Anaplastic thyroid cancer (ATC) is an extremely aggressive malignancy with dismal prognosis due to resistance to multimodal therapy. Here, we present a case of ATC treated by lenvatinib, a multikinase inhibitor. A 66-year-old Japanese woman was referred to our hospital for the treatment of recurrent ATC on her neck after chemotherapy, surgery, and radio-therapy. The tumor successfully shrank within a month after initiating treatment with lenvatinib. Treatment was interrupted twice for grade 3 hypertension and proteinuria. A rupture of the carotid artery was successfully treated by emergent surgery (ligation of the carotid artery) followed by stent insertion into the subclavian artery.

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Case 1 involved an 85-year-old woman who was seen at our department of surgery because subcutaneous hemorrhagic spots of the left breast were pointed out by a staff when she had a bathe at the day service facility. Echography revealed a multilateral hypoechoic tumor with an irregular border in the left C area where was coincident with the subcutaneous hemorrhagic spots. Case 2 involved an 86-year-old woman who visited a neighboring hospital because of the abrupt appearance of a right breast mass 2 weeks earlier. Thereafter she presented to our hospital. Echography revealed a cystic, oval-shaped, and sharply demarcated hypoechoic tumor in the right AC area. In both cases, breast cancer was diagnosed by fine needle aspiration biopsy, and radical operation was performed after general exploration confirmed the absence of distant metastases.
We have entered an era of an aging population, and not a little elderly people, especially women over 85 years old, have not received periodic breast cancer examinations and are detected to have a breast mass, skin invasion, or skin lesion by a family member or caregivers at a care home. Many patients with breast cancer present to a hospital because of a breast mass, but the tumor rarely presents with bleeding within the breast. This paper deals with two cases of breast cancer in very elderly women who had no history of trauma and presented with breakthrough bleeding within the breast.

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We describe our experience with a patient who underwent surgery for a bilateral coronary-pulmonary artery fistula and a coronary artery aneurysm associated with preoperative cardiopulmonary arrest. A 47-year old woman lost consciousness and was transported by ambulance to the hospital. The patient regained consciousness in the ambulance, and presented at the emergency & critical care medical center of our hospital, but cardiopulmonary arrest occurred during examination. Echocardiography showed cardiac tamponade. Pericardial drainage was immediately performed, and spontaneous circulation was restored. After the induction of brain hypothermia, a careful examination revealed an aneurysm, 5 mm in maximum diameter, in the right coronary artery and an aneurysm, 8 mm in maximum diameter, in the left coronary artery. Bilateral coronary-pulmonary artery fistulas had thus developed. Cardiopulmonary arrest was apparently caused by the rupture of a coronary artery aneurysm. Aneurysmectomy was performed, and the coronary-pulmonary artery fistulas were closed during cardiopulmonary bypass. Photodynamic eye was useful for the intraoperative detection of small coronary artery aneurysms. On postoperative day 12, the patient was discharged from the hospital uneventfully.

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We report a case of enlarged and ruptured abdominal aortic aneurysm (rAAA) in a patient who was treated with chemotherapy using bevacizumab (BV). A 70-year-old man presented to our hospital with severe abdominal pain for the duration of chemotherapy (using BV for recurrence of rectal carcinoma). The pulsatile mass was palpable in the abdomen. He was alert and his blood pressure was 199/116 mmHg. Enhanced computed tomography (CT) revealed fusiform abdominal aortic aneurysm with a diameter of 48 mm and post-peritoneal hematoma. The diameter of the aneurysm was 43 mm, 6 month previously. We diagnosed rAAA, and considering the adverse effect of BV, selected endovascular aneurysm repair (EVAR) for treatment. Emergency aortography was performed, and no extravasation was found. We selected the Gore Excluder endoprosthesis and completed the operation with no endoleak. Enhanced CT revealed no endoleak 2 days after EVAR and the patient was discharged on postoperative day 4. The patient was in good condition, and chemotherapy was resumed one month after EVAR. It was possible that administration of BV was associated with the rupture. Therefore, in this case, we selected the precise method of treatment considering the adverse effect of BV.

