Purpose : In our hospital, laparoscopic-assisted colectomy (LAC) is performed by both skillful staffs and residents. We discussed the feasibility of LAC performed by residents. Materials & Methods : A retrospective analysis was made on 92 colon cancers (45 in the right side and 47 in the sigmoid colon), which were subjected to LAC in our hospital from April 2004 to October 2009. These LACS were performed by residents (including junior and senior residents) (Group-R, n=46) or skillful staffs (Group-S, n=46). Background factors of the patients, duration of surgery, operative blood loss, duration of postoperative hospitalization, complications, overall survival and disease-free survival were compared between the Group-R and the Group-S retrospectively. The same factors were assessed in the Group-J (LAC performed by junior residents, n=22) and the Group-S. Results : The blood loss volume in the Group-R was significantly greater than the Group-S. (Group-R, 69.5±104.1g ; Group-S, 31.8±39.1g : p=0.023). However, this greater amount of blood loss in the Group-R did not cause any troubles during LAC. These were no significant differences in other factors between the Group-R and the Group-S. Similarly, the blood loss volume in the Group-J was significantly greater than the Group-S (Group-J, 74.9±121.4g ; Group-S, 31.8±39.1g : P=0.032). Conclusions : These results indicate that the LAC can safely be performed by residents without causing major complications under the guidance of skillful staffs.

View full abstract

Background : We analyzed postoperative morbidity and mortality in patients of age 80 or over undergoing surgery for gastrointestinal cancer.
Patients and Methods : We enrolled 327 patients of age 80 or over operated an for gastrointestinal cancer between April 2003 and March 2009 at Ohta Nishinouchi General Hospital, to study contributing factors for 30 day-mortality and postoperative morbidity.
Results : The overall morbidity was 46% (151 patients) and the 30-day mortality was 6% (20 patients). Gender, serum sodium, albumin, urea, creatinine, intraoperative blood loss, intraoperative blood transfusion and emergency operation were defined as significant risk factors for morbidity. Logistic regression analysis demonstrated that intraoperative blood transfusion was one of the strongest independent risk factors (Odds ratio 2.4) of morbidity. On the other hand, four POSSUM items involving physiological score (PS), operative severity score (OS), predicted mortality rate and predicted morbidity rate had statistically significant correlations with surgical outcomes. When the high risk group about morbidity was designated as PS 24 or more, and OS 16 or more, the morbidity rate was 65% in the high risk group, which was significantly higher than that in the low risk group (30%).
Conclusion : Intraoperative blood transfusion is a significant risk factor for surgeries of gastrointestinal cancer in elderly patients. POSSUM scores are also useful as indicators for the risk assessment of surgery for gastrointestinal cancer.

View full abstract

Since the tension free method for inguinal hernia repair was reported, operative procedures for inguinal hernia have increasingly been progressing through changes in raw materials of the mesh, its shape, and position where the mesh is placed. Recently Parietex ProGrip (Covidien) that is the self-gripping mesh to the traditional Lichtenstein repair has been announced. In order to evaluate the ProGrip, a retrospective study comparing use fulness of ProGrip, Mesh Plug, and Direct Kugel methods was made on consecutive patients operated on for inguinal hernia in our hospital. Operating times were 39.9 min in the ProGrip group, 50.1 min in the Mesh Plug group, and 55.3 min in the Direct Kugel group, showing a significantly shorter time in the ProGrip group. There were no significant differences in complications among three groups.
This is the first report on the use of ProGrip in Japan. The use of ProGrip can shorten the operating time and is useful for inguinal hernia repair.

View full abstract

We previously reported that CyberDome, a novel three-dimensional dome-shaped display (3DD) system, provided depth perception and easiness of laparoscopic performance in a standard closed box laparoscope trainer. In the present study, we first report results of clinical evaluation of the 3DD system for endoscopic surgery.
We applied the 3DD system in 15 clinical cases of endoscopic surgery until January 2010. After using it, we made a questionnaire survey to ask nine expert surgeons about the usefulness experienced with the 3DD system compared to the two-dimensional (2D) system.
With the use of the 3DD system, it was easier for operators to perform complicated manipulations such as suturing and knot tying, and also to perceive ruggedness of organs. The 3DD system would be useful for operators to perform more difficult or complicated endoscopic surgeries.

View full abstract

Atypical adenomatous hyperplasia (AAH) and bronchioalveolar carcinoma (BAC) often occur as multiple focal lesions, showing ground-glass attenuation (GGA) on high resolution CT (HRCT) scans. Here we report consecutive nine cases of bilateral multiple lesions of GGA, more than three lesions at least per patient, operated on from 1992 to 2008. The male-to-female ratio was 2 : 7. They had a total of 60 lesions, including 53 GGA lesions. Thirty-two GGA focal lesions were surgically resected, and their histological types included AAH in six lesions, BAC in 16, others in five, and non-neoplastic in five. There were two deaths. One patient died of contralateral lymph node recurrence and the other died of residual pure GGA growth despite stereotactic radiation therapy (SRT). In the survived patients, no new lesions have appeared, and their lesions remain less than 9 mm in diameter showing no increasing tendency. It might be desirable to perform radical surgical resection for focal lesions of GGA more than 10 mm in diameter. Only unresectable lesions should be indicated further treatments including re-operation, SRT, radiofrequency ablation and molecular targeting therapy.

