[in Japanese]

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The AirSeal Intelligent Flow System (iFS) presents some advantages in maintaining stable pneumoperitoneum (even under automatic and continuous suction) and continuous smoke evacuation throughout a surgical procedure. We evaluated the usefulness of the AirSeal iFS in an animal model and in a clinical setting. The suitability of the AirSeal iFS with respect to ease of operation and the suitability of the workspace were evaluated in the animal model. A total of 120 patients who underwent video-assisted thoracoscopic surgery for esophageal cancer were comparatively evaluated for surgical outcomes by dividing them into two graups ; 60 patients using the AirSeal iFS and another 60 patients using a conventional system. Thoracoscopic operative time, thoracoscopic blood loss, and intraoperative body temperature were analyzed. The mean thoracoscopic operative time was significantly shorter in the AirSeal iFS group than in the conventional group. The mean thoracoscopic operative blood loss in the AirSeal iFS group was significantly less than that in the conventional group. Intraoperative body temperature was significantly lower in the AirSeal iFS group than the other at 1 hour after the commencement of the operation and at the completion of procedures in the thoracic cavity. The difference in the body temperature between the two systems 1 hour after the operation had been completed was not statistically significant. The results indicate that the AirSeal iFS is a good smoke evacuation system, provides a good field of view, and maintains pressure well. All these factors lead to a shorter procedure time and less blood loss, with good maintenance of pneumoperitoneum.

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Cardiovascular disease is a risk factor of causing perioperative complications in performing esophagectomy for esophageal cancer, and the usefulness of β-blocker to prevent such complications has been reported. This time we present three patients operated on for esophageal cancer associated with severe cardiovascular disease who could be dealt with careful perioperative management. Case 1 involved a 79-year-old man who had LtcT3N1M0 esophageal cancer associated with triple-vessel disease. Following neoadjuvant chemotherapy, we performed esophagectomy with reconstruction by laparotomy-right thoracotomy approach, and managed him by administering percutaneous β-blocker during perioperative period. Case 2 involved a 73-year-old man who had Ut cT1bN1M0 esophageal cancer with non-ischemic cardiomyopathy (EF 32%). He was operated on by two stage operation, in whomβ-blocker was administered orally before surgery and via percutaneous route after surgery. Case 3 involved a 65-year-old man who had Lt cT3N1M1 (LN104R) esophageal cancer with stenosis of the left main coronary trunk. The case was of remnant cancer after radical chemoradiotherapy. We performed salvage operation (esophagectomy by laparotomy-right thoracotomy approach) and managed by administering β-blocker orally before surgery and via percutaneous route after surgery. In conclusion, all patients who had esophageal cancer with severe cardiovascular disease could be successfully managed during perioperative period by cooperating with other departments and by using oral and/or percutaneous β-blocker.

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Kugel repair refers to the use of the open transinguinal preperitoneal approach with preperitoneal self-expanding mesh. From January 2003 to December 2014, 2363 patients (2594 lesions) with inguinal hernias underwent Kugel repair. The mean operation time was 23 ± 13 min (median 20 min) and the operation time in patients with recurrent hernias (n = 133, 41 ± 29 min) was significantly longer than that in patients with primary hernias (n = 2461, 22 ± 11 min, p < 0.001). Overall, 20 patients (0.8%) relapsed after Kugel repair. With respect to complications, intraoperative urinary bladder injury occurred in five cases, massive bleeding in one case, postoperative intestinal obstruction in one case, mesh infection in one case, and chronic neuralgia in one case. Four of five cases with urinary bladder injury and one case with postoperative intestinal obstruction were patients with recurrent hernias after preperitoneal prosthetic repairs. Using preperitoneal self-expanding mesh, Kugel repair can cover the entire myopectineal orifice. All types of primary inguinal hernias and recurrent hernias after conventional and Lichtenstein repairs can feasibly be treated by Kugel repair. However, patients with previous preperitoneal prosthetic hernia repairs or a history of prostate cancer surgery should avoid Kugel repair because of the risk of complications due to preperitoneal adhesions.

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A man in his 60s had undergone left nephrectomy for renal cell carcinoma (RCC) 14 years ago. After two partial pneumonectomies for lung metastases performed 4 and 6 years ago, the patient had remained under regular follow-up. He was referred to our surgical department with the chief complaint of a neck mass. Ultrasonography showed some swelling of the cervical lymph nodes and a thyroid tumor occupying the left lobe. Fine-needle aspiration of both masses revealed metastatic RCC. CT showed a right aberrant subclavian artery. Total thyroidectomy and lymphadenectomy were performed. A non-recurrent inferior laryngeal nerve (NRILN) arising directly from the right cervical vagus was observed and preserved during the operation. Pathological studies established the diagnosis of metastatic RCC to the thyroid gland. A NRILN must be anticipated when a right aberrant subclavian artery is diagnosed preoperatively. When a patient with a previous history of RCC presents with some symptoms, imaging examinations are necessary owing to the possibility of delayed metastasis.

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The frequency of occurrence of mammary phyllodes tumors is about 0.3-1% or less of all mammary gland tumors, and the most frequent age of onset is in the 40s. Onset in the 10s is considered rare. We encountered a case of benign phyllodes tumor occurring in an 11-year-old girl, and report it here with a discussion of the literature. She was referred to our department with the chief complaint of a 3-cm right breast tumor showing indications of growth over the course of about two months. Needle biopsy led to a diagnosis of fibroadenoma, and imaging also yielded findings consistent with fibroadenoma, but in biopsy. Pathological results identified benign phyllodes tumor. Phyllodes tumors are often difficult to differentiate from fibroadenoma, and preoperative differentiation in the present case was challenging in light of the symptoms, images, and histological findings. Considering the possibilities of relapse or malignancy, it would be desirable for resection to include a margin of safety. However, particularly regarding benign tumors in young individuals, there is room for investigating whether to perform resection with an added margin or to perform re-excision. Careful determination of the treatment strategy is needed, including close follow-up.

