Introduction : The purpose of the present study was to determine the factors to predict recurrence in patients with acute appendicitis undergoing conservative therapy. Materials and methods : Between 2002 and 2006, we reviewed 135 patients with acute appendicitis in whom conservative treatment was effective. We studied recurrence rates of acute appendicitis in those patients after conservative treatment and compared clinical features and findings on CT scan between recurrent and non-recurrent patients. Results : Recurrent right lower quadrant abdominal pain developed in 33 of 101 patients. Thirty patients (29.7%) were given diagnoses of recurrent acute appendicitis at medical institutions, and 18 patients (17.8%) underwent operation. Rate of recurrent appendicitis was greater in young patients (under 18 years old) and in patients having high white blood cell (over 13,500 /μl) at the onset of appendicitis. Ascites, inflammatory change in the fat surrounding the appendix, and an appendix diameter of over 9 mm on CT scan at the onset of appendicitis increased the risk of recurrence, Incarcerated fecal stone in the appendix was not related to the recurrence rate. Summary : The following were considered as risk factors for recurrent acute appendicitis; young patients less than 18 years old, patients with elevated white blood cell counts, and patients with a swollen appendix with a diameter of greater than 9 mm. We should take these facts into consideration when we treat patients with acute appendicitis.

View full abstract

Introduction : There have been some reports on cases of hepatic portal-venous gas with mild symptoms that were detected using recently-developed diagnostic imaging techniques. Among these patients, for whom conservative treatment is provided, the prognosis of this disease is sometimes good. In actual emergency medical care of these patients, however, it is not easy to determine whether to implement emergency laparotomy or conservative treatment. In this study, we examined the indications for conservative treatment for cases of hepatic portal-venous gas based on blood biochemical findings obtained upon the initial visit. Methods : The subjects were 14 patients with hepatic portal-venous gas who were treated at our hospital. We compared Group A, in which conservative treatment could not be provided because of confirmed intestinal necrosis, with Group B, which consented of other cases for which conservative treatment was provided. Results : In the comparison between Groups A and B, the CRP levels were increased significantly in Group A, while the BE was significantly lower in Group B. Conclusion : Patients who exhibit BE of -3.0 mmol/l or lower, or CRP of 15 mg/dl or higher must undergo emergency abdominal surgery due to the possibility of intestinal necrosis.

View full abstract

A 74-year-old man with cancer of the mid-thoracic esophagus had a subtotal esophagectomy. Three weeks later, he developed vomiting and abdominal distension. Abdominal CT revealed intussusception of the small intestine, so he underwent surgery for ileus. Intussusception due to a 4×3 cm tumor in the small intestine 2 m in an oral direction from the ileal ending. Another intestinal tumor 2 cm in diameter was recognized 70 cm in an oral direction from the ileal ending. Partial small bowel resection was performed at the two sites. They were histopathologically diagnosed as intestinal metastases from the esophageal cancer. Esophageal carcinoma with intestinal metastasis is rare. In fact, such a case, with intussusception of the small intestine, has never been reported in Japan. We report the case and some related literature.

View full abstract

Esophageal LELC is extremely rare. Here we report a case of esophageal LELC showing partial histological response to chemotherapy. A male aged 69 had been self-aware of dysphagia, and then by upper GI esophagoscopy executed, a type 1 tumor in the thoracic part of esophagus was detected at a nearby hospital before introduced to our hospital. The third biopsy gave a suspected LELC, while esophagogram, CT, and PET-CT examination showed that the patient had a 4 cm scaled type 1 tumor in the thoracic part of lower esophagus and revealed lymphogenous metastases suspected in the cardiac part of stomach (No. 1), the lesser curvature of stomach (No. 3), and the thoracic part of middle pleuro-esophagus (No. 108), which diagnosed the patient as having a T3N2M0 Stage III of esophageal carcinoma. Through two courses of standard FP therapies thus executed, tumor shrinkage (PR) was evaluated, followed by subtotal esophagectomy with three field lymph node dissection executed. Sampled specimens revealed the metastases to two lymph nodes (No. 1, 3), but showed remarkable shrinkage of the primary lesion and thus, a histophathological effect of the treatment was judged as Grade 2. After post-operative adjuvant chemotherapy, the patient has been subjected to the follow-up as an outpatient and remained recurrence-free at present.

