Purpose : In the present study, we aimed to evaluate the outcome of emergency tension-free hernia repair using mesh for incarcerated groin hernias.
Methods : We conducted a retrospective study of patients who underwent emergency hernia repair for incarcerated groin hernias between 2001 and 2012.
Results : In total, 94 patients (55 with inguinal hernias and 39 with femoral hernias) underwent emergency surgery. Patients were divided into two groups : group A (23 patients ; hernia repair with bowel resection) and group B (71 patients ; hernia repair without bowel resection). We evaluated the difference in the background and outcomes between patients who underwent tension-free mesh repair and conventional repair. Among the group A patients, 2 patients, who underwent conventional repair and bowel resection due to bowel perforation, developed surgical-wound infections. No major complications or recurrences occurred in any of the patients.
Conclusion : Tension-free hernia repair with using mesh can be safely employed in incarcerated inguinal hernia surgery without any complications. Moreover, even in cases without any bowel perforation, tension-free mesh repair may be useful if bowel resection is needed.

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We clinicopathologically studied a total of 13 cases of breast neuroendocrine ductal carcinoma, including four cases of non-invasive and the remaining nine cases of invasive, treated at our hospital in the past five-year period from 2007 to 2012. A mean age of the patients was 67.6 years, ranging from 43 to 82. There was 12 women and one man. In all cases except one in which we could not obtain data, both ER and PgR were positive. HER2 was negative in all cases except one case of DCIS. Most patients were seen at our hospital after they noticed a breast mass, and some patients complained of abnormal nipple discharge. Tumorous lesions were revealed on MMG in most cases. On immunestaining, CD56 was positive in 12 out of 13 cases, synaptophysin was positive in all the 13 cases, and chromogranin A was positive in five out of seven cases. By conducting two kinds of immunostainings at least, we confirmed the differentiation toward neuroendocrine carcinoma. The Ki-67 level was elevated in three out of six cases. All the patients have been well without recurrence as of April 2013.
Neuroendocrine ductal carcinoma in situ of the breast is a relatively rare entity. We must further accumulate clinical cases to study the therapeutic methods and the prognosis of the disease.

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Invasive micropapillary carcinoma (IMC) is a cancer histologically characterized by micropapillary neoplastic structures lacking a fibrovascular core and surrounded by clear, empty spaces that mimic lymphovascular invasion. IMC has been reported to affect the breast, urinary tract, lung, and salivary gland. In a recent three-year period from January 2009 to December 2011, a total of 298 cases (320 lesions) of colon cancer were performed surgical resection at our hospital. Of these cases, IMC component was identified in nine cases (nine lesions) (IMC group). In the non-IMC group (289 cases), there were 153 cases of patients who had not experienced metastasis (metastasis-negative group ; Stage 0-II), while there was only one metastasis-negative case in the IMC group. There were 118 metastasis-positive (Stage III-IV) cases in the non-IMC group, versus eight metastasis-positive case in the IMC group. Among 233 cases excluding stage IV cases, recurrence was noted in 25 (11%) out of 227 cases in the non-IMC group, and in five (83.3%) out of six cases in the IMC group. IMC has a high grade malignant potential and has already progressed when it is diagnosed in many cases. The recurrence rate is also high.

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Since 2005 when the aluminum potassium sulfate and tannic acid (ALTA) regimen was clinically introduced for internal hemorrhoids, it has become widespread from its simplicity and safety. However, few reports on the therapeutic outcome have been reported. We present therapeutic outcomes of ALTA regimen used in a total of 310 cases of internal hemorrhoids in our department. The mean observation duration was 32 (5 to 65) months. The mean operation time was 15 (4 to 27) minutes. The mean total injected volume of ALTA was 25 (6 to 40) mL. The mean injected dose of ALTA was 10 (6-15) mL per one injection. Complications were noted in 28 cases (9%), all of which were relieved conservatively. Recurrence was noted in 10 cases (3.2%). These recurrences appeared as re-prolapse of internal hemorrhoid in eight cases and as swelling of external hemorrhoid component in two cases. When recurrence cases were compared with non-recurrence cases, there were no satistically significant differences in age, sex, Goligher classification, operation time, number of hemorrhoids treated, and injected dose of ALTA. A study of recurrence cases disclosed that more recurrent lesions were present in the right anterior area ; and the recurrences appeared in a two-peak fashion, namely early recurrence within five months and late recurrence 17 months after the operation. Re-treatment with ALTA regimen was conducted for these recurrent cases.
The ALTA regimen is a therapy for benign disease internal hemorrhoid and can be applied for recurrent hemorrhoids. The ALTA regimen appears to be one of standard therapies for internal hemorrhoids in terms of its superior low invasiveness and safety.

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Here, we report a case of non-functioning parathyroid carcinoma. A 62-year-old man was referred to our clinic for evaluation of a nodule located posterior to the left thyroid lobe. Ultrasonography revealed a hypoechoic round mass, 12 mm in diameter, which was preoperatively diagnosed as a parathyroid tumor on the basis of the PTH level in the fine-needle aspirate. Under the diagnosis of an intrathyroid non-functioning parathyroid adenoma, the tumor was first excised with the surrounding thyroid parenchyma. After a pathological diagnosis of parathyroid carcinoma was made, left thyroid lobectomy with lymph node dissection was also performed. However, no residual tumor was detected in the specimen. No evidence of disease recurrence has been noted for more than 1 year of follow up.

