Insufficiency of the total number of medical doctors has recently become a problem in Japan. In such a situation, the number of female medical students and doctors, the ratio of women surgeons to men surgeons, and also the needs for women doctors are increasing. In accordance with these increases, many support systems have been established at universities nationwide, most of which are supported with grants from national government. This article describes the current status of such support systems in the universities in Japan and also actual measures to improve environment for women surgeons. Activities of a working group to support child-rearing and caring in our university hospital are introduced for reference. We must continue not only to establish better systems and facilities but to enhance social environments and perceptions for closing gender gap.

View full abstract

Although colostomy or ileostomy is done palliatively for intestinal obstruction caused by advanced colorectal cancer, there are few reports dealing with this palliative operation. Twenty-six cases were assessed based on background factors, postoperative oral ingestion period, postoperative survival time, and several prognostic factors (age, sex, BMI, PS, anemia, malnutrition, tumor markers, peritoneal dissemination, and postoperative chemotherapy). The most common factor associated with an unresectable tumor was the T factor (observed in 20 cases). Average starting day of oral ingestion after surgery was 4.9 postoperative day ; and the period during which patients can keep 50% oral intake was 160 days. The hospital discharge rate was 81% ; the 50% survival time was 197 days. The mean hospital stay period of final admission was 31.2 days. The presence of decreased preoperative PS or malnutrition resulted in a significant decrease of the postoperative survival time. Postoperative chemotherapy was significantly associated with an extended survival time. Palliative colostomy contributed to improved QOL and resulted in favorable oral ingestion, as well as hospital discharge. In cases in which PS or malnutrition are observed prior to surgery, the need for colostomy should be assessed carefully.

View full abstract

Giant phyllodes tumors larger than 5 kg in weight are extremely rare. We report herein a case of a 12.7 kg giant phyllodes tumor of the breast. The patient was a 52-year-old woman who developed a large left the breast tumor had skin ulceration and infection. The tumor occupied the whole left breast. She was admitted immediately because of severe anemia and malnutrition. A phyllodes tumor was suspected. A CT scan demonstrated that the tumor did not invade the chest wall and was resectaple. Simple mastectomy with skin graft was performed to control hemorrhage and infection. The resected tumor was 12.7 kg in weight and 50 cm in maximum diameter, and the histological diagnosis of malignant phyllodes tumor was made. The Ki-67 index was more than 50%. She has not experienced either local recurrence or distant metastasis up to now.
This paper presents our case and a review of 9 cases of giant phyllodes tumor of the breast reported in the Japanese literature.

View full abstract

A 50-year-old female presented on May 2008 with an abnormal discharge from the left nipple that she first noticed a year earlier. The findings of magnetic resonance imaging (MRI), the cytological examination, and the needle biopsy did not help establish a definite diagnosis. Therefore, the patient was followed. At the end of July 2008, the patient requested to be evaluated further. Mammography revealed a cluster of pleomorphic, calcified lesions extending from the left nipple to the lactiferous sinus. The MRI scan showed a funicular, high-intensity area in the nipple. Ultrasonographic examination of the mammary glands showed an irregular, hypoechoic area in the right breast. Ductal carcinoma in situ (DCIS) was diagnosed on needle biopsy. Breast-conservation surgery with sentinel lymph node biopsy of the right breast and microdochectomy of the left breast were performed. Histopathological examination revealed DCIS in both breasts ; DCIS of the left breast was localized to the lactiferous ducts located at the nipple. Since ductal carcinoma of the nipple is very rare, we present the case report along with a review of the relevant literature.

View full abstract

A 74-year-old female had a 1.8-cm tumor in her right breast with a diagnosis of breast cancer, breast conserving surgery with sentinel lymph node biopsy was performed. The pathological diagnosis was non-invasive apocrine carcinoma. Both ER and PgR were negative ; Her2 was positive. One year later, a hypoechoic tumor was found in her left breast. Apocrine carcinoma was suggested based on core needle biopsy results. Since the MRI image suggested extensive intraductal spread, a mastectomy of the left breast with sentinel lymph node biopsy was done. The final histological diagnosis was apocrine carcinoma which was mostly non-invasive. This case is likely very rare although another previous case report of bilateral apocrine carcinoma was found on literature review.

View full abstract

We report a case of abdominal aortic aneurysm with congenital factor X deficiency. This deficiency is a rare inherited hemorrhagic disorder. The coagulative disorder was diagnosed prior to a prostate needle biopsy in an 84-year-old male patient. The patient was diagnosed of as having congenital factor X deficiency and prostate cancer. About ten years later, a 60-mm abdominal aortic aneurysm was incidentally found on computed tomography examination for a femoral fracture. Prior to surgery the adequate dose of the combined coagulation factor complex (PPSB-HT^®) was determined based on trial results. Graft replacement of the abdominal aorta was undertaken with the administration of PPSB-HT^®. In the present case, cardiovascular surgery, which needs heparin administration, was performed successfully ; no abnormal bleeding was observed during or after surgery in this patient with congenital factor X deficiency.

