We examined retrospectively 34 patients with hepatic portal venous gas experienced in our department to elucidate useful indications of surgery for hepatic portal venous gas. We divided these patients into two groups ; Group A (15 patients, treated conservatively) and Group B (19 patients, indicated surgery). We compared these two groups. The cases of shock state and those with positive peritoneal irritation sign were all involved in the Group B but not in the Group A, showing a significant difference. There were significant differences in base excess and creatine kinase between the two groups. As for the SIRS diagnostic criteria, there was significant differences in the number of positive items and pulse rate between two groups. As to CT findings, ascites, free air, pneumatosis intestinalis and expansion of the portal venous gas were examined, and no significant difference were noted. Therefore, emergency surgery was considered to be absolutely required for the shock and/or peritoneal irritation sign positive cases with hepatic portal venous gas. We also conclude that surgery should be considered for the SIRS case with tachycardia, but we cannot decide surgical indication from the quantity and expansion of the portal venous gas on CT.

View full abstract

Granulomatous mastitis is a rare benign disease of the breast. We occasionally encounter case reports of granulomatous mastitis that was pathologically diagnosed after operation with a diagnosis of breast cancer. This paper deals with our experience with a case of granulomatous mastitis caused by an infection with Corynebacterium tuberculostearicum (C. tuberculostearicum). The case involved a woman in her fifties, who presented to our hospital because of a left breast tumor with pain. On palpation, an elastic hard and well-movable tumor 40 mm in diameter was felt in the left C area. MMG, US, and MRI strongly suggested breast cancer, and a fine needle biopsy cytology was performed. Histological findings showed infiltration of inflammatory cells mainly composed of neutrophils, but malignant cells were absent. Granulomatous mastitis was suspected, and the punctured content of the tumor was submitted to the laboratory section for cultivation. Antimicrobial drugs were then administered. The culture yielded C. tuberculostearium. The tumor diameter decreased in 4 weeks after the administration. At present when eight months have elapsed after the diagnosis, the patient is doing well without aggravation.

View full abstract

A 45-year-old woman presented complaining of a mass in the left breast. An elastic, hard, poorly mobile, huge mass was found throughout the left breast, and was partially exposed at the skin surface. Ultrasonography of the mammary gland showed a clearly defined marginal boundary, and a hypoechoic mass with a relatively uniform interior was noted. Contrast-enhanced computed tomography showed a mass with marginal enhancement, measuring 18×15×14 cm, in the left breast. The mass displayed widespread contact with the pectoralis major muscle, but no obvious signs of swollen lymph nodes in the axilla. Two needle biopsies were performed, and fibroadenoma of the breast was diagnosed. As the tumor was huge with skin infiltration, and malignancy could not be ruled out, mastectomy was performed. Histopathological examination yielded a diagnosis of tubular adenoma of the breast. Tubular adenoma of the breast is a rare disease, with only 36 cases reported in Japan to date, including the present case. Tumor size in the present case was particularly large, and we report this case along with a discussion of the literature.

View full abstract

We describe the case of a 56-year-old woman who was detected to have elevation of the serum CEA level during annual postoperative monitoring for tumor marker levels after treatment for ovarian cancer. Screening FDG-PET revealed focal FDG uptake in the upper quadrants of the right breast. The patient was found to have no palpable breast mass, and mammography showed no abnormal findings ; however, breast ultrasound (US) revealed diffuse ill-defined patchy hypoechoic lesions in the upper quadrants of the right breast. US-guided core needle biopsy revealed the diagnosis of ductal carcinoma in situ (DCIS). A subsequent MRI examination of the breast revealed an extensive enhancing region in the right upper breast. Modified radical mastectomy with axillary sentinel node biopsy was performed. Histopathological examination of the resected surgical specimen revealed extensive intraductal proliferation of tumor cells that mostly showed a solid growth pattern in a fibrovascular papillary stroma. Neuroendocrine differentiation was confirmed by immunohistochemistry for chromogranin A, and neuron-specific enolase. In addition, the tumor cells were strongly positive for CEA. The serum CEA level decreased rapidly to the normal range within one month after the surgery. This is an extremely rare case, in which CEA produced by the tumor cells of DCIS of the breast caused elevation of the serum CEA.

View full abstract

Spindle cell carcinoma of the breast is a relatively rare tumor. In most cases, this breast tumor exhibits the triple-negative phenotype, namely, ER-negative, PgR-negative and HER2-negative. We report a case of chemotherapy-resistant spindle cell carcinoma of the breast. The patient was a 75-year-old female presenting with the chief complaint of a mass in the right breast. Core needle biopsy revealed findings consistent with the diagnosis of spindle-cell carcinoma. Modified radical mastectomy with sentinel lymph node biopsy was performed. The disease was classified as pT3pN0(SLN)pMX according to the TNM classification (UICC). The tumor subtype was TNBC. Adjuvant chemotherapy was administered with cyclophosphamide+dexorubicin (AC) followed by docetaxel. One month after the completion of chemotherapy, the patient developed pulmonary metastasis, for which neither bevacizumab+paclitaxel nor eribulin mesylate proved effective. Unfortunately, the patient died nine months after the operation.

View full abstract

A 63-year-old woman was referred to our hospital complaining of huge left axillary lymph nodes and left nipple erosion. Core needle biopsy diagnosis identified the breast lesion as ductal carcinoma in situ (DCIS), whereas the axillary lymph nodes showed anaplastic carcinoma. General survey showed no definitive primary site for the axillary anaplastic carcinoma. We diagnosed coexisting DCIS of the breast and axillary anaplastic carcinoma from an unknown primary site. After chemotherapy (CDDP + CPT-11), axillary lymph nodes shrank markedly. Left muscle-preserving mastectomy and axillary and subclavian lymphadenectomy were performed subsequently.
Postoperative radiotherapy of the supraclavicular, subclavian and axillary nodal areas was performed. Two years and six months after surgery, the patient is healthy with no recurrence. This rare case suggests that axillary lymph node biopsy is mandatory if any clinical discrepancy is seen between breast cancer and axillary lymph nodes.