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A case of epithelioid hemangioendothelioma that was difficult to differentiate from breast cancer preoperatively is described. The patient was a 50-year-old woman who presented with a chief complaint of a mass in her right breast. On palpation, a mass approximately 5 mm long was palpable in the lower outer quadrant of the right breast. On mammography, a focal asymmetric density (FAD) was observed, and on breast ultrasound, a well-defined, oval, hypoechoic mass (category 3b), 0.4 cm × 0.4 cm in size, was detected in the lower outer quadrant of the right breast. Histopathological findings on needle biopsy of the breast included irregular arrangement and proliferation of spindle cells, as well as degeneration and necrosis. A malignant tumor, spindle cell carcinoma, was suspected preoperatively, and quadrantectomy and sentinel lymph node biopsy were performed. The patient had a favorable postoperative course and was discharged on day 7. On histopathological evaluation of the resected sample, a diagnosis of epithelioid hemangioendothelioma originating in soft tissue near the breast was made. Epithelioid hemangioendothelioma may originate from any site in the body, but it is said to occur commonly in organs such as the lungs and the liver, and it rarely develops in the breast. The present case is reported along with a review of the relevant literature.

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We report a case of mammary pseudoangiomatous stromal hyperplasia (PASH) with an axis longer than 15 cm and a cystic component in a postmenopausal woman. The 63-year-old woman complained of a left breast mass. The mass was about 15 cm diameter. Ultrasonography showed a mixed type mass with a cystic component. Core needle biopsy indicated PASH, so a tumor excision was performed. Post-operative histopathological diagnosis was the same as the preoperative diagnosis. In immunohistochemical staining, CD34 and vimentin were negative, CD31, factor VIII, ER and PgR were also negative. We report this case together with a review of the literature.

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A case of radiation-induced angiosarcoma that occurred 5 years and 8 months after initial breast conservative surgery is described.
The patient was a 32-year-old woman who had undergone breast conservative surgery for left breast cancer when she was 25 years old, followed by CMF therapy and radiation therapy with a total dose of 50 Gy. Five years and 3 months after the initial operation, an episode of blunt trauma to the residual left breast caused internal bleeding with purpura. Since the hematoma continued for 5 months, and a tumor-like nodule developed, a needle biopsy was performed, and a radiation-induced angiosarcoma was diagnosed. She underwent a mastectomy with wide skin excision and adjuvant systemic chemotherapy with paclitaxel. However, multiple liver and bone metastases and local recurrence occurred 1 year after the second operation. She deteriorated rapidly and died 4 months after the recurrence.
Radiation therapy is commonly performed after breast conservative surgery. Radiation-induced angiosarcoma is very rare, and its prognosis is extremely poor. We must keep this disease in mind as a harmful complication of radiation therapy and should strive for its early detection and treatment.

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A 68-year-old woman diagnosed with T4cN3cM1 (OSS) Stage IV (solid tubular carcinoma, ER+, PgR+, HER2-, Ki67 labeling index : < 14%) left breast cancer was started on weekly paclitaxel plus bevacizumab (BEV) plus zoledronic acid. Although a favorable response was obtained from an early stage of treatment, the patient developed hypertension and proteinuria, thought to be adverse events associated with BEV. She developed sudden, severe back pain during the 5^th course and visited the outpatient emergency department. The cause of the pain could not be identified on plain computed tomography (CT) performed during this visit, but the symptoms improved with analgesics and rest. Subsequently, on contrast-enhanced CT performed at the completion of the 9^th course, aortic dissection (DeBakey IIIb) was incidentally detected. Because the possibility of this finding being an adverse event associated with BEV could not be ruled out, BEV was discontinued, an antihypertensive agent was started, and serious outcomes were prevented with conservative treatment. This is the first report of a case of aortic dissection occurring during administration of BEV for breast cancer as part of the postmarketing surveillance of BEV in Japan.

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A 70-year-old man who had been aware of recurrent bouts of nasal bleeding since around 50 years of age was pointed out a tumorous shadow in the left middle lung field on a chest x-ray examination at a medical checkup 6 years ealier, but he let it alone without any treatment. Recently he was seen at the Department of Cardiovascular Diseases in our hospital because of dyspnea, when blood analysis revealed severe anemia with the Hb level of 3.4g/dl due to recurrent bouts of nasal bleeding. In addition, an increase in size of the tumorous shadow and bilateral pleural effusion which might be caused by right heart insufficiency were demonstrated. Echocardiography showed a high right atrial pressure of 50 mmHg. Three-dimensional-CT scan reveled an about 6-cm sized pulmonary arteriovenous fistula at the left upper lobe. Accordingly the patient was transferred to our surgical department for the purpose of surgery. His family members were confirmed also to have recurrent bouts of nasal bleeding, and Rendu-Osler-Weber disease (ROW) was strongly suspected. Pulmonary arteriovenous fistula associated with ROW was thus diagnosed. At surgery, left upper lobectomy was performed under left posterolateral thoracotomy. His anemia showing the Hb level of 3.4 g/dl before the operation was improved up to 11.2g/dl after the operation when he was discharged. The SaO2 level was also improved from 93% before the operation to 97% (room air) after the operation. The patient was discharged on the seventh hospital day.

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A 72-year-old man with dysphagia was referred to our hospital because he suffered from difficulty in swallowing. Esophagography and computed tomography revealed a 5×4 cm diverticulum filled with saburra in the middle thoracic segment of the esophagus. He underwent a thoracoscopy assisted diverticulectomy.
According to the operative findings and pathological findings, we diagnosed this diverticulum as a mixture of traction and pulsion diverticulum.
Recently, there have been some reports of esophageal diverticulectomy by thoracoscopic surgery. Here, we report our experience of the efficient use of thoracoscopically assisted esophageal diverticulectomy in combination with gastroendoscopy.

