[in Japanese]

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Laparoscopic percutaneous extraperitoneal closure (LPEC) is a commonly used technique for inguinal hernia repair in infants, whereas a tension-free technique is conventionally utilized for inguinal hernia repair in adults. However, since the mechanism of development of inguinal hernia in young adults is similar to that in infants and young children, we hypothesized that LPEC may also be applicable to inguinal hernia repair in young adults. Between 2009 and 2014, we performed LPEC for inguinal hernia repair in 11 young adult patients, including 5 men and 6 women. There were no cases of postoperative recurrence. From these results, we believe that LPEC is a valid technique for the treatment of inguinal hernia even in young adults.

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We analyzed the clinicopathological characteristics of 5 patients with duodenal gastrointestinal stromal tumor (GIST) resected at our hospital between January 2005 and December 2015. The patients (4 males, 1 female) were aged 54 to 83 years (mean : 68 years). We suspected duodenal GIST in all patients before surgery based on endoscopy. The tumor location was in the horizontal portion in 3, descending portion in 1, and ascending portion in 1. The tumor size ranged from 25 to 75 mm (mean : 40 mm). We performed wedge resection of the duodenum in all patients. The classification was T2 in 4 and T3 in 1. The pathological stage was I in 4 and II in 1. The postoperative median follow-up duration was 52 months (range : 7-131 months). All patients were discharged at an average of 13 days (range : 10-15 days) postoperatively without complications such as pancreatic fistula or suture deficiency. All patients are alive without recurrence. In the surgical treatment of duodenal GIST, it is very important to preserve organ function.

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An 80-year-old man who had a history of myocardial infarction presented with urinary retention and persistent constipation when he was treated for congestive heart failure in our hospital. Computed tomographic angiography revealed bilateral giant internal iliac artery aneurysms (IIAs) compressing the rectum. We considered endovascular aneurysm repair (EVAR) as a treatment option. However, the reduction of the aneurysms volume might be inadequate to improve the symptoms. Thus, we performed graft replacement of the abdominal aorta and bilateral external iliac arteries, resection of the bilateral IIAs, and reconstruction of the internal mesenteric artery. He had good control of urination and defecation after surgery. His postoperative course was uneventful. Although the use of EVAR as a surgical treatment of abdominal aortic aneurysms and iliac artery aneurysms has become widespread, traditional open surgery should remain the gold standard treatment for symptomatic iliac artery aneurysms.

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A 69-year-old man who visited a neighboring hospital because of coughing was detected to have a solitary nodule 2.1 cm in maximum diameter in the left segment 8 on a chest CT scan and was referred to our hospital. A FDG-PET scan showed an abnormal uptake of FDG in the area and the CYFRA level was elevated. Primary lung cancer was suspected and partial pneumonectomy was performed to make the definite diagnosis. Intraoperative frozen section diagnosis confirmed infiltration of lymphocytes, but we could not obtain any definite diagnosis of malignant disease. Since a possibility of malignant neoplasm could not be ruled out, left S8 segmentectomy was added. The permanent specimen revealed lymphocytic infiltration into the interalveolar septa and polypoid fibrous tissue at the peripheral airways. Focal organizing pneumonia was thus diagnosed. No postoperative therapies were added, but there have been no signs of recurrence as of 8 months after the operation.

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A-68-year-old woman was referred to our hospital because of an abnormal shadow on her chest plain X-ray film. Computed tomography of the chest revealed a nodule 40 mm in maximum diameter at the right segmental 9. During a follow-up period, this nodule showed spontaneous remission and then completely disappeared. Three years later, she was referred to our hospital because her chest plain X-ray film showed an abnormal shadow in the right lower lobe again. CT scan of the chest revealed a 38-mm nodule in the same region of the right segmental 9 as that of 3 years before. CT and PET findings of the tumor looked same as those of the previous shadow. Transbronchial cytology of the tumor revealed malignancy-suspected cells, and surgical resection was performed. Histological examination confirmed invasive mucinous adenocarcinoma of the lung. The patient has been disease-free, as of one year and 10 months after the operation. This case was considered to be of very rare lung cancer that reappeared after a radiological complete spontaneous remission, and an immune response that arose out of anti-nuclear antibody might be related to the spontaneous remission of the tumor.

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We report a rare case of internal hernia following thoracoscopic and laparoscopic esophagectomy. The patient was a 79-year-old man who had been followed after thoracoscopic and laparoscopic subtotal esophagectomy with reconstruction via the posterior mediastinal route in 2013. He was brought into our hospital because of about postoperative 6-month history of vomiting and abdominal pain in 2014. An abdominal contrast-enhanced computed tomography revealed a small intestine impacted into the left thoracic cavity through the esophageal hiatus. He was diagnosed with bowel necrosis due to an internal hernia and received an emergency operation. During this operation, a 20 cm-long ileum with necrosis was seen to have been impacted into the esophageal hiatus through which a gastric tube was elevated at the previous esophageal operation. Since the impacted intestine became necrotic, partial ileectomy was performed.
Hiatal hernia through a reconstruction route after esophageal operation for esophageal cancer is rare and the causes vary. Postoperative internal hernias may be classified as early or delayed type. This case was of delayed type because it occurred 6 months after operation. On presentation of this case, the patient had an extremely reduced food intake after the initial operation, showing a BMI of 19.1. Therefore, reduction of omental fat of the elevated gastric tube might cause increase of the gap of esophageal hiatus that allowed impaction of a small intestine into there. It was also inferred that intraabdominal adhesions were of mild degree for the laparoscopic surgery. Tese were the likely causes of this hiatal hernia involving the small intestine.