View full abstract

We report a case of solitary hepatic metastasis from breast cancer. A 79-year-old female patient underwent quadrantectomy with axillary lymph node dissection when she was 66 years old. The pathologic diagnosis was invasive ductal adenocarcinoma, scirrhous carcinoma, pT1N1M0, ER and PgR positive. Radiotherapy was performed, followed by chemotherapy and endocrine therapy. Since the age of 76 years, her serum CEA level was occasionally elevated. A solitary hepatic tumor in segment 4 was found on ultrasonography 13 years after mastectomy. Although the enhanced pattern on CT and MRI was atypical, the lesion was diagnosed as intrahepatic cholangiocarcinoma. Because left hepatic duct invasion was suspected based on endoscopic retrograde cholangiography, left hepatectomy and left caudate lobectomy were performed. The histopathological findings were compatible with a solid tubular or papillo-tubular carcinoma of the breast. The lesion was both ER and PgR positive. Therefore, we finally diagnosed the lesion as hepatic metastasis from breast cancer. The patient has been alive for three years after hepatectomy. Because hepatic metastasis often presents as multiple lesions, few patients undergo hepatectomy. However, hepatectomy can be a therapeutic option as it could prolong survival in patients with solitary hepatic metastasis from breast cancer.

View full abstract

The patient was a 47-year-old woman. She had undergone mastectomy with axillary lymph node dissection for left breast cancer 5 years earlier. Additionally, postoperative chemotherapy and radiotherapy had been performed. She complained of abdominal pain and bloating, and visited a nearby clinic. She was referred to our hospital after ileus due to rectal tumor was suggested on abdominal CT. Colonoscopy showed entire circumferential stenosis at the mid-lower rectum, without neoplastic lesions of the mucosa. Endoscopic ultrasound-guided fine needle aspiration of the rectal tumor was performed, and the biopsy specimen suggested adenocarcinoma. CT showed entire circumferential wall thickening of the rectum and swelling of regional lymph nodes, without distant metastasis. We considered rectal metastasis due to breast cancer, but no definitive preoperative diagnosis was reached. We performed surgery due to ileus immediately. Operative findings revealed peritoneal dissemination and tumor invasion with a focus on the rectal posterior wall extending to the sacrum. Based on these findings, we performed Hartmann's operation. Finally, rectal metastasis from breast cancer was diagnosed histopathologically. Here, we report a rare case of rectal metastasis from breast cancer with reference to the literature.

View full abstract

We report the case of a patient with infectious endocarditis (IE) who presented with rupture of a right hepatic artery aneurysm into the gallbladder. A 77-year-old woman with a history of IE and subarachnoid hemorrhage presented with the chief complaint of acute epigastric pain. A plain CT of the abdomen initially revealed findings suggestive of cholecystitis with a gallbladder stone. While the patient was being treated conservatively, she developed lower abdominal pain of acute onset. Contrast-enhanced CT revealed an abdominal wall hematoma, which was suspected to be a result of bleeding from the left inferior epigastric artery. A right hepatic artery aneurysm rupturing into the gallbladder was also seen, which was initially thought to be a gallbladder stone. The patient was treated by transcatheter arterial embolization (TAE) for the right hepatic artery aneurysm. During the TAE, obstruction of the superior mesenteric artery was also confirmed. We suspected IE as the cause of these multiple vascular lesions. In Japan, only 8 cases of mycotic aneurysms of the hepatic artery have been reported in the literature, including the case reported here. Due to the high mortality rate associated with a ruptured aneurysm, caution is needed against such potentially life-threatening complications in patients with IE.

View full abstract

A 44-year-old woman who had higher brain dysfunction as a sequela due to an injury to the head developed into argument with her mother during a meal and got excited. Then she ate a fish (sea bream) with the bones and head, which was poached with soy sauce and sugar. Soon she felt that something was wrong at the pharynx and she became to be incapable of ingesting solid foods. Three days later she presented to our hospital. Cervical soft X-ray radiography and CT scan revealed a L-shaped fish bone to have penetrated the right side of the cervical esophagus. Endoscopic extraction of the fish bone was attempted, but we determined that the extraction was impossible due to its poor movability. Since abscess formation was absent at the perforated site, the operation was performed only to remove the foreign body. After mobilized the left lobe of the thyroid, we performed transcervical esophagotomy at the left side of the cervical esophagus which was contralateral to the perforated site to remove the fish bone. After the removal of the fish bone, the incision was immediately sutured and a drain was placed close to there. The removed fish bone was a jaw's bone of sea bream. After the operation, the patient was given cefazolin sodium for 7 days, and started to drink on the 6^th and to have meals on the 7^th postoperative day. The drain was removed on the 8^th day and she was discharged from the hospital on the 10^th day after the operation without complications.

View full abstract

A 72-year-old woman presented with far advanced esophageal cancer with a total of four lymph nodes metastases at the abdomen and the left supraclavicular fossa. The main lesion was resectable. We decided to perform an esophagectomy without superior mediastinal and cervical lymphadenectomy to avoid excessive invasive operation and to employ postoperative chemoradiation therapy (CRT) to the region left undissected superior mediastinal metastases. In June 2006, we performed subtotal esophagectomy by right thoracotomy and laparotomy and 2-field lymph node dissection. The histopathological diagnosis was type 4 cancer of the lower thoracic esophagus, pT3, pN2 (No3, No9), pStage IVa. After the operation, she removed a jejunostomy tube by herself, for that reoperation was required and CRT could not be started, with resultant enlargement of the 104L metastasis. The patient strongly desired to receive CRT which could be done on an outpatient basis, so that we selected such a palliative therapy as gave Linac X irradiation to the 104L metastasis at a dose of 50 Gy and oral medication of TS-1 alone for 5 years. As a result, the 104L metastasis almost disappeared, and a complete response (CR) has been kept for 8 years without recurrence and metastasis.

