Purpose:Traumatic diaphragmatic injury, although rare, may be catastrophic for the victim if misdiagnosed, and requires careful examination.
Patients and Methods:We reviewed clinicopathological features in 10 cases of traumatic diaphragmatic injury seen from 1997 to 2007. Diaphragmatic injury accounted for 2.1% of all thoraco–abdominal injuries.
Results:Victims were eight men and two women (mean age:50 years) suffering 8 blunt injuries and 2 penetrating. Surgery was done except in four with cardiopulmonary arrest, and only one of these six was not diagnosed correctly preoperatively. Injury did not involve visceral herniation. The diaphragm was transabdominally repaired in 5 and transthoracically in 1. Blunt–trauma injuries were more critical than penetrating trauma. None died of injury postoperatively.
Conclusions:Traumatic diaphragmatic injury outcome depends on associated injury, and appropriate diagnosis and treatment may prevent death and complications.

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Background:Endoscopic submucosal dissection (ESD) is rarely used to treat early undifferentiated gastric cancer. Patients:We assessed preoperative accuracy in evaluating tumor depth invasion, tumor size, and clinicopathological factors in 117 persons undergoing gastrectomy with lymph node metastasis and dissection for early undifferentiated gastric cancer. Results:Those with ulceration–free tumors 2.0 cm or less in diameter had no lymph node metastasis. The accuracy of depth invasion was 97.0% and 87.9% for tumor size. Lymphatic invasion and ulceration were associated with lymph node metastasis. Conclusions:The best candidates for ESD among those with early undifferentiated gastric cancer had ulcer–free tumors less than 2.0 cm in diameter. The accuracy in evaluating tumor size should be improved.

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Purpose:We studied surgical outcomes one year postoperatively orbital fractures in 9 patients undergoing autologous bone reconstruction. Methods:We evaluated (1) postoperative complications in the orbital area and at the donor bone site, (2) vision problems in daily life, (3) double vision in the oculomotor limit region, and (4) ocular motility disturbance in the Hess test. Results:No postoperative complications such as inflammation or infection were seen. Extremely slight infraorbital nerve hypesthesia occurred in 2 cases. No patients reported double vision in daily life. Ocular motility in the Hess test was essentially normal except for extremely slight oculomotor limit double vision in 3.

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BACKGROUND:We have used laparoscope–assisted gastrectomy (LAG) to treat early gastric cancer since 2006. We compared LAG and conventional open gastrectomy (OG) outcomes retrospectively to evaluate its procedural feasibility. PATIENTS and METHODS We conducted LAG in 18 persons with early–stage middle or lower gastric cancer between March 2006 and August 2008. LAG includes pylorus–preserving gastrectomy (PPG), segmental gastrectomy (SEG), and distal gastrectomy (DG). RESULTS The operating time of LAG was 80 minutes longer than OG, and the blood loss of LAG was 200 ml less than OG. First flatus and recovery to normal temperature occurred faster in the LAG group. Oral intake restart and postoperative hospital stay did not differ significantly between groups. CONCLUSIONS We introduced LAG to treat early gastric cancer without obvious disadvantage in our initial 18 cases, suggesting that LAG may be a preferable surgical alternative.

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We assessed the long–term outcome following radiofrequency ablation (RFA) in patients with unresectable liver tumors metastatic from colorectal cancer. Methods:Subjects were 10 persons with liver metastasis from colorectal cancer treated for 14 colorectal tumors using percutaneous or open surgical RFA between 2001 and 2007. Results:The mean follow–up was 42.6 months. No RFA–related complications occurred. One tumor was near the right hepatic vein, Four were over 3.5 cm in diameter. Median survival was 4 years and 5 months. Conclusions:RFA is safe and provides relatively long survival in those with unresectable liver metastasis from colorectal cancer.

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Purpose Trocar site hernia (TSH) is an uncommon sequela of laparoscopic procedures. In this retrospective study, we determined the incidence of TSH and investigated the associated risk factors in patients undergoing laparoscopic colectomy (LC).
Subjects Three hundred and ten patients who underwent LC for colorectal disease between December 1993 and February 2008 in our hospital.
Results In this series, the incidence of TSH was 1.6% (5patients). There were no differences in age, gender, body mass index (BMI), tumor site or diabetes mellitus between the TSH and non–TSH groups. Comparison between patients with and without TSH revealed no differences in trocar size, type or site. However, there were significant differences in drain placement and fascial closure at the trocar insertion site after trocar removal. All TSH occurred in the left lower abdominal region, where an abdominal trocar had been placed for sigmoid or rectosigmoid colon cancer surgery and a drain had been placed after the trocar removement. The trocar diameter was 10–mm in 3 and 5–mm in 2 patients. Surgical treatment was provided to two patients with early–onset TSH and incarceration of the small intestine, and to one with late–onset TSH patient and abdominal pain. In the other two patients, who had omental hernias after drain removal, the fascias at the trocar sites were closed under local anesthesia.
Conclusion The range of intraoperative port movement and drain placement through a port site, which involve dilatation of the trocar orifice or disturbance of the fascial closure, are risk factors for the occurrence of TSH.

