Circulating galectin-3 (gal-3) has been reported to induce angiogenetic factors, such as vascular endothelial growth factor (VEGF), intercellular adhesion molecule (ICAM)-1, granulocyte colony-stimulating factor (G-CSF), granulocyte macrophage colony-stimulating factor (GM-CSF), and interleukin (IL)-6. Circulating gal-3, VEGF, G-CSF, and IL-6 concentrations were investigated in patients with hepato-biliary and pancreatic cancer (n = 63), in relation to various nutritional and inflammatory factors, such as retinol binding protein, transferrin, prealbumin, C-reactive protein (CRP), white blood cell count (WBC), and the neutrophil/lymphocyte ratio (NLR). Serum galectin-3 concentrations were significantly higher in patients than in healthy controls (P < 0.001). Circulating gal-3 concentrations were significantly correlated with VEGF, ICAM-1, G-CSF, and NLR concentrations (P < 0.05), whereas they were inversely correlated with IL-12 production (P < 0.05). Circulating gal-3 might have a role in the induction of angiogenetic factors and Th-2-dominant immunological status in hepato-biliary and pancreatic cancer.
Splenic vein ligation with superior mesenteric vein-portal vein confluence resection at the time of pancreatoduodenectomy may result in sinistral portal hypertension presenting with congestive gastric bleeding or a decreased platelet count due to hypersplenism. Two cases who underwent pancreatoduodenectomy with division of the splenic vein and creation of a splenorenal shunt to prevent this serious complication are described. The patients were 68 and 75-year-old woman, who both had locally advanced pancreatic ductal adenocarcinoma without any distant metastases. Subtotal stomach-preserving pancreatoduodenectomy including a distal splenorenal shunt was performed. Their postoperative courses were uneventful, and postoperative CT angiography showed good patency of the shunt without any findings of gastrosplenic congestion in both cases. The clinical significance of splenic vein ligation and sinistral portal hypertension remains controversial, but this condition has been emerging as a delayed and serious complication with potentially fatal consequences after pancreatoduodenectomy with resection of the mesenteric-portal vein confluence. Our early assessment shows that a distal splenorenal shunt is a safe and feasible procedure for avoiding sinistral portal hypertension after splenic vein ligation.
The patient presented with a right axillary tumor and numbness of the upper limb had been treated for a right axillary lymph node swelling and hyperleukocytosis with a diagnosis of axillary lymphadenitis at a neighboring hospital. The tumor lesion did not respond to the therapy and the patient was referred to our hospital. When the patient was first seen, the right axillary tumor was 6 × 5 cm in diameter, elastic-hard, clearly demarcated, and ill-movable. A fine needle aspiration biopsy revealed a suspected diagnosis of lymph node metastasis of adenocarcinoma. Despite various examinations, the primary lesion was still unknown. A FDG PET/CT showed diffuse abnormal accumulations of FDG in the right axillary tumor and bone tissues in the body trunk. The measurement revealed a high serum level of granulocyte-colony stimulating factor (G-CSF). The removal of the tumor succeeded normalization of the increased white blood cell count and high serum G-CSF level. Immunohistochemistry using anti-G-CSF monoclonal antibody did not prove the existence of G-CSF. Adjuvant chemotherapy was not added. The patient has been free from recurrence, as of about two years after the operation. We present a case of metastatic axillary adenocarcinoma of unknown primary site suggestive of G-CSF production.
A 12-year-old girl consulted a pediatric clinic with a 2-year history of a rapidly growing mass in the right breast. Physical examination revealed a firm, elastic, well-defined tumor occupying the entire right breast. On ultrasound, a well-circumscribed hypoechoic tumor containing cystic spaces was observed. Core needle biopsy revealed findings consistent with a fibroadenoma, although the possibility of a phyllodes tumor was also considered. Surgical excision of the tumor was performed. The tumor was 13 cm in diameter and weighed 540 g. Histopathologically, the tumor was diagnosed as a giant juvenile fibroadenoma. At the annual follow-up examination, there was no evidence of recurrence and normal function and appearance of the breast were maintained. Giant fibroadenomas are rare, usually occurring in girls between 10 and 18 years of age, and are characterized by massive and rapid enlargement of an encapsulated mass. They can grow to huge sizes and compress the surrounding normal breast tissue. Giant fibroadenomas are almost always benign and should be treated by breast-conserving surgery. Especially in young adult women, it is important to preserve the normal function of the breast and also consider cosmetic satisfaction.
Angiosarcoma is a rare and unfavorable disease among breast tumors. A 70-year-old woman who had undergone bilateral breast augmentation with silicone gel bags 20 years ago, presented with discomfort itching, and redness in the left breast in May 2012. No tumor was observed on mammary ultrasonography. Initially, we administered antibiotics under the diagnosis of mastitis. After unsuccessful treatment of the mastitis, an oncology consultation was obtained. In October 2013, a breast mass was found unexpectedly, close to the nipple of the left breast, on abdominal magnetic resonance imaging (MRI) for follow-up of a hepatic tumor. The breast mass showed similar findings on breast contrast-enhanced MRI. Although incisional biopsy did not reveal a definitive diagnosis, angiosarcoma was suspected based on the pathological findings. Therefore, we performed left mastectomy with removal of the silicone gel bag. Finally, the tumor was confirmed as angiosarcoma. She is currently without evidence of disease recurrence.
We report two cases of recurrent breast cancer with ophthalmic metastases manifesting as visual loss. Case 1 : A 64-year-old woman presented to us with loss of vision on the right side. She had undergone bilateral breast-conserving surgery for bilateral breast cancer 11 years previously. Based on the examination findings, she was diagnosed as having right choroidal metastasis from breast cancer. Case 2 : A 55-year-old woman developed rapidly progressive visual loss on the right side and central scotoma. She had undergone right mastectomy for right breast cancer 5 years previously. Based on the examination findings, she was diagnosed as having right orbital metastasis with multiple bone, lung, and liver metastases. Both patients received radiotherapy for urgent local management of the ocular metastatic disease, in addition to systemic therapy, which was effective for preventing visual loss and improving the vision. Recurrent breast cancer with ophthalmic metastasis is rare. Early diagnosis and prompt and adequate treatment of this condition are essential.
