The prevalence of non-B non-C hepatocellular carcinoma (HCC) has recently been increasing. In this study, the clinicopathological characteristics of surgically treated patients with non-B non-C type HCC were evaluated. The 96 cases that underwent hepatectomy in our hospital were classified into three groups : N group, non-B non-C type hepatocellular carcinoma (34) ; B group, hepatitis B virus-related hepatocellular carcinoma (14) ; and C group, hepatitis C virus-related hepatocellular carcinoma (48). Clinicopathological characteristics, recurrence-free survival, and cumulative overall survival after curative resection were compared among the three groups. Although non-B non-C type showed large tumor size and needed extensive surgery, liver function was preserved, the rate of well-differentiated carcinoma was high, and the rate of cirrhosis (F4) was low. As for recurrence-free survival and cumulative overall survival, there were no significant differences among the three groups. For early detection of this disease, the establishment of appropriate surveillance is needed.
Phyllodes tumors of the breast are divided into three histotypes : benign, borderline, and malignant. A benign phyllodes tumor can recur locally and undergo malignant change. A case of phyllodes tumor with malignant change is presented. The patient was a 72-year-old woman who consulted a doctor because of a tumor, 2.0 cm in size, in the CDE-region of the left breast. A fibroadenoma was suspected based on core needle biopsy. Tumorectomy was carried out, and the histological diagnosis was mastopathy. Then, 18 months later, she again noted a mass in the same region, and after 24 months, she was re-admitted to hospital with rapid tumor growth. The tumor was 9 cm, occupying the entire left breast with nipple retraction. CT showed a tumor directly below the nipple. At this time, a borderline phyllodes tumor was suspected based on core needle biopsy. Mastectomy was performed, and the histological diagnosis was a malignant phyllodes tumor. When the previous specimen of the first operation was reconsidered, stromal overgrowth was seen in a small portion at the edge, and it seemed that the tumor had undergone malignant change. Thus, a case of phyllodes tumor with malignant change from a slight benign phyllodes tumor is described.
Neuroendocrine carcinomas of the breast are relatively rare tumors. The World Health Organization (2003) classifies neuroendocrine tumors as carcinoma with neuroendocrine features. Six patients with neuroendocrine carcinoma of the breast are reported. These patients ranged in age from 34 to 68 years (mean : 46.5 years), and 5 of the patients presented with a chief complaint of a bloody nipple discharge from a single orifice. Ultrasound showed duct ectasia and localized lesions, but mammography showed no abnormal findings in all cases. Cytology of the nipple discharge was benign. Two patients had an ultrasound-guided needle biopsy, and four patients underwent a segmental mastectomy. Histopathology with hematoxylin-eosin staining suggested neuroendocrine tumors. Based on positive immunohistochemical staining for chromogranin A and synaptophysin, neuroendocrine carcinoma of the breast was diagnosed in all cases.
A 54-year-old man was brought into our hospital by ambulance because of the abrupt onset of back pain. Chest and abdominal CT scans revealed Stanford type A acute aortic dissection associated with dissection of the superior mesenteric artery (SMA). We emergently performed ascending aortic replacement followed by placement of a stent into the main trunk of the SMA. The patient's postoperative course was uneventful, but he developed small bowel obstruction on the 11th day after initiation of oral ingestion. Considering that conservative treatment might be unsuccessful, we performed surgery on the 44th day after the onset of the symptoms. During surgery, we confirmed complete obstruction of the small intestine about 170 cm proximal to the terminal ileum and performed enterectomy. Stricture type ischemic enteritis was diagnosed based on surgical and histologic findings. If the aortic dissection may involve the SMA, we have to keep a possibility of bowel necrosis in mind in its acute phase, but in the chronic phase, we have to remind that the appearance of abdominal symptoms can indicate ischemic enteritis.
Saccular aneurysms are more vulnerable to rupture than fusiform aneurysms ; the occurrence of rupture increases the mortality rate, even if emergency surgery is performed. An 85-year-old woman who experienced sudden onset of left flank pain and vomiting was transported to our hospital. She had a history of hypertension, diabetes mellitus, hyperlipidemia, and angina pectoris. Contrast-enhanced abdominal computed tomography revealed a ruptured abdominal aortic aneurysm (48 mm in diameter) arising from the anterior wall of the terminal aorta and massive retroperitoneal hemorrhage spreading above the left renal artery. The aneurysm was classified as Fitzgerald type III. The patient was immediately transferred to the operation theater. Initially, artificial vascular grafting was planned ; however, the patient developed progressively worsening circulatory collapse. Furthermore, severe adhesions were observed around the terminal aorta. Therefore, the patch closure technique was applied to close the mouth of the saccular aneurysm in order to control the bleeding. After the procedure, the bleeding gradually ceased, the patient recovered from the circulatory shock, and the operation was successfully completed. The patient remained relatively stable after the operation. On postoperative day 23, she was discharged without any serious complications.