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A routine chest X-ray inspection detected a solid nodule in the right upper lobe in a 38-year-old asymptomatic female patient. It was not suspected of being malignant and had been followed up until the following year when a chest CT scan showed the slightly enlarged tumor. The patient was referred to our hospital for examination and treatment. Thoracoscopy-assisted partial resection of the lung was performed for diagnosis and treatment, because it was considered difficult to conduct invasive diagnostic procedures including bronchoscopy and CT-guided biopsy due to the size and location of the tumor as well as intellectual disability the patient had. The pathological diagnosis was alveolar adenoma.
Alveolar adenoma is a rare benign neoplasm. It is pathologically characterized by both proliferations of the alveolar epithelium and fibrous tissue originating from the mesenchyme. Alveolar adenoma usually affects the peripheries of the lung and appears similar to the normal lung tissue, for that we have difficulties in making the definite diagnosis by a biopsy. We need complete excision of the lesion to make the accurate diagnosis and to carry out appropriate treatment.

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An 82-year-old man was referred to our hospital due to upper thoracoabdominal pain. Chest X-ray showed air around the heart. Computed tomography revealed a fistula between the pericardium and stomach. Upper gastrointestinal endoscopy showed ulcerative lesions in the anterior wall of the stomach in the mediastinum. He was thus diagnosed with a gastroepicardial fistula, caused by perforating ulcer of the protruded stomach. Part of the gastric serosa and hernial sac were stuck together strongly, and the fistula was exposed by separation. After repair of the hiatal hernia, the ulcer was closed with omentum. Two drains were placed in the pericardium through the hiatus and the back of the xiphoid process. The patient was discharged on postoperative day 42 with no severe complications.

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An 85-year-old woman with esophageal cancer underwent thoracoscopic subtotal esophagectomy. Her postoperative course was uneventful and she was discharged on the 24th day after the surgery. She presented to our hospital because of cough and dyspnea on the 14th day after discharge, when a chest CT scan showed bilateral massive pleural effusion. She was diagnosed as having chylothorax and readmitted emergently. Despite fasting and octreotide administration, chylothorax was not improved. Lipiodol lymphangiogram by inguinal lymph node puncture indicated a leakage site to be in the thoracic duct trunk near the tracheal bifurcation and absence of anatomical variations in the thoracic duct. She underwent thoracic duct ligation thoracoscopically. In surgical treatment of chylothorax, we have to identify the course of the thoracic duct and the site of leakage before surgery. Lymphangiography by inguinal lymph node puncture is an easy and very useful preoperative examination.

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A 70-year-old man complaining of dysphagia was diagnosed as having advanced adenocarcinoma of the esophagogastric junction with lower esophageal intramural metastases by upper gastrointestinal endoscopy. After four courses of chemotherapy with S-1 and docetaxel, the primary tumor markedly decreased in size and the lesions of intramural metastases disappeared. Thoracoscopic subtotal esophagectomy and reconstruction with a gastric tube through the posterior mediastinal route were performed. Pathological examination showed most of cancer cells at the primary lesion to have severely degenerated or become necrotic, with a part where adenocarcinoma tissue remnant was seen. No viable cancer cells were evident at the site of intramural metastases. The patient received the postoperative chemotherapy with S-1 for one year, and shows no signs of recurrence as of five years after the surgery.
We successfully treated a case of adenocarcinoma of the esophagogastric junction with esophageal intramural metastases, of which prognosis is believed to be poor, by preoperative S-1/docetaxel therapy followed by radical operation.

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An 83-year-old woman sought consultation with a chief complaint of abdominal mass, abdominal pain, and fever. Palpation revealed a tender tumor the size of a child's head, left of the abdominal midline. A huge tumor with a maximum diameter of 20 cm was observed in the peritoneal cavity on abdominal contrast-enhanced computed tomography. The tumor was continuous with the gastric fundus, and was twisted at the pedicle. She underwent surgery because of exacerbation of abdominal pain observed after hospitalization. Laparotomy revealed a huge tumor with a smooth surface and pale brown coloration that was growing in the omental bursa. The tumor had been growing from the gastric fundus in the vicinity of the upper pole of the spleen. The tumor showed torsion of 360° around the base. Torsion was released and the gastric fundus, including the tumor base, was resected with an automatic suturing device. The resected specimen was a huge cystic tumor, and the lumen was filled with old blood-like liquid. Hematoxylin and eosin staining showed a solid portion containing a bundle-shaped outgrowth of spindle cells. This portion was positive for KIT and CD34, and gastrointestinal stromal tumor (GIST) was diagnosed. This is a very rare condition, but with huge gastric GIST involving abdominal pain, it is necessary to consider not only rupture and bleeding, but also pedicle torsion.