View full abstract

A 59-year-old man who underwent hypopharyngolaryngectomy, esophagectomy, and gastric tube reconstruction for hypopharyngeal carcinoma (well differentiated squamous cell carcinoma) in 2005 developed vomiting and abdominal pain from October 2006. He was admitted to our hospital with a diagnosis of adhesive intestinal obstruction. Conservative therapy was unsuccessful and an emergency operation was performed. Three tumorous lesions were found in the ileum, and partial small bowel resection was performed with the diagnosis of intestinal obstruction caused by these small bowel tumors. Histopathology revealed squamous cell carcinoma. Intestinal obstruction due to small bowel metastasis from hypopharyngeal carcinoma was thus diagnosed. As we have experienced a case of metastatic small bowel tumors originated from hypopharyngeal carcinoma which is extremely rare, this case is presented here, with a review of the literature.

View full abstract

A 83-year-old man who underwent endoscopic hemostasis for bleeding from a gastric submucosal tumor one year earlier was admitted to the hospital for abdominal pain after meal. Abdominal CT scan showed a gastric tumor prolapsing into the duodenum and gastrectasis. Emergency surgery was performed with a suspicion of a gastric submucosal tumor presented with ball valve syndrome (BVS). Operative findings showed the tumor to be prolapsing and impacting into the duodenum and the gallbladder to have necrotized partially, from where bile leaked. We reduced the tumor into the stomach and performed a partial gastrectomy and a cholecystectomy. The tumor was a gastric submucosal tumor 4 cm in diameter and histological findings showed a low risk gastrointestinal stromal tumor (GIST) which revealed c-kit(+) and CD34(+). The gallbladder necrotized partially, but there were not perforation and gallstones. This case of GIST of the stomach presented with BVS with biliary peritonitis, which is rare, is reported with a review of the literature.

View full abstract

A 62-year-old man who had been followed for a gastric submucosal tumor for these six years at a neighboring hospital was referred to our hospital because the tumor showed an increasing tendency. We confirmed a 25-mm submucosal tumor showing an intratubal growth at the anterior wall of the fornix of stomach (oral tumor) and, on the anal side of the tumor, another 15-mm submucosal tumor showing an extratubal growth (anal tumor). These two tumors were about 4 cm distant away. We resected the entire layers including the oral tumor by oral endoscopic procedures after suturing sero-muscular layers, and performed laparoscopic full thickness resection for the anal tumor after dissecting sero-muscular layer. As for the oral tumor, after dissecting the submucosal layer by ESD procedures, the dissected sero-mucosal layer was sutured by laparoscopic procedures, and the entire layers including the oral tumor was resected by oral endoscopic procedures. As for the anal tumor, the serosa and muscle layer surrounding the anal tumor was incised whole-circumferentially, and the tumor was fully pulled to the abdominal cavity side and was resected by linear stapler. We present our attempt to minimize the resection area and the deformity of the stomach for removal of two gastrointestinal stromal tumors of the gastric fornix which existed with the distance of about 4 cm.

View full abstract

A 37-year-old female visited our hospital complaining of dizziness. She was considered having chronic anemia (the Hb level of 4.4g/dl), and was admitted to the hospital for further investigations. Upper gastrointestinal endscopy detected multiple polyps of Yamada's type II with the diameter of several mm in the whole stomach.
Laparoscopy-assisted total gastrectomy was performed with the diagnosis of juvenile gastric polyposis.
Since gastric polyposis has recently been reported to have malignant potential and to be a risk factor of carcinogenesis, surgical removal is required. Distal gastrectomy has sometimes been performed to remove the polyposis only, but we recommend total gastrectomy for prevention of recurrence.
Laparoscopic surgery is useful and preferable to open surgery from a cosmetic viewpoint. However, this type of surgery is difficult, therefore, techniques and devices for maintaining the surgical space during the procedure should be warranted. As few reports have been described in Japan, this case is presented here with a review of the literature.

View full abstract

Squamous cell carcinoma (SCC) of the stomach is a very uncommon disease entity, accounting for approximately 0.1% of all gastric carcinomas. We report a case of 62-year-old man with SCC of the stomach who presented with sub-acute pyrexia and anorexia. A large, protruded tumor with regional lymphadenopathy was detected in the middle to lower third of the stomach. A preoperative endoscopic tumor biopsy suggested a histological diagnosis of poorly differentiated adenocarcinoma. A semi-urgent total gastrectomy was performed with curative intent. Histological examination of the resected specimen revealed SCC without any coexisting adenocarcinoma components. The patient received postoperative adjuvant chemotherapy with S-1 but died of aggressive tumor recurrence in the lymph nodes 9 months after the surgery. The clinical features, pathogenesis, and treatment of SCC of the stomach are discussed based on a literature review.

View full abstract

The patient was 72-year-old man. He underwent laparotomy total gastrectomy for advanced cancer in the gastric body, with pancreatic body and tail and spleen resection. The pathological diagnosis was primary gastric neuroendocrine cancer. Adjuvant chemotherapy with S-1 was administered in the first postoperative year. A solitary lung metastasis was detected one and a half year after surgery, and thoracoscopy-assisted partial resection of the right lung was performed. The pathological findings were similar to those of the gastric cancer. Accordingly, the lung lesion was diagnosed as lung metastasis from gastric cancer. The patient was kept under observation with no treatment, but has been recurrence free for five years after the first surgery.
Although lung metastasis from gastric cancer is generally a poor prognostic factor, long-term survival could be achieved with resection in the case of a solitary lung metastasis, as in the present case. The primary gastric neuroendocrine tumor was easy to detect in the lymph node metastasis and liver metastasis based on the pathological features, so recurrence-free survival after lung metastasis resection, as in the present case, seems unusual.

