Objective : In this study, we aimed to examine the diagnostic accuracy of preoperative computed tomography (CT) for inguinal hernia. Subjects and Methods : The preoperative CT findings and classification of inguinal hernia according to the Japanese Hernia Society of 198 patients with 226 lesions who underwent laparoscopic repair of inguinal hernia from January 2012 to December 2015 were evaluated. Results : The detection rate of the lesions was 92.9% ; the detection was difficult if hernia was less than 1 cm in size and if there is no bulge owing to insufficient abdominal pressure at the time of CT imaging. The diagnostic rate of inguinal hernias based on the classification of the Japanese Hernia Society was 96.7%, with a 100% detection rate of Type I, Type II, Type III, and Type V hernias, and a 30% detection rate of Type IV hernia. The detection rate of unapparent contralateral hernias was 45.0%. Conclusion : Preoperative CT showed a high detection rate of inguinal lesions. Moreover, it is suggested to be useful for the diagnosis of hernia according to its classification based on the criteria of the Japanese Hernia Society.
For the treatment of obturator hernia, coating the hernia orifice at the bladder and uterus as well as coating of the hernia orifice by artificial membranes has been reported. However, relapses have been occasionally reported, and there are no established treatment methods. At our facilities, we have been implementing TAPP as the first choice for the surgery for groin hernias ; moreover, for obturator hernia, we have selected laparoscopic repair as the first choice. For 6 cases on whom we conducted a laparoscopic repair, we reversed 3D MAX Light Mesh (hereinafter called 3D mesh) to repair the hernia orifice. We measured the angle created by the obturator hernia and the Hasselbach triangle at the Cooper ligament by using a pelvic 3-dimensional computed tomography scan, and it was found to be about 160°. When we measured the curvature at the 3D longitudinal axis, it was almost the same angle, so that by reversing the mesh, we were able to coat the obturator hernia orifice in an anatomically natural shape. Moreover, because the shape of the mesh could be maintained, it was possible to coat the hernia orifice by fixing at a minimum level. Therefore, the present method seems to be very useful as a surgery for this condition.
An 82-year-old man who visited a neighboring hospital because of a mass lesion of the left breast was detected to have a 25-mm tumor right under the left nipple. He was referred to our hospital with a diagnosis of invasive ductal carcinoma following a fine needle biopsy. On physical examination, we palpated a tumor right under the left nipple which showed redness on the skin and fixation to the chest wall. Ultrasonography (US), mammography (MMG) and computed tomography (CT) revealed invasive ductal carcinoma of the left breast. The histological diagnosis was invasive ductal carcinoma (cT2N1M0, Stage IIB) and total mastectomy with axillary lymph node resection was performed. The final pathological diagnosis was invasive micropapillary carcinoma (IMPC) and multiple metastases of axillary lymph nodes [pT2, 23×22×17mm, f, s, HG II, NG II, 1y+, v-, pN3a (Level-I : 16/17, Level-II : 10/10) ER(+), PgR(+), HER2(-), MIB-1 : 9%]. After the surgery, he received radiation therapy to the chest wall and the supraclavicular fossa and endocrine therapy. He is alive without recurrence as of 16 months after the operation. Since invasive micropapillary carcinoma rarely arises in the male breast, we present our case together with a review of the literature.
A 55-year-old woman visited our hospital because of a left breast lump and swollen axillary and supraclavicular lymph nodes. Chest enhanced CT also showed swollen supraclavicular and axillary lymph nodes on the left side. Comedo type ductal carcinoma in situ (DCIS) was diagnosed by vacuum-assisted biopsy. However, fine needle aspiration cytology of the axillary lymph node showed no malignancy. Although histological findings and CT images were not consistent, total mastectomy and sentinel lymph node biopsy were performed before anticancer drug therapy. Egg-sized, soft lymph nodes were identified and removed. Intraoperative pathological diagnosis showed no malignancy, and noncaseating epithelioid granulomas were found in the lymph nodes. Using the Ziehl-Neelsen method postoperatively, there was no growth of acid-fast bacteria. Chest X-ray and gallium-scintigraphy showed no special findings, and plasma angiotensin-converting enzyme (ACE) activity was normal. Given these results, breast cancer with swollen axillary lymph nodes accompanied by a sarcoid-like reaction was diagnosed.
A 62-year-old patient underwent a partial mastectomy of the right breast and axillary lymph node dissection for the diagnosis of Stage I breast cancer (T1N0M0). Pathological findings were an infiltrating duct carcinoma with an invasive diameter of 8 mm, negative lymph node metastasis, and ER (-) and PgR (-), as detected using enzyme immunoassay (EIA). We conducted post-operative irradiation of the remaining breast. Three years after the operation, we found pleural effusions, and diagnosed post-operative carcinomatous pleuritis using cytology. Computed tomography (CT) did not reveal any distant metastasis. At the time of recurrence, we repeated the immunostaining of the primary tumor, which proved that the tumor was ER (+), PgR (-) and HER2 (-). After pleurodesis, we initiated oral administration of doxifluridine (5'DFUR) with medroxyprogesterone acetate (MPA) and cyclophosphamide (CPA). With no adverse effects observed, we discontinued treatment four years after the recurrence. The patient has been in remission for the past 9 years. We report a case of long-term survival for 13 years after the onset of carcinomatous pleuritis.
The patient was a 64-year-old woman who underwent a living renal transplant for chronic renal insufficiency 20 years ago, and received continuous treatment with immunosuppressants. This time we found an irregular tumor in her right breast, and diagnosed breast cancer after intensive examination. We performed a breast lumpectomy and a sentinel lymph node biopsy. The histopathological diagnosis was HER2-positive breast cancer accompanied by highly-infiltrative tumor lymphocytes. As a post-operative adjuvant therapy, we administered weekly paclitaxel and trastuzumab treatment for 12 cycles. In the 9 years since the operation, the patient has experienced event-free survival. With the advancement of immunosuppressant therapy, the long-term prognosis for transplantation patients has improved, but the frequency of malignant tumor occurrence after transplantation has increased. We experienced a case who had good prognosis with administering post-operative adjuvant chemotherapy for a breast cancer that occurred after a living renal transplant. We hereby report the case with a review of the literature.
