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Toru Aoyama, Takamitsu Maehara, Kohei Ando, Shizu Saito, Munetaka Masu ...
2011 Volume 36 Issue 4 Pages
600-604
Published: 2011
Released on J-STAGE: August 25, 2012
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A 76–year–old woman was admitted for abnormal tumor shadows in chest computed tomography (CT) during a preoperative check up. Two of the 4 shadows were at left S
1+2 and S
3 and 2 at right S
2, with both lungs showing ground glass opacity. Shadows were 19, 26, 15, and 18 mm in size. The diagnosis of multiple bilateral lung cancer necessitated left upper lobectomy with lymph node dissection and partial resection at right S
2. Pathological examination showed pulmonary adenocarcinoma with bronchioalveolar carcinoma in both lungs. The woman is doing well 12 months postoperatively, with CT showing neither carcinoma recurrence nor increase in remnant atypical adenomatous hyperplasia (AAH).
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Norio Yukawa, Yasushi Rino, Hiromasa Arai, Nobuhiro Sugano, Roppei Yam ...
2011 Volume 36 Issue 4 Pages
605-611
Published: 2011
Released on J-STAGE: August 25, 2012
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We report the case of a 75–year–old man with five simultaneous separate lesions, i.e., prostate cancer, small–cell lung cancer, ascending colon cancer, and two rectal cancers. At age 65, he underwent hormonal therapy for prostate cancer and related bone metastasis, and at age 70, upper right lobectomy for small–cell lung cancer and partial colectomy for early ascending colon cancer. He also underwent radiation therapy for brain metastasis and chemotherapy for neck lymph node metastasis from small–cell lung cancer.
In 2008, he reported melena and proctodynia, for which colonoscopy showed advanced and early rectal cancer necessitating abdominoperineal resection in January 2009. In May 2009, PET–CT detected neck lymph node metastasis from small–cell lung cancer necessitating chemotherapy. In September 2009, CT showed lung and liver metastasis from rectal carcinoma. He underwent FOLFIRI and bevacizumab chemotherapy, which shrank the metastases. CT in June 2010, however, showed that liver metastases had grown. Chemotherapy was changed from FOLFIRI plus bevacizumab to mFOLFOX6 plus bevacizumab.
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Masashi Takemura, Yushi Fujiwara, Keiichiro Morimura, Takaaki Hori
2011 Volume 36 Issue 4 Pages
612-616
Published: 2011
Released on J-STAGE: August 25, 2012
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In blood flow from aortic branches to the esophagus, a longitudinal anastomosis between branches is prominent and ischemic esophageal wall changes are rare. We report a case of very rare esophageal necrosis after lower esophagectomy for early esophageal cancer. A 62–year–old man was diagnosed with early squamous cell carcinoma at the cranial esophagogastric junction. Middle and lower mediastinal lymph nodes were dissected and lower esophagectomy done thoracoscopically. Abdominal lymph nodes were dissected and esophagogastric anastomosis done via laparoscopy. On postoperative day (POD) 1, his respiratory condition worsened and air density lesion was found around the gastric tube in chest computed tomography (CT). Endoscopically, the esophageal wall had turned black 8 cm from the anastomosis and the esophageal wall was perforated. A diagnosis of esophageal necrosis necessitated emergency partial esophagectomy and esophagocutaneostomy. Rereconstruction using the pedicled jejunum was done 6 weeks after emergency surgery. Pathologically, the resected esophagus was necrotic and a mucosal layer defect found at the resected esophagus.
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Kimitaka Tanaka, Toshiaki Shichinohe, Masaki Miyamoto, Eiichi Tanaka, ...
