Taking the opportunity that a subject entitled “the current status and problem for surgical practice in the community medicine” was included as one of the special programs at the 78th annual congress of Japan Surgical Association (JSA), we conducted a questionnaire survey on the current state and problem of community-based surgical health care in each local branch, targeting managers of 45 local branches of JSA. As a result, we received answers from all branches and comprehended the following points.
Since the current clinical residency training program was enforced in 2004, it has been shown all over Japan with reality that a schema,“decrease in the number of surgeons to belong to the department of surgery in University → shortage and uneven distribution of surgeons in the region → breakdown of emergency medical systems for regional surgical support”, had emerged. Moreover, although the introduction of new board certification system for medical specialists is shortly scheduled, it seems to be difficult to improve the shortage and uneven distribution of surgeons in the region.
Under the above-mentioned condition, all the branches of JSA is now conducting trainings for young and supporting female surgeons, but their attention to “manuscript writing for publication”, “work and family-life balance” and “working environment for female young surgeons” is not yet sufficient.
In addition, many branches tried to utilize the “Branch chief recommended publication system”, “Special seminar for young surgeons” and “Japanese surgical residency system” organized by JSA to inspire the young surgeons' motivation.

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We studied 130 patients diagnosed as having acute cholecystitis, who underwent elective laparoscopic cholecystectomy (LC) after administration of antimicrobial drugs or percutaneous transhepatic gallbladder drainage (PTGBD). Perioperative results were retrospectively evaluated based on use/non-use and timing of PTGBD. This study included 78 cases that were mild, and 52 that were moderately severe in nature. While 77 patients underwent PTGBD, 53 patients did not have the procedure performed. In patients categorized as having moderately severe disease, the initial white blood cell count and C-reactive protein levels were significantly higher in the PTGBD group, associated with more severe inflammation. These patients also showed a significantly lower incidence of bleeding and the rate of conversion to an open laparotomy was lower. We compared the perioperative results between the two groups, based on the period from the onset of cholecystitis until PTGBD was performed and the period from the time the PTGBD was performed until surgery. No significant differences were observed in terms of bleeding and operative time. However, in the group with < 48 hours between the onset and the time when the PTGBD was performed, and the group with < 14 days from PTGBD until surgery, no patient required conversion to an open laparotomy. Thus, PTGBD is useful for safely planning an elective LC for moderately severe cases of acute cholecystitis. Considering the shorter hospitalization period and diagnostic costs, it is important to perform PTGBD early after onset, and to perform an LC within 14 days.

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Leakage of a duodenal stump is a post-gastrectomy complication that can become severe with inadequate drainage, thus leading to uncontrolled infection and intra-abdominal bleeding that may be life-threatening. Our hospital has used an open drainage procedure for severe duodenal stump leakage that can be life-saving in all cases.
This open drainage procedure, designed to provide complete extracorporeal drainage of duodenal fluid, involves high-pressure continuous suction through a large incision above the area of duodenal stump leakage using a double catheter with inner and outer tubes. The double-catheter drain can be removed after fistulization to allow for healing.
Our open drainage procedure is effective, convenient, and highly versatile. This open drainage procedure and postoperative management, including its effectiveness and treatment outcomes, are described in 4 patients in whom this procedure has been performed.

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Laparoscopic interval appendectomy following conservative therapy is becoming the mainstay of treatment for acute appendicitis. In Japan, an Endoloop suture and endo-linear stapler are commonly used for closure of the stump of the appendix. However, Double-Shank Titanium Ligation Clips^® (hereinafter referred to as DS Clips ; B BRAUN AESCULAP) are commercially available since 2015, and we have been using these DS Clips since December 2015. Laparoscopic interval appendectomy with DS Clips is safe and cost-effective as compared to conventional laparoscopic appendectomy.

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We often have great difficulties in treating radiation enteritis of the small intestine because intestinal obstruction and/or fistulation have occurred as a result of radiotherapy. The side-to-side anastomosis poses such problems as it may exert a limited benefit in fistulation cases and it can form a huge blind loop. Recently massive resection of the small intestine including the ileocecal region has been reported to carry favorable prognosis, however, it results in a seriously invasive surgery and the patients originally have so severe adhesion that makes the operation difficult. Accordingly we employ our bypass operation method coping with the mentioned problems by resecting the oral small bowel to the responsible lesion, anastomosing the oral surgical stump to the transverse colon, and pulling up the anal surgical stump under the skin. Subjects were three cases of small bowel fistulation and two cases of intractable ileus. At surgery, the anal small bowel where appeared to be unaffected by radiation was resected, the oral surgical stump was anastomosed to the transverse colon, and the anal surgical stump was pulled up under the skin. After the operation, all patients could start oral ingestion. One out of the five patients presented with dilatation of the blind loop that needed insertion of a long tube into the pulling cul-de-sac under local anesthesia and sustained drainage. We here present our experience, together with a review of the literature.

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It is reported that metastasis to the pulmonary hilar/mediastinal lymph nodes from colorectal cancer has extremely poor prognosis and the therapeutic effect of surgical resection for the metastasis has not been clarified as yet. We enrolled a total of 11 patients with colorectal cancer who were operated on in our hospital from January 2001 to December 2014 and thereafter underwent surgical resection for metastasis to the hilar/mediastinal lymph nodes ; and studied their clinical courses and prognoses. An average age when they were diagnosed as having colorectal cancer was 62. There were one Stage I, two Stage II, five Stage III, and three Stage IV cancers. All surgeries including two-stage surgery resulted in the R0 resection. An average interval from the initial operation to the resection of the hilar/mediastinal lymph node metastasis was 39 months. Nine out of 11 patients had heterochronous or synchronous lung metastasis. Four patients have been alive without recurrence. The 3-year and 5-year survival rates were as good as 70% and 56%, respectively. An average surviving time of the four dead patients was 25.6 months (median : 22 months), showing that they could survive for a relatively long time after pulmonary resection. We consider that there are some cases which are indicated resection of the hilar/mediastinal lymph node metastasis as a modality of multimodal therapy.