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Since non-neoplastic apocrine lesions sometimes lack myoepithelial cells, histologic evaluation of malignancy becomes difficult in low-grade apocrine tumors. We report a rare case of male intracystic apocrine papillary tumor of the breast. The patient was a 50-year-old man with a soft mass of the right breast. Ultrasonography showed a multicystic tumor with intracystic solid components. Nineteen months later, the mass had enlarged more than three times in size, and contained irregular thickening of septa. Cytological examination revealed papillary proliferation of apocrine cells with uncertain malignancy. He thus underwent total excision of the tumor. Histopathological examination revealed that all papillary structures comprised apocrine cells with low-grade cytological atypia and a lack of myoepithelial cells according to immunohistochemical examination. Based on clinical and pathological findings, we diagnosed encapsulated apocrine papillary carcinoma (EAPC) with low-grade malignancy. To the best of our knowledge, this is the first report of EAPC of the male breast.

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Dermatomyositis (DM) is complicated by malignancy in many cases, and cases associated with interstitial pneumonitis (IP) are reported to have a poor prognosis. We encountered a surgical case of premenopausal breast cancer that complicated IP and co-developed into DM and pneumomediastinum. The patient was 35-year-old woman examined for a chief complaint of a right axillary mass, decreased grip strength, and respiratory discomfort. After careful examination, the patient was diagnosed with DM, IP, and right breast cancer (T2, N2a, M0, and stage IIIa). Because patients with IP are treated with cyclophosphamide (CPA), EC therapy (epirubicin+CPA) was initiated as preoperative chemotherapy. However, the IP worsened and pneumomediastinum developed. Since the primary lesion did not decrease (but metastasis to the axillary lymph node shrunk), the patient underwent surgery. After the operation, the pneumomediastinum promptly disappeared and both DM and IP improved, suggesting that the DM and IP was a paraneoplastic syndrome of breast cancer.

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The patient was a 44-year-old woman. At the age of twelve, she had been diagnosed as having von Recklinghausen's disease associated with scoliosis. Since then, she had a long history of X-ray exposure for the scoliosis. In April 2012, she noticed a left breast tumor with bloody discharge. Computed tomography demonstrated a breast tumor, 6 cm in diameter, and enlarged ipsilateral axillary lymph nodes.
Core needle biopsy revealed invasive ductal carcinoma with ER (-), PgR (+), HER2 (1+). After neoadjuvant chemotherapy, modified radical mastectomy with axillary lymph node dissection (Bt+Ax) was performed. On pathological examination, the tumor was classified as pT4c, pN0, M0, stage IIIB, Grade 1b.
Reports of breast cancer supervening on von Recklinghausen's disease are increasing. It is well known that nearly 10% of von Recklinghausen's disease cases are associated with scoliosis. As in our case, patients with von Recklinghausen's disease associated with scoliosis show an elevated risk of developing breast cancer due to frequent X-ray exposure. We report a case of breast cancer supervening on von Recklinghausen's disease, and also discuss the potential risk of developing breast cancer from X-ray exposure.

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In February 201X, a 40s man was admitted to our hospital with a 1-week history of abdominal pain and vomiting. Physical examination revealed tenderness of the abdomen as well as rebound tenderness. Abdominal X-ray revealed a number of calcifications around the ascending colon and a niveau of the small intestine, however, no free-air was observed. Abdominal contrast-enhanced CT revealed calcification of the right colonic vein, contrast defects, and wall thickening of the ascending colon. Under the diagnosis of necrosis of the ascending colon, emergency laparotomy was performed. At the operation, necrosis of the bowel segment from the ascending colon to the center of the transverse colon was observed, therefore, resection was performed. Histopathology revealed a mucosal ulcer, calcification of the venous wall, and extensive fibrosis of the submucosal layer. The patient was diagnosed as having IMP. He was discharged after 16 days. In this case, the patient had taken the Chinese medicine (Shishihakuhitou^®) for 10 years, and our findings suggested a possible etiological association of the condition with the Chinese medicine. Currently, the patient has stopped taking this drug and is under observation.

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A 73-year-old man was admitted to our hospital because of an abnormal shadow on a chest roentgenogram, and was diagnosed with lung cancer. Chest computed tomography (CT) scan revealed absence of the infrarenal inferior vena cava (IVC), and development of tortuous, dilated lumbar venous collaterals to the azygous and hemiazygous veins. It also demonstrated a large tumor that was suspected to have partially invaded the dilated azygous vein and right upper bronchus. After remarkable shrinkage of the tumor by neoadjuvant chemotherapy, surgical resection was performed without combined resection of vessels in April 2008. Histological efficacy for the primary lung cancer was evaluated as pathological complete response (pCR). Thereafter, the serum CEA level increased, and we successfully performed surgeries for sigmoid colon cancer with liver metastasis in May 2009, for local recurrence to the anastomosis in December 2010, and new primary lung cancer in May 2014. The patient has been free from relapse up to now. These anomalies of the IVC can have significant clinical implications. Awareness of these anomalies is nesessary to avoid surgical pitfalls. It is important to pay attention to possible bleeding and maintenance of blood flow during surgery for lung cancer or colorectal cancer in such patients.

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A 48-year-old man visited a local hospital with the chief complaint of pyrexia. A chest X-ray film revealed pneumonia with atelectasis involving the entire left lung field. Findings suggestive of a neoplastic lesion in the left main bronchus were seen on chest CT, and a polypoid neoplastic lesion, which was substantially occluding the left main bronchus, was identified on bronchoscopy. Bronchoscopic findings suggested a benign tumor, and the patient was thus referred to our department to undergo bronchoscopic resection. Resection was performed under general anesthesia using a high-frequency electrosurgical snare, and low-grade mucoepidermoid carcinoma was diagnosed. Resection of the left main bronchus was performed in a second stage as a radical operation after waiting for the pneumonia in the left lung to improve. Presently, five years and six months have passed since the surgery without relapse. By performing surgery in two stages, the accurate preoperative diagnosis was obtained, and by bringing about an improvement in the pulmonary infection, there were no postoperative complications. It is believed that for low-grade bronchial tumors accompanying by obstructive pneumonia, two-stage surgery should also be considered.