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Esophageal rupture predominately occurs on the left side, and there are few reports about the mechanism of right-sided occurrence and the treatment strategies. A 66-year-old man with a history of esophageal stenosis caused by chronic reflux esophagitis was brought into another hospital by ambulance because of back pain. He was diagnosed with suspected esophageal rupture on computed tomography, thus he was transferred to our hospital. The patient was diagnosed with right-sided intrapleural perforating esophageal rupture on esophagography, and we decided to perform an emergency surgery. A large amount of contaminated pleural effusion and debris were found in the right pleural cavity, and an approximately 5-cm longitudinal tear was identified in the right-sided wall of the lower thoracic esophagus. Considering the risk of re-rupture and leakage, we performed subtotal esophagectomy and gastric tube reconstruction via a retrosternal route. Postoperatively, the clinical course was good without any complications. The weakness of the right-sided wall of the esophagus due to chronic inflammation was indicated histopathologically, and that was thought to have been the cause of the right-sided esophageal rupture. This case suggests that esophagectomy and one-stage reconstruction can be a treatment choice for esophageal rupture in generally stable patients.

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A 76-year-old man admitted for dysphagia was found in preoperative examination to have advanced esophageal cancer in the upper thoracic esophagus. Three dimensional computed tomography (3D-CT) showed a right aortic arch with an aberrant left subclavian artery and ductus arteriosus originating from a diverticulum at the descending aorta (Edwards IIIB). The esophageal cancer was located in the upper thoracic esophagus and it was diagnosed as Ut, cT3N0M0, cStage II squamous cell carcinoma according to the Japanese Classification of Esophageal Cancer. The patient underwent a subtotal esophagectomy via a left thoracotomy and reconstruction using a gastric tube through the retrosternal route. There was an aberrant left subclavian artery arising from a Kommerell's diverticulum at the proximal descending aorta, and it was also confirmed that the left recurrent laryngeal nerve looped around the ductus arteriosus between the diverticulum and the left pulmonary artery. The adjacent left recurrent laryngeal nerve was resected along with the tumor due to a suspected tumor invasion, and formed anastomosis with the vagus nerve following cervical lymph node dissection. A thorough preoperative evaluation of vascular anatomy including the use of 3D-CT is thus useful in surgery for esophageal carcinoma associated with right aortic arch.

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The patient was a 78-year-old man. An abdominal contrast-enhanced CT scan as a preoperative screening for bladder cancer showed a submucosal tumor at the gastric wall which was enhanced from the early phase to the venous phase with strong enhancement effect. Upper gastrointestinal endoscopy revealed a 25-mm submucosal tumor at the greater curvature of the upper body of the stomach. A biopsy showed cells which had oval-shaped nucleus and faintly eosinophilic cytoplasm had grown so as to surround small vessels. The tumor cells were α-SMA staining positive and then glomus tumor of the stomach was diagnosed. Although the number was small, mitotic figures were seen and a possibility of malignancy could not be ruled out. We thus decided to remove the tumor. Using intraoperative upper gastrointestinal endoscopy, we performed laparoscopic-assisted partial gastrectomy. The resected specimen was also diagnosed as gastric glomus tumor. There were no mitotic figures and malignant findings.
Glomus tumor of the stomach is a relatively rare disease. The disease is benign in most cases, but few malignant cases have been reported. It is believed that the tumor over 5 cm in diameter has a possibility of distant metastasis. Since a gastric glomus tumor preoperatively diagnosed is rare, here we present this case.

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An 84-year-old woman presented to our hospital because of suddenly exacerbated upper abdominal pain. An emergency operation was performed with a diagnosis of gastrointestinal perforation. During surgery, we confirmed gastroduodenal intussusception and gastric perforation. Observation through gastrotomy revealed a type I polyp with its root situating at the fundus of stomach, with which ball valve syndrome (BVS) was presented. Perforation occurred at the root of the peduncle. Polypectomy including the perforated site was performed. The postoperative course was uneventful. The histopathological diagnosis of the resected specimen was type “0-I” early gastric cancer.
It is rare that a tumor arisen from the fundus to the upper body of the stomach develops BVS, and is rarer that BVS causes gastoduodenal intussusception followed by gastric perforation. This paper deals with our experience of a case of type “0-I” early gastric cancer in which gastroduodenal intussusception caused gastric perforation due to BVS.

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A 69-year-old man was under follow-up for multiple submucosal tumors in the duodenum diagnosed 14 years earlier. In the history of present illness, the patient was referred to our hospital because some of the tumors had changed in characteristic to excavating tumors. Upper gastrointestinal endoscopy showed large submucosal tumors measuring about 10 mm each in diameter in the anterior and posterior parts of the duodenal bulb. Only the lesion in the anterior wall was diagnosed as a NET by biopsy. Despite that, we judged it necessary to perform lymphadenectomy, as the tumors were larger than 10 mm in diameter. Therefore, we performed distal gastrectomy with lymphadenectomy. The resected specimen consisted of four submucosal tumors. Immunostaining showed numerous synaptophysin-positive plasma cells and chromogranin A -positive plasma cells in each of the tumors. On the basis of the histopathological findings, we diagnosed the patient as a case of NET G1, pT2N0M0, Stage IIA (ENET). Only one of the tumors could be diagnosed preoperatively as a NET. Our experience of this case shows the importance of careful endoscopic analysis for multicentricity in patients with duodenal NETs.