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Fluoropyrimidine is an important agent for treatment of digestive malignancies. Dihydropyrimidine dehydrogenase (DPD) resolves and inactivates fluoropyrimidine, and patients who lack or have a low degree of activity of DPD experience severe adverse effects. In this report, we present a patient with low activated DPD who experienced severe adverse effects and eventually died after administration of adjuvant capecitabine and oxaliplatin (CapeOX). A 58-year-old man diagnosed as having rectal carcinoma underwent resection in September 2014. After receiving capecitabine and oxaliplatin (CapeOX) as adjuvant chemotherapy for 7 days, he presented to our hospital with severe dehydration and loss of appetite due to diarrhea and stomatitis. After admission, he received intensive treatment for myelosuppression and a disseminated intravascular coagulation (DIC) score of 7. On the 36^th day, the mucosa of the digestive tract showed recovery but because his stomatitis persisted, he was continued on enteral nutrition due to the risk of aspiration. On the 53^rd day, after we began an oral diet, he suddenly spiked a fever and tachycardia with a high index of suspicion for pneumonia or bacterial pericarditis, and then was noted to have cardiac arrest within several hours. DPD activity of peripheral monocytes was noted to be 4.47 U/mg (reference range 33.6-183.6), and he was diagnosed as having low activated DPD. Usually, DPD activity is not analyzed in routine clinical practice, but it is important to check the side effect closely for the short term.

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A 68-year-old man presented with the chief complaint of loss of appetite and weight. He underwent a total gastrectomy for gastric carcinoma. Five days after surgery, he developed sepsis and disseminated intravascular coagulation (DIC) for which he was administered antibiotic and recombinant human soluble thrombomodulin therapy. He required platelet transfusions for severe thrombocytopenia almost daily. He was placed on a ventilator for acute respiratory distress syndrome (ARDS) that was noted 18 days after surgery. There was a high index of suspicion for hemophagocytic syndrome (HPS) based on his clinical symptoms. Because he fulfilled the diagnostic criteria for HPS, we started steroid therapy, following which there was remarkable improvement in his septicemia and DIC. He was discharged 67 days after surgery. The steroid was tapered and eventually discontinued during outpatient follow-up. A month later, his HPS relapsed, and we restarted steroid therapy. However, it was not effective, and the patient died. There are 14 previous case reports of HPS occurring after surgery in Japan. Although HPS may be primarily caused by hypercytokinemia, it is believed that in some cases, HPS was not recognized as a postoperative complication and remained undiagnosed. Thus, physicians should be aware of and pay attention to HPS.

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A 51-year-old woman presented to our hospital with induration of the right breast. After a month, the right breast showed increased redness and swelling, and papules with redness were noted on her left breast. She was hospitalized with a differential diagnosis of inflammatory breast cancer. Ultrasonography revealed prominent thickening of the skin, increase in the subcutaneous fat layer, and dilatation of lymph vessels. She was suspected to have inflammatory breast cancer, and based on a core needle biopsy, she was diagnosed as having primary malignant diffuse large B-cell lymphoma. Positron emission tomography/computed tomography (PET-CT) scans revealed liver, spleen and bone invasion.
R-CHOP (rituximab, cyclophosphamide, hydroxydoxorubicin, oncovin, and prednisone) therapy was initiated due to high-intermediate risk based on the International Prognostic Index. Following R-CHOP, we plan to perform autologous peripheral blood stem cell transplantation.

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A 59-year-old woman who noticed a left breast mass but let it alone for 6 months presented to our hospital because of bleeding from the mass. When she was first seen, the 20-cm mass had spontaneously ruptured and bled, and was diagnosed as phyllodes tumor by a fine needle aspiration biopsy. The tumor rapidly enlarged to 30 cm in diameter for successive one month and the patient was admitted because of malnutrition and anemia. Following TPN and blood transfusion, simple mastectomy was performed 2 months after her initial visit. The tumor weight was 3,400g. She had inflammation of the surgical wound, but otherwise the postoperative course was uneventful. She was discharged from our hospital on the 31^st postoperative day. The resected specimen included a phyllodes part composed of growth of fibrous stroma and epithelium and a part composed of solid growth of stroma. In the stromal solid growth part, highly atypical cells were identified where also had features of bone sarcoma and rhabdomyosarcoma. Malignant phyllodes tumor showing a variety of histologic features was thus diagnosed. PET-CT scan performed one year after the operation showed abnormal accumulation of FDG to the mediastinal and right subclavian lymph node swellings which were diagnosed as metastases. Doxorubicin regimen followed by radiation therapy resulted in shrinkage of the metastatic foci. The patient has been free from recurrence, as of 5 years and 6 months.

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The case involved a 56-year-old woman who was diagnosed as having ductal carcinoma in situ (DCIS) at a medical check-up and underwent mastectomy + sentinel lymph node biopsy. Adjuvant chemotherapy was not selected. Three years after the operation, multiple metastases involving the bones, liver, and peritoneal lymph nodes occurred. Following 12 courses of chemotherapy regimen with THP <60 mg/m² docetaxel + 8 (6) mg/kg trastuzumab + 840 (420) mg/body pertuzumab> + 4 mg/body zoledronic acid, clinically complete cure (CR) was attained as for the visceral metastases.
Although DCIS is believed to carry favorable prognosis for the patients, our patient followed such a rare serious clinical course as mentioned above. We thus considered further therapeutic management of DCIS in terms of our experience and literature review. We conclude that even DCIS has to be treated by the chemotherapy regimen according to invasive ductal carcinomas, as the occasion demands.