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A 78-year-old man was referred to our hospital because of a tumor shadow in the right lower lung field on a chest x-ray film at a medical checkup. Chest CT and PET/CT scans revealed a 3.2-cm tumor in the middle lobe of the right lung and abnormal uptakes of FDG in the lower part of the right lobe of thyroid, right supraclavicular lymph nodes, and subcarinal lymph nodes. A CT-guided biopsy of the lung tumor revealed squamous cell carcinoma. Carotid ultrasonography revealed sporadic hypoechoic areas with the maximum diameter of 7 mm in the lower part of the right thyroid lobe, but we could not determine the areas as thyroid tumors. A fine needle biopsy of the right supraclavicular lymph nodes offered the diagnosis of lymph node metastasis of papillary carcinoma of the thyroid. We thus diagnosed the case as cN2 lung cancer associated with thyroid cancer, and performed right middle lobectomy of lung (ND2a-1) and right thyroid lobectomy (D2a).
CN3 lung cancers are not be candidates for surgery in many cases, if thyroid cancer is absent. In treating patients with lung cancer who also have nodules in the neck, we have not to make diagnosis easily as cN3 lung cancer, but have to differentiate from lymph node metastasis of thyroid cancer, parathyroid cancer, neurogenic cancer, or malignant lymphoma in order to pursue the surgical indication.

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An 86-year-old woman was diagnosed with a Morgagni foramen hernia combined with an esophageal hiatal hernia 3.5 years ago based on an abnormal abdominal roentgenogram. A wait-and-see approach was taken because she had no symptoms, and computed tomography (CT) revealed a hernia of the greater omentum protruding into the right thoracic cavity through the foramen of Morgagni. This time, she complained of difficulty in breathing on exertion, and was referred to our hospital. Surgery was performed because CT demonstrated growth of the hernial orifice and content. A laparoscopic operation was planned. First, the esophageal hiatal hernia was treated, followed by the Morgagni foramen hernia. The esophageal hiatal hernia was of the sliding type, and about 5 cm in diameter. The hiatus was closed with direct sutures and recovered using composite mesh. Next, Nissen-type fundoplication was performed. The Morgagni foramen hernia, which had an orifice of about 4 cm in diameter and contained the transverse colon, was repaired with composite mesh without direct suturing of the orifice. The postoperative course was uneventful. Laparoscopic repair of Morgagni foramen hernia and esophageal hiatal hernia is a safe procedure.

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An 84-year-old woman receiving medication for Parkinson's disease and dementia was brought to our hospital complaining of anterior chest pain and dysphagia. She wandered around the house and fell backwards on the previous night. Emergency enhanced computed tomography (CT) revealed a giant spheroid mass (4×4.5×12 cm) in the posterior mediastinum along the esophagus. The patient was suspected to have intramural hematoma of the esophagus and was treated conservatively. Magnetic resonance imaging (MRI) on hospital day 3 revealed a low-signal, large, spheroid mass in the posterior mediastinum containing sporadic high signals on T1-weighted imaging. Endoscopic examination on hospital day 4 revealed a dark-red submucosal mass protruding over three-quarters of the esophageal lumen in the middle portion of the esophagus.
Subsequent CT on hospital day 11 showed marked reduction of the lesion, and esophageal endoscopy on hospital day 14 showed reduction of the submucosal mass and the appearance of a longitudinal ulcer. Because of improving dysphagia, she was discharged on the 22nd day after admission. Follow-up endoscopy performed one month from onset showed nearly normal mucosa and luminal cavity. We report a rare case of intramural hematoma of the esophagus caused by trauma.

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Spontaneous rupture of the esophagus commonly affects the lower thoracic esophagus. We herein report a rare case of spontaneous rupture of the upper-middle esophagus in the chest relieved by conservative therapy. A woman in her sixties was admitted to the hospital because of continuous chest pain after vomiting. She had been suffered from aortitis syndrome, taking 8 mg/day of PSL for approximately 40 years. Chest computed tomography (CT) showed air bubbles outside of the esophageal wall at the site of the tracheal bifurcation, while upper gastrointestinal endoscopy revealed a longitudinal ulcer in the upper to middle portion of the esophagus. Spontaneous rupture of the esophagus was highly suspected, however, the patient's mediastinitis was localized and her general condition had not deteriorated. Therefore, we treated her conservatively, maintaining the dose of steroids at 10 mg to control the aortitis syndrome.
After confirming a decrease in air bubbles on chest CT on the fourth hospital day, the patient was allowed to resume oral intake on the 15th hospital day. She was subsequently discharged from the hospital on the 43rd hospital day.
We speculate that vulnerability of the adjacent esophageal wall due to the patient's long history of aortitis syndrome and steroid treatment may have played an important role in the etiology of rupture in this case.

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A 40-year-old woman was diagnosed with gastric cancer and underwent laparoscopically assisted distal gastrectomy. During postoperative adjuvant chemotherapy, she exhibited a sharp rise in CA19-9 in a blood sample test about 4 months after surgery. Imaging did not show findings related to high CA19-9 levels, such as gastric cancer recurrence, other malignant diseases, or biliopancreatic abnormalities, and she was therefore placed under follow-up, but general malaise and dipsia intensified at about 8 months after surgery. Various tests revealed the presence of significant hyperglycemia resulting from type 1 diabetes. Later, as glycemic control improved, CA19-9 levels also normalized. As of the time of writing, 14 months since surgery, she has not shown a return to elevated tumor marker levels. Hyperglycemia is known to be one cause of a rise in CA19-9, and elevated CA19-9 levels after gastrectomy, which is prone to cause changes in blood sugar levels, require appropriate searching and treatment while also bearing the possibility of hyperglycemia-related false-positive results in mind.