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An 88-year-old man visited a previous hospital because of frequent bouts of melena, when upper and lower gastrointestinal endoscopy did not reveal bleeding site in the colon but the presence of blood in the ileum. He was referred to our hospital with a suspected diagnosis of small bowel bleeding. Transanal double-balloon enteroscopy revealed a Meckel's diverticulum in the distal ileum, and at its origin an ulcer was identified, bleeding from the ulcer being diagnosed. Upon surgery, the Meckel's diverticulum was present 40 cm proximal to the ileocecal valve. Partial ileectomy was performed. Histopathology revealed that there were no ectopic gastric mucosa and pancreatic tissue within the diverticulum, but UI-II ulcer was present at the origin of the diverticulum. Bleeding from the Meckel's diverticulum rarely occurs in elderly people. To the best of our knowledge, all patients over 70 years reported in Japan had no ectopic gastric mucosa but ulcer at the origin of the diverticulum was observed in many of them. Accordingly we consider that causes of bleeding from the Meckel's diverticulum in elderly patients might differ from those in juvenile patients whose mechanism of the bleeding mainly lies in ectopic gastric mucosa ; and that ulcer formation caused by long-term mechanical stimulations or circulatory disturbance might induce the bleeding in the elderly.

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Cholesterol crystal embolization refers to embolization of the scattered contents of a ruptured atherosclerotic plaque to peripheral vessels causing end-organ damage by mechanical plugging. The case involved an 86-year-old man who presented to our hospital because of abdominal pain. An abdominal CT scan revealed free air in the abdominal cavity. The patient was operated on with a diagnosis of generalized peritonitis caused by gastrointestinal perforation. During surgery we confirmed small bowel perforation and performed partial enterectomy. Histopathology revealed embolization of cholesterol crystals in arteries in the small bowel wall. The patient complained of abdominal pain on the 13^th postoperative day, suggesting a recurrent bout of gastrointestinal perforation. Surgery was performed. A perforation was identified in the small intestine where was different from the previous perforation site, and partial enterectomy was performed. Histopathology revealed the same findings as the previous perforation. The perforation was considered to be caused by bowel ischemia associated with cholesterol crystal embolization. He developed pneumonia with septicemia and died on the 64^th day after the initial operation.
Gastrointestinal perforation due to cholesterol crystal embolization carries an extremely high fatality rate. In order to save the patient's life, we should sufficiently consider in selecting operative procedures and maintain symptomatic treatments according to general condition of the patient.

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A 63-year-old man presented with severe abdominal pain. He had fever, muscle pain in the neck and lower leg for two weeks prior to visiting the hospital. He was diagnosed as having pyelonephritis, and was hospitalized for six days. He was readmitted because of strong abdominal pain two days after hospital discharge and was referred to our department with the suspicion of intestinal ischemia. On physical examination, he was found to have a distended abdomen with rebound tenderness. Computed tomography showed ascites, dilation of the small intestine, and poorly-enhanced intestinal walls in a part of the small intestine. Emergency laparotomy was performed because acute mesenteric ischemia was suspected. The small intestine was generally dilated, and the color of some areas was poor. There were two areas of transmural necrosis in the small intestine, and we resected these.
Pathologically, the arteries had inflammatory cell infiltration that mainly comprised neutrophils. Many areas of angitis had fibrinoid necrosis in the small intestine. We diagnosed polyarteritis nodosa, based on the criteria of the Ministry of Health, Labour and Welfare of Japan. Steroid therapy was administered, and the patient was discharged 80 days after surgery.

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In a past 10-year period, we have experienced four cases of ileal carcinoid which is a very rare entity in this country.
An average age of these patients was 55 years, ranging from 52 to 57. The male-to-female ratio was two versus two. The chief complaints were positive reaction to the guaiac test in two cases and abdominal pain in two cases. Endoscopic studies showed a submucosal tumor yellow in color at the terminal ileum. We performed biopsies in all cases that yielded the definite diagnosis of carcinoid before surgery. On abdominal CT scans, regional lymph node swelling was pointed out in two cases, but distant metastases were absent. We thus determined that these patients could be candidates for radical operation, and performed laparoscopic-assisted ileocecal excision (D3 dissection) in all patients. Histopathology revealed an average tumor diameter to be 20 mm (ranging from 12 to 30 mm), the tumor to have grown in the muscularis propria, and the neighboring regional lymph node metastasis to be present in all cases ; namely pT2N1M0, pStage IIIB. We did not conduct adjuvant therapies and all four patients have been alive without having recurrence.

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An abdominal wall abscess is uncommon during pregnancy. A 28-year-old woman in the 31st week of gestation was admitted to our hospital for an abscess of the upper abdominal wall along with a high fever. Percutaneous drainage was performed, followed by maintenance on total parenteral nutrition without oral intake for the intestinal fistula. Her total energy intake was 1,640 kcal/day. We confirmed that fetal development was favorable. The fetus was delivered by cesarean section at the 35th week of gestation without low birth weight or congenital anomaly. Radiography and colonoscopy revealed strictures of the ileum and fistulas of the ileum and colon after the cesarean section. Crohn's disease (CD) was suspected on the basis of the findings and the clinical course. She underwent ileocecectomy, resection of the fistulas, and partial resection of the sigmoid colon 2 weeks after the cesarean section. The resected specimen showed some longitudinal ulcers and fistulas of the ileum and cecum, and the patient was diagnosed with CD. She is maintained with diet therapy after surgery. The growth of the infant was also favorable.

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A case of strangulation ileus caused by the appendix adhering to the peritoneum of the pelvis is described. A 37-year-old woman visited our hospital with a complaint of acute abdominal pain and was diagnosed as having intestinal obstruction. She had no history of laparotomy. Since the cause of intestinal obstruction could not be confirmed by CT or MRI, laparoscopy was performed and showed that the ileum was surrounded and strangulated by the appendix, which adhered to the peritoneum of the pelvis. Since the ileum showed no ischemic signs, laparoscopic appendectomy was performed. A case of strangulation ileus caused by the appendix is rare ; therefore, this case is reported along with a review of the relevant literature.

