Background: Restorative proctocolectomy has become a standard surgical procedure for patients with ulcerative colitis (UC), including pediatric patients. Children with UC have been reported to have special clinical features, such as adverse effects of corticosteroid therapy, disease severity, and growth retardation. Patients' perioperative status was investigated to evaluate the proper timing of surgery in pediatric UC patients. Methods: The medical records of 30 children with UC who underwent restorative proctocolectomy between 1984 and December 2008 were retrospectively reviewed. Results: The median cumulative dose of prednisolone was 181.5 (29.3-1,913.5)mg/kg, and the median dose of prednisolone just before surgery was 0.7 (0.1-1.8)mg/kg/day. Preoperative growth retardation was seen in 4 patients, while bone mineral density was quite decreased in 60% of patients. There was no relationship between bone abnormalities and corticosteroids. Patients with growth retardation had a younger onset and were given higher total doses of corticosteroids than those without growth retardation. The age at onset of UC and total corticosteroids given were 12 (7-14)years old and 1,228 (210-1,913.5)mg/kg with growth retardation and 14 (11-15)years old and 151.8 (29.3-1,020.9)mg/kg without growth retardation. Late complications that occurred within the 8.5 (0.2-20.3)years of follow-up included pouchitis in 6 and anal fistula in 5 patients. Four patients with an intractable anal fistula required re-ileostomy, including 2 ileal pouch amputations. The pouch failures were seen in 4/29 (13.8%) pediatric patient with UC, though in most patients (18/21), bowel habit was less than 7 times per day without soiling. Conclusion: When considering growth retardation, the indication for surgery in pediatric UC should be determined before epiphyseal line has disappeared. In addition, it may have been determined with using a criterion of 200mg/kg of total corticosteroids given. Proper evaluation of late postoperative complications and pouch functional rate needs further consideration.

View full abstract

A 54-year-old asymptomatic man diagnosed with submucosal tumor-like isolated gastric tuberculosis was found in an annual barium swallow checkup to have a gastric submucosal tumor. Gastrointestinal fiberscopy and computed tomography (CT) showed a 3cm submucosal gastric tumor at the greater mid-gastric curvature. The tumor's swift growth to 45mm in only 4 months and swollen regional lymph nodes necessitated distal gastrectomy with lymphadenectomy due to potential malignancy. Histological examination showed epithelioid granuloma with Langhans giant cells in the resected tumor and lymph nodes. To determine if the man had tuberculosis, we cultured gastric juice and sputum postoperatively, finding only the gastric juice to be positive for Mycobacterium tuberculosis. Given the possibility of remaining tubercular lesions, the man was administered antituberculosis medication for six months postoperatively. He remains alive and recurrence-free in the 3 years since surgery.

View full abstract

Juxtapapillary duodenal diverticula (JPDD) is an etiologic factor in biliopancreatic disorder designated by Lemmel syndrome, which is reported to trigger cholangitis rather than acute pancreatitis. A 68-year-old woman with a history of relapsing cholangitis seen for acute nectrotizing pancreatitis was given intensive care. After her pancreatitis improved, she underwent gastrointestinal endoscopic study, which showed the papilla of Vater lying between two large JPDD. Assuming that JPDD played a causative role in both relapsing cholangitis and acute pancreatitis, we conducted endoscopic sphincterotomy. Neither condition has recurred in outpatient follow-up in 13 months since her discharge from the hospital. This is, to the best of our knowledge, the second case of Lemmel syndrome inducing severe acute necrotizing pancreatitis. Endoscopic sphincterotomy should be considered in symptomatic JPDD as a minimally invasive therapeutic approach to prevent biliopancreatic complications including cholangitis and acute pancreatitis.