View full abstract

A 69-year-old woman was given a diagnosis of esophageal cancer and underwent surgery. We resected the abdominal esophagus, part of the stomach and gallbladder. Histopathology of the resected specimen was compatible with the neuroendocrine cell carcinoma. The tumor was positive for cromogranin A, CD56 and synaptophysin.Progression according to TNM classification was pT1a, pN1, M0, and pStage. This is the first report on a patient with neuroendocrine cell carcinoma in Barrett's esophagus.

View full abstract

We report a case of a 100-year-old woman successfully treated for upside down stomach with laparoscopic surgery. She was admitted to our hospital because of hematemesis accompanied with acute respiratory and renal failure. Chest X-ray showed the effusion in the whole left pleural cavity and atelectasis in the left lung lobe. Abdominal computed tomography revealed the entire gastric incarceration into the left pleural cavity with esophageal hiatal hernia and with gastric volvulus. She was diagnosed as upside down stomach caused by combined esophageal hiatal hernia with organoaxial gastric volvulus, and underwent laparoscopic surgery because her general condition was so stable that she could stand the operation. After the incarcerated stomach and greater omentum were easily reduced into her abdominal cavity, the hiatus could be directly closed, and then Toupet fundoplication was performed to prevent reflux esophagitis. Postoperative course was uneventful, and she was discharged on the 13th day after the operation.

View full abstract

We report a case of angiomyolipoma, rapidly growing and mimicking an inflammatory pseudo-tumor. A 29-year-old man transferred to our hospital complaining of fever and general fatigue without improvement after antibiotic and non-steroidal anti-inflammatory drug therapy. He suffered from high fever over 38°C without any infectious symptoms. Blood tests revealed inflammatory response without specific abnormalities. Two tumors, S8: 7 cm and S6: 1 cm in diameter, were observed, and CT showed these tumors to be growing. MRI revealed a filling defect in hepatocyte imaging, and diffusion attenuation in diffusion image. PET-CT revealed dense accumulation. Since the tumor was histologically diagnosed as angiomyolipoma and clinically suspected to be malignant, right hepatectomy was performed. The resected specimen was a spindle cell tumor with inflammatory cell infiltration. An immunohistochemical study showed positive staining of human melanoma black-45, CD31, vimentin, and α-smooth muscle actin.

View full abstract

Biliary anastomotic strictures are one of the most significant postoperative complications after living donor liver transplantations (LDLT), which develop in about 10-30% of recipients. Various modalities have been reported to treat these complications with an acceptable success rate. Herein, we present a case of complete anastomotic obstruction of hepaticojejunostomy, for which a successful magnetic compression anastomosis (MCA) was performed. The patient was a 56-year-old man who was given a diagnosis of biliary anastomotic strictures 9 months after LDLT. Conservative treatment, including percutaneous transhepatic biliary drainage (PTBD), was initially undertaken, however, recanalization of the bile duct anastomosis could not be obtained. An MCA was performed 3 months after the initial PTBD, which resulted in a success. In conclusion, MCA is a safe and very effective method to treat complete anastomotic strictures after LDLT.

View full abstract

Case 1: A 62-year-old woman was given a diagnosis of common bile duct stone. Magnetic resonance cholangiopancreatography (MRCP) showed the aberrant posterior hepatic duct joining the cystic duct. After endoscopic choledocolithotomy, we performed laparoscopic cholecystectomy (LC), preserving the aberrant posterior hepatic duct. On MRCP after the LC one month later, there was no stenosis of the posterior hepatic duct or remnant cystic duct. Case 2: A 63-year-old woman was admitted for fever and icterus. Acute cholangitis was diagnosed. Direct cholangiography using endoscopic nasobiliary drainage tube revealed that the aberrant posterior hepatic duct joined the infundibulum of the gallbladder, and a calculus was present in the cystic duct. We conducted open cholecystectomy with reconstruction of the posterior hepatic duct. Discussion: An aberrant hepatic duct can be detected by paying attention to the infraportal posterior hepatic duct, because most of the aberrant hepatic ducts joining the gallbladder are infraportal posterior hepatic ducts. In this type of joining with the cystic duct, LC can be performed safely by appropriate manual skill; however, depending on the type of joining with the infundibulum, body or fundus of the gallbladder, the reconstruction of the post hepatic duct should be performed after whole gallbladder resection.