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We report a case of abscess that developed in an inguinal hernia sac after appendectomy for perforated appendicitis. A 20s-year-old man underwent appendectomy for perforated appendicitis. He had no medical history except for a reducible right inguinal hernia. On the 5th day after the appendectomy, bulging with mild tenderness in the right upper scrotum appeared. Computed tomography with contrast showed abscess in the right inguinal hernia sac. Subsequently, hernioplasty and resection of the sac were performed. The hernia sac was approximately 3 cm in diameter, and had reached to the scrotum ; the sac was resected. The inguinal hernia was accompanied by a communicating hydrocele. The abscess in the inguinal hernia sac had formed without an incarcerated inguinal hernia, which suggested remnant abscess following the appendectomy for the previous perforating appendicitis. To our knowledge, this is the first reported case of abscess in an inguinal hernia sac after appendectomy for perforated appendicitis and peritonitis in Japan.

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The classification of an appendiceal mucinous tumor is controversial. Low-grade appendiceal mucinous neoplasm (LAMN) is newly classified in the Japanese Classification of Colorectal Carcinoma, Eighth Edition. Here, we report a case of LAMN. A 90-year-old woman suspected to have ileocecal abscess was admitted to our hospital. Abdominal computed tomography showed cystic dilatation of the appendix to 7.5 cm in diameter. We diagnosed appendiceal mucinous tumor and performed ileocecal resection with lymph node dissection (D2) because the possibility of mucinous cystadenocarcinoma could not be ruled out. Mucus was accumulated within the lumen. The pathological diagnosis indicated LAMN. Recent research has found that LAMN is potentially malignant ; however, a treatment strategy has not been established. Therefore, appropriate surgical intervention with careful postoperative surveillance should be considered.

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We report the rare case of a patient with ascending colon cancer who presented with Bazex syndrome. A 70-year-old man consulted our hospital for the treatment of keratotic exanthem of both legs. The exanthem was becoming worse and spreading to his entire body despite treatment with topical steroid ointments. Histopathological examination of skin biopsy specimens obtained from the lesions revealed interface dermatitis. Therefore, the dermatologist strongly suspected that the skin changes were associated with some underlying malignant tumor. Finally, after further examinations, the patient was diagnosed as having ascending colon cancer and referred to our department. We performed laparoscopic-assisted right colectomy for the ascending colon cancer. Since the exanthem improved dramatically, the patient was finally diagnosed as having Bazex syndrome. As Bazex syndrome associated with ascending colon cancer is extremely rare, we report this case with a review of the literature.

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Idiopathic perforation of the transverse colon is a rare type of colonic perforation. Only 16 cases have been reported until date in Japan. Recently, we encountered the case of a 58-year-old woman with peritonitis secondary to perforation of the transverse colon, in whom we had to perform emergency surgery. Intraoperatively, muddy ascites and localized green-colored swelling of the mesentery located 10 cm proximal to the splenic flexure were noted. The patient's postoperative course was uneventful and she was discharged on the 25^th hospital day without any complications. We could not identify the specific cause of the perforation either from the clinical or the histopathological findings. Therefore, we diagnosed the patient as a case of idiopathic perforation of the transverse colon. Herein, we report the case with some review of the literature on idiopathic perforation of the transverse colon.
Idiopathic colonic perforation is most commonly encountered in the sigmoid colon ; on the other hand, the reported frequency in the transverse colon is about 8%. Furthermore, it occurs more often on the antimesenteric side than on the mesenteric side. Although our case was an untypical case of idiopathic colon perforation, the clinical course was favorable because of the localized involvement.

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A 72-year-old woman who was admitted to our hospital because of cholelithiasis was incidentally found to have descending colon cancer by close examinations. Preoperative 3D-CT scan showed inferior mesenteric arteriovenous malformation (AVM) and mesocaval (IMV to IVC) shunt (Retzius shunt). Laparoscopic descending colectomy, D3 lymph nodes dissection and cholecystectomy were performed. Operative findings included the Retzius vein crossing the abdominal aorta to the inferior vena cava (IVC) and a number of engorged vessels in the mesentery. The Retzius vein was clipped without major bleeding. Histopathological examination showed hyperplasia of the dilated vessels connected to feeder arteries and drainage veins. The postoperative clinical course was good, and she was discharged from our hospital 10 days after the surgery.
Inferior mesenteric AVM with Retzius shunt without accompanying by portal hypertension due to liver cirrhosis is extremely rare. So we report our case with a review of the literature. Preoperative 3D-CT scan of vessels is very useful.

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The patient was a 63-year-old woman who was seen in our hospital internal medicine department for lower abdominal pain and fever 8 days earlier. There was abnormal dilation of the sigmoid colon with surrounding free air on abdominal CT. She was referred to surgery with a diagnosis of peritonitis due to sigmoid colon perforation. Additional contrast-enhanced CT showed thrombus over the splenic vein from the inferior mesenteric vein and multiple nodules in both lungs. Emergency abdominal surgery was performed on the same day, with resection of a small length of sigmoid colon including the area of perforation, and an artificial anus was created with the sigmoid stump. Postoperatively, lung function and liver function did not worsen. A case of peritonitis due to colonic perforation with septic pulmonary embolism is relatively rare ; therefore this case is reported along with a review of the relevant literature.