2011 Volume 36 Issue 4 Pages
617-622
Published: 2011
Released on J-STAGE: August 25, 2012
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A 65–year–old man reporting heartburn was diagnosed with esophageal cancer and admitted for surgery. With a history of chronic obstructive pulmonary disease (COPD) and thoracic aorta graft replacement for a ruptured thoracic aortic aneurysm, he had left recurrent laryngeal nerve palsy following the previous surgery. After two weeks of preoperative pulmonary rehabilitation, he underwent esophagectomy in video–assisted thoracoscopic surgery (VATS) without technical difficulty thanks to the absence of severe adhesions in the right thoracic cavity and mediastinum. With mild pneumonia as the only postoperative complication, the man was discharged on postoperative day 46. Preoperative pulmonary rehabilitation and VATS, which preserves respiratory muscles, are generally known to decrease postoperative pulmonary complications in those with COPD. Preoperative pulmonary rehabilitation to strengthen respiratory muscles and lower VATS invasiveness may play an important role in perioperative safety. Those with previous thoracic aortic graft replacement without thoracic cavity and mediastinum adhesions may possibly undergo esophageal resection.
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Kouichiro Yamaoku, Chikara Kunisaki, Tsutomu Sato, Takashi Oshima, Sho ...
2011 Volume 36 Issue 4 Pages
623-629
Published: 2011
Released on J-STAGE: August 25, 2012
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A 70–year–old woman with a 25 mm submucosal gastric tumor had been followed up since January 2006. During follow–up, the tumor developed a small central depression. Four endoscopic biopsies showed group I–IV. Histopathologically, biopsied tumor specimens showed low–grade dysplasia, but adenocarcinoma could not be verified. Laparoscopy–assisted distal gastrectomy was done in March 2008 becanse the possibility of marignancy could not be clinically excluded. Histopathlogically, the specimen showed well–differentiated adenocarcinoma extending to the submucosal layer and heterotopic gastric gland cancer cells. Heterotopic gastric glands showed severe submucosal layer atypia, considered early gastric cancer derived from heterotopic submucosal gastric mucosa.
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Kazuhiro Takami, Tomoya Abe, Takayuki Ii, Yasutaka Aoki, Takahiro Kami ...
2011 Volume 36 Issue 4 Pages
630-634
Published: 2011
Released on J-STAGE: August 25, 2012
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We report a case of false–positive CEA, CA19–9, SPan–1, and DUPAN–2 tumor markers in which a relationship to hepatic function disorder following gastric carcinoma surgery was suspected.
A 59–year–old man underwent total gastrectomy and splenectomy (D2) for gastric carcinoma. Histopathologically, this involved moderately differentiated adenocarcinoma, pT1 (SM), pN0, and pStage IA. One month after surgery, increasing transaminase led to checking for hepatic function disorder from fatty–liver malnutrition. Eight months after surgery, increasing tumor markers CEA and CA19–9 and subsequently increasing SPan–1 and DUPAN–2 necessitated digestive tract scanning and PET–CT, but both were negative for gastric carcinoma recurrence and pancreaticobiliary malignancy. Chemotherapy was considered, with rigorous follow–up. From month 21 after surgery, hepatic function was in remission and tumor markers decreased. No gastric carcinoma recurrence or malignancy has been observed in the 26 months since surgery.
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Yusuke Tajima, Keiichiro Ishibashi, Norihiro Haga, Tohru Ishiguro, Yoz ...
2011 Volume 36 Issue 4 Pages
635-640
Published: 2011
Released on J-STAGE: August 25, 2012
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We report a rare case of juvenile polyposis (JP) in an older subject. A 77–year–old man admitted for frequent vomiting was found in gastroscopy and colonoscopy to have pyloric antrum polyposis and one polyp each of the sigmoid colon and rectum. Gastric polyps were biopsied and colorectal polyps resected. Histologically, biopsy specimens showed typical juvenile polyposis features—glandular epithelial hyperplasia, cystic dilation, and mucus retention. JP was diagnosed based on clinical and pathological findings and observed conservatively. When pyloric stenosis and hypoproteinemia were not relieved, he underwent distal gastrectomy, after which hypoproteinemia quickly disappeared. The Japanese literature from 1990–2010 showed 18 cases, including ours, diagnosed as JP, undergoing total or subtotal gastrectomy. Of those, hypoproteinemia found in 14 was relieved in 11.
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Kazuhiro Suzumura, Nobukazu Kuroda, Yuji Iimuro, Toshihiro Okada, Hisa ...