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Carcinosarcoma of the stomach is a rare neoplasm, and a total of 61 cases have been reported from 1950. We experienced a case of gastric carcinosarcoma arisen after local resection of the stomach for early gastric cancer (GC). The patient was a 78-year-old man, who underwent local resection for three early GCs at the age of 74. Pathologically, all lesions were intramucosal adenocarcinoma and the surgical margins were all negative, but lymphatic vessel invasion was detected in one lesion which resected up to the depth of muscle layer. The patient stopped attending our hospital after the operation in his own judgement. Three years and 8 months after the local gastric resection, an abdominal CT scan performed in other hospital showed a suspicion of recurrence of GC, and he consulted us for further investigation. A gastric tumor was detected in the upper gastric corpus, where was just the same site that the former resection with muscular layer had been performed. Result of biopsy was non-epithelial malignancy. The patient underwent total gastrectomy. Pathologically, the central part of the tumor consisted of sarcoma and the surroundings, adenocarcinoma, then carcinosarcoma (CS) was diagnosed. So far six cases of CS arisen in the operated stomach have been reported. This is the first case of CS arisen in the lesion which had been locally resected at the former operation. Histogenesis of carcinosarcoma in the present case was considered to lie in dedifferentiation of adenocarcinoma from the clinical course.

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Alpha-Fetoprotein (AFP)-producing gastric cancer is a rare tumor with high rates of lymph node/liver metastasis and a poor prognosis. We report a case of AFP-producing gastric cancer with synchronous and multiple liver metastases, which disappeared after gastrectomy and chemotherapy ; long-term survival was observed after resection of a metachronous lung metastasis. A 55-year-old man underwent upper GI endoscopy because of anemia. A type 2 tumor was detected in the lower body of his stomach. The biopsy result was poorly differentiated adenocarcinoma. The serum AFP level was elevated up to 4,000 ng/ml. CT scan revealed multiple liver metastases and lymph node metastases. Distal gastrectomy with D2 lymph node dissection was performed. The tumor cells were partly positive for AFP staining. After the surgery, continuous hepatic arterial infusion chemotherapy with 5-FU and epirubicin combined with systemic chemotherapy with S-1 was started. Serum AFP was lowered below the normal level after 6-month treatment. Liver metastases also became undetectable on imaging. Chemotherapy was switched to oral tegafur/uracil ; however, a lung metastasis emerged with elevation of AFP. Partial resection of the lung via video-assisted thoracic surgery was performed ; subsequently, no recurrence has been detected for seven years and seven months after the first operation.

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A 64-year-old man underwent distal gastrectomy for early gastric cancer in 1990, and total gastrectomy for remnant gastric cancer in 1997. The patient noticed a tumor on the upper abdominal wall in 2013, and adenocarcinoma was detected by biopsy in September 2014. Further examination did not reveal any other metastases. The tumor and remnant gastric cancer specimen showed similar patterns on pathological examination. We therefore diagnosed recurrent gastric cancer with metastasis to the abdominal wall. The patient was administered chemotherapy comprising 2 courses of capecitabine plus cisplatin. Tumor size was reduced, and surgery was then performed. Postoperatively, chemoradiotherapy was performed because of positive margins. To date, the patient has remained in good health without any cancer recurrence.

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A 39-year-old man presented with right lower abdominal pain. Palpation revealed severe right lower abdominal tenderness and laboratory data showed inflammation. Enhanced abdominal computed tomography showed an inflammatory mass in the right lower abdomen. We diagnosed acute panperitonitis due to appendix perforation and performed single-port laparoscopic surgery. Laparoscopy showed a normal appendix and the presence of contaminated ascites. An inflammatory mass, with a hole at the base, was detected on the mesenteric side about 90 cm proximal to the end of the ileum. Mass resection was performed with partial ileal resection. Histological examination indicated intestinal duplication with perforation. Intestinal duplication with peritonitis is rare in adults, and laparoscopic surgery is useful for diagnosis and treatment of this condition.

