Stent (SEMS : self-expandable metallic stent) treatment for malignant colonic obstruction has been available since 2012 in Japan, and is covered by the public health insurance system. In this review, I describe the present conditions and future prospects of the procedure, based on data from the literature. The current indication in Japan is malignant colorectal stenosis. Stent use in palliative treatment, avoidance of colostomy, release of obstruction, shorter duration of hospitalization, and better quality of life have been widely reported. Moreover, stent use can be a bridge to surgery (BTS), enabling shorter duration of hospitalization, and reduced postoperative complications, colostomy rates, and mortality rates, as compared to emergency surgery. Although the reported complication rate is low, adequate preparation and informed consent are important because complications can still occur. There are some tips and points to consider to ensure a safe procedure with minimal adverse incidents. The Colonic Stent Safe Procedure Research Group has compiled information on the colonic stent, and the guidelines have been published on the society's website. Reference to the guidelines before performing any procedure is recommended.
The necessity for totally implantable central venous access devices is increasing in association with the aging population and the progress of chemotherapy. Percutaneous subclavian vein puncture is a common method for implantation, but it is associated with complications such as pneumothorax and pinch-off syndrome. We analyzed the differences in operation times, complications, and success rates between the cephalic vein cutdown method and the percutaneous subclavian vein puncture method. Between April 2013 and August 2015, 224 patients underwent one of the procedures, with 190 patients receiving the cephalic vein cutdown method and 34 receiving the percutaneous subclavian vein puncture method. With the percutaneous subclavian vein puncture method, we found a mean operation time of 25.0 min and a total complication rate of 9.8%, with pneumothorax occurring in 3 patients. Although the success rate of the cephalic vein cutdown method was 72.1%, we conclude that it is a safe method.
Generally, a chest tube is placed in the right thoracic cavity after esophagectomy for esophageal cancer as a therapeutic strategy. The placement of the tube, however, may cause pain in patients and can delay postoperative recovery, because the tube is hard and thick. We have performed video-assisted thoracoscopic surgery for esophageal cancer (VATS-E) since 1996. We have been using a 15Fr silicon drainage tube and an 8Fr catheter since 2010. Both tubes are placed in the operation. On the day following the operation, we remove the 15Fr drainage tube, if pneumothorax and air leak are absent on chest X-ray examination. The 8Fr catheter is connected to the portable suction reservoir without continuous low-pressure suction, and is removed when the discharge comes to less than 200 ml/day. A total of 286 patients underwent VATS-E and received the postoperative chest drainage management using the 15Fr silicon tube and the 8Fr catheter from 2010 to 2014. Of the 286 patients, postoperative pneumonia occurred in 18 cases (6.3%), chylothorax in six cases (2.1%), and suture failure in three cases (1.0%). Twelve (4.2%) patients needed the additional drainage of pleural effusion. An average day when the patients started to walk was postoperative day 1.0. An average duration of chest drainage was 5.7 ± 3.7 days. We conclude that the drain management using the 8Fr catheter alone since the day following the operation is effective and safe.
In order to analyze whether changes of the serum CEA values during first-line chemotherapy for metastatic colorectal carcinoma can predict the overall survival, we enrolled 40 patients with elevated serum CEA levels who were receiving first-line chemotherapy with an oxaliplatin-based regimen. First, patients in whom the serum CEA values continued to increase even after the start of chemotherapy were separated into one group. Then, the remaining patients were divided into two groups according to the half-life of serum CEA during first-line chemotherapy. We analyzed the overall survival and percentage of patients who could receive 3rd and further-line chemotherapy in the patient groups. Significant differences in the overall survival and percentages of patients who could receive 3rd or further-line chemotherapy were observed among the groups classified on the basis of changes in the serum CEA values during first-line chemotherapy. The CEA value per se had no relationship to the overall survival. These results suggest that the degree of change of the serum CEA levels during first-line chemotherapy can predict the overall survival in patients with advanced colorectal carcinoma.