A 77-year-old man had undergone endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) 47 mm in diameter and a left common iliac aortic aneurysm at another hospital in April 2010. During the operation, type II endoleak was confirmed. Thereafter yearly follow-up CT scanning had been conducted in our hospital. Enlargement of the AAA up to 73 mm in diameter was noted in July 2013. He was referred to our department for the purpose of surgery. Laparotomy was performed by the abdominal midline incision, and the thick lumbar artery, inferior mesenteric artery and left internal iliac artery which might cause type II endoleak were ligated from the outside of the aneurysm. After the central and peripheral sides of the stent grafts were taped and snared, the AAA and the left common iliac arterial aneurysm were incised. We confirmed retrograde blood flow from the lumbar artery into the aneurysm sac, so that we performed hemostasis by sutures and plication suture for the aneurysms. Taping and snaring of the central and peripheral sides of stent grafts is a useful method which can prevent from hemorrhage due to migration of the stent graft by surgical procedure of latent type I endoleak.
Herein, we report two cases of superior mesenteric arterial occlusion (SMAO) in which second look laparoscopy was necessary even though angiography was effective for primary treatment. [Case 1] A 44-year-old woman presented with severe abdominal pain. Computed tomography (CT) revealed SMAO and the superior mesenteric artery was recanalized by interventional radiology (IVR). Because she had abdominal pain after IVR, laparoscopy was performed to examine the intraperitoneal organs. Her bowels were not ischemic. She was discharged from the hospital on post-operative day 14. [Case 2] A 79-year-old-woman presented with severe abdominal pain. CT revealed SMAO and the superior mesenteric artery was recanalized by IVR. Because she had bloody stools after IVR, laparoscopy was performed to examine the intraperitoneal organs. Her bowels were not ischemic. She was discharged from the hospital on post-operative day 18. Because we had two cases of SMAO in which second look laparoscopy after IVR was necessary, we report these cases with a review of the literature.
A 44-year-old woman who had been followed regularly in the clinic of internal medicine for pure red cell aplasia was pointed out having a thymoma incidentally through chest X-ray and was referred to our department of chest surgery. A chest contrast-enhanced CT scan showed a 4-cm segmented tumor shadow at the anterior mediastinum. A thymoma associated with pure red cell aplasia was suspected. She underwent video-assisted thoracoscopic thymothymectomy. The resected specimen was 5.5×4.0×2.8 cm in diameter. The pathological diagnosis was type AB thymoma of the WHO classification, and Masaoka stage I. Before the operation, medical treatment by cyclosporine A was given, but the anemic state was poor and transfusion treatment was carried out several times. After the operation, anemia showed an improvement tendency and the dose of cyclosporine A could be reduced. There has been neither an anemic advance nor recurrence of thymoma as of one year and five months after the operation. Thymomas can be associated with various autoimmune disorders such as myasthenia gravis and pure red cell aplasia. This paper deals with a case of a thymoma with pure red cell aplasia performed thymothymectomy that improved the resistance of the disease to the treatments.
A 57-year-old woman, who had undergone total hysterectomy for a uterine leiomyoma at the age of 42, was referred to our department because of abnormal shadows noted on a chest radiograph at a medical checkup. A chest computed tomography scan revealed a nodule with a clear margin, approximately 23 mm in diameter in the left S10, and multiple small nodules less than 10 mm in diameter in the bilateral lungs. Tumor markers were in normal ranges and a FDG-PET scan revealed no abnormal accumulation of FDG in any nodules. Since the tumor in the left S10 had enlarged to 30 mm in diameter, thoracoscopic partial lung resection of small nodule was performed to facilitate a diagnosis. Histologically, the tumor was diagnosed as a benign metastasizing leiomyoma. The patient received hormonal therapy. The tumor in the left S10 had decreased temporarily, but enlarged again. A malignant tumor was suspected, and the tumor was removed by open thoracotomy 5 years after his first visit. Histologically, the tumor was suggested to be a benign metastasizing leiomyoma with malignant transformation. We report a rare case of a benign metastasizing leiomyoma with malignant transformation and review the available literature.