View full abstract

We studied surgical cases of entero-Behçet's disease experienced in our department during the past 10 years. A total of seven consecutive patients were enrolled in this study. An average age of them at the initial surgery was 55 years old. All patients were female. Their reasons for operations were perforation in two cases, stenosis in two, bleeding in two, unsuiTable candidate for medical treatment in two, and associated malignancy in one. These lesions were mainly located in the ileum, cecum, ascending colon, and stomach. The resected materials in all cases showed non-specific ulcer histopathologically. In all patients performed operations of the ileum and/or the colon, intestinal fistula was made, and some patients required multiple operations for anastomotic leakage or re-perforation. Six out of the seven patients experienced recurrence of the lesion or complications such as anastomotic leakage at the surgical anastomotic region involving the closed intestinal fistula or in the vicinity of the anastomosis.
Entero-Behçet's disease that can easily develop postoperative comlplications such as suture failure or recurrence of the lesion is a disorder that is difficult to treat. In order to control the progression of the disease as well as to minimize postoperative complications at the anastomotic region, early intervention of medical treatment would be important after surgery.

View full abstract

We clinically studied consecutive 20 patients on hemodialysis undergoing surgery for colorectal carcinoma in our hospital from March 2003 through September 2010. Of these 20 patients, 18 patients underwent elective surgery and the remaining two, emergency surgery. Operative procedures included laparotomy in 16 patients, laparoscopic-assisted surgery in three, and laparotomy shifted from laparoscopic surgery in one. Radical operation was able to be done in all the patients. Reconstruction was made in 19 and colostomy was done in only one emergency case. Postoperative complications occurred in five (25%) patients and were conservatively treated. The survival rates in hemodialysis patients with colorectal cancer were compatible with the general population when the death cases due to other diseases were excluded. Surgery for malignant colorectal tumors has been widely performed safely even in patients who are receiving maintenance hemodialysis. However, it is thought that dialysis patients are still in a high risk group because of increases in the number of elderly patients, as well as patients with many complications such as diabetes mellitus and coronary artery diseases, and the long duration of hemodialysis therapy. Better outcomes after surgical treatment for hemodialysis patients with colorectal cancer rely on meticulous and intensive perioperative care, in addition to positive surveillance and early diagnosis.

View full abstract

We report a 37-year-old woman with granulomatous mastitis and arthralgia. She presented to our hospital with a painful, hot and tender mass in her right breast in April, 2009. Core needle biopsy of the mass revealed numerous epithelioid cells admixed with multi-nucleated giant cells, plasma cells, lymphocytes and histiocytes, leading to a diagnosis of granulomatous mastitis. A month after the first medical examination, she complained of arthralgia. Low dose corticosteroid therapy was effective for these symptoms.

View full abstract

We report a case of early onset mammary hemangioma with calcification on mammography. A 29-year old woman noticed a mass in her left breast in 2008. On physical examination, we suspected breast cancer. Surgical excision of the lesion was performed under local anesthesia. The breast biopsy was interpreted as cavernous hemangioma. No additional procedure was performed. Twenty-four months has passed since the operation, and no sign of recurrence has been observed.

View full abstract

A 73-year-old man presented with a firm mass accompanied by a skin-rash located in the left axillary region. Mammography, ultrasonography, and CT scan showed no evidence of tumors in the mammary glands. A skin biopsy revealed a poorly differentiated adenocarcinoma. The immunohistochemical analyses showed that the tumor cells were positive for estrogen receptor and gross cystic disease fluid protein-15, but were negative for E-cadherin. Invasive lobular carcinoma was diagnosed, and tumor resection with left axillary lymph node dissection was done. The tumor measured 3.0 cm, and there was no evidence of lymph node metastasis. Postoperative histological findings indicated the presence of mammary gland tissue components that were partially infiltrated by tumor cells. The final diagnosis was invasive lobular carcinoma originating from the accessory breast. He was given tamoxifen and has survived, so far, disease-free for 6 months after surgery.

View full abstract

We report a rare case of intraductal apocrine carcinoma of the breast. The patient was a 33-year-old woman who complained of a mass in her right breast. An elastic hard mass with ill-defined margin, measuring 2.5 cm, in the A area was observed. Mammography showed a focal asymmetric density (FAD). US disclosed an irregular heterogeneous low echoic mass about 30 mm in size. CT and MRI image findings indicated intraductal spreading, and fine needle aspiration showed atypical cells. Core needle biopsy yielded ductal carcinoma in situ (DCIS) with apocrine metaplasia. A wide excision and sentinel lymph node biopsy was performed. Histological examination revealed an intraductal apocrine carcinoma which spread to 5 cm in diameter.

View full abstract

Invasive cribriform carcinoma (ICC) is a histological type of breast cancer, first reported by Page et al in 1983. They classified this breast cancer into classical and mixed types, but now a pure type has been added to World Health Organization (WHO) Classification of breast cancer. Herein, we report a case of ICC who had felt a lump in her right breast 10 years prior to resection. The patient was a 71-year-old woman. She had been aware of a lump in her left breast since 2000, but did not go to a hospital. From January 2010, she felt the lump enlarging, and she visited our department in April. Aspiration biopsy cytology showed the lump to possibly be malignant. As she refused further examination, modified radical mastectomy and left axillary node dissection were performed. The histopathological diagnosis was ICC (pure type), 30mm tumor, WHO grade 1, ly(-), v(-), ER(+), PgR(+), HER2(1+), n0, pT2pN0M0, pStageIIA. In foreign countries, the incidence of ICC is reportedly 0.3 to 4.9% of all breast cancers, but there are few reports of this tumor in Japan. The prognosis of ICC patients is reported to be excellent, because the 5- and 10- year survival rates are 100% and 91%, respectively. Moreover, reported positive rates for ICC estrogen receptors and progesterone reseptors are 100% and 69%, respectively, and the HER2 positive rate of ICC is 0%. We consider these factors to possibly contribute to the excellent prognosis of ICC patients.