A 40-year-old woman presented to our hospital for close exploration of a right thyroid tumor which was detected at a medical checkup in her workplace. Ultrasonography revealed a 20-mm tumor at the superior pole of the right thyroid gland, and a fine-needle aspiration (FNA) cytology of the tumor was performed. The FNA cytology results indicated it to be a follicular tumor, but it was difficult to make the differential diagnosis. When about 30 minutes had passed after FNA, the patient abruptly developed swelling of the anterior cervical region, pain from the neck to the posterior aspects of the bilateral ears, and sore throat at swallowing. Dyspnea and hoarseness were absent. Ultrasonography revealed pronounced edematous swelling of the bilateral thyroid lobes with crack-like interstice within the center part. Furthermore, we confirmed swollen tissues in the anterior aspect of the thyroid, including the sternocleidomastoid muscle and anterior muscles of the neck. We administered 125mg of Solu-Medrol® by drip infusion and observed the clinical course. Her sore throat subsided 6 hours, the cervical swelling disappeared 18 hours, but dysphagia at swallowing persisted until 72 hours after the onset of symptoms. Then she was orally given 15mg of prednisolone for 3 days, followed by decreased dose of 10mg for further 3 days. Transient thyroid swelling following FNA cytology of the thyroid gland is a rare complication. We present our case together with a review of the literature.
Myofibroblastoma of the breast is rare and recognized as a benign mammary tumor of mesenchymal origin. We report a case of myofibroblastoma of the left breast in a 66-year-old woman. She visited our clinic, as she noticed a left breast tumor on the day before her visit. The oval elastic-hard tumor measuring 3.0×2.5cm was palpated in the ECD area of the left breast. A mild degree of concave at the nipple was noted. Mammography demonstrated a 2.3×2.0cm lobulated mass and partially obscure margin. Solid tubular carcinoma was suspected. Ultrasonography revealed a 2.3×2.7×2.5cm lobulated mass with low heterogeneous echoic area. So we suspected the tumor to be malignant. Fine needle aspiration cytology revealed an inadequate finding with spindle-shaped cells without appreciable nuclei atypia. On a core needle biopsy, phyllodes tumor was strongly suspected. Excisional biopsy was performed and an oval well-circumscribed lobulated tumor was removed. Histological specimens revealed proliferation of spindle-shaped cells, and immunohisitochemistry revealed that the tumor cells were positive for actin, alfa-SMA and vimentin but negative for cytokeratin and S-100 protein. Therefore the tumor was diagnosed as myofibroblastoma.
A 76-year-old woman had recurrent breast cancer (BC) with carcinomatous pleuritic and multiple liver metastases 15 years after BC surgery. Despite sequential endocrine therapy and chemotherapy, her condition deteriorated with the development of hepatic failure. Her performance status (PS) was 4, but the patient wanted to continue treatment. Therefore, very-low-dose ethinyl estradiol (EE2) 0.5 mg/day was started to avoid any adverse effects. After 7 days, the patient's overall condition improved, and the jaundice decreased ; after 1 month, her tumor markers decreased. A partial response was achieved over the following 6 months. Although a relatively high incidence of adverse events with EE2 has been reported, no adverse events occurred in this patient. Based on our search of the literature, BC response to EE2 at doses ≤ 1.0 mg/day has not been reported. Thus, this interesting case is reported.
A 45-year-old woman, who had severe motor and intellectual disabilities (SMID), underwent mastectomy for Stage IIB apocrine cancer of the right breast. The cancer showed ER, 0% ; PgR, 0% ; HER-2, 3+ immunohistochemically. Two years later, computed tomography (CT) findings revealed recurrences at the ipsilateral axillar and supraclavicular lymph nodes. After making diagnosis of the recurrence, 3-weekly administration of trastuzumab was initiated. After 3 months of the therapy, breast CT examination demonstrated reduction in sizes of multiple lymph nodes. Although pertuzumab, trastuzumab, and docetaxel should have been administrated, rather than trastuzumab alone, in this case, based on the results of the CLEOPATRA trial and recommendation of Japanese clinical guidelines for the breast cancer, it was difficult to assess the tolerability of a combinational chemotherapy in this patient. There are some barriers to the clinical course for care of breast cancer in SMID persons. It is difficult to estimate the tolerability against the therapies in SMID persons compared with non-handicapped persons. We should plan individually for the planning and treatment of patients with SMID who exhibit breast cancer or recurrence.
