Background: Interventional transcatheter arterial embololization (TAE) is one of the treatment options for the treatment of gastric cancer bleeding when endoscopic treatments fail. The clinical usefulness of TAE for bleeding associated with advanced gastric cancer was retrospectively evaluated.

Methods: Nine patients with bleeding from advanced gastric cancer underwent TAE between January 2012 and December 2015 were enrolled in this study. If the patient was discharged from hospital without transfusion for thirty days after TAE, we defined the procedure as clinical success. We retrospectively reviewed the clinical success rate and the clinical outcome.

Results: The overall clinical success rate was 56% (5/9). One case of Grade 3 splenic infarction, one case of Grade 3 pylorus stenosis, three cases of Grade 2 abdominal pain were found. In five cases of successful TAE, three patients were performed chemotherapy and one patient underwent gastrectomy. The overall survival was 8.1 months and 1.4 months in successful and unsuccessful cases, respectively.

Conclusions: In patients with bleeding from advanced gastric cancer, TAE was useful because the clinical success rate of TAE was 56% and patients were able to be discharged and undergo chemotherapy if TAE was successful.

Amid the nationwide shortage of pathologists, the absence of pathologists is not uncommon in hospitals, especially in less than middle-sized hospitals. Conversely, in breast cancer lesion cases, intraoperative frozen-section diagnosis is imperative to plan the surgical method based on sentinel lymph node biopsy and ascertain the need for additional resection of the stump of the mammary glands. Telepathology, which we introduced in 2007, is a system that facilitates intraoperative frozen-section diagnosis in hospitals without the need for a pathologist. At our hospital, the results obtained with telepathology are not inferior to those obtained with standard intraoperative frozen-section diagnosis and have demonstrated the likelihood of introduction of telepathology in hospitals where pathologists are absent.

A 74-year-old woman was admitted to our hospital because of back pain and difficulty of breathing, which started the previous night. She had a history of multiple traumas caused by a traffic accident 4 months prior. She was developing a shock but showed no signs of peritonitis. A computed tomography scan showed dilation of the small intestine and effusion in the right pleural cavity. The diagnosis of delayed traumatic diaphragmatic hernia was confirmed, and emergent laparotomy was performed immediately. The ileum was incarcerated in the right pleural cavity through an orifice approximately 2cm in diameter at the top of the right diaphragm. The orifice was incised and widened enough to pull back the ileum. The necrotic segment was resected and anastomosed. The hernia orifice was closed with a 3-0 Prolene^™ knotted suture. Her postoperative course was uneventful. Obstructive posttraumatic diaphragmatic hernia has been rarely reported, but recently, its incidence has increased in Japan. Obstructive posttraumatic diaphragmatic hernia often requires organ excision and lead to a life-threatening event.

A 23-year-old man with eating disorder was suffered from stomachache and admitted to our hospital. 3D reconstructed images by MDCT showed a spoon and a toothbrush located at ileocecum and causing bowel obstruction. A laparotomy was performed, and there were the objects running pallarel, whose tips got into the ileocecal valve. They were removed through the incised hole, and it was closed by the suture. In the history taking, it was revealed that he had eaten them one year ago. The postoperative course was unremarkable, and at follow-up more than 6months after surgery, the patient remained free of symptoms.

An 83-year-old with no history of abdominal surgery was admitted to our hospital as an emergency outpatient with symptoms of abdominal pain and nausea. Computed tomography revealed a distended intestine and gallstone obstructing of the ileum. There was a missing border between the gallbladder and duodenum, so gallstone ileus with cholecystoduodenal fistula was suspected. Obstruction of the ileum persisted despite three daysʼ conservative treatment with an ileus tube. Single-port laparoscopic enterolithotomy was performed on the fourth day of hospitalization without morbidity. Gallstone ileus is relatively rare among ileus, and it often requires surgical treatment. Single-port laparoscopic surgery can be performed without morbidity even in an elderly patient.

Introduction: Paracecal hernia on the lateral side of the cecum is one of the least common types of internal hernia. We report herein a case of paracecal hernia on the lateral side of the cecum that was successfully diagnosed preoperatively by computed tomography (CT) and treated laparoscopically.

Case presentation: A 95-year-old man with a history of appendectomy was referred to our hospital for further evaluation. He was admitted with a diagnosis of small bowel obstruction (SBO) and was treated conservatively with placement of a long intestinal tube. Symptoms and abdominal findings immediately improved, but a large amount of fluid continued to be drained. We therefore carefully reevaluated the obstruction. CT revealed SBO caused by paracecal hernia resulting from intestinal invagination into a pouch on the lateral side of the cecum. Laparoscopic surgery was performed on hospital day 8, and we intraoperatively confirmed and repaired lateral paracecal hernia. The patient was discharged without major complications.

