-positive. False-positive cases had : an average age of 60.3 years (all cases : 55.8 years) ; an average tumor diameter on ultrasonography of 16.8 mm (all cases : 15.3 mm) ; an extensive intraductal component on imaging with 3 cases positive and 4 negative ; histological classification of noninvasive ductal carcinoma in 2 cases, papillotubular carcinoma in 2 cases, solid-tubular carcinoma in 2 cases, and scirrhous carcinoma in 1 case ; and the nuclear grade was Grade I/II/III in 1/2/4 cases. Histopathologically, no tumor cells were observed within 5 mm of the surgical margins in all 7 cases, and there were no benign proliferative lesions, near the margins that could be diagnosed as malignant in cytology. The false-positive rate of fine-needle aspiration cytology during the period examined was 0.07%, with characteristics that were different from those of scrape cytology of the surgical margins.

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Cancerous involvement of a ureter is sometimes encountered in pelvic surgery for malignancy. In these cases, resection and reconstruction of a ureter is indicated. We usually employ transureteroureterostomy (TUU) for reconstruction of a ureter in the cases of unilateral lower ureteral involvement. We report here the outcomes of patients treated with TUU in our hospital. We retrospectively reviewed the medical records of 10 patients who underwent TUU from June 2006 to May 2014. Primary disease was colon cancer in four patients, rectal cancer in four patients, uterine cervical cancer and ovarian cancer in each one patient. Early postoperative complication occurred in only one patient who developed ureteral obstruction and hydronephrosis due to anastomotic hematoma. Follow up periods ranged from 1 to 61 months with a median of 16.5 months. During the follow up periods, no patients experienced either worsening of the renal function or recurrent urinary tract infection. TUU which is a useful and safe ureteral reconstruction method should be considered as a preferable treatment option in patients who undergo resection of the ureter involved by pelvic malignancy.

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With the spread use of the three-point lap-diagonal seat belt restraint, there has been a reduction in the number of deaths caused by motor vehicle collisions. However, a new pattern of injury has emerged. Herein, we report a case of seat belt injury in which contrast-enhanced CT scan was effective in the diagnosis and treatment of the hemorrhage within the breast. A 47 year-old woman injured by a motor vehicle collision was brought into our hospital by ambulance. The swollen left breast was still growing in spite of performing the compression to the left breast. Contrast-enhanced CT scan showed an extravasation of contrast medium into the left breast. An emergent surgery for hemostasis of the pulsating bleeding from a perforating branch of the internal thoracic artery was performed under local anesthesia. Postoperative recovery was quick without having wound infection and cicatrzation, and the result of surgery was also satisfactory from a cosmetic viewpoint. Contrast-enhanced CT scan was useful for deciding the treatment strategy of the uncontrollable active bleeding into the breast due to the seat belt injury.

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A 62-year-old woman who visited a neighboring hospital because of a right breast mass was referred to our hospital with a diagnosis of breast cancer with cartilaginous and osseous metaplasia based on a fine needle biopsy. A well-movable tumor 4.5 cm in diameter was palpated in the right AC area. It was revealed as a heterogeneous hypoechoic tumor with a center part with echogenic spots on ultrasonography, and as a high density tumor with coarse calcifications on mammography. Bone scintigraphy showed accumulation of radioactive material at a portion where was identical with the breast tumor. We performed right modified radical mastectomy and sentinel lymph node biopsy. Histopathology disclosed proliferation of spindle-shaped tumor cells and tumor cells showing differentiation toward osteoblast, osteoclast-like giant cells, and chondrocyes ; there were no epithelial components. Accordingly stromal sarcoma with cartilaginous and osseous metaplasia of the breast was diagnosed. The patient experienced lung metastasis and bone metastasis and recurrence one year after the operation. Chemotherapy was unsuccessful and she died one year and eight months after the operation. As this case is of rare stromal sarcoma with prominent cartilaginous and osseous metaplasia, we report this case together with a review of the literature.

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A 74-year-old woman who had a breast lump and felt pain in her right breast presented to our hospital. On palpation, there was an indistinct nodule, 2 cm in diameter, in the inner upper quadrant of her breast. Mammography showed an indistinct mass with high density in the right inner upper area, while ultrasonography showed an irregular mass, 2.3 cm in diameter, at the 12 o'clock position. On magnetic resonance imaging, there was ring-enhancement of the margin of the tumor from the early phase, and augmentation of enhancement in the late phase. Fine needle aspiration cytology and core needle biopsy suggested ductal carcinoma with massive necrosis. Highly aggressive breast cancer was anticipated. Partial mastectomy and sentinel lymph node biopsy were performed. The pathological diagnosis was nodular infarcted necrosis in the center of the tumor and micro-invasive ductal carcinoma in the separated area. This case was considered very rare and worth reporting because there have been very few reports of breast cancer with almost complete infarcted necrosis.

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Colorectal metastasis from breast cancer is clinically uncommon. We experienced a patient who presented with metastatic cancer 19 years after a radical operation for breast cancer without lymph node involvement.
A 71-year-old woman underwent a modified radical mastectomy for right breast cancer (T1N0M0, stage I) 19 years ago. Lower gastrointestinal endoscopy was performed by the local doctor after she found fresh blood in her stool, 19 years after the mastectomy. Type 2 lesions were detected in the transverse colon. Biopsy indicated a group 5 tub2 tumor. A laparoscopy-assisted transverse colon partial colectomy was performed for the transverse colon cancer. Histopathological examination of the resected specimen indicated that it was a metastasis from the previous breast cancer.