The case involved a 73-year-old man. When he was 71-years old, he was performed video-assisted thoracoscopic left upper lobectomy for left upper lobe lung cancers (synchronous multiple primary lung cancers of adenocarcinoma and squamous cell carcinoma), which were accidentally revealed by CT for a survey of a traffic trauma. After two years from the operation, a small nodule at the right upper lobe was detected by follow-up CT examinations. The feature of it suggested metastatic lung cancer, but we could not rule out a possibility of second primary lung cancer, and considered the case to be a candidate for an operation. We finally performed video-assisted thoracoscopic wedge resection, because the nodule was small and situated at the periphery of the right upper lobe that appeared to secure the curability and to preserve his pulmonary function. The postoperative histopathology revealed that the nodule was large cell neuroendocrine carcinoma, and the final diagnosis of metachronous multiple primary lung cancer was made. It is believed that the prognosis of metachronus multiple primary lung cancers is favorable compared with that of recurrence or lung metastasis, and therefore we should consider an operation, unless the possibility of metachronous multiple lung cancer is denied. However, activities of daily living (ADLs) can decline after the operation so that we have to decide operative indication and procedures after careful consideration of patient's background factors.
A 67-year-old man presented with a nodular lesion in the lower lobe of the left lung. Computed tomography that was carried out as a screening for his elevated serum carcinoembryonic antigen (CEA) level detected a small nodule at the posterior basal segment (S10) of the left lung. The pulmonary nodule developed a tendency to enlarge in a half year. Because of a clinical suspicion of malignancy, he underwent a thoracoscopic wedge resection of the left lower lung. Histopathologically, the tumor was composed of atypical cells arranged in trabecular or alveolar pattern, and the tumor cells had clear cytoplasm. No ductal structures were found throughout the tumor. Immunohistochemical staining showed the tumor cells to be positive for 34βE12, S-100, α-SMA, and P-63. On the basis of the above features, the tumor was diagnosed as primary myoepithelial carcinoma of the lung. The patient is doing well without recurrence for 4 years and 9 months after the operation.
The transmanubrial approach is a standard operative procedure for Pancoast tumors, but few reports on the complications with the procedure have been described. We report a case of a patient with a superior sulcus tumor, who developed postoperative surgical site infection and pleural empyema, which were successfully treated by myoplasty. A 78-year-old male patient underwent the resection of a superior sulcus tumor in the right upper lobe (squamous cell carcinoma) with the involved chest wall and brachiocephalic vein, using the transmanubrial approach after chemoradiotherapy. Ten days after the surgery, he developed postoperative surgical site infection and pleural empyema, and underwent a second operation. After debridement and washing of the thoracic cavity and mediastinum, a right latissimus dorsi muscle flap was harvested and intrathoracic transposition was performed to fill the upper section of the right thorax and to cover the mediastinal and cervical structures. There has been no evidence of recurrence of either the tumor or the infection over the two years and four months since this operation.
The case involved a 46-year-old man who had sustained injuries to the chest due to scattered pieces of hard metal which composed the press machine and contacted with copper products ; the hard metal had broken for a load resulting from malfunction during he pressed the products. He visited a neighboring hospital and was confirmed to have foreign bodies of metal concentration in the right thoracic cavity. After a thoracic drain was placed for right hemopneumothorax, he was brought into our hospital. Emergency operation was performed with diagnoses of right traumatic hemopneumothorax, foreign bodies in the right lung, and right lung contusion (penetrating trauma). A right side forth intercostal thoracotomy was made with a 6.5-cm long right axillary incision, and video-assisted thoracoscopic surgery was performed. Massive hematoma was confirmed, and a total of 1600g of hematoma and blood in the right thoracic cavity was removed. A metal piece was found at a portion where was the exit of the lung laceration which was made by the metal piece passing through the upper lobe of the right lung after it penetrated to the right thoracic cavity from the right subclavian second intercostal space. We performed partial resection of the upper lobe of the right lung by intending to shape a surgical area so as to involve the penetrating trauma entirely. No blood transfusion was done. The thoracic drain was removed on the 3rd postoperative day and he was discharged from our hospital without particular complications on the 11th POD. We present this successful emergency surgery for a thoracic trauma caused by a broken metal piece which had penetrated from the chest wall to the lung, which is rare.