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A rare case of pulmonary tumor embolism is reported. A 62-year-old woman underwent a mastectomy for left breast cancer in September 1994. The histopathologic diagnosis was Paget's disease of the breast (pT1 mic N0M0, Stage IA). In July 2009, she was found to have an abnormal shadow on chest X-ray. CT showed axillary, supraclavicular, and mediastinal lymph node enlargement. Biopsy showed recurrent lymph node metastases that were ER/PgR-negative and HER2-positive. Paclitaxel and trastuzumab were started, and a partial response (PR) was achieved after 4 cycles of treatment. However, the patient refused to continue chemotherapy and discontinued her follow-up appointments.
In January 2013, the patient was hospitalized for exertional dyspnea, and cardiac catheterization showed pulmonary hypertension. Pulmonary arterial microthrombosis of unknown cause was suspected, and anticoagulant therapy was started. However, treatment was ineffective, and on hospital day 4, the patient's respiratory status worsened and she died. Autopsy examination showed tumor cell invasion in the pulmonary arterioles and in the liver, thyroid, and bone marrow microvessels. The diagnosis was pulmonary tumor embolism.

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An 86-year-old woman with a chief complaint of exertional dyspnea was diagnosed with multiple aortic aneurysms ranging from the ascending aorta to the abdominal aorta. A 3-stage procedure for the multiple aortic aneurysms was planned, including ascending aortic arch replacement, abdominal debranching, and abdominal stent graft replacement (TEVAR). The cardiac apex was perforated with a left ventricular vent during arch replacement, and felt reinforcement was used for repair.
After hospital discharge, abscess formation from the cardiac apex to the left precordium was noted, so antibiotic treatment was started. Despite drainage on two occasions, the abscess did not resolve, and all cultures were negative. Because sterile abscesses are often refractory to conservative treatment, omental implantation at the cardiac apex and abdominal branching were performed simultaneously.
The patient had a satisfactory postoperative course, and TEVAR for residual aneurysm was performed. This completed treatment for the multiple aortic aneurysms.

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An 80-year-old man was evaluated for exertional dyspnea. Echocardiography showed an aortic valve orifice area of 0.51 cm² and a mean left ventricular-aortic pressure gradient of 41 mmHg (maximum : 93 mmHg). Severe aortic stenosis was diagnosed. Aortic valve replacement (AVR) under cardiopulmonary bypass was planned, but the patient had a past history of cryoglobulinemic purpura.
AVR is usually performed at a moderately low body temperature. But because patients with cryoglobulinemia can develop thrombosis when exposed to cold, surgery in this case was performed under normothermic cardiopulmonary bypass. Normothermic antegrade intermittent coronary perfusion and retrograde continuous coronary perfusion were also used for myocardial protection. In addition, heating with a blanket was used to maintain body temperature at ≥37°C.
No serious perioperative complications occurred, no perioperative plasmapheresis was required, and the patient was discharged on postoperative day 19. This relatively rare case of severe aortic stenosis in a patient with cryoglobulinemia in whom AVR was performed under normothermic cardiopulmonary bypass is described along with a discussion of the relevant literature.

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We report the case of a 64-year-old woman who had walked with the assistance of crutches all her life because of right leg paralysis caused by poliomyelitis during infancy. On examination, a tumor shadow was identified in her right axillary region. Thereafter, she developed numbnesss and pain in her right upper extremity. Contrast-enhanced computed tomography demonstrated a fusiform aneurysm of the right brachial artery measuring 25 × 22 mm with thrombotic occlusion. Good collateral circulation was observed via the anterior circumflex humeral artery that provided blood flow to the periphery artery. An elective surgery was performed due to the risk of rupture and thromboembolism. During the operation, we only resected the aneurysm and did not perform a bypass operation because the blood flow through the radial and ulnar arteries, based on the findings of a Doppler ultrasonic flow velocity distribution meter. Although a brachial artery aneurysm is rare, it can result in rupture and thromboembolism, and therefore surgical treatment should be considered for such cases.

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A 57-year-old man presented with loss of consciousness was transported by ambulance to our hospital, and computed tomography CT showed intraperitoneal hemorrhage.
CT showed that the intraperitoneal bleeding was due to an aneurysm of the posterior superior pancreaticoduodenal artery (PSPDA). CT also showed celiac artery stenosis due to median arcuate ligament syndrome (MALS), an aneurysm of the anterior inferior pancreaticoduodenal artery (AIPDA), and a splenic artery aneurysm. Emergency treatment with interventional radiology (IVR) with coil embolization was performed for the PSPDA aneurysm rupture.
Since MALS was thought to be the cause of the PSPDA and AIPDA aneurysms, division of the median arcuate ligament (MAL) was planned. However, because of concern about splenic artery aneurysm enlargement due to increased blood pressure in the celiac trunk with division of the MAL, a splenectomy was also planned, followed by IVR for the AIPDA aneurysm.
A laparoscopic-assisted splenectomy was performed, and the MAL was then divided from the small incision. This was followed by IVR with coil embolization for the AIPDA aneurysm. Currently, 10 months after symptom onset, the celiac artery stenosis has resolved, and there has been no recanalization of the aneurysms.