There are few reports of abdominal aortic aneurysm (AAA) infection with Campylobacter fetus. We report a case of AAA infected with C. fetus, in which the aneurysm rapidly expanded. A 65-year-old man initially presented with the chief complaint of high fever and severe lumbar pain. Contrast-enhanced computed tomography (CECT) on arrival showed a 43-mm fusiform AAA with a slightly thickened aortic wall, suggestive of either an inflammatory or an infected AAA. The symptoms improved with antibiotic administration for three days. However, the C-reactive protein level remained high. Two sets of blood cultures collected on admission revealed the presence of C. fetus on day 13. CECT on day 14 showed that the AAA had rapidly expanded to 55 mm in diameter. We diagnosed an AAA infected with C. fetus, and performed replacement in situ surgery using a rifampicin-bonded graft, due to the high risk of rupture. At the 5-month follow-up, the patient was symptom-free and follow-up CT was uneventful.
Pulmonary tumor thrombotic microangiopathy (PTTM) is a cancer related complication presented with pulmonary hypoxemia and hypertension. It is pathologically characterized by tumor embolus of the peripheral lung arteries and fibro cellular intimal proliferation with eccentric luminal narrowing. We report a case of a 68-year-old female patient with breast cancer associated with PTTM. The patient who had a 3-week history of exertional dyspnea was admitted to our hospital with a diagnosis of moderate pulmonary hypertension and severe hypoxemia. Enhanced computed tomography ruled out a diagnosis of acute pulmonary embolism, but revealed Stage IV left breast cancer with bone metastasis. PTTM was suspected and iodine density images showed poor blood flow on the peripheral lung that was compatible with PTTM. Hypoxemia rapidly progressed and she died on the tenth day of admission. The needle necropsy findings revealed tumor embolus and wall thickening of the peripheral pulmonary arteries that led to the final diagnosis of PTTM. When observing progressing hypoxia without findings of pulmonary embolism in patients with cancer, PTTM is one of the differential diagnosis.
When the aorta is damaged during blunt injury, the patient may die before arriving at the hospital, and saving the aorta may be difficult. We used thoracic endovascular aortic repair (TEVAR) for insulted aortic treatment in a short time period along with diaphragmatic treatment. A 32-year-old man was injured because of a motorbike accident. He was in a shock state when he was brought in an ambulance. He was diagnosed with traumatic diaphragmatic hernia and thoracic aortic injury by Chest X-ray and enhanced computed tomography (CT). His diaphragm was restored by laparotomy after TEVAR under general anesthesia. He was discharged 23 days postoperatively. Priority of the treatment to the multiple diseases of the patient is important, and the combination of TEVAR was thought to be effective during multiple injuries with aorta damage.
A 79-year-old woman presented at our hospital with severe upper abdominal and back pains. On arrival, she was in shock and had a blood pressure of 50/30 mm Hg. Abdominal computed tomography revealed incarceration of the transverse colon and the entire stomach within a hiatal hernia. Emergency surgery was performed. The hernial orifice was 7 cm in diameter. The incarcerated transverse colon was already necrotic on repositioning. Segmental necrosis was also observed from the terminal ileum to the sigmoid colon. We made a diagnosis of non-occlusive mesenteric ischemia, and subtotal colectomy and iliosigmoidostomy were performed. The crura of the diaphragm were directly sutured to the hernia orifice. In spite of complications such as cerebral infarction and multiple gastric ulcers, the patient was discharged from the hospital 54 days after the operation.
The patient was an 83-year-old man who underwent curative esophagectomy with retrosternal gastric tube reconstruction by the transhiatal non-thoracic approach for esophageal cancer a year earlier. He had been followed up in a relapse-free condition. He presented with feeling of fatigue and abdominal pain, and was transferred to our hospital with a suspected diagnosis of incarcerated hiatal hernia. An emergency operation was performed because of his worsening respiratory status. Intraoperative findings showed that the transverse colon had prolapsed into the right thoracic cavity through the hiatus. Although the incarcerated hernia was released, partial resection of the transverse colon and colostomy were performed because an ischemic change was identified in the colon. The enlarged hiatus was repaired by sutures. Sometimes we encounter cases of hiatal hernia after esophagectomy, in which the reconstruction had predominantly been performed via posterior mediastinal route and extremely rarely done via retrosternal route. The mechanisms of the onset of hiatal hernia after retrosternal reconstruction are predicted to be a vulnerability of the hiatal tissue and smallness of the lateral segment of the liver. Intraoperative findings showed the hiatus to be narrow and strong but not to be covered by the lateral segment. The decrease of adhesions in the thoracic or abdominal cavity by transhiatal non-thoracic approach or HALS technique might also contribute to the risk of causing hiatal hernia after esophagectomy.
A 50-year-old woman with dysphagia lasting for a year underwent a medical check-up, and a chest-X-ray examination showed an upper mediastinal mass. Then she was referred to our hospital. Chest computed tomography scan revealed a mass lesion, 7 cm in longer diameter, located in the upper thoracic esophagus. An upper gastrointestinal endoscopy revealed submucosal tumor (SMT) at the same area. A biopsy taken from the bulging site of the tumor led to the diagnosis of schwannoma (immunohistochemically S-100 positive and c-kit, CD34, Desmin, and SMA negative). MIB-1 index was noted to be 2-3%. Since the tumor was large in size and was located in the proximity of cervical area on the left side of the esophagus, we preferred the en bloc-resection rather than the enucleation. The final histopathological diagnosis was esophageal schwannoma. Her postoperative course was uneventful. The patient was discharged from our hospital on the 21st postoperative day. Esophageal schwannoma is a relatively rare benign esophageal SMT ; to our knowledge, including ours, only 53 cases of esophageal schwannoma have been reported in the Japanese literature. In this report, we present a case of esophageal schwannoma along with a review of the literature to elucidate the clinical characteristics and the treatment strategy.