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A 55-year-old woman was referred to our hospital because of an abnormal chest X-ray shadow in the right upper lung field. A chest wall mass was observed just below the first right costal cartilage in CT. Neurogenic tumor was suspected. We performed thoracoscopic surgery for this. The tumor was parietal extrapleural mass protruding from the first intercostal space. We excised this tumor with the parietal pleura. The pathological diagnosis was desmoid tumor. Local recurrence occurred one year after the operation. The tumor was present in the dorsal side of the right first rib, and had destroyed a part of the rib. We performed re-operation for this. The tumor was resected en bloc together with the right brachiocephalic vein side wall, part of the 1&2 ribs and right lung upper lobe. We rebuilt the defect of the chest wall by using Composix mesh. The pathological diagnosis was desmoid tumor too. She was discharged on the 13th postoperative day. We gave continuous administration of meloxicam followed by radiotherapy at 54Gy in our clinic. There has been no recognizable re-recurrence as of 2 years and 7 months after the second surgery. We have experienced a surgical case of a locally recurred chest wall desmoid tumor.

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The patient was a 74-year-old man who was pointed out an abnormality of the liver at a medical checkup and was revealed to have a nodule shadow with calcification in the right S10 segment by a subsequent lung CT scan. As the patient did not hope to receive close examinations including bronchoscopy, he had been followed by periodic CT scans. No changes had been seen until 2 years after his initial visit when the shadow showed an increasing tendency on CT. A possibility of malignancy could not be ruled out and bronchoscopy was performed that did not provide definite diagnosis. Thoracoscopy-assisted right S7+S10 segmentectomy was performed for diagnosis and treatment. A foreign body which appeared to be a fish bone and small quantities of pus were present in the center of the nodule. Culture of the pus yielded Actinomyces. Pathological examinations revealed dilatation of the bronchus and granules of actinomyces within it, and pulmonary actinomycosis caused by the bronchial foreign body was diagnosed. It was still unclear whether he had accidentally breathed some foreign body or not. Even if we could not know whether the patient breathed a foreign body, we should differentiate a bronchial foreign body in diagnosing a localized shadow, a lesion within the bronchial wall, or a shadow with the center of hyper absorption. Furthermore we must keep in mind that pulmonary actynomycosis can be associated with a foreign body.

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A 57-year-old woman who had undergone total colectomy for sigmoid colon cancer and familial adenomatous polyposis 21 years earlier was seen at our hospital because of anal bleeding. Close exploration revealed advanced cancer of the remnant rectum and multiple nodules of the right lung suggestive of pulmonary metastases. Operation for the rectal cancer resulted in a local curative resection. As we determined these multiple nodules of the right lung to be possibly removed completely, right middle lobectomy, S6 segmentectomy, partial resections of S2, S8, and S10 were performed 50 days after the rectal operation. Before and during the operation, metastatic pulmonary tumors were suspected, but the histopathological diagnosis was multiple pulmonary sclerosing hemangiomas.
Pulmonary sclerosing hemangioma accounts for about 1% of all pulmonary tumors and multiple cases are rare. Such multiple hemangiomas lack specific imaging findings and it might be difficult to make diagnosis preoperatively in this case in which advanced rectal cancer was associated. However, we confirmed some imaging findings which should not be identical with those of metastatic pulmonary tumors. Furthermore, a comparison with the pathological findings disclosed that the CT findings refracted pathological characteristics of sclerosing hemangioma. In treating multiple pulmonary nodules, we should keep sclerosing hemangioma in mind as a differential diagnosis and carefully determine the therapeutic guideline considering a possible coexistence of other disease.

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A 78-year-old male patient was admitted to the emergency department complaining of epigastric pain and anorexia. He gave a history of having sustained a stab injury on the left side of his chest about 50 years previously. Two years previously, he was diagnosed as having diaphragmatic hernia, which had been treated conservatively at a private clinic. The associated symptoms of epigastric pain and anorexia sometimes recurred, and had worsened one week prior to admission. He complained of loss of appetite and was unable to eat anything at the time of admission. Physical examination showed abdominal distention and epigastric tenderness, with no evidence of peritoneal irritation. A plain abdominal X-ray and abdominal CT showed a gastric bubble in the left thoracic cavity, confirming recurrence of the diaphragmatic hernia associated with a gastric volvulus. Attempts to reduce the volvulus by upper gastrointestinal endoscopy failed. Surgical repair was performed four days after admission. The postoperative course was uneventful and the patient was discharged after one week.
In most cases of gastric volvulus associated with delayed posttraumatic diaphragmatic hernia, surgical management is required. We think that laparotomy is a better operative approach than thoracotomy, because it offers a clearer view and the capability of dealing with potential organ resection and repair.