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Birt-Hogg-Dubé (BHD) syndrome is an autosomal dominant disorder that predisposes to fibrofolliculomas, pulmonary cysts, and renal neoplasia. A 57-year-old man consulted to our hospital due to dyspnea. He received operation for left spontaneous pneumothorax 13 years previously. A chest X-ray film revealed right pneumothorax and a chest CT scan showed multiple bilateral thin walled pulmonary cysts predominant to the lower mediastinum side of the lung field. Because thoracic drainage was unsuccesful, we performed thoracoscopic pulmonary wedge resection. He also had skin eruptions on the face and upper torso, and a biopsy revealed them to be fibrofolliculoma, which was compatible to BHD syndrome. On a genetic analysis, a mutation was identified on FLCN exon 11. BHD syndrome was definitely diagnosed.
He has been followed-up without recurrence of pneumothorax or renal neoplasia. BHD syndrome is a rare condition but should be considered for differential diagnosis of the cause for pneumothorax, because it entails renal malignancy or familial involvement.

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Malignant peripheral nerve sheath tumor (MPNST) is a rare soft tissue sarcoma. The lung is the most common metastatic site of MPNST. The patient was a 79-year-old woman who had been diagnosed with neurofibromatosis type 1 several decades previously. She underwent extended tumorectomy with irradiation (66 Gy) for MPNST in the left femur in the Department of Orthopedics 6 months earlier. Chest X-ray showed a 2-cm nodule in the left upper lung field. Chest computed tomography showed a 17×14mm solitary tumor in the left upper lobe (S¹⁺²) of lung. However, no local recurrence was found. The lung tumor which invaded from the visceral pleura to the lower lobe was resected via video-assisted thoracic surgery, and histologically diagnosed as pulmonary metastasis of MPNST. No adjuvant therapy was conducted. Multiple lung metastases and chest wall recurrence occurred 2 months after pulmonary metastasectomy. Despite palliative treatments including pain control, the disease progressed and she died 4 months after the second surgery.

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A 73-year-old man who underwent thoracoscopic and laparoscopic subtotal esophagectomy and posterior mediastinal gastric tube reconstruction for esophageal cancer elsewhere was admitted to our hospital because of abdominal pain and vomiting about 35 months after the operation. A computed tomography scan showed bowel prolapse into the left thoracic cavity. We diagnosed him as having a diaphragmatic hernia and performed operation. The operative findings showed that a transverse colon had prolapsed into the left thoracic cavity through the esophageal hiatus on the left side of the elevated gastric tube. The transverse colon had no signs of necrosis and the esophageal hiatus was closed with direct suture and covered with the greater omentum. The patient was discharged on the 22nd postoperative day without any complications. No evidence of recurrence of the hernia was seen until the patient died with pleural carcinomatosis on 76th postoperative day. A literature review indicates that diaphragmatic hernia after esophagectomy is increasing, occurs even in late term of postoperative period, and can be a life-threatening complication.

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A 48-year-old man underwent laparoscopic-assisted total gastrectomy (D1 + dissection, Roux-en-Y anastomosis) for cStage IA gastric cancer at the upper and middle body of the stomach ; he had no postoperative complications and was discharged from our hospital on the ninth postoperative day. On the 16^th day after discharge, he had hematemesis and presented to our hospital because of tarry stool. An abdominal contrast-enhanced CT scan revealed retention of contrast medium in the vicinity of the esophagojejunostomy and a pseudoaneurysm at the surgical stump of the left gastric artery. From these findings, rupture of the pseudoaneurysm of the left gastric artery (perforation of the esophagojejunostomy) was diagnosed and abdominal angiography was performed. Abdominal arterial angiography revealed a pseudoaneurysm and extravascular leakage of contrast medium at the surgical stump of the left gastric artery, for that endovascular coil embolization was performed. After the embolization, no further bleeding occurred and the postoperative course was uneventful. He was discharged from our hospital on 18^th postoperative day. In this case, the patient had any possible causes inducing pseudoaneurysm formation, including suture failure and pancreatic fistula after gastrectomy. It was inferred that some injury to the arterial wall due to energy devices used during the surgery or escaped clip might contribute to the aneurysm formation. In performing laparoscopic gastrectomy, we would need appropriate measures by keeping a possibility of pseudoaneurysm formation in mind.

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A 78-year-old man presented to our hospital with the chief complaint of being unable to move his left arm after lifting a dog weighing 4 kg. Examination revealed pathological fracture of the left humerus in a setting of gastric cancer ; therefore, we suspected an pathological bone fracture due to metastatic bone disease. However, bone scintigraphy pointed primarily toward metabolic bone disease. Bone tissue was harvested during osteosynthesis, and histopathological examination revealed no malignancy. A blood examination showed elevated plasma PTHrP and calcium levels and a low parathyroid hormone level. He was subsequently diagnosed as having a pathological bone fracture caused by humoral hypercalcemia of malignancy (HHM) owing to a PTHrP-producing gastric carcinoma. The patient underwent distal gastrectomy and was administered tegafur/gimeracil/oteracil (S-1) adjuvant chemotherapy. No recurrence has occurred within 3.5 years after surgery. The gastric cancer that had caused HHM was noted to be at a very advanced stage, yet our patient has survived for a longer period than patients in other reported cases. The increase in the prognosis time could have been because the PTHrP elevation in our patient was mild compared to that observed in patients in other reported cases.