View full abstract

A 78-year-old man, who had been aware of a left chest wall tumor since 3 or 4 years earlier, was referred to our hospital because of gradual enlargement of the tumor with development of tenderness. A 5 cm-sized tumor was found in the left chest wall which was fixed to the pectoralis major muscle. Ultrasonography showed a low echoic mass with unclear margin. An enhanced flat mass was detected at the surface of the left pectoralis major muscle on enhanced CT. PET-CT showed a maximum standardized uptake value of 2.4 in the tumor, and no other abnormal uptake was detected. Aspiration cytology could not give definite diagnosis. The patient underwent surgery under general anesthesia. The tumor was located in the pectoralis major muscle, and resection of the pectoralis major muscle was performed with enough surgical margins. The pathological diagnosis was dedifferentiated liposarcoma and the tumor was completely resected. No recurrence has been seen 5 months after the surgery with postoperative radiation.
Liposarcoma of the chest wall is rare, and the dedifferentiated type carries poor prognosis. Although the present patient has not experienced recurrence after the complete resection followed by radiation, careful observation is still needed.

View full abstract

We report a case of localized malignant pleural mesothelioma. A 79-year-old woman who had no histories of smoking and asbestos exposure was seen at our hospital because of dyspnea on effort in January 2008. An abnormal mass shadow in the right lung field was noted on plain chest X-ray. Chest CT and MRI showed an intrathoracic tumor which was about 8cm in diameter touching the right thoracic wall and right pleural effusion. Histological findings using a fine needle biopsy of the tumor showed malignant pleural mesothelioma. Therefore, video assisted thoracic surgery was carried out. The tumor was fist-sized, had a smooth surface and showed fibrous adhesions with the parietal pleura. A stalk from the visceral pleura to the tumor was also observed. The tumor including the parietal pleura was removed. Immunohistochemically, CK5/6, calretinin, and D2-40 were positive, and the histological diagnosis was epithelial malignant pleural mesothelioma. A possibility of localized malignant pleural mesothelioma should be considered in treatment for a solitary thoracic tumor.

View full abstract

A 59-year-old male with a mass in the upper lobe of the right lung and elevated serum NSE and CEA levels had a bronchoscopic biopsy. A diagnosis of small cell lung carcinoma (T4N3M1) was made. He received chemoradiotherapy ; his response was categorized as progressive disease (PD). He was scheduled to receive second-line chemotherapy. However, he developed abdominal pain with muscular guarding and rebound tenderness. Abdominal CT scan revealed a thickened small bowel wall and free air in the surrounding areas. Panperitonitis due to intestinal perforation was diagnosed, he underwent emergency surgery. A small intestinal metastatic lesion was found in the ileum, 35 cm proximal from the cecum ; the center of the lesion was necrotic and had perforated. Partial resection of the small bowel was performed. The resected specimen had an ulcer on the mucosal surface. When immunostained, the specimen was positive for synaptophysin and CD56 ; these findings were identical to the findings of the bronchoscopic biopsy specimen. Thus, a small intestinal metastasis of small cell lung carcinoma was diagnosed.

View full abstract

A 60-year-old man was admitted to our hospital because of epigastralgia due to gastric cancer. Gastrointestinal endoscopy revealed a type 2 tumor at the antrum of the stomach, histologically diagnosed as tubular adenocarcinoma. Abdominal computed tomography showed a marked thickening of the gastric wall, enlarged lymph nodes and portal tumor embolism, but there was no evidence of liver metastasis. At surgery, we found a tumor embolism from the right gastroepiploic vein to the portal vein. Distal gastrectomy, combined with portal resection and end-to-end anastomosis of the stumps, was performed. He underwent chemotherapy with S-1 and remains alive without signs of recurrence 5 years after surgery. Although gastric cancer with portal tumor embolism is rare and its prognosis is very poor, it is possible for survival to be prolonged with extensive surgery.

View full abstract

We report a case of solitary gastric metastasis from pancreatic head cancer after pylorus preserving pancreaticoduodenectomy combined with portal vein resection. Gastric metastasis from pancreatic cancer is very rare. There is only one report on surgery for gastric metastasis from pancreatic cancer. A 55-year-old man had gastric metastasis from pancreatic head cancer 3 years after pancreaticoduodenectomy. An enhanced solitary mass at the stomach on CT scan was detected as a submucosal tumor by upper gastrointestinal endoscopy. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed high FDG accumulation in the stomach. Based on these findings, partial gastrectomy was performed based on the diagnosis of solitary gastric metastasis from pancreatic cancer. The patient received adjuvant chemotherapy with gemcitabine. He is alive 5 years and 3 months to date since the first operation. We discuss this case along with a review of the literature.

View full abstract

We report a case of gastrointestinal stromal tumor (GIST) located in the posterior wall of the duodenal bulb, which could be resected laparoscopically. A 53-year-old man with tarry stools was endoscopically diagnosed as having a submucosal tumor, 15mm in size, in the duodenal bulb. GIST was suspected by endoscopic ultrasonography and biopsy. On abdominal CT, the primary tumor was well-demarcated and neither invasion nor metastasis was found. Preoperatively, the diagnosis was GIST without metastasis. Laparoscopic resection was performed. The tumor was located in the posterior wall of the duodenal bulb. The patient underwent laparoscopic resection with reconstruction of the duodenectomy defect using intracorporeal suturing techniques. Operative time was 229 minutes and blood loss was minimal. The patient had no postoperative complications and was discharged on postoperative day 9. The histopathological diagnosis was GIST with low risk. Laparoscopic partial resection of the duodenum seems to be one of the treatment choices for duodenal GIST, if the size and location of the tumor are appropriate.