A man in his 70s underwent right hepatectomy for a huge hepatocellular carcinoma. He was suspected of having intra-abdominal bleeding on postoperative day (POD) 1 ; thus, emergency surgery was planned. However, he experienced cardiopulmonary arrest due to Takotsubo cardiomyopathy (TC) during induction of general anesthesia. Percutaneous cardiopulmonary support (PCPS) was attached within 15 minutes. Fortunately, he recovered from the cardiopulmonary arrest without any late adverse events, including brain death. Coiling embolization therapy for hemostasis was performed under angiographic guidance after his general condition recovered. He was moved to another hospital for rehabilitation on POD 36. TC is characterized as abnormal cardiac wall motion, mainly at the left ventricular apex. While many patients with TC do not experience adverse events, recent case reports have described that some patients have died because of the onset of lethal arrhythmia. Epidemiologically, older adults tend to have TC, and thus, mortality due to TC is estimated to increase with the aging society in the near future. This case report is important because it suggests the possibility of recovery in patients with cardiopulmonary arrest due to TC, using immediate PCPS.
A 64-year-old woman who underwent colectomy for colon cancer was diagnosed as having aortic stenosis and a thoracic aortic aneurysm, and underwent aortic valve replacement and ascending aortic replacement surgery. She had a unicuspid aortic valve (UAV). Reintubation after extubation was repeate because of acute respiratory failure. Obstruction of the trachea with the aortic aneurysm was noted on computed tomography. Tracheal stent placement and a tracheotomy were performed, with resolution of her respiratory failure due to tracheomalacia.
We have performed video-assisted thoracic surgery (VATS) for two patients with spontaneous hemopneumothorax. Patient 1, a 37-year-old man, visited the emergency clinic in our hospital complaining of chest pain. Chest X-ray film and CT scan revealed pulmonary collapse and hemopneumothorax in the left lung. Large quantities (1,100ml) of dark-red blood drained after placement of a trocar. Three hours after admission, outpouring of fresh blood (300ml) occurred from the thoracic cavity and he went into hemorrhagic shock. Emergency surgery with VATS for hemostasis was performed. Bleeding from a cord arisen from the parietal pleura was stopped by clipping. The patient's post-operative course was uneventful, and he was discharged on the 8th postoperative day. Patient 2, a 44-year-old man, visited the emergency clinic in our hospital complaining of chest pain. Chest X-ray film and CT scan revealed pulmonary collapse and hemopneumothorax in the left lung. Large quantities (870ml) of dark-red blood drained 5 hours after admission. Emergency surgery with VATS was performed to stop bleeding and to remove a pulmonary cyst. Bleeding from the parietal pleura at the apex was stopped by soft coagulation. The patient's post-operative course was uneventful, and he was discharged on the 5th postoperative day. Emergency surgery as well as strict monitoring after admission is recommended for spontaneous hemopneumothorax because it entails a risk of causing hemorrhagic shock.
A 75-year-old man who had undergone right lower lobectomy for primary lung cancer (adenocarcinoma, pT1aN0M0, p-stage IA) developed pyrexia and purulent pleural effusion on the post-operative day (POD) 9. Bacterial culture of the effusion detected methicillin-resistant Staphylococcus aureus, and the patient was diagnosed with postoperative empyema and treated with chest tube drainage and antibiotic therapy. Despite these treatments, the disease was refractory, and open-window thoracostomy was carried out on POD 52. Infection control was immediately achieved, and the bacterial test turned negative by 5 days after the thoracostomy. Since closure of the empyema cavity by muscle plombage and thoracoplasty seemed difficult due to anatomical reason, negative pressure wound therapy (NPWT) was applied. To prevent lung injury caused by the negative pressure, the infill (V. A. C. ®GranuForm®) was covered with two-ply non-adhesive gauze, and suction was proceeded at a relatively low pressure (-50mmHg). During the NPWT, the infill was exchanged every 72 hours while evaluation of the presence of parenchymal injury or ischemia was carefully performed. Finally, complete epithelization and closure of the cavity was accomplished 100 days after the initiation of NPWT. NPWT is a useful device that can achieve complete wound healing with very low suction and packing in a body cavity.
The case involved a 44-year-old man who underwent sutures for closing esophageal perforation and the fundic patch operation using the fundus of the stomach through left thoracotomy for spontaneous esophageal rupture in September 2014. His postoperative course was uneventful and he was discharged from our hospital on the 18th postoperative day. Thereafter he had been well without having major complications until seven months after the operation, when he presented with vomiting and was admitted to our hospital. An abdominal CT scan revealed volvulus of the stomach associated with diaphragmatic hernia. We performed endoscopic repair followed by surgical operation. It has relatively rarely been reported that diaphragmatic hernia occurs after operation for spontaneous esophageal rupture, so that we present our case together with a review of the literature.