A 49-year-old woman visited our hospital after noticing that a lump in her left breast had recently begun to grow. The lump was first noticed 10 years previously. A tumor with a maximum diameter of 6 cm was palpated in the lower outer quadrant of the left breast without lymph node swelling in the left axilla. Ultrasonography showed an intracystic tumor with a sessile solid part. A core needle biopsy was performed, and a diagnosis of ductal carcinoma and mucinous carcinoma was made. A bone scintigraphy revealed abnormal accumulation in multiple bone lesions, and multiple bone metastases were highly suspected. However, it was considered that most of the breast tumor was situated within the cyst, and a bone computed tomography (CT) scan did not show typical findings of bone metastasis. Additional CT and magnetic resonance imaging scans revealed that the multiple bone lesions were consistent with polyostotic fibrous dysplasia. The patient was therefore diagnosed with early breast cancer, and underwent a left mastectomy and sentinel lymph node biopsy. Since fibrous dysplasia of bone shows similar findings to that of bone metastasis detected by bone scintigraphy, distinction between the two is critical for managing patients with breast cancer.
A 71-year-old woman had been treated with breast-conserving surgery (Bq+Ax) for the left breast 13 years previously. An enlarged lymph node was noted in her right axilla. A core needle biopsy of the lymph node revealed metastasis of the adenocarcinoma, resulting in the suspicion of breast cancer. A magnetic resonance imaging scan revealed a tumor near the surgical scar in the left breast. The tumor was diagnosed as invasive ductal carcinoma by an ultrasound-guided vacuum-assisted biopsy. Lymphoscintigraphy showed lymphatic flow from the left breast to the right axilla and left parasternal area. According to this finding, the patient was diagnosed with contralateral axillary lymph node metastasis. Left total mastectomy, right axillary lymph node dissection, and left parasternal lymph node biopsy were performed. No metastasis was found in any of the remaining right axillary lymph nodes ; except for an enlarged node and a left parasternal lymph node. The patient received adjuvant therapy (HCN+wPTX) and has remained free of disease for 18 months. A change was observed in the lymphatic flow from the left breast. The aberrant lymphatic flow was thus deemed to have caused the contralateral axillary lymph node metastasis. These irregular occurrences were identified based on the findings of a sentinel lymph node biopsy.
The patient was a 44-year-old woman in whom a mediastinal cyst was detected on chest radiography during a medical examination. A chest computed tomography (CT) showed a posterior mediastinal tumor. She was referred to our department of thoracic surgery. A preoperative diagnosis of benign posterior mediastinal cyst was established by using magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET-CT). The patient underwent thoracoscopic resection of the posterior mediastinal tumor. The mediastinal tumor was a monolocular cyst covered with a thin capsule and showed no adhesions to the surrounding tissue. Pathological examination showed a posterior mediastinal müllerian cyst, in which the cystic wall was composed of mono- or multi-layered low cylindrical ciliated epithelial cells and both estrogen and progesterone receptors were positive on immunohisto chemistry. Müllerian cyst was thus diagnosed. After the surgery, she got Horner signs that vanished 6 months later. When we encounter a posterior mediastinal cyst in perimenopausal women, mullerian cyst should be suspected.
We treated an iliac aneurysm complicated with an arteriovenous fistula by stent-graft surgery with a good outcome. The subject was a 58-year-old man. He visited our hospital with the chief complaint of right leg edema. Physical examination revealed swelling of the right lower leg and tenderness in the right groin region. The ultrasound examination of the lower legs showed arterial pulsatile signals in the right femoral veins that suggested an arteriovenous fistula. Contrast-enhanced computed tomography (CT) examination indicated a 70-mm right common iliac aneurysm. Since the veins in succession to the common iliac vein appeared with marked enhancement on arterial-phase CT, we diagnosed rupture of a right common iliac aneurysm complicated with an arteriovenous fistula. We performed an emergency coil embolization for the internal iliac artery and an emergency stent-graft placement in the right iliac artery. On post-operative day 5, the CT examination showed disappearance of the arteriovenous fistula, but because of the development of thrombosis in the right iliac vein, we started anticoagulant therapy. On day 14 of illness, the patient was discharged. Subsequent CT examinations indicated that the thrombosis in the iliac vein disappeared and that the aneurysm decreased in size.
A 60-year-old man with right chest pain, dyspnea and general fatigue presented to our hospital. Chest X-ray examination showed that pleural fluid with niveau filled the right thoracic cavity. We diagnosed the case as right pyopeumothorax, and promptly started continuous suction drainage of the right thoracic cavity and administration of antibiotics. However, dirty drainage and inflammation persisted, and we added one more chest tube for continuous irrigation. The inflammation immediately subsided, but the size of the abscess cavity was not reduced by irrigation and drainage. We thus performed right open window thoracostomy to curette and abundantly wash the abscess cavity. On the postoperative day 2, the vacuum assisted closure (VAC) therapy with insertion of dressing foam into the abscess cavity was begun. The VAC therapy was continued for a month, and the abscess cavity and wound were completely closed in approximately a month after the end of the VAC therapy. The early introduction of the VAC therapy after open window thoracostomy for refractory pleural empyema may be an effective tool for accelerating reduction of abscess cavity and wound healing.
We report a case of pulmonary plasmacytoma with amyloid deposition. An 80-year-old man was referred to our hospital because of an enlarging pulmonary nodule in the right lower lobe. Chest CT scan showed a 14-mm solid nodule with air bronchogram in the right S9. We suspected lung cancer and performed surgery. Since the intraoperative pathological study by video-assisted thoracoscopic surgery showed no malignancy, we performed partial resection of the right lower lobe. Pathological studies revealed a growth of mature plasma cells at the lesion and interstitial amyloid deposition. Immunohistochemistry showed a large number of IgA-κ positive plasma cells. The final pathological diagnosis was extraosseous plasmacytoma with nodular pulmonary amyloidosis. M-protein was not detected in the serum and urine by immunoelectrophoresis and a bone marrow examination revealed no abnormalities. The patient has been free from recurrence for two years after the operation. Extramedullary plasmacytomas arise mostly in the upper airway or oral cavity but very rare in the lung.