A 65-year-old man presented with a chief complaint of epigastric pain, and he was initially diagnosed with a tumor-like lesion in the upper gastric body and localized peritonitis. Upper GI endoscopy showed a 3-cm submucosal protuberance just below the gastric cardia, with no changes in the mucosal surface. Ultrasound endoscopy showed a lesion contiguous with the 4th layer, and abdominal CT showed multiple liver metastases. Since a gastrointestinal stromal tumor (GIST) was suspected based on the endoscopic appearance, proximal gastrectomy was performed. A tumor was present from the muscularis to the subserosa, with infiltration and proliferation of highly atypical cells, but there was no evidence of differentiation. Immunohistochemistry excluded a diagnosis of a mesenchymal tumor such as GIST, malignant melanoma, malignant lymphoma, or a germ cell tumor. Epithelial markers were positive. Metastases from another organ were also ruled out. The diagnosis by exclusion was undifferentiated gastric cancer. Undifferentiated gastric cancer presenting as a submucosal lesion without exposure to the mucosal surface has not previously been reported. This rare case in Japan is reported and discussed.
A 69-year-old man was evaluated by his primary physician for a chief complaint of epigastric discomfort in September 2012. Upper GI endoscopy showed a type 2 lesion extending mainly from the gastric cardia to the lesser curvature of the gastric body. A biopsy showed squamous cell carcinoma (SCC). CT showed no evidence of distant metastases or metastases from a cancer of another organ. The patient was diagnosed with primary SCC of the stomach. In October 2012, total gastrectomy (D2 lymph node dissection and p-Roux-en-Y reconstruction) and cholecystectomy were performed. Histopathology showed no evidence of adenocarcinoma or any continuity between the tumor and stratified squamous epithelium of the esophagus. Therefore, a final diagnosis of primary gastric SCC (100×80 mm, pT3 (SS), int, INFb, ly1, v1, pN0, M0, pStage IIA) was made. Postoperative adjuvant chemotherapy with S-1 was given for 1 year. To date, the patient has achieved recurrence-free survival for 3 years and 6 months since surgery. This rare case of primary SCC of the stomach is presented along with a discussion of the relevant literature.
A 76-year-old man was diagnosed as having gastric varices and 0-IIa+IIc gastric cancer after treatment for lung cancer. CT showed a venous shunt between the gastric varices and a renal vein. Balloon occluded retrograde transvenous embolization (BRTO) was performed because of the risk of rupture of the gastric varices. After the gastric varices disappeared completely, distal gastrectomy was performed for this patient with gastric cancer. Clinical and pathological findings showed poorly differentiated adenocarcinoma, T1b2(SM2), N1, CY0, P0, H0, M0, and the final stage was IIA. No further metastasis or recurrence has occurred, as of four months after the operation. Distal gastrectomy was performed for a patient with biliary cirrhosis, gastric varices, and gastric cancer, and the patient had an uneventful postoperative course.
We report a very rare case of adult intussusception induced by duplication of the ileum. The patient was a 16-year-old man who was referred to our hospital with acute severe abdominal pain. Abdominal CT revealed findings suggestive of ileocolic-type intussusception. A gastrografin enema failed to reduce the intussusception, therefore, emergency operation was performed. After reduction of the intussusception by the Hutchinson method, a mass arising from the ileal wall was found 30 cm proximal to the ileocecal valve. Because this was considered as the cause of the intussusception, segmental resection of the ileum including the mass was performed. In the resected specimen, a cystic mass was found at the mesenteric aspect of the ileal wall. Histolopathological examination showed that the mass was lined by intestinal mucosa, and contained a proper muscle layer contiguous with that of the adjacent ileum. From these findings, the mass was diagnosed as duplication of the ileum. Although duplication of the alimentary tract is one of the main causes of intussusception in children, it is rarely encountered in adulthood. We report a rare case of adult intussusception induced by duplication of the ileum, and present a review of the past literature published in Japan on duplication of the alimentary tract and intussusception in adults.