A 57-year-old man who had undergone total gastrectomy followed by Roux-en-Y reconstruction for gastric cancer (pT2 pN0) complained of severe nausea and heartburn after the surgery. He had malnutrition and weight loss (15 kg in 5 months). Medication was not effective and his body weight varied around 38 kg. Gastrointestinal endoscopy revealed severe reflux esophagitis (Los Angeles Classification : Grade D), and bile reflux was observed 72.6%, predominantly in supine position with 24-hour bilirubin monitoring. The length between the esophagojejunostomy and jejunojejunostomy was found to be short (30 cm) on upper gastrointestinal radiography ; this was considered to be the cause of severe reflux esophagitis. Reoperation was performed ; the jejunojejunostomy was divided and the oral jejunum anastomosed to the jejunum 90 cm distal to the esophagojejunostomy. After the reoperation, heartburn subsided and gastrointestinal endoscopy showed no reflux esophagitis. Twenty-four-hour bilirubin monitoring showed no bile reflux. His body weight increased to 65 kg 1 year after the reoperation. Esophageal 24-hour bilirubin monitoring was useful to objectively evaluate duodenal fluid reflux and prompt appropriate treatment for reflux esophagitis after total gastrectomy.
We have experienced four cases of retropharyngeal lymph node (Rouviere lymph node) metastasis after surgery for cervical esophageal cancer. The initial therapies for the cervical esophageal cancers were surgery in three cases and chemoradiotherapy (CRT) in the remaining one. Case 1 : The patient was found having Rouviere lymph node metastasis 2 months after the surgery. CRT for the metastasis was ineffective and the patient died 7 months after the surgery. Case 2 : The patient had solitary metastasis to the Rouviere lymph node 2 months after the surgery for the primary lesion. A complete response could be achieved by chemotherapy and the patient has been alive as of 5 years after the surgery. Case 3 : Metastasis to the right Rouviere lymph node alone occurred 43 months after the surgery for which CRT yielded a complete response. The patient has been alive as of 5 years after the surgery. Case 4 : The patient developed bilateral Rouviere lymph nodes metastases 8 months after the initial CRT, which were unresectable by salvage operation. The patient died 19 months after the initial CRT. In the Japanese Classification of Esophageal Cancer, the Rouviere lymph nodes are not involved in the regional lymph nodes of cervical esophageal come, so that Rouviere lymph node metastasis should be considered as distant metastasis. However, favorable therapeutic results and long-term survival could be gained in two out of four cases in our series. We consider that early diagnosis of Rouviere lymph node metastasis and appropriate treatments are important.
A 61-year-old woman presented with a submucosal tumor, measuring approximately 20 mm in diameter, located in the gastric antrum. The tumor was identified when the patient underwent gastrointestinal fiberscopy. Gastric schwannoma was preoperatively diagnosed on endoscopic direct vision biopsy with an incision of the mucosa. We performed laparoscopic partial gastrectomy. Histopathological examination revealed spindle-shaped cells arranged in palisades. The specimen was positive for S-100 protein, but negative for desmin, α-SMA, c-kit, and CD34. Mitotic figures were rare. Based on these findings, the tumor was diagnosed as a benign gastric schwannoma. Endoscopic images and findings of gastric schwannomas are not specific but similar to those of other submucosal tumors. Endoscopic direct vision biopsy with an incision of the mucosa was valuable for establishing the preoperative diagnosis of gastric submucosal tumor. In gastric schwannomas, laparoscopic surgery can be a useful and minimally invasive technique for treatment.
Angiodysplasia of the intestine causing massive gastrointestinal bleeding is rare. A 54-year-old man presented to us with the complaint of tarry stools. An upper gastrointestinal endoscopy revealed no abnormalities. However, 2 days later, the patient developed massive gastrointestinal bleeding with hemorrhagic shock. Abdominal CT showed intraluminal extravasation in the upper small gut. On laparotomy, a 10-mm-long submucocal tumor (SMT) could be palpated in the jejunum and intraoperative gastroendoscopy also confirmed the SMT tumor. Resection of a 10-cm segment of the jejunum including the jejunal SMT was performed. Histopathological examination confirmed angiodysplasia of the jejunum. We report a rare case of jejunal angiodysplasia with a review of the literature.
