An 80-year-old woman underwent laparoscopic Toupet fundoplication and mesh repair for esophageal hiatal hernia. Stenosis of the esophagogastric junction appeared postoperatively, and balloon dilatation was repeated. Subsequent upper gastrointestinal endoscopy revealed mesh penetration into the abdominal esophageal lumen. The patient was referred to our department for treatment and surgery was performed. The area around the hiatus of the esophagus was tightly scarred, and the mesh penetrated the right side of the esophagus. The mesh was removed from the diaphragm, and the penetrated lesion was excised including the gastric cardia side and the lower esophagus. Reconstruction was performed using the double-tract method, and the dilated esophageal hiatus was covered with the remnant stomach. The use of mesh in esophageal hiatal hernia has been reported to lead to complications, such as stenosis and penetration. In this case, we performed lower esophagectomy and proximal gastrectomy with double-tract reconstruction for esophageal penetration. This technique is useful because it avoids anastomosis at the scar lesion of the esophagus and can allow closure of the esophageal hiatus with the remnant stomach.
A 47-year-old woman was admitted to our hospital for further examination of a tumor adjacent to the hepatic caudal lobe. Abdominal CT showed a 43-mm hypovascular tumor. The tumor gave hypointense and hyperintense signals on T1- and T2-weighted images, respectively, in abdominal MRI. There was no sign of tumor invasion. The patient was followed up every six months under a diagnosis of schwannoma. Two and a half years later, the tumor had grown to 56 mm and was compressing the surrounding vessels. After laparoscopic exploration to rule out clear invasion, tumor resection by laparotomy was performed. Intraoperative findings revealed that the tumor had arisen from the nerve plexus around the left hepatic artery. The histopathological diagnosis was schwannoma, with positive staining for S-100 protein. A schwannoma arising from the nerve plexus around the left hepatic artery is very rare.
Extrahepatic portal vein obstruction (EHPO) is a late complication of intraoperative radiotherapy (IORT) and it generally causes portal hypertension, which can, in turn, lead to gastrointestinal bleeding due to varices. A 67-year-old man had undergone pylorus-preserving pancreatoduodenectomy with IORT (25 Gy) for carcinoma of the papilla of Vater 24 years prior to admission. From the eighth year post operation, EHPO and extrahepatic collateral vessel development, which were considered late radiation complications, were detected. He was referred to our hospital for melena. Gastrointestinal endoscopy revealed bleeding from the ectopic varices in the jejunum limb. After the patient underwent endoscopic sclerotherapy of the jejunum limb varices, a Rex shunt was applied as a curative therapy. A right internal jugular vein graft was used to create a jejunal limb vein–portal umbilical bypass. On the fourth day post operation, graft occlusion, due to a thrombus, and intraperitoneal hemorrhage were observed, and reoperation was performed. The thrombus was removed from the graft, and a spiral vein graft made from the left great saphenous vein was used as an interposition graft to recreate the bypass. The patient received anticoagulant therapy on the second postoperative day and was discharged without any thrombus in the graft.
A 73-year-old woman underwent right hepatic trisectionectomy for a mass forming type of intrahepatic cholangiocarcinoma (ICC) of 4.5 cm in size. She then underwent five resections for intrahepatic recurrence at the following times after the initial surgery: i) 2 years and 1 month, 2 cm in segment 1, ii) 2 years and 9 months, 3 cm in segment 1, iii) 3 years and 8 months, 1.5 cm in segment 2, iv) 5 years and 9 months, 2 cm in segment 3, and v) 6 years and 11 months, 3 cm in segment 2. Histopathologically, all the resected tumors were diagnosed as the mass forming type of ICC with moderately differentiated adenocarcinoma, but without capsule or vessel invasion. The patient remains alive and disease-free at 12 years after the initial surgery. We report a rare case of long-term survival achieved with repeated resections for intrahepatic recurrences of ICC.
Recently, immunohistochemical staining for ΔNp63 (p40) has been widely used to diagnose squamous cell carcinoma. While there have been many reports that have evaluated the usefulness of ΔNp63 (p40) for diagnosing squamous cell carcinoma of the lung to date, the number of reports of the diagnostic usefulness of ΔNp63 (p40) for other carcinomas has increased. We report three cases of adenosquamous cell carcinoma of the pancreas and evaluate the usefulness of ΔNp63 (p40) in diagnosing them. Case 1: A 71-year-old man underwent distal pancreatectomy for carcinoma of the pancreatic body. Case 2: A 81-year-old woman underwent pylorus preserving pancreaticoduodenectomy for carcinoma of the pancreatic head. Case 3: A 55-year-old man underwent distal pancreatectomy for carcinoma of the pancreatic tail. All cases were histologically diagnosed as adenosquamous carcinoma of the pancreas. The squamous cell carcinoma components of these cases were positive for ΔNp63. ΔNp63 allowed us to easily recognize squamous cell carcinoma components in areas in which it was difficult to discriminate whether squamous carcinoma components were included due to unclear cell differentiation. It is conceivable that immunohistochemistry for ΔNp63 could be useful in diagnosing adenosquamous carcinoma of the pancreas.
A 65-year-old woman was found to have a white mass on the serosal surface of the small intestine during laparoscopic sacral vaginal fusion for a cystocele. The patient was diagnosed with a small intestine tumor. Laparoscopic partial resection of the small intestine was performed. Histopathological examination revealed spindle-shaped cells with collagen fibers, scattered calcification, and infiltration of inflammatory cells, such as plasma cells and lymphocytes. Immunohistochemical examination of the spindle cells in the resected specimen revealed expression of factor XIIIa. Therefore, the tumor was finally diagnosed as a calcifying fibrous tumor (CFT). The patient is alive without recurrence at 9 months after surgery.
A 73-year-old man with duodenal cancer underwent duodenojejunal segmental resection at a previous hospital. Abdominal CT performed 9 months after surgery showed an enhanced tumor in the right front wall of the lower rectum. Subsequent CT revealed that the tumor was growing gradually. Peritoneal disseminated recurrence from duodenal cancer was suspected and the patient was referred to our hospital for further examination and treatment. On FDG/PET-CT, the recurrence site was limited to a solitary peritoneal dissemination and was deemed resectable. The patient underwent laparoscopic low anterior resection, including resection of the peritoneal dissemination. Histopathological findings showed that the resected tumor was consistent with metastasis from duodenal cancer. Rectal metastasis of duodenal carcinoma is very rare and there is no established treatment. Resection may be an option in treatment for limited metastases from duodenal cancer.
We present a case of locally advanced anal fistula cancer that was resected by total pelvic exenteration with genitalia resection and extensive perineal skin tissue resection. The patient was a 56-year-old man with a history of anal fistula treated at another hospital 15 years earlier. He was referred to our hospital for intractable anal fistula exacerbation and presented with many fistulas and drainage from the buttocks to the scrotum and penis. He was diagnosed with anal fistula cancer by biopsies from a fistula in the posterior wall of the anal canal. Preoperative CT and MRI revealed small bowel fistulas and suspected fistulas involving the urethra and bladder, which caused severe inflammation in the perineum. We performed sigmoid colostomy to improve his general condition prior to curative surgery. The patient then underwent total pelvic exenteration with genitalia resection, extensive perineal skin tissue resection, and treatment with a rectus abdominis musculocutaneous flap. He is currently alive without evidence of recurrence 19 months after surgery. For locally advanced anal fistula cancer with massive invasion into surrounding tissues and perineal skin, a wide en bloc resection including external genital resection is the preferred treatment.