Purpose: We evaluated the feasibility of dye–guided sentinel lymph node (SLN) biopsy in subjects with primary breast cancer.
Patients and Methods: From July 2001 to February 2006, we conducted SLN biopsies in 101 cases with backup axillary lymph node dissection (ALND) using indigocarmine blue dye.
Results: SLN identification was 88.1% (89/101), and age alone correlated statistically significantly with identification. Identification was 92.2% in a later series of 51 cases compared to 84.0% in an earlier series of 50 cases. All cases with negative SLN had negative ALND. Two cases in which frozen sections showed no metastatic foci in SLN had metastatic foci in paraffin sections, indicating that dye–guided SLN showed false–negative detection of 7.1%, sensitivity of 92.9%, and specificity of 100%.
Conclusion: Dye–guided SLN biopsy use eliminates the need for ALND.

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Objectives:We reviewed 25 cases of resected gastrointestinal stromal tumor (GIST) and analyzed diagnostics, surgical procedures, and outcomes. Methods:Subjects were 25 persons—14 men and 11 women with a mean age of 62 years–undergoing GIST surgery between January 2002 and October 2008. Results:Tumors in the stomach (n=18), duodenum (n=1), small intestine (n=4), and rectum (n=2) averaged 3.4 cm in median size for the stomach, 6.5 cm for the duodenum, and 6.8 cm for the small intestine and rectum. The most common symptoms were gastrointestinal bleeding and abdominal pain. Six cases of gastric and 1 case of rectal GIST were diagnosed pathologically preoperatively using endoscopic ultrasound–guided fine–needle aspiration biopsy (EUS–FNAB). Surgery involved 15 open and 9 laparoscopic procedures and 1 per anal resection. Subjects in the laparoscopic gastrectomy group lost less blood and were discharged sooner than those in the open gastrectomy group. Seven subjects (28%) classified as high–risk had a disease–free survival of 25.1%, indicating a relatively dismal postoperative outcome. Conclusions:Laparoscopic GIST resection appears preferable to gastric GIST resection due to the association of lower blood loss and shorter postoperative hospital stay.

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We retrospectively reviewed laparoscopic cholecystectomy (LC) results for 134 cases treated from 2004 to 2008 at the Gifu, Japan, university School of Medicine Department of Surgical Oncology, focusing on the conversion from laparoscopic to open cholecystectomy (OC). LC was successful in 125 subjects (93.3%), but conversion to OC was required in 9 subjects (6.7%). Pre– and intra/post–operative factors were studied statistically.
Results:Statistically significant differences were seen in white blood cell count on admission, blood loss during surgery, operating time, and postoperative hospital stay. Cases tending to be converted to OC following preoperative imaging diagnosis involved gallbladder wall thickening (≥ 5 mm) and incarcerated gallbladder neck stones.

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Patients and Methods:We compared open appendectomy (OA) (n=62) and laparoscopic appendectomy (LA) (n=142) results for operating time, postoperative hospital stay, postoperative complications and wound infection.
Results:Mean operating time was significantly longer in the LA group–58.7 ±1.8 min–than in the OA group–49.5 ±3.3. Mean postoperative hospital stay was shorter in LA–9.8 ±1.7days–than in OA–6.4 ±0.5 days. Wound infection was significantly less in LA–2.8%–than in OA–29%. Obese subjects undergoing LA were discharged sooner–7.1 ±1.9 days–than their OA counterparts–17.3 ±5.8days.
Conclusions:Results indicate that LA has advantages over OA in less wound infection and shorter postoperative hospital stay, particularly for obese patients.

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A 68–year–old woman seen in June 2005 for a mass of the left axilla was found in physical examination to have a left axillary node 3 cm in diameter palpated, but both breasts were normal. No abnormal findings were noted in mammography;neck, breast, and abdominal, ultrasonography (US);chest X–ray;neck, chest, and abdominal computed tomography (CT);fecal occult blood tests;upper gastrointestinal endoscopy;or pelvic examination. Core needle biopsy of the node indicated metastatic invasive ductal carcinoma with positive estrogen receptor (ER).
Based on suspected occult cancer of the breast, we undertook left modified radical mastectomy. Histopathological examination indicated an invasive 3×2 mm ductal carcinoma lesion with presumed axillary metastasis. Once occult breast cancer is suspected, a proper diagnosis becomes difficult. In our case, with other possible primary sources ruled out and axillary node biopsy positive for ER, occult breast cancer was suspected and surgery conducted. Histological examination of the mastectomy specimen confirmed the primary lesion of axillary metastasis and a definitive diagnosis of breast cancer.