2011 Volume 36 Issue 4 Pages
641-644
Published: 2011
Released on J-STAGE: August 25, 2012
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An 88–year–old man seen elsewhere for jaundice was hospitalized at our institute with a diagnosis of duodenal papilla cancer. He underwent pylorus–preserving pancreaticoduodenectomy (PPPD). Histologically, the tumor was due to papillary adenocarcinoma. The man remains alive without recurrence 3 years after surgery. Insofar as we can find, he is the oldest person to have undergone PPPD for duodenal papilla cancer. While invasive surgery should be avoided in the elderly, PPPD can, however, be considered even for the elderly if it is curative and judged safe.
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Akira Umemura, Akira Sasaki, Jun Nakajima, Hiroyuki Nitta, Go Wakabaya ...
2011 Volume 36 Issue 4 Pages
645-648
Published: 2011
Released on J-STAGE: August 25, 2012
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We performed intraoperative endoscopic sphincterotomy (EST) using rendezvous technique (RT) during laparoscopic cholecystectomy (LC). The case was a 62–year–old woman visited our clinic for the complaints of abdominal pain and vomiting. She was admitted based on a diagnosis of acute cholangitis and secondary acalculous cholecystitis caused by cholestasis. Since hepatic function impairment and exacerbation of inflammatory findings was getting worse the day after admission, she was judged to have moderate acute cholangitis unresponsive to initial treatment and endoscopic retrograde cholangiopancreatography (ERCP) was performed. The presence of peripapillary duodenal diverticula made it difficult to employ a selective approach to the CBD even after a total of two implementations of ERCP. Then we performed LC and intraoperative EST using RT in order to perform endoscopic biliary drainage and cholecystectomy simultaneously. RT is a well–established procedure as a single–stage therapy using an antegrade approach for the treatment of choledocholithiasis, and is able to reduce the incidences of complications. Since RT has some disadvantages such as requiring special operating room equipments and numerous specialists, it is therefore necessary to examine the usefulness of RT in combination with LC as a single–stage surgical treatment for choledocholithiasis.
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Tomoaki Harada, Shuichi Nakatani
2011 Volume 36 Issue 4 Pages
649-653
Published: 2011
Released on J-STAGE: August 25, 2012
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We report treating what appears to be Japan′s oldest case of pneumatosis cystoides intestinalis (PCI).
A 101–year–old woman seen for abdominal bloating was found to have the entire abdomen distended, but with neither pain nor peritoneal irritation. Abdominal radiography showed significant free air in the bilateral subphrenic space. Abdominal computed tomography (CT) showed intestinal swelling and free air. When oxygenation (5l/min. mask) was initiated under suspicion of PCI, abdominal bloating was eventually relieved and free air and intestine disappeared from CT on day 18 of hospitalization.
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Fumiaki Shiratori, Satoshi Yajima, Tatsuki Nanami, Takashi Suzuki, Yok ...
2011 Volume 36 Issue 4 Pages
654-657
Published: 2011
Released on J-STAGE: August 25, 2012
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Ileus is caused by torsion occurring during jejunostomy where is attached to the abdominal wall. Ileus is released by detaching the jejunum from the abdominal wall and reintegrating it with the intestine.
Torsion must be avoided to prevent ileus. This is done by using “lines”to affix the intestine to the abdominal wall.
Nutritional support began early after surgery is an important to recovery, so we recommend that those undergoing invasive operations such as esophagectomy, undergo jejunostomy simultaneously to ensure that parenteral nutrition is begun immediately thease after.
We report two cases of ileus due to esophagectomy, jejunostomy.
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Norio Yukawa, Yasushi Rino, Nobuhiro Sugano, Tsutomu Sato, Roppei Yama ...
2011 Volume 36 Issue 4 Pages
658-664
Published: 2011
Released on J-STAGE: August 25, 2012
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Appendiceal mucinous cystadenoma is rare, with only 31 cases of laparoscopic resection having, to our knowledge, been reported in original Japanese articles since 1995.