View full abstract

An 87-year-old woman complaining of vomiting and abdominal pain was referred to our hospital after unsuccessful conservative therapy for the symptoms at another hospital. We diagnosed the case as small bowel obstruction caused by an intestinal foreign body or a small intestinal tumor, and performed an emergent abdominal operation. Operative findings revealed two diverticula in the upper jejunum, with one enterolith in a diverticulum and one enterolith in the terminal ileum. Because no abnormal findings were seen in the biliary tract, the enterolith was considered originating in the jejunal diverticulum. We performed an enterotomy to remove the enteroliths, and did not resect the diverticula in consideration of its invasiveness. A postoperative upper gastrointestinal series showed the presence of another two diverticula in the horizontal portion of the duodenum. The enterolith obstructing the terminal ileum might be originated from the duodenal diverticula.
Small bowel obstruction caused by an enterolith originating in jejunal or duodenal diverticula is a very rare event, which is difficult to diagnose and manage. This disease should be considered as a possible differential diagnosis of small bowel obstruction. And an appropriate treatment should be selected according to the individual case.

View full abstract

Patient 1 : A 46-year-old man was transferred to the emergency unit of our hospital with a complaint of lower abdominal pain. On examination at arrival, he had tenderness in the right lower abdomen and muscular defense over the whole abdomen. Pan-peritonitis due to perforation of Meckel's diverticulum was diagnosed based on the result of contrast-enhanced computed tomography (CT) images of the abdomen resulting in an emergency operation. Partial resection of the ileum including the diverticulum and end-to-end anastomosis of the small intestine were performed.
Patient 2 : A 50-year-old man visited the department of gastrointestinal medicine of our hospital with complaints of abdominal pain and queasy. Bacterial enteritis was diagnosed and he went home with a prescription of oral medicines. However, he visited our hospital again because of worsening of abdominal pain. On examination at the second visit, he had tenderness and rebound pain in the right lower abdomen. Meckel's diverticulitis was diagnosed based on the result of contrast-enhanced CT images of the abdomen. An emergency operation was performed. The swelling Meckel's diverticulum was laparoscopically extracted from the body. The full thickness wedge resection of the diverticulum at the base and layer-to-layer anastomosis were performed. A foreign body suspected to be a fruit seed was found impacted in the base of the diverticulum, and the mucosa on the peripheral side from the diverticulum was necrotic. With the recent progression in the diagnostic imaging, lesions that had been difficult for detection by imaging in the past has become enable to be detected. In the differential diagnosis as a probable cause of acute abdomen, it is important that CT images of the abdomen should be seen carefully with consideration of Meckel's diverticulum.

View full abstract

The patient was a 73-year-old male, who developed constipation. Colonoscopy revealed an elevated lesion in the terminal ileum that appeared to be a submucosal tumor. On histology, a diagnosis of carcinoid was made based on the results of the biopsy specimen obtained from the ileal lesion. A laparoscopically assisted ileocecal resection with lymph node dissection was done. The resected specimen included a submucosal tumor, in diameter, located in the terminal ileum. On histology, the carcinoid tumor was found to deeply invade the submucosal layer ; a regional lymph node metastasis was present. In Japan, carcinoid tumors of the ileum are rere, but they are very frequently associated with metastasis. Therefore, carcinoid tumors of ileum should have a lymph node dissection irrespective of tumor size. A literature review of carcinoid tumors of the ileum smaller than 10 mm in diameter is presented in this paper.

View full abstract

A 56-year-old female, who was on hemodialysis due to chronic renal failure developed a high fever, cough, and abdominal pain. She was diagnosed as having a gastrointestinal perforation on CT, and was referred to the Jichi Medical University Hospital for further treatment. On CT, the colonic wall was found to be thickened and dilated, but the site of the perforation could not be identified. An emergency operation was carried out ; amyloid deposition was seen from the jejunum to the rectum, with dense depositions on the ascending colon and the sigmoid colon. Two small perforations were detected in the cecum. Ileocecal resection with ileostomy was performed. The post operative course was uneventful. Histopathology was consistent with a diagnosis of colonic perforation due to gastrointestinal amyloidosis. Based on previous reports, perforation of the gastrointestinal tract is rare in patients with gastrointestinal amyloidosis. Early treatment is mandatory because otherwise the prognosis is very poor and the fatality rate is high.

View full abstract

A 73-year-old man was admitted to our hospital with right lower quadrant abdominal pain and right thigh pain. He also exhibited right abdominal tenderness. Laboratory data indicated high inflammatory status. We suspected acute appendicitis and performed abdominal computed tomography (CT). He was diagnosed with acute appendicitis with iliopsoas abscess. The abscess was relatively localized, and laparoscopic appendectomy and drainage were performed. The appendix vermiformis was behind the cecum ; and the retroperitoneal abscess was induced by the rupture from the tail end of the appendix vermiformis. CT examination on the 10^th day after operation revealed no residual abscess, and he was discharged on the 25th day after the operation. Laparoscopic surgery was successful because of the following factors : localized abscess, effective drainage, and good sensitivity toward antibiotics. Laparoscopic appendectomy helped in maintaining the quality of life of our patient. This is an interesting case report that will lead to widening of the indication of laparoscopic surgery.

View full abstract

A 55-year-old woman came to our hospital because of a positive fecal occult blood test. Colonoscopy revealed a reddish elevated lesion, 12 mm in diameter, in a diverticulum of the ascending colon. As a magnified view with crystal violet staining showed Kudo's VN type pit pattern, we diagnosed the lesion as invading the deep submousa. Endoscopic ultrasonography showed that the main tumor existed outside of the colonic wall. Pelvic CT scan showed a swelling appendix, linking to the ascending colonic wall, and a swelling lymph node near the tumor. We diagnosed the case as appendiceal carcinoma which invaded the diverticulum of the ascending colon, and performed right hemi-colectomy and lymph node dissection. The final diagnosis was appendiceal carcinoma CV, pType5, 45×23mm, pSI, ly1, v0, pN0, sH0, sP0, sM0, and pStageII). The patient has been free from necurrence, as of 2 years 11 months after the operation.
It is etiologically considered, in this case that appendiceal carcinoma invaded the diverticulum of the ascending colon and exposed to the inside of the colonic wall, so much so that the lesion presented a specific endoscopic appearance.