Conclusions: Preoperative diagnosis of internal hernia, including paracecal hernia, is relatively difficult. CT represents the most successful diagnostic modality, but requires careful examination, and laparoscopic surgery can play a useful role in definitive diagnosis and repair of SBO. Moreover, preoperative decompression facilitates safe laparoscopic surgery.

A 48-year-old woman was admitted to our hospital emergency department with right lower abdominal pain and fever from the day before the visit. There were tenderness and rebound pain localized in the lower right quadrant. In the blood test, the inflammatory response increased. CT examination revealed enlarged appendix, wall thickening and abscess formation confined and lymph node enlargement along the ileocecal artery. We diagnosed abscess forming appendicitis. Since there were no symptoms of acute generalized peritonitis and the general condition was stable, we started conservative treatment. We planned to perform detailed examinations after improvement. After hospitalization, improvement of symptoms and inflammatory response was observed by antibiotic administration, so we allowed discharge from the hospital. Although abnormal findings were not observed at the later colonoscopy, CT examination revealed thickening of the appendiceal wall, liquid accumulation in the appendix, and remnant of lymph node enlargement. We suspected appendiceal tumor and performed ileocecal resection (D3 LN dissection) after adequate informed consent. Pathological findings were appendiceal mucinous carcinoma with lymph node metastasis. Abscessing appendicitis may be associated with appendiceal carcinoma. Therefore, conservative treatment should be done if possible, and examination should be performed after improvement. If there are abnormal findings, we should positively perform surgery.

A strategy of treatment of low-grade appendiceal mucinous neoplasm (LAMN) has not yet been established. We experienced 2 cases operated by laparoscopic surgery. The first case is 75 year-old-female, detected a cyst in the appendix by Computed tomography, and diagnosed as an appendix mucinous cyst. Laparoscopic appendectomy was carried out. Operation time was 45 minutes and the amount of bleeding were a little. The specimen was 8×4cm and mucinous liquid was collecting inside the cyst. The histopathological diagnosis was LAMN. Second case is 36 year old female, aware of the lower right abdominal tumor. Computed tomography showed cystic tumor in a point of an appendix, we diagnosed mucinous cyst of appendix. We performed laparoscopic appendectomy because the tumor was present in a point of the appendix. Operation time was 52 minutes and the amount of bleeding were a little. The specimen was 11×5cm, filled with mucinous liquid. The histopathological diagnosis was LAMN, and the resection margin was negative. We have experienced two case of appendectomy to LAMN. This paper deals with our case with a review of the literature.

The subject of the case is a woman in her 40ʼs, with a chief complaint of lower abdominal pain. She underwent upper gastrointestinal radiography in a medical checkup. She visited a nearby doctor five days after the examination because of lower abdominal pain. Barium retention in the colon was shown by abdominal X-ray. Barium removal using endoscopy was ineffective. The next day, abdominal CT revealed free air; therefore, she was brought to our hospital. Abdominal contrasting CT revealed barium retention mainly in the sigmoid colon and abdominal dropsy in the peritoneal cavity. We diagnosed a colon perforation, caused by barium retention, and performed an emergency surgery. The peritoneal cavity was affected by feces-related abdominal dropsy, with a perforation located in the center of the sigmoid colon. We performed Hartmannʼs operation, and the patient was released 28 days after the surgery without any complications. Colon perforation after an examination for barium is rare, but the quality of life decrease significantly, even if it is controlled. The management of bowel movements in this disease state on taking this disease is required．

An 82-year-old woman was admitted to evaluate aortic valve stenosis and anemia. Sigmoid colon cancer was pointed out by colonoscopy. A laparoscopic sigmoid colectomy was performed as definitive treatment. Pathological findings revealed sigmoid colon cancer composed of moderately differentiated tubular adenocarcinoma that was surrounded by endocrine cell carcinoma. The endocrine cell carcinoma accounted for 90 percent of the total components whereas adenocarcinoma component accounted for 10 percent. Finally this tumor was diagnosed as endocrine cell carcinoma. In endocrine cell carcinoma component, the expression of p53 was positive, and Ki-67 index was 80-90%, which was higher than in adenocarcinoma component. In general, patients with colorectal tubular adenocarcinoma involved with endocrine cell carcinoma have poor prognosis. Although it has passed 48 months since she underwent the surgery, she is still alive with no recurrence.