A 61-year-old woman was brought into our hospital by ambulance because of unconsciousness due to hypoglycemia. A huge abdominal tumor was palpated. Non-islet-cell tumor hypoglycemia (NICTH) due to the abdominal tumor was likely and we started sustained administration of glucose. On the third hospital day, she developed ventricular fibrillation (VF) due to hypokalemia, for that defibrillation successfully resumed the heart beat. Thereafter strict management of blood glucose and electrolytes levels was kept, and the tumor was removed on the 20th hospital day. After the operation, both hypoglycemia and hypokalemia improved and declined blood peptide C and insulin levels were normalized. Histopathology revealed patternless proliferation of spindle shaped cells. The tumor cells were CD34 (+), bcl-2 (+), SMA (-), and c-kit (-) on immunohistochemistry. Solitary fibrous tumor was thus diagnosed. Although we sometimes encounter case reports of NICTH caused by solitary fibrous tumor arising in the mesentery, this is the first case of NICTH in which abrupt onset of hypokalemia caused VF. This case which appears to be instructive is presented here.
A 70-year-old woman who underwent a partial colectomy for colon cancer 7 days earlier developed diarrhea. A stool sample was positive for Clostridium difficile toxin, and oral treatment with vancomycin (VCM) was initiated for Clostridium difficile colitis. Six days later, computed tomography showed diffuse thickening and dilatation of the right hemi-colon, typical of toxic megacolon. Laparoscopic right hemi-colectomy with ileostomy and colostomy was performed urgently under a preoperative diagnosis of fulminant Clostridium difficile colitis (FCDC). The specimen showed severe pseudo-membranous formation. VCM was prescribed for Clostridium difficile infection from the colonic fistula. The patient recovered quickly after the operation and was discharged on the 35th postoperative day. It is important to know that minimally invasive surgical treatment for FCDC should be performed before the patient's condition deteriorates markedly.
A 60-year-old male was admitted to our hospital complaining of lower abdominal pain. Abdominal contrast-enhanced CT showed a tumor in the sigmoid colon and peritoneal free air. On the basis of these findings, the patient was diagnosed as having penetrated sigmoid colon cancer with lymph node metastasis. Elective laparoscopic sigmoidectomy was performed. At operation, the right hypogastric nerve was found to be invaded by the tumor, therefore it was resected. Two cord-like structures were recognized on the right side of the rectum, one of which was also invaded by the tumor. We resected this structure also, after confirming that it was the right ureter. However, another ureter was also seen emerging from the lower pole of the right kidney. We reconstructed the urinary tract by end-to-side anastomosis. Duplicated ureter is not very rare, therefore, the possible existence of urinary tract malformations must be kept in mind during colorectal surgery.
A 60-year-old woman was admitted to our hospital for further examination of a liver tumor detected by ultrasonography at a health check. Dynamic CT showed a tumor with a diameter of 12 mm, with peripheral enhancement in segment 5 of the liver. Since the tumor was small and atypical, she was observed on an outpatient basis. Six months later, dynamic CT showed that the liver tumor had grown to a diameter of 20 mm. On EOB-MRI, the tumor showed low intensity on T1WI and high intensity on T2WI. A benign tumor, such as an inflammatory pseudotumor, was suspected. However, since malignancy could not be completely excluded, she underwent laparoscopic partial hepatectomy. Pathological examination showed that it was an inflammatory pseudotumor with parasite eggs. Laparoscopic hepatectomy is one of the effective solutions for liver tumors for which definitive diagnosis is difficult.
A 73-year-old man who presented with epigastric and abdominal pain was admitted to our hospital with a diagnosis of calculous cholecystitis. Based on his status, we made him hospitalized and planned elective surgery. We performed laparoscopic cholecystectomy using standard procedures. Starting 69 hours after surgery, we observed redness around the drain site, with rapid spread from the navel to the right lower back. At 72 hours after surgery, the patient lapsed into a pre-shock state, and had evidence of bacterial growth in subcutaneous soft tissue and fluid retention on abdominal computed tomography of the area corresponding to that of redness. Due to concern about the risk of hemorrhage and worsening infection, we treated the patient with antibiotics and cardiopulmonary support, but his infection progressed, with disseminated intravascular coagulation complicating sepsis, and death on day 4 after surgery. Later that day, we isolated Aeromonas hydrophila from the culture of subcutaneous exudate obtained from the area of redness. The onset of soft tissue infection caused by this bacterium is reportedly associated with a high mortality rate. We report here our experience with a case of Aeromonas hydrophila infection with sudden onset after laparoscopic cholecystectomy.