A case of intra-abdominal bleeding from a posterior superior pancreaticoduodenal artery (PSPDA) aneurysm following total gastrectomy for gastric cancer treated by transcatheter arterial embolization (TAE) is reported. Hemostasis was achieved by embolization to the gastroduodenal artery (GDA), anterior inferior pancreaticoduodenal artery (AIPDA), and posterior inferior pancreaticoduodenal artery (PIPDA). Although the primary blood supply of the head of the pancreas from both the celiac artery and the superior mesenteric artery was blocked by TAE, ischemic necrosis of the pancreas and other complications did not occur. A communicating artery such as the dorsal pancreatic artery from the splenic artery was thought to supply arterial blood flow to this region.
The case involved a 65-year-old man. A bridge type artificial tooth with clasp was recognized in the lower esophagus, and a diagnosis of foreign body ingestion (foreign body in the esophagus) was made. We tried to remove it endoscopically but it was difficult. We dropped the denture into the stomach and shifted to an emergency operation. We performed percutaneous endoscopic intragastric surgery in order to minimize the sizes of abdominal wall wound and stomach wall incision wound. A small laparotomy of 3 cm in length was placed in the upper left abdomen, and a woundretractor S was inserted. A 2-cm incision was made in the stomach wall, and a woundretractor XS was inserted. A 5-mm camera and grasping forceps were inserted into the stomach by the glove method, and the denture was identified. The denture was guided to the wound site, and extracted under direct view. By applying the percutaneous endoscopic intragastric surgery technique to the artificial tooth with clasp in the stomach, it was possible to remove the denture with the minimum incisional wound. The know-how of intra-gastric surgery, which has been conventionally performed as a surgery for early gastric cancer, is considered to be applicable also to removal of a foreign body in the stomach.
AFP-producing gastric cancer is a rare gastric neoplasm metastasizing to the lymph nodes and the liver and having a poor prognosis. In this study, we report on a patient with HER2-positive/AFP-producing/unresectable advanced gastric cancer who achieved a long-term survival following multidisciplinary treatment including trastuzumab administration. The patient was a 64-year-old man. He had type 2 gastric cancer in the lesser curvature of the gastric angle, which was unresectable and had advanced with multiple liver metastases as well as multiple lymph node metastases including the periaortic lymph node. With elevated serum AFP levels, histopathology revealed AFP immunostaining positive and HER2 protein 3+ (IHC). After three courses of S-1/CDDP/trastuzumab, the hepatic metastases and lymphadenopathy were not indicated. Elevated serum AFP levels and re-enlargement of the regional lymph nodes appeared four months following the start of the treatment. Although the primary tumor had shrunk, it was diagnosed as group four upon a biopsy. Distal gastrectomy was performed five months after the initial treatment. Adjuvant chemotherapy was performed. The patient has survived with no relapse as of five years following the initial treatment.
We herein report a case of right orbital metastasis from gastric cancer developed after curable gastrectomy. The case involved a 57-year-old man who underwent laparoscopic proximal gastrectomy combined with D1 plus lymphadenectomy for gastric cancer in the upper third of the stomach in April 2014. Histopathologically, the gastric adenocarcinoma was classified as T3(SS)N3bM0, Stage IIIB cancer. Eight cycles of S1 monotherapy (100 mg/body/day) were administered for adjuvant chemotherapy. He visited an ophthalmological clinic presented with hyperemia, exophthalmos, and pain of the right eye 15 months after the gastrectomy. Brain CT scan revealed an enhanced soft tissue in the right-sided orbit. An orbital biopsy under local anesthesia showed a pathological diagnosis of adenocarcinoma which was similar to the primary adenocarcinoma of the stomach. This finding was compatible with orbital metastasis from gastric adenocarcinoma. Chemoradiotherapy with oral S1 administration (100 mg/day/body conforming with irradiation date) and radiation at 50 Gray (2 Gray/25 Fraction) was performed for the orbital metastasis. His eye symptoms improved gradually and a partial response was achieved after the chemoradiotherapy. However, he died from leptomeningeal carcinomatosis seven months after the diagnosis of orbital metastasis. Orbital metastasis from gastric cancer is extremely rare, and we report details of our case with a review of the literature.
We have experienced a case of breast metastasis of gastric cancer which is rare. The case involved a 69-year-old woman who underwent total gastrectomy for gastric cancer in December 2014. The tumor was diagnosed as T4aN3bM1 (P1, CY1) and stage IV ; the therapy resulted in a curability C ; and the histologic type was signet ring cell carcinoma. Since the patient refused to receive adjuvant chemotherapy, we had followed her clinical course until January 2016 when she noticed a tumor occupying the entire left breast. A fine needle biopsy cytology revealed signet ring cell carcinoma. Immunohistochemistry proved that the breast specimen was identical with the gastric cancer tissue. Breast metastasis of gastric cancer was thus diagnosed. A literature review since 1980 revealed a total of 29 cases of breast metastasis of gastric cancer, including our case, to have been reported. These tumors were characterized by frequent occurrence in relatively young women and many cases to be of signet ring cell carcinoma or poorly differentiated adenocarcinoma. When the breast metastasis was diagnosed, the disease had often progressed and involved other organs. The one-year survival rate after the diagnosis was as poor as 14.9%. The significance of local therapies in these patients is low and further clinical studies of highly effective general therapies would be required to improve the prognosis.
