Purpose: The purpose of this study was to assess the effectiveness for contrast enhanced intraoperative ultrasound (CE-IOUS) using perflubutane (Sonazoid^TM). Methods: We investigated 28 nodules in 18 patients who underwent liver resection or radiofrequency ablation (RFA) between April 2011 and March 2013. In preoperative imaging, contrast enhanced ultrasound (CE-US), enhanced CT, enhanced MRI, and PET, were used and compared with the contrast enhanced intraoperative ultrasound (CE-IOUS) using perflubutane. Results: The highest rate of preoperative imaging was 88.9% on MRI. The diagnostic rate of CT was 75.0%. CE-IOUS detected all nodules. Two nodules showed high echoic nodules without perfusion defect. There were 19 nodules detected after chemotherapy, of which 9 nodules were 5–10 mm in size, and all nodules were detected using CE-IOUS. Conclusion: Despite the fact that some detected nodules were 5–10 mm in size after chemotherapy, CE-IOUS was effective in intraoperatively diagnosing liver metastases of colorectal cancer. We believe that CE-IOUS could be an effective tool in colon cancer liver metastasis of colorectal cancer.

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We present a case of a 74-year-old man who underwent distal gastrectomy for gastric cancer successfully 14 years after coronary artery bypass grafting (CABG) with the right gastroepiploic artery (RGEA). The patient underwent CABG using RGEA at the age of 59. He was well until age of 73 when an early gastric cancer was diagnosed. Esophagogastroduodenoscopy (EGD) revealed a 0-IIc lesion with a diameter of 4 cm at the lesser curvature of the antrum. He underwent endoscopic submucosal dissection (ESD). The resected specimen showed tub2, SM1, UL (–), ly (+), v (–), pHM0 (2 mm) pVM1. Although positive deleterious factors such as ly (+) and pVM1 usually indicated additional surgical resection, he was carefully observed instead, considering the high surgical risk of the resection of RGEA. A year later he was found to have lymph node metastasis around the antrum by abdominal CT. Eventually he underwent distal gastrectomy with D2 lymph node dissection successfully after percutaneous coronary intervention (PCI) to restore coronary blood flow independent from RGEA. RGEA grafts have been used frequently for CABG because of good short and long-term patency. Recently more patients with CABG using RGEA are found to have gastric cancer and require the resection of the RGEA for lymph node dissection as in this case. For safe and successful surgery, it is crucial to restore the coronary flow independent from RGEA with PCI or CABG prior to surgery, and monitor patients carefully with ECG and cardiac function with cooperating anesthesiologists and cardiac surgeons during the surgery.

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An 84-year-old man presented with anorexia and epigastric pain. Endoscopic examination revealed a type 3 tumor of the entire circumference of the antrum. The pathological diagnosis of a biopsy specimen was squamous cell carcinoma. Thoracoabdominal pelvic contrast CT revealed no distant metastasis. Squamous cell carcinoma or adenosquamous carcinoma was diagnosed and distal gastrectomy with Roux-en-Y anastomosis, D2 lymph node dissection, omentectomy, and cholecystectomy were performed. The histological diagnosis of the resected tumor was pure squamous cell carcinoma without an adenocarcinomatous component, of which most carcinoma cells were immunoreactive to p40 antibody. The pathological findings were as follows: pT3 (SS), int, INFb, ly0, v2, pN0, M0, P0, CY0, H0, and Stage IIA. Primary gastric squamous cell carcinoma is considered very rare and the incidence of this histological type is approximately 0.09%. Here we report a rare case of primary gastric squamous cell carcinoma diagnosed by immunohistochemical analysis of p40.