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Esophago-pulmonary fistula with advanced esophageal cancer causes cough, pneumonia and malnutrition, therefore adversely affects quality of life. Palliative treatments such as stenting or bypass surgery are often selected. We report three cases of esophago-pulmonary fistula with esophageal cancer curatively resected. One patient was diagnosed with esophago-pulmonary fistula before treatment. She underwent two courses of chemotherapy in fasting. Remaining two patients were diagnosed with esophago-pulmonary fistula during treatments (chemotherapy in one and chemoradiotherapy in another). Despite temporary interruptions, the treatments were completed in them. Response evaluations resulted in partial response in all three patients, and then they underwent curative resection including partial pneumonectomy. Tumor cells had invaded the lung parenchyma in one case. All three patients had good postoperative courses, and they returned to their daily lives after discharge. Curative resection after chemotherapy or chemoradiotherapy can be a useful treatment for patients with esophageal cancer associated with esophago-pulmonary fistula.

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A 66-year-old man underwent radical total gastrectomy with Roux-en-Y reconstruction for gastric carcinoma. He complained of dyspnea, and chest computed tomography showed acute pulmonary empyema due to anastomotic leakage of the esophagojejunostomy on post operative day (POD) 5. Despite thoracic drainage and antibiotic therapy, a high fever persisted, and the same metallo-β-lactamase-producing bacteria were detected within the thoracic abscess and on blood cultures. The bacteremia persisted due to the continuous backflow of digestive juice to the thoracic cavity. Therefore, interruption of the continuity of the Roux limb without transection and jejunostomy for feeding were planned on POD 51. With continued thoracic drainage and antibiotic therapy, and with the initiation of enteral nutrition after the reoperation, the bacteremia disappeared on POD 69, and the anastomotic fistula was completely closed on POD 106. The staple lines of the Roux limb recanalized naturally, and the patient left hospital on POD 118. This case demonstrates the successful treatment of refractory anastomotic leakage of an esophagojejunostomy after total gastrectomy by interruption of the Roux limb.

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A 70-year-old man was found to have a tumor of the stomach. Upper gastrointestinal series, gastrointestinal fiberscope, and computed tomography showed a submucosal-like tumor on the anterior wall of the antrum. Biopsy indicated a poorly differentiated adenocarcinoma. A subtotal gastrectomy and D2 lymph node dissection were performed. The pathological examinations, including immunohistochemical staining, showed that the tumor and lymph node metastasis were pure neuroendocrine carcinoma with no adenocarcinoma element and a Ki67 labeling index > 80%. S-1 was prescribed as adjuvant chemotherapy for 1 year after surgery. Although gastric neuroendocrine carcinomas with a high Ki67 labeling index are rare with poor prognosis, the patient has been well, with no recurrence for 6.5 years. Herein, we report the patient's case with a review of the literature.

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A 74-year-old woman visited our department in March 2011 with chief complaints of low-grade fever and lower back pain. Blood biochemistry tests revealed disseminated intravascular coagulation, and multiple bone metastases to the spine, ribs, and pelvis were suspected from the osteosclerotic images on thoracoabdominal CT examination. Her past medical history included total gastrectomy to treat type III advanced gastric cancer in November 1997. A primary tumor could not be identified on gastrointestinal endoscopy and CT scans, and a detailed examination was scheduled. However, on the second day of hospitalization, the patient fell in her hospital room and suffered a head injury. She was diagnosed with an acute subdural hematoma, and a small emergency craniotomy was performed for hematoma removal ; however, the patient died on the fourth day of hospitalization. At a later date, pathological examination of the skull specimen from the craniotomy was conducted, and poorly-differentiated adenocarcinoma was detected. Although more than 13 years had passed since gastric cancer surgery, since there were no other lesions suspected as the primary tumor, and the histopathological images of the bone specimen and the gastric cancer were similar, the condition was diagnosed as multiple bone and bone marrow metastases caused by gastric cancer. Metastatic recurrence of gastric cancer over 10 years after surgery is extremely rare. These findings are reported with an additional literature review.

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Duodenal carcinoid tumors measuring less than 10 mm in diameter are generally considered to be associated with a low frequency of lymph node and distant metastases. Herein, we report the case of a 68-year-old man with a macroscopic carcinoid tumor measuring 8 mm in diameter at the duodenal bulb, with lymph node metastases. Preoperative abdominal CT revealed an 8-mm intrapyloric lymph node, although FDG-PET did not show accumulation in either the main tumor or in the lymph node. Distal gastrectomy with lymph node dissection (D1+) was performed, because two intrapyloric lymph nodes (2/3) detected intraoperatively were diagnosed by histopathology as metastases. However, since lymph node #13 (posterior surface of the pancreatic head) was diagnosed as being negative for metastasis, highly invasive surgery, e.g., pancreaticoduodenectomy, was avoided. The tumor was diagnosed by histopathology as NET G1 (carcinoid tumor) ; the Ki-67 (MIB-1) index of the main tumor was grade 1 (1.81% ; 44/2430), and the mitosis index was grade 1 (below 5/50 HPF). At present, one year since the surgery, the patient remains alive without recurrence. Thus, lymph node dissection should be carefully considered even in patients with tumors measuring less than 10 mm in diameter.