Gastrinoma is a rare disease. We encountered a patient with perforative peritonitis and refractory esophagostenosis due to Zollinger-Ellison syndrome resulting from a duodenal gastrinoma. The patient was a 74-year-old man. He had been diagnosed with reflux esophagitis three years prior. Two repeated episodes of duodenal perforation developed despite ongoing treatment for reflux esophagitis, requiring twice surgeries. Circumferential narrowing of the lower esophagus ensued, and endoscopic balloon dilation (EBD) did not resolve the patient's symptoms. Contrast-enhanced computed tomography and SACI testing were performed, which led to a diagnosis of gastrinoma in the duodenal bulb. The patient was considered a poor candidate for esophagectomy with thoracotomy because he also had chronic obstructive pulmonary disease. Thus, we planned surgical and endoscopic treatment. The surgery consisted of duodenal bulb resection to remove the tumor, distal gastrectomy to decrease acid production, and Roux-Y reconstruction to reduce backflow of the duodenal juice into the esophagus. EBD was performed postoperatively to treat the esophageal stricture. This strategy proved successful for our poor risk patient ; he was able to resume oral intake. No relapse was noted three years postoperatively.
An 81-year-old man underwent colonoscopy for a positive fecal occult blood test at a medical checkup. The patient was then referred to our hospital for surgical resection of a 30-mm tumor of the ascending colon detected by the colonoscopy. A biopsy showed the tumor to be high-grade dysplasia or extremely well differentiated adenocarcinoma. Preoperative screening with esophagogastroduodenoscopy unexpectedly revealed a tumor in the fourth portion of the duodenum. The lesion was diagnosed by biopsy as well-differentiated tubular adenocarcinoma. We consulted several high-volume endoscopic centers regarding the possibility of endoscopic treatment of the duodenal tumor, but none of them recommended endoscopic therapy because of the location and the suspected invasion depth of the tumor into the submucosal structure. Hence, we performed segmental resection of the duodenum together with ileocecal resection under laparotomy. Early carcinoma of the fourth portion of the duodenum is extremely rare and the early detection by screening is difficult. We report here a rare case of early primary cancer of the fourth portion of the duodenum that was detected by screening esophagogastroduodenoscopy, along with a review of the relevant literature.
A 57-year-old man was evaluated for a chief complaint of a 5-day history of epigastric pain. Examination revealed tenderness of the right upper quadrant and an elevated inflammatory response. Contrast CT showed an enlarged gallbladder, cholecystitis was suspected, and the patient was admitted to hospital. However, after admission, localized edema of the small bowel, increased surrounding fat density, and fluid accumulation contiguous with the small bowel lumen was noticed on the same imaging study. Small bowel perforation was suspected, and emergency surgery was performed. Intraoperative findings showed a diverticulum of the mesentery 40 cm proximal to the ileocecum. The tip was necrotic with some abscess formation and adhesions at the base of the mesentery. The diagnosis was perforation of Meckel's diverticulitis and abscess formation. A CT scan one year previously had shown a Meckel's diverticulum with an enterolith, and the CT on the current admission showed spontaneous expulsion of the stone from the diverticulum and passage to the recrum. A review of the literature with a search for “Meckel's diverticulum” and “enterolith” found 14 case reports, but none with apontaneous expulsion of the stone. This case of Meckel's diverticulitis with spontaneous expulsion of an enterolith is reported along with a review of the relevant literature.
A 77-year-old man underwent graft replacement for an abdominal aortic aneurysm. When he started oral intake, feces-like liquid flowed out from the operative wound. Abdominal computed tomography (CT) revealed an enterocutaneous fistula (ECF) to the sigmoid colon caused by ischemic colitis. On day 39 after the first operation, the patient underwent radical surgery, including left hemicolectomy, small intestinal resection, and colostomy. Nevertheless, 11 days after the surgery, wound dehiscence was found and intestinal fluid collection flowed out. A CT scan showed an ECF of the intestine caused by anastomotic leakage. As surgical treatment was thought to be difficult because of the patient's condition, conservative treatment with negative pressure wound therapy (NPWT) was selected. Ninety-eight days after starting NPWT, the ECF was completely closed without remarkable complications. NPWT may be useful for ECF after surgery in infectious conditions.
We report a case of laparoscopic Ladd procedure for intestinal malrotation with midgut volvulus in an adult. A 25-year-old man presented with the abrupt onset of severe abdominal pain and vomiting. Abdominal enhanced CT scan showed a whirl sign involving the engorged superior mesenteric vein (SMV) and soft tissue twisting around the superior mesenteric artery (SMA). We diagnosed the case as small bowel volvulus and performed emergency laparoscopic surgery. Laparoscopic findings showed that the bowel from the origin of jejunum to the ascending colon was twisted counter-clockwise by 540 degree around the SMA. After the laparoscopic reduction of the volvulus, the cecum and ascending colon were not fixed to the right retroperitoneum, the ligament of Treitz was not formed, and fibrous peritoneal bands (Ladd's bands) were found. Midgut volvulus with intestinal malrotation was diagnosed, and we added Ladd procedure and prophylactic appendectomy. The operation was completed laparoscopically. The patient had uneventful recovery, and is doing well as of 36 months after the surgery without having anomalies such as intestinal obstruction. Intestinal malrotation with midgut volvulus in adults is rare. Laparoscopic Ladd procedure for this setting is still controversial. This case suggests that laparoscopic Ladd procedure for intestinal malrotation with midgut volvulus is an effective treatment option that may reduce surgical stress, if intestinal ischemia or dilatation is absent and good vision under laparoscopy can be kept.
A 61-year-old man was referred to our hospital with a history of abdominal pain and abdominal distension persisting for five days. His heart rate at admission was 125/min, the blood pressure was 92/68mmHg, and the shock index was 1.4. Abdominal contrast-enhanced CT revealed a 23.1×12.4 cm mesenteric mass with extravasation of contrast material. We performed emergency surgery for the bleeding intra-abdominal mass. Before the laparotomy, we occluded the superior mesenteric artery (SMA) with a PTA balloon. A 30×25 cm tumor was found to be located in the mesentery of the jejunum. After we ligated and divided the J2 branch which fed the tumor, we resected the tumor together with the small intestine. Histopathologically, the tumor was diagnosed as a desmoid tumor. The patient's postoperative course was satisfactory, and he was discharged on the 6th day after his surgery. Desmoid tumors presenting with massive tumor hemorrhage are extremely rare, and there are no case reports in the literature so far.
