Ablation by 30 mCi radioiodine (I-131) has been performed in 102 patients with thyroid cancer at Tokyo Women's Medical University Hospital since it was approved in Japan in 2010. Herein, we report our success rates and problems encountered. Ablation was considered successful if thyrotropin-stimulated thyroglobulin level was <= 2 ng/mL, the I-131 whole body scan was negative for anti-thyroglobulin (TgAb)-negative patients, or if the I-131 whole body scan was negative for TgAb-positive patients. Success rates were 76.7% (95% CI : 66.0-87.4%) for TgAb-negative patients and 82.4% (95% CI : 64.2-100%) for TgAb-positive patients. Three patients required 100 mCi I-131 therapy after two unsuccessful 30 mCi I-131 ablations. The problems were inter- and intra-observer variations in the interpretation of the whole body scans and that some patients required 100 mCi I-131 ablation because of the failure of 30 mCi I-131 ablation.
Breast cancer initially metastasizes to the bone in the highest frequency and the bone metastasis is reported to be found in 30 - 85% of patients with advanced breast cancer1)∼3). As there have been few reports on comparison of prognoses between breast cancer patients with bone metastasis alone and those with organ metastasis other than the bone, we made a retrospective study analyzing prognoses of breast cancer patients with bone metastasis. We enrolled a total of 222 patients diagnosed with breast cancer with bone metastasis in our hospital from June 1997 to December 2013. They were divided into three groups by the initial recurrence sites ; the bone alone (Group A), organs other than bone (Group B), and the bone and other organs simultaneously (Group C). These patients were followed up for 60 months. The survival time without having aggravation was as longest as 48.2 months in the Group A, followed by 42.2 and 42.0 months in the Group C and B, respectively. The mean survival rates during the follow-up period were 86%, 73%, and 65% in the Group A, B, and C, respectively. A significantly longer survival rate was noted in the Group A (p=0.036) which was composed of patients who had initial metastasis to the bone alone. From these findings, a long-term survival can be expected for breast cancer patients whose initial metastasizing site is bone alone.
On pathological examination, minocycline-induced blackish brown pigmentation in thyroid tissue is termed black thyroid and is very rare. The patient was a 52-year-old woman treated with minocycline for about 20 years for a skin disease. A thyroid tumor was noted during follow-up after surgery for breast cancer. On thorough examination, it was diagnosed as papillary thyroid carcinoma, and total thyroidectomy and cervical lymph node dissection were scheduled. The thyroid, showing blackish brown discoloration, was observed during surgery, but the surgery was completed without changing the surgical procedure. The patient's postoperative course was favorable. On histopathological examination, the deposition of a melanin-like substance in the cytoplasm of follicular cells was observed in the non-tumorous region of the thyroid, based on which it was diagnosed as black thyroid. Black thyroid lacks clinical characteristics other than a blackish brown color, and most cases are incidentally discovered during surgery or autopsy. It is not necessary to take specific action once it is identified, but it is a rare disease, and it may not be readily diagnosed unless it is already known to be present. Thus, this case is reported along with a literature review.
A 73-year-old man presented to our hospital because a nodule measuring 2cm in diameter in the right lobe of the thyroid 5 years earlier increased to 4cm in diameter. He also had subjective symptom of the cervical mass. On ultrasonography, the nodule about 4cm in diameter revealed homogenous hypoechogenicity. Fine needle cytology revealed undeterminated diagnosis. CT showed the thyroid nodule measuring 4.4cm in diameter without extension to the adjacent tissues, lymph node metastasis, and distance metastasis. Operative procedures included total thyroidectomy and D2a lymph node dissection. The histopathological diagnosis was papillary thyroid carcinoma with fasciitis-like stroma (PTC-FS), invasion to the trachea and metastatic right III lymph node. Sixteen months after the operation, he developed rapidly local recurrence in the neck, solitary metastasis to the left frontal lobe, and multiple metastases to the bone, lung and liver, and died of abrupt worsening of the disease. In some cases, the prognosis of PTC-FS can be poor when PTC-FS has enlarged rapidly. In the future, it will be extremely important to perform radioiodine treatment and/or molecular targeting treatment for PTC-FS when poor prognosis is speculated.