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The patient was a 66-year-old woman who was referred to our hospital with abdominal pain. She had no previous history of undergoing abdominal surgery. An abdominal contrast-enhanced CT scan showed dilatation of the small bowel and closed loop findings. She was diagnosed as having strangulated ileus. Therefore, she underwent emergency laparoscopic surgery under general anesthesia. Laparoscopic observation indicated that the ileum was strangulated by a loop of fatty appendices of the sigmoid colon. The adhesions of the fatty appendices to the mesentery were resected. As the strangulated small bowel did not exhibit any ischemic changes, bowel resection was not required. The patient was discharged 9 days after the surgery without complications. There have been few reports of strangulated ileus caused by fatty appendices of the sigmoid colon. Herein, we discuss this case with a review of the literature.

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A 60-year-old female patient was referred to our hospital complaining of abdominal pain. Abdominal CT revealed a multilocular cystic tumor of the sigmoid colon causing colonic stenosis. Sigmoidectomy with D2 lymph node dissection was performed semi-emergently because of sub-ileus. The tumor was 7×5×3cm in size, multilocular, and contained mucinous fluid. Histological examination revealed that the cyst was covered with columnar epithelium, and an eosinophilic layer consisting of short spindle cells, the so-called ovarian-like stroma, was clearly observed under the epithelium. The stromal cells showed immunopositivity for estrogen receptor, progesterone receptor, and inhibin. On the basis of the findings, the tumor was diagnosed as a mucinous cystic neoplasm of the sigmoid colon.
Mucinous cystic neoplasms with an ovarian-like stroma are rare tumors and most often arise from the pancreas or the liver ; such tumors arising from other sites are extremely rare. There are no case reports yet of MCN of the colon in the literature. We are therefore reporting this case here, with a review of the literature.

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Cases of colon gastrointestinal stromal tumor (GIST) are rare, and the prognosis for such patients is poor compared with that for patients with gastric GIST. In general, a majority of GISTs show positive results on immunohistochemical staining for KIT. In the case of KIT-negative GIST, the identification of “Discovered on GIST-1 (DOG1)” staining is very useful. Here, we report a case of KIT-negative, DOG1-positive sigmoid colon GIST with peritoneal metastasis. Upon admission, the patient complained only of mild abdominal pain on the left side, and the disease progressed rapidly following sigmoidectomy.

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The patient was a 53-year-old woman complaining of lower abdominal pain and watery stools. She had undergone postoperative radiotherapy for cervical cancer of the uterus about 13 years previously. Laboratory examination revealed evidences of acute inflammatory response (the WBC count of 18600/mm³, serum CRP level of 18.4mg/dl). An abdominal contrast enhanced CT scan showed that the enhancement effect was absent at the dilated sigmoid colon wall, and the rectal wall was thickened with submucosal edema. We carried out Hartmann's procedure for the necrotizing rectum and penetrating mesentery of the sigmoid colon on an emergency basis. During the surgery, we suspected that the resected stump on the anal side of rectum might be necrotizing, however, it was difficult to peel around the rectum due to severe adhesions in the pelvis. We also carried out omental implantation repair because we concerned about possible secondary perforation at the resected stump on the anal side of rectum. Pathological examination of the resected specimen showed that the rectum became necrotic, and the mesentery of the sigmoid colon was penetrated. Late reaction by radiation therapy was the most likely cause because of vascular narrowing and occlusion by hyalinized thickening, and marked fibrosis in the large intestinal wall. After the surgery, perforation of the resected stump on the anal side of rectum occurred, however, she did not go into severe peritonitis. She could escape having serious condition owing to the pelvic omental implantation repair.

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The case involved a 44-year-old man who underwent very low aterior resection + D3 dissection for rectal cancer, RbP, type 3, pA, pN0, cM0, pStage II, R0, and CurA, at a previous hospital. His treatment was completed after a 6-month adjuvant chemotherapy with oral UFT 600mg/day followed by a 5-year follow-up study, without having recurrence. This time when 6 years and 9 months had elapsed after the operation, the patient presented to our hospital because of lumber pain and numbness from the right gluteal region to the lower limb. As a result of a biopsy of the sacrum, metastatic bone tumor derived from rectal cancer was diagnosed, but otherwise he had no metastatic lesions. The FOLFOX + Bmab regimen was started with zoledronic acid regimen simultaneously. During the chemotherapy, his pain was aggravated, so that irradiation was conducted to alleviate the pain. His pain was alleviated and the chemotherapy was resumed. Now he has been on the chemotherapy.
The frequency of recurrence of Stage II rectal cancers developed more than 5 years after surgery is as low as 0.94%. In this case, it took about 2 months until we made the diagnosis of recurrence. It is reported that bone metastasis alone carries relatively favorable prognosis to the patients, however, early diagnosis and multimodal as well as individual therapies are important.

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We present a case of gastrointestinal stromal tumor (GIST) which appeared to have arisen from the internal sphincter muscle of anus. The patient was a woman in her sixties who presented to our hospital because of a sense of discomfort and a lump at the perineum. We palpated an elastic-hard tumor with the size of a walnut at the 11 o'clock direction in the subcutaneous structure in the vicinity of the anus. No changes on the skin surface were seen. Visual and digital examinations and anosigmoidoscopy revealed no abnormal findings on the mucosa and lumen of the anal canal and rectum. Imaging studies revealed a 30-mm well-circumscribed tumor showing iso-density to that of muscle in the perineal subcutaneous structure, but we could not determine from where the tumor had arisen. Percutaneous tumorectomy for the purpose of incision biopsy revealed that the tumor connected to the sphincter muscle of anus in the deep structure so that we had to divide and remove a part of the tissue at the tumorectomy. Histopathological diagnosis was GIST derived from the internal sphincter muscle of anus. The patient was considered to belong to a clinically high risk group of recurrence and she has been on adjuvant chemotherapy with imatinib. She is doing well without signs of recurrence, as of 14 months after the operation.