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A 52-year-old male patient was referred to our hospital because of a 2-year history of dysphagia with suspected diffuse esophageal spasms. Upper gastrointestinal endoscopy and chest computed tomography showed no apparent abnormalities. Conventional esophageal manometry indicated that the lower esophageal sphincter (LES) pressure and the residual pressure were 49.0 mmHg and 30.4 mmHg, respectively. These findings revealed no relaxation of the LES. Esophageal body manomery findings showed retrograde peristalsis in all 10 wet swallows. The diagnosis was made as non-specific esophageal motility disorders (NEMD), and laparoscopic Heller myotomy and Dor fundoplication was performed. The operative time, estimated blood loss, and peri-operative complications were 210 minutes, a little, and none, respectively. He was discharged on the post-operative day 4 and has been followed in the clinic. After the surgical treatment, dysphagia had completely disappeared. Retrograde peristalsis was entertained, which to date has not been reported.

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We report a case of a giant hyperplastic polyp of the stomach. A 74-year-old woman was diagnosed with a hyperplastic polyp of the stomach. She referred to our hospital because of rapid growth of the polyp. Gastrointestinal endoscopy revealed a giant polyp more than 10 cm in diameter.
Pathological examination of the polyp determined it was hyperplastic and the surrounding gastric mucosa also showed hyperplasia. Comorbid malignancy was suspected because of the size of the polyp, so we carried out a total gastrectomy to resect the giant polyp, including the surrounding mucosa. The pathological diagnosis was hyperplastic polyp and the size of the polyp was 11×8 cm, no comorbid of malignancy was seen. The carcinogenesis from a giant hyperplastic polyp is not uncommon. When a giant polyp is difficult to resect endoscopically, surgical resection should be considered.

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A 69-year-old woman was referred to our hospital because of appetite loss and a palpable abdominal tumor. Imaging diagnostic methods revealed a well demarcated tumor with the heterogeneous center part in the right upper quadrant of abdomen. Gastrointestinal stromal tumor (GIST) was suspected and the patient was operated on. At surgery we identified a 15-cm diameter tumor in the subserosal structure at the lesser curvature of the stomach, and performed partial gastrectomy. Pathological findings primarily suggested GIST on hematoxylin/eosin staining. Immunohistochemistry, however, showed that the tumor was KIT (-) and CD34 (+), and did not harbor c-kit gene mutation and platelet-derived growth factor receptor α (PDGFRA) gene mutation. Finally c-kit gene mutation negative and PDGFRA gene mutation negative, high risk GIST was diagnosed. Adjuvant chemotherapy was considered, but imatinib has not been administered because no gene mutations are seen and her clinical course is under observation.

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A 61-year-old man with chief complaints of upper abdominal pain and fever was referred to our hospital. Dilation of the gallblader and common bile ducts and a hemorrhagic tumor, 1.5 cm in size, in the duodenal papilla were detected, and poorly-differentiated adenocarcinoma was diagnosed based on biopsy. Based on a diagnosis of cancer of the duodenal papilla, subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) was performed, and the results of histopathological examination, including immunostaining of the resected specimen, gave a final diagnosis of carcinosarcoma. The patient was discharged on postoperative day 38 and, based on his request, received no adjuvant therapy. On postoperative day 49, the patient visited our hospital with complaints of cold limbs and abdominal pain, and the onset of multiple liver, residual pancreatic, and lymph node metastases, as well as peritoneal dissemination, was evident. The patient had severe anemia due to intra-abdominal hemorrhage resulting from the recurrent tumor, and his condition rapidly deteriorated despite transfusions and other treatments. He subsequently died on postoperative day 63. Carcinosarcoma of the duodenal papilla is an extremely rare disease, having only been reported in five patients, including the present case. Although all patients were treated with surgery, three developed liver metastases and died within eight months following surgery, suggesting that this disease has a poor prognosis, as with carcinosarcoma of other organs.

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We experienced a case of pneumatosis cystoides intestinalis (PCI) that was completely treated with hyperbaric oxygen. An 83-year-old woman was admitted to our hospital due to fever, diarrhea and abdominal distention. Abdominal X-ray film revealed a lot of intraperitoneal free air, so we suspected perforation of the gastrointestinal tract. However, abdominal computed tomography (CT) scan showed pneumatosis in the intestinal wall, and we diagnosed it as PCI. Because the patient did not show any abdominal muscle guarding, we chose a conservative therapy. However, the CT scan on the 6^th day did not show a reduction of the pneumatosis in the intestinal wall and intraperitoneal free air. Therefore, on the nineteenth day, we started hyperbaric oxygen therapy and the CT scan on the twenty-sixth day showed that the peumatosis was no longer visible in the intestinal wall and there was no intraperitoneal free air. It has been reported that hyperbaric oxygen is effective for PCI, so if we diagnose a patient having PCI without abdominal muscle guarding, we should choose treatment with hyperbaric oxygen.

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A 70-year-old man, who had a medical history of a total gastrectomy with splenectomy for early gastric cancer, came to our hospital complaining of strong abdominal pain that had suddenly emerged an hour before. On physical examination, he showed abdominal pain with muscular defense. The abdominal computed tomography (CT) revealed whirl sign. He was diagnosed with a strangulated ileus, and an emergency operation was performed. On laparotomy, we found milk-colored ascites that indicates chylous ascites. The small intestine was twisted 720 degrees and caused ischemic change. The bowel resection was not necessary because blood flow was quickly recovered after detorsion. We fixed the small intestine to the mesentery of the colon and used an ileus tube as the internal fixation to prevent recurrence. His post-operative course was good without recurrence for over 2 years.