Small bowel cancer that invades into the external iliac artery is rare. Here, we present a case of a radical resection of a small bowel cancer invading into the external iliac artery and ureter. A 72-year-old woman who complained of abdominal pain and distension was admitted to our hospital with a diagnosis of ileus. Circumference stenosis was observed at the terminal ileum via colonoscopy, and it was diagnosed as adenocarcinoma in pathological examination. An ileocecal tumor and right-side hydronephrosis were recognized in a preoperative CT. In addition, the tumor was compressing the right external iliac artery. She underwent surgery in the diagnosis of appendiceal cancer or small bowel cancer invading into the right ureter. On laparotomy, the tumor had invaded into the right ureter and right external iliac artery. The right ureter was partially resected and anastomosed. After performing the bypass by using the left great saphenous vein, external iliac artery was partially resected with tumor. Pathology results revealed pT4b (rt-ureter, rt-external iliac artery) N1M0 pStage IIIa. We performed a curative resection with a blood vessel bypass, and her postoperative course was good. The patient received adjuvant chemotherapy. The patient died from a peritoneal recurrence, 43 months after the initial surgery.
A 38-year-old man who visited a neighboring hospital because of a one-week history of high fever, abdominal pain and diarrhea was suspected to have acute appendicitis and was referred to the emergency clinic in our hospital. When he was first seen, the body temperature was 39.0°C, the abdomen was flat and soft, and an egg-sized tumor with tenderness was palpated in the right lower quadrant of abdomen. Blood analysis revealed increases in the white blood cell count and CRP level. An abdominal CT scan showed a retroperitoneal abscess adjacent to a swollen appendix. Perforation appendicitis was suspected and appendectomy was performed. The resected appendix showed mild degree of inflammation and thickening of the wall at the center of the appendix. The pathological diagnosis was signet ring cell carcinoma of the appendix. Postoperative colonoscopy did not reveal any tumorous lesions in the colon and rectum but multiple diverticula in the ascending colon. Edematous redness was identified in one of those diverticula, and retroperitoneal abscess due to perforation of the diverticulum was suspected. On the 19th postoperative day, the patient was admitted again to our hospital and underwent laparoscopic-assisted right hemicolectomy with D3 dissection on the 21st postoperative day. Lymph node metastasis was absent and the final histopathological diagnosis was signet ring cell carcinoma of the vermiform appendix, pSS, pN0, and fStage II. The patient has been free from recurrence as of four years after the last operation.
A 71-year-old woman underwent laparoscopically assisted ileocecal resection at another hospital in 2013 (T3N1H0P0M0 Stage IIIa colon cancer). She underwent postoperative follow-up at the same hospital after adjuvant chemotherapy. She experienced atypical genital bleeding 7 months after the surgery, and visited a gynecology clinic. The findings of the examinations indicated cancer of the uterine body that had invaded to the cervix ; therefore, she was referred to our hospital. Computed tomography and magnetic resonance imaging showed that a tumor lesion was located at the posterior of the uterine cervix, and the boundary between the tumor lesion and rectum was partially unclear. A biopsy of the uterine cervix showed adenocarcinoma that was cytokeratin 7 negative and cytokeratin 20 positive by immunohistochemistry, indicating a uterine cervix metastasis from cecal cancer. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed by a gynecologist. The patient's postoperative course was uneventful, and she was discharged from our hospital 12 days after surgery. Histopathological examination showed a well to moderately differentiated tubular adenocarcinoma, and she was diagnosed with uterine cervix metastasis from cecal cancer. She remained disease-free after surgery. Uterine cervix metastasis from colon cancer is very rare. We reported this case and reviewed previous studies and case reports.
Acquired hemophilia presents with bleeding symptoms. It occurs in individuals with no history of bleeding diatheses or any family history of hemophilia, and is caused by the appearance of inhibitors of clotting factors in the blood. Acquired hemophilia is an extremely rare disease, although cases are being reported more and more frequently. An 83-year-old female had been discharged from the hospital after an uneventful postoperative course following laparoscopic right hemi-colectomy for ascending colon cancer. More than one month after the operation, she was diagnosed as having acquired hemophilia after she presented with hematomas in her upper right arm and examination of the coagulation profile revealed a prolonged activated partial thromboplastin time (APTT). Proper cancer treatment led to complete remission. Since this disease has a high fatality rate, treatment needs to be initiated before a definitive diagnosis can be established. This disease is most frequently encountered in older people, and patients with autoimmune disorders or malignant tumors account for over a half of the patients. In cases presenting with bleeding of unknown cause and prolongation of the APTT, acquired hemophilia needs to be ruled out.