View full abstract

A 72-year-old man who had undergone distal gastrectomy and Billroth-I reconstruction for early gastric cancer at 58 years old was judged to require further examination in a gastric cancer screening. Upper gastrointestinal endoscopy performed at our hospital showed an elevated lesion at the esophagogastric junction, a 0-IIa lesion on the proximal side of the gastroduodenostomy site, and ulcerative scarring in the posterior wall of the cardiac greater curvature. Biopsy results were por2, tub1, and no malignant findings, respectively. Simultaneous carcinomas in the gastric remnant were diagnosed, and total resection of the gastric remnant and Roux-en-Y reconstruction were performed. Immunohistochemical staining showed that the elevated lesion at the esophagogastric junction was positive for synaptophysin and CD56, with Ki-67 at 48%, and 9 mitotic figures per 10 high power fields, and based on these findings, neuroendocrine carcinoma was diagnosed. Neuroendocrine carcinoma occurring simultaneously with differentiated tubular adenocarcinoma in the gastric remnant and detected in the early stage of cancer is very rare. Along with a discussion of the literature, we report on our experience with this case in which preoperative diagnosis was difficult, and in which the small number of accumulated cases made it difficult to decide the treatment strategy.

View full abstract

We report a case of a 78-year-old female who was diagnosed with gastric carcinoma with difficulty in staging diagnosis. She was referred to our hospital because a IIa+IIc lesion was found on the lesser curvature of the angular notch on endoscopy at a medical checkup. An abdominal CT scan showed paraaortic lymph nodes swelling, and she was suspected to have Stage IV gastric carcinoma. However, no regional lymph node swelling was found and an endoscopic examination revealed a IIa+IIc lesion suggestive of sm invasion. PET examination was thus performed to discriminate the staging diagnosis. FDG-PET showed FDG uptakes around the aorta and bilateral hilar lesions. Accordingly we strongly suspected those lymph nodes swelling to be resulted from sarcoidosis or malignant lymphoma we performed distal gastrectomy with B-I reconstruction, D2 lymph nodes dissection and simply biopsy of paraaortic lymph nodes. The pathological diagnosis was moderately differentiated tubular adenocarcinoma, pT1b, ly0, v0, pN0, M0, Stage IA. In the dissected regional and paraaortic lymph nodes, granuloma was found due to sarcoidosis without metastasis of adenocarcinoma.
When nonspecific and multi lesional lymph nodes swelling are found with a malignant disease, careful diagnosis for staging and adequate decision for treatment would be necessary by keeping a possible association of general disease including sarcoidosis in mind.

View full abstract

A 38-year-old man was brought to our hospital owing to lower abdominal pain. He was diagnosed as having right paraduodenal hernia with intestinal malrotation based on contrast-enhanced computed tomography findings, for which he underwent an emergency operation. The ligament of Treitz was not present, and the fusion of the right mesocolon was incomplete. The small bowel was strangulated both inside and outside the hernial sac, and most part of the small bowel was ischemic. There was a risk of short bowel syndrome if the ischemic bowel would have been resected ; therefore, we decided to close the abdomen without resecting the bowel and follow the patient's course carefully ; if intestinal necrosis was suspected during the postoperative course, the necrotic part would be resected in a second operation. The postoperative course was good, and the patient was discharged without the need for a second operation. The characteristic anatomy of a right paraduodenal hernia with intestinal malrotation causes the coexistence of normal and ischemic bowel both inside and outside the hernial sac. This feature is reflected in contrast-enhanced computed tomography findings and is useful in diagnosis.

View full abstract

The patient in our case was a 64-year-old woman who underwent medical examination in our outpatient clinic. She chiefly complained of upper abdominal pain and fever. On questioning her and recording her clinical history, we found that she had swallowed needles in an attempt to commit suicide approximately 1 month previously. Abdominal contrast-enhanced computed tomography (CT) detected 2 needle-like foreign bodies (each 5 cm long) in the abdomen. One of them penetrated the portal vein and crossed the duodenal bulb ; this penetration was accompanied by a thrombus in the portal vein. The other needle was found near the ascending colon in the abdomen. We urgently performed upper gastrointestinal endoscope operation and evulsed the needles in the portal vein on the same day. At a later date, we laparoscopically removed any residual needle in the abdomen. Thereafter, we conducted a surgery under fluoroscopic guidance and confirmed the absence of any residual needle in the abdomen. We could not identify any apparent perforated site. The patient's condition steadily improved after the surgery. She was administered warfarin for the treatment of the thrombus in the portal vein. We encountered a case of a patient who had attempted suicide by swallowing needles that penetrated the abdomen and portal vein. We could safely remove the needles endoscopically and laparoscopically. We report here, with bibliographic consideration, the first case in Japan of a patient who swallowed needles that penetrated the portal vein.

View full abstract

A 76-year-old female was admitted to our hospital with a history of easy fatigability and fever. Laboratory tests showed pancytopenia. In the initial course of hospitalization, the patient was diagnosed as having myelodysplastic syndrome and infections however, treatments proved ineffective with the patient gradually developing loss of consciousness and slipping into circulatory shock. The symptoms improved initially after steroid pulse therapy administered considering the possibility of a vasculitis syndrome, however, the symptoms worsened thereafter, with the appearance of the abdominal pain. Abdominal CT revealed free air and an increase of the ascites volume, and an emergency operation was performed under the tentative diagnosis of gastrointestinal perforation. The operative findings revealed intestinal gangrene and histopathological examination of the resected specimen revealed the diagnosis of intravascular lymphoma (IVL). The patient was admitted to the intensive care unit after surgery, and showed marked improvement of the clinical condition with chemotherapy for the IVL.

