Purpose: We have administered recombinant human soluble thrombomodulin (rTM) for septic disseminated intravascular coagulation (DIC) since December 2010, because anticoagulant therapy was considered to be important in the treatment of septic DIC in parallel with treatment of the cause of the disease. The aim of this study was to investigate the effects of rTM in patients with septic DIC arising from abdominal disease perioperatively in digestive surgery. Methods: We examined 43 patients with septic DIC arising from abdominal disease perioperatively from 2007. The patients were divided into two groups; 23 patients who were administered rTM (rTM group), and 20 patients who were not administered rTM (non-rTM group) and we compared the patient backgrounds, sepsis treatments, general condition rating score, and outcomes between the two groups. Results: There were no significant differences in the patients’ backgrounds between the two groups. Most of the rTM group received rTM+AT combination therapy. DIC scores in the rTM group improved earlier than the non-rTM group; the rTM group improved significantly on day 3. Non-rTM group improved significantly on day 7. SIRS score in the non-rTM group did not show significant improvement during days 0–7, and the rTM group improved significantly on day 5. The SOFA score on day 7 in the rTM group improved significantly compared with the non-rTM group. White blood cell count, CRP and T. Bil in the non-rTM group were higher than that of the rTM group. There was no significant difference in the duration of hospital stay between the two groups, but ICU stay in the rTM group was significantly shorter. No mortality was observed in the rTM group within 30 days, and the survival rate at 30 days in the rTM group was higher than that of the non-rTM group. Conclusion: It is considered that rTM has not only anti-inflammatory effects but also anticoagulant activity for patients with septic DIC. Rapid improvement for systemic microcirculation by rTM inhibits the progression of organ damage, therefore it may contribute to short-term prognosis. We conclude that rTM administration for septic DIC caused by abdominal disease was effective.

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We report a case of pancreatic metastasis from gastric cancer. A 75-year-old man underwent total gastrectomy for gastric cancer followed by adjuvant chemotherapy with S-1 for 12 months. After 4 years of gastrectomy, contrast enhanced CT demonstrated a splenic vein thrombus (1.5 cm). The thrombus extended to the portal vein over a period of 7 months. FDG-PET revealed increased uptake at the pancreas body, but no findings could be seen at the pancreas body on CT. MRCP showed stricture of main pancreatic duct. Although it was difficult to confirm the diagnosis, primary pancreatic cancer or pancreatic metastasis from gastric cancer were suspected. Distal pancreatectomy with tumor thrombectomy was performed. Macroscopic findings showed a 3.5 cm solid tumor at the pancreatic body with the tumor thrombus. Microscopic examination revealed moderately differentiated adenocarcinoma compatible with pancreatic metastasis from gastric cancer. The patient received adjuvant chemotherapy with S-1 after surgery and revealed no signs of recurrence. This is a rare case of pancreatic metastasis from gastric cancer accompanied by tumor thrombus.

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It is still unclear whether the remnant stomach can be preserved when we perform distal pancreatectomy (DP) in cases of post distal gastrectomy (DG). Recently, several studies have reported that intraoperative indocyanine green (ICG) fluorography was useful in evaluating organ perfusion. In this case, we performed intraoperative ICG fluorography to assess the blood flow of the remnant stomach during DP. A 59-year-old man consulted a local hospital with a chief complaint of epigastric pain. He received DG because of gastric ulcer 25 years ago. Pancreatic body cancer was diagnosed which raised the possibility of splenic artery and venous invasion. Preoperative contrast enhanced CT revealed that the left gastric, right gastric and right gastroepiploic arteries and veins were cut in a prior operation. We performed intraoperative ICG fluorography after ligation of the left gastroepiploic, short gastric and splenic arteries. ICG fluorography showed that the remnant stomach was perfused from esophageal or small omental blood vessels. We safely preserved the remnant stomach and the postoperative course was uneventful except for minor pancreatic fistula. ICG fluorography has a potential to evaluate the blood flow of the remnant stomach.

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In most cases, the prognosis for the carcinoma of duodenal ampulla is better than for bile duct carcinoma or pancreatic carcinoma. However, in some cases, very poor prognostic carcinomas causing rapid distant metastases after surgery were reported. A 64-year-old man with a chief complaint of jaundice was admitted and we diagnosed carcinoma of the duodenal ampulla that might involve lymph nodes around the head of the pancreas and the root of the first jejunal artery. Endoscopic biopsy specimen was diagnosed as poorly differentiated adenocarcinoma with components of undifferentiated carcinoma. We thought in this case radical surgery was indicated, and pylorus- preserving pancreato-duodenectomy was performed. Multiple lung and liver metastases occurred within 7 weeks and ‍he died 2 months after surgery. The tumor was histopathologically diagnosed as poorly differentiated adenocarcinoma with a component of undifferentiated carcinoma by histopathology. Among 8 resected cases of poorly differentiated adenocarcinoma of duodenal ampulla, including the present case, 3 patients died within 6 months after surgery because of rapid distant metastasis. These results suggest we might avoid unnecessary surgery for patients who have potentially poor prognosis with poorly-differentiated adenocarcinoma of ampulla, if we can determine these patients before surgery.