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The three siblings described here consisted of the elderly daughter who had been conservatively treated for acute appendicitis, the son and the younger daughter. Case 1) : The younger daughter, 15 years old, was admitted to our hospital because of right lower quadrant abdominal pain. The physical examination revealed tenderness in the right lower quadrant of abdomen. CT examination showed a swollen appendix. She was diagnosed with acute appendicitis and underwent appendectomy. Retrocecal gangrenous appendicitis with a fecalith was finally diagnosed. Case 2) : The son, 17 years old, was admitted to our hospital because of right lower quadrant abdominal pain with a fever. There were rebound tenderness and muscular defense in the right lower quadrant. An abdominal CT examination showed a fecalith. He was diagnosed with acute appendicitis and underwent appendectomy two days after the younger daughter's operation. Retrocecal phlegmonous appendicitis with a fecalith was finally diagnosed. This simultaneous occurrence of acute appendicitis in the siblings might be owing to some hereditary factor generating retrocecal formation of the appendix which might cause appendicitis in addition to dietary factor, infection and information. We emphasize the importance of family history in the treatment and indication of surgery for acute appendicitis.

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The classification of appendiceal mucinous tumors is controversial, and a strategy of treatment has not yet been established. Here, we report a case of low-grade appendiceal mucinous neoplasm (LAMN) in a 78-year-old man hospitalized owing to abdominal pain. Abdominal CT showed cystic dilatation of appendix. We diagnosed appendiceal tumors and performed ileocecal resection with lymph node dissection. The appendix was swollen to 6 cm in diameter, and there was accumulating mucus within the lumen. The proximal end was invaginated into the cecum. The pathological diagnosis indicated LAMN. Recent research has recognized that LAMN is potentially malignant because of its nature as the precursor to disseminated pseudomyxoma peritonei. Therefore, appropriate surgical intervention with careful postoperative surveillance should be considered to achieve a successful long-term outcome.

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The patient was a 76-year-old woman who had been pointed out having a vesicoenteric fistula since 4 years earlier. As she had undergone surgery for right inguinal hernia and a tumor was revealed in the right lower quadrant of abdomen on abdominal CT scan, it was likely to be foreign-body granuloma due to the mesh or to be relevant to any tumor of appendix. No increases in tumor makers (CEA and CA19-9) were noted. At laparotomy, a tumor which appeared to be primary appendiceal tumor was present in the right lower quadrant. The tumor had involved the mesh, and further invaded the bladder to form a vesicoenteric fistula. The removal of the tumor involving the ileocecal region was performed with associated partial resection of the bladder. At the same time the mesh was also removed. The histopathological diagnosis of the tumor of appendix was low-grade appendiceal mucinous neoplasm.
Mucocele of appendix is a relatively rare disease, and most rare of all is such a case as the disease has formed a fistula with other organ. This paper presents our experience with a case of mucocele of appendix with vesicoenteric fistula formation involving the mesh after surgery for inguinal hernia, together with a review of the literature.

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A case of appendiceal endometriosis is reported. A 45-year-old woman was seen at another clinic for bloody stool. Barium enema demonstrated a cecal tumor, and she was sent to our hospital for further examination. Abdominal CT showed cystic changes of the appendix. She was diagnosed as having an appendiceal mucocele. However, mucinous cystadenoma and mucinous cystadenocarcinoma of the appendix could not be excluded, so a laparoscopic ileocecal resection with lymph node dissection was performed. Microscopic findings showed endometrial stroma and glands in the appendiceal mucosa, submucosa, muscularis propria, and subserosa, and she was diagnosed with appendiceal endometriosis. Appendiceal endometriosis should be considered when diagnosing appendiceal mucocele.

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A 73-year-old man developed abdominal pain after straining his abdomen due to constipation. He had undergone repair of an abdominal incisional hernia using a composite mesh in another hospital at the age of 67 years. He visited our hospital after 2 days because his abdominal pain persisted. Abdominal CT showed gas and an irregularly deformed mesh in the abdominal wall. A diagnosis of mesh infection due to intestinal penetration was made, and an emergency operation was performed. The composite mesh had been placed in the abdominal cavity, and folding of the mesh margin toward the abdominal cavity was observed. The mesh had adhered to, and had penetrated, the cecum. The mesh was removed, and the penetrated area was closed with sutures. For abdominal incisional hernias, repair using a composite mesh is widely performed. When the polypropylene mesh layer is exposed to the abdominal cavity, there is a risk of its strong adhesion to the intestinal tract, causing intestinal obstruction and enterocutaneous fistula. Therefore, mesh fixation at the abdominal wall requires careful attention.

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An 80-year-old woman receiving anticoagulant therapy was seen at our hospital because of abdominal pain 10 days after she had fallen down during walking. A series of detailed examinations showed accumulation of bloody ascites and a tumor-like mass of the colon at the splenic flexure, which was suggestive of an intramural hematoma of the colon. The patient's general condition was improved by conservative treatment, and abdominal symptoms soon subsided. However, severe abdominal pain suddenly developed 16 days after the episode of the trauma, and therefore enhanced computed tomography was immediately performed, leading to the diagnosis of perforation of the digestive tract. An emergency surgery demonstrated that the perforated site was located at the splenic flexure and surrounded with resolving intramural hematoma of the colon ; therefore, segmental colon resection and colostomy were chosen as the operative strategy. The histopathological findings showed formation of granulation tissue replacing rupture of the muscular layer, and relatively-chronic ischemic changes of the colon wall. Until now, only four cases of delayed colon perforation after an abdominal blunt trauma have been reported in the Japanese literature. In all reported cases, ischemic changes of the colon wall secondary to the blunt injury might be associated with the cause for delayed perforation. Likewise, in our case, the same underlying mechanism might be deeply involved in delayed perforation, but in particular, bleeding tendency associated with anticoagulant therapy might aggravate acute colonic intramural hematoma due to the blunt abdominal trauma, resulting in worsening of ischemic changes of the colon wall, followed by perforation of a fragile site.