View full abstract

A 49-year-old man with a 10-year history of Crohn's disease presented with abdominal pain after meals. Computed tomographic examination showed almost complete obstruction of the ileocecum by a large intraluminal mass. Colonofiberscopy findings showed a mass consisting of numerous filiform polyps, and subsequently, a laparoscopy-assisted right colectomy was performed. Filiform polyps were located from the cecum to the transverse colon, and were not present in the ileum of the resected specimen. Histological findings of the mass confirmed the clinical diagnosis of localized giant inflammatory polyposis, consisting of regenerated epithelium and inflammatory stroma with lymphoid hyperplasia. Epithelioid granulomas including multinucleated giant cells were seen. There was no evidence of dysplasia or malignancy. Giant inflammatory polyposis may be associated with Crohn's disease, but is a rare cause of colonic obstruction, while intestinal obstruction in Crohn's disease is one of the common complications, requiring surgery, usually shows ulceration and constriction with fibrosis.

View full abstract

We report a 31-year-old woman who had been treated with oral administration for Crohn's disease and was admitted to our hospital due to lower abdominal pain. She exhibited extreme tenderness in the right lower flank with a high fever of 40.4°C, but no peritoneal signs. Abdominal computed tomography revealed free air adjacent to the ileocecum, several collections of gas in the peripheral branches of hepatic portal veins, and superior mesenteric venous thrombus. Emergency open laparotomy was performed under a diagnosis of ileal perforation accompanied by exacerbation of Crohn's disease. Since laparotomy disclosed funicular indurations of the ileocolic vein and last branch of the ileal vein, ileocecal resection was performed. Histopathological findings showed perforation of the terminal ileum with a longitudinal ulcer, which is compatible with Crohn's disease. The venous thrombus was formed due to septic thrombophlebitis. Intravenous infusion of heparin was administered continuously right after the operation. Postoperative course was uneventful and the patient was discharged on postoperative day 28. Hepatic portal venous gas used to be well known as a severe complication of ischemic bowel disease, but some cases are complicated with Crohn's disease. In our case, early diagnosis and decision to perform emergency laparotomy enabled the patient to achieve an excellent prognosis.

View full abstract

The sigmoid colon, and rectum are major sites of endometriosis development, but in contrast, small intestinal endometriosis is rare. We encountered a case of endometriosis of the ileum with endosalpingiosis in the regional lymph node treated surgically because of recurrent bowel obstructive symptoms. A 50-year-old woman presented with recurrent bouts of bowel obstruction, the cause of which could not be determined through multiple evaluations. She was re-hospitalized because of recurrent abdominal distension. Although an abdominal computed tomography revealed a suspected tumorous lesion in the terminal ileum and dilated small bowel, we could not determine the final diagnosis. Exploratory laparotomy was performed for recurrent bowel obstruction. Serosa of the terminal ileum exhibited scarring with induration, resulting in bowel obstruction, and ileocecal resection was performed. Histological examination revealed glandular structures of various sizes comprising cubical and columnar epithelium surrounded by spindle cells from the subserosal to submucosal layers of the ileum. As we observed glandular structures comprising cubical epithelium in the regional lymph node, we diagnosed the case as bowel obstruction caused by endometriosis of the ileum with metastatic involvement of endosalpingiosis in the regional lymph node.

View full abstract

Lynch syndrome is an inherited disease caused by a pathological germ-line mutation in one of the mismatch repair genes, and is characterized by the development of colorectal cancer and endometrial cancer, among others. We report herein two patients with small bowel cancer associated with Lynch syndrome.
Case 1. A 76-year-old man was admitted with small bowel obstruction. He had undergone total colectomy for duplex rectal cancer and triple colon cancer 15 years earlier. Small intestinal endoscopy revealed tumor filling the lumen in the jejunum. The tumor was diagnosed as well differentiated adenocarcinoma by histological examination. Partial resection of the jejunum with regional lymphadenectomy was therefore performed.
Case 2. A 69-year-old woman was admitted to receive surgery for transverse colon cancer in the vicinity of the anastomosis by colonoscopy. She had undergone surgery for ascending colon cancer 20 years earlier. We incidentally detected two tumor lesions in the jejunum and terminal ileum during surgery and also performed partial resection of the small intestine.
Both cases met the criteria of the revised Bethesda guidelines, and the microsatellite instability (MSI) test showed MSI-H, so we clinically diagnosed Lynch syndrome.
We report two cases along with a literature review, because small bowel cancer with Lynch syndrome is considered relatively rare.

View full abstract

A 69-year-old man was referred to our hospital complaining of abdominal pain in the right lower quadrant. An about 3-cm tumor at the distal portion of the ileum detected by computed tomography scan showed an elevated standard uptake value (SUV) of ¹⁸F-fluorodeoxyglucose by positron emission tomography scan. The presence of malignant tumor in the ileum was suspected and the patient was operated on. At surgery, we found a Meckel's diverticulum in the ileum about 40 cm proximal to the ileum end and palpated an elastic-hard tumor in the diverticulum. He underwent segmental resection of the ileum along with the Meckel's diverticulum. The elastic hard tumor found in the diverticulum was diagnosed as adenocarcinoma localized in the submucosal layer histologically. Although this carcinoma was surrounded by both ectopic gastric and pancreatic tissue, it was concluded pathologically to arise from the ectopic gastric mucosa because of its histological continuity and identical immunohistochemical staining pattern with the ectopic gastric mucosa. Since carcinoma in a Meckel's diverticulum has rarely been demonstrated to arise from the ectopic gastric mucosa in the diverticulum by histopathological studies, this case is presented with a review of the literature.

View full abstract

A 73-year-old man visited our department with a chief complaint of abdominal pain. Tenderness and muscular guarding were observed in the right lower quadrant. Abdominal ultrasonography showed target signs in the right lower abdomen, and abdominal contrast-enhanced computed tomography showed intussusception led by the cecum. Emergency surgery was therefore performed. Upon laparotomy, the cecum was seen to have folded into the ascending colon, producing an intussusception. The invagination was released using Hutchinson's maneuver, but impaired blood flow was observed in the intestines, and a tumor lesion was palpable in the cecum, so cecal cancer was suspected and ileocecal resection (D3 dissection) was performed. The resected specimen showed a circular, clearly defined, elevated lesion (diameter, about 3 cm) in the cecum. Pathological examination identified lymphangioma. Lymphangioma is a benign tumor that frequently affects the head and neck or axilla in childhood, and finding this entity in the abdominal cavity is rare. Large intestine intussusception in an adult is also relatively uncommonly caused by a benign tumor, and that caused by lymphangioma is extremely rare. We encountered and report herein on a case of cecal lymphangioma that developed intussusception and for which ileocecal resection was performed.

