Purpose: Hemorrhage from the residual rectum after subtotal colectomy for ulcerative colitis is a rare but dreaded complication. The aim of this study was to examine the clinical course, management, and outcome of hemorrhage from the residual rectum after subtotal colectomy for ulcerative colitis. Materials and Methods: A retrospective observational study was conducted on 6 consecutive patients who suffered from hemorrhage from the residual rectum after undergoing subtotal colectomy for ulcerative colitis at our institution. Result: As the surgical hemostasis, five patients underwent proctectomy, and 1 underwent suturing for bleeding of the perianal area. Among five patients who underwent proctectomy, 3 underwent partial resection of the rectum and Hartmann closure, and 2 underwent complete proctectomy, ileal pouch-anal canal anastomosis and ileostomy. Among 6 patients who suffered from hemorrhage from the residual rectum, 5 patients underwent ileostomy take-down. Conclusion: Massive hemorrhage from the residual rectum after subtotal colectomy for ulcerative colitis is a serious complication. Because local perianal hemostasis for massive hemorrhage is often difficult and fails, it is necessary to perform proctectomy immediately including the bleeding area.
Since April 2014, we have introduced single-incision laparoscopic-assisted percutaneous extraperitoneal closure (SILPEC) for pediatric inguinal hernia in our hospital. Herein, we report the initial results compared with high ligation (conventional method). We retrospectively examined 131 patients who had undergone the conventional method prior to the introduction of SILPEC and 150 patients who had undergone SILPEC thereafter. The operative time for the conventional method was significantly shorter for females in unilateral cases, and the time for SILPEC was significantly shorter for males in bilateral cases. Sixty-six out of 141 SILPEC cases (46.8%) who had been preoperatively diagnosed as having unilateral hernia were found to exhibit contralateral patent processus vaginalis during the operation and were treated at the same time. There were no differences in postoperative complications, recurrence, or postoperative hospital stay. Compared with the conventional method, SILPEC is an equally safe and efficacious procedure. SILPEC can be a useful procedure because it has a better cosmetic outcome, and we can also check and treat contralateral hernia during the operation.
A 69-year-old male patient was referred to our hospital to undergo treatment for multiple gastric cancers with the complaint of melena. Gastroendoscopy showed an ulcerative lesion surrounding an elevation in the middle gastric body and a shallow depressed lesion with marginal elevation in the lower gastric body. Biopsy specimens revealed poorly-differentiated adenocarcinoma and poorly- to moderately-differentiated adenocarcinoma, respectively. Enhanced abdominal CT imaging showed some enlarged lymph nodes in the perigastric region (cT4aN+M0 Stage III). We performed total gastrectomy and splenectomy with D2+ lymph node dissection. Histological examination showed that the former was a type II tumor with adenosquamous carcinoma invading into the subserosa. In addition, adenocarcinoma components were seen in the No. 16-b1-latero lymph node by HE. Since gastric primary adenosquamous carcinoma account for 0.2–0.6% of all gastric cancers, multiple synchronous gastric cancers with adenosquamous carcinoma and the common type are extremely rare and the clinical outcome remains to be elucidated.
We report a case of intraperitoneal hemorrhage due to rupture of liver metastases from a pancreatic neuroendocrine tumor (pNET) during administration of sunitinib. The patient was a 78-year-old woman who had undergone distal pancreatectomy 8 years ago and was subsequently diagnosed with pNET G2. Two years and 3 months after surgery, multiple liver metastases appeared, and she was treated with everolimus with a total of 10 transcatheter arterial chemoembolizations over 3 years. Since extrahepatic lesions appeared, treatment with sunitinib was initiated. Two months after the treatment started, dynamic CT showed multiple metastatic liver tumors exhibiting low-level enhanced hypovascular change. Sixteen days later, she was transported to emergency with hemorrhagic shock due to rupture of the liver metastatic tumors, and was immediately saved by emergency transcatheter arterial embolization. She was subsequently treated with streptozocin, and dynamic CT showed that the metastatic liver tumors shrunk remarkably at 4 months after the initiation of treatment and the partial response continued for 2 years. She was alive 8 years and 7 months after the first surgery. The possibility of rupture of liver metastases from pNET should be considered when dynamic CT shows that lesions exhibit lowly enhanced hypovascular changes during the administration of sunitinib.
A 25-year-old man presented to our hospital due to sudden abdominal pain and lumbago pain. Results of blood test showed that the white blood cell count and C-reactive protein levels were high. Abdominal CT and MRI revealed a giant cystic mass in the retroperitoneum. As the clinical symptom of pain and inflammatory reaction were improved by administration of antibiotics, elective surgery was performed. During laparotomy, a giant cystic tumor with 10×15×7 cm in size was located in the retroperitoneum. Although it adhered to the second portion of duodenum and the inferior mesenteric artery, complete resection was achieved. The pathological findings showed that there were no malignant cells. On immunohistochemical staining, the cells along the cystic wall were positive for calretinin, mesothelin, and D2-40, and negative for Ki-67, leading to the diagnosis of retroperitoneal benign multicystic peritoneal mesothelioma. In this paper, we report this case of retroperitoneal benign multicystic peritoneal mesothelioma that was discovered due to acute abdomen.