We report a case of mucinous cystadenoma of the appendix resected using laparoscopy–assisted partial cecectomy. A 49–year–old man undergoing colonoscopy due to occult stool blood was found to have a submucosal cecal tumor. Barium enema showed an intussusception from the cecum to the ascending colon, which was then relieved by air injection. Abdominal CT and ultrasonography showed a club–like cystic lesion on the right side of the abdomen, diagnosed as appendiceal mucinous cystadenoma. Laparoscopy–assisted partial cecectomy was done without lymph node dissection. Neither ascites, peritoneal dissemination, nor pseudomyxoma was detected. He was discharged on postoperative day 5. The resected specimen showed a markedly swollen appendix with a large quantity of mucin. Histological examination confirned mucinous cystadenoma.
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Keiichiro Ishibashi, Norimichi Okada, Kensuke Kumamoto, Tomonori Ohsaw ...
2011 Volume 36 Issue 4 Pages
665-669
Published: 2011
Released on J-STAGE: August 25, 2012
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Surgical approaches for an appendiceal mucocele remain controversial, since caution needs to be exercised during surgery to avoid inadvertent rupture of the lesion, which may cause pseudomyxoma peritonei if the lesion is neoplastic. We report a case of mucinous cystadenoma of the vermiform appendix treated successfully by single–incision laparoscopic surgery (SILS). A 71–year–old woman was admitted for the treatment of a cystic mass in the right iliac fossa. Abdominal computed tomography revealed a well–encapsulated cystic mass measuring 30 mm in diameter, adjacent to the cecum. SILS ileocecal resection with lateral–to–medial mobilization and extracorporeal anastomosis was performed via a 3.5–cm–long transumbilical incision. The operative time was 145 minutes and the blood loss was about 10 mL. There were no intra– or postoperative complications. The histological diagnosis was mucinous cystadenoma. SILS seems to be a useful option for minimally invasive treatment of appendiceal mucocele, however, as mentioned above, care is needed to prevent complications.
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Mitsunori Saito, Michiko Hinata, Tetsuya Aono
2011 Volume 36 Issue 4 Pages
670-674
Published: 2011
Released on J-STAGE: August 25, 2012
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A 61–year–old man admitted after 1 month of chronic abdominal pain and gas accumulation was found in abdominal computed tomography (CT) to have a tumor–like sigmoid colon lesion and an enlarged proximal intestine. Contrast study showed the sigmoid colon to be obstructed. When conservative treatment was inffective, we conducted sigmoidectomy. The resected specimen showed diverticulosis and sigmoid colon stenosis due to wall thickening. Pathological examination showed normal mucosa, a thickened muscular layer, and inflammatory cell infiltration. No malignancy was seen. We determined that stenosis may have been caused by wall thickening due chronic diverticulitis changes. Chronic diverticular disease with intestinal obstruction rarely involves surgery.
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Shinya Amano, Shoichi Fujii, Tsutomu Sato, Teni Godai, Takashi Oshima, ...
2011 Volume 36 Issue 4 Pages
675-680
Published: 2011
Released on J-STAGE: August 25, 2012
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A 60–year–old woman with anal bleeding underwent colonoscopy. The biopsy specimen showed malignant melanoma, preoperatively T1 (SM), N0, Stage I. Because the lesion did not extend beyond the submucosa and the margin was sufficient, we conducted intersphincteric resection and ileostomy with D2 lymph node disection. The tissuetype and diagnosis were malignant melanoma, Tis (M), N0 (0/11), Stage 0.
Because the margin was sufficient, we followed the guidelines for malignant skin tumors, malignant melanoma (Tis, T1a), no chemotherapy, and ambulatory care. The woman survived postoperatively for 17 months with no sign of recurrence.
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Takaaki Kato, Satoshi Katagiri, Shunichi Ariizumi, Yoshihito Kotera, Y ...
2011 Volume 36 Issue 4 Pages
681-686
Published: 2011
Released on J-STAGE: August 25, 2012
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Sarcomatoid intrahepatic cholangiocarcinoma is comparatively rare in Japan.
We report such a case. A 71–year–old man admitted for abdominal pain and a liver tumor detected elsewhere was confirmed in plain computed tomography (CT) to have a hypoattenuating lesion 9 cm in diameter in the posterior hepatic segment. Enhanced CT showed a heterogenous hypoattenuating lesion in the arterial and portal phases, yielding a diagnosis of intrahepatic cholangiocarcinoma. He underwent right hepatectomy and right adrenal gland and right kidney resection in December 2007. Histopathologically, the tumor consisted of pleomorphic spindle cells. Immunohistochemically, tumor cells were positive for MUC–1, EMA, and vimentin and negative for Hep–1.