View full abstract

Hepatic epithelioid hemangioendothelioma (EHE), a rarely malignant non epithelial tumor, is often nonresectable, when found, due to multiple bilateral hepatic lobes-hence the few reports of liver resection. We report such a resection in EHE with focal nodular hyperplasia (FNH) and hepatic cavernous hemangioma (HCH). A normally healthy 44-year-old woman, taking oral contraceptives for many years in October 2008, was found in a medical checkup to have liver dysfunction. Abdominal ultrasonography (US) indicated multiple tumors, but computed tomography (CT) and magnetic resonance imaging (MRI) results were inconclusive. Liver biopsy indicated EHE and she was referred for treatment potentially including liver transplantation. Right hepatic lobectomy and partial S2, 3, and 4 resection were done in February 2009. Histopathologically, findings included EHE, HCH, and FNH. In so far as a search of the literature indicated, only one other such case has been reported.

View full abstract

We report a case of rare long-term survival in abdominal wall hepatocellular carcinoma (HCC) metastasis. A 64-year-old man undergoing the laparoscopic microwave coagulation for HCC of the right inferior posterior segment was found three years later to have a mass at a site different from the surgical scar. The new mass was diagnosed as solitary abdominal wall HCC metastasis and resected. The elevation of tumor maker PIVKA II 7 months later led to discovery of a mass at the same site by computed tomography (CT), diagnosed as a relapse of solitary abdominal wall metastasis and necessitating reresection of the mass and a rib 9. Similar PIVKA II elevation 8 months later led to diagnosis of a mass as recurrent solitary abdominal wall metastasis. Despite radiation therapy, local solitary abdominal wall metastasis recurred at the same site 5 months later, necessitating resection, after which no recurrence has been seen as of this writing.

View full abstract

A 63-year-old man admitted for epigastralgia and jaundice was found in laboratory data to have elevated serum bilirubin. Cholecystocholedocholithiasis was diagnosed preoperatively based on abdominal X-ray, computed tomography (CT) and endoscopic retrograde cholangiopancreato-graphy (ERCP). After endoscopic nasobiliary drainage to decrease serum bilirubin, cholecystectomy and choledocholithotomy were conducted through the cystic duct. The gallbladder, containing slimy and solid limy bile, had an impacted calcium bilirubinate stone 1cm in diameter at the neck. Material removed from the bile duct was rubbery limy bile containing 93% calcium carbonate but no gallstone. Cystic duct obstruction is causative in limy bile formation, but no case has, to our knowledge, been reported of limy bile produced by a calcium bilirubinate stone and obstructive jaundice induced by limy bile alone. The impacted calcium bilirubinate stone appeared to induce limy bile in the gallbladder and limy bile moving from the gallbladder to the bile duct relieved the cystic duct obstruction causing obstructive jaundice.

View full abstract

Biliary peritonitis due to transudation through the gallbladder not associated with perforation is very rare. A 75-year-old woman admitted for right abdominal pain was diagnosed with biliary peritonitis based on physical examination and diagnostic imaging. Biliary ascites was seen without cholecystic perforation, and no abnormal hepatic, common bile duct, or upper intestinal findings were made. Laparoscopic cholecystectomy yielded a diagnosis of biliary peritonitis due to transudation through the gallbladder. Macroscopically, there was slight mucosal inflammation but no necrosis, congestive edema, or denaturation at the serosa. Serosal degeneration was suspected to have been due to circulatory failure by gallbladder ischemia. Laparoscopic surgery was effective in diagnosis and treatment.

View full abstract

A 57-year-old woman admitted for an abdominal tumor was found in abdominal computed tomography (CT), magnetic resonance image (MRI), angiography, and upper gastrointestinal endoscopy to have a gastrointestinal stromal tumor (GIST) of the duodenum with an extra pedunculated gastrointestinal growth. In the operative findings, a 10cm tumor outside the duodenum and an independent 4cm tumor in the pancreas head were diagnosed as pancreatic tumors with lymph node metastasis, necessitating pancreaticoduodenectomy. Histological examination showed these tumors to be extra-GIST of the pancreas with lymph node metastasis or peritoneal dissemination. We report this rare case together with a review of the literature.