A 31-year-old man was referred to our clinic for evaluation of hypercalcemia. Ultrasonography revealed three enlarged parathyroid glands. Enhanced CT scan showed a large tumor measuring 12 cm in maximum diameter in the anterior mediastinum. Multiple endocrine neoplasia type 1 with primary hyperparathyroidism and a thymic neuroendocrine tumor was suspected, and extended total thymectomy and partial lobectomy of the right lower pulmonary lobe through a median sternotomy were performed at first. The pathological diagnosis of atypical carcinoid made him undergo external radiation therapy at 60 Gy for the mediastinum. A mutation of the MEN1 gene was also identified by a genetic analysis. Thereafter, a total parathyroidectomy with autotransplantation to the forearm was performed, and the pathological diagnosis was multiglandular parathyroid hyperplasia. His postoperative calcium level is within the normal range on oral supplementation of 1μg alfacalcidol per day, and recurrent carcinoid or newly developed MEN1-related tumors are not found, as of six months after the parathyroid surgery.
Neuroendocrine carcinoma (NEC) of the breast has similar histological features to those of NECs of the gastrointestinal tract and lungs, and expresses neuroendocrine markers. In 2012, the World Health Organization defined such breast cancers as ‘carcinoma with neuroendocrine features’, which has further been classified into three subtypes. Breast NEC is relatively rare and represents approximately 2-5% of all breast cancers ; male cases of the disease are reported to represent 0.1% of all male invasive breast cancers. A 73-year-old man was admitted to our hospital because of recurrence of clavicular masses that had been partly excised 10 years previously. Recurrent NEC was strongly suspected on core needle biopsy, and multiple metastases to the bones, pleura and mediastinal lymph nodes were also identified. The primary lesion was considered to be in the mammary gland. Since the tumor cells were positive for both the estrogen and progesterone receptors. Treatment with tamoxifen was initiated. As a result, pleural effusion and tumor marker expression were reduced. The patient has maintained on this therapy.
A 54-year-old woman was diagnosed with inoperable breast cancer (T2 N1 M1 (PER, PLE), Stage IV) and received chemotherapy with paclitaxel (PTX). She showed primary tumor reduction and disappearance of her pleural effusion, but her ascites remained unchanged. On laparoscopic examination, the entire peritoneum was thickened, and the small intestine, colon, and omentum coalesced to form an omental cake. Part of the peritoneum was submitted for pathological examination, and it showed peritoneal dissemination of breast cancer. Based on these results, PTX and bevacizumab (BV) combination chemotherapy was started, and the ascites decreased. However, gastrointestinal perforation occurred on the 26th day of the 2nd course of PTX + BV, and emergency surgery was performed. During the operation, the omental cake was removed, and it was possible to examine the full length of the gastrointestinal tract. Two small perforations of the small intestine were recognized 120 cm from the ligament of Treitz. Simple closures of the perforations and peritoneal lavage drainage were performed. Although the patient had septic shock, she improved. It was thought that the small intestinal perforations had occurred because the addition of BV was very effective as chemotherapy. Gastrointestinal perforation caused by BV given for breast cancer is very rare and has not been reported so far in Japan. This very rare and valuable case was reported along with a discussion based on the literature.
A 30-year-old man was admitted to our hospital with abdominal pain. He reported no significant medical history. The abdominal pain became severe after hospitalization, and we performed surgery. We found small intestinal segmental necrosis at laparotomy, and performed segmental resection. Twenty-five days later, he developed a pulmonary infarction and portal vein thrombosis. Blood examination confirmed congenital antithrombin III (AT-III) deficiency. Pulmonary infarction and portal vein thrombosis resolved with thrombolytic and anticoagulant therapy. However, he developed an adhesive ileus. The ileus did not improve, and we performed reoperation with administration of concentrated AT-III. The postoperative course was uneventful, and he was discharged 32 days after reoperation. We report the details of the case and present a literature review.
Papilloma of the lung concomitantly occurred with lung cancer is extremely rare. A 70-year-old woman was referred to our hospital with a mass in the right upper pulmonary lobe incidentally discovered on a chest X-ray film. Serial CT examination confirmed another smaller mass in the left lower lobe. Both lesions gradually grew. Bronchoscopy revealed the right lesion as squamous papilloma. Video-assisted right upper lobectomy and wedge resection of the left lower lobe were performed. Histological diagnoses were squamous papilloma for the right lesion and papillary adenocarcinoma for the left. Her postoperative course was uneventful and she has been free from recurrence, as of one year after the operation. Solitary papilloma of the lung or bronchus, especially coexisting with primary lung cancer, is extremely rare. In our case we supposed that they coexisted incidentally because the coexisting cancer was adenocarcinoma which is a rarely associated histologic type, they were not adjacent each other, and she did not have shared risk factors such as smoking history and human papilloma virus infection.