View full abstract

We present a case of retroperitoneal follicular dendritic cell sarcoma. Abdominal ultrasound revealed retroperitoneal tumor in a 72-year-old woman. Contrast-enhanced computed tomography (CT) showed a well-demarcated mass in the retroperitoneal space, necessitating surgery for suspected retroperitoneal soft-tissue malignancy. The resected specimen was immunohistochemically confirmed to be of follicular dendritic cell origin. Extracapsular invasion and lymph node metastasis were also seen, with the resected tumor proving histopathologically to be follicular dendritic cell sarcoma (FDCS). FDCS is a rare malignant tumor originating in lymphoid tissue. FDCS is definitively diagnosed by immunohistochemical examination using specific markers.

View full abstract

We report a rare case of metastatic anaplastic thyroid carcinoma to the small intestine causing intussusception. A 41-year-old man admitted to our hospital complaining abdominal pain and general fatigue. Abdominal ultrasonography and computed tomography represented target signs in the abdominal cavity, which was diagnosed as intussusception of the small bowel. We conducted an emergency laparoscopic operation. Repositioning the intussusception, necessitating partial small bowel resection was performed for the two sites of the small bowel. Tumors were observed in the jejunum 50 cm distal to the Treitz ligament and in the ileum 200 cm proximal to the ileocaecal valve. They were histopathologically confirmed as anaplastic carcinoma that metastasized from thyroid carcinoma.

View full abstract

The patient was a 44-year-old woman. She was admitted to our hospital with a complaint of right lower abdominal pain and fever. Computed tomography showed a 35 mm diverticular structure in the lower abdominal region with air-fluid level, accompanied by a fecal stone. Free gas was seen in the abdominal cavity and ascites was confirmed in the pelvis. Blood tests demonstrated severe inflammation. The patient was given a diagnosis of diffuse peritonitis due to perforated diverticulitis of the small intestine, and underwent emergency operation. Ileal duplication was seen at the mesenteric side 50 cm oral from Bauhin's valve. It was 10 cm long and communicated with the ileum. The blind sac was perforated. Wedge resection of the ileum was performed, including the ileal duplication. Histopathological examination revealed the muscular layer and the mucosal lining that were continuous with the ileum. The blind sac developed severe active inflammation thought to be caused by perforation due to fecal stone impaction. In Japan, there are only six reported cases of ileal duplication due to perforation in adults, including our case. Ileal duplication due to perforation in adults is extremely rare but must be kept in mind as a differential diagnosis of the acute abdomen in adults.

View full abstract

A 29-year-old man underwent interval laparoscopic appendectomy. The stump of the appendix was invaginated by purse string suture. He was discharged on the 1^st postoperative day; however, on the 4^th postoperative day, he returned with a stomachache. Abdominal CT scan revealed that the reason of his abdominal pain was intussusception of the right side colon. An enema with gastrographine was given and we achieved reposition. This image showed an edema shaped like a tumor around the stump of the appendix. This pseudotumor produced an intussusception. Burying the stump of the appendix is the common procedure for appendectomy. However, the therapy strategy for acute appendicitis at present varies. The operative method as well as planning of therapy has many variations. This raises the question of the most appropriate strategy for dealing with the stump of the appendix.

View full abstract

We report an extremely rare case of ulcerative colitis (UC) with huge pseudopolyps which appeared like a brain in the cecum and ascending colon. A 24-year-old woman with UC was treated with medical treatments including leukocytapheresis (LCAP). During those treatments, A pseudopolyp lesion which extended from the cecum to the ascending colon was found by lower gastrointestinal tract examinations. The patient's blood tests showed a slight elevation of C-reactive protein (CRP) and CEA on admission. The patient underwent laparoscopic-assisted total colectomy and ileo-pouch anal anastomosis (IPAA). The resected specimen showed 10×7 cm of the pseudopolyp in the ascending colon and the cecum, which resembled a gyrus, and inflammatory polyps in the transverse and descending colon. Histopathological findings were consistent with a UC pattern: erosion, crypt abscess, cryptitis and deformity of crypts in the tumor lesion and other colon tissue. There were no findings of granuloma and/or neoplastic change. After surgery, the patient did not have UC or UC-associated symptoms. Most patients with UC are treated by medical treatment, but some patients still need surgical treatment. Surgical treatment yielded a good prognosis and QOL in this case.