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A 76-year-old woman who had been diagnosed as having a tumor (hemangioma), 12 mm in diameter of the liver (S4) during close follow-up period for other disease at the age of 64. Follow-up observations of the tumor conducted at irregular intervals revealed gradually increasing tendency in size. About 4 years after the last observation, she was referred to our hospital because a significant enlargement of the tumor was noted. Abdominal CT scan showed that the inside of the tumor was mostly solid with a low density area suggestive of necrosis or a cyst. MRI scan showed a low intensity area in T1-weighted images and coexistence of low to high intensity areas in T2-weighted images. In every study, the tumor was stained heterogeneously from early phase. There were no other lesions. Hepatocellular carcinoma and angiosarcoma were suspected, however, atypical. Central sectionectomy of the liver was performed for the purpose of treatment and diagnosis. The histopathological diagnosis was G2 neuroendocrine tumor of the liver. Primary hepatic neuroendocrine tumor is rare and we could observe the long course of the tumor which grew gradually for as long as 12 years in this case. We also present a literature review of G1 and G2 primary hepatic neuroendocrine tumors.

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In acute cholecystitis, the gallbladder becomes inflamed and inflammation extends to the surrounding organs to form pericholecystic, hepatic, and subdiaphragmatic abscesses. It is relatively uncommon that the inflammation penetrates the abdominal wall to form abdominal abscess and then to become a cholecystocutaneous fistula. Recently we have experienced a case of cholecystocutaneous fistula with extrahepatic portal obstruction. The case involved an 82-year-old woman who presented to our hospital because of a one-week history of a painful right hypochondriac tumor. An abdominal CT scan showed a soft tissue tumor in the right-sided abdominal wall. The gallbladder had shrunk but was present close to the tumor. We identified extrahepatic portal obstruction at the same time. The patient was admitted for close exploration. On the next day, the tumor spontaneously ruptured and dark-red pus was discharged. Fistulography revealed communication with the gallbladder, and choecystocutaneous fistula was diagnosed. Cholecystectomy, fistulectomy and partial colectomy were performed under laparotomy. Histopathology showed no malignant findings, and we diagnosed the case as cholecystocutaneous fistula and extrahepatic portal obstruction associated with gallstone cholecystitis. With a recent progression of medical treatment, cholecystocutaneous fistula has become a rare entity. So far no cases of cholecystocutaneous fistula associated with extrahepatic portal obstruction have been reported as far as we could review.

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Pancreatic mucinous carcinoma is a rare tumor and accounts for 0.6 % of all pancreatic tumors. We present a case of pseudomyxoma peritonei derived from pancreatic mucinous carcinoma, together with a review of the literature. The case involved a 78-year-old man who was referred to our hospital for close examination of right lateral abdominal pain. An abdominal CT scan showed a cystic tumor about 6 cm in diameter at the pancreatic body and tail. MRI scan also revealed a cystic tumor having the thick wall and septa within it. Furthermore, images suggesting fluid collection were seen in the omental bursa, liver surface, and right juxtacolic groove. Intraomental penetration of intraductal papillary mucinous adenocarcinoma was diagnosed and resection of the pancreatic body and tail was performed. Upon laparotomy, we confirmed mucus collection in the omental bursa surrounding the tumor, in the perihepatic area and the Douglas pouch. Pseudomyxoma peritonei was thus diagnosed. The histopathological diagnosis was mucinous carcinoma. After the operation, he developed pancreatic fistula at the surgical stump of the pancreas, but it was relieved conservatively. Abdominal CT scan performed 9 months after the operation showed only a small amount of ascites around the liver and the patient who is on internal S-1 regimen has been followed in our clinic.

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A 23-year-old man who visited a neighboring hospital because of left-sided abdominal pain presented to our hospital on the next day because no symptomatic remission was gained. Following blood analysis and abdominal contrast-enhanced CT scan, he was diagnosed with acute pancreatitis and was admitted to our hospital. Another enhanced CT scan performed on the next day to observe the clinical course clarified a 26-mm low density tumor at the pancreas tail. In addition there was a poorly enhanced area in the pancreas head parenchyma. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a displacement of the main pancreatic duct of the pancreas tail due to compression by the tumor. Tumor markers and pancreatic hormone levels were in normal ranges. Pancreatic neuroendocrine tumor (pNET) was likely and he was operated on 3 months after the onset of pancreatitis. Laparoscopic distal pancreatectomy with associated splenectomy was performed. The tumor was 25 mm in maximum diameter, ash color, and solid. The histopathological diagnosis was pNET (G1).
It is rare that acute pancreatitis affects patients with pNET, especially those with pNET of low-grade malignancy. This paper deals with a case of non-functioning pNET (G1) presented with acute pancreatitis.

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A 62-year-old man who visited a neighboring hospital because of headache was referred to our hospital. A CT scan of the whole body revealed left chronic subdural hemangioma and tumorous lesions at the pancreas tail and the spleen. He was then referred to our department. Upper and lower gastrointestinal endoscopy showed no malignant findings. No tumor markers were elevated. The IL2R and IgG4 levels were elevated to 1,500 U/ml and 181.0 mg/dl, respectively. FDG-PET scan offered a suspicion of malignant lymphoma. The patient was thus admitted for the purpose of operation. Operative findings included a 6-cm splenic tumor and a 7-cm tumor at the pancreas tail, each of which had smooth surface and was white in color and hard. We performed associated resection of the pancreas body and tail and the spleen. After the operation he developed fistula of pancreas, but it was conservatively treated. He was discharged from the hospital on the 27^th postoperative day. On histopathology, a possibility of malignant lymphoma was ruled out, and inflammatory pseudotumor was diagnosed. The elevated IgG4 level was normalized and neurotic symptoms subsided, suggesting the most likely diagnosis of IgG4-related autoimmune pancreatitis.