Bile duct cancer is notorious for poor prognosis, and metachronous extrahepatic bile duct cancer is rare. The case involved a 68-year-old man who underwent extended left hemi-hepatectomy for hilar bile duct cancer at the age of 62. Pancreatobiliary muljunction was absent in preoperative imaging studies. The tumor, 2cm in diameter and mainly situating in the porta hepatis, was moderately differentiated tubular adenocarcinoma, and surgical margins were histologically negative, T2bN0M0 Stage II. He had been disease free for 6 years when a poorly enhanced mass 3 cm in diameter in the pancreatic head was detected by CT. Pancreaticoduodenectomy was performed, and the pathological evaluation revealed mucinous adenocarcinoma arising from the lower bile duct, T3N1M0 Stage IIB. The tumor had invaded the pancreatic parenchyma and metastasized to the adjacent lymph nodes. Immunohistochemistry demonstrated that the first tumor was SMAD4-, MUC1+/MUC2-/MUC5AC+, whereas the second tumor was SMAD4+, MUC1+/MUC2+/MUC5AC-. Distinctive pathological characteristics of the tumors suggested that they were independent metachronous extrahepatic bile duct cancers. Given the recent advancement of the surgical technique and perioperative management, aggressive curative-intent surgery might be warranted for metachronous bile duct cancer.
Resectable pancreatic metastases from breast cancer are rare. We report a case of pancreatic metastasis from breast cancer resected by using pancreaticoduodenectomy. The patient was a 63-year-old woman who underwent right mastectomy after receiving neoadjuvant treatment at age 60 years. At 3 years after surgery, she presented with an obstructive jaundice due to a pancreatic head tumor, which was difficult to determine whether it was the primary cancer or a metastatic pancreatic cancer from the breast cancer. We performed pancreaticoduodenectomy. Histopathological examination and immunohistochemical features revealed that the tumor was compatible with metastatic pancreatic adenocarcinoma from breast cancer. Although surgical resection is not recommended for distant metastases from breast cancer, it could be considered for confirming a diagnosis, palliation of symptom, or reconfirmation of characteristics of metastatic breast cancer.
An 81-year-old woman who had undergone total hysterectomy and postoperative radiotherapy for uterine cervical cancer 45 years earlier visited Department of Urology in our hospital with the chief complaint of diarrhea and pain of the perineal region. Vesico-recto-vaginal fistula with pyelonephritis was diagnosed by a plain CT scan. Her general condition improved by antibiotics and percutaneous nephrostomy. However, urine and fecal fluid still flowed from the vagina, and she complained of marked pain at the perineal region due to erosion and ulcer. She was referred to our department to resume oral ingestion and to improve ADLs. Ileo-vesical fistula was also diagnosed by a plain abdominal CT scan with oral contrast medium on the 16th hospital day. Laparotomy revealed firm bowel adhesions with multiple loops and radiation enteritis in the pelvic cavity. Considering that division of the adhesions might entail a high risk of bowel injuries, we performed a by-pass anastomosis of the small bowel and mode a transverse colostomy. Defluxion of digestive fluid from the vagina considerably reduced and the patient was discharged from our hospital on the 55th postoperative day. Entero-vaginal fistula is a rare disease, especially, small bowel-vaginal one in extremely rare. This paper presents a case of ileo-vesico-recto-vaginal fistula caused by late complication of radiotherapy, together with some discussion on the literature.
An 85-year-old woman was admitted to our hospital because of fever lasting from the previous day. When she was first seen, the body temperature was 39.5°C. Physical examination revealed distension and a mass with tenderness in the lower abdomen. Abdominal computed tomography suggested the presence of an ovarian cystic teratoma penetrated into the sigmoid colon, because the tumor had gas, fluid, and a stick shaped high density structure. Emergency drainage under local anesthesia was performed because her general condition was poor. The content of the tumor was fecal juice. After a few days of the drainage she underwent surgery under general anesthesia. The left ovarian tumor and the sigmoid colon were removed because the tumor firmly adhered to the sigmoid colon. The tumor was diagnosed as an ovarian mature cystic teratoma on pathological examinations. Because the fistula between an ovarian tumor and the gastrointestinal tract may cause some severe general complications, we should diagnose and treat it as soon as possible.