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A 61-year-old woman hospitalized for schizophrenia consulted our hospital because of aggravation of abdominal pain lasting for 3 days. Blood analysis revealed severe leukocytosis and an elevated level of CRP. Contrast-enhanced abdominal CT scan showed marked dilatation of the transverse colon. Volvulus of the transverse colon was suspected. Since we judged that the medical repositioning might entail a high risk of inducing perforation, we performed an emergency surgery. Operative findings included that the transverse colon showed necrotic changes for almost full length and moderate amount of hemorrhagic ascites was accumulated. We performed transverse colectomy and functional end to end stapled anastomosis. Postoperative progress was good, and she was transferred to the psychiatric hospital 10 days after the operation. Colonic volvulus accounts for approximately 3% of all colorectal mechanical obstructions. Moreover transverse colonic volvulus is rare, because 90% of colonic volvuli affect the sigmoid colon. In our case, transverse colonic volvulus developed in this patient during hospitalization for schizophrenia. Since she had been suffering from chronic constipation due to administration of plural psychotropic drugs, bowel motility disorder was considered to be an onset factor of colonic volvulus. Fortunately postoperative progress was good by colectomy and primary reconstructive surgery in our case. It is important for this disease to choice the appropriate therapeutics based on etiology. We report a case of transverse colonic volvulus with schizophrenia with a review of the literature.

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A 38-year-old man was admitted to a nearby clinic for abdominal pain and abnormal stools. A tumor was seen involving the entire circumference of the sigmoid colon on lower gastrointestinal endoscopy, and the biopsy showed group 5 (adenocarcinoma). Abdominal computed tomography showed liver and adrenal gland lesions, leading to a diagnosis of multiple organ metastases of colon adenocarcinoma. Surgery was performed because of the abdominal pain caused by the stenosis. Peritoneal dissemination was found during surgery. On pathological examination, the diagnosis was primary choriocarcinoma of the colon. The patient then underwent chemotherapy based on the colon adenocarcinoma (mFOLFOX6+ bevacizumab), but liver function deteriorated rapidly, and he died of hepatic failure 59 days after surgery.
Primary gastrointestinal choriocarcinoma is rare ; only 10 cases of primary colonic choriocarcinoma have been reported worldwide. Since metastases are very likely to be present at the initial visit, as in the present case, these patients' prognosis is very poor.

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We report a patient with a huge and high-risk gastrointestinal stromal tumor (GIST) of the rectum treated with imatinib mesylate followed by laparoscopic intersphincteric resection. A 43-year-old man presented with difficulty in defecation and melena lasting for 2 months. Colonoscopy revealed a submucosal tumor in the anterior wall of the lower rectum, and computed tomography showed the solid mass measuring 90 mm in diameter which compressed the prostate and rectum. On digital examination, a protruding tumor was palpated at the anterior wall of the rectum, about 3 cm proximal to the anal verge. Transrectal needle biopsy revealed proliferation of spindle cells arranged in fusiform fashion which was positive for c-kit and CD34 immunostaining, indicating GIST of the rectum. Because the tumor was large that might demand difficulties in performing surgery and the patient hoped to preserve the anus, neoadjuvant treatment with imatinib mesylate was performed for six months. When the tumor was confirmed to decrease to 45 mm in diameter, he underwent laparoscopy-assisted intersphinteric resection with partial resection of the prostate. The present case suggests that neoadjuvant therapy with imatinib mesylate is useful for large rectal GISTs from the standpoint of preservation of the anal function and less invasive surgery.

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A 79-year-old Suggest adding gender : man or woman, who showed a high level of carcinoembryonic antigen (CEA) in a routine blood examination. Enhanced abdominal computed tomography (CT) study showed a tumor on the left side of the rectum, 23×22 mm in diameter, with heterogeneous staining. Colonoscopy revealed a submucosal tumor and normal mucous membrane. Under suspicion of a malignant tumor, a laparoscopy-assisted lower anterior resection was performed. Histopathologically, the diagnosis was a moderately differentiated tubular adenocarcinoma. There was no continuity between the cancer and the mucous membrane, and no primary tumors were found in the other organs. In a review of the literature, only 13 reports of rectal cancer which occurred in the submucosa were found in Japan.

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An extremely rare case of rectal cancer complicated by crossed fused ectopic kidney is reported. The patient was a 70-year-old man in whom rectal cancer was detected on colonoscopy conducted due to a positive fecal occult blood test, and who was diagnosed with crossed fused ectopic kidney during preoperative testing. Crossed fused ectopic kidney has been reported to often involve vascular and ureteral malformations, as with other renal malformations such as horseshoe kidney. In order to ensure safe surgery, it is necessary to determine the course of the vessels and ureters preoperatively. In the present case, abdominal contrast-enhanced computed tomography angiography (3D-CTA) was used to preoperatively confirm the course of the vessels and ureters. As for surgery, laparoscopic high anterior resection was performed using the medial approach. By detaching tissue along the ventral layer of the subretroperitoneal fascia, the ureters, gonadal arteries and veins, and autonomic nerves were preserved on the dorsal side, and surgery could be completed without damaging them. The present case suggests that, even in cases complicated by renal malformations, laparoscopic surgery can be safely performed by maintaining the correct detachment layer.

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We report a case of a 76-year-old man, who visited another hospital due to a persistent bloody stool during the previous 6 months. The colonoscopy revealed two type-2 cancers on the sigmoid colon and the lower rectum (Rb). A mediastinal lymph node was found to be enlarged and positron emission tomography indicated high uptake in the mediastinal lymph node and a retroperitoneal mass (left pararenal area). We diagnosed it as double cancer of the sigmoid colon and Rb with a mediastinal lymph node metastasis and retroperitoneal tissue metastasis (M1). At the time of surgery, the mediastinal lymph node dissection was performed first, and the frozen section diagnosis was not metastasis but lymphoma, therefore the retroperitoneal mass and rectal resection were resected by lymphadectomy with a transverse colostomy. Histopathological findings showed a diffuse large B-cell lymphoma of the mediastinal lymph node and the left pararenal area. Such a case is rare, so we report with a review of some of the literature.