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A 73-year-old man who had been undergoing hemodialysis for end-stage renal disease resulting from diabetic nephropathy, underwent gastroscopy because of positive findings noted on a screening fecal occult blood test. Gastroscopy showed an ulcerative lesion that measured 3 cm in diameter, in the antrum, and a biopsy of the tumor revealed an adenocarcinoma. Abdominal computed tomography revealed stones in the gall bladder and common bile duct. He underwent a subtotal gastrectomy and cholecystectomy after an endoscopic sphincterotomy for choledocholithiasis. Histopathological examination revealed early gastric endocrine carcinoma predominantly located in the deeper submucosal layer than gastric moderate differentiated adenocarcinoma existed. Immunohistochemical staining showed that the tumor cells were positive for CD56. The pathological stage was IA. Three years later, he has not shown any recurrence. Gastric endocrine carcinoma is a rare condition with an extremely poor prognosis because of significant vascular invasion at an early stage. We present a case of early gastric endocrine carcinoma in a patient with end-stage renal disease, together with a review of literature.

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We report a case of an intractable enterocutaneous fistula that was successfully treated with a fascial graft and musculocutaneous flap. An 85-year-old man who had undergone distal gastrectomy with Roux-en-Y repair for early gastric cancer was diagnosed with general peritonitis due to postoperative pancreatic fistula seven days after the operation. Emergency open drainage and enterostomy were performed. An enterocutaneous fistula, located on the jejunal limb, was noted at the site of the surgical incision, causing mucosal eversion. After re-peritonealization was observed, the fistula was closed, and the skin defect was covered with a fascial and skin graft. Oral intake was initiated on postoperative day (POD) 3. On POD 9, intestinal discharge was observed from the site of the surgical incision, with recurrence of the enterocutaneous fistula. A reoperation was performed following re-peritonealization. The fistula was closed again, and the skin defect covered with a musculocutaneous flap. On POD 27 after the re-operation, oral intake was re-started, and the fistula was noted to be cured.

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We present the case of a 54-year-old man who complained of sudden onset of severe abdominal pain after lunch. An abdominal computed tomography (CT) scan and selective angiography showed an isolated superior mesenteric arterial dissection. A self-expandable vascular stent was placed in the true lumen, and blood flow to all branches of the superior mesenteric artery was restored. However, on the 28th day after stenting, he was noted to have developed delayed small intestinal stenosis. Partial resection of the small intestine with single-incision laparoscopic surgery was performed on the 34th day after stenting. During a 25-month follow-up period, the patient did not experience recurrence of abdominal pain, and his abdominal CT scan did not reveal any significant changes or findings. We conclude that even after successful stenting is performed to treat superior mesenteric arterial dissection, careful follow-up is indispensable because of the risk of delayed intestinal stenosis.

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We have experienced a case of strangulated obstruction squeezed by mucinous cystadenocarcinoma of the appendix coexisted with an appendicular schwannoma. The case involved an 80-year-old man who visited a neighboring hospital because of abdominal pain and vomiting in July 2016 was referred to our hospital with a suspicion of intestinal obstruction. His abdomen was distended. There was mild tenderness in the entire abdomen, but peritoneal signs were absent. An abdominal CT scan showed an ileum to have formed a closed loop and a poorly enhanced tumor of which continuity with the intestine could not be clearly pursued. Strangulated obstruction due to some cord-like structure was likely and an emergency operation was performed. The tip of the appendix had enlarged and the appendix itself squeezed the ileum to cause strangulated obstruction. The ileum revealed only impaired blood flow and had not become gangrenous. Preserving the ileum, we performed appendectomy and completed the operation. The histopathological diagnosis was mucinous cystadenocarcinoma of the appendix coexisted with a schwannoma. In September 2016, ileocecal resection was performed. In the treatment of strangulated obstruction, we should keep in mind that the appendix itself can be the strangulation band.

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We performed vascular reconstruction followed by right hemicolectomy with associated resection of vessels for a case of advanced cecum cancer invading the right external iliac artery and vein. The case involved a 64-year-old woman complaining of poor appetite. Imaging studies indicated cecum cancer invading the right external iliac artery and vein. Since ileus symptoms persisted, we performed ileotransversostomy. Severe adverse event occurred during anticancer therapy and anemia due to intestinal bleeding progressed. We thus determined that tumor resection with associated vascular resection and reconstruction might be needed. Operation was preceded by graft bypass operation using an artificial vessel between the left and right femoral arteries. Then the surgical field was divided and right hemicolectomy with associated resection of the right external iliac artery and vein and right oophorectomy was performed. We performed extended resection and dissection including disseminated nodules in the vicinity of the tumor, revealing T4b, N1, M1(P1), stage IV, R0. After the operation, the patient developed intraabdominal abscess, cholecystitis and wound infection, however, the graft was kept intact. The patient was discharged from our hospital on the 71^st postoperative day.

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On colonoscopy, ischemic colitis can present with a fungating mass or stricture mimicking malignancy. Most cases of ischemia can be managed conservatively, but symptomatic colonic strictures or asymptomatic strictures with any suspicion of neoplasia should be managed surgically. A case of stricture-type ischemic colitis in the ascending colon requiring surgical intervention is presented. An 81-year-old man was admitted to our hospital because of abdominal pain. Colonoscopy showed stenosis around the entire circumference of the ascending colon. Mucosal biopsies were taken, but they were inadequate for diagnosis. Since tumor markers were negative, and an abdominal computed tomography scan showed inflammatory changes of the ascending colon, he underwent conservative treatment. However, he became anorexic from anxiety about his colon becoming perforated due to the stenosis. Ileocecal resection was then performed. The patient recovered completely after surgery, and the pathological findings were consistent with ischemic colitis.

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A 48-year-old man was referred to our hospital because of fecal occult blood. Colonoscopy showed a type 3 tumor in the ascending colon. A biopsy revealed well or moderately-differentiated adenocarcinoma. Laparoscopic right hemi-colectomy and lymphadenectomy were performed. Histopathologically, neuroendocrine carcinoma and adenocarcinoma were found in the tumor, and each carcinoma accounted for more than 30% of the tumor. The diagnosis was mixed adenoneuroendocrine carcinoma (MANEC). After the operation, adjuvant chemotherapy (cisplatin+etoposide) was performed. At 30-month follow-up, the patient was well with no recurrence. Survival for more than 2 years after surgery for colonic MANEC is rare. We report this case with a review of the literature.