A 54-year-old woman was admitted with a type 2 cancer in the ascending colon. Abdominal CT showed the ascending colon in the center of the lower abdomen, the small intestine in the right upper quadrant, and semi-circumferential wall thickening of the ascending colon. 3D-CT angiography showed that the superior mesenteric artery (SMA) was to the right of the superior mesenteric vein (SMV), and running ventral to the SMV. The patient underwent right hemicolectomy with D2 lymph node dissection. At operation, a normal Treitz's ligament was found, with no Ladd's ligament, and the small intestine passed through the root of the mesentery behind the transverse colon. Therefore, the diagnosis of a paraduodenal hernia with intestinal malrotation was made. In Japan, only 42 cases of colon cancer with intestinal malrotation have been reported to date ; herein, we review these cases and present our first case with paraduodenal hernia type of intestinal malrotation.
Lynch syndrome is caused by a germ-line mutation in a mismatch repair gene. It is an autosomal dominant hereditary disorder and increases the risk of developing colorectal cancer and various other types of cancers. Recently we have experienced a case of Lynch syndrome which could be diagnosed based on clinicopathological characteristics, though the patient lacked family history of cancer. The paper deals with the case with a review of the literature. A 40-year-old man presented with positive reaction to the guaiac test was diagnosed with cancer of the cecum and transverse colon, and underwent extended right hemicolectomy with D3 dissection. Although he had no family members with cancer in the first degree, his neoplasms were of juvenile synchronous multiple colon cancers and revealed histological findings such as intra-tumorous infiltration of lymphocytes which are characteristic to colorectal cancers of highly unstable microsatellite instability (MSI-H). Accordingly, Lynch syndrome was suspected. On a MSI examination, it was identified as MSI-H. Immunostaining for mismatch repair protein resulted in lacks in MLH1 and PMS2. Genetic examinations after gene counseling disclosed germ-line mutation of MLH1. Lynch syndrome was finally diagnosed.
We have experienced a case of KRAS exon 2 wild/exon 4 mutation colonic cancer which appeared to be resistant to anti-epidermal growth factor receptor (EGFR) combined therapy. A 29-year-old woman presented to our hospital because of high fever and abdominal pain and was diagnosed with sigmoid colon cancer 9 cm in diameter associated with invasion into the bladder and abdominal wall and an abdominal wall abscess. As radical resection was impossible and her tumor was KRAS exon 2 wild-type (which could be subjected to the conventional KRAS analysis), we performed four courses of mFOLFOX6 + cetuximab as the first line therapy followed by two courses of FOLFIRI + cetuximab as the second line therapy. However, both therapies resulted in exacerbation of the disease. The third line therapy with FOLFIRI + bevacizumab was effective and the primary lesion had shrunk to the diameter of 5 cm after nine courses of the third therapy, when radical resection could be done. Thereafter, additional testing of ALL RAS disclosed mutation of KRAS exon 4. It suggests a possibility that mutation of KRAS gene might disturb cetuximab to exert the tumor shrinking effect.
The patient was a 47-year-old woman with sigmoid colon cancer and multiple hepatic metastases. The liver metastases were no less than 30 lesions, with a maximum diameter of 9 cm ; they were initially considered unresectable, and the patient was treated with FOLFOX + cetuximab. After 7 courses of chemotherapy, the liver metastases decreased in size significantly, and R0 resection with sigmoidectomy and the ALPPS procedure was planned. Laparoscopic sigmoidectomy, partial hepatectomy of the left liver lobe, cholecystectomy, right portal vein ligation, and in situ splitting were performed as the first operation. Then, 15 days later, extended right liver lobectomy was performed as the second operation after carefully examining remnant liver function. The patient's hospital course was uneventful, and she was discharged 16 days after the second operation. She is currently alive without recurrence for 1 year after the operation and is in the middle of receiving adjuvant chemotherapy of 5-FU/LV + bevacizumab. It is important to develop a plan with a multidisciplinary approach involving a colorectal surgeon, hepatobiliary surgeon, and medical oncologist to perform R0 resection and achieve a good prognosis.