We must avoid pulmonary vascular injury most of all in the lung surgery. Surgeons have faced the surgery after reading the anatomy of the pulmonary vessels from CT findings prior to surgery in the past. However, we can encounter an unexpected branch of vessels by chance during an operation because many variations of the pulmonary vessels exist. Therefore, it is crucial to have correct understanding of angioplany preoperatively. We report a case of lung cancer in which surgery was safely performed by keeping pulse on the exceptional branch of V2 terminalis by three-dimensional angiography including the bibliographic consideration. The exceptional branch of V2 terminalis predominantly appears in men and in the right side. It often drains into the left atrium and can be associated with the angioplany of the bronchus or the right aortic arch.
In Japan a minority of cases of diaphragmatic hernia after partial resection of diaphragm have been reported. Here we report a case of incarcerated diaphragmatic hernia which developed after left partial diaphragmatic resection with automatic suturing device and which was able to be repaired laparoscopically. The patient was a 57-year-old woman who underwent left partial diaphragmatic resection for thoracic endometriosis. Postoperative chest pain and left upper quadrant pain appeared about three months after the surgery. We diagnosed the case as incarceration of fundus of stomach to the diaphragmatic hernia on the chest X-ray study and chest abdominal CT scan. She emergently underwent laparoscopic diaphragmatic hernia repair on the same day. The postoperative course was uneventful and she was discharged from the hospital on the postoperative day 6. Better view under laparoscopy might enable us to evaluate the incarcerated organs and to close the hernia opening.
Bochdalek hernia in an adult is rare. An 83-year-old woman had undergone total gastrectomy and splenectomy 23 years prior because of malignant lymphoma. She was subsequently diagnosed with an asymptomatic diaphragmatic hernia, and was followed at another hospital. She presented to our hospital because of abdominal distention. She had no abdominal tenderness, but her vital signs were unstable. Abdominal contrast computed tomography showed herniation of the transverse colon into the left thoracic cavity. We suspected a diaphragmatic hernia. Because of impending shock, she underwent emergency surgery. Since an adult Bochdalek hernia may progress rapidly, proper diagnosis is needed.
A 62-year-old man presented with dysphagia, and was suspected to have esophageal cancer on upper gastrointestinal endoscopy. The patient was diagnosed with cStage III esophageal squamous cell carcinoma in the abdominal esophagus (cT3N1M0). Treatment before surgery included 2 rounds of chemotherapy (5-fluorouracil and cisplatin) and 20 rounds of radiotherapy (40 Gy), and resulted in a partial response. Aiming at curative excision, we performed subtotal esophagectomy, posterior mediastinal reconstruction of the gastric tube, three-field lymphadenectomy, and an enterostomy. Seven days after the surgery, chest radiography and computed tomography showed intestinal gas in the left thoracic cavity, and an asymptomatic hiatal hernia was diagnosed. Because the intestinal tract significantly bulged into the left thoracic cavity through the esophageal hiatus, we performed laparoscopic repair as a second surgery. The herniated transverse colon was reduced and the esophageal hiatus was sutured and repaired with a sheet of mesh. The patient recovered well and was discharged twenty days after the first surgery.
A 56-year-old female patient with dysphagia was diagnosed as having squamous cell carcinoma of the middle thoracic esophagus in the clinical stage of cT3, N0, M1(thoracic vertebra), cStage IV (UICC7th) by detailed examination. As the definitive chemoradiotherapy (dCRT), he received two courses of systemic chemotherapy with 5-fluorouracil (5FU) plus cisplatin (CDDP), and concomitantly a total of 60Gy of irradiation(FP regimen). Another two courses of the FP regimen were added. A CR was achieved One year and nine months after dCRT, a CT scan revealed swelling of the gastric lesser curvature lymph node (#1), and the common hepatic artery lymph node (#8a). Four courses of the FP therapy were conducted, however, imaging studies revealed the residual tumor, and thus abdominal lymph node dissection (#1, 3a, 7, 8a, 9, 12a) was performed. Pathological examination revealed metastasis to a lymph node (# 8a). One year and four months after abdominal lymph node dissection (or 4 years and one month after the initial therapy), a CT scan revealed swelling of the para-aortic lymph node (# 16a2 inter). The FP therapy was administered for 2 courses, however there was the residual tumor. Thus para-aortic lymph node dissection (#12b, 12c, 16a2 inter, 16b1 latero, 16b1 inter) was performed. Pathological examination revealed metastasis to the lymph node (#16a2 inter). The patient remains in good condition without any evidence of recurrence as of 2 years and 5 months after the operation or 7 years after the initial treatment.
Case 1 : A 77-year-old man with cancer of the middle thoracic esophagus (Mt type0-IIc T1bN0M0 cStage IA) underwent chemoradiotherapy that achieved a complete response. Four years later, an esophagogastroduodenoscopy (EGD) revealed local recurrence, which was treated by photodynamic therapy (PDT). Two months after PDT, local re-recurrence was observed, and he underwent salvage subtotal esophagectomy under right thoracotomy and laparotomy. He has been alive without recurrence as of 3 years and 8 months after the operation. Case 2 : A 56-year-old man with cancer of the middle thoracic esophagus (Mt type0-IIa+IIc T1bN0M0 Stage IA) underwent chemoradiotherepy that achieved a complete response. Five years later, an EGD showed local recurrence, which was treated by endoscopic submucosal dissection (ESD) with concurrent PDT. A year and a half after ESD and PDT, local re-recurrence appeared near the ESD scar, and salvage subtotal esophagectomy under right thoracotomy and laparotomy was performed. He has been recurrence free as of 3 months after the salvage surgery. We present two cases of esophageal cancer in which salvage esophagectomy for local recurrence after PDT was helpful.