View full abstract

Pancreatic carcinosarcoma is a rare pancreatic neoplasmic variant with a dismal prognosis. We report the case of a large tumor of the pancreatic body in abdominal ultrasonography (US). A 58-year-old man was found in abdominal contrast computed tomography (CT) to have a 5cm low density mass at the pancreatic body. Based on a diagnosis of pancreatic cancer, we conducted distal-pancreatectomy from which the pathological specimen showed pancreatic carcinosarcoma involving invasive ductal adenocarcinoma and a sarcomatous area of short spindle cells. Sarcomatous cells stained immunohistochemically positive for a mesenchymal marker, yielding a diagnosis of pancreatic carcinosarcoma. Gemcitabine was administered in adjuvant chemotherapy. We found multidisciplinary treatment including surgery and chemotherapy effective in this case.

View full abstract

Intraductal tubular neoplasms are rare. We report a case highlighting clinicopathological features of such neoplasms. A 62-year-old man referred for acute pancreatitis was found in contrast-enhanced computed tomography to have a low-density area slightly enhanced in the pancreatic body. The distal main pancreatic duct (MPD) was dilated. MRCP and ERCP showed a small MPD filling defect. Cytologically, pancreatic juice at ERCP was Class IV. Based on intraductal tubular carcinoma or ductal carcinoma suspected from these findings, we conducted distal pancreatectomy. Macroscopically, the MPD was dilated to 7mm in diameter and filled by a polypoid tumor 6mm in diameter, histologically diagnosed as intraductal tubular carcinoma.

View full abstract

We report a case of histiocytic sarcoma of the small intestine occurring with ileus. A 52-year-old woman admitted for lower abdominal pain was found in computed tomography (CT) to have small-intestine dilation and a tumor 3cm in diameter connecting the small intestine to the right side of the uterus and producing uneven contrast. Ultrasonography (US) and magnetic resonance imaging (MRI) suggested similar results. Based on a diagnosis of ileus due to a small intestinal tumor, we conducted laparotomy, finding a solid, light gray tumor originating in the small intestine 10cm from the iliocecal valve. Lymph nodes in the mesenterium were enlarged. We resected 60cm of the iliocecal lesion and lymph nodes. Immunohistochemical findings indicated histiocytic sarcoma of the small intestine. FDG-PET a month after surgery showed metastasis had disappeared. The woman is doing well in the 13 months since surgery and shows no relapse.

View full abstract

We report a case of appendiceal metastasis from pleomorphic lung carcinoma. A 59-year-old man undergoing upper left pneumolobectomy for pleomorphic lung carcinoma (T2N0M0: stage II) 12 months earlier admitted for diarrhea and fever, and failed to improve with conservative therapy for acute enteritis and was found in abdominal CT to have a cystic mass 5cm in diameter in the right pelvic cavity. In laparotomy based on a preoperative diagnosis of appendiceal tumor, the appendiceal cystic tumor was found to be perforated with retroperitoneal abscesses necessitating ileocecal resection with D2 lymph node dissection. Pathological findings indicated invasive pleomorphic carcinoma, compatible with lung carcinoma resected 12 months earlier. The definitive diagnosis was appendiceal metastasis from lung carcinoma. The man died of peritoneal dissemination 14 months after his final surgery despite systemic chemotherapy.

View full abstract

We report a rare case of rectal cancer with a rhabdoid feature. A 75-year-old man seen for anal pain and bleeding and suspected rectal cancer had tumor invasion to the anal skin. Colonoscopy showed a rectal tumor 10cm in diameter indicated in computed tomopgraphy and magnetic resonance imaging to have infiltrated the sacrum, nscessitating abdominoperineal resection. Histologically, the tumor consisted of rhabdoid cells with homogenous lateralized nuclei and acidophillic cytoplasm. Immunohistochemical staining showed cells to be positive for vimentin and cytokeratin. Electron microscopy showed ultrastructural intermediate cytoplasmic filament whorls. The man suffered inguinal lymphatic metastasis 2 months postoperatively despite chemotherapy, because septic, and dieded 5 months after surgery. Colorectal cancer with a rhabdoid feature, as with other organs, may have a high biological grade and a dismal prognosis.