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A 32-year-old man with sudden onset of right abdominal pain and anemia was immediately admitted because abdominal contrast enhanced CT showed an 8-cm mass with internal hemorrhage, which was located in the duodenal second portion. After establishing conservative hemostasis, a biopsy of the duodenal submucosal tumor via upper gastrointestinal endoscopy was performed, leading to the diagnosis of gastrointestinal stromal tumor (GIST). A thorough examination of hemostasis was carried out for a prolonged prothrombin time (PT), resulting in the diagnosis of congenital factor VII (FVII) deficiency. We conducted subtotal stomach-preserving pancreaticoduodenectomy with careful attention to the following point. With a goal of keeping PT-international normalized ratio ≤1, the patient was perioperatively managed by the administration of recombinant activated FVII at intervals of 4 to 6 hours. The duodenal GIST caused a large amount of bleeding due to tumor congestion, but good hemostasis was achieved after the completion of tumor extirpation. The patient had no postoperative complications, and was discharged 16 days after surgery. Histopathological examination of the resected specimen showed that the tumor cells did not invade the surrounding tissue. Immunohistochemically, the tumor had an MIB-1 labeling index of 30 to 40%, was positive for c-kit and DC-34, but negative for desmin and S-100. On the basis of the above findings, the present case was diagnosed as high-risk GIST. We reported a very rare case of hemorrhagic duodenal GIST with congenital FVII deficiency, and mentioned a management of congenital FVII deficiency when performing major surgery.

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A 67-year-old man was admitted to our hospital to evaluate a pancreatic tumor. The serum level of IgG4 was elevated and abdominal CT showed a solid mass accompanied with a cystic mass in the tail of the pancreas. FDG-PET revealed high accumulation at the site of the pancreatic solid mass. ERCP revealed obstruction of the main pancreatic duct in the body of the pancreas. EUS-FNA did not reveal any plasma cells of autoimmune pancreatitis or cancer cell. We diagnosed pancreatic cystic tumor associated with autoimmune pancreatitis preoperatively, and performed distal pancreatectomy. Gross inspection of the resected specimen showed a solid mass associated with a cystic lesion with mucus in the tail of the pancreas. Pathological examination showed fibrosis with infiltration of IgG4 positive plasma cells and the cystic mass consisted of mucus and single cuboidal epithelium. We diagnosed pancreatic retention cyst containing mucus, associated with autoimmune pancreatitis.

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A 68-year-old man, with a history of hypertension, angina pectoris, chronic heart failure, surgery of axillo-femoral bypass for arteriosclerosis obliterans and left renal excision for stenosed renal artery, and chronic renal failure, was referred to our hospital due to right lower abdominal pain. CT showed portal venous gas and thickened walls in the transverse colon with lower mucosal enhancement. Nine hours after admission, he presented with high fever and watery diarrhea. Colonoscopy revealed 3 segments of necrosis in the right side of the colon, therefore extended right hemicolectomy followed by ileocolostomy was performed. Twelve months after a favorable recovery, he was readmitted due to left upper abdominal pain. CT showed portal venous gas and thickened bowel wall around the ileocolostomy. Colonoscopy showed necrosis of the ileum in the anastomosis, and bowel resection of the anastomosis was performed. Fortunately, he had a complete recovery. Because necrotic ischemic enteritis is a serious disorder with possible recurrence, recurrence prevention, such as maintaining a stable condition, appropriate and mild control of circulatory dynamics, and avoiding dehydration and elevation of bowel pressure, should be considered.

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A 67-year-old woman underwent upper and lower gastrointestinal endoscopy for melena at a local hospital, but the bleeding source was not identified. Capsule endoscopy showed a small protruding tumor with erosion at the distal ileum. Abdominal enhanced CT demonstrated ileo-cecal intussusception and a small nodule with contrast-enhancement in the early phase at the anal part of the tumor. The patient underwent laparotomy, in which ileo-cecal intussusception, 10 cm proximal to Bauhin’s valve was demonstrated. Although the color of the intestine was good, the intussusception was extensive, and therefore ileocecal resection was performed. The macroscopic appearance of the resected specimen revealed the tumor to be 20 mm in diameter and originated from the ileum. The pathological diagnosis was pyogenic granuloma. Her postoperative course was uneventful, and she was discharged on the 8th day after surgery. We herein reported a rare case of intestinal intussusception due to a pyogenic granuloma arising from the ileum, and review the literature.