Background. Reconstruction following esophagectomy for gastrectomized patients with esophageal cancer is highly invasive and complicated that poses problem of adhesion of the organ for reconstruction. We have actively applied a two-stage operation for high risk patients with esophageal cancer. We recently applied the two-stage operation for two high-risk gastrectomized patients that ensured safe resection and reconstruction. Cases. Patient 1 had synchronous esophageal cancer and hypopharyngeal cancer. Following total pharyngo-laryngo-esophagectomy, a free jejunal graft was transplanted, and the distal end of the jejunum was placed into the neck as jejunostomy during the 1st operation, because vascular anastomoses would be difficult during the 2nd operation. Reconstruction with right colon was performed at the 2nd operation. Patient 2 who was an elderly had a past history of pancreatico-duodenectomy with declined cardiac function. During the 2nd operation, the operative approach was limited just around the right colon used for reconstruction because tight adhesion was recognized in the upper abdomen. Both patients had an uncomplicated postoperative course. Conclusion. The two-stage operation would lead to expand the indication of operation for high-risk patients with esophageal cancer.
The case was a 23-year-old female patient. At the age of 18, she visited our hospital with the chief complaint of dizziness and sense of fatigue. Anemia was noted. An endoscopic examination of her upper gastrointestinal tract revealed multi-nodular gastrointestinal stromal tumor (GIST), and owing to its extensive lesion, we performed a laparoscopic distal gastrectomy. During the follow-up period, at the age of 22, she was found to have a 10-mm nodule in the lingular segment of the left lung, for which we conducted thoracoscopic partial lung resection. The pathological diagnosis was a lung chondromatous hamartoma. Six months later, an endoscopic examination of the upper gastrointestinal tract showed a 15-mm submucosal tumor at the residual side of the lesser curvature, and biopsy of the mucosal incision yielded a pathological diagnosis of GIST. When the patient's age was 23, we performed a laparoscopic and endoscopic cooperative surgery of gastric partial resection and preserved the residual stomach. The present case was a rare case of incomplete-type Carney's triad of gastric GIST complicated with lung chondromatous hamartoma, having features different from those of ordinary, adult-type gastric GIST. We report our case, together with other 11 cases published in Japan, and a review of the literature.
A 40-year-old man with sudden abdominal pain was brought to our hospital by ambulance. He had undergone laparoscopic distal gastrectomy at an other hospital two years prior. Since strangulated ileus was suspected on abdominal CT, emergency surgery was performed. The small intestine showed intussusception due to edema and ischemic change. After manual replacement by Hutchinson's maneuver, improvement in the ischemic change and absence of any necrotic change were confirmed in the intussuscepted small intestine, and the operation was finished without resection. The findings showed that distal gastrectomy with Roux-en-Y reconstruction had been performed, and that the part of the small intestine toward the anal side of the Roux-en-Y anastomosis was retrogradely intussuscepted approximately 15 cm to the Y limb toward the ligament of Treitz. The patient's postoperative course was uneventful, and he was discharged 10 days after the surgery. Esophagogastroduodenoscopy performed after discharge showed no findings such as a tumor or polyp that might have formed the end of the intussusception on the part of the small intestine toward the anal side of the Roux-en-Y anastomosis. Although intussusception after gastrectomy is a rare complication, the possibility of intussusception occurring due to the reconstruction method used after gastrectomy has not been sufficiently analyzed.
Carcinoid of the small intestine often metastasizes to the lymph nodes, even when the lesions are small. We encountered a case of carcinoid tumor of the ileum, in which the lymph node metastatic tumor was larger than the primary lesion. A 62-year-old man presented to his primary care doctor with a history of constipation and diarrhea. Abdominal CT revealed an ileocecal tumor, and the patient was referred to our hospital. We diagnosed the patient as having an ileocecal mesenteric tumor and performed laparoscopic ileocecal resection with lymph node dissection. However, a carcinoid tumor was found in the terminal ileum, and the ileocecal mesenteric tumor was histopathologically diagnosed as a lymph node metastasis from the carcinoid tumor. The primary and metastatic lesions measured 15 mm and 30 mm in diameter, respectively. In cases of lymph node metastasis from carcinoid tumors of the small intestine, metastatic tumors are not uncommonly larger than the primary lesion. It is important to differentiate such lymph node metastases from mesenteric tumors.
We have experienced a case of strangulation ileus caused by adhesion of the appendix to the mesentery of the colon. The case involved a 75-year-old man who presented to the emergency clinic in our hospital because of a 3-day history of abdominal pain and dysphagia. The entire abdomen slightly distended. There was mild tenderness in the right lower quadrant of abdomen but the abdomen was elastic-soft. There was no rebound tenderness. Blood analysis revealed mild degree of inflammatory reaction. Following abdominal x-ray examination and CT scan, ileus was diagnosed. Placement of a long tube was unsuccessful and the patient was operated on. Laparotomy disclosed that the tip of the appendix was adherent to the mesentery of the ascending colon and squeezed the ileum, at where the ileum was strangulated. Appendectomy released the strangulation. We saw the involved ileum not to be gangrenous. Histopathological studies showed no diseases such as a mucinous cyst of the appendix and we hardly confirm inflammatory findings. Since it is rare that the appendix itself becomes strangulation band, we present our case together with a review of the literature.