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We report a case of intrahepatic cholangiocarcinoma with superficial spread arising after long-term follow-up of hepatolithiasis. A 72-year-old woman who had been observed for hepatolithiasis for 12 years was admitted to our hospital for treatment of choledocolithiasis. Abdominal CT revealed an atrophic right lobe of the liver, hepato- and choledocolithiasis, though no tumor was observed. Stenosis in the right hepatic duct was observed during endoscopic retrograde cholangiography, and adenocarcinoma was determined by curettage of the stenotic site. Under a diagnosis of hilar cholangiocarcinoma of right hepatic duct, right hepatectomy was performed. Histologically, though intraepithelial carcinoma was seen widely along large and small hepatic bile ducts, the resected stump of the left hepatic duct was found to be free from cancer. Although intraepithelial carcinoma was histologically detected partially at the resected margin of the liver, no invasion was seen. At the time of writing, the patient is alive without any evidence of recurrence 24 months after surgery.

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We report a case of torsion of Meckel’s diverticulum at the neck following an internal hernia due to mesodiverticular band. A 34-year-old man was admitted with a complaint of sudden onset of abdominal pain around the navel. An abdominal CT scan showed an encapsulated fluid collection with an internal gas without a whirl sign of the mesenterium. We performed laparotomy under the suspicion of intraabdominal abscess or localized torsion of the small intestine. An internal hernia without ischemia through a cord between the mesenterium and diverticulum was found. The internal hernia was easily released after dissection of the cord. The cord revealed a mesodiverticular band on the tip of 7.5×4.5 cm Meckel’s diverticulum on the ileum 90 cm proximal to the terminal ileum. The diverticulum had become necrotic due to torsion clockwise by 360° at the neck. Segmental resection of the ileum including the diverticulum was performed. Torsion of Meckel’s diverticulum at the neck is a relatively rare complication, and we found 28 reports, including the present case, in Japanese literatures.

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An 87-year-old woman was admitted to our hospital with abdominal pain, nausea and vomiting. An abdominal radiography showed intestinal obstruction with niveau formation, and CT scan revealed a closed loop of the small intestine in the vicinity of ileocecum. We diagnosed ileus due to internal hernia. Initially, conservative therapy with an ileus tube was performed. Since improvement of the obstruction was not achieved and we conducted an operation on the ninth hospital day. The laparotomy revealed that the ileum was incarcerated 50 cm proximal from the terminal ileum into a posterior mesenteric defect of the terminal ileum. On a diagnosis small intestinal inamesenteric hernia we reduced the incarceration and closed the defect. No intestinal resection was required. The patient improved and was discharged from hospital on the 13th postoperative day. The occurrence of the small intestinal inamesenteric hernia is uncommon and only 4 cases, including ours, have been reported in the Japanese literature from 1983. We report this case and discuss the cases of the small intestinal inamesenteric hernia previously reported in Japan.

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A 73-year-old woman was admitted to our hospital with a sudden onset of upper abdomimal pain and nausea. Small intestinal volvulus was diagnosed based on the presence of a “whirl sign” on contrast-enhanced abdominal CT and emergency surgery was performed. The small intestine had rotated 720° clockwise. We rotated the small intestine back to the correct position. The small intestine showed no necrosid. A mass 5 cm in diameter was found to originate from the jejunal wall, 30 cm distal from the ligament of Treitz. She underwent resection of the jejunal mass. The cecum was liberated from the retroperitoneum. This was a rare case of small intestinal volvulus with free cecum and duplication.

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A 48-year-old man presented with nausea and vomiting. Physical examination revealed abdominal tenderness. Abdominal CT scan showed obstruction of the proximal jejunum and a mass located in the proximal jejunum. Following nasogastric decompression, elective surgery was undertaken. Intraoperatively, there was a 30 mm tumor in the jejunum, 5 cm distal to the ligament of Treitz. The tumor adhered to the mesentery of jejunum, 30 cm distal to the tumor, resulting in internal hernia. We released the adhesion and resected part of the jejunum. The clinical course was good and he was discharged from the hospital 6 days after operation. Histopathological findings revealed type I aberrant pancreas according to the Heinrich classification. Aberrant pancreas with clinical symptoms is rare, generally presenting with intussusception. We review cases of symptomatic aberrant pancreas of the small intestine reported in the literature.