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A 49-year-old man presented to our emergency department with disturbance of consciousness and significant abdominal distension following insufflation of compressed air into his anus by a coworker as a practical joke. He additionally experienced respiratory distress and required mechanical ventilation following endotracheal intubation. An abdominal X-ray showed a large amount of intraperitoneal free air and an elevated diaphragm. A computed tomography (CT) scan revealed compression of the intra-abdominal viscera and a collapsed inferior vena cava. He was diagnosed as having perforation of the sigmoid colon with tension pneumoperitoneum, and an emergency surgery was performed. Compressed air escaped when the laparotomy was performed. The abdomen was decompressed and systemic perfusion showed improvement. A perforation measuring about 5 cm in length was noted in his sigmoid colon. He underwent resection of the segment containing the perforation, and a colostomy was performed. Incorrect insufflation of compressed air may result in tension pneumoperitoneum. If symptoms suggest tension pneumoperitoneum in a patient, immediate decompression is necessary.

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We present a case of cancer of the splenic flexure of the colon with synchronous multiple splenic metastases. A 74-year-old man presented to our hospital because of obstructive symptom due to splenic flexure colon cancer. An abdominal CT scan when he was first seen revealed wall thickening of the splenic flexure of the colon and multiple splenic tumors. Splenic flexure colon cancer and multiple splenic metastases were diagnosed, but there were no metastases to the liver and lung. Since he had a previous history of undergoing complete cystectomy for bladder cancer and swelling of the spleen due to tumors, he underwent left hemicolectomy and splenectomy under laparotomy. The pathological diagnoses of the splenic tumors were adenocarcinoma compatible with metastasis from the colon cancer. Prominent venous invasion indicated that hematogenic metastasis appeared to be most likely. The postoperative course was uneventful and he was discharged from our hospital without noteworthy complications on the 19^th postoperative day. Adjuvant chemotherapy with 8 courses of S-1 + oxaliplatin was completed, and he has been followed as of 12 months after the operation. Although splenic metastasis of colon cancer is uncommon, we recommend aggressive surgical resection if it is resectable.

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A 62-year-old woman whose occult blood test was positive at a medical checkup was referred to our department. Colonoscopy revealed a 10-mm sized type Isp tumor in the lower rectum, We performed endoscopic mucosal resection that revealed the tumor as tub1, T1b (2,000μm), ly0, v1, budding grade 1, HM0 (250μm), and VM0 (500μm). Laparoscopic-assisted low anterior resection of the rectum + D2 dissection was performed. Histopathology revealed no tumor remnant, showing T1b, N0, M0, and Stage I. A CT scan performed 6 months after the operation demonstrated tumors at the bilateral ninth limbs. FDG-PET scan showed abnormal accumulation of FDG (SUVmax7.8) to the tumors. CT-guided biopsy identified the tumors to be well differentiated tubular adenocarcinoma, and metastases of rectal cancer to the ribs were diagnosed.
As bone metastasis from early rectal cancer without associating with liver or pulmonary metastasis is rare, this case is presented, together with a review of the literature.

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A 63-year-old man with chief complaints of scrotal swelling, erythema, and left lower abdominal pain for 2 days was transported by ambulance to our hospital. On initial examination, partial necrosis around the left buttocks with a foul smell was present, and CT showed gas in the buttocks and inguinal regions, mainly around the left scrotum. The patient was diagnosed with Fournier's gangrene. Emergent debridement and a double-barreled transverse colostomy were performed on the same day.
The patient was extubated on day 5, and intra-wound continuous negative pressure and irrigation treatment (IW-CONPIT) was started. The inflammatory response improved gradually, so continuous irrigation was discontinued on day 8, but negative pressure wound therapy (NPWT) was continued. The patient improved and was discharged on day 64.
NPWT is useful for decubitus ulcers and open wounds that are difficult to close, but it basically cannot be used for infected wounds. However, IW-CONPIT, which combines continuous irrigation with NWPT, enables early use of NPWT in patients such as the present one with an infected wound to achieve good outcomes. This case is reported along with a discussion of the relevant literature.

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A 68-year-old man developed jaundice during outpatient treatment for ulcerative colitis at our hospital. A CT scan one year earlier showed a 15-mm gallstone with a normal gallbladder. However, abdominal contrast CT now showed atrophy of the gallbladder, dilated intrahepatic ducts, stenosis at the right and left hepatic duct confluence, and compression of the common bile duct by the gallstone. Mirizzi's syndrome was diagnosed. Surgery was scheduled after preoperative ERBD (endoscopic retrograde biliary drainage) to reduce the jaundice.
Findings at surgery showed severe atrophy of the gallbladder due to inflammation, with embedding of the gallbladder into the liver bed. The gallbladder wall was dissected, and the gallstone was identified and removed. A 2-mm cholecystocholedochal fistula was also present. To close the fistula, the gallbladder lumen was filled with the round ligament of the liver to cover the fistula. The patient had a satisfactory postoperative course without complications and was discharged. Postoperative DIC-CT confirmed patency of the repaired area of the bile duct.
This patient with Mirizzi's syndrome and a cholecystocholedochal fistula in which the fistula was patched with the round ligament of the liver after gallstone removal is reported.