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The patient was an 84-year-old man who was referred to our hospital with abdominal pain. He had no history of previous abdominal surgery. He was diagnosed as having ileus, and a long tube was inserted, however, the acute abdominal pain recurred on the following day. Therefore, a laparotomy was performed. During surgery, the ileum was found to be obstructed by a loop of appendix epiploica of the sigmoid colon. The appendix epiploica was dissected. Bowel resection was performed because the incarcerated intestine was necrotic. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. Intestinal obstruction due to appendix epiploica is thought to be rare. There have been very few reports of strangulated ileus caused by epiploic appendages ; this is the 21th case report, with the exception of the conference record in Japan. We have discussed this case with a review of the literature.

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A 30-year-old woman visited our hospital with a chief complaint of abdominal pain. Abdominal ultrasonography revealed a multilocular cystic mass, 11 cm × 7 cm in size, on the left side of the abdomen, and it showed mobility in the direction perpendicular to the mesenteric axis. Since abdominal contrast-enhanced CT showed a fluid-fluid level in the cyst, intracystic hemorrhage was suspected. Although the mass had reduced in size with conservative treatment, due to considerations related to the risk of rebleeding and rupture, etc., laparoscopic-assisted resection was performed. Histopathologically, there was a mixture of D2-40-positive lymphatic malformation and CD31-positive/D2-40-negative venous malformation, and the patient was diagnosed with lymphatic-venous malformation of the small intestinal mesentery. At 3 years postoperatively, recurrence has not been observed.
Conditions that were previously referred to as lymphangioma and hemangioma have recently become classified under the ISSVA classification as lymphatic malformation and venous malformation. In Japan, there have only been 2 reported cases of the combination of small intestinal mesentery lymphatic malformation (lymphangioma) and venous malformation (hemangioma). Since this condition was thought to be extremely rare, the findings are presented along with a literature review.

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An asymptomatic 61-year-old man underwent an FDG-PET examination, and high FDG uptake was seen in the abdomen. Although sclerosing mesenteritis was suspected on several examinations, such as CT, MRI, and FDG-PET/CT, malignancies could not be ruled out. Thus, a laparoscopic examination of the abdomen was performed, and a thickened mesentery and yellowish fatty masses were observed. Sclerosing mesenteritis was confirmed by biopsies. At the time of writing, the patient continues to have no complaints, and this lesion has not changed over the six months of follow-up with no drug therapy.
In Japan, there have been no reports of an FDG-PET examination performed for sclerosing mesenteritis. Since FDG-PET examinations are being done more frequently, the number of similar cases that are difficult to distinguish from malignancies is expected to increase. In these cases, laparoscopic examination should be performed for a definitive diagnosis.

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We present two patients with enteropathy-associated T-cell lymphoma (EATL) combined with intestinal perforations. They were 53- and 74-year-old men who were diagnosed as having panperitonitis due to intestinal perforation, and underwent emergency surgeries. The former had multiple perforations in the small intestine and the colon. The latter had two lesions in the small intestine one of which was perforated. Despite the complete resection of the perforated bowels, the former patient died of multi-organ failure without receiving any chemotherapeutic agents on the 11^th postoperative day. Another patient also died of the disease 5 months after the surgery despite receiving postoperative chemotherapy.
A review of a total of 63 domestic cases disclosed that EATL carried an extremely poor prognosis, except few long-term survivors. Because EATL often appears as multiple lesions simultaneously, it is important to resect all lesions by investigating the entire bowels. Another issue which could contribute to long time survival of the patients with EATL with bowel perforation might be early postoperative chemotherapy for T-cell lymphoma as soon as possible.

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A 79-year-old man visited the emergency department of our hospital complaining of abdominal pain ; the patient was observed to have a bloody bowel discharge following admission. He had a history of myelodysplastic syndrome and chronic heart failure, and was warfarinized. After admission, his condition worsened. An emergency right hemicolectomy was performed in order to diagnose the cause of intra-abdominal bleeding. Surgery revealed massive bloody ascites and a large hematoma (15 cm in diameter) in the wall of the ascending colon, spreading to the adjacent mesentery. The cause of bleeding remained unclear. We assumed that the cause of bleeding was due to the combined effect of myelodysplastic syndrome and warfarinization. Forty-one cases of intramural bleeding of the alimentary tract have been previously reported.

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A desmoid tumor is a rare tumor that develops in soft tissue. The case of a 61-year-old man who developed a sporadic desmoid tumor with the primary site at the serosa of the transverse colon is presented. A mass near the transverse colon was discovered on abdominal contrast-enhanced CT examination after gastric cancer surgery. At the 6-month follow-up, enlargement of the tumor was observed (from 18 mm to 63 mm), and the patient subsequently underwent surgery. Laparotomy findings showed a pedunculated contiguous tumor from the transverse colon, and the transverse colon and tumor were resected together in one lump. Immunohistological staining showed the tumor to be a desmoid tumor. Moreover, the tumor developed from the colon serosa towards the outer wall of the intestinal tract, and the primary site was therefore considered to be colon serosa. There are very few cases of sporadic desmoid tumor, and this report is the first in Japan to describe intestinal tract serosa as the primary site of the tumor. Surgical resection is generally used to treat desmoids tumors. However, it has been reported that there is a high probability of local recurrence even with a negative microscopic margin. Thus, when there is high preoperative suspicion of a desmoid tumor, an operative procedure that ensures an adequate extent of resection should be considered.