A 63-year-old man, who complained of cough and exertional dyspnea and was found to have massive pleural effusion on chest radiography, was admitted to our hospital for further examinations. Multiple extrapleural and diaphragmatic nodules were observed on a chest CT scan, but no evidences of parenchymal lung diseases and abnormal signs of mediastinum were found. There was no malignancy in the pleural fluid cytology and so thoracoscopy was performed for diagnosis. There were many black or brown nodules of all sizes on the visceral and parietal pleura and diaphragm. Thoracoscopic biopsy of these lesions offered the definite diagnosis of malignant melanoma. The melanoma was considered to have originated in the congenital nevus on the back skin.
We describe a case of paraesophageal hernia with herniation of the stomach and transverse colon treated by laparoscopic mesh repair. A 59-year-old woman was detected an abnormal shadow in the left thoracic cavity on a chest x-ray examination at a medical checkup. Thoracoabdominal CT scan demonstrated herniation of the stomach and transverse colon through the left diaphragm. She had postprandial distress and we performed laparoscopic repair electively. We found a type IV paraesophageal hernia with prolapsed stomach and transverse colon. The herniated stomach and transverse colon were easily reduced into the abdomen. The hiatal hernia defect was closed by primary suture of the diaphragmatic crus and was reinforced by ParietexTM Composite (PCO) mesh placement. Fundoplication with the Toupet method was then performed. After the surgery, the patient has been in good condition, without any recurrence of hiatal hernia.
An asymptomatic 65-year-old man undergoing screening esophagogastroduodenoscopy was found to have a broad redness area with an elevated lesion in long-segment Barrett's esophagus (LSBE) which had encircled the entire esophagus and spread 15 cm in length. Based on the biopsy findings, esophageal adenocarcinoma in LSBE was diagnosed. The endoscopic resection of the lesion was thought to be difficult due to the fuzziness of the tumor margin and the broadness of the lesion from the findings of narrow band imaging with magnifying endoscopy observation and multiple biopsies. He underwent thoracoscopic esophagectomy with mediastinal lymphadenectomy and gastric tube reconstruction. Histopathological findings of the resected specimen demonstrated the existence of LSBE with broad spreading well differentiated Barrett's adenocarcinoma 12 cm in length occupying almost whole area of LSBE. The deepest area of the cancer had infiltrated beyond the neomuscularis mucosae (pT1a-LPM) and no lymph node metastasis was observed. We experienced a rare resected case of Barrett's adenocarcinoma spread over almost whole area of broad LSBE.
The patient was a 71-year-old man with a history of total gastrectomy with D2 lymph node dissection for type 2 gastric cancer located at the middle of the gastric body. The histological diagnosis was poorly differentiated adenocarcinoma and signet ring cell carcinoma (pT2 (MP), ly1, v0) without lymph node metastasis. Both the proximal and distal margins were negative for cancer. Esophagogastrointestinal endoscopy about 1 year after the first operation showed esophageal recurrence. Curative resection of the tumor was carried out. The tumor started at a point about 5 mm proximal to the staple line. The histological type was again poorly differentiated adenocarcinoma and signet ring cell carcinoma (T1a (MM), ly0, v0) without lymph node metastasis. It was concluded that primary gastric cancer cells were implanted in a part that suffered esophageal injury at the time of automatic suture device insertion.
The patient was an 82-year-old man who had undergone extensive gastrectomy with Billroth-I reconstruction for duodenal ulcer in his twenties. He complained of reflux symptoms and underwent upper gastrointestinal endoscopy, which revealed an elevated lesion with a central depression (5 mm in diameter) on the anterior wall of the greater curvature side of the site of residual stomach-duodenum anastomosis. On a biopsy, the lesion was diagnosed as a G1 neuroendocrine tumor (NET). Endoscopic ultrasonography (EUS) indicated that the tumor had invaded the fourth layer, and the depth of invasion was predicted to be deeper than the lamina propria. Considering the patient's great age, we planned to perform laparoscopic and endoscopic cooperative surgery (LECS) for local resection of the anastomosis site. A sufficient surgical margin from the tumor was secured, and all layers were perforated using a needle knife. Then, the anastomotic site was locally resected under laparoscopy along the perforated marking, and the defect was closed by laparoscopic suturing. Histopathologically, the surgical margin of the resected specimen was negative. The use of LECS for NET at the anastomosis site enabled us to completely resect the tumor and preserve the organ function.