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We report a case of long-term disease-free survival from lymphatic recurrence of AFP-producing gastric cancer treated with multidisciplinary therapies including surgery. A-68-year-old man underwent distal gastrectomy for gastric cancer. The final diagnosis was T1N2H0P0M0 in Stage II, and immunohistological examination showed AFP-producing gastric cancer. Although we began adjuvant chemotherapy with UFT/LV, lymph node metastasis (No.13, No16b1) was diagnosed. Therefore, we changed to the second line chemotherapy using S-1 and the third line chemotherapy using S-1/CDDP. However, these treatments were not sufficiently effective. PTX was administered as the fourth line chemotherapy, and the serum AFP level fell remarkably in a normal range. The serum AFT level, however, began to increase again. After confirming that there was no other non-curative factor with CT and PET, we performed metastatic lymph node resection.
Thereafter the serum AFP level dropped in a normal range, and the patient is alive with no recurrent tumor, as of 6 years and 4 months after the second operation, or 8 years and 8 months after the first operation.

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R-CHOP chemotherapy is the standard therapy for B cell lymphoma and exerts an excellent efficacy. However, we sometimes encounter case reports on cicatricial stenosis, a complication of R-CHOP, which required surgery. In this paper we present eight cases of gastrointestinal malignant lymphoma in which cicatricial stenosis developed after the chemotherapy required surgical resection in our hospital. The histological type was diffuse large B-cell lymphoma in all cases and R-CHOP chemotherapy was conducted in them. The stenosis most frequently appeared in 1-4 courses of R-CHOP. These stenoses were considered to be located in areas where the lymphoma lesions existed, including the duodenum in one, the stomach in three, the ileocecal region in two, the ileum in one and the ascending colon in one case. Surgical resection was performed in seven cases that resulted in pathological CR. In the remaining one case in which bypass operation was done, the outcome was rated as clinical CR. Histopathologically the tumors disappeared and were replaced with fiber tissue. Six patients are alive without recurrence, one patient died of other disease and one died of this disease. We must remain alert for passage disturbance due to cicatricial stenosis which can occur as a complication after the chemotherapy.

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A 56-year-old man was admitted to hospital suspected of having ingested a ceramic fragment. Chest and abdominal radiographs demonstrated no definite foreign body. No further evaluation was performed, and the patient was sent home. The next day, he was admitted to hospital with upper abdominal pain and a high fever. Abdominal computed tomography revealed the presence of a hyperdense foreign body in the duodenum. The patient was diagnosed with penetration of the duodenum due to an ingested ceramic fragment, and emergency surgery was performed. We removed the fragment by making an incision into and opening the duodenum. The postoperative course was uneventful, and the patient was discharged on postoperative day 23. Here, we report a rare case of duodenal penetration due to the ingestion of a ceramic fragment.

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Benign tumors such as adenomyomatous hyperplasia (AMH) rarely occur in the bile duct. As no characteristic diagnostic imaging findings have been suggested, accurate preoperative diagnosis is currently difficult. Here, we report a case of AMH that occurred in the papilla of Vater.
The patient was a 70-year-old man who was referred to our hospital for detailed examination of obstructive jaundice. Levels of tumor markers such as DUPAN-II were found to be increased.
No redness or swelling of the papilla of Vater was found on endoscopic and macroscopic examinations.
Abdominal computed tomography revealed a mass lesion in the distal bile duct, while endoscopic retrograde cholangiography detected a filling defect. We performed subtotal stomach pancreaticoduodenectomy for suspected cancer of the papilla of Vater. Histologically, mildly atypical glands and hyperplasia of muscle fibers and fibrous tissue were observed. Based on these findings, a final diagnosis of AMH of the papilla of Vater was made.

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A 77-year-old woman was admitted to the emergency department with chief complaints of upper abdominal pain and vomiting. Upper gastrointestinal contrast studies and irrigoscopy did not show any formation of the ligament of Treitz, and the small intestine had traveled to the right and the colon had traveled to the left from the duodenum. Abdominal contrast-enhanced CT showed a whorl-like pattern where the small intestine had rotated around the superior mesenteric artery. An obstruction site was noted in the vicinity of the transition from the duodenum to the jejunum. Duodenal obstruction associated with intestinal malrotation and midgut volvulus was diagnosed. The intestinal tract showed no blood flow impairment and no findings of strangulated ileus, so she underwent an elective laparoscopic Ladd procedure. Postoperatively, she showed no relapse of symptoms. Adult-onset intestinal malrotation is rare, and symptoms vary, so the question of whether laparoscopic surgery is indicated should be judged on a case-by-case basis.

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A 39-year-old man sustained an injury to his lower abdomen by hitting it on an iron bar while teaching uphill cycling to his son. Initially, the pain subsided. However, he developed lower abdominal pain and began vomiting after dinner, and visited a neighborhood hospital. He was admitted to the hospital for observation, and developed a high fever the next morning. Abdominal computed tomography revealed free air in his abdomen. He was transferred to our hospital and diagnosed with perforation of the digestive tract. We found edema of the distal ileum and thickened mesentery tissue, and performed partial resection of the ileum. The resected specimen revealed a longitudinal ulcer and histopathological examination revealed epithelioid cell granuloma and inflammatory cell infiltration into all layers of the intestinal wall. We diagnosed the patient with Crohn's disease.
Patients with Crohn's disease are likely to develop perforation of the intestinal tract from mild blunt abdominal trauma. Although it is rare, Crohn's disease should be considered in patients with perforation of the intestinal tract by mild blunt abdominal trauma.

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A 43-year-old man visited our hospital after experiencing dull right lower abdominal pain for 7 days. He had a history of appendectomy in his youth. Enhanced computed tomography revealed abscess formation in the mesentery of the ascending colon. Because the clinical symptoms and inflammation findings were mild and marginal, he underwent laparoscopic surgery 24 days after onset. Laparoscopy-assisted right colectomy was performed to remove a 4-cm inflammatory mass in the mesentery of the ascending colon. The resected specimen revealed that the patient's cecum was duplicated (but not ectopic) near the mesenteric abscess. Histopathological analysis revealed that the cecum was penetrated due to inflammation. The penetration of duplicated alimentary tracts is rare in adults. Here, we present a case and review the relevant literature.