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A man in his 30s who was diagnosed with ulcerative colitis 18 years previously was being treated with conservative therapy and underwent annual surveillance colonoscopies. A colonoscopy detected a 25-mm reddish neoplastic lesion in the rectum, and biopsy showed high-grade dysplasia. However, endoscopic ultrasonography, computed tomography, and barium enema indicated colitic cancer complicated by ulcerative colitis. A restorative total proctocolectomy and ilial pouch-anal anastomosis with D3 lymph nodes dissection was performed. The final pathological diagnosis was well-differentiated tubular adenocarcinoma > mucinous adenocarcinoma, SS (A), ly0, v1, n0, Stage II. Further analysis of the resected specimen indicated a complicated sub-mucinous cancer with widely spread low and high-grade dysplasia that almost reached the dentate line.

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A 59-year-old man visited a local doctor because of low abdominal pain and was referred to our hospital for careful investigation of an intra-abdominal tumor. Abdominal CT showed a necrotic mass measuring 12 cm in diameter in the abdominal cavity. Fiberoptic colonoscopy showed no apparent abnormalities. A laparotomy was performed, which revealed a tumor in the transverse mesocolon, that was found to be infiltrating the serosa of the colon. Peritoneal dissemination was detected in the mesentery proper, pouch of Douglas, and the surface of the left lateral segment of the liver. Tumorectomy, with removal of a part of the transverse colon was performed. Histopathological examination revealed no tubules, mucus production or neuroendocrine granules, suggestive of undifferentiated cancer. Mesenteric solid malignat tumors are extremely rare, and we discuss the origin of this cancer, together with a review of the literature.

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A 59-year-old woman with right lower abdominal pain and fever was admitted to another hospital and diagnosed as having colitis. However, the pain gradually worsened, and follow-up CT on day 10 after the symptom onset revealed findings suggestive of advanced ascending colon cancer. She was admitted to our hospital and diagnosed as having neuroendocrine cell colon cancer, Stage IIIb, based on the colonoscopy, histology and CT findings. Neoadjuvant chemotherapy was initiated with CDDP+CPT-11, a regimen commonly used for the treatment of small cell lung cancer, and partial response was obtained. The neoadjuvant chemotherapy was followed by laparoscopic-assisted right hemicolectomy ; the same regimen was then repeated after surgery, in combination with 5 courses of XELOX, as adjuvant chemotherapy. Until now, 18 months since the operation, there has been no evidence of recurrence. Neuroendocrine- type colon cancer is very rare and its prognosis is quite poor. Herein, we report a patient with neuroendocrine cell-type colon cancer, for which multidisciplinary therapies, including neoadjuvant chemotherapy, was effective. Especially, it is suggested that neoadjuvant chemotherapy is effective, because of the remarkable outcomes in this case and also in a previously reported cases.

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An 80-year-old man was admitted to our hospital with left lower abdominal pain 1 year and 5 months after surgery for left lung cancer (poorly differentiated adenocarcinoma, Stage IB). Abdominal computed tomography showed a sigmoid colon tumor with extramural invasion of the mesentery and transverse colon. Colonoscopy showed an elevated lesion, similar to a submucosal tumor, in the sigmoid colon. A gastrointestinal stromal tumor was suspected, and left hemicolectomy was performed. Analysis of the resected specimen indicated a 10 × 10 cm sarcomatoid tumor in the sigmoid colon that invaded the mesentery and transverse colon. Pathological examination of the tumor indicated spindle cell carcinoma. Immunohistochemical analysis of the tumor indicated that it was CK7 positive, and CK20 negative. Therefore, we diagnosed colon metastasis from lung cancer. Lung metastasis and pelvic recurrence were detected 3 months after the operation and the patient died 5 months after the operation. Colon metastasis from lung cancer is rare, and spindle cell carcinoma is extremely rare. We report this case with reference to the relevant literature.

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An 83-year-old man underwent laparoscopic low anterior resection for rectal cancer of Rs(SM, N1 (1/14), M0 Stage IIIa) 10 months earlier. No abnormalities were found during the post-operative course, but he was referred to the outpatient department due to an abdominal mass, 3.5 cm in diameter, below the navel. The tumor was visualized as a hard mass on ultrasound elastography, and the interior of the tumor mass on contrast-enhanced CT showed lighter contrast. The tumor showed high signal intensity on MRI diffusion-weighted imaging. Aspiration cytology of the tumor was negative. A port site recurrence of rectal cancer after surgery was suspected due to a history of cancer, and thus the mass was resected. On histological examination, an inflammatory granuloma was seen in the rectus abdominis muscle aponeurosis. No foreign body could be confirmed, and a diagnosis of Schloffer tumor was made. A subcutaneous mass of similar size (3.0 cm) appeared suddenly at the port site near the left lower quadrant of the abdomen two months later, and the patient underwent tumor resection of a suspected inflammatory granuloma. This case illustrates the difficulty in differentiating a Schloffer tumor from abdominal wall metastasis of cancer.