View full abstract

A 53-year-old woman was seen at the hospital because she was pointed out an abnormal finding at mass-screening examination for cancer of the breast. Ultrasonography revealed a hypoechoic tumor shadow 5 mm in diameter in the left breast and a tumor 14 mm in diameter at the left axillary region. Axillary metastasis of breast cancer was suspected. Echo-guided aspiration biopsy cytology of the axillary tumor induced radiating pain to the left hand (Tinel sign). Cytodiagnosis demonstrated spindle shaped cells, and the most likely diagnosis was neurogenic tumor. The tumor was enucleated under general anesthesia while a nerve which seemed to be the intercostobrachial nerve was conserved. The pathological diagnosis was schwannoma. The patient's postoperative course was uneventful.

View full abstract

We report two cases of catamenial pneumothorax. The first case was a 46-year-old woman who had repeat episodes of pneumothorax. Thoracoscopic evaluation was performed, and catamenial pneumothorax was suspect. Videothoracoscopy showed multiple perforations in the endinous part of the diaphragm. The second case was a 43-year-old woman who also had repeat episodes of pneumothorax. Red lesions were found on the diaghram and pleura by videothoracoscopy. On pathology, endometriosis was diagnosed. In this paper we review the causes of catamenial pneumothorax.

View full abstract

We describe the case of an 84-year-old female complaining of appetite loss, nausea and vomiting who was admitted to our hospital. Chest X-ray showed an abnormal shadow on the right cardiodiaphragmatic angle. Abdominal computed tomography revealed Morgagni hernia with a herniation of the transverse colon and the stomach. Upper gastrointestinal series using a gastrographin revealed a herniation of the stomach (pyloric part) and the duodenum (bulb). Laparoscopically, we made a definitive diagnosis of Larrey hernia with a hiatus of 6 × 4 cm in diameter. We performed a laparoscopic repair using a Composix Kugel Patch^® and a hernia stapler without an excision of the hernia sac. She was discharged on the 7th postoperative day without complications. Larrey hernia is an unusual type of diaphragmatic hernia, and the duodenum is a very rare hernia location. Laparoscopic repair of a Larrey hernia is a minimally invasive surgery, making it safe and feasible for elderly patients.

View full abstract

We report a case of inflammatory myofibroblastic tumor (IMT) developed under the diaphragm in the adult. The patient was a male aged 45 years. He visited with a chief complaint of left hypochondrium pain to our department. A tumor having central abscess in left diaphragm and an extrahepatic regional border and having a slightly unclear margin was showed by CT. This was diagnosed as the tumor originated from the left diaphragm with hepatic infiltration or originated from the liver with diaphragmatic infiltration. Removal of parts of the left diaphragm, left lateral segment of the liner and pericardium were conducted. The tumor was grossly present between the liver and the diaphragm, and its size was 8.0 × 7.0 × 3.0 cm. The tumor was white on its cut surface, with the abscess in its central area. A granuloma-like lesion with necrosis was histologically observed between the liver and the diaphragm, and atypical spindle-shaped cells proliferated in its circumference. The tumor expanded over the diaphragm and the liver and progressed to the pericardium. The tumor was diagnosed as IMT by its immunohistochemical findings. This was IMT developed between the diaphragm and left hepatic lobe in the adult and was a rare case.

View full abstract

An 67-year-old man was visited a hospital because of back pain over a 1-year period. Abdominal CT revealed a giant abdominal tumor, and he was referred to our hospital. Abdominal CT and MRI performed at our hospital showed a giant 18×10 cm-diameter polycystic tumor that was compressing the liver, gall bladder, colon, duodenum, stomach, and pancreas. The tumor was heterogeneously enhanced inside and was found to have a solid part that was attached to the stomach. Upper gastrointestinal endoscopy showed a normal mucosal surface, and abdominal angiography indicated the right gastroepiploic artery as the feeding artery. These findings suggested that the tumor was a gastrointestinal stromal tumor (GIST) or malignant fibrous histiocytoma (MFH) that originated in the stomach or omentum ; but no definitive diagnosis could be made. Because the tumor was attached to the anterior wall of the stomach, tumor resection was performed together with a partial gastrectomy. The resected specimen was 22×13×10 cm in size and weighed 965 g. Histopathological testing revealed the presence of both spindle cells and round cells in the specimen. Immunohistochemical analysis showed that the specimen was positive for c-kit and CD34, and the patient was coclusively diagnosed as having GIST of the stomach. Cases of GIST with giant cyst formation are occasionally reported, but GISTs of the stomach that are more than 20 cm in diameter seem to be rare ; therefore, we have reported this case, together with some bibliographical information.

View full abstract

The case was a 76-year-old woman who had noticed stomach discomfort for 2 months and black stools for 1 week. She was referred to our hospital by a neighborhood doctor as she was suffering from hemorrhagic shock. Upper gastrointestinal endoscopy revealed a hemorrhagic, blackish tumor that appeared as a large hematoma in the cardiac region of the stomach. Endoscopic hemostasis was difficult. Computed tomography revealed multiple metastases to the liver and lungs. Proximal gastrectomy was performed as palliative surgery. Malignant melanoma was diagnosed by pathological findings ; she was then transferred to the department of dermatology at another hospital. Dacarbazine treatment was minimally effective and she died on the 153^rd postoperative day. Malignant melanoma of the stomach is often metastatic, and primary cases are extremely rare. Only 2 such cases have been reported in Japan. We describe our case with a brief literature review.