A 52-year-old woman was admitted to a hospital because of intermittent abdominal pain and was administered medication due to suspected ileus. Two weeks later, she visited our hospital complaining of a sense of fullness and abdominal pain with mild tenderness. Abdominal computed tomography revealed slight ascites and a boundary of small intestine with dilated and non-dilated areas in the right lower quadrant. We performed emergency surgery with a diagnosis of a strangulated ileus. A 2-cm white mass on the mesentery of the small intestine 40 cm from the terminal ileum was revealed. The mass wrote up a serosa of the small intestine and formed a strangulation point. Partial resection of the ileum was performed. Because of the possibility of malignant disease dissemination, we searched the entire intraperitoneal space, but no malignant findings were noted. The patient was discharged from our hospital 10 days postoperatively. We herein reported a rare case of a 2-cm diameter mesenteric fibromatosis without familial adenomatous polyposis or laparotomy history.
A 60-year-old woman was admitted to our hospital with the chief complaint of generalized malaise. Laparoscopic surgery was performed under the suspicion of a tumor in the right ovary, however, a tumor was found in the distal appendix. We performed ileocecal resection for the appendicular tumor suspecting that it was malignant. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. Immunohistochemically, the tumor cells were positive for S-100 protein, but negative for c-kit, CD34 and α-SMA, and based on the findings, the tumor was diagnosed as a schwannoma of the appendix. Appendicular schwannoma is a rare disease of the appendix. A review of the Japanese literature using the Igaku Chuo Zasshi search engine revealed 5 case reports, including the present case. The results of the review are presented.
A 12-year-old boy was referred to our hospital with nausea and epigastralgia. Enhanced computed tomography (CT) showed a swollen appendix with a large fecal stone and a moderate amount of ascites. He was diagnosed with gangrenous appendicitis with local peritonitis and underwent an emergency appendectomy. On examining the vermiform appendix, the root was found to originate from the posterolateral side of the ascending colon, which was the anal side of the connection to the terminal ileum. The mesoappendix was resected, and the vermiform appendix was removed. No appendix-like protrusion was found at the end of the cecum. Pathological examination of the resected specimen confirmed the vermiform appendix, which had rich lymphoid follicles at the wall, and it was diagnosed as gangrenous appendicitis. A malformation of the appendix is quite rare. A few cases of agenesis of the appendix or double appendix have been reported, but no case of the appendix originating from the large intestine other than the cecum has been reported in Japan, while only three cases have been reported worldwide. A rare case is presented along with some discussion.
A 74-year-old woman complaining of general fatigue was referred to our hospital for the investigation of an ileocecal tumor detected by abdominal CT scan. Laboratory data on admission showed anemia and inflammation. Tumor markers including CEA and CA19-9 were in normal limits. Colonoscopy revealed a type 2 tumor completely encircled the bowel from the ileocecal region to the ascending colon. Enhanced CT scan showed a huge tumor in the pelvic cavity with right hydronephrosis, suggesting the tumor invasion to the right ureter. Distant metastasis was not detected. After a ureteral catheter was placed, right hemicolectomy with D3 dissection was performed. The histopathological diagnosis was poorly differentiated squamous cell carcinoma of the cecum without lymph node metastasis (ss, ly1, v1, n0, and Stage II). The postoperative course was uneventful. She has been treated with UFT/LV as adjuvant chemotherapy, and is doing well without recurrence 6 months after the surgery. Among colorectal carcinomas, squamous cell carcinomas are very rare, especially those arising in the colon. Herein we report this rare case with a review of the literature.
We present a case of strangulated obstruction of the transverse colon. The patient was a 79-year-old woman who was admitted to our hospital for sudden severe abdominal pain at night, without laparotomy history. In the following day, both computed tomography and ultrasound (US) showed intestinal expansion and increased fluid collection. Furthermore, blood flow was not detected by color Doppler US. We diagnosed the patient with strangulated obstruction of the colon. She underwent an emergency laparotomy. During laparotomy, the transverse colon was strangulated by the band between the descending colon's appendix epiploica and peritoneum. The band was resected. Partial colectomy and end-to-end anastomosis were performed. We report the clinical presentation and imaging findings of this rare case.
A 57-year-old woman was referred to our hospital for thorough examination of anemia and a positive fecal occult blood test. Colonoscopy revealed a type 1 tumor of the descending colon. A biopsy led to a diagnosis of poorly differentiated adenocarcinoma. There were no obvious abnormalities suggestive of metastasis in thoracoabdominal computed tomography. We performed partial resection of the descending colon with D2 lymphadenectomy with the diagnosis of carcinoma of the descending colon. Immunohistochemistry showed positive reaction for α-fetoprotein (AFP), and the final diagnosis of AFP producing carcinoma of the descending colon was made. The serum AFP level was as high as 176.1ng/ml in one month after the operation, but thereafter it decreased to the normal range. The patient survives without recurrence as of 4 years and 4 months after the operation. Although AFP producing colon cancer is relatively rare, it is reported that the potential for liver metastasis is high and the prognosis is very poor. We report a rare case of a patient with AFP-producing carcinoma of the descending colon who has achieved long term recurrence-free postoperative survival, together with a review of the literature.