A 70-year-old man presented to our hospital with a left lower abdominal tumor. We performed drainage of the abscess, which was revealed in the abdominal wall on computed tomography. Colonoscopy showed a type 2 tumor at the sigmoid colon with a stenosis, which was diagnosed as well-differentiated adenocarcinoma based on the pathological examination. We performed a sigmoidectomy with abdominal wall resection after bowel decompression via the colorectal tube. Pathological findings were: S, circ, type 2, 70×50mm, tub1>muc, pT3, pN0, H0, P0, M0, and pStage Ⅱ; no cancer cells were identified in the abdominal wall.

Colorectal cancer should be considered in patients with unknown abdominal wall abscesses. Furthermore, surgery should be taken into consideration after abscess drainage, to improve inflammation.

A 59-year-old woman having initially presented to a clinic with abdominal distension was referred to the gynecology department in our hospital for the treatment of a pelvic tumor Abdominal contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lobulated pelvic tumor measuring 20cm in size that showed internal heterogeneous enhancement, indicating necrotic or cystic lesions. The submucosal vein of the sigmoid colon and the inferior mesenteric vein were both markedly dilated. A diagnosis of a pelvic tumor originating from the mesentery of the sigmoid colon was made, and the tumor was surgically removed. Gross inspection of the specimen revealed a solid multinodular tumor, 20×15×7cm in size and weighing 1,740g. Histologically, the tumor was composed of spindle-shaped cells with vessel growth, which were immunohistochemically positive for CD34, vimentin, and Bcl-2, and negative for c-kit, desmin, and S-100. The final diagnosis was that of a solitary fibrous tumor (SFT). The patient has been disease-free for 15 months following the surgery.

SFT originating from the mesentery of the sigmoid colon and rectum is a rare tumor, with only 31 cases, including our own, reported in the literature to date. Although the incidence of malignant SFT is low, complete resection and long-term follow-up is very important.

A woman in her seventies, who was experiencing bloody anal discharge, came to our hospital. Lower endoscopy showed a 30 mm 0-I lesion in the lower rectum. The tumor progressed to the anal side beyond the anal canal edge. In view of the observed bleeding from the venous plexus, the patient underwent combination surgery, consisting of endoscopic submucosal dissection (ESD) and transanal resection (TAR). Afterwards, there was little bleeding, and the horizon and vertical margins were negative.

Based on the success of combination surgery to treat this lower rectal tumor, which had progressed to the anal side beyond the anal canal edge, we predict that the combination of ESD and TAR may enable tumors to be resected more safely and completely.

Primary neuroendocrine tumor of liver is an extremely rare disease. We encountered two cases of hepatic neuroendocrine tumor. Case 1: A 65-year-old male was given a diagnosis of liver cyst adenoma. Partial hepatectomy was performed. Immunohistochemically, the final diagnosis was primary hepatic neuroendcrine tumor G2 (World Health Organization classification, 2010). Case2: A 72-year-old male patient was given hepatocellular carcinoma. Laparoscopic partial hepatectomy was performed. Immunohistochemically, the final diagnosis was primary hepatic neuroendcrine carcinoma G3 (World Health Organization classification, 2010). Here, we report two cases of rare primary hepatic neuroendocrine tumor together with a review of the literature.

Liver metastasis of carcinoma of the papilla of Vater related with poor prognosis and contraindication of surgery.

A woman aged 55 years was referred to our clinic for the follow-up of a adenoma of the papilla of Vater and an elevation of CA19-9. 5cm hepatic mass is detected at S5. She had undergone partial hepatctomy (S5) and the tumor was considered metastatic adenocarcinoma.

We found the polyp progression from dysplasia to carcinoma, and performed open pancreaticoduodenectomy with D2 lymph node dissection (SM, N0, H1 Stage Ⅳ). After the first surgery, she received TS-1 adjuvant chemotherapy.

6 months after the first surgery, three liver metastasis was detected. Chemotherapy was started and complete response. The clinical effects was complete response.

Single liver metastasis was detected at 2 years and 4 months, 5 years and 4 months , 8 years and 8 months after the first surgery. So we had perfomed repeat hepatetomy for three times because it was the single metastasis, and there were no extrahepatic metastasis.

She is alive without a recurrence for 13years and 4months after the first surgery.

An 81-year-old man was referred to our department for an 5-cm tumor occupying the lateral segment of the liver by abdominal ultrasonography at a medical check-up. Further work-up demonstrated dilatation of the intrahepatic bile ducts peripheral to the tumor, no enlarged hepatic hilar lymph nodes and no distant metastatic lesions. Under the suspicion of intrahepatic cholangiocarcinoma of mass-forming type, left hepatectomy was performed.