This paper deals with a case of cecal cancer presented with neurologic symptoms due to synchronously occurred solitary brain metastasis, in which removal of the brain metastasis followed by resection of the primary lesion resulted in disease-free 15-month survival without chemotherapy. The case involved a 69-year-old woman who presented to the Department of Cerebral Surgery in our hospital because of memory deterioration starting in around August 2014 and the onset of dysphasia and decreased myodynamia at the beginning of September of the year. Following close exploration, brain metastasis of cecal cancer was diagnosed. Since her neurologic symptoms rapidly progressed, emergency craniotomy for enucleating the brain metastasis was performed 2 weeks after the onset of the symptoms. In addition, following stereotactic radiotherapy (SRT) for the tumor bed, we performed laparoscopic-assisted ileocecal excision with D3 lymph node dissection. The final diagnosis was C, type2, tub2 (>tub1), pT3, int, INFb, ly1, v2, pN0, pM1(brain) and fStage IV. The patient did not hope to receive adjuvant chemotherapy and we selected to follow her clinical course. Fortunately she has been free from neurologic symptoms and recurrence, as of 15 months after the initial treatment.
A 79-year-old man presented with pleural effusion and ascites was found to have sigmoid colon carcinoma in June 2015 and was referred to our department for the purpose of surgery in July. After admission, however, he suddenly developed chill and high fever and went into shock. Streptococcus bovis (S. bovis) was isolated from a blood culture, and septic shock was diagnosed. His general condition was improved by administration of antimicrobial agents and laparoscopic-assisted sigmoidectomy was performed in August. The postoperative course was uneventful and he was discharged from our hospital on the 12th postoperative day. The pathological diagnosis was T2 (MP), N0, M0, pStage I. S. bovis is an enterobacterium. It exists in the enterobacterial flora in about 10% of healthy individuals, but it is reported that as high as 29 to 59% of patients with colorectal cancer carry S. bovis. We sometimes encounter clinical reports that early colorectal cancer presented with S. bovis bacteremia. Our understanding of the correlation between S. bovis and colorectal cancer appears to be important clinically, and thus we present our case with a review of the literature.
Cardiac metastasis may rarely cause a tumor embolism. We experienced a case in which, after resection of sigmoid colon cancer, left atrial invasion of the metastasis from the lung caused a left ulnar artery embolism, cerebral infarction, and splenic infarction due to tumor embolism. The case was a 47-year-old female patient. Four years and 3 months after the resection of sigmoid colon cancer, bilateral lung metastasis was observed. We performed thoracoscopy-assisted left lung subsegmental resection in 2 stages. We post-operatively administered chemotherapy for 7 months, but after 2 years and 3 months, we observed metastasis again in the right lung. This recurrent metastatic cancer decreased in size after stereotactic irradiation, but 11 months after the recurrence, left upper arm pain occurred. Contrast-enhanced computed tomography revealed left atrial invasion metastasized from the lung and a left ulnar artery embolism. We performed removal of the embolus by a catheter and histopathologically diagnosed it as a tumor embolus. One month later, multiple cerebral infarctions occurred, and a further 2 weeks later, splenic infarction developed. Since there were no other factors such as arrhythmia and arteriosclerosis, we suggest that the series of disease progression was caused by multiple tumor embolisms due to the left atrial invasion of the lung metastasis from the sigmoid colon cancer. Subsequently, chemotherapy was administered, and the patient remains alive. In the case of a cancer-carrying patient, it is necessary to take into consideration a tumor embolism that may occur in multiple organs.
The patient was a 52-year-old woman who had undergone low anterior resection with D3 lymph node dissection for advanced rectal cancer. The final histopathological diagnosis was advanced lower rectal cancer, pT4a N0 M0, pStage II. An abdominal ultrasound examination performed 10 months after the surgery revealed a tumor measuring 33 mm in diameter in front of the left common iliac artery. FDG-PET showed increased uptake in the tumor. Solitary lymph node metastasis from the rectal cancer was suspected. Because abdominal CT and PET-CT showed no evidence of any other metastases, a laparotomy was performed. The nodule was located at the root of the superior rectal artery that had been resected at the initial surgery ; therefore, it was considered as recurrence in #252 lymph node. Histopathological examination of the resected specimen, which included two laparoscopic clips, however, revealed inflammatory changes and elastic fibers with no malignant cells. Thus, the tumor was diagnosed as an inflammatory pseudotumor. The patient has been followed-up for one and a half years, and has shown no evidence of recurrence.
We have experienced a case of anorectal malignant melanoma in an very elderly woman who follows a favorable postoperative course after local resection without complains. The case involved a 90-year-old woman who presented to our hospital because of a 2-month history of anal bleeding at defecation. On digital examination, a painless elastic-hard tumor 20 mm in diameter was palpated at the anoretal region. Colonoscopy performed for further close examination disclosed a pedunculated tumor having the base at the dentate line. A biopsy resulted in anorectal malignant melanoma. Abdominal and pelvic CT scans showed bilateral inguinal swellings. We considered that radical operation including abdominoperineal resection and lymph node dissection might be difficult because her performance status (PS) was 3 due to the great age. However, her hemorrhagic symptom at defecation was so serious that we decided to perform local resection alone that complied with her and her family's wishes. The patient's postoperative course was uneventful, and she has been free from local recurrence and distant metastasis as of 27 months after the operation. The bilateral inguinal lymph node swellings have been unchanged in size.
A 53-year-old man visited our hospital because of epigastric pain. Abdominal ultrasonography and computed tomography (CT) showed a 3.5-cm abscess with a needle-like structure in the lateral segment of the liver. The foreign body had penetrated the stomach and caused the hepatic abscess. Following improvement of the hepatic abscess with antibiotics, removal of the foreign body with laparoscopic lateral hepatic segmentectomy was performed. The foreign body was a toothpick. The postoperative course was uneventful. In this case, CT was very helpful in making the diagnosis. Laparoscopic surgery was minimally invasive, and was useful for removing the foreign body.