View full abstract

Interposition of the intestine, into the right subphrenic space is known as Chilaiditi syndrome. We report a case of small intestine type Chilaiditi syndrome with strangulated ileus, which required intestinal resection. A 52-year-old woman was admitted to the hospital because of abdominal pain and vomiting. We diagnosed this case as small intestine type Chilaiditi syndrome with strangulated ileus from a CT scan and subsequently an emergency laparotomy was performed. During the operation, the part of the small intestine which was strangulated, was incarcerated into the right subphrenic space. The incarcerated small intestine was reduced, but intestinal resection was required. In Chilaiditi syndrome the large intestine is generally asymptomatic, so most cases are simply followed up. However, careful attention and further examination should be given to patients with small intestine type Chilaiditi syndrome, which is prone to cause ileus and requires an emergency laparotomy.

View full abstract

Small bowel volvulus is a comparatively rare entity. We report a case of small bowel volvulus which was thought to be caused by jejunal diverticulum. A 90-year-old woman was admitted to our hospital complaining of gradually increasing abdominal pain. Abdominal CT showed the whirl sign which was peculiar to small bowel volvulus. We performed an emergency operation and found the small intestine was twisted counterclockwise 720 degrees around the superior mesenteric artery. Since there was no ischemic change of the small intestine, we only reduced the axis rotation. Then we found the jejunal diverticulum at 30 cm distal from the Treitz ligament. The diverticulum was thought to be the cause of axis rotation because of its location. The diverticulum was resected and closed primarily. We should consider small bowel volvulus in making diagnosis of small bowel obstructions. Jejunal diverticulum must be resected to prevent recurrence of small bowel volvulus.

View full abstract

The patient was a 59-year-old male who received bevacizumab + mFOLFOX6 therapy for synchronous multiple liver metastases after resection of multiple rectal carcinoma lesions. In the 12^th month after the commencement of treatment, the patient was judged to have progressive disease. Thus, the treatment was changed to bevacizumab + FOLFIRI therapy. On the 5^th day after the second administration of bevacizumab + FOLFIRI (bevacizumab : 14 total treatments), the patient developed abdominal pain and vomiting. The patient was diagnosed as having a strangulated ileus based on the results of plain X-rays of the abdomen and abdominal CT. Therefore, an emergency operation was performed that day. Intraoperative findings included necrosis in a 30-cm part of the small intestine beginning from approximately 5 cm from the ligament of Treitz. The necrotic intestine was removed, and a side-to-side anastomosis was performed. There were no postoperative complications ; FOLFIRI therapy was commenced again on postoperative day 48. Starting on postoperative day 73, the concomitant administration of bevacizumab was allowed for a total of 7 times. The patient died 23 months after starting the initial treatment. Complications caused by the delayed healing of a wound can be avoided by selecting an appropriate anastomotic method for the intestinal tract, even during emergency surgery performed subsequent to bevacizumab administration.

View full abstract

Inflammatory myofibroblastic tumors (IMT) of the small intestine are rare. We report a case of IMT of the small intestine presenting with ileus. A 79-year-old man was admitted to our hospital with abdominal pain and vomiting. Abdominal CT showed a contrasted mass lesion in the small intestine and luminal dilatation of the oral side. A tumor of the small intestine with ileus was diagnosed and ileocecal resection was performed. Histological examination showed the tumor to be composed of fibroblast-like spindle cells with inflammatory cells. Immunohistochemically, the spindle cells were positive for smooth muscle actin. Herein, we address the diagnosis of IMT by histology and immunohistochemistry.

View full abstract

A 70-year-old man visited our hospital with a chief complaint of right lower quadrant pain. Since he had guarding in the right lower quadrant, and abdominal CT showed free intraperitoneal air in the upper abdomen, the patient was diagnosed with acute generalized peritonitis caused by gastrointestinal perforation, and emergency surgery was performed on the same day.
A 5-mm-diameter perforation was found in the ileum 55 cm proximal to the terminal ileum, and enlargement of mesenteric lymph nodes around the perforation site was observed.
The pathological sample showed diffuse proliferation and infiltration of atypical lymphocytes in all layers of the intestinal wall, which had lost its normal structure. Based on testing positive for CD20 and CD79a and negative for CD3, the patient was diagnosed with diffuse large B-cell lymphoma.
The patient's general condition worsened rapidly 23 days after surgery, and he died on the 24^th day. Autopsy showed intraperitoneal dissemination of malignant lymphoma. Hemophagocytosis by histiocytes was seen in the spleen and bone marrow, indicating hemophagocytic syndrome.
A case of malignant lymphoma originating in the small intestine that manifested with perforative peritonitis, was complicated postoperatively by hemophagocytic syndrome, and deteriorated rapidly is described with reference to the literature.

View full abstract

A 50-year-old woman was referred to the hospital because of epigastralgia and lower abdominal pain. She visited Japan from the Philippines when she was 30 years old, and had been living in Japan after marriage to a Japanese man. We diagnosed the case as acute appendicitis, so we performed an emergency appendectomy. Pathological findings showed that many ova of schistosomiasis japonicum were found in all layers of the appendix wall.
The Kofu Basin, Yamanashi is known as the schistosomiasis japonicum plague spot in Japan. The eradication of Miyairi shellfish, the intermediate host, has diminished the risk of infection with schistosomiasis japonicum. There is the possibility of an old disease from a plague spot if ova of schistosomiasis japonicum were found by a pathology organization specimen. However, some imported infections of schistosomiasis japonicum have been reported every year recently, so we should consider the possibility of activity infection, and monitor this disease.