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A 51-year-old man was admitted with chief complaints of upper abdominal pain and vomiting. He was diagnosed with ileus caused by a small intestinal tumor on abdominal CT. Primary small intestinal cancer or gastrointestinal stromal tumor (GIST) was suspected, and laparoscopically assisted surgery was performed. Intraoperative findings revealed a 5-cm diameter tumor in the ileum, about 50 cm on the oral side of Bauhin's valve. Tumor excision through a small incision was considered possible, so we performed partial excision of the small intestine. An annular stricture-type tumor was observed in the resected specimen. Histopathological examination diagnosed small intestine mucinous adenocarcinoma, and metastasis to the lymph nodes near the tumor was observed. The tumor was defined as pT3 (SS), ly(+), N1 (1/4), stage IIIA (UICC, seventh edition). We encountered a rare case of primary small intestine mucinous adenocarcinoma that was discovered because of ileus symptoms and was excised under laparoscopic assistance, and report it here with some discussion of the literature.

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A 56-year-old man, who was referred to the Department of Medicine in our hospital for close exploration of fresh blood at diarrhea in December 2011, was found having multiple diverticula in the ascending colon by colonoscopy. We confirmed that the blood gushed out of one of these diverticula and stopped the bleeding by clipping. In addition, fresh blood was found from a proximal part of it. Further exploration of the intestine up to the cecum revealed pulsatile bleeding from the orifice of the appendix. Clip hemostasis was difficult and her anemia had progressed. On the same day, an emergency operation (partial excision of cecum including the appendix by laparotomy) was performed. Macroscopic findings of the resected specimen disclosed three diverticula in the appendix, and mucosa in only one of the diverticula was noted to turn red. Pathology could not identify any demonstrable ruptured vessels in the area, but we diagnosed the case as bleeding from a true diverticulum of the vermiform appendix because the diverticulum has thinned muscle layer. Diverticulosis of the appendix is a rare entity and preoperative diagnosis is difficult. Bleeding from such a diverticulum is much rarer. Here we present our recent experience with a case of bleeding from pseudodiverticulum of the ascending colon and true diverticulum of the vermiform appendix occurred simultaneously.

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A 69-year-old man was referred to our hospital because of a tumor of the appendix detected at a medical checkup. There was slight tenderness in the right lower quadrant of abdomen. Serum biochemical studies revealed no abnormal findings. The serum level of CEA slightly elevated to be 8.2 ng/ml. An abdominal contrast-enhanced CT scan showed an enlarged appendix 70×30 mm in diameter, with fluid collection in it. Colonoscopy revealed a volcano sign, which designates that the orifice of the appendix has bulged like a dome. Although a biopsy gave negative findings, mucinous cystadenoma of the appendix was suspected. We performed ileocecal resection and dissection of lymph nodes up to the root of the ileocolic artery. The resected specimen included transparent, colorless and jelly like mucus in the lumen of the appendix. Histopathological studies showed mucus producing tumor cells at the tip of the appendix and mucinous cystadenoma was diagnosed. In addition we found a tumor composed of goblet cells mainly located in the submucosal layer at the root of the appendix. As a result of immunohistochemical studies, it was diagnosed as goblet cell carcinoid.

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We report a rare case of phlegmonous colitis. A 69-year-old woman was admitted to a clinic owing to complaints of diarrhea. Rebound tenderness was present in her right lower abdomen. Following the diagnosis of acute abdomen, the patient was transferred to our hospital. She had received hemodialysis for diabetic nephropathy for 17 years. Non-contrast computed tomograms showed intramuscular gas formation in the cecum, and operative findings revealed complete necrosis of the cecum with an extremely thin wall. Histological examination showed abscess formation in the submucosal layer, and massive bacterial flora were scattered in this layer. She was diagnosed phelegmonous colitis. The patient developed severe postoperative complications. However, she was discharged after intensive care treatment, on the 112^th postoperative day.

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A 46-year-old woman presented to the emergency clinic in our hospital because of intermittent lower abdominal pain. There were tenderness, rebound tenderness, and muscle guarding localized in the right lower quadrant of abdomen. An abdominal contrast-enhanced CT scan showed a tumor shadow in a laminar structure in the ascending colon. Accordingly intussusception was diagnosed. There was no ascites and no prominent tumorous lesions were revealed. The intussusception was reduced by using a colonoscope that resulted in prompt disappearance of abdominal symptoms. Thereafter close exploration showed no intestinal organic disorders which might cause intussusception. Idiopathic intussusception was thus diagnosed. The patient has been followed in the outpatient clinic without having recurrence for 6 months. As idiopathic intussusception in adult reduced endoscopically has rarely been reported, the case is presented here together with review of the literature.

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A 79-year-old male patient complaining of dysphagia was diagnosed with gastric cancer (cT3 (SS) N1M0, cStage IIB) and underwent distal gastrectomy with bursectomy. On postoperative day (POD) 6, he suddenly developed septic shock, with acute renal and respiratory failure. CT imaging revealed pneumomediastinum and subcutaneous emphysema, and no focus of the infection was identified. He was kept under intensive care to stabilize his general condition. After resuming to eat a meal, he developed an abdominal abscess on POD 14. Drainage tubography revealed perforation of the transverse colon. He underwent loop ileostomy, and the perforation was closed. The results observed in the present case suggest that it is important to consider the possibility of perforation of the transverse colon in case of pneumomediastinum.