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A 72–year–old man with a history of gastrectomy and ileocecectomy seen for dysphagia was found in upper gastrointestinal examination to have a large 6 cm polypoid mass of the thoracic esophagus. Based on a diagnosis of esophageal cancer, we conducted subtotal esophagectomy with regional lymph node dissection, including reconstruction using the left colon. The main 12 cm tumor had a stalk from changed IIc mucosal area. Based on standard pathological transition zone finding of both carcinomatous and sarcomatous lesions, the main tumor was diagnosed as carcinosarcoma invading the deep submucosa (sm3). Multiple squamous cell carcinoma found in the part showing dysplasia extended widely around the bulky main lesion. To our knowledge, only two cases of esophageal carcinosarcoma, including our case have been reported with multiple squamous cell carcinoma.

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We present a case of gastric cancer developing in the reconstructed gastric tube 4 years after esophagectomy for thoracic esophageal cancer. A 62–year–old woman who had undergone total thoracic esophagectomy and retrosternal reconstruction using a gastric tube for thoracic esophageal cancer was found 3.5 years after in endoscopy to have a lesion (0–IIc) 5 mm in diameter at the lower part of the gastric tube, Endoscopic biopsy showed well–differentiated adenocarcinoma, necessitating fractionalized endoscopic mucosal resection (EMR). Histopathological findings showed well–differentiated adenocarcinoma, m, ly0, v0, lm(–), v(–). No sign of recurrence has been seen and the woman is doing well a year after EMR. It is technically difficult to resect gastric tubes and surgical stress is severe. If possible, EMR is suitable for gastric tube cancer therapy. It is important to follow patients up in regular endoscopic examination after esophagectomy to find any disease at the earliest possible stage.

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Esophageal perforation due to traumatic or failed endotracheal intubation is clinically rare, and we report such a case occurring after upper right lobectomy for lung carcinoma. A 55–year–old woman diagnosed with lung carcinoma who underwent successful endoscopic upper right lobectomy with ND2a suffered severe dyspnea soon after extubation due to upper airway obstruction. Trial endotracheal intubation had failed and she required emergency tracheostomy, which relieved her dyspnea immediately. Despite her improved postoperative condition, she suffered a continuous low grade fever from postoperatrive day (POD) 5 , and computed tomography (CT) indicated a cervical esophageal fistula to the mediastinum. Suspecting esophageal perforation associated with mediastinitis due to failed endotracheal intubation, we conducted primary perforation repair and mediasternal drainage, together with intravenous antibacterial agent injection and continuous mediastinal lavage. Her condition gradually improved, postoperative esophagography showed no evidence of residual fistulation. She was discharged mobile 8 weeks after the second surgery.

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A 52–year–old man was admitted for an abdominal tumor 20 cm in diameter confirmed in abdominal computed tomography (CT) and magnetic resonance imaging (MRI) to be connected to the stomach by a 1.5×2.0 cm pedicle. Surgery was conducted based on a diagnosis of gastric tumor with a pedunculated growth. Cytology of bloody ascites was class IV and peritoneal metastasis was positive. The tumor connection to the anterior gastric wall necessitated partial gastrectomy with a linear stapler. The resected 21×18×8 cm tumor consisted histologically of spindle–shaped cells with a mitotic index of 1/50 HPF.
Immunohistochemically, KIT and CD34 were positive, yielding a definitive diagnosis of gastrointestinal stromal tumor (GIST). Only 29 cases of gastric GIST with a pedunculated growth have, to our knowledge, been reported in Japan.

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We encountered a patient with a perforated duodenal ulcer, who developed multiorgan failure after resuscitation from cardiopulmonary arrest, but was able to resume a normal life after emergency surgery. The patient was a 60–year–old woman who was emergently admitted to a previous hospital because of epigastric pain and fatigue. Several hours later, she showed a loss of consciousness, followed by cardiopulmonary arrest. However, since the heartbeat resumed after tracheal intubation and 15 min of resuscitative efforts, she was emergently referred to our hospital at the request of the previous hospital. After admission to the ICU, she showed post–resuscitation encephalopathy, and received initial intravenous fluids and blood transfusions for hemorrhagic shock, and hemodialysis for hyperkalemia secondary to acute renal failure. Because of the physical findings of marked abdominal distention and the passage of large amounts of tarry stools, plain abdominal CT was performed, showing ascites and free air mainly in the upper abdominal cavity. Although recovery to a normal state seemed very unlikely, emergency surgery was performed at the earnest request of her family. After the aspiration of a dark–red, purulent ascetic fluid, a 2–cm perforated ulcer was identical in the anterior wall of the duodenum. Extensive gastrectomy with Billroth II anastomosis was performed. The patient underwent tracheostomy for mechanical ventilation on the third postoperative day, but was removed from the ventilator on the ninth postoperative day, and started oral feeding on the 19th postoperative day. She started walking training on the 36th postoperative day, and was discharged on the 52nd postoperative day without any neurological deficit or organ impairment. She is currently being followed–up on a regular outpatient basis.