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A 73-year-old woman visited our hospital due to elevation of tumor markers (CEA : 142.1ng/ml, CA19-9 : 789.2U/ml). Nine years before admission, she had undergone low anterior resection with a diagnosis of rectal cancer and had been followed after a 2-year adjuvant chemotherapy. Abdominal CT scan revealed swollen lymph nodes around the abdominal aorta. PET-CT showed no abnormal uptake of FDG in another regions. Suspecting lymph node metastasis from rectal carcinoma, we conducted chemo-radiation therapy. The lymph nodes decreased in size rapidly and the elevated tumor markers decreased within normal limits. However, the lesion recurred 8 months after the therapy. Despite sustained chemotherapy, the disease gradually progressed and she finally died 49 months after the recurrence of the disease.
We present a case of rectal cancer with metastasis which occurred after a lapse of as long as 9 years after the initial radical operation.

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A 36-year-old man presented to our hospital with general fatigue and abdominal pain. His abdomen was swollen, and blood tests revealed severe anemia. Abdominal computed tomography revealed multiple isodense liver tumors, with contrast extravasation from some lesions. Transcatheter arterial embolization was performed and was successful in achieving hemostasis. Intra-abdominal hemorrhage from the hepatic tumors subsequently recurred, so transcatheter arterial embolization was performed a second time. His abdominal pain worsened the next day, along with hypotension and a rapid deterioration in his level of consciousness. Emergency surgery was therefore performed. Intraoperatively, bleeding was seen from multiple lesions in the liver. Complete hemostasis was impossible to achieve, so gauze tamponade was utilized. A second operation revealed that hemostasis had been achieved, and so we removed the gauze. Uncontrollable bleeding subsequently reoccurred. We explained his condition to his family, who decided against further invasive treatment. The patient died on post-operative day 5.

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An 82-year-old woman with non-alcoholic steatohepatitis and diabetes mellitus was diagnosed as having a liver tumor in S4/8 without lymph node and distant metastases, and she underwent laparoscopy-assisted hepatic resection. Histological findings showed moderately to poorly differentiated hepatocellular carcinoma and poorly differentiated cholangiocarcinoma coexisting in the tumor, and the surgical margin was negative. On the 26th postoperative day, she developed dyspnea and hypoxemia, and diffuse bilateral ground-glass opacities were seen on chest CT. This was considered to be acute respiratory distress syndrome. Though intensive treatment was started, she died of respiratory failure after 42 days. Necropsy examination of the lung showed proliferation of adenocarcinoma similar to the cholangiocarcinoma and extensive fibrillation in bilateral lungs, compatible with the diagnosis of pulmonary lymphangitis carcinomatosa. Several factors may have been responsible for the early postoperative lymphangitis carcinomatosa, including the cholangiocarcinoma component that was considered to have a higher grade of malignancy, aging, and increased surgical stress from the extensive liver resection area, which might have all accelerated tumor proliferation and metastasis.

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An 83-year-old man was brought into our hospital by ambulance because he had fallen from the second floor. He complained of right lateral chest pain. When he arrived at our hospital, the blood pressure was 64/58 mmHg, and the pulse was 74 times/minute. There were rebound tenderness and mild degree of muscular defense localized in the right hypochondrial region. On blood biochemical analysis, the Hb level was 9.1 g/dl, and there were no prominent abnormalities in liver function and increases in biliary enzyme levels. Ultrasonography revealed a swollen gallbladder with the edematous wall showing laminar thickening and air fluid level formation within the gallbladder. Abdominal CT scan revealed no ascites and the gallbladder wall to be thickened in low density area. Gallbladder injury due to a blunt trauma was likely. Emergency exploratory laparotomy was performed. Upon laparotomy, there were small quantities of serous ascites, the serosa of the gallbladder was intact, and the serosa from the gallbladder to hepatoduodenal mesentery was edematous and green in color, with a dark-red part. Cholecystectomy was thus performed. The resected specimen included an about 2-cm laceration on mucosa of the gallbladder bed. The histopathological findings included rupture of the mucosa and muscle layer at the lateral gallbladder bed and a subserosal hematoma. It is etiologically inferred that abrupt attraction and extension added to the gallbladder from the gallbladder bed to the cervical direction might have caused the mucosal laceration.

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We report a case of laparoscopic cholecystectomy performed for a pregnant woman with repeated cholecystitis due to gallbladder stone. A 35-year-old pregnant woman presented to our department with persistent epigastralgia at 21 weeks of gestation. Although her condition improved with conservative management, we were concerned about the risk of recurrent cholecystitis and of undernutrition caused by fasting. Furthermore, we thought it might be more difficult to perform cholecystectomy in the third trimester. Therefore, laparoscopic cholecystectomy was carried out during the 26th week of gestation. Laparoscopic cholecystectomy was performed under general anesthesia, under CO2 pneumoperitoneum (less than 8 mm Hg). We monitored the fetal heart movements using ultrasound during the operation. Ritodrine hydrochloride was administered by the gynecologist during the perioperative period to prevent premature labor. Her postoperative course was uneventful. She delivered a healthy baby girl at 36 weeks of gestation.