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A 73-year-old man who had received total laryngectomy for laryngeal cancer injured his air way while doing tracheostomy care by a cotton swab, and he was admitted to our hospital. Chest computed tomography showed rupture of the lower part of the trachea and mediastinal emphysema, and bronchoscopic findings showed membranous tracheal rupture with a defect necessitating surgery. On the next day, surgery via right lateral thoracotomy demonstrated membranous tracheal rupture slightly craniad to the azygos vein. Direct closure of the rupture was carried out with placement of a pedicled right 5^th intercostal muscle flap between the esophagus and the injured site. The postoperative course was uneventful. In the case of membranous tracheal rupture due to a blunt trauma increasing the endotracheal pressure, conservative therapy can be employed. However, this case was of an injury associated with a transmural defect, in which spontaneous closure could not be expected. Early surgical closure was thus performed. We could select thoracoscopic surgical procedure to dissect the esophagus. Considering his primary lesion to be laryngeal cancer, we performed this procedure by using a pedicled intercostal muscle flap, with favorable outcome.

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The patient was a 59-year-old male who underwent partial colectomy (transverse colon) and D3 lymph node dissection with a diagnosis of transverse colon cancer. The postoperative course was uneventful, and the patient was discharged 11 days after surgery. However, he revisited due to abdominal distension, abdominal pain, and vomiting 3 days after discharge, and was diagnosed with superior mesenteric artery syndrome. After admission, symptoms were alleviated by fasting and gastric intubation, oral feeding was resumed 17 days after admission, and no recurrence was noted thereafter. Superior mesenteric artery syndrome is considered to be caused by narrowing of the angle between the superior mesenteric artery and aorta. In this patient, we serially evaluated this angle before onset, at onset, and after the resolution of symptoms by MDCT (in axial and sagittal views) and investigated the etiological mechanism.

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A man in his thirties visited our hospital with oliguria and abdominal distension. He suffered from numbness and motor palsy below the Th4-6 level due to a spinal cord injury caused by a traffic accident sustained 16 years previously. He was diagnosed as having urinary tract infection, and administered antibiotic treatment. However, his condition did not improve and he complained of nausea and several episodes of vomiting in the following few days. Abdominal CT was performed, and perforation of the sigmoid colon and leakage of stools into the abdominal cavity were detected. However, the patient did not show any typical signs or symptoms of peritonitis, such as tenderness, muscle rigidity, or rebound tenderness. Emergency sigmoidectomy and sigmoidostomy were performed. Although re-operation was required twice, the patient could be saved and was discharged on postoperative day 52.
Assessing abdominal complications in patients with high spinal cord injury is very difficult, because the typical symptoms of acute abdomen cannot be detected in these patients. In cases of colonic perforation, a delayed diagnosis can result in fatal complications. The present case provides an example of a patient with spinal cord injury, and emphasizes the need for appropriate diagnosis and early treatment.

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A 63-year-old man complained of hematochezia, and was referred to our hospital with a diagnosis of rectal cancer. Preoperative examination of enhanced CT and 3D-CT angiography revealed the inferior mesenteric artery arising from the superior mesenteric artery. Laparoscopic high-anterior resection was performed for this patient. The postoperative course was uneventful, and the patient was discharged on postoperative day 6. The pathological diagnosis was tubular adenocarcinoma (moderately differentiated type), type 2, tumor size 64×39 mm, pT3, pN0 (0/34), Stage II. The patient was disease-free after 1 year. Between 2007 and 2014, a total of 1516 cases were treated for cancer of the left colon and rectum in our hospital, and only one case showed abnormality of the inferior mesenteric artery arising from the superior mesenteric artery. We report this extremely rare case.

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Granular cell tumor of the colon is relatively rare. We encountered a case of multiple granular cell tumors of the cecum that were discovered because of early gastric cancer and were resected simultaneously by laparoscopy. A 47-year-old man was referred to our hospital with chief complaints of epigastric pain and indications of II c lesions in the gastric antrum on upper gastrointestinal endoscopy. Computed tomography showed a tumor about 1 cm in size in the cecum, and lower gastrointestinal endoscopy showed two submucosal tumors at the same site, 12 and 10 mm in diameter. The patient was diagnosed with early gastric cancer and submucosal tumors of the cecum, and underwent laparoscopically assisted distal gastrectomy with ileocecal resection. Postoperative histopathological examination diagnosed multiple granular cell tumors of the cecum. Surgery was repeated on postoperative day 8 due to suture failure, but the subsequent course was favorable, and he was discharged in remission on hospital day 23. No standard treatment has been defined for granular cell tumors of the colon. The present case underwent ileocecal resection at the same time as a procedure for early gastric cancer, and we consider this as a valid surgical procedure in light of the fact that these multiple tumors were not diagnosed preoperatively.

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We report the case of a 75-year-old man suffering from metachronous adenocarcinoma arising at a colostomy site with inguinal lymph node metastasis. The patient first visited our hospital complaining of fever and a hard, swollen mass at the colostomy site. Physical examination and computed tomography revealed a tumor at the colostomy site invading into the skin with adjacent infection and left inguinal lymph node metastasis. We performed radical resection including colostomy and resection of surrounding organs, total left inguinal lymph node dissection, and reconstruction of a colostomy at another site. Pathological examination revealed well-differentiated adenocarcinoma invading the surrounding skin, and no lymph node metastases around the colostomy. One metastasis was detected in the dissected inguinal lymph nodes. Adenocarcinoma arising at a site of colostomy with inguinal lymph node is very rare, but total surgical resection should be considered when possible to obtain better outcomes, even if inguinal lymph node metastasis is present.

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Peliosis hepatis is a benign vascular condition of the liver. This condition is characterized by the presence of cystic blood-filled cavities throughout the liver parenchyma. It sometimes progresses to be fatal. Because lesions appear as nonspecific hepatic masses on imaging studies, the correct diagnosis can be difficult. We report a case of a 74-year-old man with multiple hepatic tumors, which were found at a medical check-up. Laparoscopic liver biopsy was performed to ensure the preoperative diagnosis of hemangiosarcoma. On laparoscopy, multiple purplish areas were found at the surface of the liver. Each of these areas was soft and flat. A biopsy specimen obtained from the lesion that was partially resected on S5 showed evidence of peliosis hepatis. His postoperative course was uneventful and he was discharged from our hospital. The patient died from rupture of peliosis hepatis, 10 months after discharge. Even though biopsy of a peliotic lesion carries the risk of bleeding because of the vascular nature of peliosis hepatis, laparoscopic liver biopsy is a useful and safe tool in diagnosing peliosis hepatis.