View full abstract

A 60-year-old woman had been followed at a local clinic after undergoing laparoscopic partial resection of the descending colon for descending colon cancer. She visited the outpatient emergency department of our hospital due to abdominal pain and vomiting that developed after she took laxatives for colonoscopy. Plain abdominal CT showed a fecal mass, approximately 7 cm in diameter, at the functional end-to-end anastomotic site, and fecal ileus was suggested. After removing the impacted fecal mass in the intestine on the anal side of the anastomotic site using a Gastrografin contrast enema and breaking it up under colonoscopy, hard stool was spontaneously passed, and the patient recovered. The fecal ileus was thought to have resulted from impaction in the intestine on the anal side of the anastomotic site of a fecal mass that had formed at the functional end-to-end anastomotic site, which had become diverticulum-like. The present case demonstrates the need to ensure that the anastomotic diameter must not be unphysiologically large relative to the intestinal diameter on the anal side when performing functional end-to-end anastomosis of the colon, in order to avoid excessive diverticulum-like changes of the anastomotic site.

View full abstract

A 78-year-old man who had undergone pylorus preserving pancreatoduodenectomy for bile duct carcinoma 1.5 years earlier was seen at the hospital because of lower abdominal pain, when pneumaturia was noted as well. The patient was thus admitted to the hospital. Abdominal CT scan revealed that a lost tube of a pancreatic catheter which had been indwelt at the anastomosed site between the pancreas and stomach had strayed into the urinary bladder. Barium enema study showed a sigmoidovesical fistula. Accordingly transurethral removal of the lost tube of the pancreatic catheter was parformed. However, pneumaturia recurred thereafter, so that closure of the sigmoidovesical fistula was performed under laparotomy. The patient was associated with diverticulosis of the sigmoid colon and then it was inferred that the lost tube had penetrated into the urinary bladder through the diverticulum.
It is general that a lost tube is excreted per anum after it has spontaneously fallen out, however, it can stray into the parenteral sites like in this case. We must follow the clinical course by keeping the fact in mind.

View full abstract

A 58-year-old man with sigmoid colon cancer underwent laparotomy. However, the tumor was diagnosed as unresectable because of its extensive invasion to the urinary bladder.
Chemotherapy with mFOLFOX6 was initiated as a part of multidisciplinary therapy administered after admission to our hospital. Abdominal computed tomography (CT) scan revealed reduction in tumor size and cytoscopy showed no invasion of colon cancer to the urinary bladder mucosa after the 6^th cycle of mFOLFOX6. Subsequently, we performed urinary bladder-conserving sigmoidectomy. Pathologic diagnosis of surgical specimen was tub2, pSS, pN0, cH0, cP0, cM0, and StageII. Down sizing chemotherapy might improve the quality of life (QOL) of colon cancer patients with extensive invasion of urinary bladder.

View full abstract

A 62-year-old male was admitted to our hospital with an occipital bruise and abrasion. On the day after admission, he accidentally swallowed his partial denture. On abdominal X-ray the dentures were found to not have any sharp metal edges. Thus, the patient was followed carefully without therapy because the possibility of damage to the intestinal mucosa was considered to be low. The dentures were expected to pass spontaneously. However, the patient developed nausea and vomiting on the 7th admission day. Abdominal X-ray and CT were performed on the 8th admission day, and he was diagnosed as having a bowel obstruction caused by the denture. An emergency operation was performed. During the operation, a tumor on the upper ascending colon and the denture on its oral side were palpated. A radical resection of the colon cancer and removal of the bowel involved in the obstruction were performed.
Examination of the resected specimen showed an invasion depth of SE, mild invasion to the lymphatic vessels and no lymph node metastasis. We present a rare case in which a laparotomy was performed to remove foreign body causing a bowel obstruction, and colon cancer was diagnosed incidentally.

View full abstract

A man in his seventies visited a hospital because of body weight loss, when he was found to have anemia and occult blood test was positive. Colonofiber scopy was thus performed and a type 2 tumor was detected in the upper portion of the rectum. A biopsy of the tumor showed moderately differentiated adenocarcinoma. An abdominal echogram revealed a left renal tumor. On physical examination, no surface lymph nodes were palpable. CT scans from the abdomen to pelvis revealed that each of the regional lymphnodes swelled up both the left kidney and the rectum. In October 2008, operation and renal biopsy were performed with a diagnosis of obstructing rectal cancer. From macroscopic and microscopic findings of the resected specimen, the rectal tumor was diagnosed as collision tumor of malignant lymphoma and moderately differentiated adenocarcinoma, and the left renal tumor was clarified to be malignant lymphoma presenting the same findings as those of the rectal tumor.
We report here this case of collision tumor in the rectum, which is rare, together with some bibliographical comments.