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A 76-year-old man with no history of trauma or laparotomy visited a nearby physician with a chief complaint of abdominal pain. He was diagnosed with intestinal obstruction and hospitalized. The next day, symptoms worsened and he was transferred to our hospital. On arrival at the hospital, the entire abdomen showed board-like induration. Abdominal contrast-enhanced computed tomography showed a slightly enhanced loop of small bowel, images of clustered mesenteric vessels, and ascites. Strangulated ileus was diagnosed, and emergency surgery was performed. Laparotomy revealed hemorrhagic ascites and a necrotic gastrointestinal tract. An abnormal hiatus was found in the ileal mesentery, 30 cm from the ileocecal valve ; the ileum was impacted, twisted, and necrotic, so 100 cm of the ileum was excised. After surgery, he developed aspiration pneumonia and needed to undergo antibiotic treatment and minitrach insertion, but his condition improved and he was discharged on postoperative day 24. Transmesenteric hernia is a kind of internal hernia that most commonly occurs in children, and is rare in the elderly. We report here, with a discussion of the literature, our experience with a case of strangulated ileus due to transmesenteric hernia onset in an elderly patient.

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A 54-year-old woman presented to our emergency department with severe acute abdominal pain and fever. Computed tomography revealed a mass with a diameter of 8 cm in the mesentery of the small intestine and free air around the mass. We performed emergency surgery for acute peritonitis. The tumor was located in the mesentery of the small intestine and had ruptured. The tumor had infiltrated the transverse colon, but perforation of the colon was not confirmed. Histological examination revealed a desmoid tumor comprising spindle cells with collagen fibers.
We report a case of ruptured mesenteric desmoid tumor of the small intestine that caused acute peritonitis and required emergency surgery.

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The last-known new occurrence of Schistosoma japonicum (S. japonicum) in the country was in 1978. This report describes a case wherein S. japonicum eggs were detected in the appendix of a patient who underwent laparoscopic appendectomy for acute appendicitis. The previous finding of S. japonicum in Kofu was 69 years previously ; therefore, the case reported in this study is a relatively rare case of appendicitis believed to be caused by S. japonicum eggs.
The patient was a 79-year-old man who was admitted to our department in March 2015 because of right lower abdominal pain, vomiting, and difficulty in dietary intake. Examination of laboratory data revealed increased leucocyte count and C-reactive protein levels. The patient was diagnosed with acute appendicitis, and surgery was scheduled because a swollen appendix associated with fecalith was observed on abdominal computed tomography. A swollen appendix was noted during the surgery ; therefore, laparoscopic appendectomy was performed. Histopathological examination showed lymphoid follicle formation and chronic inflammation of the mucous membrane, fibrous thickening of the appendix wall, and multiple calcified eggs of S. japonicum, suggesting an old granuloma. Postoperative fecal egg examination did not reveal abnormality, although chronic hepatitis and liver cyst were observed on US MRI. No other obvious abnormalities were observed.

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A 55-year-old man with mental retardation who was confined to the bed presented at our hospital with abdominal pain and distention and was admitted. He had undergone endoscopic repositioning for sigmoid volvulus 3 months previously. Abdominal radiography examination revealed a markedly dilated bowel and computed tomography revealed whirl sign, bird beak sign, and ileocecal valve and ileum at the right side of cecum. He was diagnosed with cecal volvulus. Colonoscopy showed a normal sigmoid colon. Repositioning for cecal volvulus was not possible, and emergency surgery was performed. The ileocecal region was markedly dilated with a 270°counterclockwise torsion and necrotic change. Its fixation to the retroperitoneum was incomplete. Right colon resection was performed. Metachronous cecal volvulus is rare, but should be include in differential diagnosis when volvulus is suspected.

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A 78-year-old man admitted to our hospital because of persisting fever and general fatigue had a palpable fist-sized tumor in the right lower quadrant of abdomen. An abdominal CT scan showed a 7cm-sized clearly demarcated tumor with a low density area in its inner part at the inside of the ascending colon. Colonoscopy revealed a submucosal tumor like lesion in the ascending colon, but no definite diagnosis was made. High fever, increased CRP level, and impaired hepatic function persisted and no symptomatic remission was gained by conservative therapy. Laparotomy was thus performed for diagnosis and treatment. Laparotomy disclosed a tumor about 7 cm in diameter within the ascending colon mesentery and ileocecal resection was performed. The histopathological diagnosis was undifferentiated pleomorphic sarcoma probably arisen from the mesentery. Adjuvant chemotherapy was not done. The patient has been free from recurrence as of one year and seven months after the operation.
Few cases of the disease have been reported and the characteristics have not been clarified as yet. Since complete resection of the tumor can carry a long-term prognosis for the patients, our efforts to perform radical operation and further accumulation of clinical cases would be critical.