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A 48–year–old woman with advanced sigmoid cancer obstruction undergoing Hartmann′s procedure in November 2003 and having multiple initially unresectable hepatic metastases without extrahepatic disease underwent six systemic neoadjuvant FOLFIRI chemotherapy cycles with good response. Imaging indicated that postchemotherapy liver metastases were resectable in planned two–stage resection and portal vein embolization (PVE). Stage–1 lateral segmentectomy in June 2004 was followed by additional adjuvant FOLFIRI chemotherapy and PVE. Stage–2 right hepatectomy and partial segment 4 resection were completed without complications in November 2004. In the 3 years and 10 months since stage 2 hepatectomy, she remains disease–free with no evidence of extrahepatic metastases and/or local recurrence, demonstrating the potential efficacy of these procedures in treating initially unresectable hepatic metastasis from colorectal cancer.

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A 68–year–old man with intractable diarrhea was found in abdominal computed tomography (CT) to have a 10 cm pelvic mass confirmed in colonoscopic biopsy to be rectal cancer. The man′s poor digestive condition necessitated Hartmann′s operation. Histologically, the tumor was stage IIIA (ss,n1,H0,P0).
Postoperatively, 4 courses of 5FU–LV and UFT–LV therapy were administered. The man developed hematuria, however, 9 months after surgery. Local recurrence in the bladder wall and solitary metastasis to the left lung were found in CT. For hemostasis and histological diagnosis, TUR–Bt was conducted, followed by concurrent chemoradiotherapy (FOLFOX4 therapy + pelvic radiotherapy at a total dose of 60 Gy). FOLFOX4 therapy was conducted 11 times before allergy (grade 3 occurred) some 15 months after local recurrence was detected, positron emission tomography–computed tomography (PET–CT) confirmed good local control and isolated pulmonary metastasis necessitating partial pulmonary resection.
In the 3 years and 8 months after initial surgery, 5FU–LV–bevacizumab therapy for mediastinal lymph node metastasis has been started, the patient′s quality of life (QOL) has been maintained, and outpatient treatment coutinues.

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A 60–year–old woman undergoing colonoscopy for anemia and diagnosed with advanced cecal cancer was admitted for postcolonoscopic abdominal pain. Cecal cancer associated with intussusception was diagnosed from computed tomography (CT) based on the specific CT multiplex layer configuration. Emergency right hemicolectomy without intussusception relief was conducted to avoid inspersion of malignant disease. The cut surface of the resected specimen showed, a type 2 mass 4×3.8 cm in diameter found histologically to be moderately differentiated adenocarcinoma with subserosal invasion. Intussusception thus should be included in the differential diagnosis of postcolonoscopic abdominal pain.

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A 57–year–old man presenting with discharge from an anal fistula due to Crohn′s disease (CD) was found in further examination to have ascending colon stenosis. The patient was informed that colonic stenosis could worsen in Infliximab use to treat the fistulas but gave consent for its use. The fistula was successfully treated with a triple infusion of Infliximab at a dose of 5 mg/kg. Colonic stenosis also improved.
Infliximab, a new CD medication, has seen restricted use in cases with intestinal stenosis. In this case, the patient responded well to infliximab, which may be useful in treating fistula recurrence.

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We report a rare case of adenomyoma of the common bile duct and review the medical literature. A 63–year–old man in whom liver dysfunction was found during a medical checkup for diarrhea was referred for a detailed medical examination. Abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) revealed a dilated left intrahepatic duct and the common hepatic duct, but no evidence of tumors or stones in biliary trees. Endoscopic retrograde cholangiopancreatography (ERCP) showed distal bile duct stenosis and proximal bile duct dilation. Based on a preoperative diagnosis of cancer of the common bile duct, he underwent pancreatoduodenectomy. Gross examination of the resected bile duct showed an elevated 13×10 mm lesion, consisting microscopically of grandular hyperplasia and smooth muscle fiber proliferation. Histology was consistent with adenomyoma of the common bile duct. The postoperative course was uneventful and the patient was discharged on postoperative day (POD) 33 and remains well at 3–year and 6–month follow–up.