Case 1 involved a 72-year-old woman who was referred to our hospital because blood analysis during therapy for cerebral infarction showed increases in hepatic enzyme levels. Abdominal CT and MRI scans visualized interruption of the bile duct in the right posterior segment and dilatation of the peripheral bile duct. Intrahepatic bile duct cancer was suspected. No malignant findings were revealed by endoscopic retrograde cholangiopancreatography (ERCP) and cytodiagnosis of bile juice. Following hepatic biopsy, IgG4-related sclerosing cholangitis was suspected. Methyl prednisolone regimen at 500 mg/day for 3 days was unsuccessful and the patient developed acute cholangitis. Since a possibility of malignancy could not be ruled out, posterior segmentectomy of liver was performed. The pathological diagnosis was IgG4-related sclerosing cholangitis. Case 2 involved a 77-year-old woman who was referred to our hospital for close exploration of anemia which was pointed out at blood analysis. Following colonoscopy, histological diagnosis and abdominal CT scan, hepatic metastasis of colon cancer was diagnosed. We performed right lobectomy of liver and right hemicolectomy. Histopathological studies of the resected liver showed no malignant findings. Immunohistochemistry revealed a large number of IgG4-positive cells. The final diagnosis was advanced colon cancer with IgG4-related inflammatory pseudotumor. Inflammatory pseudotumor of the liver associated with IgG4-related disease is difficult to differentiate from malignant tumors and is often resected surgically. Surgery can be avoided if the definite diagnosis of the disease is established preoperatively.
A case of cholangitis of the right hepatic duct caused by an ingested fish bone is reported. A 70-year-old man developed symptoms of acute cholangitis and was admitted to our hospital two times within the space of half a year. Abdominal CT and MRI showed evidence of acute cholangitis with dilatation of the right hepatic duct. Underlying intrahepatic bile duct cancer was considered as the cause of the relapsing cholangitis and dilatation of the right hepatic duct. Under the suspected diagnosis of intrahepatic bile duct cancer, an exploratory laparotomy was performed. The junction between the duodenum and common bile duct was cut, and the intrabiliary wall was observed with a cholangioscope. A foreign body was found to be stuck to the bile duct wall, which was considered to be the cause of the acute cholangitis. The foreign body was removed endoscopically with forceps. Histopathologically, the foreign body was diagnosed as a bone stump, and the needle-shaped appearance suggested that it was a fish bone. This is the first reported case of an ingested fish bone found in the upper bile duct.
An 85-year-old female patient was admitted to our hospital with a history of abdominal pain and constipation. Examinations revealed the diagnosis of gallstone ileus with fistulous communication between the gallbladder and duodenum. Initial conservative therapy by insertion of an ileus tube did not have the desired effect, therefore, surgery was performed. Intraoperative intestinal fluoroscopy through the ileus tube during the single-port laparoscopic surgery allowed easy visualization of multiple stones in the ileum. Although the limitations in respect of touch sensation and operative field during laparoscopic surgery might make it difficult to detect stones, intraoperative fluoroscopy can compensate for these limitations and is an effective diagnostic modality.
To clarify clinical characteristics of gallbladder torsion, we retrospectively examined five patients including one man and four wemen, who were operated on for gallbladder torsion in our hospital between 2006 and 2015. The median age was 85 (range 83-92). We were able to diagnose two out of five patients by CT preoperatively, and the remaining three patients underwent surgery because they had bloody bile discharge from their percutaneous transhepatic gallbladder drainage (PTGBD). PTGBD patients included two in whom PTGBD was inserted through the free peritoneal cavity, and their intraoperative findings did not include bile discharge into the peritoneal cavity. All five patients had findings on plain CT, which were significant gallbladder enlargement without gallstone obstruction and high density area in its walls. Three patients had deviation of the cystic duct, and one had a tapered and twisted cystic duct which appeared as a mass. Cholecystectomy was performed under laparotomy in four patients and under laparoscopy in the remaining one. Abdominal CT findings were helpful in confirmation of the diagnosis of gallbladder torsion. PTGBD for gallbladder torsion was performed safely in our cases. It may be useful as a diagnostic tool when diagnostic imaging is difficult.
A 65-year-old man was referred to our hospital with localized intrahepatic bile duct dilatation of segment 6. Endoscopic retrograde cholangiopancreatography (ERCP) showed localized stenosis and distal dilatation of the bile duct in liver segment 6. A computed tomography (CT) scan did not reveal any space occupying lesion. Endoscopic nasobiliary drainage (ENBD) was placed in dilated B6 for cytology of the bile juice, which revealed no malignancy 6 times. PET imaging did not show abnormal FDG accumulation. The patient was diagnosed to have inflammatory bile duct stenosis and was followed-up. During the follow-up period, CA19-9 increased gradually, and a tumor in S6 became evident on abdominal CT scan. The patient underwent posterior sectionectomy of the liver 11 months after the first consultation. The histopathological diagnosis was moderately-differentiated tubular adenocarcinoma. This case is reported because it demonstrates the importance of close follow-up of localized intrahepatic bile duct dilatation.
A 69-year-old woman visited a doctor with the chief complaints of nausea and generalized malaise. Abdominal CT revealed a mass lesion measuring 7 cm in diameter invading the liver and duodenum. Upper gastrointestinal endoscopy revealed duodenal invasion and histopathological examination of a biopsy specimen revealed the diagnosis of adenocarcinoma. The patient was referred to our department complaining of persistent melena. Because there were no obvious factors contraindicating resection, we performed both partial hepatectomy and pancreatoduodenectomy and grossly resected the entire tumor. Histological examination revealed that the tumor was composed mainly of circular and fusiform-shaped nuclei, with small portions showing differentiation into glandular duct-like structures. Immunostaining revealed positive staining for CAM5.2 and AE1/AE3, focal positive staining for 34betaE12, and negative staining for p40. Gallbladder carcinosarcoma was diagnosed on the basis of negative immunohistochemistry results for neuroendocrine and myogenic markers, except for focal positivity for S100. A relapse was found in the abdominal wall in the third postoperative month, however, the tumor promptly shrank with radiation therapy. The patient remains alive at present, 5 months after the surgery. We hereby report a rare case of gallbladder carcinosarcoma, with some bibliographic considerations.