View full abstract

A 67-year-old woman was admitted to the hospital because of hand arthralgia and dyspnea. Gottron sign, heliotrope eruption, and periungual erythema were noted. Together with muscle weakness and abnormally high levels of muscle enzymes, a diagnosis of dermatomyositis was established. Interstitial pneumonia with severe restrictive pulmonary disorder was also found. Examination for malignancy revealed rectosigmoid cancer. First, we administered corticosteroid for the restrictive pulmonary disorder. After pulmonary function had improved enough for an operation, a low anterior resection of the rectum (D3) and temporary ileostomy were performed for the rectosigmoid cancer. Histologically, the tumor was classified as SS, N1, H0, P0, M0 ; Stage IIIa. Serum CPK normalized postoperatively, and both the dermatomyositis and the interstitial pneumonia showed rapid amelioration. Since a liver metastasis was found seven months after surgery, partial hepatectomy and closure of the ileostomy were performed. When malignancy coexists with dermatomyositis, we should consider the possibility of the dermatomyositis being a paraneoplastic event. Even high dose corticosteroid is administered, as far as the general condition of the patient permits, it is important to perform surgery without hesitation.

View full abstract

The patient was a 52-year-old man. In 1986 he was diagnosed as having ulcerative colitis. In 1999, a colonoscopy was done due to the presence of a bloody bowel discharge on histology, a sigmoid colon cancer was diagnosed. He had a subtotal colorectomy and a J-pouch anastomosis in November 1999 (MPN0M0 stage I). His tumor marker level increased in January 2008, and on colonoscopy an irregular mucosa was noted in the remaining rectum. Rectal cancer was diagnosed. A Miles resection was done in March 2008. On histopathology and immunohistochemistry, endocrine cell carcinoma of the rectum was diagnosed. On the 25th post operative day modified FOLFOX6 chemotherapy was started. On follow-up in January 2009, no recurrence was noted. Endocrine cell carcinoma of the rectum is unusual. This is only the 60th case reported in Japan since 1984. There is the first case of endocrine cell carcinoma located in the remnant of the rectum left after ulcerative colitis surgery reported in Japan.

View full abstract

A 58-year-old woman who was found to have a 5mm-sized hypoechoic area in the liver segment 5 in the early phase of abdominal ultrasound in November 2006 had been followed until July 2007, when the size of the area increased to 20 × 40 mm in diameter. Abdominal contrast-enhanced ultrasonography revealed a tumor about 2 cm in diameter with enhanced tumor margin, and enhanced cuneus periphery in the late phase as well. On abdominal contrast enhanced CT scan in the early phase, deep staining was seen in the margin around the cuneate periphery and center. On FDG-PET an accumulation of FDG (SUV : 4.8) was seen at the same area. No extrahepatic malignant diseases were seen, and a percutaneous needle biopsy was performed. Factor VIII-positive cells were suggested, but poor staining made diagnosis difficult. Suspecting a malignant lesion, S5 segmentectomy was performed in November of the year. Histopathologically many dyskaryotic, highly epithelioid cells were seen in the fibrotic interstitium. These cells were positive for Factor VIII and vimentin, and so epithelioid hemangioendothelioma (EHE) was diagnosed.
Few cases of EHE have been reported in Japan. We report the present case of EHE with some bibliographical comment.

View full abstract

Hepatocellular Carcinoma (HCC) with biliary invasion is rare, with a reported frequency of 3.4%. We describe 2 cases of HCC with biliary invasion. Case. 1 : A 75-year-old man with HCV infection. Because serum AFP was elevated, he underwent CT examination and HCC with biliary invasion was diagnosed. He developed obstructive jaundice, and an endoscopic nasal biliary drainage (ENBD) tube was inserted to decrease the serum bilirubin level. Because he needed right lobectomy, but the resection rate was calculated to be 69.3%, percutaneous transhepatic portal embolization (PTPE) was performed. The resection rate decreased to 45.9% 4 weeks after PTPE. Right lobectomy was safely performed. Case. 2 : A 71-year-old man was noted to have jaundice and came to our hospital. HCC with biliary invasion was diagnosed. An ENBD tube was inserted into his left biliary tree and his serum bilirubin level decreased. Right lobectomy was planned but the resection rate was 64.5%. The resection rate was 41.9% 4 weeks after PTPE. Right lobectomy was safely performed. In both cases, biliary thrombus could easily be removed through a choledocotomy.

View full abstract

A 76-year-old man underwent distal gastrectomy and D2 lymph node dissection for type 3 advanced gastric cancer in June 2006. Postoperative pathological diagnosis was tub1, pT3, INFβ, ly2, v1, pN1, f-Stage IIIA, and the surgery was classified as curability B. Adjuvant oral UFT was given until January 2007 and the patient was followed up thereafter. In July 2007, a CT scan revealed a metastasis 2 cm in size in the S6 segment of the liver. RFA was selected as the treatment method in accordance with the patient's wishes, and the first session was performed in September 2007. Subsequently, metastases ≤3 cm in size developed asynchronously in the S4, S1, and S8 segments of the liver up to December 2009, and recurrence of ablated lesions was also observed. RFA was performed a total of six times during the approximately two years and three months since the time of the first session. No other distant metastasis or recurrence was observed during this period.
In the present patient, althtough asynchronous multiple liver metastases were observed in a short interval, RFA alone was thought to have had a certain degree of therapeutic effect because few metastases were present at any one time and all were ≤3 cm. In indicated patients, RFA may be effective for local treatment of liver metastasis of gastric cancer.