View full abstract

Retrograde intussusception of the colon is a rare disease in adults. This paper describes our recent experience with a case of retrograde intussusception due to sigmoid colon tumor in light of the related literature. A 89-year old woman was admitted to our hospital because of abdominal pain and distension. The Coronal re-construction view acquired by abdominal computed tomography clearly showed retrograde invagination of the sigmoid colon into the transverse colon. Judging from this information, we diagnosed retrograde intussusception of the sigmoid colon, and laparotomy was immediately performed. The sigmoid colon was firmly invaginated into the transverse colon retrogradely and manual repositioning was impossible, so we performed left hemi-colectomy. The resected specimen showed a large-sized pedunculated polyp (5.5 cm) at the top of the intussusception. Microscopic examination clarified that the polyp was a tubulovillous adenoma. Computed tomography is useful in the diagnosis of retrograde intussusception of the colon. Because almost all cases of retrograde colonic intussusception in adults are due to tumor that could be malignant, it is important to perform adequate colon resection including lymph node dissection in surgical treatment.

View full abstract

We present a rare case of pseudo-Meigs' syndrome caused by metachronous ovarian metastasis from sigmoid colon cancer. A 34-year-old woman underwent sigmoidectomy with D2 lymph node dissection for sigmoid colon cancer in June 2007. Two years and 2 months later, she was admitted to our hospital with a complaint of abdominal distension. A huge mass was palpable in the hypogastric lesion. Preoperative examinations revealed a huge left ovarian tumor, a large amount of ascites and right pleural effusion. Pelvic exenteration without urinary bladder was performed. Histological examination showed well differentiated adenocarcinoma, and immunohistochemical analysis with cytokeratin revealed the ovarian tumor was a metastasis from the colon cancer. The postoperative course was uneventful. After the operation, pleural effusion decreased remarkably. The final diagnosis was pseudo-Meigs' syndrome caused by ovarian metastasis from sigmoid colon cancer. The patient is still alive without any evidence of recurrence 10 months postoperatively.

View full abstract

A 49-year-old woman was admitted to the hospital due to melena. A dark-colored type 1 tumor was observed in the sigmoid colon on colonoscopy, and no metastases from the skin or other internal organs were observed; thus, the diagnosis was primary malignant melanoma (pSS, cH0, cP0, pN2; fStage IIIb) of the sigmoid colon. Lymph node metastasis was observed 5 months after surgery. DAC-Tam (dacarbazine [DTIC], nimustine [ACNU], cisplatin, and tamoxifen) chemotherapy was given; however, subsequent metastasis to the breast and brain occurred, and the patient died 11 months after surgery. Only 15 cases of primary malignant melanoma in the colon have been reported in the literature since 1938. No difference in age of incidence exists between Japan versus Europe and the United States, and it is most frequently observed in the left colon. Current treatment options do not appear to be effective, although surgery is thought to be useful in the treatment of malignant melanoma of the rectum and anus. Reports of malignant melanoma of the colon are few, and surgical outcomes are uncertain.

View full abstract

A 53-year-old woman was diagnosed with rectal cancer (RS). Low anterior resection (D3 lymph node dissection) was performed in March 2006. Three metastases were observed in the lymph nodes. The tumor was diagnosed pathologically moderately differentiated adenocarcinoma, the depth of invasion of se, H0, P0, n1, stage IIIa. Adjuvant chemotherapy with oral anticancer drugs was given for 6 months. CT was performed in October 2006. The CT images revealed a tumor mass with unclear margins in the left kidney. MRI showed the tumor with the iso signal intensity in T1 weighted images and low intensity in T2 weighted images, leading to suspicion of either atypical renal cell cancer or metastatic tumor mass. Nephrectomy was performed in November. Heterocysts forming large and small alveolars in the area of marked necrosis and proliferating were observed and a part of them formed glandular lumen. Since immunohistological staining was negative for CK7 and positive for CK20 and CDX2, the tumor was diagnosed as metastasis of rectal cancer. Chemotherapy with FOLFOX6 was given for postoperative 6 months. She has relapse-free survival of 53 months after the initial surgery.