A 58-year-old man consulted a local medical clinic, complaining of malaise and abdominal pain. Computed tomography (CT) revealed a granular shadow and cavernous lesions in both lungs, and an intraperitoneal abscess with a gas collection. Sputum and gastric aspirate smears showed tuberculosis infection. He was transferred to our hospital with the diagnosis of active pulmonary tuberculosis and gastrointestinal perforation due to intestinal tuberculosis. We considered emergency surgery for the intraperitoneal abscess, but his overall clinical and nutritional status was poor, and the risk of surgery was considered very high. Conservative treatment was provided, and elective surgery was planned after his nutritional status was improved. We started antituberculous drugs, continued drainage for the intraperitoneal abscess and administered antibiotics. The intraperitoneal abscess gradually developed a fistula and remitted. He was discharged on the 115th hospital day. We report a case of jejunal perforation and intraperitoneal abscess due to intestinal tuberculosis that was treated conservatively.
Duplication of the gastrointestinal tract is a congenital disorder that can occur anywhere in the gastrointestinal tract and present with a variety of abdominal symptoms. This congenital disorder is usually discovered during early childhood and is relatively rarely found in adults. Strangulated intestinal duplication has seldom been reported, and preoperative diagnosis is difficult. An adult patient with strangulation of duplicated intestine who presented with an acute abdomen is reported along with a discussion of the relevant literature. A 33-year-old man developed colicky pain after eating lunch. Later that night, he had severe abdominal pain and vomiting, and he was evaluated in an emergency department. Abdominal contrast CT at the time of arrival showed dilated small bowel in the lower abdominal midline with proximal intestinal strangulation. The patient was diagnosed with strangulation ileus, and an urgent laparotomy was performed. At 210 cm from the ligament of Treitz, normal intestine crossed the duplicated intestine, and at this branch point, there was clockwise rotation of 720° with ischemia. A partial small bowel resection, including the intestinal duplication, was performed. The patient had a satisfactory postoperative course and was discharged 4 days after surgery.
A 72-year-old man who had undergone an operation for cholecystocholedocholithiasis 30 years ago was referred to our hospital because of abnormal findings on chest radiography. His chest computed tomography (CT) revealed an abnormal mass with a 45-mm diameter in the hepatic flexure of the colon. A foreign body was suspected and we performed tumorectomy for diagnosis. We found that the mass was present in the transverse mesocolon. Because it adhered to the transverse colon and pancreatic head, we resected the mass with the portion of the transverse colon to which it adhered. Postoperative pancreatic fistula and anastomotic leakage were observed and treated using drainage alone. Histopathologically, the mass was filled with coagula, with many fragmented surgical sutures in the fibroid wall region of the mass. Therefore, we diagnosed an iatrogenic mesenteric artery aneurysm due to the previous operation. Aneurysms of the mesenteric artery are usually diagnosed following intraabdominal hemorrhage or gastrointestinal bleeding due to aneurysmal rupture. This case is rare because it was asymptomatic and was incidentally detected via CT.
A 67-year-old man presented with the complaints of fever, right-sided coxalgia, and right lower abdominal pain. An abdominal CT revealed a thickened wall of the appendix and abscess formation in the right iliopsoas muscle. Subsequent colonoscopy confirmed diagnosis of cecal cancer (moderately differentiated adenocarcinoma) with an iliopsoas muscle abscess. A laparoscopy-assisted ileocecal resection with D3 lymph node dissection and abscess drainage were performed. A few detectable disseminations were detected in the small intestinal mesentery, but all the visualized lesions were fully resected. There have been reports of colon cancer complicated by iliopsoas muscle abscess, but this is the only case in which the condition was treated by laparoscopic surgery. Laparoscopic-assisted surgery allows us to identify local lesions and observe the retroperitoneum at a low level of invasiveness. This case would be of interest for adaptation and the expansion of laparoscopic surgery.