View full abstract

Gastric outlet obstruction caused by an impaction of a gallstone into the duodenal bulb is called Bouveret syndrome which is a rare entity. This paper describes a case of Bouveret syndrome.
An 89-year-old woman complaining of vomiting was found to have pneumobilia and a gallstone existing in the duodenal bulb by an abdominal CT scan. Upper gastrointestinal endocopy showed an impacted gallstone into the duodenal bulb. The patient was operated on with a diagnosis of Bouveret syndrome. Since the patient's general condition was unstable due to her great age and firm adhesions surrounding the gallbladder were noted, only lithotripsy under gastrotomy was performed. The patient's postoperative course was uneventful and she was discharged from the hospital one month after the operation. An abdominal CT scan and upper gastrointestinal endoscopy performed 6 months after the operation confirmed the closure of the fistula.
In the treatment of this disease, a problem may lie in whether the fistula is treated or untreated. As far as we could review, all untreated fistulas in the Japanese literature spontaneously closed within one year. Accordingly we consider that the closure of the fistula is not always necessary. It would be appropriate to select operative procedure based on the patient's general condition and a local status of the disease.

View full abstract

The patient was an 87-year-old woman with diabetes mellitus and Alzheimer dementia. The chief complaint she developed right hypochondralgia associated with mild tenderness. On laboratory testing, leukocytosis, marked elevation of CRP, and hyperglycemia were found. Gas was detected in the gallbladder on plain CT scans of the abdomen. On the day of admission, percutaneous transhepatic gallbladder drainage (PTGBD) was carried out under ultrasound guidance, pathogenic bacteria were not detected in the bile. Imaging after PTGBD showed no cystic duct obstruction. On the 8th day after PTGBD, a laparoscopic cholecystectomy was performed. The postoperative course was uneventful, and the patient was discharged on the 7th day after surgery.

View full abstract

We report a 41-year-old woman who had undergone parathyroid gland resection 13 years prior. Pancreatic tumor was discovered by chance on ultrasonography during follow-up of a relapsing renal stone. Dynamic CT revealed a solitary tumor, 11mm in diameter, in the pancreatic body, and the tumor was enhanced. There were no findings of lymph node or distant metastasis. The serum glucose, gastrin and glucagon levels were normal, and we diagnosed this tumor as a non-functioning endocrine tumor. As ultrasonography performed during the operation showed the tumor and the Wirsung duct to be separate, enucleation of the tumor was possible. Malignancy was not detected in the resected specimens, and only insulin was positive on immunohistochemistry. There was also a parathyroid tumor, and we finally confirmed MEN type 1. Non-functioning pancreatic endocrine tumors are often large when found, causing symptoms due to compression of surrounding organs. However, our case is rare because the tumor was discovered by chance while still small.

View full abstract

We herein describe a case of pancreatic non-functioning endocrine tumor with extrapancreatic lesions that complicated tumor diagnosis (benign or malignant). A 42-year-old woman was referred to us with a pancreatic tumor that was incidentally identified during a health check-up. Radiological and endoscopic examinations revealed the following findings : a calcified tumor of 3-cm diameter in the pancreas tail and adhered to the stomach, occlusion of the splenic vein, and several calcified nodules scattered around the stomach. Furthermore, positron emission tomography-computed tomography revealed 18F-fluorodeoxyglucose accumulation in the tumor. On the basis of these findings we performed a distal pancreatectomy and partial resection of the stomach.
Microscopic examinations revealed that the nodules were scattered from the pancreatic tumor ; the tumor was a non-functioning endocrine tumor classified as the well-differentiated tumor with borderline malilgnancy according to the WHO classification criteria. Because she had 2 experiences of blunt abdominal trauma during childhood, the extrapancreatic lesions might be caused by the trauma and the peritoneal nodules might be implanted from the original tumor. Although she has shown good recovery at 1 year after surgery, care should be taken to avoid possible relapse of the disease.

View full abstract

The patient was a 74-year-old man who had pylorus-preserving pancreaticoduodenectomy for intraductal papillary mucinous neoplasm (IPMN) in February 2003. No findings of dysplasia at the resection margin were found by intraoperative pathological examination with frozen section. The postoperative pathological diagnosis was IPMN with carcinoma in situ, and moderate dysplasia at the branches of the pancreatic duct in the resection margin. A follow-up blood analysis in April 2008 showed serum levels of CEA and CA19-9 to be increased for the first time after the initial resection. An abdominal CT scan showed a recurrent tumor at the site of pancreaticojejunostomy in the remnant pancreas. Complete pancreatectomy with total gastrectomy and combined resection of the transverse mesocolon was performed. The pathological diagnosis was IPMN and invasive carcinoma.
Intraoperative pathological examination with frozen section is important to determine the status of the resection margin, but it is difficult to diagnose in some cases. A long-term careful follow-up after surgery is critical for IPMN with dysplasia at the resection margin because of a risk of cancer recurrence.

View full abstract

A 48-year-old man who had previous histories of chronic pancreatitis and diabetes mellitus visited a hospital because of dizziness and abdominal pain late in July 2009. An abdominal CT scan showed retention of massive bloody ascites and findings suggestive of rupture of the spleen, and intra-abdominal bleeding due to splenic rupture was diagnosed. The patient was admitted to our hospital and underwent emergency laparotomy. Upon laparotomy, massive bloody ascites and clots were identified in the abdominal cavity and the pancreas macroscopically showed to be in a status of chronic pancreatitis. Since he had no previous history of trauma, it was etiologically inferred that chronic pancreatitis had been aggravated acutely that caused infiltration of inflammation into the spleen, with resultant rupture of the spleen. Resection of the pancreas body and tail was performed. Histopathologically Berlin blue staining revealed deposits of hemosiderin in the extramural areas of the veins, so that old hemorrhage was suggested. The patient's postoperative course was uneventful and he was transferred to the former hospital on the 12th day after the operation.
Splenic ruptures are divided into two general groups by their causes, namely, traumatic and spontaneous (non-traumatic), and the latter is comparatively rare. This paper deals with this patient with spontaneous splenic rupture whose life could be saved by splenectomy.