His postoperative course was uneventful and the patient was discharged on the 8th postoperative day. Macroscopically, the tumor was solid 5cm in size with obscure border and yellowish white. Pathological diagnosis was hepatic IPT.

For IRT, conservative treatment or careful follow-up is the first choice. However, surgery could be considered in case ①symptoms persist, ②major organs are compressed by the tumor, or ③the definitive diagnosis cannot be made (malignancy cannot be ruled out). However, there is no specific findings on imaging studies. In addition, it is difficult to differentiate hepatic IPT from cancer, because the contrast pattern of IPT varies according to time of the inflammation. Hepatic IPT should be included in the differential diagnosis of a liver tumor.

We report a rare case of a bleeding remnant pancreatic cancer. An 83-year-old woman was admitted to our hospital with anemia and melena. She had a past medical history of pancreatodenectomy for cancer of the ampulla of Vater 8 years earlier and a right hemicolectomy for colon cancer 2 years earlier. The cancers of the ampulla of Vater and colon were histologically diagnosed as well- and moderately-differentiated tubular adenocarcinomas, respectively (Stage ⅠA and Stage ⅡB). Abdominal CT showed a tumor on the main pancreatic duct of the remnant pancreas. Double-balloon enteroscopy revealed a bleeding tumor at the anastomotic site of the pancreaticojejunostomy. The biopsied specimen was histologically diagnosed as a well-differentiated tubular adenocarcinoma showing morphological features similar to the cancer of the ampulla of Vater. In lieu of surgery, which the patient refused, we performed transcatheter arterial embolization to control the bleeding. The surgery was successful and the patient was discharged 6 days after embolization. According to the literature, 6 Japanese patients with remnant pancreatic cancer after pancreatodenectomy for cancer of the papilla of vater went on to develop pancreatic cancer 5 years or later after the first operation. Long-term follow-up of patients undergoing pancreatodenectomy is recommended.

A case of bilateral simple testicular cysts is reported. A 74-year-old male patient on hemodialysis was found to have bilateral simple testicular cysts on CT performed for screening of blood in stool and low abdominal pain. Because of characteristic ultrasonic findings of simple testicular cyst, such as hypoechoic cyst with regular wall and no echogenicity, negative tumor markers and negative for metastatic tumor, a diagnosis of simple testicular cyst was made, which was followed up without surgery. We reported the present case because including this case, there have only been a total of 24 reported cases of simple testicular cyst in Japan. The differential diagnosis between other cysts in testes is discussed.

Although simple renal cysts are often found during routine health checkups, spontaneous disappearance of the cysts is rare. A 57-year-old male patient was referred to our department because of right renal cyst found by ultrasound during his annual health checkup. CT showed a simple renal cyst, 2.5cm×2.3cm in size, at the middle pole of the right kidney, and patient had been followed yearly by ultrasound. On the follow-up ultrasound performed 8 years after the diagnosis, the cyst was not detected. The following CT revealed the disappearance of the cyst, leaving only minute residual tissue of the cyst wall. As the patient has been asymptomatic over the past year after the last examination when the cyst was noted by ultrasound, the cyst was considered to have disappeared spontaneously. We reported the present case because including this case, there has only been a total of 3 reported cases of spontaneous disappearance of simple renal cyst in Japan, and because we thought it is worthwhile to let not only urologist but surgeon know this phenomenon.

An 80-year-old man underwent laparoscopic assisted total gastrectomy for early gastric cancer, and the pathological stage was T1aN0M0 Stage IA. Follow-up CT scan, done 26 months after primary surgery, showed 75mm mass which was suspected to be intra-abdominal sarcoma in pelvic cavity. At laparotomy, the tumor had smooth surface and located at mesenterium, and we could completely resect the tumor combined with partial ileum. The postoperative immunohistochemical study showed positive staining of nuclear β-catenin expression. Therefore, we diagnosed the tumor as a desmoid tumor. Although desmoid tumors are frequently associated with episodes of antecedent trauma and surgical intervention, the relationship between desmoid tumors and laparoscopic surgery is unknown. After abdominal surgery, it is important to observe carefully with the possibility of occurrence of intra-abdominal desmoid tumor in mind.

We herein report a case of adult jejunal mesenteric lymphangioma resected via single incision laparoscopically. A 40-year-old woman developed abdominal pain. Computed tomography and magnetic resonance imaging showed a cystic lesion about 7cm in diameter in the jejunal mesentery. We diagnosed her with jejunal mesenteric lymphangioma. Considering risks such as volvulus, we performed single-incision laparoscopic excision. We conducted partial resection of the small bowel including the lesion. Lymphangioma is a disease that often occurs in young people and is relatively rare in adult mesentery. There have been no previous cases in which it was resected under a single incision laparoscopically. We discuss previous studies and report the outcomes of our case.