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Highly sensitive assays developed to detect circulating tumor cells (CTCs) in peripheral blood are currently being evaluated for clinical relevance prior to first–line therapy initiation in persons with metastatic breast cancer. We report a case examined using CTCs for this purpose. A 34–year–old woman with multiple liver metastases from breast cancer monitored using CTCs asaay before and during chemotherapy had undergone radical mastectomy for left breast cancer in July 2000, In September 2006 she was treated with combining Xeroda, Zoladex, and Fareston for multiple liver metastases and she had a complete response in CT 3 months after chemotherapy. Parallel with CT, we examined CTCs in a 7.5–ml blood sample using fiber–optic array scanning before and during chemotherapy. No CTCs were seen 3 months after chemotherapy, even though 10 CTCs had been detected before chemotherapy.

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We report a case of intracystic medullary breast carcinoma. A 40–year–old woman seen for mild left breast pain was found to have a soft elastic flat mass of 6 cm above the left nipple. Mammography showed a dense well–defined tumor and ultrasonography a cystic lesion. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a defined 4 cm cystic lesion with a mural nodule. Fine–needle aspiration cytology indicated adenocarcinoma necessitating partial left breast resection definitively diagnosed as intracystic carcinoma. The resected specimen showed a cystic lesion with a papillary mural nodule. Histopathology showed medullary carcinoma with microinvasive atypical cell foci to the wall. Immunostaining showed cancer cells to be negative for antiestrogen receptor and progesteron receptor antibodies and HER2/neu protein. Postoperative irradiation and adjuvant chemotherapy (5FU, epirubicin, cyclophosphamide) have left the woman disease–free 13 months postoperatively.

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We report a case of esophageal leiomyoma with marked calcification. An 81–year–old woman admitted for an asymptomatic esophageal submucosal tumor was found in esophagography to have a lesion protruding from upper thoracic esophagus wall. Chest computed tomography (CT) showed a markedly calcified 5 cm tumor necessitating surgery due to a lesion size suggesting potential malignancy. The massively calcified submucosal tumor, resected in right thoracotomy using video–assisted thoracic surgery was 50×25×15 mm diagnosed histologically as benign leiomyoma. Since esophageal leiomyoma with calcification is rare, we report this case together with a review of the literature.

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Abstract:Gastric hair concentrations known as trichobezoars are mostly extracted by laparotomy due to the difficult removal by endoscopy. We report a case of laparoscopic trichobezoar extraction. A 34–year–old woman with epigastralgia found in physical examination to have an upper abdominal mass confirmed in abdominal computed tomography (CT) and barium X–ray to be a giant gastric mass. Gastrointestinal endoscopy showed a giant trichobezoar. Laparoscopic surgery instituted after endoscopic extraction failed produced two masses–one 11×4.5 cm weighing 220 g and the other 3 cm weighing 100 g. The postoperative course was uneventful and the woman was discharged on postoperative day 7.

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We report a case of ectopic gastric pancreas treated by laparoscopic partial gastrectomy with stay sutures lifted onto the abdominal wall. A 35–year–old man found in upper gastrointestinal radiography to have a 3 cm elevated lesion associated with lower gastric anterior–wall bridging folds and referred for further tumor workup was confirmed in endoscopy to have the submucosal lesion thus described. Histopathological biopsy specimens from the lesion showed normal mucosa, and minimally invasive laparoscopy was conducted to resect the tumor, whose location was first confirmed endoscopically. The tumor′s serosal side was marked and the tumor resected leaving an adequate surgical margin using laparoscopic coagulating shears. The entire gastric wall thickness were three–stitch–sutured from the greater to the lesser curvature. Sutures were pulled through out the abdominal wall using an Endoclose^TM. The resection site was closed using three endoscopic staples while adjusting the two stay sutures lifted onto the abdominal wall. The postoperative course was uneventful and the man was discharged on hospital day 14.