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A 40-year-old male underwent an emergent laparoscopic cholecystectomy for acute cholecystitis in March, 2012. At the time, abdominal computed tomography showed a liver hemangioma, measuring 55 mm in size, with extrahepatic growth at segment 4. The laparoscopic cholecystectomy was completed without complications, and a laparoscopic hepatectomy for the hemangioma with extrahepatic growth was subsequently performed in May, 2012. The wound of the previous operation was used. Blood loss was 20 mL, and the operating time was 141 min. The postoperative course was uneventful, and the patient was discharged from the hospital on the fifth postoperative day. Liver hemangioma with extrahepatic growth is considered a relative indication for surgery to avoid rupture. Only 12 cases of hemangioma with extrahepatic growth treated with laparoscopic hepatectomy have been reported in Japan. However, due to its minimally invasive nature, this procedure is a superior method for benign tumors such as hemangioma.

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A routine medical checkup revealed a very large hepatic cyst in a 52-year-old woman, who was referred to our hospital for epigastric discomfort. Contrast-enhanced CT showed a cystic lesion within the right lobe of the liver. It was 18 cm in diameter, with sharply defined margins and smooth, thin walls. In an MRI, the cystic lesion was homogeneously hypointense on T1-weighted imaging and homogeneously hyperintense on T2-weighted imaging. The communication between the cyst and the biliary tree could not be identified. Laparoscopic deroofing was performed after diagnosis of a symptomatic simple hepatic cyst. During this maneuver, a connection between the hepatic cyst and the biliary tree was found. The lesion was closed by laparoscopic suturing. We reported a rare case of hepatic cyst with biliary communication that was successfully treated by laparoscopic surgery.

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A 59-year-old man with fever was referred to our hospital under a diagnosis of liver abscess. The laboratory data showed mild leukocytosis and elevated serum level of C-reactive protein. Abdominal enhanced CT and MRI showed a mass of 45 mm in size, demonstrating an early ring-like enhancement, in the anterior segment of the right hepatic lobe. The patient eventually underwent hepatic resection not only because his clinical condition did not improve even after percutaneous drainage but because his serum CA 19-9 levels showed an increasing trend. The surgically resected liver revealed a relatively well-defined grayish-white solid mass showing extensive central necrosis and infiltrative growth margin. Histopathological examination revealed a diffuse proliferation of oval or short spindle-shaped neoplastic cells, and immunostaining confirmed the final diagnosis of sarcomatoid carcinoma, possibly derived from cholangiocarcinoma. Despite aggressive treatment, the patient died on 39th day after the surgery due to cancerous pleuritis and multiple bone metastases. The development of sarcomatoid carcinoma of the liver is reportedly associated with prior treatments such as transarterial chemoembolization, while the present patient had no history of anticancer therapy. This very rare case with some bibliographical comments is presented.

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A 65-year-old man who was diagnosed with rectal cancer underwent laparoscopic assisted low anterior resection with D3 lymph node dissection (well differentiated adenocarcinoma, ss, n0). After the surgery, he received transverse colostomy because of anastomotic leak with generalized peritonitis. Five months later, CT showed a 25-mm tumor at S5 of the liver. He was referred to our hospital with a diagnosis of liver metastasis of the rectal cancer. He underwent subsegmentectomy of the liver and closure of the colostomy. The resected specimen included a 19 × 18 mm well-circumscribed solid tumor with no malignant findings. The tumor was composed of many formations of granuloma with central necrosis. Grocott staining confirmed small spherical structures of fungal spore. These findings were consistent with a diagnosis of inflammatory granuloma of fungi. It seems that generalized peritonitis induced by anastomotic leak might cause this tumor, because no liver tumor was present at the initial operation. We report the clinical course of inflammatory granuloma in this case with bibliographic consideration.

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We report a case of a communicating accessory bile duct (CABD) with gallbladder stones. A 60-year-old woman pointed out having gallbladder stones at a mass examination was admitted to our hospital for surgical treatment. When she was in her fifties, dilatation of the common bile duct was detected, but endoscopic retrograde cholangiopancreatography (ERCP) revealed no abnormal findings. Thereafter her clinical course had been followed until this episode. Contrast enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed gallbladder stones 2 cm in diameter in the gallbladder neck and mild dilatation of the intrahepatic and common bile ducts, but no abnormalities of the bile duct were detected before operation. Laparoscopic cholecystectomy was performed and a CABD between the gallbllader neck and the right anterior branch was detected by intraoperative findings and intraoperative cholangiography. The CABD was ligated and divided with surgical clips. Although increased serum concentrations of hepatic enzymes were observed in postoperative course temporaliry, she was discarged on day 9 after the operation.

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A 58-year-old female was referred to our hospital from a nearby physician because of impaired liver function. Blood analysis revealed a slightly elevated level of transaminase. Abdominal CT scan revealed wall thickening of the middle and lower bile duct. MRCP and percutaneous transhepatic cholangiography revealed stenosis of the middle and lower bile duct. The stenosis was seen to taper off. Bile duct cancer was suspected and pancreatoduodenectomy was performed. The resected specimen showed black bilirubin pigment deposited to the mucosa of the narrowed lesion and wall thickening of the bile duct. Histopathology showed no malignancy but revealed findings of cholangitis with necrosis affecting the full thickness of the bile duct. In addition, there were no findings of primary sclerosing cholangitis and IgG4 positive cholangitis. In this paper, we report a case of inflammatory sclerosing biliary stricture from unknown origin, which needed differentiation from bile duct cancer.