View full abstract

Intra-aortic balloon occlusion (IABO) is effective for achieving emergent hemostasis in patients with intra-abdominal bleeding. On the other hand, IABO should not be used for long periods of time because it occludes a wide area which can include non-bleeding sections. We used IABO in a patient with traumatic spleen injury immediately before opening the abdomen. A 72-year-old woman, riding on a bicycle, fell down and hit the left side of her abdomen. She sustained rib fractures and a splenic rupture. She was in hemorrhagic shock. On abdominal ultrasound massive bleeding was found in the Douglas and Morrison fossae. IABO was inserted through the right femoral artery in the emergency room, and a CT scan was done. We diagnosed splenic injury and an emergency splenectomy was performed. Immediately before opening the abdomen, we occluded the aorta via IABO. Thus obtaining temporary hemostasis, the splenectomy was performed safely under a satisfactory range of vision. The aorta occlusion time was 19 minutes ; no complications were identified post-op. This method minimizes occlusion time.

View full abstract

A 57-year-old female was found to have a splenic tumor on a CT done for mammary cancer follow-up. Since the tumor gradually increased in size, and had a high FDG accumulation on FDG-PET, we were not able to rule out malignant disease. Therefore, a laparoscopic splenectomy was done. The splenic tumor was diagnosed as a splenic sclerosing angiomatoid nodular transformation (SANT) on histopathology. SANT is a very rare splenic tumor that was initially reported in 2004. A laparoscopic splenectomy is a very useful minimally invasive treatment for SANT.

View full abstract

A 74-year-old man, with no history of abdominal trauma, developed constipation, and a tumor was detectcd in the left upper abdomen on ultrasonography (US). ; the approximately 20-cm tumor moved with breathing. US and computed tomography revealed a poorly enhanced tumor with central necrosis pressing on the left kidney and spleen. Magnetic resonance imaging showed liquid degeneration at the center of the tumor. The left adrenal, left sub-phrenic, and splenic arteries were detected as feeding vessels on angiography. All tumor markers and adrenal hormone levels were within normal limits. A preoperative diagnosis of a neurogenic tumor was made ; the tumor was resected. The tumor did not invade adjacent organs. The weight of the resected tumor was 4700 g. On histopathology, an adrenal hematoma without neoplastic findings was diagnosed. Thus, an idiopathic adrenal hematoma, with no hemorrhagic tendency, was found. This is a rare disease, and a precise preoperative diagnosis is difficult to make. However, surgery can possibly be avoided, if a hematoma is considered in the preoperative differential diagnosis.

View full abstract

We report a case of strangulated ileus caused by a hemangioma of the greater omentum which is rare.
A 17-year-old female was admitted to the hospital because of acute abdominal pain. Abdominal enhanced CT scan showed a spindle-shaped tumor and strangulation of the small intestine adjacent to the tumor. We suspected strangulated ileus caused by a Meckel's diverticulum and performed emergency operation. Upon laparotomy, a spindle-shaped tumor 5 cm in longer diameter was present in the greater omentum which was connected, with a restiform band, to the small intestine 110cm proximal to the end of ileum and caused strangulation. The tumor was resected and the strangulation was released. Histopathological examination of the excised specimen confirmed a diagnosis of venous hemangioma. No histological findings specific to Meckel's diverticulum or vitelline artery were recognized.
Hemangioma of the greater omentum is very rare and our case is the 17th case reported in Japan. This case with a review of the literature is presented here.

View full abstract

A 58-year-old man, who had been treated under a diagnosis of gastrointestinal stromal tumor, underwent a laparoscopy-assisted partial resection of the stomach. Eighteen days after the operation, he complained of severe abdominal pain and a CT scan showed marked edema of the small intestinal wall with thrombosis from the superior mesenteric vein to the intrahepatic portal vein. Emergency laparotomy was performed under a diagnosis of/acute abdomen possibly caused by intestinal infarction. Operative findings revealed congestive necrosis of the small intestine caused by thrombosis of the superior mesenteric vein (SMV). Approximately 140cm of the intestine was safely resected, to assure intestinal viability, including the necrotized bowel. Thrombectomy of the SMV was slso performed using a Fogarty catheter, but without success. Since a coagulation study showed a low protein S antigen level, this was thought to be a case of SMV thrombosis due to protein S deficlency. There have been no sings of recurrence for seven months, to date, since the operation.

View full abstract

We report a case suffering from the onset of ileus symptoms after rapid body weight loss. At first, plain abdominal CT examination revealed remarkable dilation of the stomach and stenosis in the third portion of the duodenum. He was diagnosed as having superior mesenteric artery syndrome based on further examinations after admission to our hospital. He was treated with nasogastric decompression and fasting. He underwent laparoscopic omental flap transposition after conservative therapy for three days. Intraoperatively the duodenum was compressed between the superior mesenteric artery and abdominal aorta. We filled the omentum between the superior mesenteric artery and abdominal aorta and released the duodenal compression. Food was started on postoperative day 3. The postoperative course was uneventful. It is thought that laparoscopic omental flap transposition is one of the effective treatments for superior mesenteric artery syndrome.