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A 66–year–old man with general discomfort and malaise had been treated for tongue cancer 16 and again 6 years earlier by gastrostomy and tracheostomy. Findings included an elevated hemorrhagic lesion from the lesser curvature to the posterior middle and lower gastric wall, abnormally high serum α–fetoprotein (AFP) and protein induced by vitamin K absence or antagonists–II (PIVKA–II), and a lesion 15 mm in diameter at S5 of the liver. The diagnosis was gastric cancer with lymph node and liver metastases. Due to the man′s severe anemia, we conducted distal gastrectomy to control the bleeding. The large gastric lesion consisted of solid sheet–like hyperplasia with extremely atypical cells, and capillary vessels within cell nests, yielding a definitive diagnosis of hepatoid adenocarcinoma. This case is interesting from the viewpoint of gastric cancer blast transformation–AFP and PIVKA–II decreased markedly immediately after gastrectomy and tumor markers normalized after radiofrequency ablation for liver metastasis, suggesting that production of both proteins by gastric cancer cells had contributed to their increase.

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We report a rare case of a simple small intestine ulcer. An 83–year old man seen in an emergency for vomiting and abdominal pain was found in radiography to have a dilated small intestine and pneumonia. Computed tomography confirming these findings yielded a diagnosis of adhesive ileus. When long–tube intestinal decompression did not relieve abdominal pain, we undertook X–ray examination, which showed a small intestine obstruction.
The obstruction found 130 cm distal to Treitz′ ligament necessitated partial iliectomy that definitively confirmed a simple ulcer of the small intestine due to a deep Ul–IV ulcer and nonspecific inflammation. Following complications of pneumonia and exacerbated heart failure, he died of disseminated intravascular coagulopathy (DIC) on postoperative day 15.

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A 73–year–old man with melena, fever and lower abdominal pain was found to have a palpable tumor and lower abdominal tendernes. Abdominal computed tomography (CT) showed a solid 14 cm tumor with bleeding, internal necrosis, and surrounded by air bubbles different from intestinal lumen. The tumor was fed from the jejunal artery. The size, location, and perforation suggested a gastrointestinal stromal tumor (GIST). Laparotomy confirmed a giant small intestine tumor adheding to the posterior bladder wall and retroperitoneum. Inflammatory change involved the appendix. We partially resected the small intestine including the tumor and part of the bladder wall, also conducting, appendectomy and drainage. Histopathological findings showed tumor cells positive for c–kit and confirming a definitive diagnosis of small intestinal GIST. Imatinib mesylate was started 8 months later as chemotherapy. No recurrence has been seen in the 21 months postoperatively.

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A 74–year–old woman with anemia found in abdominal ultrasonography to have an intrapelvic tumor confirmed to be 13 cm in diameter in abdominal computed tomography (CT) was shown in abdominal magnetic resonance imaging (MRI) to have the tumor compressing the rectum and having boundaries with the uterus. A small bowel series showed that the tumor lumen was continuous with the small intestine. Barium enema confirmed rectal compression. Surgery under a tentative diagnosis of small intestine gastrointestinal stromal tumor (GIST) or malignant lymphoma confirmed a small intestine tumor 15 cm in diameter invading the rectum 250 cm from Treitz ligament and 10 cm from the terminal ileum, necessitating partial ileal and low anterior resection. Pathological examination showed GIST and mesenteric lymph node metastasis and immunohistochemical findings positive results for c–KIT and CD34. The woman died two months after multiple liver metastases were detected 9months postoperatively. Our case underscores the need for lymph node dissection in cases of small intestine GISTs.

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We report a case of small–intestine cancer diagnosed preoperatively and operated on in laparoscopic surgery. A 79–year–old man seen for diarrhea and epigastralgia had a 5 cm mobile hard elastic tumor palpated in the right abdomen seen in imaging as an invagination. Although Gastrographin enema reduced the invagination, he had been followed without treatment because no tumor was found by Gastrographin enema. The invagination relapsed 3 months later, and colonic endoscopy a showed a 3 cm tumor extending to the ascending colon 15 cm from the valve of Bauhin. Biopsy indicated adenocarcinoma necessitating laparoscopic ileocecal resection. Pathological resected specimen findings showed well–differentiated tubular adenocarcinoma.

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A 60–year–old man with schizophrenia hospitalized for lower abdominal pain showed terminal–ileum thickening in multidetector computed tomography (MDCT) 36 hours after pain onset, but no diagnosis emerged. MDCT reconstructed the next day showed a 2.5 cm high–density lesion penetrating the small intestine and diagnosed as intestinal fishbone perforation based on a fish dish the man had eaten two days before pain onset. Laparotomy showed an ileal perforation 2 mm in diameter necessitating segmental ileal resection. The elusive fishbone failed to appear in either the resected specimen or in intraoperative endoscopy. MDCT on postoperative day 15 located it in the rectum, from which it was removed by colonoscopy. This case suggests that potential fishbone mobility beyond the digestive tract perforation site may require preoperative or intraoperative MDCT.