View full abstract

An 84-year-old man was admitted to our hospital with a 4-week history of dyspnea. Myasthenia gravis had been diagnosed 33 years earlier and the patient was being treated with anti-cholinesterase therapy after thymectomy. Bloody stool suddenly occurred five days after admission to our hospital and a mass was palpable in the right lower abdomen. Abdominal ultrasonography and computed tomography scan showed a ‘target sign’ in the ileocecum, and intussusception was diagnosed. An emergency operation was performed and revealed the ileocolic type of intussusception. Ischemic change was seen in the invaginated ileum, and ileocecal resection was therefore performed. No polyp or tumor or diverticulum which might have caused intussusception was found in the ileum. Idiopathic intussusception was thus diagnosed. Adult idiopathic intussusception is rare. Moreover, cases of myasthenia gravis with idiopathic intussusceptions are very rare.

View full abstract

This patient was a 53-year-old man with pain and a right lower quadrant mass that was first noted in April 2009. Colon cancer was suspected on abdominal echography. On CT, the presence of metastases was suspected given the visualization of intraabdominal lymphadenopathy as well as multiple abdominal wall masses and left lung involvement. CF revealed bulky polyps in the ascending colon. Moreover, because the Barium enema showed multiple diverticula and an ileocecal stenosis in the same lesion, the patient was hospitalized ; a type 5 progressive colon cancer was suspected. After repeat CF and Barium enema studies, the cancer still could not be identified. However, his abdominal pain did not improve ; and abdominal CT showed possible invagination. The patient had an ascending colon resection and a small intestine segmental resection. On pathology, the ileocecal IFP resulted from inflammation of the colon diverticulitis, and IFP presented as an invagination on imaging.

View full abstract

A 71-year-old man was admitted to our hospital, complaining of progressively worsening abdominal pain. An abdominal CT examination demonstrated ascites, free air, and a gallstone in the sigmoid colon. The patient underwent emergency laparotomy under a diagnosis of panperitonitis with a perforation associated with gallstone ileus. Operative findings showed a perforation and an impacted stone in the sigmoid colon. A sigmoid colectomy and loop ileostomy were performed. Despite being in a state of sepsis shock, the patient recovered and was discharged.

View full abstract

We report a case of pneumatosis cystoides intestinalis diagnosed during laparoscopic exploration. A 42-year-old woman underwent bone marrow transplantation for aplastic anemia when she was 23 years old ; she underwent chemo-radiation therapy and on esophagectomy for esophageal cancer at 35 years of age, and chemo-radiation therapy for tongue cancer at 42 years of age. She was admitted for resection of lymph node metastasis from the tongue cancer and developed abdominal pain following admission. Abdominal CT demonstrated free air around the liver. We performed laparoscopic exploration to rule out intestinal perforation although she did not have abdominal tenderness on examination. Laparoscopic exploration disclosed extensive pericolic gas around the transverse colon. It was determined that she had developed pneumatosis cystoides intestinalis 19 years after bone marrow transplantation and 7 years after chemo-radiation therapy. There may an association between her medical history and the subsequent development of pneumatosis cystoides intestinalis.

View full abstract

Although schwannomas are common in the neck, brain, and extremities, they are relatively rare in the gastrointestinal tract. In particular, schwannomas arising in the large intestine are rare. We present a rare case of schwannoma of the sigmoid colon showing high-uptake on FDG-PET.
A 75-year-old woman developed increased stool frequency and was referred to our department. Colonoscopy showed a submucosal tumor in the sigmoid colon. The tumor showed high-uptake on FDG-PET ; thus, a malignant tumor such as a GIST or a malignant lymphoma was suspected. A laparoscopy-assisted sigmoidectomy was done. On pathology the post-operative diagnosis was schwannoma. There was no sign of malignancy. FDG-PET is one metabolic imaging approach which can also be used to diagnose malignant tumors. However, there are reports that though schwannomas are benign, they may show high up-take on FDG-PET. Thus, high uptake is not always indicative of malignancy.

View full abstract

We report two cases of sigmoid colon cancer diagnosised with skin metastasis. Case 1 : A woman in her 50's complained of a subcutaneous mass on her left back. The mass showed an invasive growth in an abdominal MRI and levels of CEA in blood were high ; further examination using colonoscopy identified a tumor in her sigmoid colon. Clinical diagnosis was sigmoid colon cancer with subcutaneous metastasis, and she underwent a sigmoidectomy and postoperative chemotherapy. Eighteen months after the operation, she was found to have right adrenal metastasis, and died 8 months thereafter. Case 2 : A woman in her 70's was found to have redness, and induration in the right femoral region. Histological examination of the biopsy revealed metastatic adenocarcinoma. Further examination showed that the diagnosis was sigmoid colon cancer with skin and liver metastasis. The skin metastasis showed rapid growth. An expandable metallic stent was used to treat the obstruction of the sigmoid colon. She was treated with palliative care and died 2 months after being diagnosised.