In this case report, we describe a rare case of heterochronous colon metastasis from a fallopian tube carcinoma. The patient was a woman in her 70's who presented to us with a history of having undergone simple total hysterectomy, bilateral salpingo-oophorectomy, omentectomy and sigmoidectomy for left fallopian tube cancer with possible direct invasion of the sigmoid colon. The cancer was diagnosed by histopathology as a serous adenocarcinoma, pT1c Nx(cN0) M0, stage I. Postoperative adjuvant chemotherapy was not employed. An abdominal CT performed 3 years after the operation showed nodular shadows suggestive of peritoneal dissemination in the pouch of Douglas and behind the ascending colon. Total colonoscopy revealed a type 1 intraluminal tumor of the ascending colon. Because the patient was suffering from severe anemia caused by bleeding from the tumor, we performed open ileocecal resection. The histo-pathology report revealed serous adenocarcinoma with lymphatic invasion and lymph node metastasis, and the histological type was identical to that of the previously resected fallopian cancer. As there was no evidence of penetration of the surface of the visceral peritoneum by the tumor, it was considered that the metastasis had occurred via the lymphogenous route.
An 83-year-old woman was seen by a local physician for a chief complaint of constipation with abdominal pain, and she was sent to our hospital with a suspected obstructive ileus. CT showed circumferential thickening of the descending colon wall, marked dilation of the proximal colon, left hydronephrosis, and a left upper ureteral mass. Imaging showed two lesions at separate sites. Because of a high risk of large bowel perforation, a colostomy with double transverse colon orifices was urgently performed on the same day as the referral. A colonoscopy, which was later performed, showed a stricture in the descending colon, but a biopsy showed no malignant findings. Urine cytology also showed no malignant findings, but clinically, the patient was diagnosed with double cancers of the descending colon and left ureter. A left hemicolectomy, left nephrectomy, and total resection of the left ureter were performed. Macroscopic examination of the resected specimen showed hard fibrotic thickening of the descending colon wall, but the mucosal surface was intact, without evidence of colon cancer. Histopathology showed tissue resembling ureteral transitional cell carcinoma (TCC) in the descending colon wall, and the lesions were not contiguous, so the diagnosis was ureteral TCC with descending colon metastases. This rare case of ureteral TCC with colon metastases is reported.
A 49-year-old woman with a positive fecal occult blood test on medical examination, underwent lower digestive tract endoscopy, and was diagnosed with type 0 -I sp early sigmoid colon cancer of a 20 mm diameter. The polyp was excised by endoscopic mucosal resection and pathologically analyzed. The pathology results revealed a moderately differentiated tubular adenocarcinoma, which had invaded upto the submucosa, with a cancer positive vertical-stump. Laparoscopic sigmoid colectomy (D2 dissection) was performed after two months. No residual tumor cells were found in the resected specimen, which showed four pericolic lymph node metastases (pT1N2aM0, Stage IIIA). As the back pain persisted from perioperative period deteriorated, the patient underwent bone scintigraphy and MRI. Bone metastasis of 2nd thoracic vertebra was susected. The results of a needle biopsy confirmed a diagnosis of bone metastasis of the colon cancer ; hence, she was given chemoradiation. The pain was alleviated ; although the chemotherapy was continued the tumor was at an increased trend, and she died at 1 year and 8 months after surgery.
An 80-year-old man was transported to our hospital with melena and epigastralgia. Abdominal enhanced CT revealed findings suggestive of cholecystic hemorrhage. Laboratory tests revealed significant prolongation of the prothrombin time due to the warfarin that the patient was taking for deep venous thrombosis. Therefore, Vitamin K was administered first for neutralizing the warfarin. Then, a nasobiliary drainage tube was inserted endoscopically for relief of the cholestasis caused by the bleeding into the bile duct. Unfortunately, blood discharge from the nasobiliary drainage tube persisted, and the patient's anemia became worse. Therefore, on the following day, urgent laparoscopic cholecystectomy was performed. Cholecystic hemorrhage is comparatively rare, reportedly accounting for only about 1% of all cases of upper gastrointestinal bleeding. Because of the risk of complication by hemorrhagic shock, prompt diagnosis and treatment are needed. In this case, laparoscopic cholecystectomy was urgently performed for the cholecystic hemorrhage. In patients with stable hemodynamics, early laparoscopic cholecystectomy is a valid treatment modality for cholecystic hemorrhage, as this therapy is radical while being less invasive.