An 88-year-old man visited us with the chief complaint of anal pain. A gastrografin enema study showed circular stenosis in the lower rectum. During colonoscopy, the scope could not be introduced past the severely stenotic lesion. No definitive diagnosis could be made by endoscopic biopsy. A trans-anal incisional biopsy during surgery revealed the diagnosis of poorly differentiated adenocarcinoma or neuroendocrine cell carcinoma. Therefore, we performed laparoscopic rectal amputation and laparoscopic right hemicolectomy for rectal cancer and ascending colon cancer. The pathological diagnosis was Rb, type 4, 45×35 mm, neuroendocrine carcinoma, pT3 (A), pN1 and A, type 2, 75×65 mm, tub1+muc, pT3 (SS), pN0. Immunohistochemistry revealed positive staining for proGRP, which is relatively specific for rectal cancer. We report a very rare case of lower rectal cancer that showed the characteristics of a diffuse infiltrative neuroendocrine cell carcinoma.
Prognosis of hepatocellular carcinoma (HCC) with macroscopic portal vein tumor thrombus (PVTT) is very poor. We report a case of giant HCC with PVTT successfully treated by perioperative multidisciplinary therapy including preoperative radiotherapy. A 59-year-old man complaining of body weight loss was admitted to our hospital. He was diagnosed with hepatitis B more than 20 years previously, but he had not received appropriate treatment. He was HBs-antigen positive and HCV-antibody negative. The ICG R15 was 5.3% and he was categorized into Child-Pugh Grade B. An abdominal computed tomography scan revealed a 18×10×13cm hypervascular tumor in the left hepatic lobe occupying more than 60% of the liver with PVTT-extending from left branch of the portal vein to the right anterior and posterior branches and the total occlusion of the left portal vein branch with tumor thrombus. After transcatheter arterial infusion chemotherapy (TAI) and transcatheter arterial chemoembolization (TACE) as the first live therapy, for the purpose of reduction of PVTT, preoperative intensity modulated radiation therapy (56Gy/8Fr) was performed. Although imaging studies conducted one month after the radiotherapy did not reveal shrinkage of the tumor but only decreased enhancement effect of the tumor thrombi, on the 46th days after the radiotherapy, extended left hepatectomy with removal of the tumor thrombi was performed. TACE was done for intrahepatic metastasis of the cancer remnant 5 months after the surgery. The patient has been alive with no recurrence 28 months after the surgery. This case suggests that some patients with advanced HCC having more than 10 cm in diameter with PVTT can achieve a long-term survival by multidisciplinary therapies.
An 86-year-old man who had undergone laparoscopic distal gastrectomy with Roux-en Y reconstruction for gastric cancer 6 years earlier presented with acute obstructive suppurative cholangitis. Abdominal CT revealed enlargement of the gallbladder. Percutaneous transhepatic gallbladder drainage (PTGBD) was instituted on the first hospital day. Because of the Roux-en Y reconstruction, endoscopic treatment was not possible. We attempted to remove the choledocholith via the PTGBD tube on the 13th hospital day, but were unable to cannulate the cystic duct. The choledocholith was removed by straightening the cystic duct during laparoscopic cholecyctectomy on the 25th hospital day.
Whether the remnant stomach can be safely preserved when performing distal pancreatectomy (DP) in patients with a prior distal gastrectomy (DG) remains unclear. Recent studies have reported that intraoperative indocyanine green (ICG) fluorography is useful in evaluating organ perfusion. A case of successful DP with intraoperative ICG fluorography to assess the blood flow of the remnant stomach is reported. An 88-year-old man visited a local hospital with a chief complaint of upper abdominal pain. He underwent DG because of a gastric ulcer 25 years earlier. Pancreatic tail cancer was diagnosed by CT and endoscopic ultrasound-fine needle aspiration. Preoperative contrast-enhanced CT showed that the bilateral gastric arteries and bilateral gastroepiploic arteries had been cut in a prior operation. Intraoperative ICG fluorography was performed after ligation of the splenic artery, and it showed that the remnant stomach was perfused from esophageal or small omental blood vessels. The remnant stomach was safely preserved, and the patient's postoperative course was uneventful. ICG fluorography has potential to be used to evaluate the blood flow of the remnant stomach.