View full abstract

A 76-year-old woman underwent surgery for ascending colon cancer. On pathology, a poorly differentiated adenocarcinoma, pSE, pN0, M0, ly2, v1, pStage II was diagnosed. Subsequently, 2 months after the operation, multiple subcutaneous tumors were noted predominantly in the lower legs. Most were resected ; on pathology, they were found to be colon cancer metastases. PET done 1 year after the first operation only revealed subcutaneous and skin metastases. However, 20 months after the first operation, the patient died as a result of other distant metastases. Subcutaneous metastasis in the lower legs of colon cancer patients is very rare. Therefore, we report this case with a review of the literature.

View full abstract

The patient was a 68-year-old man who had previous histories of undergoing lower anterior resection of rectum and partial resection of bladder for rectal cancer, hepatic resection for a metastatic tumor, and trans-urethral therapy for a bladder tumor. In February 2009, suddenly he developed disturbance of consciousness and food-contaminated urine. He visited the former hospital, and was diagnosed as having hyper-ammonemia and an ileovesical fistula. He underwent ileo-cecostomy at the proximal ileum of the fistula, but no symptomatic remission was attained. He visited our hospital and underwent, second surgical treatment in October 2009. He had chronic liver failure and diabetes mellitus as preoperative complications. Using the ileo-cecostomy, a pouch of the ileum with the fistula was made for the purpose of the separeation of the fistula from the route of digestion. After the second surgery, the symptoms due to hyper-ammonenia disappeared. We examined the changes in the blood level of ammonia, urea nitrogen, chloride, and potassium after the surgery. The high blood levels of ammonia, urea nitrogen and chloride were significantly deceased after the surgery, but no change in serum potassium level was noted.

View full abstract

We report a case of descending colon cancer with a liver abscess. A 61-year-old woman was admitted to our hospital because of high grade fever lasting for 2 weeks. Abdominal ultrasonography revealed a solitary liver abscess (4 cm in diameter) in the left lobe of the liver. She was admitted to the hospital with the diagnosis of liver abscess, and was administered antibiotics. Although inflammatory reaction subsided in 14 days, an enhanced computed tomography showed a 4-cm irregulaly enhanced thickening wall of the descending colon. Colonoscopy revealed a type 2 tumor completely encircled the descending colon that had caused stenosis. We expected decompression with an ileus tube inserted by the transanal route, but she showed an obstructive ileus condition, and went into septic shock two days later. Hartmann's procedure was emergently perfomed. The pathological findings were tub1, se, n1, and final stage IIIa. The patient has been free from liver metastasis and liver abscess 4 years after the operation. In conclusion, a pyogenic liver abscess can be caused by colon cancer though it is rare, so we must the lower gastrointestinal tract to detect causes of liver abscess.

View full abstract

A 73-year-old woman found to have a 5-cm mass in the S1 area of the liver by medical examination 18 years previously, and further investigation was recommended. However, she declined further tests. Recently, she had a checkup for epigastralgia, and underwent computed tomography (CT). CT showed a low density mass in the plain phase and a mildly enhanced mass in the hepatic arterial and portal phases. Abdominal magnetic resonance imaging scan suggested the existence of a fat component in the tumor. We suspected that the liver tumor was hepatocellular carcinoma or hepatic angiomyolipoma, and caudate lobe resection was performed. Histopathologically, the tumor was finally diagnosed as well differentiated hepatocellular carcinoma, though tumor histology was similar to liver cell adenoma. Clinically and histopathologically, well-differentiated hepatocellular carcinoma may be difficult to distinguish from liver cell adenoma.

View full abstract

A 70-year-old man with right hypochondrium pain was seen at a neighborhood hospital in October, 2009. He was hospitalized that day because of a tumor with hematoma in the liver detected by CT scan. His condition was stable with conservative management of the liver tumor and hematoma, and he was referred to our hospital in January, 2010. Hepatitis B virus and hepatitis C virus markers were negative, and serum tumor markers were elevated. Abdominal CT scan indicated the mass lesion to be a hepatocellular carcinoma (HCC) with hematoma, and hepatectomy was performed. The resected tumorous specimen was 5 cm in diameter. Histopathology was poorly differentiated HCC. He was discharged from our hospital on postoperative day 20. Ruptured HCC within a subcapsular hematoma is relatively rare. We describe the present case with reference to the literature.

View full abstract

A 72-year-old man was admitted to our hospital due to high grade fever. Ultra-sonography indicated a tumor in valving segments 3 to 4 of the liver. The tumor was suspected to be a liver abscess or a cholangiocarcinoma based on its heterogeneous density and low tumor enhancement on computed tomography. An aspiration biopsy showed undifferentiated carcinoma. Based on a preoperative diagnosis of intrahepatic cholangiocarcinoma or undifferentiated carcinoma, we conducted an extended left lobectomy. Histopathologically, the specimen showed osteoid and chondrocyte formation as well as clear cytoplasm and spindle-cell sarcoma with poorly formed cytoplasm. Immunostaining was positive for cytokeratin and glypican3, suggesting an original hepatocyte character. The final histological diagnosis was hepatic carcinosarcoma. The patient remains alive 5 months postoperatively. Hepatic carcinosarcoma is quite rare and could be among the differential diagnoses when a heterogenous low density tumor is found in the liver.

View full abstract

A 41-year-old woman visited our hospital with a chief complaint of right upper abdominal discomfort. Preoperative examination revealed that the gallbladder had two lobes separated by a septum located in the lumen. However, this was initially diagnosed as a bent gallbladder. Gallstone cholecystitis with choledocholiths was diagnosed, and laparoscopic cholecystectomy was performed after endoscopic choledocholithotomy. During surgery, the gallbladder was found to have a normal appearance ; there was no anomaly of the cystic duct. The excised gallbladder was bilobed and divided into the two lobes by a septum. On histopathology, both lobes had mucosa and muscular layers ; the lobes were joined at the subserosal layer. Thus, a diagnosis of bilobed gallbladder separated by a septum was made.
Double gallbladder is a rare malformation of the gallbladder in particular, the subtype of bilobed gallbladder is very rarely reported. We successfully treated a case of bilobed gallbladder by performing a laparoscopic cholecystectomy.