View full abstract

A 29-year-old woman with lower abdominal pain, high fever, and a leukocyte count of 11,200/mm³ was found in An abdominal computed tomography (CT) to have a low-density mass in the right obturator canal suggesting right obturator hernia. After 2 days of conservative antibiotic treatment before mechanical ileusand ischemic change in some organs were recognized, she was referred forlower right quadrant tenderness and muscle guarding. Laparoscopic examination showed the right fallopian tube to be swollen and tightly incarcerated in the right obturator canal. The fallopian tube was removed from the canal and the pelvic obturator canal orifice was closed. The fallopian tube was nonnecrotic preserved. Obturator hernia in young woman is rare and fallopian tube incarceration has not, to our knowledge, been previously reported. The laparoscopic approach is thus useful for diagnosing and treating obturator hernia.

View full abstract

Pseudoaneurysm of the postoperative hepatic artery tends to cause repeated bleeding, complicating therapy. We report a case of pseudoaneurysm of the proper hepatic artery after distal gastrectomy for gastric cancer and repeated bleeding. Hemostasis was finally achieved by directry embolizing the pseudoaneurysm just in front of the vascular bifurcation using a soft interlocking detachable coil after emergency laparotomy and intravcascular treatment to control bleeding. Hemostasis has resentry reportedly be achieved using a covered stent for pseudoaneurysm of the hepatic artery but it is often difficult for sites near a vascular bifurcation.

View full abstract

We report a rare case of internal hernia of the rectouterine pouch and suggest caliber ileal change in the pelvic space in computed tomography (CT) may indicate this disease. A 31-year-old woman admitted for abdominal pain, vomiting, and diarrhea was found in enhanced CT hospital day 2 to have a small-bowel obstruction and caliber ileal change on the dorsal side of the uterus in the pelvic space. Immediate ileus tube insertion to decompress the gastrointestinal tract temporarily relieved symptoms until hospital day 6, when abdominal pain was aggravated. CT showing free air and ascites in the peritoneal cavity necessitated emergency surgery based on a diagnosis of peritonitis due to intestinal perforation. The terminal ileum was found incarcerated in an abnormal peritoneal opening of the rectouterine pouch, along with two small ileal perforation sites 20cm from the incarceration. Releasing the incarcerated bowel revealed a peritoneal opening 1.5cm in diameter. In the absence bowel necrosis, we closed the peritoneal opening and drained ileal perforation sites. The abnormal peritoneal opening appeared to have developed congenitally.

View full abstract

We analyzed the clinicopathological features and treatment outcome of 7 subjects aged 64-79 years (male/female ratio: 5 : 2, mean age: 72 years) with pancreatobiliary (PB) intraductal papillary-mucinous neoplasm of the pancreas (PB IPMN) seen from 1991 to 2009. Of these, three were symptomatic, macroscopic IPMN determined in clinical imaging were 3 main duct and 4 branch duct. Histologically, one involved adenoma and six IPMN-derived invasive carcinoma. All underwent surgery, and three with severe stromal invasion postoperative chemotherapy. The three with distant metastases survived a mean 26.4 months, with two developing liver metastasis and one metastasis to the lungs and bones. The four surviving have remained disease-free a mean 30.7 months. The invasive cancer rate was high at resection. Histopathologically, the three recurrent cases showed severe lymphatic, venous, or perineural invasion or invasion to retropancreatic tissue. Recent pancreatic juice cytology in IPMN comfirmed its subclassifiability, histomorphologically, cytologically, and immunocytochemistrically, but treatment decisions require sufficient knowledge of PB IPMN clinicopathological behavior.

View full abstract