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A 13-year-old boy presented with abdominal pain and vomiting. On physical examination, his abdomen was hard with tenderness in the upper abdomen and the right lower quadrant. Abdominal enhanced CT showed findings of ileus: a dilated and saccular intestine about 12×12×6 cm in size with niveau formation in the lower abdomen and pelvis. The enhancement of the intestine was reduced. We suspected strangulation of the small intestine, so we performed an emergency operation. During the operation, we found a dilated, saccular, and necrotic intestine with purulent ascites. The intestine communicated to the ileum on the mesenteric side at 60 cm oral to the Bauhin valve. It was strangulated and developed a 360° volvulus at its base. We diagnosed volvulus duplication cyst, because the saccular intestine had a common mesentery with the ileum. We resected the necrotic tissue in the duplication cyst from the ileum. There have only been a few reports of volvulus duplication cysts. We report this case, in addition to a review of existing literature.

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Congenital factor V deficiency is estimated to occur in only one of every 1 million people, while congenital factor VII deficiency is thought to occur in only one of every 500,000 people. Furthermore, the combined deficiency of these factors has not been reported. Here, we report a case of combined deficiency of factors V, VII, and VIII in a patient who underwent an operation for colonic diverticulum bleeding. A 68-year-old man was admitted to our hospital for hemorrhagic shock due to melena. Colonoscopy showed bleeding from a transverse colonic diverticulum. We performed a right hemicolectomy because conservative treatment was ineffective. During treatment, we noted low activities of factors V, VII, and VIII, but their inhibitors were absent. Although the patient had a temporary bleeding tendency, the activities of each factor were considered sufficient for hemostasis. Eventually, we were able to manage the patient’s condition without serious bleeding or clotting complications by reference to prothrombin time, activated partial thromboplastin time, and thrombin time and by the timely administration of fresh frozen plasma, factor VII, and factor VIII preparation.

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An 84-year-old man was admitted because of abnormal bowel movement and liver tumor. Laboratory data showed moderate leukocytosis (10,900/mm³). Colon fiberscopy revealed a rectal tumor and histological examination revealed undifferentiated carcinoma. A CT scan showed a tumor in the liver which suggested liver metastasis, therefore Hartmann’s operation was performed. Microscopically, significant neutrophil infiltration among cancer cells was observed. Immunohistochemistry performed using a specific monoclonal antibody against G-CSF was positive, and serum levels of G-CSF was elevated. Therefore, we diagnosed this tumor as a G-CSF-producing carcinoma. Cetuximab therapy was initiated to treat the liver metastasis, but was ineffective. Metastatic liver tumors enlarged rapidly and local recurrence developed on day 50. The patient developed cerebral stroke caused by multiple cerebral infarctions and Trousseau’s syndrome was diagnosed on day 54. He died 58 days after surgery.

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Abdominal cocoon is a rare disease characterized by total or partial encasement of the small bowel by a thick fibrous membrane. The etiology of this disease is unknown. We report a case of strangulated ileus caused by abdominal cocoon. A 77-year-old woman presented with persistent abdominal pain. Enhanced abdominal CT revealed a cluster of dilated jejunal loops with ascites surrounded by a thick sac-like structure. Emergency laparoscopic surgery was performed under a diagnosis of a strangulated ileus. The dilated jejunum loops were found to be encased in a thick fibrous membrane. Laparoscopic surgery was suspended and minimum laparotomy was carried out to reduce the risk of accidental damage to the small bowel and ascertain the membrane. After total excision of the membrane, the jejunum loops were viable and needed no resection. The postoperative period was uneventful and the patient was discharged after 2 weeks. No recurrence has been observed during follow-up.

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