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A 48-year-old Colombian woman visited our hospital with persistent abdominal pain that developed the same morning. Computed tomography (CT) showed an enlarged spleen without enhancement and large splenic cyst. The “whirl sign” of the splenic vessels was revealed at the splenic hilum. The patient had visited our hospital with abdominal pain one year previously. CT had shown a wandering spleen without any torsion at that time. Emergent operation was performed for the presumptive diagnosis of splenic torsion with infarction at this time. The spleen was twisted 3 1/2 times and had become necrotic. The color did not improve with repositioning. Therefore, the spleen was resected. The pathological exam demonstrated marked in faction with bleeding in the spleen.

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A 56-year-old woman was referred to our hospital because of abdominal distention and anemia. The abdomen was markedly distended. Abdominal computed tomography revealed massive splenomegaly occupying half of her abdominal cavity, and she was pathologically diagnosed with splenic marginal zone lymphoma by cervical lymph node biopsy. Early splenectomy was recommended for imminent splenic rupture. She underwent conventional splenectomy following selective embolization of the splenic artery to avoid the risk of intraoperative hemorrhage. The postoperative course was uneventful, and the patient was discharged from the hospital 11 days postoperatively.
In order to reduce intraoperative bleeding from the spleen and splenic vessels, preoperative arterial embolization might be useful for patients with massive splenomegaly.

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Splenic cord capillary hemangioma is a rare disease and is difficult to distinguish from a malignant tumor in the spleen. We report a case of this disease with a concurrent hepatocellular carcinoma (HCC). A 68-year-old man was admitted to our hospital with obstructive jaundice. Abdominal enhanced computer tomography (CT) showed an HCC in the anterior segment of the right hepatic lobe, with tumor thrombus located within the intrahepatic bile duct. However, many tumors were also seen in the spleen on CT. These splenic tumors were 3 to 14 mm in diameter and were enhanced in the early phase, but poorly enhanced in the late phase. Magnetic resonance imaging (MRI) showed low signal areas in these tumors on T1-weighted images and slightly high signal areas on T2-weighted images. We suspected a malignant tumor of the spleen and performed laparoscopic splenectomy. These tumors showed relatively well-demarcated macroscopic findings and increased vascular production on histopathological examination. Immunostaining results were positive for CD34 and negative for CD8. Therefore, we diagnosed a splenic cord capillary hemangioma. We should consider splenic cord capillary hemangioma if a splenic tumor shows abnormal findings on imaging.

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A 73-year-old man presented to our institute because of the abrupt onset of severe abdominal pain when he got out bed. The patient was diagnosed with diffuse peritonitis with acute renal failure, and was taken to the operating room for urgent laparotomy. Preoperative urethral catheterization was encountered difficulty from the urethral stenosis, and large amount of urine was evacuated by the catheterization. The operative findings revealed copious peritoneal fluid and diffuse inflammation in the peritoneal cavity, however, the causative lesion was not identified, and the procedure was completed with peritoneal drainage. Since the serum laboratory findings indicating acute kidney injury were more rapidly improved than usual postoperative findings, we suspected that rupture of the bladder had resulted in peritonitis and pseudo-renal failure, and the bladder rupture was diagnosed by a cystography afterward. The additional history taking unveiled the history that the patient suffered a blunt injury to the perineal region in the childhood. The subsequently performed cystoscopic study revealed urethral stenosis being compatible with the previous history of injury. The patient recovered rapidly and uneventfully from peritonitis. Rupture of the urinary bladder should be listed as one of the differential diagnoses in cases of peritonitis with unknown origin presenting acute renal injury.

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Two patients with aggressive angiomyxoma (AAM) of the pelvis received preoperative neoadjuvant hormone therapy. Patient 1 was a 46-year-old woman with a double-headed tumor. The inferior pole reached the right wall of the vagina and invaded the pelvis. The longest diameter of the tumor was 10 cm. AAM was diagnosed by transperineal needle biopsy. The patient received preoperative hormone therapy with a gonadotropin-releasing hormone agonist and tamoxifen, following which the longest tumor diameter decreased to 6.8 cm. Patient 2 was a 43-year-old woman with a tumor that extended from the subcutaneous tissue of the right buttock to the right dorsal side of the uterus in the pelvis. The tumor was 17.3 cm in its longest diameter. The patient received tamoxifen monotherapy, following which the longest diameter of the tumor decreased to 14.7 cm. The tumors in both patients could be resected with no macroscopic evidence of residual tumor, although in Patient 2, histopathological examination revealed a positive resection margin. AAM commonly arises at sites that are anatomically difficult to access, and we believe that preoperative hormone therapy is a useful treatment strategy for reducing the tumor size.

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A 42-year-old woman was admitted to our hospital because of a right groin mass, and underwent laparoscopic transabdominal preperitoneal repair with a diagnosis of right inguinal hernia. Intraabdominal observation revealed no hernia orifice. Preperitoneal dissection revealed a solid tumor arising from the right round ligament of uterus and growing into the inguinal canal. We made the diagnosis of a tumor originating from the round ligament of the uterus, resected the tumor and reinforced the posterior wall of the inguinal canal with a mesh. The histopathological diagnosis of the resected tumor was leiomyoma. Leiomyomas originating from the round ligament of the uterus are extremely rare, and so far no cases treated by laparoscopic surgery have been reported. Although it is rare, the tumor originating from the round ligament of the uterus should be considered when a groin mass is encountered in adult women.