View full abstract

An 80-year-old woman who had been internally treated for hypertension was pointed out an intra-abdominal tumor about 2 cm in diameter on the ventral aspect of the lower pole of the right kidney when she was performed abdominal ultrasonic examination before surgery for left breast cancer. An abdominal enhanced CT scan showed a hypervascular tumor with cystic degeneration. Blood catecholamine levels were in normal ranges. Although no definite diagnosis could be made preoperatively, laparoscopic-assisted operation was performed. The tumor was found to be present in the transverse mesocolon, and it was completely removed without any remnants. The histopathological diagnosis was paraganglioma.
Paraganglioma arisen in the transverse mesocolon is extremely rare, and no cases of the disease removed under laparoscopy have been reported in Japan. This case is reported here, together with a review of the literature.

View full abstract

A 68-year-old man with left abdominal pain was found by abdominal US to have a retroperitoneal cystic lesion measuring 4cm in diameter. CT and MRI showed a heterogenous tumor with neither calcification nor fat contents. At surgical resection under a retroperitoneal tumor diagnosis, a dark-red tumor was identified in the ventral site of the left iliopsoas muscle near the left iliac artery and showed severe adherence to surrounding tissues. The resected tumor was elastic soft with a hemangioma-like appearance and exhibited myxoid stroma. Retroperitoneal vascular malformation of combined type was diagnosed based on postoperative histopathological examination.

View full abstract

A 60-year-old man who had been followed for atrial fibrillation in our hospital was performed colonoscopy because of anemia and positive fecal occult blood test. Colonoscopy revealed cancer of the transverse colon and multiple colon polyps. Prothrombin time (PT), activated partial thromboplastin time (APTT) and bleeding time were within normal limits. He underwent polypectomy at first. After the polypectomy, he developed melena and required endoscopic hemostasis. After hemostasis was achieved endoscopically, transverse colectomy was performed to treat transverse colon cancer. He developed vomiting on the P.O.D 15 and abdominal CT scan showed colonic ileus due to an intra-abdominal hematoma. Intestinal contrast studies via a long tube showed a narrowing encircling the entire lumen of the transverse colon which was as same as CT scan. On the P.O.D 22, abdominal CT scan showed reduction of the hematoma and improvement of colonic ileus. Further laboratory findings showed a low level of factor VIII activity (50%) and hence he was diagnosed as having hemophilia A.
When unusual bleeding occurs after surgery, hemophilia should be considered.

View full abstract

We present a case of idiopathic pneumoperitoneum due to a fall trauma.
A 35-year-old woman was brought into our critical care center by an ambulance because she had fallen from a high place and got injured. When she arrived at the center, a mild degree of clouding of consciousness was noted, but her ventilation and circulation were stable. An abdominal enhanced CT scan showed retroperitoneal bleeding due to fracture of the pelvis and intraabdominal free air in the liver surface and the inferior surface of the liver. On physical examination of the abdomen, peritoneal signs were absent, but gastrointestinal perforation was the most likely diagnosis. Accordingly transcatherter embolization for retroperitoneal bleeding was performed, followed by emergency laparotomy. However, only a retroperitoneal hematoma was seen and gastrointestinal injuries were absent. Idiopathic pneumoperitoneum was thus diagnosed.
We etiologically consider that free air in the abdominal cavity in this case might occur due to air which was let in the abdominal cavity via transvaginal route or through the uterine tube when she had fallen. Or we can infer that the pleural pressure had increased at the moment she reached the ground that might let air in the abdominal cavity through the mediastinal route.

View full abstract

A 31-year-old female was found to have a presacral tumor. The 7-cm presacral cyst was found when the patient was pregnant in March 2008. Transvaginal aspiration of fluid in the cyst was performed at the time of delivery. MRI showed re-growth of the tumor in April 2009, which was resected using a sacral approach with the patient in a jack-knife position. Macroscopically, the smooth-surfaced cyst contained a clay-like substance ; no tumor lesion was seen in the wall. Microscopically, the inner cyst wall consisted of keratinized squamous epithelium with sweat glands. Thus, a diagnosis of a dermoid cyst was made. In this paper, we review 19 cases of presacral dermoid cyst, including our case, reported in Japan. Presacral cysts must be completely excised because of the risk of complications such as infection and carcinogenesis. They should be treated by appropriate operative procedures based on tumor size, location, and direction of growth.

View full abstract

An 82-year-old female developed a fever and abdominal pain two years after a mesh repair for an incisional hernia that was done using a Composix Kugel patch. On abdominal CT scan an abscess cavity was seen in the abdominal wall. A delayed mesh infection was diagnosed. Initially incision and drainage were done as per the patient's request, but her infection did not abate, and she required surgical removal of the mesh. The patient's postoperative course was uneventful, and she was discharged on the 12th postoperative day. On follow-up, no recurrence of the hernia or abscess formation has been observed. In this paper, we present this case of late mesh infection occurring two years after mesh repair for incisional hernia in detail and discuss the relevant literature.

View full abstract

A 72-year-old man underwent an abdominoperineal resection for rectal cancer. The postoperative course was uneventful, and the patient was discharged on the 19th postoperative day. After discharge from hospital, he developed a perineal bulge and severe discomfort ; a perineal hernia was diagnosed. A herniorrhaphy with Composix mesh^® was performed via a perineal approach 2 months postoperatively. There has been no recurrence of the hernia during 1 year and 1 month of follow-up. Perineal hernia is an uncommon complication of abdominoperineal resection and pelvic exenteration. A perineal approach with the use of a Composix mesh^® is less invasive than a transabdominal approach. Furthermore, a reconstruction of the pelvic floor can be performed easily.

View full abstract