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Adult retrograde intussusception of the colon is very rare. We encountered a case of retrograde intussusception due to pedunculated adenocarcinoma of the sigmoid colon. A 54-year-old man was admitted to our hospital with left flank pain and vomiting. Retrograde intussusception was diagnosed by abdominal computed tomography and emergency surgery was performed. The sigmoid colon was firmly invaginated in a retrograde manner. Sigmoidectomy with lymph node dissection was performed after manual repositioning. The resected specimen showed two pedunculated polyps at the top of the intussusception. Microscopic examination clarified that one represented papillary adenocarcinoma in adenoma. Since more than half of retrograde intussusceptions have been reported to be caused by pedunculated malignant tumors, intestinal tract excision with lymph node dissection should be considered.

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Although there are a lot of case reports of toxic shock syndrome (TSS) after surgery, most of these cases are of acute onset of TSS developed shortly after surgery. Here we present a case of TSS developed 25 days after rectal surgery for rectal cancer when the patient had been discharged.
A 62-year-old man presented with frequent bouts of defecation underwent rectal amputation with bilateral lateral lymph node dissection with the diagnosis of advanced rectal cancer. He was discharged without having complications at the postoperative day 8. He came to our emergency clinic because of a 3-day history of diarrhea at the postoperative day 28. He was diagnosed with dehydration and admitted to our hospital. After admission he had rapidly progressed hypotension, peripheral hypoperfusion and altered mentation, and then septic shock was diagnosed. He had fulminant course of septic shock, disseminated intravascular coagulation and multiple organ failure and died 70 hours after re-admission in spite of multimodality therapy. In consequence of autopsy and bacterial examination, he was diagnosed with TSS caused by MRSA infection of pelvic lymphocele. There are few case reports of late onset of TSS which occurred after a lapse of three weeks or more following the surgery. Because TSS could occur at any time after surgery, rapid and proper treatment should be done for postoperative sepsis with rash.

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We report two cases of micropapillary carcinoma (MPC) of the rectum and reviewed 32 cases from the Japanese literature from 2005 to 2014. Case 1 involved a 63-year-old man who underwent high anterior resection for a diagnosis of rectal cancer with liver metastasis. Histopathological findings showed poorly differentiated adenocarcinoma accounting for most of the tissue, with a potion showing a so-called “inside-out -pattern”. MPC of the rectum was diagnosed. As well as multiple liver metastases, marked lymphatic invasion and multiple lymph node metastases were seen. Case 2 involved a 59-year-old woman in whom rectal cancer was identified during examination of uterine cancer. We planned chemoradiotherapy for the uterine cancer and performed Hartmann's operation for the rectal cancer. In histopathological findings, well to moderately differentiated tubular adenocarcinoma including an MPC component was revealed. Marked lymphatic invasion was present, but no lymph node metastasis. MPC is recognized as a high-grade malignant tumor with a high propensity for lymph node metastasis and distant metastasis. We examined clinicopathological characteristics of MPC of the colorectum.

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Carcinoma of the anal canal is classified as intra- or extramucosal, but preoperative diagnosis is often difficult because extramucosal carcinoma of the canal generally offers scant mucosal surface findings. The present case involved poorly differentiated squamous cell carcinoma of the anal canal presenting with an extramucosal development that made diagnosis difficult. A 70-year-old woman visited our hospital with a chief complaint of anal pain. Rectal examination showed circumferential stenosis 3 cm from the anal verge. A largely immobile induration was found on palpation, and was accompanied by pain. Lower gastrointestinal endoscopy showed scant changes in the mucosal surface, and biopsy tissue diagnosis from the stenotic area showed no obvious atypical cells or tumor cells. Transanal needle biopsy also failed to give a definitive diagnosis, and abdominoperineal resection of the rectum was implemented for diagnosis and treatment. The resected specimen exhibited tumor cells with an extramucosal distribution from the submucosal layer, centered on the transitional epithelium of the anal canal. Histopathological examination showed a scarce number of keratotic portions and intercellular bridges in one limited portion within the tumor. The patient was finally diagnosed with poorly differentiated squamous cell carcinoma.