This case involved a 78-year-old woman who was unable to walk without assistance. The woman was transported to the emergency department and underwent emergency surgery on the same day. The patient was diagnosed with bowel obstruction due to stricturing ischemic colitis in the sigmoid colon, and colostomy was performed in the transverse colon. Blood in the stool was noted starting on day 10 postoperatively ; hence, endoscopy was performed. Edema and ulceration were noted from the ascending colon to the terminal ileum, and oozing bleeding was also evident. Although these symptoms were considered to be most likely due to non-occlusive mesenteric ischemia (NOMI) conservative treatment was continued per the request of the patient's family. On day 20 postoperatively, bleeding stopped. Endoscopy on day 40 postoperatively indicated scarring from healed ulcers. Subsequently, the patient's condition improved wherein normal diet was resumed. This case is extremely interesting in terms of identifying the mechanism for the development of that condition, and this case is also extremely rare because endoscopy revealed changes in that condition over time. NOMI has a poor prognosis, but it may respond to conservative treatment, similar to the current case.
A 69-year-old man was initially diagnosed with sigmoid colon cancer and simultaneous S6 hepatic and bilateral adrenal metastases. After resection of the primary lesion, the patient was treated with 5 courses of chemotherapy. This was followed by a laparotomy for a posterior hepatic segmentectomy and bilateral adrenalectomy. Since the right adrenal tumor directly invaded the liver, the right adrenal gland was resected en bloc with the posterior hepatic segment. The left adrenal gland also had tumor and was completely resected. Preoperative adrenocortical function was not decreased. Prior to intraoperative clamping of the porta hepatis for a hepatectomy, methylprednisolone was given by intravenous infusion, and on the following day, supplemental steroid therapy by intravenous infusion of hydrocortisone was started. The patient was gradually weaned from steroid therapy and switched to a maintenance dose of 15 mg/day of oral hydrocortisone on postoperative day 6. The patient improved gradually without acute adrenal insufficiency and was discharged. Bilateral single-stage adrenalectomy for adrenal metastases from colorectal cancer has not been previously reported in Japan. [It this your intended meaning? You report primary tumor resection, 5 courses of chemotherapy, then laparotomy for hepatectomy and bilateral adrenalectomy.] This case report presents the safe performance of bilateral adrenalectomy and hepatectomy in a single stage with supplemental steroid therapy in a patient with liver and adrenal metastases from colorectal cancer.
A 34-year-old man fell from mountain and was accidentally stabbed in his anus with a broken bamboo. He removed the bamboo and visited our hospital. He had diffuse abdominal tenderness with guarding and rigidity. Abdominal computed tomography scan showed free air around the rectum. Colonoscopy showed a defect of the half lumen of the rectal wall on the anterior side. An emergency surgery was performed under the clinical diagnosis of traumatic rectal perforation. Laparoscopic examination revealed minimal blood at the rectovesical pouch. A 4 × 1-cm perforation was found in the peritoneal reflection. Bamboo pieces located in the route of impalement injury were removed laparoscopically, and transanal suture was performed for the rectal perforation. The postoperative course was uneventful, and the patient was discharged on the 15th day. We report that laparoscopic evaluation was useful in the treatment of rectal impalement.
A 78-year-old Japanese man was referred to our surgical department for further investigation of anemia and bloody stool during his orthopedic hospitalization due to fracture of the right femur. An abdominal CT scan showed multiple concentric ring sign in the lower rectum. In addition, a rectal tumor was found by colonoscopy. Rectal intussusception due to rectal cancer was diagnosed. No ischemic changes were seen in the rectum and we employed elective surgery. At surgery we identified the intussusception not to be reduced and performed resection of the lower rectum including the intussuscepted portion with colostomy. Macroscopic specimen revealed a type 2 rectal tumor which included moderately differentiated adenocarcinoma histologically (Ra, type 2, 60×35 mm, tub2, pT3, INFb, ly1, v1, pN0 (0/14), pRM0, pDM0, and pStage II). Unlike intussusception in children, adult onset intussusception, especially rectal involvement caused by type 2 rectal cancer, is very rare. So far only five adult cases of rectal intussusception due to type 2 rectal cancer, including our case, have been reported in the Japanese literature.
The case of a 14-year-old girl who developed ulcerative colitis (UC) at 6 years of age and visited our hospital for treatment is presented. She was diagnosed with well-differentiated adenocarcinoma during lower gastrointestinal tract endoscopy as a follow-up evaluation. The patient then underwent laparoscopic total colectomy, D3 dissection, ileal pouch-anal anastomosis, and ileostomy. UC often occurs concurrently with colon cancer, and the frequency of colon cancer in UC patients is reportedly 1.8% within 10 years, 8.3% within 20 years, and 18.4% within 30 years of developing UC. In our institution, we have performed laparoscopic total colectomy for UC since 2007. Laparoscopic surgery may be a viable treatment option for the removal of colitic cancer in UC patients.
A 43-year-old woman was referred to our department because of hepatic tumors. Two years earlier, she underwent operation for meningeal hemangiopericytoma (HPC) at the Department of Neurosurgery in our hospital. When she was first seen at our department, tumor markers were in normal limits and the hepatic reserve was favorable. Preoperative abdominal dynamic CT showed a low density tumor lesion in the segment 8 and 4. The tumors were remarkably enhanced during the hepatic arterial phase. Because of her characteristic past history and multiple lesions arisen in the normal liver, a diagnosis of hepatocellular carcinoma (HCC) was ruled out and hepatic metastasis of HPC was diagnosed. Partial hepatectomy to remove the segment 8 and 4 was performed. Pathological findings of the tumors were similar to the previous meningeal tumor. She has no recurrence and is still alive with a good performance status as of 22 months after the surgery. Image findings of hepatic metastasis of HPC include hypervascularity on CT and MR like HCC. However, if patients with liver tumors have a history of surgical treatment for HPC, and they don't have any risk factors of HCC such as viral hepatitis, alcoholic hepatitis and non-alcoholic steatohepatitis, the possibility of hepatic metastasis of HPC should be considered.