View full abstract

We report a very rare case of presacral myelolipoma discovered incidentally by preoperative examination of the sigmoid colon cancer, which we resected simultaneously with resection of another cancer. A 70-year-old man seen for melena was admitted to our hospital and given a diagnosis of sigmoid colon cancer. In the preoperative routine checkup, computed tomography revealed a round and heterogonous tumor located in the presacral space. Magnetic resonance imaging also revealed a round heterogonous tumor in the same place. Based on a preoperative diagnosis of presacral liposarcoma, we conducted sigmoidectomy and resection of the presacral tumor. The presacral mass, 4 cm in diameter, was encapsulated and solid, and was strongly attached to the surface of the sacrum, but there was no invasion. Microscopically, the adipose tissue and bone marrow elements, megakaryocytes, normoblasts, and myelocytic cells were noted. There were no malignant findings and myelolipoma was diagnosed. Myelolipoma is a benign tumor which is usually found in an adrenal gland and is rarely found in extraadrenal areas, including the presacral space. When we examined the fat-containing presacral mass, differentiation of liposarcoma and myelolipoma was quite difficult, so it can be said that surgical resection is efficient if lipoma cannot be diagnosed.

View full abstract

We report a rare case of late infection of Composix Kugel patch (CKP), discuss procedures to prevent intestinal adhesion to the patch and review the relevant literature. A 75-year-old woman who had undergone abdominal incisional hernia repair with CKP in another hospital 3 years previously was admitted to our hospital suffering from late mesh infection. Drainage and antibiotics therapy were not effective, so surgical removal of the mesh was required. Intestinal adhesion to the circularly exposed polypropylene mesh caused by turnover of the polytetrafluoroethylene sheet of CKP was observed in the operation. We removed the CKP and localized abscess between the mesh and intestines, and directly sutured the abdominal wall to close the defect. No complication was observed after the operation. We thought that there were some problems while fixing the CKP in this case, and it is necessary to be careful about fixing it.

View full abstract

A pseudo cyst of the retroperitoneum is rare; only 13 cases have been reported in Japan to date. A 37-year-old man suffered from right upper abdominal pain. He had a history of multiple trauma caused by a traffic accident 10 years before. Abdominal CT scan revealed a cystic tumor 10 cm in size in the right upper retroperitoneal space, and the gallbladder, duodenum and pancreas head were pushed to the frontal side. We performed total resection of the cystic tumor. The tumor was 10×11×7.8 cm in size, including lemon yellow serous fluid. Pathologically, the wall of the cystic tumor was constituted with hyperplasia of collagenous fiber and cellular infiltration of lymphocyte. No epithelial cells were found. We diagnosed the tumor as a retroperitoneal pseudo cyst.

View full abstract

Gastric tube-bronchial fistula is an unusual complication after esophagectomy for cancer. Between and, We encountered five cases of gastric tube-bronchial fistula. The mean age of subjects, consisting of 4 men and 1 woman, was 60.4 years. All subjects received subtotal esophagectomy for esophageal cancer with reconstruction of the gastric tube through the posterior mediastinal route. The causes were gastric tube necrosis in 3 cases, anastomotic leak in 1 case and gastric tube ulcer in 1 case. Symptoms occurred between 16 to 630 days after the initial operation. The sites of fistulas in the tracheal side were high trachea for the anastomotic leak case, low trachea for gastric tube necrosis cases, and right bronchus for the gastric tube ulcer case. Therefore, the causes varied for the different sites of fistulas in the trachea. Operations were performed in 4 cases while conservative management was possible in 1 case. We needed resection of the gastric tube and closure of the fistula with transposition of a pedicled muscle flap. However, it was possible for limited cases such as small fistula to be managed conservatively. Gastric tube-bronchial fistula is a fatal complication, and therefore diagnosis and rapid treatment are essential.

View full abstract