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When a passenger is thrown from a moving personal watercraft (PWC), the jet propulsion can cause a characteristic recto-vaginal injury. Though this is rare among the PWC related injuries, its damage morphology is very complicated and difficult to treat ; and sometimes it can be fatal. Case1 : A 25-year-old woman was thrown backward from a moving PWC. The patient had profound perineal bleeding and was transferred to our hospital. Anal laceration and rectal injuries were noted. One of the rectal injuries had reached above the peritoneal reflection and a diverting colostomy was performed. The patient was discharged from our hospital on 12^th hospital day. The closure of her colostomy has not been completed. Case 2 : A 27-year-old woman was thrown backward from a moving PWC. Multiple recto-vaginal injuries and profound bleeding were noted. Her rectal injury was controllable with a diverting colostomy, however the vaginal bleeding originating from the fornix was quite difficult to control. Though the patient once lapsed into severe hemorrhagic shock, the bleeding was successfully controlled with a trans-catheter arterial embolization. The patient was transferred to another hospital on 35^th hospital day.

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A 66-year-old woman who had been followed for fatty liver was detected to have a highly echogenic tumor in the segment 3 of the liver on an abdominal ultrasonography. An abdominal plain CT scan showed a low density area 55 mm in the maximum diameter with a heterogeneous inner portion at the same site of the liver that the ultrasonography demonstrated ; there was a high density part. Hepatic angiomyolipoma was likely, but a malignant neoplasm such as hepatocellular carcinoma was possible. Accordingly laparoscopy-assisted lateral segmentectomy of the liver was performed. The resected specimen involved a sharply demarcated tumor 55 mm in diameter. Histopathological study showed that the tumor had fatty tissue, spindle-shaped cells and the growth of vessels, with a part which had been encircled by a fibrous capsule-like structure. Immunohistochemical stainings were HMB-45 and α-SMA positive. Hepatic angiomyolipoma was thus diagnosed.
Hepatic angiomyolipomas are comparatively rare tumors, among of which the tumors extremely rarely have a capsule. Here we present a case of encapsulated hepatic angiomyolipoma.

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The patient was a 54-year-old woman with liver dysfunction that was diagnosed during a routine health examination. A hepatic mass was detected on examination, for which she was referred to our department for consultation. Computed tomography revealed two masses (diameters 10 and 15 mm, respectively) without contrast enhancement in the center and marginal enhancement in S6. Magnetic resonance imaging revealed low-signal intensity masses on T1-weighted images that showed high signal intensities on T2- and diffusion-weighted images. The masses were small and therefore were expected to increase in size. Partial liver resection involving S6 was performed. Histopathological analysis revealed marked inflammatory cell infiltration and fibrous elements that led to the diagnosis of inflammatory pseudotumor of the liver. Blood test results confirmed Epstein-Barr virus infection. This indicates that the inflammatory pseudotumor of the liver in this case may have been associated with chronic Epstein-Barr virus infection.

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More and more elderly patients are receiving surgery because of the aging of the population. Such patients have various comorbidities and cognitive decline, thus rendering therapeutic decision making complicated. A 75-year-old man was admitted to our hospital with a diagnosis of bile duct cancer. He had moderate cognitive decline and limited activity of daily living. We carefully evaluated his physical and cognitive status, as well as his family's support. Subsequently, we performed bile duct resection with careful consideration of his background and general condition. In the present case, organ-preserving surgical procedures and discrimination between dementia and delirium were helpful in deciding the therapeutic strategy. Early participation of healthcare providers was also helpful in ensuring a smooth hospital and post-hospital course.

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An 85-year-old man was admitted to another hospital for continuous epigastric pain. Acute cholecystitis was suspected, and he was referred to our hospital. He had developed a stroke approximately two months previously and was undergoing anticoagulant therapy. Abdominal CT scan showed gallbladder (GB) hemorrhage and perforation of the GB wall at the anterior side of the GB neck. Based on a diagnosis of hemorrhagic cholecystitis caused by anticoagulant therapy, we performed emergency operation (cholecystectomy). The resected specimen contained a slightly elevated lesion with a central depression at the peritoneal side of the GB fundus ; we had been unable to detect this lesion on preoperative imaging diagnosis or intraoperative findings. On histopathological examination, it was diagnosed as adenocarcinoma, and an exposed artery at the bottom of the central depression in the tumor had ruptured with agglutination of red blood cells. Therefore, we diagnosed this case as hemorrhagic cholecystitis due to the occult GB cancer. Cases of GB perforation caused by hemorrhagic cholecystitis are relatively rare. Furthermore, cases of hemorrhagic cholecystitis caused by GB tumor are extremely rare. We have reported a case of occult GB cancer that caused a rupture, resulting in hemorrhagic cholecystitis.