Common bile duct stones with metallic clips/elastic yarn as the core after choledocholithotomy and C-tube drainage is rare. We report the case of a 79-year-old man with a previous history of gastrectomy who had undergone cholecystectomy, choledocholithotomy and C-tube drainage 5 months earlier. He presented to our emergency department with fever and upper abdominal pain. Abdominal CT revealed a common bile duct stone ; therefore we repeated the choledocholithotomy. Perioperative cholangioscopy revealed a stone with metallic clips and elastic yarn as the core. We closed the common bile duct by suture without T-tube drainage after removing the stone, clips and elastic yarn. The postoperative course was uneventful and the patient has been followed up at the outpatient clinic with no evidence of recurrence.
We present a case of diffuse large B cell lymphoma (DLBCL) of the extrahepatic bile duct. A 72-year-old man presented with abdominal pain was pointed out having jaundice at a neighboring hospital and was referred to our hospital. An abdominal CT scan showed remarkable thickening of the wall from the cystic duct to extrahepatic bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) revealed stricture at the extrahepatic bile duct. Cholangiocarcinoma was diagnosed and the resection of the extrahepatic bile duct and regional lymph node dissection were performed. The histopathological diagnosis was DLBCL. A FDG PET/CT taken after discharge confirmed invasion into the bone, so that the R-CHOP regimen was carried out. The lesion completely responded (CR) to the regimen and the patient has been alive, as of 9 months after the operation. Malignant lymphoma of the extrahepatic bile duct is extremely rare and is difficult to differentiate from cholangiocarcinoma based on imaging studies. Since therapeutic guidelines and prognosis greatly differ from jaundice caused by malignant lymphoma to that caused by another disease, it is desirable to conduct preoperative cytological and histological explorations as well as active biopsy diagnosis, if it is possible. Actually, however, we often have difficulties in making preoperative diagnosis and surgery is considered to be an effective measure for precise diagnosis and treatment.
The patient was a 63-year-old woman who had undergone distal pancreatectomy for a solid pseudopapillary neoplasm (SPN) 21 years ago at another hospital. Regular postoperative follow-up was completed with no signs of recurrence, and she was attending our hospital for management of diabetes and hypertension. Twenty-one years after the primary surgery, she complained of anorexia and an abdominal computed tomography scan and magnetic resonance imaging revealed a large mass (> 10 cm) on the left hepatic lobe. Extended left lobectomy was performed for diagnosis and treatment. Pathologically, the liver tumor was similar to the primary SPN specimen and the tumor was positive for vimentin, CD10, CD56, and progesterone receptor. These findings indicated that the tumor was a liver metastasis of SPN. We experienced a very rare case of complete excision of a liver metastasis of an SPN that was resected 21 years ago.
Benign multicystic mesothelioma of the peritoneum (BMMP) is a rare tumor, suggested to be caused by reactive mesothelial proliferation associated with chronic inflammation in the abdomen. Herein, we report two cases of BMMP developing after abdominal surgery. Case 1 : A 66-year-old female diagnosed as having sigmoid colon perforation underwent sigmoidectomy and colostomy. During the colostomy closure performed 5 months later, numerous small cystic tumors were observed in the peritoneum and resected. The tumors were diagnosed by histopathology as BMMP. Residual tumor growth was observed 5 months postoperatively. Case 2 : A 57-year-old female who had undergone breast resection and hepatectomy was diagnosed as having a cystic tumor in the right lower abdomen. At laparotomy, numerous cystic tumors were observed and completely resected. Until now, 19 months since the surgery, there has been no recurrence. BMMP has a tendency to recur and also shows potential for malignant transformation ; thus, complete resection and long-term follow-up are essential.
We report a rare case of malignant peritoneal mesothelioma without evident exposure to asbestos, which mimicked mesenteric panniculitis. A 66-year-old male patient was admitted to another hospital with fever and abdominal pain. Laboratory data revealed slightly elevated white blood cell count and C-reactive protein. Abdominal computed tomography showed a focal increase in density of the mesenteric fat. According to the clinical symptoms and these findings, he was diagnosed with mesenteric panniculitis and treated with antibiotics and fasting. Because he repeated hospitalization for the same symptoms three times in half a year, the steroids therapy was considered. In order to rule out malignancy, he was referred to our hospital for laparoscopic mesenteric biopsy. The diagnostic laparoscopy findings included many small yellowish white nodules in the entire peritoneum, small quantities of ascites, and the slightly thickened omentum which adhered to the abdominal wall. A part of the omentum was resected and ascites was collected for cytodiagnosis. Histological examination of the resected specimen showed proliferating malignant epithelioid cells that stained strongly for calretinin, which was compatible with malignant peritoneal mesothelioma. Malignant peritoneal mesothelioma is a rare malignancy. It is difficult to diagnose because clinical symptoms and findings are nonspecific. We recommend that malignant peritoneal mesothelioma should be included in the differential diagnosis of patients with mesenteric panniculitis, though it is rare.
A 46-year-old woman was referred in July 2014 for outpatient gastroenterological evaluation at our hospital. Upper GI endoscopy and colonoscopy showed no abnormalities. However, abdominal ultrasound showed a tumor-like lesion on the left side of the inferior vena cava (IVC). Contrast CT showed a 30 × 17 mm tumor on the left side of the IVC, and a paraganglioma was suspected. Urine catecholamine levels were slightly elevated. FDG-PET and MRI showed findings consistent with a paraganglioma. Laparoscopic resection of the retroperitoneal tumor was performed. No intraoperative bleeding from a major vessel was noted. The patient had a satisfactory postoperative course without any blood pressure abnormalities and was discharged 4 days after surgery. There has been no tumor recurrence as of 1 year 7 months of postoperative follow-up. Laparoscopic surgery for a primary retroperitoneal paraganglioma near a great vessel has rarely been reported. This case is reported along with a review of the relevant literature.