View full abstract

We report a case of subtotal stomach-preserving pancreaticoduodenectomy after coronary artery bypass operation using a right gastroepiploic artery graft. The case involved an 80-year-old man who had been performed coronary artery bypass operations at the ages of 55 and 78 years. This time obstructive jaundice was suspected from high fever and jaundice and cancer of the lower bile duct was diagnosed following close examinations. Considering the clinical stage of the disease before surgery and his advanced age, we performed subtotal stomach-preserving pancreaticoduodenectomy with the gastroduodenal artery intact. During surgery, we confirmed that vascular treatment had been done at the greater curvature aspect of the gastric pylorus ; and that the right gastroepiploic artery graft which was the periphery of the gastroduodenal artery showed favorable pulsation and run toward the cranial direction to the mediastinum on the ventral aspect of the lateral area of the liver. At surgery, dissection of the stomach was performed first, and then under direct vision, the gastroduodenal artery-right gastroepiploic artery graft was treated from the widely exposed anterior surface of the pancreas head, and a branch of the pancreaticoduodenal artery was treated from the periphery to the base of the gastroduodenal artery. By employing these procedures, we could perform the surgery relatively easily. No noteworthy postoperative complications occurred and the patient's postoperative course was uneventful.

View full abstract

A 55-year-old man was referred to our hospital for the investigation of thrombocytopenia, which had been first noted 17 months prior. Laboratory data on admission showed a low platelet count (7.8×10⁴/μl). Tumor markers were normal. Abdominal CT showed a large tumor (7.5 cm in diameter) of the pancreatic tail, which invaded the spleen and occluded the splenic vein. FDG-PET showed abnormal uptake in the pancreatic tumor. Under the diagnosis of pancreatic acinar cell carcinoma, a distal pacreatectomy and a splenectomy were performed. On histopathology, the preoperative diagnosis was confirmed. The patient is doing well and is without recurrence 12 months after surgery. It is well known that splenic vein occlusion results in splenomegaly and thrombocytopenia. However, thrombocytopenia as the initial presentation of pancreatic acinar cell carcinoma as occurred in our case has not been previously reported. Herein we report this rare case and review of the literature.

View full abstract

A 50-year-old man was seen at the hospital because of high fever and abdominal pain. There were tenderness in the entire abdomen and he had inflammatory reaction and diabetes. Abdominal CT and ultrasonic examinations revealed a cystic lesion in the spleen, and splenic abscess was diagnosed. Despite administration of antibiotics, no symptomatic remission was gained and percutaneous drainage was started on the third hospital day. A bacteriological examination of ash-colored purulent aspirated fluid about 1500 ml yielded Streptococcus sanguinis oralis, an oral microorganism. On the 32 nd hospital day, his high fever and respiratory and circulatory conditions took downhill course. Accordingly prolonged septicemia was diagnosed and splenectomy was performed on the 38 th hospital day. Pathological studies showed findings of splenic infarction due to bacterial mass. Echocardiography under suspicion of infectious endocarditis demonstrated a verruca at the anterior cusp of the mitral valve and serious mitral insuffciensy. Cardiac failure caused by these conditions was thus diagnosed. The patient was transferred to another hospital and underwent mitral valve replacement 14 days after the splenectomy.
We reported a case of splenic abscess with splenic infarction caused by infectious endocarditis due to an oral microorganism.

View full abstract

We encountered a case of pseudo-Meigs' syndrome caused by ovarian metastasis of ascending colon cancer. A 49-year-old woman visited another hospital with complaints of anemia and abdominal fullness. Abdominal CT scan showed a bilateral ovarian tumor and subsequently she visited our hospital. Colonoscopic examination showed ascending colon cancer. Chest X-p and CT showed right pleural effusion, so we performed drainage and removed 800 ml of effusion. We performed a right hemicolectomy with D3 dissection and bilateral oophrectomy with hysterectomy. Pathological diagnosis was a metastatic ovarian tumor of the ascending colon.

View full abstract

Strangulated ileus is a serious disease which can progress to intestinal necrosis if the diagnosis is delayed and the chance for surgery lost. We report three cases of strangulated ileus caused by internal herniation into an abnormal hiatus of the greater omentum and transverse mesocolon. The courses differed but went well after surgery. Case 1 : A 67-year-old man. He had sudden abdominal pain, and was diagnosed with strangulated ileus by computed tomography. Jejunectomy was performed as the jejunum incarcerating through the hiatus of greater omentum showed ischemic change. Case 2 : A 55-year-old woman. Intestinal obstruction was sustained after insertion of a long nasointestinal tube. Intra operatively, some of the ileum showed ischemic change and the omentum had an organized hiatus. Omentectomy was performed. Case 3 : A 73-year-old woman. Upper gastrointestinal series performed for evaluation of bile vomitus revealed a constriction of the jejunum. Laparotomy revealed some of the small intestine incarcerating through the hiatus of transverse mesocolon into the omental bursa and it was strangulated. Internal hernia is difficult to diagnose especially in the absence of symptoms. It is very important to make full use of diagnostic images such as enhanced computed tomography or upper gastrointestinal series at the time of symptom manifestation.