View full abstract

A 64-year-old man who underwent PET/CT for cancer screening was found to show accumulation of FDG at the appendiceal orifice. Colonoscopy showed a small protrusion at the appendiceal orifice, and a biopsy revealed findings of colitis. A second colonoscopy performed 6 months after the first revealed a reddish, mulberry-like polyp measuring 2 cm in diameter at the appendiceal orifice. The repeat biopsy also showed colitis. A laparoscopy-assisted ileocecal resection was performed. In the resected specimen, the polyp had disappeared, and only a dark red protrusion measuring 2 mm in diameter was found. The histopathological diagnosis was lymphoid hyperplasia at the appendiceal orifice. Lymphoid hyperplasia is common at the end of the ileum. However, solitary nodular lymphoid hyperplasia at the appendiceal orifice increasing or decreasing in size during follow-up is rare.

View full abstract

A 78-year-old woman was diagnosed as having intestinal obstruction due to transverse colon cancer and underwent colectomy at our hospital. The pathological diagnosis was moderately differentiated adenocarcinoma, SE, ly1, v1, N0(0/7), H0, P0, M0, Stage II. The risk of recurrence was high, and postoperative adjuvant chemotherapy with capecitabine was started. The patient was admitted to our hospital because of febrile neutropenia (Grade 2), diarrhea (Grade 3), and stomatitis (Grade 3). Antibacterial drugs with granulocyte-colony stimulating factor improved febrile neutropenia, but the persistent enterocolitis resulted in septic shock. The dihydropyrimidine dehydrogenase (DPD) activity of the peripheral blood mononucleocytes was remarkably low at 11.8 U/mg protein. Low DPD activity was diagnosed.

View full abstract

A 61-year-old man underwent endoscopic examinations because of anemia. Colonoscopy revealed type 0-Ip lesions in the rectum and the right side of the transverse colon. Both lesions were removed via endoscopic resection. Pathologically, the lesion with a depressed area in the transverse colon was diagnosed as a 5-mm-sized tub2 carcinoma in serrated adenoma. The carcinoma, which corresponded to the depressed area, invaded the submucosa (pT1b) and lymphatic vessels. Furthermore, a poorly differentiated solid adenocarcinoma was observed in the submucosal layer. Computed tomography (CT) showed two swollen lymph nodes along the middle colic artery and abdominal aorta. Therefore, additional surgery was required. Histological examination of the resected specimen showed that the transverse colon cancer had spread to the two lymph nodes detected on CT. Postoperative adjuvant chemotherapy was administered, but the patient died of cancer development 2 years and 9 months after additional surgery. We report this rare case of submucosal invasive (T1) colon cancer with skip and distant lymph node metastases.

View full abstract

An 83-year-old woman was admitted to the hospital with vomiting and abdominal pain. Abdominal CT revealed obstruction of the ileum and a dilated jejunum, with ascites. No apparent evidence of small bowel ischemia was detected. Despite the placement of a long gastrointestinal tube for 11 days, no improvement was noted. Therefore, laparoscopic surgery was performed under the diagnosis of strangulated ileus. Adhesion of epiploic appendix of the sigmoid colon was found to be the cause of the ileus. After dissection of the adhesion, the strangulated ileal loops were found to be viable and therefore left unresected. The postoperative period was uneventful and the patient was discharged without any complications on the 11th postoperative day. No recurrence has been observed during the one-year follow-up since.

View full abstract

The patient in our case was a 90-year-old man with a medical history of resection of the lower anterior rectum for the treatment of a rectal carcinoid tumor 24 years previously. The possibility of the presence of right pleural fluid was considered ; however, this possibility was ruled out by his chest radiography results. Computed tomography (CT) showed the presence of a tumor lesion in the S5 region of the liver. However, his chest CT findings were normal. At first, we intended to resect the intrahepatic bile duct tumor, but considering the patient's old age, we performed a partial S5 liver resection. The results of a histological examination led to the diagnosis of a neuroendocrine tumor (NET) ; the disease was later identified as liver metastasis of the rectal carcinoid tumor that was resected 24 years previously. At present, 7 months after the surgery, the patient is still alive without recurrence. In general, rectal carcinoid tumor is thought to be a low-grade tumor. Thus, tumor progression is slow. Therefore, the possibility of recurrence after a long period of time should be considered during treatment of patients with a medical history of a rectal carcinoid tumor.

View full abstract

The case involved a 79-year-old man engaged in agriculture and forestry, who had been pointed out having an 85-mm hemangioma at the lateral segment of the left hepatic lobe when he underwent operation for gastric cancer 16 years earlier. The hemangioma showed no increasing tendency and he had been asymptomatic. This time a branch 3 cm in diameter hit him on the epigastric region during tree felling in a forest, and he began to have a high fever since several days after the injury. Despite administration of antimicrobial agents at a neighboring hospital, the high fever persisted and he was referred to our hospital. From imaging findings, we determined the most part of the hemangioma to have formed an abscess and performed percutaneous transhepatic drainage. Bacterial culture isolated penicillin-resistant E. coli, but clear route of this infection was undetermined. The drainage and other treatments decreased the fever, but the hemangioma structure was left and the abscess cavity did not diminish. Then operation (lateral segmentectomy of the left hepatic lobe) was performed. The resected liver was 155g in weigh and there was a cystic lesion covered with a fibrous capsule in the center, the inside of which was filled with pus. Histopathology demonstrated hemangioma structure and the abscess formation within the legion.
We present a case of abscess formation of a liver hemangioma which is rare, together with some consideration including operative indications.