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A 45-year-old woman visited our hospital because of the presence of an abdominal tumor on palpation. Abdominal CT showed a low-density, well-circumscribed mass in the pancreas head measuring 8 cm in diameter. MRI of the pancreas revealed a hypointense mass on T1-weighted images and a hyperintense mass on T2-weighted images. Magnetic resonance cholangio-pancreatography showed no marked change in the main pancreatic duct and common bile duct. Angiography showed tumor vascularization with the superior anterior and posterior pancreaticoduodenal arteries as the feeders. We preoperatively diagnosed the condition as a solid pseudopapillary tumor from the pancreas and performed a pancreatoduodenectomy. The tumor was solid, with strong myxomatous degeneration with a film-forming of 80 mm in the histopathological exam. Histopathology of the pancreatic tumor also revealed a schwannoma and no sign of malignancy. S-100 protein was detected by a immunohistochemical stain. Pancreatic schwannoma is very difficult to diagnose preoperatively. In cases of pancreatic schwannoma, surgical resection should be considered because of the possibility of malignancy.

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A 74-year-old man who visited a neighboring hospital because of epigastric discomfort was found having a submucosal tumor lesion at the posterior wall of the gastric antrum by gastric endoscopy. He was referred to the Department of Digestive Medicine in our hospital and was diagnosed with moderately to poorly differentiated adenocarcinoma by a boring biopsy. On abdominal CT scan, invasion into the anterior surface of the pancreas and lymph node metastasis were suspected. Neoadjuvant chemotherapy was employed with a diagnosis of gastric cancer cT4b cN1 cM0 cStage IIIb, and 2 courses of TS-1 + CDDP and 2 courses of TS-1 alone were performed. Following the chemotherapy, the pancreatic invasion was ameliorated and the swollen lymph nodes diminished in size. Thereafter the patient was referred to our department. We performed distal gastrectomy and D2 dissection. Histopathological study showed tumor cells associated with a mucin lake and neighboring ectopic pancreatic tissue and ducts with nuclear atypia. Mucinous carcinoma of the ectopic pancreas was thus diagnosed.
Ectopic pancreatic carcinoma is a rare entity and we often have difficulties in making diagnosis before surgery. By closely examining endoscopic and abdominal CT findings, we have to consider the disease as well as submucosal type gastric cancer and GIST as possible differential diagnosis and to select appropriate and sufficient operative procedures including lymph node dissection.

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A 64-year-old woman who felt something wrong around the navel was found having a mass lesion in the pancreatic body. Computed tomography (CT) only revealed an enhanced marginal lesim in the delayed phase. Magnetic resonance imaging (MRI) showed slightly high signal in T1-weighted image and low signal in T2-weighted image. Positron-emission tomography (PET) and studies on tumor markers gave negative findings. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) also revealed no recognizable tumor cells. Based on these findings, we diagnosed the case as solid pseudopapillary tumor and made operative procedure. During surgery, the mass was found in the tissue at where the pancreas was adjacent to the splenic artery, and it was uncertain if the primary focus was in the pancreas. The resected specimen pathologically showed that spindle-shaped cells were growing, nuclear atypism was low, and no pancreatic tissue was found. In addition, Bcl-2 and CD34 were positive in immunostaining. According intraperitoneal solitary fibrous tumor was diagnosed.

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The patient was a 67-year-old man who had begun experiencing abdominal distention in August 2012. When concomitant dorsal pain developed, he visited a physician. A large volume of ascites was visible during an abdominal ultrasonography, and the patient was referred to the Department of Gastrointestinal Medicine of our hospital. CT showed a 6-cm ischemic mass accompanied by calcification directly below the lower median abdominal wall, and bladder infiltration was suspected. Moreover, a large volume of ascites and nodes in the greater omentum was noted. FDG-PET showed accumulation in the greater omentum, but accumulation in the mass was mild. Cystoscopy showed only exclusion by the tumor. On the basis of these findings, the physicians suspected urachal cancer accompanied by peritoneal dissemination, and the patient was referred to our department for excisional biopsy. The abdominal cavity contained 3,500 ml of yellow ascites, and many peritoneally disseminated nodes were present in the greater omentum and mesentery. The tumor was continuous with the bladder through infiltration. The greater omentum and a part of the bladder were removed by combined resection. The postoperative recovery was smooth, and the patient was discharged on day 8. Histopathological examination showed that the tumor was mucinous adenocarcinoma and was continuous with the residual urachus below the bladder mucosa. Thus, the tumor was diagnosed as urachal cancer. The patient is now under systemic chemotherapy treatment with mFOLFOX6+bevacizmab.

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Urachal carcinoma grows invasively and metastasizes locally in most cases. We have experienced a rare case of urachal carcinoma causing solitary bone metastasis without local recurrence after radical operation.
A 77-year-old man with previous histories of pulmonary emphysema and arrhythmia underwent total cystectomy with en bloc removal of the tumor and radical lymphadenectomy under the diagnosis of urachal carcinoma in April 2004. The histopathological diagnosis was well differentiated adenocarcinoma (pT3b, n0, m0). He had been followed after 2 courses of adjuvant chemotherapy (CDDP + 5-FU). In February 2008 he was given close examinations because right chest pain developed, and an image study showed a 3-cm mass shadow in the right 7^th rib without other abnormal lesions. Although tumor markers were in normal limits, we suspected primary bone tumor or bone metastasis from urachal carcinoma, which is a rare manifestation in bladder carcinoma. In March 2008, the patient was re-operated on for the solitary bone tumor. The tumor was 3.0 × 3.0 cm in size. The histological findings of the specimen were extremely similar to those of the previously resected urachal carcinoma. He remains free from the disease 5 years after the second operation. Although bone metastasis of urachal carcinoma is rare, periodic observation for probable bone metastasis might be required.