A 63-year-old woman with a history of chronic pancreatitis was admitted to the hospital with anemia, hematemesis, and high serum amylase level. No bleeding point was shown on upper endoscopy. Abdominal computed tomography (CT) revealed a pseudoaneurysm of the splenic artery ; thus, we diagnosed hemosuccus pancreaticus, with a ruptured pseudoaneurysm into a pancreatic duct. Therefore, emergency diagnostic angiography and interventional radiology (IVR) treatment were performed. The pseudoaneurysm was successfully treated with coil embolization of the splenic artery. However, 2 months after the IVR, the patient was again admitted to the hospital with hematemesis. CT revealed a new splenic pseudoaneurysm on the distal side of the coil embolization. Thus, we performed a distal pancreatectomy and splenectomy. No gastrointestinal bleeding has occurred since then. Herein, we present a rare case of hemosuccus pancreaticus associated with pseudoaneurysm of the splenic artery.
A 66-year-old man was admitted to our hospital for detailed examination of an intrapancreatic bile duct tumor. He had undergone gallbladder bed resection and extrahepatic bile duct resection with choledochojejunostomy as treatment for gallbladder carcinoma caused by pancreaticobiliary maljunction with congenital biliary dilatation. One year later, positron emission tomography demonstrated high accumulation of 18F-fluorodeoxyglucose in the intrapancreatic bile duct. Endoscopic retrograde cholangiography demonstrated pancreaticobiliary maljunction and a filling defect in the intrapancreatic bile duct. Pathologically, the diagnosis was adenocarcinoma. With a diagnosis of intrapancreatic remnant bile duct cancer, pancreaticoduodenectomy was performed. The patient remains free of recurrence 28 months after the surgery. Although remnant intrapancreatic bile duct cancer after bile duct resection and biliary reconstruction for pancreaticobiliary maljunction is rare, our experience suggests that we must always consider the possibility of the occurrence of carcinoma in the remnant bile duct after such surgery.
A 40-year-old man was referred for evaluation of hypertension. Abdominal computed tomography (CT) showed a 24×18 mm splenic artery aneurysm near the splenic hilum. Because of a risk of rupture, spleen-preserving laparoscopic aneurysmectomy of the splenic artery was planned. An interventional radiology approach was another option, but the diameter of the splenic artery was too large to treat with coiling. Prior to the operation, enhanced CT angiography was performed to determine the blood flow in the spleen after ligation of the splenic artery. The proximal axis and distal upper and lower branches of the splenic artery were clipped, and the aneurysm was excised. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. Postoperative enhanced CT angiography showed adequate blood flow to the spleen through collateral flow. This is an optional operative method for an aneurysm of the splenic artery.
We report the case of a 59-year-old man who underwent a left radical nephrectomy for renal cell carcinoma (RCC, clear-cell type, G2 T1bN0M0 stage I). Brain metastasis was found, and craniotomy and postoperative radiotherapy were performed. Multiple lung metastases were found, and he was treated with pharmacotherapy. At 29 months after nephrectomy, he presented with black stools. Esophagogastroduodenoscopy revealed a semi-pedunculated tumor in the body of the stomach. Partial gastrectomy was performed to prevent bleeding or perforation. Immunohistology confirmed the diagnosis of metastatic RCC. Gastric metastasis from RCC is rare. We report a case of gastric metastasis from RCC treated with surgical resection.
Primary retroperitoneal teratoma is a relatively rare disease that occurs most often in children and is very rare in adults. An adult case with a diagnosis of mature cystic teratoma treated by surgical resection is presented. A 78-year-old woman visited our hospital because of back pain, and a diagnosis of a retroperitoneal tumor was made on CT scan. The tumor was about 8 cm×5 cm and was in front of the left ovarian artery. As preoperative diagnose, mucinous tumor, teratoma, and so on were suspected, and tumor resection was performed. The resected specimen was a cystic tumor with a smooth surface, filled with a brownish-red viscous liquid. Histopathologically, the tumor was a cystic tumor with a sebaceous gland, and the diagnosis was mature cystic teratoma without malignant findings. The patient's postoperative course was uneventful, and the patient was discharged from the hospital on the 8th postoperative day. Primary retroperitoneal mature cystic teratoma is a very rare disease in adults. A case with malignant transformation has a poor prognosis, but in a case found before malignant transformation, resection provides a good prognosis. Surgical resection should be performed for retroperitoneal teratoma in adults.
It is not unusual to encounter a retroperitoneal tumor, but it is comparatively rare to find a tumor so large that it is accompanied by vertebral scalloping. We experienced such a case in which a one-stage resection was performed by a 4 divisions-joint surgery. The patient was a woman in her sixties. She was transported by ambulance to hospital due to abdominal pain and vomiting, and was diagnosed with acute pancreatitis. Computed tomography (CT) revealed a large retroperitoneal tumor. After remission of pancreatitis, we performed a retroperitoneal tumor resection. On the day prior to the surgery, we embolized the feeding vessels with coils by interventional radiology, and on the day of the surgery, we inserted a right ureteral stent before the surgery commenced. At first, we detached the tumor that had invaded the vertebral body with the patient in the dorsal position. Then, with the patient in the supine position, by ligating the perforating branches from the inferior vena cava we incised the anterior longitudinal ligament of vertebra, and removed the tumor without membrane damage. The specimen was a sandglass-type tumor over 20 cm in size and weighing 1,756 gm. The pathological examination revealed the spindle-type, disordered cell proliferation, positive S-100 protein staining, and a MIB-1 index of less than 1%. Therefore, the tumor was diagnosed as a benign schwannoma. Three years after surgery, the patient was free from numbness, and alive without recurrence. Although a giant schwannoma accompanied by vertebral scalloping is rare, we successfully resected it using one-stage surgery. Thus, we report the case with a review of the literature.