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A female patient had been diagnosed as having congenital biliary dilatation and treated by extrahepatic bile duct resection, cholecystectomy and biliojejunostomy at 5 months of age at the department of pediatric surgery. At 13 years of age, the patient was diagnosed as having postoperative hepatolithiasis. She was admitted to our hospital because of refractory cholangitis at 26 years of age. MDCT revealed multiple stones in the region of the local intrahepatic biliary dilatation of the left hepatic duct and B3, with anastomotic and bile duct strictures. We diagnosed postoperative hepatolithiasis and performed left hemihepatectomy with re-biliojejunostomy. The postoperative course was uneventful and no recurrence of hepatolithiasis was observed during the follow-up.
The present case was relatively rare, because postoperative hepatolithiasis is usually diagnosed around 10 years after the operation for congenital biliary dilatation. In the present case, hepatectomy was effective for complete resection of the region showing local intrahepatic biliary dilatation with anasotomotic and bile duct strictures.

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An 87-year-old woman who underwent lateral segmentectomy of liver for hemangioma 30 years earlier had been diagnose with a hemangioma at the caudate lobe since 7 years earlier. The hemangioma did not show any increasing tendency. In February 2014, she had the sudden onset of chest pain without history of trauma and visited a previous hospital. A contrast-enhanced CT scan revealed leakage of contrast material from the hemangioma in the caudate lobe to the abdominal cavity. The patient was diagnosed with spontaneous rupture of the hepatic hemangioma and was transferred to our hospital. Hemostasis was achieved by transcatheter arterial embolization. The course was uneventful without any complications. We considered her to be at high risk of having bleeding again, but after giving informed consent, we determined not to perform hepatectomy due to high risk for operation. She was discharged from our hospital on the 15^th postoperative day, and there were no further episodes of rupture at 12 months after the transcatheter arterial embolization.
Spontaneous rupture of hepatic hemangioma is rare. There have been no reports of only transcatheter arterial embolization without hepatectomy for ruptured hepatic hemangioma. We present a case and a review of the literature.

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A 74-year-old woman visited a local physician because of diarrhea and loss of appetite. She was referred to our hospital after the laboratory data indicated elevation of the serum bilirubin level. Abdominal CT showed pneumobilia. ERCP showed the formation of a fistula between the shrunken gallbladder and the hepatic flexure. Colonoscopy showed a fistula on the right side of the transverse colon, and fistulography enabled visualization of the gallbladder and the common bile duct. We diagnosed this patient as a case of cholecystocolonic fistula and performed an operation via the laparoscopic approach. At operation, the fistula was resected using an endoscopic linear stapler and cholecystectomy was performed. The postoperative course was uneventful and the patient was discharged on postoperative day 11. Laparoscopic surgery is feasible for the treatment of cholecystocolonic fistulas.

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A 35-year-old man with lower abdominal pain was admitted to our hospital. Abdominal computed tomography revealed a 2-cm funic structure connected to the small intestine suggesting inflammatory Meckel's diverticulum. At first, conservative therapy with antibiotics was attempted, and the patient's abdominal pain temporarily improved before recurring later. Laparoscopic surgery was performed. Meckel's diverticulum with severe inflammatory change was detected in the ileum about 120 cm proximal to the ileal end, and was resected using an endoscopic linear stapler. Histological findings showed that the acute inflammation was limited to Heinrich type I ectopic pancreatic tissue within the tip of the diverticulum. There are only two clinical reports of ectopic pancreatitis in a Meckel's diverticulum in the literature and this is the first report of treatment by laparoscopic surgery, highlighting the extreme rarity of this clinical entity.

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A 44-year-old woman was admitted to our hospital with epigastric pain. Abdominal computed tomography revealed a tumor with inflammation between the stomach and pancreas, and upper esophagogastroduodenoscopy revealed a benign ulcerating lesion at the gastric antrum, suggesting localized peritonitis due to a perforated gastric ulcer. Her condition improved with conservative management. However, the inflammation returned after 2 years and 5 months. Reactivation of the abscess or malignant tumor was suspected, and laparotomy was performed. A sclerotic tumor was found on the wall of the greater curvature of the stomach during the operation. The tumor was separate from the surrounding tissues and tumorectomy was performed. Microscopic findings revealed ectopic pancreas with chronic inflammation, and the pathological diagnosis was chronic abscess due to ectopic pancreas with pancreatitis. Although ectopic pancreas is asymptomatic in many cases, those with symptoms or suspected malignancy are candidates for surgery. We experienced a case of gastric ectopic pancreas with pancreatitis.

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A 57-year-old man underwent pancreatoduodenectomy for intraductal papillary mucinous neoplasm of the pancreas. After the surgery, a pancreatic fistula developed, and bloody drainage was observed on postoperative day 37. Angiography demonstrated a pseudoaneurysm at the stump of the gastroduodenal artery, and the patient was diagnosed as having postpancreatectomy hemorrhage (PPH) induced by rupture of the pseudoaneurysm. After confirming that the arterial blood flow to the liver was maintained even after clamping of the common hepatic artery and proper hepatic artery, embolization of the arteries was performed for control of the PPH. The treatment was successful, and the patient continued to be followed up. CT examination performed five months after the embolization revealed no recurrence of the pseudoaneurysm. However, eight months after the first interventional radiologic procedure, he visited our hospital again with abdominal discomfort. Abdominal CT examination showed a recurrent pseudoaneurysm at the confluence of the left and right hepatic arteries, which was located next to the treated proper hepatic artery. By the percutaneous transhepatic approach, Histoacryl and thrombin were injected into the pseudoaneurysm for embolization. The treatment was successful, and the patient remains alive without any recurrence of the pseudoaneurysm one year and one month after the treatment for the recurrent pseudoaneurysm.