Perivascular epithelioid cell tumors (PEComas), characterized by mixed myogenic and melanocytic phenotypes, are rare. We herein present a case of retroperitoneal PEComa-not otherwise specified (PEComa-NOS). Follow-up computed tomography (CT) performed after treatment of left breast cancer in a 56-year-old woman revealed a 3.5 × 2.3 cm tumor in the pancreatic body. Although abdominal enhanced CT, magnetic resonance imaging, and 18-fluoro-2-deoxyglucose positron emission tomography/CT failed to indicate a definitive diagnosis, immunohistological analysis revealed that the tumor cells, obtained by using endoscopic ultrasonography-guided fine-needle aspiration, were positive for HMB-45. Therefore, the diagnosis of PEComa originating from the pancreas or retroperitoneum was confirmed. Laparoscopic resection of the tumor, which easily peeled off the pancreas, was performed successfully. The established diagnosis of the tumor was benign retroperitoneal PEComa-NOS.
A 74-year-old woman with intraductal papillary mucinous neoplasm of the pancreas head was performed pancreatoduodenectomy under general and epidural anesthesia. Preoperative laboratory data including the platelet count and coagulation ability were within normal limits. She had not taken anticoagulant and antiplatelet agents. The preparation of epidural anesthesia was performed without any troubles ; epidural puncture succeeded in one time without bleeding, and an epidural catheter was inserted smoothly. On the seventh postoperative day when her surgical pain remained quiescent, she developed severe backache just after extraction of the epidural catheter, followed by sensory paralysis and paraplegia in 30 min. Magnetic resonance imaging scan indicated the presence of epidural hematoma in the range of Th6-10. Emergent laminectomy was performed and the hematoma was removed, but apparent bleeding source was unknown. After laminectomy, her backache disappeared, sensory paralysis slightly improved up to Th11, and she was able to keep sitting position, but paraplegia persisted. She continues physical rehabilitation. Epidural anesthesia is useful to ameliorate the surgical pain especially for patients after laparotomy, but it is reported to bring about a serious complication of epidural hematoma due to the risk factor of coagulation. We here report an extremely rare case of epidural hematoma unpredictably occurred following extraction of the epidural catheter in a patient without any risk factors.
An 86-year-old man noticed a lower abdominal skin ulcer about 6 months before, which gradually increased in size. Finally, he presented to the emergency department with a complaint of intestinal prolapse from his lower abdomen. We also found that he had a right inguinal irreducible hernia. The prolapsed intestine was strangulated through the abdominal wall defect, which was in the center of the skin ulcer, and turned purple-black in color and necrotized. Thus, emergency operation was performed. The abdominal wall defect, communicated with the right inguinal hernia sac. However, the hernia orifice was not the cause of strangulation. We removed the necrotized intestine and performed iliopubic tract hernioplasty. Based on the biopsy result of the skin ulcer and erosion of the genitals, we made a diagnosis of extramammary Paget disease. We conclude that because of the coexistence of right inguinal irreducible hernia and extramammary Paget disease, the abdominal skin ulcer progressed and communicated with the inguinal hernia sac, and the intestine prolapsed and was strangulated through the abdominal wall defect.
A 77-year old woman was admitted to our hospital with a chief complaint of an uncomfortable feeling in the lower abdomen of one month's duration. Computed tomography demonstrated small intestine herniated into the right greater sciatic foramen. Elective laparoscopic surgery was performed because her abdominal symptom was thought to be caused by the sciatic hernia. During surgery, the sciatic foramen defect was identified, and the defect in the foramen was repaired with a mesh plug and patch. Sciatic hernias are very rare, and laparoscopic repair for sciatic hernias has not often been reported in Japan. This case is presented and discussed in the context of a review of the literature on sciatic hernia.
Cryptococcosis is an opportunistic infection that rarely develops in healthy individuals. Cryptococcosis is acquired by inhalation of soil contaminated with the fungus Cryptococcus. Accordingly, cryptococcosis usually affects the lungs, and it rarely spreads hematogenously to the adrenal glands. The current authors encountered a case of adrenal cryptococcosis where the patient concerned had no underlying condition and no apparent pulmonary lesions. The patient was a 66-year-old man who presented with a fever of unknown origin and was initially seen at the Department of Internal Medicine in our hospital a year and a half previously. Further testing was performed, and a CT scan incidentally revealed a mass 23 mm in diameter on the right adrenal gland. Subsequent examination indicated that the mass was a non-functioning adrenal tumor, so the tumor had been followed thereafter by periodic examinations. A CT scan performed a year and a half later revealed that the tumor had enlarged to 38 mm in diameter. The patient was then referred to our department. We performed laparoscopic right adrenalectomy, and pathological findings indicated cryptococcosis involving the right adrenal gland. Cerebrospinal fluid was tested after the surgery and cryptococcal meningitis was diagnosed. Treatment with an antifungal agent was begun, and the patient visited our clinic periodically to measure his Cryptococcus antibody titer and cryptococcal antigen levels. The patient's antibody titer and antigen levels gradually decreased, and the antifungal regimen was terminated about a year and a half postoperatively.
A 74-year-old man was evaluated for bleeding, pain, and pustular discharge of the left buttocks. Sixteen years previously he had undergone surgery with incision and drainage for chronic perianal pyoderma. Contrast CT and MRI now showed a large tumor-like lesion in the subcutaneous tissue of the left buttocks, but without any distal metastases. Biopsy showed squamous (prickle) cell carcinoma. Because of the tumor bleeding, refractory abscess, and difficult-to-control pain, tumor resection was planned to improve the patient's quality of life and activities of daily living. Surgery was performed in three stages. The first stage was a colostomy for local control of infection. The second stage was extensive tumor resection. After histopathology showed that the surgical resection margins were negative, a third stage was performed for reconstruction using gracilis muscle and posterior thigh flaps. Management was complicated because of the buttock and perineal wounds and body position, thus making reconstruction after extensive resection more difficult. This case of squamous cell carcinoma arising in chronic perianal pyoderma is reported along with a review of the relevant literature on management and reconstructive surgery in these cases.