A 59-year-old man with no history of abdominal surgery was referred to our hospital with a chief complaint of sudden upper abdominal pain. The initial examination showed evidence of peritoneal irritation, while contrast-enhanced abdominal computed tomography (CT) showed dilation of the small intestine without enhancement on the abdominal side of the gastric lesser curvature. Furthermore, a part of the intestine formed a closed loop. An emergency laparotomy was performed under a diagnosis of strangulated ileus caused by an internal hernia. At the time of surgery, a small amount of bloody ascites, as well as two dark-colored loop formations of the small intestine, was found on the ventral side of the lesser curvature. The gastrocolic ligament could not be observed due to aplasia of the major omentum and dysraphism of the major omentum and transverse colon. The bursa omentalis was extensively open. Furthermore, the ileum was seen passing to the dorsal side of the stomach through the bursa omentalis and herniated to the ventral side through an abnormal minor omental hiatus that measured 2 cm in diameter. It was strangulated and necrotic over a length of 40 cm. A partial ileectomy was performed, and the omental hiatus was closed by suturing. No other abnormal intraperitoneal findings were noted. A transomental hernia through an abnormal minor omental hiatus associated with congenital omental aplasia is extremely rare. The details of this case along with a review of relevant past reports are presented.
A 67-year-old-woman who had undergone emergency open abdominal surgery for perforated duodenal ulcer six years prior was aware of an upper abdominal bulge one year after the surgery. She subsequently developed a gastric ulcer that did not improve significantly despite continuous medical treatment since the fourth year after surgery. Therefore, she was referred to our department with suspected intractable gastric ulcer. Gastroduodenoscopy revealed an active gastric ulcer in the pyloric ring of the stomach. Abdominal contrast-enhanced computed tomography showed an incisional hernia with protrusion of the gastric antrum and stagnant contrast agent in the right gastroepiploic vein. Based on these findings, she was diagnosed with intractable gastric ulcer caused by congestion of the right gastroepiploic vein, and the upper abdominal incisional hernia was successfully repaired. Gastroduodenoscopy performed 41 days after the surgery showed a healing gastric ulcer. Herein, we present our experience of successful treatment of an intractable gastric ulcer after repair of abdominal incisional hernia with a review of the literature.
An 88-year-old woman who had no history of laparotomy and complained of vomiting and abdominal distention was referred to our hospital with a diagnosis of small bowel obstruction because an abdominal plain X-ray study showed dilated small bowel and air-fluid level formation at another hospital. Abdominal contrast-enhanced computed tomography showed a dilated small bowel situated right lateral to the cecum. She was diagnosed with small bowel obstruction and a long tube was placed to start conservative therapy. The abdominal symptoms improved, but the bowel obstruction persisted. Small bowel obstruction due to an internal hernia was suspected and on the 14th day after admission, laparoscopic surgery was performed. Operative findings revealed a lateral type of paracecal hernia. The hernia orifice was incised and opened to reduce the obstruction as well as to prevent recurrence with three-port laparoscopic surgery. The bowel could be kept intact. In cases of internal hernias including paracecal hernias, preoperative diagnosis is relatively difficult and laparoscopic surgery may be useful for diagnosis and treatment.
The case was a 79-year-old female patient. She presently is obese, with a body mass index of 36. When she was straining to defecate, she found the stool coming out from the right umbilical region. Thus, she visited the nearest clinic and was referred to our hospital for hospitalization and treatment. We found a fist-sized bulge at the umbilical region and mushy feces draining out of the part where skin necrosis had occurred. Abdominal computed tomography revealed a hernia in the umbilical region, with an orifice of 35 × 80 mm. The hernia content covered the small intestine, the large intestine, and the greater omentum, and free air was found to exist in the hernia sac. Based on the diagnosis of bowel perforation accompanying hernia incarceration, we performed the following surgery. We made a median incision, to extend the surgical wound of the skin fistula. We circumferentially detached the hernia sac under the skin to open the space and found that the greater omentum was adhered to the hernia sac, and that the transverse colon was prolapsed from a gap in the greater omentum and was incarcerated and perforated. The small intestine did not show any sign of ischemia, and strangulation by the umbilical hernia itself was not observed. We excised the perforated part and made a functional end-to-end anastomosis by using an end GIA. Due to the contaminated wound, we did not use meshes and finished the hernia repair by adopting a simple closure. Post-operative conditions were good, and the patient was discharged on day 20.
An adult case of sacrococcygeal mature teratoma is reported. A 38-year-old man with a tumor in the right buttock was referred to our hospital. CT and MRI identified a cystic tumor in the right buttock, located in front of the coccyx. There was no pre-existing increase in the level of serum tumor markers. The preoperative diagnosis was dermoid cyst of the buttocks, epidermoid cyst, tail gut cyst, or teratoma. A radical operation was performed. The operation involved extraction of the cystic region of the right buttock and coccyx, without collapsing the tumor in the jack-knife position. The tumor was a multicystic tumor, measuring 90 × 60 × 55 mm. Histopathological examination showed that the tumor was a mature cystic teratoma with a mucinous border. The patient's postoperative course was good, with no recurrence of the tumor and no neurological disorders. In general, sacrococcygeal teratoma occurs in early childhood, with adult onset being very rare. A radical operation is needed in adult patients because of the possibility of malignant transformation.
A case of giant hematoma due to neurofibromatosis in a 73-year-old woman is reported. At 70 years of age, after ablation for paroxysmal atrial fibrillation, anticoagulant therapy was continued. When going to the toilet, she noticed a table- tennis ball-sized tumor in her left hip, and because of the rapid enlargement of the hip tumor, she was brought to the emergency department. In the left hip there was a very large, 16 × 14 cm, subcutaneous hematoma, accompanied by spontaneous pain, and across her entire body, chestnut/azuki bean-sized neurofibromas and pigmented patches (café au lait spots) were observed. From the physical findings, Neurofibromatosis type 1 was diagnosed. Because anemia developed, anticoagulant therapy was stopped. Then, after blood transfusion and hematoma compression, elective surgery involving hematoma and tumor resection was performed on the 5th day of hospitalization. It is believed that the causes of bleeding in this case were the anticoagulant therapy and the ease at which neurofibromas bleed.