View full abstract

Case 1 : A 52-year-old man presented with right hypochondriac pain. He was diagnosed with cholecystitis, and treated with antibiotics. After pain resolved, laparoscopic cholecystectomy was performed. During the operation, a reddish-brown nodule was found attached to the gallbladder. Pathologically, the nodule represented liver tissue and was identified as an accessory liver.
Case 2 : A 74-year-old woman visited the local doctor with epigastralgia. She was diagnosed with cholecystitis and choledocholithiasis, and treated with removal of the stone by ERCP and antibiotics. Pain resolved and she was referred to us for laparoscopic cholecystectomy. During the operation, a reddish-brown nodule was found attached to the gallbladder. Pathologically, the nodule represented liver tissue and was identified as an accessory liver.
Accessory liver is a rare variation that has been described in about 100 cases. Generally, this finding has been identified during operations for other diseases, as in our cases. We encountered these 2 cases, and report with some additional considerations.

View full abstract

A 77-year-old man presented to our hospital with the chief complaints of abdominal pain and vomiting. Detailed examination revealed evidence of cholangitis and obstructive jaundice caused by a juxtapapillary diverticulum, and the patient was diagnosed as having Lemmel syndrome. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, however, selective biliary cannulation was difficult because of the presence of two papillary diverticula. The patient improved with conservative treatment, and did not wish to undergo surgical treatment. Approximately 11 months later, recurrence of Lemmel syndrome was confirmed. The patient's condition improved again with the administration of antibiotics, however, he returned again approximately 1 month after discharge with the complaint of abdominal discomfort. Detailed examination revealed multiple stones in the common bile duct. The patient was diagnosed as having acute choledocholithiasis associated with Lemmel syndrome and was hospitalized for surgical treatment. Because papillary dysfunction was suspected, endoscopic sphincterotomy (EST) using the intraoperative rendezvous technique and endoscopic removal of the stones in the common bile duct were performed. The results indicated that EST using the intraoperative rendezvous technique is an effective method that provides good postoperative outcomes in cases of Lemmel syndrome with multiple stones in the common bile duct.

View full abstract

Eosinophilic cholecystitis (EC) is a rare disease that manifests in a similar manner to acute cholecystitis. We report the case of a 41-year-old man with a history of bronchial asthma (BA) and eosinophilic sinusitis (ES) who presented with epigastralgia. Enhanced computed tomography and ultrasonography findings suggested acute cholecystitis, and cholecystectomy was performed. However, epigastralgia persisted. Upper gastrointestinal endoscopy was performed to investigate the cause of epigastralgia, and revealed ulcers in the stomach and duodenum. In addition, laboratory test results revealed abnormally high levels of eosinophils. The patient was diagnosed with eosinophilic gastritis and cholecystitis and was treated with steroids and anti-ulcer drugs, which improved the epigastralgia. Although EC is a rare, it must be considered in patients with BA and ES who present with epigastralgia.

View full abstract

A 61-year-old man visited a local clinic for abdominal pain and was diagnosed with cholelithiasis. Detailed preoperative examination showed early colon cancer at the hepatic curvature of the transverse colon, but endoscopic resection was considered difficult, so he was referred for surgery. He underwent laparoscopic right hemicolectomy and cholecystectomy. During surgery, a mass was observed in the cystic duct, which was excised so as to include the tumor. The resected specimen showed a yellow, semipedunculated tumor measuring 14×10 mm in the cystic duct. On histopathological examination, tumor cells showed circular-to-oval nuclei and eosinophilic granular reticulum, and grew in alveolar, trabecular, or ribbon-like shapes. Immunostaining showed positive findings for synaptophysin and chromogranin A, and negative results for CD56. Ki-67 index was 3-4%. Cystic duct carcinoid was diagnosed. The tumor did not show any mitotic figures or vascular or perineural invasion, but did show invasion into the fibromuscular layer. As of 4 years and 6 months postoperatively, no recurrences have been encountered.

View full abstract

A 70-year-old man was referred to our hospital with jaundice. Contrast-enhanced computed tomography revealed a mass lesion in the bile duct. The patient was diagnosed with bile duct cancer, and subtotal stomach-preserving pancreatoduodenectomy combined with D2 lymph node dissection was performed. The pathological and immunohistochemical diagnosis was small cell carcinoma with adenocarcinoma (Bd, 2.3×1.5 cm, flat-infiltrating type, ss, INFγ, ly1, v1, pHinf0, pGinf0, pPanc0, pDu0, pPV0, pA0, pHM0, pDM0, pEM0 T2, N0, H0, P0, M0 Stage IB). The patient is alive without recurrent disease 16 months after the operation, without any adjuvant chemotherapy. Small cell carcinoma of the bile duct is an extremely rare neoplasm. The treatment strategy for this disease has not yet been established, but curative surgery plays an important role.

View full abstract

A woman in her forties sustained abdominal injuries in a traffic accident, and was admitted to our hospital. Abdominal CT showed concomitant pancreatic head injury and rupture of the duodenal bulb with intra-abdominal bleeding. An emergent operation was planned and laparotomy showed complete rupture of the head of the pancreas at the right verge of the portal vein and transection of the duodenal bulb accompanied by bleeding at the root of the gastrocolic trunk. Damage control surgery was performed at first, and pancreato-jejunostomy, diverticulization, and gastro-jejunostomy were conducted 6 days later.
Although appropriate choice of surgery for pancreatic injuries is still controversial, preservation of pancreatic function should be considered to the fullest extent possible. Primary damage control surgery could provide safe secondary reconstruction.