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A 77-year-old woman presented to the hospital near her home complaining of upper abdominal pain. Abdominal CT revealed mild swelling of the falciform ligament, and the patient was referred to our hospital for further examination. We suspected falciform ligament abscess, and initially treated her conservatively with antibiotics, in view of the presence of comorbidities such as acute renal failure and severe cardiac dysfunction. However, as the infection persisted, resection of the falciform ligament was eventually performed. The patient recovered promptly after the procedure. Adult falciform ligament abscess is a relatively rare disease, and only 8 cases, including our present case, have been reported from Japan. Antibiotics and percutaneous drainage are valid treatment options, however, surgical resection is the safest and most reliable.

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We report a case of intractable liver abscess, which was cured by operative resection. A 68-year-old woman with a previous history of undergoing open surgeries because of a traffic accident and undergoing cholecystectomy for gallstones was referred to our hospital with a history of fever. Abdominal CT revealed 6-cm-sized and 3.5-cm-sized low-density areas in the liver, suspected to be liver abscesses. The patient was initially treated conservatively, however, the abscesses proved intractable. Therefore, operative resection was performed 35 days after the diagnosis. The patient was discharged on day 22 after the operation. The operative resection was effective.

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A 48-year-old-woman was referred to our hospital with a history of chest discomfort. Abdominal CT revealed a hepatic mass measuring 2 cm in diameter arising from the lateral segment of the liver. Based on this imaging finding and the increasing size of this tumor, we could not completely rule out the possibility of hepatocellular carcinoma (HCC), and performed laparoscopic lateral segment hepatectomy. Immunohistochemistry revealed positive results for HMB-45 and α-SMA expressions. The final histopathological diagnosis was hepatic angiomyolipoma (HAML). HAML is a rarely encountered benign hepatic tumor. There are numerous reports of cases in which it was difficult to distinguish HAML from other fat-containing hepatic tumors, such as lipoma, liposarcoma and HCC preoperatively. We believe that laparoscopic hepatectomy is useful for both the diagnosis and treatment of hepatic tumors.

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A 69-year-old male was referred to our hospital for a tumor in the liver detected during a medical checkup. The patient had undergone pancreaticoduodenectomy for a solid-pseudopapillary neoplasm (SPN) 9 years earlier at our hospital. Abdominal contrast-enhanced CT showed a 50-mm sized mass in segment 4/8 of the liver. Laparoscopic partial liver resection was performed under a preoperative diagnosis of liver metastasis from the SPN. The first port was placed in the right lower abdomen to avoid intraperitoneal adhesions anticipated underneath the midline incision made for the primary tumor resection. Adhesiolysis was performed just to expose the surgical field. Then, partial liver resection was performed laparoscopically using the clamp crushing method, without any intraoperative complications such as significant bleeding or bile leakage. Histopathological examination of the surgical specimen showed tumor cells with eosinophilic cytoplasm and oval-shaped nuclei in a pseudopapillary architecture. These histopathological features were identical to those of the pancreatic tumor resected before, suggesting that this tumor was a metastasis from the SPN. The results of immunohistochemical staining were also consistent with those of the SPN. This patient was discharged on postoperative day 7 without any complications, and has not shown any evidence of recurrence until now, 1 year after the operation.

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A 78-year-old man who underwent enucleation of a tumor at the left shoulder in 2001 received an abdominal CT scan in 2012 which showed each one tumor in the lateral segment of the left lobe of liver and in the left kidney, respectively, which revealed early enhancement and wash out. We performed left lobectomy of liver, left partial nephrectomy and cholecystectomy with the diagnosis of double cancer involving bile duct cystadenocarcinoma and left renal cell carcinoma. The histopathological diagnoses of the liver and kidney tumors were both hemangiopericytoma (HPC). Confirmation of histopathological findings of the left shoulder tumor resected in 2001 to survey the primary site disclosed to be HPC which had similar findings to those of the liver and renal tumors. From clinical course together with pathologic findings, metastases to the liver and kidney of HPC arising from the subcutaneous structure of the left shoulder were diagnosed. In the 2013's WHO classification, HPC was integrated into the solitary fibrous tumors (SFT), but few cases of liver and renal metastases of SFT arisen from the soft tissue have been reported. Accordingly we present our case with a review of the literature.

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An eleven-year-old girl was admitted to our hospital a day after she presented with a history of upper abdominal pain and nausea of sudden onset. Localized tenderness was noted in the right upper quadrant of the abdomen, and the serum levels of inflammatory markers were elevated. Abdominal enhanced CT obtained the day after admission showed gallbladder distension and enhancement of the gallbladder wall. Magnetic resonance cholangiopancreatography revealed distension of the gallbladder but obstruction of the cystic duct. We made the diagnosis of gallbladder torsion and performed emergency laparoscopic cholecystectomy. During the surgery, the gallbladder was found to be ischemic and rotated 360 degrees counterclockwise around the cervical portion as the pivot. She was discharged on day 4 after cholecystectomy without any trouble.
We encountered this rare case of gallbladder torsion and report it with a review of published case reports.

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The patient was a 73-year-old woman who had been diagnosed as having cancer of the pancreatic head and undergone pylorus-preserving pancreaticoduodenectomy. Thirteen days after the operation, the patient developed hepatorrhagia ; she was treated by drainage and antibiotic therapy, however, 28 days after the operation, she developed melena.
An emergency colonoscopy failed to identify the source of bleeding. Considering the stable general condition of the patient, she was merely followed up. At 33 days after the operation, melena occurred again, and an angiographic examination was performed, which revealed extravasation from a pseudoaneurysm of the cystic artery in the reconstructed jejunum near the choledochojejunostomy. Under the diagnosis of ruptured aneurysm of the cystic artery in the reconstructed jejunum, the right hepatic artery was embolized using microcoils, and the bleeding was successfully controlled. After the embolization, the clinical progress was satisfactory, and the patient was discharged from the hospital on day 50 after the operation. In patients developing an intraabdominal abscess after operation, the serious complication of a pseudoaneurysm/pseudoaneurysmal rupture could occur. It is important for an angiographic examination to be performed in cases of intraabdominal bleeding and gastrointestinal bleeding, to obtain an early diagnosis and administer prompt treatment.