An 86-year-old woman with chronic rheumatoid arthritis was transferred to the Kawaguchi Municipal Medical Center due to acute abdomen with free air. The patient was suspected to have panperitonitis caused by diverticular perforation of the sigmoid colon based on the findings of contrast-enhanced abdominal computed tomography (CT). The CT findings showed massive ascites and free air with thickened sigmoid colon wall. Emergent laparotomy revealed perforation at the uterine fundus with accumulated pus. However, no perforated sites were present of the sigmoid colon. Subsequently, abdominal partial hysterectomy and bilateral salpingo-oophorectomy were performed. The patient received intensive care after surgery because of septic shock. The patientʼs general condition eventually became stable. Generally, it is rare frequency for pyometra to progress peritonitis caused by perforation. In addition, free air is commonly associated with gastrointestinal perforation. Such situations sometimes can induce delayed diagnosis and fatal conditions. Therefore, we need to consider perforative pyometra as a differential diagnosis in aged women with free air, especially in the case of long-term steroid user.

Background: A concurrent underlying infection must be considered when immunocompromised patients present with multiple muscle abscesses. Disseminated nocardiosis is a rare infectious disorder that may disseminate to the muscle and other tissues, including the central nervous system. Here we describe the case and management of an immunocompromised patient who presented with disseminated nocardiosis and multiple muscle abscesses. In such cases, the by surgical drainage of muscle abscesses and subsequent early diagnosis and identification of the causative organism may facilitate appropriate treatment.

Case Presentation

A 70-year-old woman was admitted with general fatigue and left lower abdominal and hip pain. She had a 10-year history of treatment with azathioprine and prednisolone for AQP4-antibody-related neuromyelitis optica spectrum disorders. Although her vital signs were normal, laboratory data indicated a C-reactive protein concentration of 22.9mg/dL, and computed tomography revealed a coin-sized lesion in her right lung and abscesses in the left abdominal oblique and gluteal muscles. A blood culture was positive for multidrug-resistant Staphylococcus epidermidis. We surgically drained the multilocular abscesses and conducted a bacteriological evaluation, which revealed the presence of Nocardia spp. The patient recovered and was given a plan of sulfamethoxazole–trimethoprim therapy for 6 months.

Conclusions

Regardless of the positive result of blood culture consistent with multiple abscess formation, we should consider for disseminated nocardiosis in immunocompromised patients. To prevent central nervous infection and relapse, aggressive bacteriological evaluation and appropriate antibiotics therapy may be essential.

Background

The component separation technique (CST) allows reconstruction of large ventral defects, which may be beneficial under contaminated conditions, but the rate of surgical site infection is relatively high. Negative pressure wound therapy (NPWT) potentially offers better wound closure in such conditions.

We present a patient having multiple complex incisional hernias with parastomal hernias who underwent ventral herniorrhaphy with the combined use of CST and NPWT.

Case presentation

This 78-year-old woman had a history of Hartmannʼs operation 5 years previously. She was complicated with median incisional hernia and parastomal hernia. We performed herniorrhaphy with stoma closure simultaneously, with CST and NPWT. After colon anastomosis and simple suture repair of the parastomal hernias, her median abdominal wall defects were assessed as 180mm at upper and 150mm at lower abdomen. Although fascial closure was completed by CST with some tension, dead space remained under the skin and subcutaneous fat layer. Therefore, we combined NPWT on the fascial plane. There was no severe surgical site infection and there was no evidence of hernia recurrence for a year after the operation.

Conclusions

CST followed by NPWT may be an effective alternative for repair of huge and complex incisional hernias, particularly in contaminated conditions.

A woman in her 70ʼ visited a nearby clinic with the complaint of a bulge in the left inguinal region without pain. The mass could be reduced easily, and the patient was referred to our department with the diagnosis of inguinal hernia. Although the inguinal mass could not be reduced at the first visit, as the computed tomographic (CT) findings were suggestive of the presence of an edematous canal of Nuck, and not a segment of the intestine in the mass, we performed elective surgery. The surgical diagnosis was femoral hernia, and the herniated structure was the left fallopian tube. Salpingectomy was performed for incarceration of the fallopian tube. We repaired the hernia by inserting a plug into the femoral ring. Currently, at 5 months after the surgery, the patient remains without recurrence of the hernia. We report a case of femoral hernia, in which the herniated structure was the fallopian tube.