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Paraganglioma is a rare tumor that arises from the retroperitoneum. Although most paragangliomas are non-functional or asymptomatic, they entail a risk of inducing unexpected abnormal hypertension during operation if they are not diagnosed preoperatively. Here, we report a case of asymptomatic multiple paragangliomas that were safely resected using preoperative antihypertension therapy on the basis of the preoperative diagnosis. A 32-year-old man who complained of abdominal pain underwent an abdominal contrast-enhanced computed tomography, which revealed three masses in the retroperitoneum. Paraganglioma was diagnosed because ¹²³I-MIBG scintigraphy showed MIBG uptake to the masses. Despite the high level of urinary noradrenaline, the patient did not develop hypertension, hyperglycemia, hypermetabolism, headache, or hyperhidrosis. We diagnosed the tumors as asymptomatic, functional paragangliomas. To prevent intraoperative hypertension due to the catecholamines released from the tumors, a selective α₁-adrenergic receptor blocker, doxazosin, was administered for 7 days before surgery. The retroperitoneal tumors were completely resected without intraoperative hemodynamic instability. Histopathology indicated that each of the three tumors was composed of atypical cells with granular amorphous cytoplasm that proliferated in a nests-like pattern. We finally diagnosed the patient with multiple retroperitoneal paragangliomas. The patient has been recurrence-free for 12 months since the surgery.

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We report two cases of spontaneous peritoneum. Case 1 was an 85-year-old man, and Case 2 was a 69-year-old man. In both cases, radiographic examination revealed some free air in the abdomen, although there were no signs of peritonitis (such as Blumberg's sign or muscle guarding). We selected conservative management. Case 1 was followed up by periodic radiography, computed tomography, laboratory tests and physical examination, while Case 2 was followed up by periodic radiography, laboratory tests and physical examination. In both cases, the prognosis was favorable, and the free air in the abdomen disappeared over time. These findings suggest that conservative treatment could be a valid option for the management of spontaneous pneumoperitoneum.

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The case involved a 73-year-old woman who underwent total abdominal hysterectomy and bilateral adnexectomy by means of the Pfannenstiel incision for an ovarian cyst and myoma of the uterus in August 2014. The patient developed bulging and a sense of discomfort in the lower abdomen from around March 2015, and was referred to our hospital. An abdominal CT scan showed each one abdominal incisional hernia at the bilateral lower quadrants of abdomen. Surgery was planned and the patient underwent laparoscopic radical repair of the abdominal incisional hernia in April of the year. The both hernia orifices were situated at the lateral aspect of the rectus muscle of abdomen and inward and upward of medial aspect of the inguinal fossa. The mesh was fixed to the abdominal wall by the Duoble Crow method using a tacker cranially ; and caudally, in order to avoid to fix the mesh above the bladder, the peritoneum was incised, the mesh was spread over the preperitoneal space, and the mesh was fixed to the Cooper ligament, rectus muscle of abdomen and transverse muscle of abdomen by using a tacker, followed by suture and fixation of the peritoneum to the mesh. The patient's postoperative course was uneventful and no recurrence has occurred. This paper deals with our experience of a case of abdominal incisional hernia after a Pfannenstiel incision, which is a rare incisional hernia.

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A 90-year-old woman was admitted to our hospital with chief complaints of sudden left inguinal pain and vomiting. Abdominal computed tomography showed a dilated small intestine and a left obturator hernia with small intestinal incarceration, leading to a diagnosis of an incarcerated obturator hernia with ileus. Laparoscopic surgery was performed. After the incarcerated small intestine was released by injection of saline into the hernia sac, the obturator hernia orifice was repaired with polypropylene mesh. The postoperative period was uneventful, and she was discharged without any complications on the 9^th postoperative day. No recurrence has been observed during follow-up. Laparoscopic surgery is useful for incarcerated obturator hernias because it enables accurate diagnosis, evaluation of the viability of the incarcerated organ, and repair of the hernia orifice simultaneously.

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We present three cases of inguinal bladder hernia diagnosed by preoperative CT scan and treated by Direct Kugel method. Case 1 involved a 74-year-old man who had a 4 × 6 cm bulge without tenderness from the left inguinal region to the scrotum which could not be reduced manually. Following an abdominal CT scan, incarcerated bladder hernia was diagnosed. Emergency operation revealed a fist-sized bladder wall which had slid from the internal inguinal ring. Case 2 involved a 74-year-old man who had a 4-cm diameter painless bulge at the right inguinal region which was diagnosed as bladder hernia by an abdominal CT scan. Elective surgery confirmed the sliding bladder wall from the internal inguial ring. Case 3 involved a 75-year-old man who was referred to our hospital because of bilateral inguinal hernias. We palpated each one painless swelling several centimeters in diameter at the bilateral inguinal regions. The right swelling was diagnosed as bladder hernia on CT. Elective surgery confirmed the bladder with the size of tip of the thumb which had slid into the internal inguinal ring. In addition, internal inguinal hernia was present.
Bladder hernia entails a risk of injuring the bladder during surgery and so preoperative diagnosis is important. In these three cases, abdominal plain CT scans greatly contributed to making the diagnosis. Especially the case 3 was of rare in terms of prolapse of the bladder internally as well as externally.

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