A 66-year-old man consulted a nearby doctor with the chief complaints of upper abdomen bloating and loss of appetite. He was diagnosed as having an abdominal mass, and was referred to our hospital for detailed examination and treatment. Abdominal CT showed a huge tumor measuring 25 cm in the retroperitoneal space. Based on EUS-FNA pathological findings, the tumor was diagnosed as a gastrointestinal stromal tumor (GIST). Preoperative chemotherapy with imatinib and sequential sunitinib was started in consideration of surgical risks and preservation of the surrounding organs. The size of the tumor did not change after chemotherapy. Since reduction of the tumor seemed to be not possible, surgical intervention was selected as the treatment choice. As the tumor originated from the retroperitoneum, and was severely adherent to the pancreas body and tail, it was extirpated with the distal pancreas and the spleen. The tumor was ultimately diagnosed as extragastrointestinal GIST by histopathological examination. Imatinib was subsequently administered for three years as an adjuvant therapy. The patient is alive without any recurrence 5 years after the surgery.
A 87-year-old man visited a nearby clinic with the chief complaint of frequent urination. CT showed an ileocecal mass. Lower gastrointestinal endoscopy showed no abnormalities on the mucosal surface. Since he was old and had no subjective symptoms, he did not wish to undergo surgery. The abdominal mass had a maximum diameter of 6.1 cm at the time of detection, and increased 8.6 cm after 10 months, and 17 cm after 17 months. A feeling of fullness in his abdomen also developed and he requested to undergo surgery. He was ultimately referred to our hospital 18 months after the abdominal mass had been discovered. He underwent open right hemicoloectomy including D3 lymph node dissection. Histopathological examination revealed a 25×18×13 cm large ascending colon leiomyosarcoma with extramural growth. Since 1998, when the gastrointestinal stromal tumor (GIST) concept was established, leiomyosarcoma of colon has been extremely rare. There have been 18 cases reported in Japan, including our case. Extramural growth occurs less frequently than intramural growth. Our case was rare as it represented the largest tumor size and had an 18-month observation period prior to surgery.
A 75-year-old man who suffered from dysuria with elevated serum prostate specific antigen (PSA) level was diagnosed as having prostate carcinoma by needle biopsy. Upon further examination, Type 2 rectal carcinoma was found in the anterior wall of the lower rectum concurrently. MRI imaging of the pelvis revealed that the prostate carcinoma was adjacent to the anterior wall of the rectum above the anal canal and also close to the rectal carcinoma. CT revealed multiple lymph node metastases of mesorectal, lateral and inguinal lesions and PET-CT showed metastases to some bones. After one cycle of anti-androgen therapy for Stage D prostate carcinoma, the PSA level was normalized and shrinkage of the metastatic lateral lymph node (LLN) was assessed, followed by laparoscopic abdominoperineal resection for the rectal carcinoma. Pathological findings of the rectal cancer showed well-differentiated adenocarcinoma, pT2, pN0, pStage I and the origin of the mesorectal lymph node (MLN) metastasis was prostate carcinoma with neuroendocrine differentiation. Metastatic prostate carcinoma to the MLN is very rare but it is important to keep this unsuspected pattern of lymphatic spread in mind, especially in case of infiltrative high-risk prostate carcinoma.
Purpose: We investigated the factors related to avoiding insertion of a drainage tube and achieving early postoperative discharge during laparoscopic fenestration (LF) of symptomatic liver cysts. Method: This study investigated 44 patients who underwent LF in our department during the last 9 years. The male-to-female ratio was 10:34, which showed that it was more common among females, and the mean age was 65 years. Most of the cysts were present in the right lobe, and the average maximum diameter was 15.9 cm. Results: All 12 patients with polycystic liver disease who underwent LF were Gigot classification type I. Eleven patients underwent preoperative placement of endoscopic nasobiliary drainage (ENBD) tube. Intraoperative bile leakage was found in 5 cases during the procedure; however, there was no bile leakage postoperatively. The mean operation time was 122 minutes. Postoperative ascites retention was only observed in 2 patients at the time of introduction, and all 10 patients who underwent LF with no insertion of intra-peritoneal drainage tube in 2018 were discharged on postoperative day 2. Conclusion: Secure treatments for bile leakage from the cutting edge and luminal surface of the cyst wall during LF of liver cysts enabled us to avoid the perioperative complications and discharge the patients earlier after surgery even without insertion of a drainage tube.