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One of the worst post–laparoscopic cholecystectomy complications is bile leakage that, in serious cases, require reoperation. We present such a case involving a choledocholith with juxtapapillary duodenal diverticula. A 72–year–old man was admitted with an ER biliary drainage (ERBD) tube inserted after undergoing endoscopic retrograde cholangiopancreatography (ERCP) and experiencing difficulty with endoscopic sphincterotomy (EST) for lithotripsy complicated by juxtapapillary duodenal diverticula. After conducting EST, we removed a 16×7 mm choledocholith and inserted a 5Fr endoscopic nasal biliary drainage (ENBD) tube followed by laparoscopic cholecystectomy. ENDB radiography showed bile leaking extensively from the cystic duct at the Penrose drain on the evening of postoperative day. Suspecting ENBD obliteration (POD) 1, on POD 2, we tried replacing the 5Fr ENBD tube with a 6Fr tube but encountered obstruction by flexion due to juxtapapillary duodenal diverticula. Following drain replacement, bile leakage ceased. This underscores the need for careful tube management when complications such as juxtapapillary duodenal diverticula arise.

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A 68–year–old man admitted for epigastralgia and vomiting in December 2004 was found in laboratory examination to have elevated biliary enzymes. Ultrasonography (US) and endoscopic retrograde cholangiopancreatography (ERCP) showed a gallbladder tumor and contrast–enhanced us tumor blood flow. Under the diagnosis of gallbladder carcinoma, we resected the liver bed with D2 lymph node dissection. The resected specimen showed an invasive papillary tumor 20 mm in diameter at the gallbladder fundus. Pathological examination showed signet ring cell carcinoma with invasion to the gallbladder serosa and metastasis to regional lymph nodes. These findings yielded a definite diagnosis of signet ring cell carcinoma of the gallbladder (pT3pN1M(–), fStage III). Computed tomography (CT) showed local recurrence 18 months postoperatively and the man died of the disease 2 years and 10 months after surgery.

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A 71–year–old man admitted for epigastralgia and tarry stool whose laboratory tests on admission showed only anemia was found in abdominal computed tomography (CT) to have an unevenly light–enhanced duodenal mass 5×4.5 cm in diameter. Upper gastrointestinal endoscopy showed an elevated soft 5 cm lesion. Magnetic resonance imaging (MRI) showed an elevated duodenal lesion apparently unrelated to the papilla of Vater or pancreas. Pancreatic and bile ducts were normal. Upper gastrointestinal endoscopic biopsy showed undifferentiated carcinoma with osteoclastoid giant cells. The man underwent pylorus–preserving pancreatoduodenectomy. Pathological examination showed giant cell osteoclastoid carcinoma of the pancreas. Multiple liver metastases observed 4 months after surgery were treated with hepatic infusional 5Fu chemotherapy. As of October 2008, he is living under ongoing treatment.

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We report a case in which hepatectomy was performed to treat a patient with metastatic liver cancer 12 years after nephrectomy for renal cell carcinoma. The patient was a 56–year old man. Abdominal CT and MRI showed tumors with diameters of 8.5 cm and 2.5 cm in S2 and S4, respectively, of the liver, and many nodules with a diameter of 1 cm or less, all in the left hepatic lobe. FDG–PET/CT revealed a SUVmax of the tumors of 35, suggesting very high accumulation of FDG. Based on the history of renal cell carcinoma and normal hepatitis virus marker values a diagnosis of metastatic liver cancer from renal cell carcinoma was made. Distant metastasis was found only in the liver. Extended left hepatectomy was carried out, and the histologic findings confirmed metastasis by renal cell carcinoma. The patient had a good surgical postoperative course and was discharged on postoperative day 7. No signs of recurrence were observed at the 20 month follow–up examination. Hepatic metastasis by renal cell carcinoma generally has a poor prognosis, and since no specific, effective pharmacotherapy has been established, hepatectomy is an option, if the safety of surgery can be assured.