View full abstract

Two cases of internal ileus caused by intramesosigmoid hernia were laparoscopically treated during the last one year. Case 1 involved a 79-year-old man complaing of abdominal pain and poor appetite and case 2 involved an 80-year-old man complaining of left lower quadrant pain. A long tube was placed and after enough decompression of the small intestine, intestinal gastrograffin contrast study through it revealed obstruction of the small intestine in both cases. Internal hernia was thus diagnosed preoperatively and operations were carried out with laparoscopy on the third day in case 1 and on the 9th day in case 2 after admission. Operative findings showed an about 4 cm or about 3 cm defect in the left side of sigmoid mesocolon in the case 1 and case 2, respectively. The ileum was successfully freed from the hernia sac and the hernia orifice was sutured under laparoscopy in both cases. Their postoperative courses were favorable and they were discharged from the hospital on the 11th and 6th postoperative day, respectively.
Intramesosigmoid hernia is very rare. In this paper we present such two cases radically treated by laparoscopic procedure after decompression of the small intestine by the long tube, with a review of the literature.

View full abstract

A 59-year-old female was admitted to our hospital for diabetes where a CT scan indicated an abdominal tumor. Enhanced CT showed that the tumor was oval-shaped with a smooth surface, 4.5 cm in diameter located on the outside of the gastric antrum wall, and presented a strongly enhanced central region. MRI showed low signal intensity on the T1 and high signal intensity of the central region on the T2-weighted images. The border between the gastric wall and the tumor was unclear on endoscopic ultrasound. Laparoscopic resection was successfully performed. Intraoperative findings showed that the tumor was derived from the greater omentum. Pathologic examination revealed the tumor to be the hyaline vascular type of Castleman's disease.

View full abstract

A 21-year-old woman underwent emergency surgery under a diagnosis of intestinal perforation in February 2008. Perforation of the rectum due to stool impregnation was identified, followed by peritonitis. The rectum including the perforation site was resected and a colostomy was made at the sigmoid colon. However, 39 days after discharge, sigmoid colon perforation under the colostomy was found, requiring another emergency operation. The presence of an undergoing illness was suspected because of the two colon perforations in a short period, the ease of intestinal injury and weak arterial tissue found twice intra-operatively, as well as the vulnerabilities of vessels, tissues, and joints on past history. Skin biopsy was performed for pathology and gene analysis. She was diagnosed as having the vascular type of Ehlers-Danlos syndrome. It is necessary to suspect this syndrome in young cases of non-induced colon perforation. Close follow-up is essential after the diagnosis.

View full abstract

The patient was a 70-year-old female who underwent resection of a malignant hemangiopericytoma of the intrapelvic retroperitoneum following intra-arterial infusion chemotherapy in January 1996, and had a local recurret tumor which was removed with the sacrum in April 1998. Thereafter there had been no evidence of recurrence until 2007 and she decided on her own to stop visiting the hospital. In November 2009, about 13 years after the initial operation, she was found having an intraperitoneal mass demonstrated by ultrasonography for screening medical checkup. Abdominal enhanced CT scan revealed a heterogeneous intraperitoneal mass with clear margin adherent to loop of the small intestine. Relapse of the malignant hemangiopericytoma of the intrapelvic retroperitoneum was diagnosed based on the past histories and abdominal CT findings. In March 2010 resection of the intraperitoneal mass was performed. The intraperitoneal mass was covered with the omentum, and so it was resected with a part of the omentum. Histopathological diagnosis was recurrence of malignant hemangiopericytoma. Since hemangiopericytoma may relapse 10 years or more after the resection, close long-term follow-up is required after the operation.

View full abstract

A 6-year-old girl visited our hospital because of right gluteal pain. An induration was noted, and a subcutaneous abscess was formed one month later. The abscess improved with drainage, however, because she had repeated episodes of the gluteal subcutaneous abscess from childhood, further examinations were performed. Magnetic resonance imaging (MRI) and computed tomography (CT) showed a cystic tumor located between the rectum and the coccyx. It was diagnosed as a presacral cystic tumor, and was resected via the posterior sagittal approach. The incision started at the inferior border of the coccyx and continued down through the midline, ending at the border of the anus. Incision continued through the center of the external sphincter and the levator muscle, the tumor was exposed and removed. Microscopically, the cyst wall was composed of keratinized squamous epithelium, and no cutaneous appendages were found. The pathological diagnosis was epidermoid cyst.
She has remained well without reccurence or bowel dysfunction in nine months since the operation. Posterior sagittal approach is thought to be one of the useful operations for the treatment of a presacral mass.

View full abstract

An 81-year-old man was transported to our hospital, because he was aware of an incongruity at the back of his waist and it gradually increased and was presented with abdominal pain. A simple CT showed small intestinal expansion in the pelvis and an obturator hernia. We made a diagnosis of small intestine obstruction due to the obturator hernia impaction. His symptoms disappeared after the CT, and after performing the enhanced CT, the obturator hernia also disappeared. Enhanced effects of the small intestinal wall were sufficient and even without findings to suspect necrosis, we planned an operation for thirty days later. The patient underwent surgical hernia repair by the groin method with a Direct Kugel Patch, and he was discharged on the third postoperative day. One year has past post-operation without recurrence.
This case developed in a man and we experienced one case of obturator hernia that traced a rare course that displayed a natural reduction. Because it seemed that surgical repair using a Direct Kugel Patch^® in useful, we add it here and report on the relevant literature.

View full abstract