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A 73-year-old woman was admitted to our hospital in 2009 with complaints of anal pain and hematochezia. She had undergone hysterectomy for uterine body cancer in 1998, while she was diagnosed with branch-duct intraductal papillary mucinous neoplasm (IPMN) of the head of the pancreas. Subsequently, she underwent bilateral partial mastectomies for breast cancers in 2005 and subtotal distal pancreatectomy for cancer of the pancreatic body in 2006. As the IPMN displayed no signs of malignancy, resection was not performed. This time, anoscopy detected an ulcerating tumor in the anal canal and histological examination revealed the tumor was adenocarcinoma. Several lymph nodes were depicted in the left inguinal region on computed tomography. The IPMN in the remnant pancreas showed no changes. The patient underwent abdominoperineal rectal amputation, but died of recurrence 9 months after surgery. IPMT of the pancreas is well known to coincide with cancer of other organs, but cases with multiple primary cancers are rare. The prognosis of such cases of IPMN with multiple cancers often depends on the malignant behavior of cancers in other organs, and careful follow-up is therefore necessary for patients with IPMN.

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A 76-year-old woman was admitted with a provisional diagnosis of left inguinal mass lesion. Physical examination revealed a tender left inguinal mass, which could not be reduced. Abdominal computed tomography showed left inguinal tumor and peritoneal thickening connected with the lesion. We diagnosed left inguinal hernia with invagination of the greater omentum or left ovary. We planned transabdominal preperitoneal repair (TAPP). A nodular lesion was detected in the hernia sac by laparoscopy and subsequently resected. We could not determine if the left inguinal tumor was connected with the peritoneal lesion. The inguinal tumor was resected using the anterior approach, and TAPP was performed. The pathological findings showed that both the inguinal lesion and peritoneal lesion were malignant peritoneal mesothelioma. We encountered a case of malignant peritoneal mesothelioma detected during investigation for inguinal mass.

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A 72-year-old man developed a bulge from the right inguinal region to the scrotum during colonoscopy. The scrotum had swollen to 20 cm in size. From abdominal CT findings, right inguinal hernia in which the greater omentum and the colon had been incarcerated was diagnosed. Since the hernia could not be reduced by manipulation, an emergency operation under general anesthesia was performed. The patient was as extremely obese as the BMI of 35 and his incarcerated hernia was so huge that demanded us to approach to the hernia from a midline laparotomy at the lower abdomen and from the inguinal region. The hernia contained the greater part of the omentum and the transverse colon. The omentum was partially excised ; the contents in the colon were absorbed from a small opening at the injured transverse colon to decompress the pressure within the colon ; and the herniated organs were able to be returned in the abdomen. After closure of the small opening, the inguinal hernia was repaired by the iliopubic tract repair method. He developed respiratory failure after the operation, but it was ameliorated in a short time.
Incarcerated hernia as a complication of colonoscopy has rarely been reported so far, and clinical cases of inguinal hernia in which the transverse colon is incarcerated are extremely rare. Accordingly our case is presented here, together with a review of the literature.

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We report a case of pilonidal sinus on the umbilicus. A 35-year-old man was seen at the hospital on referral from his family doctor because of umbilical exudates and subcutaneous induration for three months. The doctor suspected urachal remnant. Abdominal computed tomography showed an enhanced high-density area corresponding with the umbilical fossa, but no positive findings of urachal remnant. The umbilicus was covered with hard hair. We made an incision into the subcutaneous induration under spinal anesthesia, and found a granulomatous pouch filled with hair. This finding allowed us to diagnose pilonidal sinus on the umbilicus. Pilonidal sinus on the umbilicus has been reported in 6 cases, including this case, so far in Japan. Surgical resection is proposed as the definitive treatment, because the hair causes inflammation.

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