A 65-year-old man was admitted to our hospital because of a pelvic tumor detected on abdominal ultrasonography during a medical checkup. Abdominal contrast-enhanced CT and MRI scans showed a 50-mm sized tumor suggestive of a teratoma on the ventral aspect of the urinary bladder in the pelvic cavity. Since a possibility of malignancy could not be ruled out, we decided to perform surgery. The tumor showed no mobility during preoperative examinations. Although laparotomy was performed by lower abdominal incision, no tumor could be detected in the pelvic space. However, an X-ray study performed after the operation showed a tumor with calcification at the left side of the abdomen. A peritoneal loose body of 50 mm in maximum diameter was immediately removed by reoperation. Peritoneal loose bodies with the maximum diameter of 50 mm or more are very rare. And there have been few cases which could be diagnosed before operation. Although some reports indicated the usefulness of laparoscopy as a diagnostic tool, our knowledge of typical radiological findings and the characteristic feature of movement of the tumor can lead to be proper diagnosis and avoid unnecessary operation even in asymptomatic cases.
A 72-year-old man was evaluated for the complaint of hematuria, and was found to have a recurrent left renal stone. The patient was also found to have a 4-cm incidental tumor mass in the left pelvic extraperitoneal space on computed tomography. Since a malignant tumor could not be ruled out, we performed laparoscopic surgery. The tumor mass was elastic and hard, and had a brown capsule. The patient was diagnosed with a chronic expanding hematoma (CEH) by pathological examination. CEH is defined as a hematoma that develops following surgery or injury, and slowly expands without natural resorption. With no history of surgery/injury in the left pelvic region, the possible cause of hematoma in this case was extracorporeal shock wave lithotripsy (ESWL), which had been used multiple times for the treatment of his refractory left renal/ureteral stone. Herein, we report our experience of a rare CEH case treated with laparoscopic surgery, together with a literature review.
A 59-year-old man presented with a chief complaint of right lower abdominal pain and a mass. Two weeks previously, the patient sustained blunt abdominal trauma and noticed post-traumatic hematuria. Abdominal US and CT showed an 18-cm cystic lesion in the right lower peritoneum compressing and kinking the right ureter. Right hydronephrosis was also present. The history and preoperative examination suggested a post-traumatic pseudocyst, and together with the right hydronephrosis, improvement with conservative management was considered unlikely. Therefore, total laparoscopic resection of the pseudocyst was performed. Histopathology showed a pseudocyst without any epithelial elements. No abnormalities other than the blunt abdominal injury were found. The history, preoperative examination, intraoperative findings, and histopathology were all consistent with a final diagnosis of a post-traumatic retroperitoneal pseudocyst. Retroperitoneal pseudocysts due to trauma have rarely been reported. This rare case is reported along with a discussion of the relevant literature.
Leiomyoma arising within the ischiorectal fossa is rare. A woman in her 60's presented to us with a 6-year history of a large painful swelling in her right buttock. CT showed an 8-cm cystic mass in the right ischiorectal fossa, and a solid lesion near the anal canal. On MRI, the mass was visualized as a low signal intensity on T1-weighted images and as a high signal intensity on T2-weighted images. There was a clear border between the mass and the rectum. The tumor was resected via a trans-gluteal approach. Histopathological examination showed that the tumor was composed of cells that appeared well differentiated into smooth muscles cells, with central necrosis. Immunohistochemistry revealed positive staining for Desmin, and negative results for CD34, c-kit, DOG1 and S-100 protein. The Ki labeling Index was less than 5%, and the tumor was diagnosed as a leiomyoma. This case is of interest, as the origin of this tumor remains under debate and it was difficult to determine its malignant potential. The patient is being carefully followed up, because a few cases have been reported in which such as tumor was histopathologically diagnosed as a “leiomyoma,” but the tumor recurred some years after the operation.
Internal herniation through a defect in the falciform ligament is very rare. In the majority of previously reported cases, the condition has been attributed to congenital abnormalities. However, an iatrogenic source of falciform ligament defects has emerged over the last decade, with the start of the era of laparoscopic surgery. A 56-year-old female patient who had undergone laparoscopic cholecystectomy 10 years previously was transferred to our department with a history of progressively worsening upper abdominal pain. Abdominal CT showed internal herniation of the small intestine through a defect in the falciform ligament, with strangulation of a loop of the small bowel. We performed emergency laparotomy and confirmed the incarceration of the small intestine from right to the left through a defect in the falciform ligament, which was probably created by the subxyphoid port insertion during the previous laparoscopic cholecystectomy. The round ligament of the liver was divided to open the falciform ligament and release the herniated intestinal loop. The necrotic small bowel was resected and primary anastomosis was performed. The patient developed a postoperative wound infection and was discharged 17 days after the surgery. It must be borne in mind that falciform ligament defects that are accidentally caused during surgery may result in internal herniation. Thus, adequate closure or opening of the defect should be considered.