View full abstract

Pancreatic ductal carcinoma of the usual type often invades the portal vein, but rarely causes portal vein tumor thrombus. We here present a case of pancreatic invasive ductal adenocarcinoma with portal vein tumor thrombus.
A 72-year-old man presented with fever and vomiting was found having an impacted pancreatic stone in the main pancreatic duct and dilatation of the caudal pancreatic duct on CT. Endoscopic retrograde cholangiopancreatography (ERCP) revealed stricture of the main pancreatic duct and the lower bile duct. Contrast-enhanced CT scan and endoscopic ultrasonography (EUS), however, showed no tumor shadow at the pancreas head. Histopathology also revealed no malignant findings. We decided to follow the clinical course of the patient with a diagnosis of stricture due to chronic cholangitis. Two months later the patient developed obstructive cholangitis and close exploration using CT and EUS showed a tumor shadow in the portal vein. Although no pathological definite diagnosis could be achieved, we confirmed and abnormal uptake of FDG to the pancreatic head on FDG-PET CT as well as decreased diffusion on MRI. Pancreaticoduodenectomy and associated resection of the portal vein were performed. The histopathological diagnosis was well differentiated adenocarcinoma widely extending in the pancreas parenchyma. Invasion into the wall of portal vein was noted and the tumor in the portal vein was clarified to be tumor thrombus.

View full abstract

A 68-year-old man presented with lower abdominal pain and fever was referred to our hospital. Abdominal computed tomography scan showed a mass suggestive of a urachal abscess, which continued from the navel to the bladder. Further examination revealed a fistula between the urachal cyst and the small intestine. He was therefore diagnosed as having an infected urachal cyst infiltrating to the ileum, and underwent operation. Surgical findings showed the urachal abscess firmly adhered to the small intestine 90 cm from the ileum end, which appeared to be the fistula. En bloc resection of the umbilicus, the infected urachal cyst and the ileum by approximately 15 cm in length was performed. The pathological findings were consistent with urachal abscess rupturing to the perineal cavity causing adhesion to the adjacent small intestine, and forming an entero-urachal fistula. The postoperative course was good and the patient was discharged 15 days after the surgery. This report describes a very rare case of a urachal abscess which penetrated to the small intestine, with a review of the literature.

View full abstract

A 54-year-old man who underwent distal gastrectomy for early gastric cancer in February 2007 developed a right adrenal tumor about six months later and underwent extirpation of the tumor in October of the year. The histopathological diagnosis was malignant pheochromocytoma. The patient was discharged from the hospital on the 12^th postoperative day, but developed allolalia on the 10^th day after discharge. Multiple brain metastases were diagnosed. Thereafter metastases to the lung and the ischiorectal fossa appeared. We performed surgical resection and irradiation as local therapies, and, as the general therapy, combined chemotherapy with cyclophosphamide, vincristine, and dacarbazine for about two years. However, he died of aggravation of the multiple brain metastases in October 2010.
The prognosis of pheochromocytoma is often determined by endocrine symptoms due to excessive catecholamine secreted from the metastatic lesions. This paper deals with a case of a patient who was diagnosed with nonfunctioning malignant pheochromocytoma in whom distant metastases of the tumor, especially those to the brain, carried a fatal course that is extremely rare.

View full abstract

A 32-year-old man visited our department as an outpatient with a 2-day history of right lower abdominal pain. Physical findings showed pain on pressure and rebound tenderness localized to the right lower abdomen from the right flank region. Abdominal computed tomography showed an elevated area of adipose tissue that was intraperitoneally localized from the right flank just below the navel. Since the patient had no history of trauma of findings of torsion, idiopathic segmental infarction of the greater omentum was diagnosed. After admission, the patient was fasted and treated conservatively with antibiotics, but showed no improvement in symptoms. On hospital day 3, he underwent laparoscopic omentectomy. In surgical findings, part of the right greater omentum was discolored dark red, and edema was observed, with adhesion to the abdominal wall. Postoperative course was favorable, and he was discharged on postoperative day 3. Idiopathic segmental infarction of the greater omentum is a rare disease that presents with acute abdominal symptoms, and is often difficult to distinguish clinically from acute appendicitis. In many previous cases, this pathology was first diagnosed on surgery, but imaging has enabled preoperative diagnosis. We encountered and report herein a case of idiopathic segmental infarction of the greater omentum that was diagnosed preoperatively on CT and treated using laparoscopic surgery.

View full abstract

A 66-year-old man underwent examination because of the chief complaint of a swelling in his right inguinal region (groin). The examination revealed swelling in the groin on both the right and left sides indicating a diagnosis of bilateral inguinal hernia. As requested by the patient, we performed laparoscopic inguinal hernia repair (the transabdominal preperitoneal approach method), on the right side only. One month thereafter, the patient requested surgery for hernia the left side that was performed by an anterior approach. About one month following that surgery, he returned complaining of swelling and pain in the region extending from the right lower abdomen to the groin. Careful examination indicated a diagnosis of mesh infection following surgery for right inguinal hernia. Although transcutaneous drainage was performed, the elsion had not healed. Therefore, surgical removal of the mesh was carried out, following an anterior approach, using concurrent laparoscopy. As there have been very few reports on mesh infection following laparoscopic inguinal hernia repair, its treatment was difficult.

View full abstract

We present a case of interparietal hernia, a rare subtype of inguinal hernia, diagnosed and repaired laparoscopically.
A 65-year-old man complaining of nausea and vomiting was admitted to our hospital with a diagnosis of intestinal obstruction. Computed tomography (CT) scan showed a dilated small intestine presented to the inside of the inferior epigastric vessels and compressed the testicular vessels and umbilical artery dorsalward. Operation was performed on suspicion of internal hernia or strangulated ileus due to an abnormal band.
On laparoscopy, bloody ascites and redness of the small intestine were observed. Incarceration had been released. A hernia sac was recognized on the inner back side of the internal inguinal ring, and incarceration of the small intestine to the space was diagnosed. Dissection of the preperitoneal space disclosed the hernia sac situating between the transverse fascia and peritoneum. From these findings, interparietal hernia was diagnosed. The hernia sac was resected, and the hernia was repaired with mesh in the preperitoneal space by transabdominal preperitoneal repair method.

View full abstract