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A 41–year–old woman referred for a painful lower right abdominal tumor was found in abdominal computed tomography (CT) and magnetic resonance imaging (MRI) to have an intraabdominal abscess and ileocecal and right ovarian tumors. Emergency surgery necessitated by elevated fever and pain revealed a cecal tumor invading the terminal ileum and abdominal wall and a right ovarian tumor. We resected the ileocecum, dissected local swollen lymph nodes, and conducted right oophorectomy. Material removed included the 8.0×7.0×5.0 cm tumor at the vermiform appendix orifice and a 5.0×2.5 cm right ovarian tumor including cystic and nodal components.
Histopathological findings indicated moderately differentiated tubular adenocarcinoma arising in the appendix with right ovarian metastasis. Postoperative chest CT showed multiple lung metastases.
The definitive clinical diagnosis was sSI (ileum), pN2, sH0, pP2 (ovary), cM1 (lung), fStage IV. Chemotherapy was conducted with leicovorin, 5–fluorouracil, oxaliplatin, and irinotecan (FORFOX4, FOLFIRI).

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A 29–year–old–woman admitted for lower right abdominal pain was found in laboratory examination to have an elevated white blood cell (WBC) count. Abdominal computed tomography (CT) and pelvic magnetic resonance imaging (MRI) showed a 6×3 cm tumor of the appendix. Under a preoperative diagnosis of suspected primary appendiceal carcinoma, we conducted ileocecal resection with D2 lymph node dissection. The histological diagnosis was poorly differentiated adenocarcinoma of the appendix. Pathological results indicated serosal invasion without metastasis to lymph nodes, stage II. The tumor was positive in immunohistochemical staining for AE1/AE3 and negative for hCG. One year postoperatively, she remains alive and disease–free.

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We report a case of giant lipoma presenting with transverse colon intussusception. A 60–year–old woman admitted for abdominal pain was found in abdominal computed tomography (CT) to have transverse colon intussusception necessitating emergency laparotomy. Intussusception on the left side of the transverse colon was detected and partial transverse resection was performed. The resected specimen had a smooth–surfaced 11×3×3 cm submucosal tumor shown pathologically to be benign transverse colon lipoma. An uneventful postoperative course enabled her to be discharged 18 days postoperatively.

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A 54 years old man had a checkup with the main complaint of an anal region tumor. There was a wide–based goose egg sized tumor at his anus. CT and MRI imaging revealed a cyst–related tumor extending to the perineum from the anus. Dermoid cyst, epidermoid cyst, teratoma, duvlication of the intestinal tract, and tailgut cyst were potential diagnosed of the tumor in the sacral region. The tumor was surgically removed from the patient′s anus, and proved to be a cyst. The lumen of the cyst composed ciliated columnar epithelium including goblet cells and stratified squamous epithelium without keratinization or granules. The histological findings of this cyst suggested a teratoma. The current postoperative follow up is 1 year 4 months, but no sign of recurrence has been recognized.

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We report a case of scirrhous hepatocellular carcinoma (SHCC) accompanied by hepatocellular carcinoma (HCC). A 66–year–old man having liver tumors was found in computed tomography (CT) to have a heterogeneous high–density tumor 9×6 cm in diameter at S6 in the arterial phase, a delayed–enhancement tumor 5×3 cm in diameter at S2, and a nonenhanced tumors 1 cm in diameter at S5 and S8. Based on a diagnosis of HCC with intrahepatic metastasis (IM), he underwent resection of the posterior segment, part of S8, and part of S2 in September 2006. Histopathological findings showed moderately differentiated HCC tumor cells with a trabecular pattern in the posterior segment. Tumors at S8 and S2 were SHCC.

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An 81–year–old man underwent pancreatoduodenectomy with a modified Child′s reconstruction for duodenal tumor. On the 27th postoperative day, he developed shock after massive hematemesis. Emergency angiography showed a pseudoaneurysm of the common hepatic artery, which was successfully embolized using microcoils. Gastrointestinal bleeding after pancreatoduodenectomy should be considered possibly due to rupture of the pseudoaneurysm of the celiac artery branches.