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We encountered a patient with liver metastasis from a pancreatic ductal adenocarcinoma, who was successfully treated by hepatectomy and chemotherapy. A 68-year-old female was treated by distal pancreatectomy for pancreatic ductal adenocarcinoma. After the surgery, she was given gemcitabine treatment for six months. Abdominal CT revealed a hepatic metastatic lesion 14 months after the surgery. Therefore, chemotherapy with S-1 as the second line therapy was started. Abdominal CT showed an increase of the tumor diameter, therefore, hepatectomy was performed for the liver metastases from the pancreatic ductal adenocarcinoma 28 months after the primary surgery. She has survived without any recurrence for more than 37 months since the hepatectomy.

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Some reports have suggested that polycythemia vera (PV) could be a risk factor for thrombosis and bleeding in surgical patients, indicating that careful perioperative management is important. We report a patient with PV who underwent resection of pancreatic carcinoma. A 74-year-old man had been treated for PV with hydroxyurea and aspirin for 20 years and had a history of cerebral infarction 14 years earlier. He was admitted to another hospital with epigastric pain after meals and elevated serum amylase levels. Pancreatic carcinoma was diagnosed from CT and he was referred to our hospital for surgery. Phlebotomy was performed just before the operation, which was subtotal stomach-preserving pancreaticoduodenectomy. For postoperative prophylaxis of thrombosis, he wore compression stockings and intermittent pneumatic compression was employed. He was also treated with gabexate mesilate for 5 days. There were no thrombotic or bleeding complications and he was discharged on postoperative day 28.

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Wandering spleen is a condition characterized by displacement of the spleen from its normal location due to the loss or weakening of ligaments holding the spleen in the left upper quadrant. The possibility of torsion of the spleen is mostly due to the long and mobile nature of the vascular pedicle. The most common complication related to torsion is infarction. Presentation as left portal hypertension and gastric varices is extremely rare. Here, we report a 20-year-old woman who presented with gastric varices secondary to chronic volvulus of ectopic spleen. Computed tomography scans visualized the pelvic mass, which measured 14.6×11.8×5.4 cm. Gastric fundal varices were observed on esophagogastroduodenoscopy. Laparoscopic splenectomy was performed successfully. In our case, splenomegaly, left portal hypertension, and gastric varices may have developed as a result of vascular congestion associated with chronic torsion.

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A 42-year-old woman presented with a 3-day history of peri-umbilical pain and fever. She had suffered from sigmoid colon diverticulitis 2 years earlier and had been treated with conservative therapy. Abdominal computed tomography revealed urachal abscess, suggestive of communication with the sigmoid colon. After management with abscess drainage and antibiotic administration, en bloc resection of the urachal mass, sigmoid colon and bladder cuff was performed. Urachal-sigmoid colon fistula caused by diverticulitis is extremely rare and only 4 cases, including ours, have been reported in Japan. We report this case with a review of the literature.

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An 80-year-old man developed omental panniculitis in September 2012 that was alleviated by steroid therapy. Steroids were continued until January 2013. In February, he began to experience repeated intestinal obstruction. Computed tomography (CT) during this time did show changes in the extent of dilation of the small intestine, but no change in positional relationships of the small intestine, and an encapsulated structure was also observed, leading to the diagnosis of encapsulating peritoneal sclerosis in which an adhesive membrane-like structure encapsulated the small intestine. The patient underwent laparotomy in April after intestinal obstruction recurred. Laparotomy revealed that the entirety of the small intestine was covered with a thickened, white-toned coating, with firm adhesion to the retroperitoneum and bladder in the lower abdominal area and firm adhesion with the parietal peritoneum in the upper left abdominal area. The thickened coating was excised as much as possible, to peel off the adhesion of the entire small intestine. Postoperative course was favorable and the patient was transferred to another hospital on postoperative day 38 without recurrence of intestinal obstruction. We encountered and hereby report a case of encapsulating peritoneal sclerosis secondary to omental panniculitis, along with some discussion of the literature.

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A 67-year-old man was admitted with the complaint of a painless mass in the left upper abdomen. Hematological examination revealed a WBC count of 17500/ml and serum CRP of 7.04 mg/dl, indicating the presence of inflammation. Abdominal CT and MRI revealed findings suggestive of an omental tumor or advanced pancreatic body cancer with invasion of the stomach, or a gastrointestinal stromal tumor, however, no definitive diagnosis could be made. Total gastrectomy and pancreatic body and tail resection including the tumor with splenectomy was performed. The final histopathological diagnosis was undifferentiated pleomorphic sarcoma (UPS) of the omentum, the equivalent of inflammatory malignant fibrous histiocytoma (MFH) according to the previous WHO classification. Local recurrences were discovered and resected at 4 years and 8 years after the first operation. Documented cases of omental UPS with a long survival are rare.

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A 34-year-old woman was admitted to our hospital with upper abdominal discomfort in April 2014. She had undergone abdominal tumorectomy at another hospital in 2004. We diagnosed her with a malignant tumor of the greater omentum, and pathology revealed extraskeletal myxoid chondrosarcoma. Contrast-enhanced abdominal computed tomography (CT) revealed a segmented tumor 15 cm in diameter with calcification in the left upper quadrant, compressing the lateral segment of the liver. Two peritoneal nodules invading segment 6 of the liver were also found. A needle biopsy of the left upper quadrant led to a diagnosis of adenoid cystic carcinoma based on positive responses for p63, c-kit, and epithelial membrane antigen immunostaining. These results were histologically and immunopathologically identical to those of the patient's previously resected tumor, and we diagnosed her with recurrence of adenoid cystic carcinoma. Lateral segmentectomy of the liver with diaphragm resection was performed, and the tumors were completely removed. This case is the first report of adenoid cystic carcinoma of the greater omentum.

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