A 45-year-old man without a history of abdominal surgery presented with right lower abdominal pain. Abdominal radiography and computed tomography (CT) revealed a small bowel obstruction. There were no emergency indications, so a long tube was placed to decompress the bowel. The long tube improved the small bowel obstruction and he was discharged. Eight days later, he was admitted to the hospital again because of abdominal pain. Abdominal CT showed that the dilated and looped small bowel was compressing the anterior wall of the bladder in the right lower abdomen. A long tube was placed again to decompress the bowel. After improvement of the small bowel obstruction, laparoscopic surgery was performed. Laparoscopic findings revealed an internal supravesical hernia, so we performed a laparoscopic supravesical hernia repair via the transabdominal preperitoneal approach. It is difficult to diagnose internal supravesical hernias before surgery because they are rare.
A 65-year-old man who had a 2-year history of a left inguinal bulge was advised to undergo surgery. Because of enlargement of the bulge, he visited our hospital. Abdominal computed tomography (CT) revealed a soft-density mass in the left groin that contained part of the urinary bladder. The diagnosis was suspected to be a left inguinal hernia with bladder herniation. Laparoscopic transabdominal preperitoneal (TAPP) hernia repair was performed. The patient had an uneventful postoperative course in the hospital and was discharged on the sixth postoperative day. CT is considered a useful diagnostic method for a bladder hernia. A preoperative diagnosis of bladder hernia is important to prevent intraoperative bladder injury. We report a case of laparoscopic TAPP repair for an inguinal bladder hernia and reference the relevant literature.
The patient was an 87-year-old man. He underwent total cystectomy and ileum conduit diversion because of bladder cancer. A year after the operation, he noticed bulging around the stoma and abdominal pain. A year after the onset of the symptoms, he visited our office. He had a defect of the muscle layer around the ileum conduit visible on computed tomography. We diagnosed a parastomal hernia with chronic pain as a complication of his prior surgery, and he underwent laparoscopic repair by the Sugarbaker technique using composite mesh. He was discharged 7 days after the operation. A post-operative seroma developed, but it spontaneously resolved and the hernia did not recur. We experienced a case of parastomal hernia of the ileal conduit that was repaired by laparoscopic surgery. We report the techniques used in laparoscopic repair of this hernia.
A 62-year-old woman was found to have a parastomal hernia after laparoscopic rectal amputation for cancer, and underwent laparoscopic repair using the keyhole method. The patient was examined at our hospital 23 months after the hernia repair, complaining of pain around the stoma ; parastomal hernia incarceration was diagnosed using abdominal computed tomography. After initial manual repair of the hernia, we performed elective laparoscopic repair. We located the hernia orifice between the previously used keyhole mesh and elevated colon, and repaired it with the Sugarbaker method using ParitexTM Parastomal mesh overlapped onto the existing mesh. Laparoscopic surgery for parastomal hernia has been occasionally reported, but there are only a few reports describing treatment of recurrences. Herein, we report our experience of laparoscopic repair of a recurrent parastomal hernia after laparoscopic surgery, together with a literature review.
Gastrointestinal stromal tumors (GIST) arisen from the urinary bladder wall is extremely rare. We have experienced surgical intervention for a patient who had a GIST (30 cm in diameter) arisen from the bladder, and a GIST (7.5 cm in diameter) arisen from the jejunum. Besides, he was simultaneously diagnosed as having neurofibromatosis type I. A 58-year-old male patient was referred to our institute because of abdominal distention. Abdominal and pelvic CT scans showed a huge solid and cystic tumor 30 cm in diameter in the pelvic to abdominal cavity and an abnormal up-take to the solid component in this tumor was found on the positron emission tomography (PET) CT. At the same time, we confirmed café au lait spots in his body trunk and schwannoma at the dorsum of the hand. Neurofibromatosis type I was diagnosed. He underwent surgery to improve his symptom and to prevent progressive anemia. Operative findings indicated that the tumor was seemingly arisen from the urinary bladder wall and we resected the tumor combined with a part of the bladder wall. We also found another tumor of the jejunum, and resected it. Histopathological examination demonstrated that the both tumors were c-kit positive and were diagnosed with GIST. Proliferation of spindle tumor cells which continued from the proper muscle of the bladder in the main tumor demonstrated the GIST to have arisen from the bladder.
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