A 67-year-old woman was referred to our hospital for further evaluation of a submucosal tumor (SMT) located at the posterior wall of the stomach. She had undergone distal pancreatectomy 22 months prior for pancreatic body cancer diagnosed using trans-gastric endoscopic-guided fine needle aspiration (EUS-FNA). Esophagogastroduodenoscopy revealed that the SMT was located very close to the puncture site of the previous EUS-FNA. In addition, a biopsy specimen of the SMT demonstrated tubular adenocarcinoma resembling the resected pancreatic body cancer. Needle tract seeding (NTS) of the pancreatic cancer to the gastric wall was suspected, and we performed partial resection of the stomach. The immunohistochemical staining pattern of the SMT was completely consistent with the resected pancreatic cancer, indicating NTS caused by EUS-FNA. Although NTS is a very rare complication of EUS-FNA, careful attention should be paid to the gastric wall after distal pancreatectomy in patients who were previously diagnosed by trans-gastric EUS-FNA.
A 63-year-old man with untreated diabetes visited a local hospital for abdominal pain and was admitted with a diagnosis of cellulitis. He was subsequently transferred to our hospital because his abdominal pain exacerbated. He did not present with muscular guarding, but had necrosis and tenderness in the epigastric region, as well as a subcutaneous abscess in the left side of the trunk. His abdominal computed tomography revealed a large amount of gas in the left side of the trunk, which had caused the abdominal wall all layers in the umbilical left. There was no free gas image and ascites in the abdominal cavity. Debridement was immediately performed under the diagnosis of necrotizing fasciitis. Leading to the umbilical left, feces were discharged. The site of perforation was identified to be the diverticulosis of the sigmoid colon. We had diagnosed necrotizing fasciitis caused by penetration of a sigmoid diverticulum, and performed the Hartmann operation. Here, we thus present a case of necrotizing fasciitis caused by penetration of a sigmoid diverticulum.
A case of omental panniculitis associated with appendectomy is described. A 54-year-old woman was admitted to hospital for abdominal pain and diagnosed with acute appendicitis when she was travelling abroad. Appendectomy was performed. After she returned home, she developed symptoms of generalized peritonitis. Abdominal CT showed inflammation of the greater omentum, pericardial and pleural effusions, and ascites. Because she was diagnosed with omental panniculitis, laparotomy was performed. Histopathological findings showed infiltration of neutrophils throughout the entire greater omentum. After operation, steroid and antibiotics were administered intravenously, and she was discharged on the 14th day after the second operation. A case of omental panniculitis occurring immediately after appendectomy is rare.
A 37-year-old woman was found to have a tumor 38 mm in longer diameter at the presacral area at a one-month postpartum examination. The tumor showed no enhancement effect on a contrast-enhanced CT scan. It showed high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. There was no continuity with surrounding organs and preoperative diagnosis was difficult. She was thus referred to our hospital for the purpose of operation and treatment. We were required to consider various differential diagnoses including ovarian tumor, GIST, sarcoma, lymph node swelling, and retroperitoneal tumor whether it was benign or malignant. Laparoscopic tumorectomy was performed for the treatment and diagnosis. Operative findings included a white hen's egg-sized tumor in the pelvic cavity which had no continuity with the surrounding tissues and was completely freed in the abdominal cavity. The tumor was removed. The histopathological diagnosis was leiomyoma. Since she had no previous history of abdominal surgery, the tumor was considered to be a spontaneous parasitic myoma. The laparoscopic surgery was less invasive and useful in the diagnosis and treatment.
A 68-year-old woman visited our hospital with right lower quadrant pain, abdominal distension, and metrorrhagia. Abdominal CT and MRI showed massive ascites and an enhancing tumor in the region of the ileocecum. Laparotomy revealed a large amount of mucus and a ruptured tumor of the appendix. Ileocecal resection was performed, and sodium bicarbonate was used for dissolution of the mucus. Although the tumor was diagnosed as a mucinous adenocarcinoma, there has been no evidence of recurrence during the course of the 4 years since the surgery. Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy, known as a standard therapy for pseudomyxoma peritonei, is a highly invasive operation with a high morbidity rate, that is uncommonly performed, except at some specialized institutions. In our case of pseudomyxoma peritonei, sodium bicarbonate seemed to be useful for removal of the mucus.