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We report a case of omental desmoid tumor diagnosed preoperatively as local rectal cancer recurrence.
A 63–year–old–man admitted for anal incongruity had undergone abdominal perinial resection after preoperative chemoradiotherapy for rectal cancer and anal metastasis. In postoperative workups, Abdominal computed tomography (CT) 8 months postoperatively showed a 15 mm mass beneath the left seminal vesicle, but no radiotracer fluorodeoxyglucose (FDG) uptake.
By one year postoperatively, however, the mass has increased to 28 mm and positron emission tomography/computed tomography (PET/CT) showed FDG uptake in the mass and left inguinal lymph nodes. The mass and left inguinal lymph nodes were resected under a diagnosis of local recurrent rectal cancer and left inguinal lymph nodes metastasis.
Histological examination showed spindle–shaped tumor cells with collagen fiber progression, yielding a definitive diagnosis of desmoid tumor originating in the omentum. No cancer cells were detected in resected inguinal lymph nodes.

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A 61–year–old man seen for a gradually worsening abdominal pain diagnosed as acute abdomen was found to have a partially edematous small intestine and ischemic change without necrosis, necessitating exploratory laparotomy. Arthralgia on postoperative day (POD) 5 was followed by graclually increasing abdominal pain and lower–limb purpura. Blood showed an elevated white blood cell count and CRP, suggesting Henoch–Schoenlein purpura (HSP). But rest decreased purpura, abdominal pain, and unfavorable blood test results, and he was discharged on POD 35. Adult HSP rarely involves abdominal symptoms before eruptions. It is necessary to make out an image in mind when an abdominal symptom came before, although acute abdomen invariably involves laparotomy.

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An 82–year–old man undergoing massive bowel resection for a strangulated intestinal obstruction required 4 days for weaning from mechanical ventilation and 7 days until oral intake. His temperature rose to 39.6°C on postoperative day (POD) 17. Removal and inspection of the central venous catheter tip and bacterial culture on POD 17 detected methicillin–resistant staphylococcus aureus (MRSA). Following treatment, his fever went down but he suffered lumbago after POD 20. Magnetic resonance imaging (MRI) on POD 50 showed pyogenic spondylitis, which was resolved by bed rest and intravenous vancomycin and teicoplanin administration. He was discharged on POD 80. Pyogenic spondylitis must therefore be considered as a potential postoperative complication in patients with lumbago following sepsis.

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We report the case of a prune–seed–induced incarcerated inguinal hernia. A 23–month–old boy presenting with a right inguinal bulge in December 2007 and diagnosed with a right inguinal hernia presented again with a right inguinal bulge and vomiting in April 2008. The bulge was palpated as a small, roundish firm right inguinal mass, yielding the same diagnosis. Computed tomography (CT) showed a high–density elliptical foreign body in the incarcerated region, necessitating emergency surgery. Opening of the inguinal canal by the Lucas–Championniere method showed no herniated bowel ischemia and the palpable foreign body was soon reduced spontaneously. On postoperative day (POD) 2, initiated oral intake yielded a 2.3×1.5 cm foreign body in the feces. The boy′s parents stated that he had eaten prunes preceding this episode.

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Internal herniation through a uterine broad–ligament defect is rare. We report 2 such cases. Case 1:A 50–year–old woman, gravida 2 para 2, admitted for abdominal pain, nausea, and vomiting was diagnosed with strangulated internal hernia based on computed tomography (CT), indicating a dilated small–bowel loop in Douglas′ fossa, small–intestine obstruction on the left dorsal side of the uterus, and uterine deviation to the right side. Open laparotomy showed that the ileum had herniated into a left broad–ligament uterine defect. Case 2:An 85–year–old woman, gravida unknown para 3, who had undergone adnexectomy in her 40s, was admitted for abdominal pain and vomiting. CT indicated small–intestine dilatation, diagnosed as strangulated internal hernia, whose precise location could not be determined. Open laparotomy showed that the ileum had herniated into a residual right broad–ligament uterine defect.

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A 36–year–old woman admitted for a low abdominal painful mass was found to have a 2.5 cm diameter mass under a caesarean section scar. Suspecting a Schloffer tumor or endometriosis of the abdominal wall, we conducted resection with sufficient margin. Histopathological examination showed gland proliferation consistent with columnar epithelium in interstitial tissue, yielding a diagnosis of endometriosis of the abdominal wall, classified as cutaneous endometriosis. It should thus be kept in mind that abdominal wall endometriosis may occur after gynecological surgery with adequate resection.

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