A 90-year-old man underwent laparoscopic abdominoperineal resection (APR) for rectal cancer. The tumor was fstage II (T2N0M0) according to the UICC classification. He was discharged on the 18th postoperative day with no complications. About 6 months after the APR, he was aware of distension in the perineum. He complained of pain and an unpleasant feeling when he walked for a long time. Abdominal MRI showed that the small intestine protruded from the pelvic area to the perineum. A secondary perineal hernia was diagnosed. Repair of the perineal hernia was performed with Composix mesh. There has been no recurrence of the hernia. A secondary perineal hernia is rare. Excluding those presented in conference proceeding, 23 cases have been reported in Japan. The present case is described, and the clinical features are reviewed based on the relevant literature.
A 58-year-old man had been involved in a traffic accident, with injuries to the spleen and intestine. Emergency surgery was performed at another hospital. Two years later, a bulge in the right lateral abdomen appeared. On examination, a fist-sized bulge in his right lateral abdomen was found, and abdominal computed tomography showed a defect of the right abdominal muscle and herniation of the ascending colon into the subcutaneous space. Thus, a delayed traumatic abdominal wall hernia was diagnosed and successfully repaired laparoscopically. The patient's postoperative course was uneventful, and he was discharged from our hospital on postoperative day 3. There have been no signs of recurrence. Thus, a laparoscopic repair was useful for the treatment of a delayed traumatic wall hernia.
A 65-year-old man underwent Kugel hernia repair at our hospital for a right inguinal hernia in 2007. In 2013, he developed right lower abdominal induration, and follow-up was continued. In August 2015, he was evaluated by the urology department for a chief complaint of pyuria. A CT scan showed a preperitoneal abscess, and he was referred to our department in October 2015. Percutaneous drainage of the abscess was performed, and abscess imaging showed a contiguous preperitoneal abscess in the appendix and bladder. The patient was diagnosed with a late-onset mesh infection with fistula formation into the appendix and bladder. Therefore, mesh removal, an appendectomy, and a partial cystectomy were performed. A postoperative wound infection and re-opening of the bladder fistula occurred, but the patient improved with conservative treatment. There was no recurrence of infection, but a small abdominal incisional hernia developed. Late-onset mesh infection after inguinal hernia repair has been reported occasionally, including in Japan. However, an abscess with fistula formation into the appendix and bladder, as in the present patient, is rare. This case is reported along with a discussion of the relevant literature.
We report a case of adhesive intestinal obstruction after transabdominal preperitoneal (TAPP) surgery. A 75-year-old man presented to our hospital because of abdominal distention one month after bilateral inguinal herniorrhaphy. Contrast-enhanced computed tomography revealed intestinal obstruction due to incarcerated small bowel in the Retzius cavity and adhesions between the small bowel and the mesh. We inserted a nasal ileal tube, but symptoms did not resolve after 7 days. Therefore, we performed adhesiolysis between the small bowel and the mesh, followed by closure of the Retzius cavity to prevent recurrent bowel obstruction. On postoperative day 7, the patient presented with a subcutaneous abscess, which we drained and treated with antibiotics. He was discharged on postoperative day 19. The possibility of adhesive intestinal obstruction after TAPP should be considered.
The case of a patient with an inguinal hernia treated by a tension-free repair with a pedicled tensor fascia lata flap is reported. A 71-year-old man was admitted to our hospital because of vomiting and left lower abdominal pain that had started 2 weeks earlier. He had a history of pelvic exenteration for advanced rectal cancer. Enhanced abdominal computed tomography (CT) showed diverticulitis of the colon close to the site of the colostomy, a parastomal hernia of the urostomy, and a right inguinal hernia. The stasis of the colon did not improve, and elective surgery was performed. Resection of the colon and hernioplasty of the parastomal hernia with direct closure were performed. The surgical field was contaminated because of colonic diverticulitis. The inguinal hernia orifice was about 6 cm in diameter. Reconstruction was successfully achieved with a pedicled tensor fascia lata flaps, with minimal morbidity.
A 76-year-old man was referred to our hospital for movement-related hypogastric pain. A 23×23×52 mm, ring-enhanced, low-density area was detected in the left side of the abdominal rectus muscle on CT scan. The mass had low signal intensity on T1/T2 and high signal intensity on diffusion-weighted images of MRI. The findings of an ultrasound-guided core needle biopsy were suggestive of spindle cell sarcoma. Tumor resection was performed. The resected tumor was histopathologically characterized by bone trabecula at the periphery, called a zonal pattern, and myositis ossificans was diagnosed. There were no clinical findings of recurrence postoperatively. Since myositis ossificans in the abdominal rectus muscle is extremely rare, this case is reported along with a review of the literature.
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