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A 27–year–old man admitted for upper right quadrant pain, and tenderness not eased by analgesics was found in laboratory findings to have marked inflammation but no other elevated data. Computed tomography showed no gallbladder wall thickening but the gallbladder was in front of hepatoduodenal ligament. The cystic duct was not enhanced. When four days of inpatient antibiotic therapy failed to alleviate his worsening upper right quadrant pain we conducted magnetic resonance imaging. Suspecting gallbladder torsion, we immediately undertook laparoscopic cholecystectomy (LC), finding a gross typeII floating gallbladder twisted 360 degree at the axis in the cystic duct. The Histopathological finding was gallbladder wall necrosis and submucosal membrane edema caused by gallbladder torsion.

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A 95–year–old woman admitted for lower right abdominalpain with tenderness, rebound tenderness, and muscle guarding was confirmed in X–ray and abdominal computed tomography (CT) to have massive amounts of abdominal free air and bowel dilation. Suspecting bowel–perforation peritonitis and right–colon volvulus, we conducted emergency surgery, finding the ascending colon rotated 150 degrees clockwise from its fulcrum and inflected dorsomedially. The dilated cecum had all teniae disrupted, marked wall thinning, and a 3 mm perforation. Repeated rotation and inflection of the loosely fixed cecum apparently caused bowel ischemia and atrophied the muscle layer, destroying the teniae structure. As cecal extensibility and capacity increased, twisting and inflection increased putting pressure on the intraluminal area and eventually perforating the cecum.

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A 47–year–old woman who had lost 40 kg in nine months due to eating disorder was hospitalized for week–long pyrexia and slight abdominal pain. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed rectal wall thickening, copious free air, and ascites. Emergency laparotomy for suspected perforative rectal cancer found copious odorless dirty yellow ascites for which we conducted drainage and created a defunctional stoma. Postoperative ventilator respiration was needed for extended acute respiratory distress syndrome. Three months later, she underwent curative resection. We suspect that restrictive eating disorder was symptomatic of perforation.

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A 62–year–old man admitted for a pancreatic lesion had undergone right nephrectomy for renal cell carcinoma (RCC) 7 years earlier and partial left lung lobectomy for tumor metastasis from RCC. Abdominal computed tomography (CT) showed an enhanced tumor 2 cm in diameter in the pancreatic head and dilation of the main pancreatic duct in the pancreatic body and tail. Endoscopic retrograde cholangiopancreatograms showed a tumor protruding from Vater′s papilla was diagnosed by biopsy as clear cell carcinoma. The pancreatic RCC metastasis necessitated pylorus–preserving pancreatoduodenectomy. Three years postoperatively, the man is doing well with no sign of recurrence. RCC metastasis to the pancreas is uncommon and, due to its slow appearance, requires long–term monitoring. Our experience suggests that resection may improve the prognosis.

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Inguinal hernial sac tumors within inguinal hernias are relatively rare. We report a case of renal cell carcinoma metastasizing into an inguinal hernia sac. An 89–year old man with a right inguinal mass found a year earlier underwent surgery in March 2007 for right inguinal hernia. An 80–mm solid tumor connected to the omentum and sac was removed simultaneously with hernia repair using a mesh plug. Histopathological examination showed renal cell carcinoma metastasis. Postoperative computed tomography (CT) suggested a 50 mm tumor in the left kidney, with generalized lymphadenopathy, ascites, and increased peritoneal concentration. The diagnosis was systemic lymph node metastasis from left renal cancer and peritonitis carcinomatosa resulting in Stage IV renal cancer for which the man and his family requested no further treatment. He died of the primary disease 3 months thereafter. Histopathological examination is essential in cases in which the hernia sac and the content are macroscopically unusual.

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Dedifferentiated retroperitoneum liposarcoma accounts for a very low 0.5% of all retroperitoneal tumors. We report two dedifferentiated retroperitoneal liposarcoma cases and their immunohistochemical analysis.
Case 1:An 80–year–old woman with lower abdominal discomfort was diagnosed with left rectal liposarcoma treated by excising the tumor and part of the mesorectum, total hysterectomy, and partial cystectomy. The tumor was histologically assessed as dedifferentiated liposarcoma with well–differentiated lipoma–like liposarcoma.
Case 2:A 62–year–old woman with abdominal bloating and leg edema was diagnosed with multiple giant peritoneal liposarcomas on the greater omentum, greater gastric curvature, mesocolon, and front right kidneytreated by immediate tumor excision. Tumors were histopathologically assessed as well–differentiated liposarcoma and dedifferentiated liposarcoma.
In both cases, MIB–1 indices were high for dedifferentiated liposarcoma. Histological malignancy grading suggests a high recurrence risk reguiring careful, comprehensive monitoring and follow–up.

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