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Tatsuki Nanami, Akira Tamura, Kentaro Shirasaka, Takashi Suzuki, Yoko ...
2011 Volume 36 Issue 4 Pages
687-692
Published: 2011
Released on J-STAGE: August 25, 2012
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A 63–year–old man diagnosed with left–side gallbladder was seen for epigastric pain. Biochemical blood tests showed severe inflammatory reaction and significantly elevated liver biliary enzyme. Abdominal computed tomography (CT) showing cholecystitis and choledocholithiasis necessitated hospitalization. Ultrasonic abdominal evaluation, abdominal CT, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP) confirmed gallbladder wall thickening, a stone in the common bile duct, left–side gallbladder, and portal vein anomaly. The stone was removed by endoscopic surgery, followed by laparoscopic cholecystectomy started using the four usual ports but adding a hypochondrium port to facilitate laparoscopy. Calot′s triangle was obscured due to gallbladder inflammation, so the gallbladder was first partially detached from the liver bed, then removed. We believe that a left–side gallbladder involving cholecystitis can be safely removed by laparoscopic cholecystectomy provided that anatomical positioning is fully understood and preoperative surgical planning, including port positioning, is done carefully.
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Kazushige Ito, Akihiro Mimuro, Shingo Tachibana, Yasuharu Hayashida, K ...
2011 Volume 36 Issue 4 Pages
693-696
Published: 2011
Released on J-STAGE: August 25, 2012
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Splenic abscesses are very rare. We report a splenic abscess caused by gastric cancer. A 66–year–old man with shivering and palpitations had a high fever, rebound tenderness, and muscular defense. Blood tests showed anemia and a high–grade inflammation. Abdominal computed tomography (CT) showed abdominal cavity effusion, a lacerated spleen, and a primary gastric tumor causing gastric wall thickening. Based on a diagnosis of peritonitis or splenic bleeding due to the lacerated spleen and malignant gastric tumor, we conducted emergency surgery. His spleen was lacerated by a splenic abscess, and we found a gastric tumor in the gastric body adhering to the spleen and pancreas. We conducted total gastrectomy and pancretosplenectomy with D1 dissection. Pathologically, the gastric cancer had penetrated the spleen.
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Takahiro Koizumi, Toshiaki Ohishi, Genki Tatsuno
2011 Volume 36 Issue 4 Pages
697-701
Published: 2011
Released on J-STAGE: August 25, 2012
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A case of giant retroperitoneal cystic lymphangioma is reported. A 38–year–old man referred to our hospital because of abdominal fullness. Abdominal ultrasonography revealed an abdominal cystic mass. Computed tomography revealed a huge cystic tumor occupied from the upper abdomen to pelvic space. In May 2010, the tumor was removed. A 18×14×7 cm tumor with slight yellow serous fluid, occupied the right side abdomen and adhered to the 3rd portion of the duodenum, pancreas, inferior vena cava (IVC) and Gerota′s fastia. The surface of the tumor was smooth and there was no nodules in the innerlumen. Histopathological findings confirmed cystic lymphangioma. No recurrence has been found as of March 2011.
Lympangiomas are common in children and often affect the face, neck, and axillae. Lymphangiomas of the retroperitoneum are rare, accounting for only 0.25% of all lymphangiomas. Although benign, these tumors do not disappear spontaneously and must be completely resected for a good prognosis. Recurrence and malignant change in lymphangiomas have been reported, necessitating careful follow–up.
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Norifumi Hirooka, Takuji Mori, Ryo Tanaka, Takuya Yamaguchi, Tetsuya S ...