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A 69-year-old woman was found to have a tumor, 1.5 cm in size, at the head of the pancreas on abdominal CT examination that was performed for repeated bleeding of a diverticulum of the large intestine. PET-CT examination showed mild FDG accumulation at the tumor site, and pancreatic cancer could not be excluded. Under probable diagnoses of tumor-forming pancreatitis or pancreatic cancer, pancreaticoduodenectomy and right hemicolectomy were performed. The histopathological diagnosis was pancreatic hamartoma. Pancreatic hamartoma is extremely rare, and it is commonly found incidentally because it lacks specific clinical symptoms. Moreover, preoperative diagnosis can be problematic due to the variety of histological types, and the diagnosis is often made postoperatively. This case of pancreatic hamartoma is presented along with a review of the relevant literature and summary of reported cases.

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A 73-year-old man was admitted to our hospital because of general fatigue and dyspnea on exertion. Blood tests showed severe anemia (hemoglobin 4.8 g/dl), and a gastrointestinal endoscopy revealed a nodular lesion near the Vater's papilla. An abdominal computed tomography scan revealed a low density mass about 28 mm in diameter at the head of the pancreas. T2-weighted magnetic resonance imaging revealed an area of heterogeneous intensity, with a rim of low intensity area. Suspecting a solid pseudopapillary tumor, we performed a pancreatoduodenectomy.
The final histological diagnosis was a pancreatic neuroendocrine tumor (G2). Invasion of the duodenum by a nonfunctioning pancreatic neuroendocrine tumor is rare, with only 6 such cases having been reported in Japan.

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Solid pseudopapillary neoplasm (SPN) of the pancreas is generally regarded as a tumor of low malignant potential and distant metastasis is very rare. Here we report a case of a long-term surviving patient who underwent surgical resection of peritoneal dissemination of SPN. A 21-year-old female was referred to our hospital because of back pain. There was a previous history of undergoing pancreatic cyst-jejunostomy for a pancreatic pseudocyst due to a trauma at the age of 10. Abdominal computed tomography revealed a cystic mass in the pelvic cavity and a cystic lesion in the pancreatic tail. The pelvic tumor was resected and the histopathology revealed characteristic features of SPN. The cystic lesion of the pancreatic tail was subsequently resected and the patient was diagnosed with peritoneal dissemination from SPN of the pancreas. The patient remains in good health without having signs of recurrence, as of 9 years and 8 months after the first operation. Peritoneal metastasis from SPN is mainly caused by dissemination of tumor cells following rupture or surgical manipulation of SPN. Therefore, radical surgical resection of these lesions may improve therapeutic outcomes.

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The patient was a 78-year-old woman who underwent resection of the pancreas body and tail for a 12-cm solid pseudopapillary neoplasm at the pancreas body in 1997, which did not invade serosa, did not involve lymph nodes, and had not ruptured. An abdominal CT scan performed in 2010 revealed appearance of a 6-mm nodule in the anterior surface of the ascending colon. Thereafter the nodule increased to 16 mm in diameter, for that laparoscopy-assisted removal of the tumor was done in March 2013. The tumor was pathologically similar to the specimen resected in 1997. Namely the both specimens were positive for synaptophysin, vimentin, β-catenin, and CD10 and negative for AE1/AE3 and chromogranin A ; the Ki-67 labeling index being 5%. Further 3 months after the reoperation, six recurrent tumors were demonstrated on the diaphragm which required surgical removal. Metastasis or recurrence of the disease as peritoneal dissemination has been rarely reported. In this case, 16 years had elapsed after the initial operation when peritoneal dissemination occurred as recurrence, but there were no findings suggesting a biologically intensified malignant potential.

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A 24-year-old woman who returned to Japan from Malaysia 8 days earlier developed diarrhea and abdominal pain. She was transported to our hospital, where physical examination disclosed severe tenderness and peritoneal signs over the entire abdomen. Abdominal enhanced computed tomography showed ascites and portal vein gas without free air. A preoperative diagnosis of diffuse peritonitis due to perforation or necrosis of the intestinal tract was considered, and emergency laparotomy was performed. Upon entering the peritoneal cavity, purulent ascitic fluid of approximately 1 L was encountered. No intestinal tract necrosis or perforation was identified. The omentum had no evidence of twisting or abscess formation, but it was dark red, and was resected due to suspected inflammatory change. No gynecologic inflammatory disease was identified. Ascitic fluid drawn for cultures subsequently grew Fusobacterium species in pure culture, and the diagnosis was spontaneous bacterial peritonitis, which has been reported in patients with liver cirrhosis, nephrotic syndrome, and immunodeficiency disease. However, spontaneous bacterial peritonitis occurs rarely in young, healthy people. Thus, a case of such a disease in a young, healthy woman caused by Fusobacterium species is presented along with a review of the relevant literature.

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A 77-year-old woman who had been on hemodialysis for chronic renal failure elsewhere presented to a previous hospital because of vomiting and abdominal pain, when she presented with hypotension and shock. She was referred to our hospital with a diagnosis of panperitonitis. A contrast-enhanced abdominal CT scan showed collection of ascites and bowel dilatation. Panperitonitis caused by bowel ischemia was suspected and an emergency operation was performed on the same day. During surgery, there was defluxion of massive white purulent fluid, but no abnormalities were found in the digestive tract. The wall of the urinary bladder extensively became necrotic, and two perforated sites were seen at the top of the bladder which changed to black in color. Simple cystectomy was performed with a diagnosis of necrosis and rupture of the urinary bladder. It was etiologically considered that rupture of the urinary bladder might occur due to gangrenous cystitis caused by chronic cystitis in a hemodialysis patient. Rupture of the urinary bladder caused by gangrenous cystitis is so rare that only five cases, including our case, have been reported in Japan, as far as we could review. Preoperative diagnosis was difficult and the prognosis was poor. We present this case, together with a review of the literature.