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A case of splenic infarction and splenic artery aneurysm caused by antiphospholipid syndrome is reported. A 65-year-old woman who had undergone heart valve replacement 9 years earlier and had been taking aspirin and warfarin visited our hospital with left upper quadrant pain. The first abdominal CT scan showed splenic infarction, and the patient was treated conservatively. The second CT scan, taken 10 days later, showed a splenic artery aneurysm, and interventional radiology was needed. Because her lupus anticoagulant was positive and she had a history of miscarriage, the patient was diagnosed with antiphospholipid syndrome. Splenic infarction and artery aneurysm due to antiphospholipid syndrome are rare, and both splenic infarction and splenic artery aneurysm need investigation of their cause. Transcatheter arterial embolization is minimally invasive and effective for the treatment of splenic artery aneurysm.

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A distal pancreaticosplenectomy is generally performed to treat a splenic artery aneurysm located at the distal pancreas and splenic hilum. However, we report a case wherein we successfully preserved the pancreas and spleen by laparoscopic selective ligation of only the blood vessels associated with a splenic artery aneurysm. We used laparoscopic techniques of lymph node dissection at the splenic hilum as used in surgery for gastric cancer. The small splenic arterial and venous branches were selectively exposed and processed, and only inflow and outflow branches of the aneurysm were ligated without resection of the distal pancreas and spleen. We report the case of a 73-year-old woman who underwent abdominal contrast computed tomography (CT) that revealed a splenic artery aneurysm approximately 2.0 cm in diameter, at the splenic hilum, originating from an upper branch of the splenic artery. We laparoscopically selectively ligated the inflow and outflow arteries of the aneurysm. Six months after ligation, a CT scan showed no recurrent aneurysm and no disturbance of the splenic blood flow.

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A 77-year-old man was diagnosed with prostate cancer 8 years earlier. The patient was initially evaluated while on endocrine therapy for a left supraclavicular mass, and aspiration cytology was suspicious for prostate cancer metastases. In addition, upper GI endoscopy performed after eradication therapy for H. pylori gastritis showed gastric varices that were not present in the previous year. The platelet count was decreased to 74,000/μl. Abdominal CT showed a 4-cm mass at the splenic hilum. The patient was diagnosed with segmental portal hypertension due to the splenic hilar mass, and distal pancreatectomy and splenectomy were performed.
Macroscopic examination of the resected specimen showed a 25-mm, grayish-white, hard elastic mass. Histopathology showed positive PSA staining, and prostate cancer metastases were diagnosed. There was tumor microinvasion in the pancreatic and splenic parenchyma, with tumor emboli in the splenic vein. After surgery, the platelet count normalized, and upper GI endoscopy showed disappearance of the gastric varices.
Tumor metastases to the splenic hilum have seldom been reported, and the present patient is the only known case with segmental portal hypertension.

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A 53-year-old man was admitted to our hospital complaining of acute onset right flank pain. Abdominal CT showed rupture of a right adrenal tumor. Endocrine studies suggested a cortisol-secreting tumor. Therefore, open right adrenalectomy was performed. Postoperative pathological examination confirmed adrenal cortical carcinoma. No metastatic lesion was found at that time. Oral mitotane and external beam irradiation over the tumor bed were given as adjuvant therapy. The patient achieved recurrence-free survival of 24 months. Spontaneous rupture of adrenal cortical carcinoma is very rare and thought to indicate a high risk of postoperative recurrence, even though radical resection is possible. Therefore, multimodal therapy is desirable postoperatively. This case is reported along with a review of the relevant literature.

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The case involved a 43-year-old man who had had a right inguinal bulge but let it alone since several years earlier. Recently the bulge became prominent and he visited a neighboring hospital. He was referred to our hospital with a suspicion of a giant inguinal hernia. When he was first seen, the scrotum had remarkably enlarged to 25 cm in size. A CT scan revealed a diagnosis of giant inguinal hernia at where the right hemicolon from the ileum to the transverse colon had protruded. The hernia was irreducible, but there were no symptoms of strangulation. We thus performed surgery electively via the inguinal approach. We identified the hernia contents to be the protruded right hemicolon from the ileum to the transverse colon as well as the greater omentum. Since the omentum was too hypertrophic to reduce into the abdominal cavity, we transected the protruded omentum, and performed prophylactic appendectomy followed by reduction of the protruded bowel into the abdominal cavity. The inguinal canal was reinforced according to the ileopubic tract repair. The postoperative course was uneventful and the patient was discharged from our hospital on the sixth postoperative day. We present our case together with a review of the literature.

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The principles of pilonidal sinus treatment require eradication of the sinus tract. Simple closure may cause wound dehiscence or recurrence. Several surgical techniques have been described over the years, but the ideal surgical technique remains controversial. A case of pilonidal sinus successfully treated with W-plasty is presented. The patient was a 22-year-old man who presented with a several-year history of swelling, drainage, and bleeding of the intergluteal cleft. He had a pilonidal sinus, 7 cm in length, on his buttocks. The pilonidal sinus tract was excised, and W-plasty was carried out to relieve tension and prevent entering the fistula due to rotational motion of the intergluteal cleft. No postoperative recurrences and dehiscence have occurred. W-plasty could be a reasonable technique, because it is an easy surgical procedure with tension-free skin coverage and a low recurrence rate.

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