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A 60-year-old man presented with gradually increasing abdominal pain for 10 days. Abdominal computed tomography (CT) showed an omental abscess and chronic inflammatory lesions due to a fish bone penetration. Laparoscopic partial omentectomy was performed and histological examination of the resected specimen revealed omental actinomycosis. The patient received 1 month of antibiotic therapy with oral penicillin G and achieved complete clinical recovery 19 months after the operation.
The perforation and penetration of the digestive tract due to an ingested fish bone can cause acute or chronic inflammation. We experienced the latter provoked by actinomycosis, inducing chronic inflammation forming an abscess or a fistula. We revealed from literature search that the type of pathogenic bacterium may make the difference between acute or chronic inflammation. Moreover, we reported the appropriate administration period of antibiotics and the efficacy of laparoscopic surgery.

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A man in his sixties had visited hospital because of an abdominal mass. A huge mass was detected in the abdomen, and therefore, he was admitted to our hospital. Computed tomography and magnetic resonance imaging revealed a tumor, 30 cm in size, with a mixture of adipose tissue and areas of calcification. Surgery was performed, and the tumor was found to be located in the retroperitoneal and properitoneal space. The resected specimen was 30 × 25 × 14 cm in size and weighed 5,500 g. Histopathologically, the adipose tissue component was diagnosed as well-differentiated liposarcoma and the calcification was diagnosed as low-grade osteosarcoma. The final diagnosis was a extraperitoneal well-differentiated liposarcoma with a low-grade osteosarcoma component. The patient has been well for 14 months after the surgery.

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Encapsulating peritoneal sclerosis (EPS) is a disease that affects peritoneal dialysis patients and can cause intestinal obstruction resulting from adhesions and encapsulation. On the other hand, refeeding syndrome is a syndrome that induces heart failure and spasm mainly due to a decrease in the phosphorus level when rapid glucose loading is given to individuals who have been starved. In this paper we present a case of EPS associated with refeeding syndrome.
A 41-year-old woman underwent ablation of adhesions for EPS and infusion therapy at a dose of 1000 kcal/day was initiated. The serum level of phosphorus decreased to 0.6 mg/dl on the fifth day after the initiation when signs of heart failure appeared. Thereafter administration of phosphorus resulted in stabilization of the symptoms. In our department, refeeding syndrome has been noted in about 50% of survivors after surgery for EPS. EPS is considered to entail a high risk of causing refeeding syndrome, so that appropriate supplementation of energy and electrolytes is required under careful monitoring.

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The case involved a 52-year-old male who underwent renal transplantation in 2005 and, subsequently, axillo-femoral bypass surgery with a vascular prosthesis in 2008. He presented with the complaints of a bulge with pain in the right inguinal region since a month earlier, and the right inguinal hernia was diagnosed. It was shown that the subcutaneous vascular prosthesis was located ventrally and the implanted ureter might run dorsally close to the right inguinal canal based on nonenhanced CT scan. Lichtenstein procedure was selected with a skin incision made parallel to the vascular prosthesis on the caudal site of the inguinal canal. We avoided exposure of the prosthesis, keeping it embedded in the subcutaneous fat tissue. Mild adhesions were seen around the inguinal canal and spermatic cord. The hernia was finally diagnosed as supravesical class II-1 hernia. For the inguinal hernia surgery after kidney transplantation, Lichitenstein operation is considered suitable to avoid an inadvertent injury to the implanted ureter.

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A 75-year-old man had not received treatment for an enlarging right inguinal hernia. Visiting our hospital, he presented with a right groin swelling to the size of an infant's head, and groin reached under the middle point of the thigh. Computed tomography revealed that the hernia contained omentum and the ileocecal portion of the intestine, and the diameter of hernia orifice was 56 mm. During the intraoperative period, using the inguinal method we reduced the content of hernia and returned it to the abdominal cavity, and performed reefing of the hernia orifice, in addition to reinforcing the rear wall of the inguinal canal by the Lichtenstein repair. Additionally, using single-incision total extraperitoneal repair (TEP) we reinforced the myopectineal orifice (MPO) by attaching a mesh. With the addition of the single-incision laparoscopic approach, which can minimize any additional skin incisions and facilitate the laparoscopic approach by ceding the exfoliation of the hernia sac to the inguinal method, it could be a good candidate for the treatment of giant inguinoscrotal hernia.

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The patient was a 67-year-old woman with a history of surgery for left and right inguinal hernias. She presented to our hospital with chief complaints of epigastric pain, right upper leg pain, and right inguinal swelling. The symptoms had resolved, and the right inguinal swelling was no longer visible at the time of the medical examination. CT herniography was performed, and the patient was diagnosed with a right femoral hernia and a right obturator hernia. The surgery involved the Kugel method, and a Kugel patch (M) was placed covering the obturator canal. CT herniography is a plain pelvic CT that is performed after herniography with the patient in the prone position. It is invasive and requires high technical proficiency. CT herniography is an imaging method that should be considered for inguinal or pelvic hernia that is difficult to diagnose.

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Reports of incarcerated femoral hernias treated with laparoscopic surgery are rare. We report two patients with incarcerated femoral hernias repaired with a transabdominal preperitoneal approach (TAPP). Case 1 was a 77-year-old woman with a two-day history of abdominal pain and nausea who was referred to the emergency department of our hospital. CT showed a left incarcerated femoral hernia. Because strangulation of the incarcerated femoral hernia was strongly suspected, we performed emergency surgery via the TAPP. We could confirm the viability of the incarcerated bowel laparoscopically. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. Case 2 was a 76-year-old man with right groin pain who was referred to our hospital. CT showed a right incarcerated femoral hernia. We performed emergency surgery with TAPP because the incarcerated femoral hernia could not be reduced manually. It was easy to reduce the hernia laparoscopically, and we could confirm that the incarcerated femoral hernia was not strangulated. The postoperative course was uneventful, and the patient was discharged on the third postoperative day. Laparoscopic surgery is useful for easily reducing incarcerated femoral hernias and affords the opportunity to inspect the incarcerated bowel for determining its viability.

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