The case involved a 78-year-old man whose screening abdominal CT scan performed for aggravation of diabetes mellitus revealed a plethoric cystic tumor at the caudal side of the inferior flexure of duodenum. Duodenoscopy revealed extramural compression at the inferior flexure of duodenum. Laparoscopic surgery was performed with a diagnosis of a submucosal tumor arisen in the duodenum or a mesenteric tumor of the ascending colon. In operative findings, it was a retroperitoneal tumor, and at the dorsal aspect of the tumor, firm fibrous adhesions between the aorta and the inferior vena cava were seen, among of which there were multiple short arteries and veins which directly drained into and outpoured from the tumor. Laparoscopic surgery enabled us to see the dorsal aspect of the tumor through the horizontal view, so that we were safely able to treat the short pedunculated tumor vessels which drawn into the dorsal aspect of the tumor. The removed specimen showed a 55×42 mm tumor in which solid and cystic parts were concomitantly present. The pathological diagnosis was paraganglioma. We present a case of retroperitoneal paraganglioma, a rare entity, resected by laparoscopic surgery.
A 35-year-old man developed sudden and severe abdominal pain and vomiting. Multidetector row computed tomography showed multiple gas-filled loops in the lesser sac posterior to the liver hilum and anterior to the inferior vena cava, and revealed intestinal obstruction due to herniation through the foramen of Winslow. We attempted placing a long intestinal tube in expectation of spontaneous hernia reduction. However, the treatment was ineffective, and we performed emergent laparotomy. The ileum was invaginated through the foramen of Winslow, and we reduced it manually. As the ileum had progressed to ischemia and necrosis, we performed intestinal resection and closed the foramen of Winslow. Surgery is considered as definitive and standard therapy and is clearly superior to preservative therapy with a long intestinal tube. Recent reports suggest that laparoscopic surgery can be performed for this condition. However, emergent surgery should be carefully considered on an individual basis, with emphasis on safety in this benign disorder.
Linea alba hernia is an abdominal hernia in which preperitoneal adipose tissue or intraabdominal organ has prolapsed from a split of aponeurosis of abdominal rectus muscle. We report a case of linea alba hernia in which prolapsing preperitoneal adipose tissue could be restored by preperitoneal approach following single-incision totally extraperitoneal (TEP) approach. A 46-year-old man was diagnosed as having linea alba hernia by CT enforced by the examination of an epigastric subcutaneous mass. During an operation, hernia orifice was not observed as a view from the abdominal cavity, but it was observed as a prolapse of preperitoneal adipose tissue from the linea alba in exfoliated extraperitoneal-space. We enforced reinforcement by the mesh after entire detachment of the contents. This is the first reported case treated by single-incision laparoscopic surgery against the adult linea alba hernia in Japan, then we report the details including consideration from the literature.
A 77-year-old woman presented to a neighboring clinic with a 4-day history of gradually increasing swelling and pain of a pre-existing lump in the right groin. The patient was diagnosed with incarcerated femoral hernia, and was referred to our hospital for further evaluation and treatment. Abdominal ultrasonography and contrast-enhanced CT scan revealed a right femoral hernia with incarceration of the appendix within the hernia sac. We performed routine open appendectomy, and the hernia was repaired by using UHS® mesh via the same site. Up to the present date, the patient has been doing well, without postoperative complications or recurrence. A femoral hernia is a relatively common disorder in middle-aged to elderly postmenopausal women, which entails a high risk of strangulation (30-50%). De Garengeot hernia is defined as a femoral hernia incarcerating the appendix vermiformis within a femoral hernia sac, and has rarely been reported. This article describes our case of de Garengeot hernia.
Popliteal venous aneurysm (PVA) is rare and causes fatal acute pulmonary embolism. A 70-year-old woman was admitted to our hospital for palpitation and shortness of breath on exertion. A computed tomography scan revealed multiple pulmonary artery emboli and right saccular PVA (20 mm diameter × 6 cm length) with a thrombus. She was immediately started on thrombolytic therapy ; the thrombus in the saccular PVA disappeared. She was followed up with novel oral anticoagulants (NOACs) for anticoagulation therapy. The thrombus in the PVA recurred (5 months after the onset of acute pulmonary embolism) and we recommended surgical treatment. Lateral tangential aneurysmectomy and lateral venorrhaphy for the saccular PVA were performed. No postoperative complications occurred, and she was discharged on the 9th postoperative day. She was followed up with NOACs for anticoagulation therapy and use of compression stockings. At the seven months after surgery, no recurrence of PVA was seen. Surgical treatment of symptomatic PVA is a safe and useful strategy.
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