2011 Volume 36 Issue 4 Pages
702-706
Published: 2011
Released on J-STAGE: August 25, 2012
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Transomental hernias are relatively rare and difficult to diagnose preoperatively due to the lack of specific clinical findings. We report a case of transomental hernia diagnosed preoperatively by abdominal multidetector computed tomography (MD–CT), followed by emergency surgery. A 30–year–old man admitted for vomiting and right lower abdominal pain had neither rebound tenderness nor muscular defense. MD–CT showed a strangulated small intestine protruding through a hernia of the greater omentum. Diagnosing the case as transomental hernia, we conducted emergency surgery. Laparoscopy showed poor intestinal circulation and the smallintestine incarcerated through a 3 cm defect in the greater omentum. The incarceration was released, avoiding dissection of the intestine. The man was discharged 12 days after surgery.
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Tomoaki Kaneko, Nagato Shimada, Yoshiko Honda, Takamaru Koda, Kentaro ...
2011 Volume 36 Issue 4 Pages
707-712
Published: 2011
Released on J-STAGE: August 25, 2012
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We report a case of ruptured incisional hernia treated in single–stage surgery by component separation (CS). An 86–year–old man had an abdominal incisional hernia with an orfice about 10 cm in transverse diameter.
Due to his age and comorbidity, we had hoped to treat him without surgery, but his intestines prolapsed and he was admitted in an emergency. His abdomen was distended, his abdominal wall had ruptured, and 20 cm of his intestines had prolapsed from a medial dehiscence in the lower abdominal wall. We closed the abdominal wall by CS and conducted single–stage surgery, including hernioplasty. With the high possibility of postoperative infection, artificial material use is restricted. CS uses autogenous tissue and simple surgical repair for relatively large hernial orifices, and is recommended in surgery where the possibility of postoperative infection is high.
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Ryo Yoshida, Hideho Takada, A–Hon Kwon
2011 Volume 36 Issue 4 Pages
713-717
Published: 2011
Released on J-STAGE: August 25, 2012
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Morgagni hernias account for 1–3% of all diaphragmatic hernias. We repaired a Morgagni hernia laparoscopically using Bard Composix Mesh
®. A 78–year–old woman admitted for a two–year history of chest and abdominal pain, obstinate constipation, and vomiting was found in chest–abdominal computed tomography (CT) to have a diaphragmatic muscle defect with the transverse colon herniating through the defect, suggesting a Morgagni hernia. In laparoscopic repair, one 12 mm and two 5 mm trocars were inserted into the abdomen and CO
2 gas insufflated to an intraabdominal pressure of 6–8 mmHg. The transverse colon and omentum had herniated through a 5×6 cm oval defect in the sternocostal triangle of the thoracic diaphragm. Herniated organs were repositioned and Composix Mesh
® placed over the hernia and fixed to the diaphragm using Absorba Tack
®. The postoperative course was uneventful, and the woman was discharged on postoperative day 7. No signs of recurrence have been seen in the 6 months operatively, and laparoscopy has provided a minimally invasive approach to Morgagni hernia repair.
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Noriyuki Isohata, Yoshihiko Naritaka, Shinichi Asaka, Kentaro Yamaguch ...
2011 Volume 36 Issue 4 Pages
718-722
Published: 2011
Released on J-STAGE: August 25, 2012
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We report a rare case of spinal epidural lumbar abscess following ileal surgery. A 66–year–old woman with a history of cervical cancer surgery was seen for abdominal pain and nausea. She was diagnosed with ileus by abdominal X–ray and computed tomography. When treatment using a long intestinal tube did not relieve symptoms, surgery was conducted on day 8 after admission. During the operation, a catheter was inserted via the right internal jugular vein. On postoperative day 22, she suffered from a fever exceeding 39°C. The catheter was removed and MRSA detected from a catheter culture. Five days later, she reported steadily worsening lumbago. Spinal lumbar MRI showed an epidural abscess between L1 and L3 compressing the spinal cord and an abscess of the bilateral iliopsoas muscles. We conducted percutaneous CT–guided abscess drainage of the bilateral iliopsoas muscles. When the epidural spinal lumbar abscess did not improve, we conducted surgical drainage. The MRSA infection had apparently spread in pyogenic lumbar spondylitis with the epidural abscess and iliopsoas muscle abscess from the central venous catheter after fasting in ileus treatment made the woman a compromised host.
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