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A 50-year-old man was admitted with complaints of lower left abdominal pain, fever, and hemorrhagic stool. Abdominal and pelvic CT revealed a tumor 35 mm in diameter, showing a high density area in contact with the wall of the ileum. Surgery was therefore performed. The small bowel tumor was partially exposed to the bowel lumen and a nodular lesion was present in the surrounding peritoneum. We performed a partial resection of the small bowel and peritoneum. Histopathological examination showed a proliferation of fibroblast-like spindle-shaped cells with marked infiltration of neutrophils and eosinophils. Immunohistochemical staining was positive for vimentin, anaplastic lymphoma kinase, and alpha-smooth muscle actin. From these findings, the patient was given a diagnosis of multiple inflammatory myofibroblastic tumors. The chief symptoms disappeared immediately after surgery, but relapsed one month later. At that time, abdominal and pelvic CT revealed a new tumor in the small bowel near the site of anastomosis; additional partial resection of the small bowel was therefore performed. Histopathological examination yielded findings similar to the lesions that were resected in the initial surgery, and the tumor was diagnosed as a residual lesion of an inflammatory myofibroblastic tumor. In Japan, reports of multiple inflammatory myofibroblastic tumors in the small bowel are extremely rare, and we report this case in addition to a review of existing literature.

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A 78-year-old woman with a history of open appendectomy with an uneventful postoperative course at 17 years of age, occasionally presented with redness and swelling in the surgical scar since she was 70 years old, resulting in spontaneous skin ulceration and leakage of a feces-like liquid at age 76. The intestinal wall then gradually prolapsed through the abdominal wall, and became a labial fecal fistula which appeared to be an end stoma after about one year. There was leakage of a feces-like liquid chiefly when the patient was constipated, suggesting that the labial fecal fistula originated from a distal part of the cecum. Diagnostic imaging such as CT and fistulography provided clear evidence to support the presumption. The patient underwent surgery to remove the fecal fistula. A hernia orifice with a diameter of 1 cm existed in the surgical scar after appendectomy. The cecal wall passing through that orifice was resected with the surrounding skin. Histopathological findings showed the continuity between the colonic mucosa and the cutaneous epithelium. Our speculation on the mechanism for the formation of a labial fecal fistula is that the patient had already developed a small cicatricial hernia after appendectomy. At the age of 70, a Richter’s hernia may have occurred at that defect of the abdominal wall resulting in partial necrosis of the cecal wall responsible for recurrent wound infection, leading to eventual formation of a labial fecal fistula.

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Hereditary angioedema (HAE) is a disease with symptoms of abdominal pain or dyspnea caused by local edema. Therefore, caution is required in perioperative care when HAE patients are placed under general anesthesia, which requires intratracheal intubation. We report a case of rectal carcinoid complicated with HAE, where low anterior resection was performed safely using novel perioperative care techniques. A 60-year-old man presented at our hospital complaining of hematochezia. He was diagnosed with rectal carcinoid on the basis of colonoscopy findings, in which surgery was indicated because the tumor was 20 mm. He had a history of hospitalization for abdominal pain and a family history of edema attack. HAE was confirmed on the basis of patient history, family history, serum complement value, and the low activity of the C1 inactivator. He underwent low anterior resection under epidural and spinal anesthesia after administration of danazol, tranexamic acid, and C1 inactivator. His postoperative course was uneventful without edema attack.

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A 79-year-old woman who had rectal cancer was admitted and laparoscopic abdominoperineal resection was performed. The duration of surgery was 5 h 35 min and blood loss was 35 g. On the first day after surgery, she developed consciousness disturbance, and blood chemistry examination showed hypokalemia. In addition, hypophosphatemia and hypomagnesemia were observed. Refeeding syndrome (RFS) was diagnosed by both blood chemistry data and clinical symptoms. An administration of additional phosphate, potassium and magnesium improved her consciousness level. The RFS was first described to be caused by starvation under severe circumstances such as war. The RFS causes some adverse events such as metabolic, cardiovascular, hematologic and neurologic complications associated with significant hypophosphatemia and other electrolyte disturbance. Recently, the RFS has also been reported to occur in patients with gastrointestinal cancer. Therefore, it is necessary to recognize that RFS occasionally may occur in elderly patients undergoing surgery for malignancy.

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