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A 56-year-old woman was admitted to our hospital because of cholelithiasis. Abdominal computed tomography (CT) showed a 40-mm intra-abdominal mass under the liver, and celiac angiography showed a hypervascular tumor with a rich vascular supply from the gastroduodenal artery, etc. A laparoscopic resection was performed without intraoperative hypertension. The solid tumor was located in the greater omentum and had an encapsulated surface. The histopathological diagnosis was paraganglioma. The patient has remained free of disease for 16 months. To the best of our knowledge, this is only the fifth reported case of greater omentum paraganglioma.

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A 20-year-old man, who had been involved in a traffic accident while driving a scooter, was transferred to our facility. A computed tomography examination showed a 4 cm × 6 cm defect in the aponeurosis adjacent to the left rectus abdominis and a herniation of the small intestine below the subcutaneous tissue. We suspected a traumatic Spigelian herniation and operated immediately. There was a defect of approximately 7 cm in the aponeurosis of the external abdominal oblique muscle and transversus abdominis, along the rectus sheath. The final diagnosis was a traumatic Spigelian herniation. There was no other damage to the abdomen, and we performed a simple closure of the fascia. The patient was uneventfully discharged on postoperative day 7 and remained well, with no recurrence of herniation at the 21-month follow-up examination. Given that traumatic Spigelian herniation is rarely reported in our country, we have reported this case, along with a review of the literature.

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A 45-year-old woman was seen at our emergency clinic because of lower abdominal pain. On physical examinations, slight degree of tenderness was present at the scar of previous cesarean section, but there were no rebound tenderness and muscle guarding. A contrast enhanced abdominal CT scan revealed dilatation of the small intestine, but no findings suggesting strangulation were seen. Multiple uterine myomas and endometrial cystic lesions in the pelvis and narrowing intestine in the surrounding area were suspected. Thereafter conservative therapy was unsuccessful, and the patient was operated on. Operative findings showed a normal ovary, absence of endometrial findings, an about 7-cm long intestine which had impacted into the right pararectal fossa, and a defect in the peritoneum at the same region. Internal incarcerated hernia was thus diagnosed. The defect was closed by simple suture and partial resection of the small intestine was performed because the herniated small intestine became necrotic. The patient's postoperative course was uneventful and she was discharged from our hospital on the 21^st postoperative day. She has been free from recurrence as of 6 months after the operation.
Although internal hernia arisen in the pararectal fossa is very rare, it must be kept in mind as a differential diagnosis of intestinal obstruction of unknown origin.

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The incarceration of the vermiform appendix within a femoral hernia is a rare entity. It is called de Garengeot's hernia and has rarely been reported in Japan. This paper deals with two cases of de Garengeot's hernia with a review of the literature.
Case 1 involved a 93-year-old woman who presented to our hospital because of a gradually enlarging right inguinal bulge. Following ultrasonography and contrast-enhanced CT scan, incarceration of the vermiform appendix within a right femoral hernia was diagnosed and an emergency operation was performed. Laparoscopy-assisted surgery was initiated, but the incarceration was irreducible. After transected the appendix at its base, we converted to the inguinal method, removed the appendix, and repaired the hernia by using UHS^® mesh. Case 2 involved a 38-year-old man complaining of lower abdominal pain who was referred to our hospital with a suspicion of incarcerated inguinal hernia. A simple abdominal CT scan offered a diagnosis of incarceration of the appendix vermiform within a right femoral hernia. Emergency operation was performed on the same day. We selected to approach via the inguinal method, resected the appendix and repaired by McVay method. Both two patients have not experienced either postoperative complication or recurrence of hernia.

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A 32-year-old woman presented to our hospital because of right lateroabdominal pain. Abdominal CT scan showed a tumor 12 cm in diameter at the right lobe of the liver. We found a type 0-IIa lesion on the greater curvature of the gastric upper body in gastrointestinal endoscopic examination. The result of gastric biopsy was tub2-por1. HBs-Ag and HCV-Ab were negative, and she had no liver disease. She had a mild developmental disorder. Hepatocellular carcinoma associated with early gastric cancer was diagnosed. We decided to perform hepatic resection at first. We performed right lobectomy of liver by laparotomy and right thoracotomy under general anesthesia. After the operation, she needed mechanical ventilator support because her spontaneous breathing was not satisfyingly restored due to prolonged muscular relaxation. At this time, myotonia phenomenon was confirmed by a neurologist. Since her uncle and mother were found to have myotonic dystrophy (MD) by a patient interview, she was diagnosed with MD. She left from respirator on the 2nd postoperative day. One month later, she was performed endoscopic submucosal dissection for the gastric cancer.
Twelve months have passed after the hepatectomy when she is doing well without having recurrence. Although the combination of MD and a malignancy is rare, we should be careful for perioperative management.

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