Torsion of an Accessory Spleen; Diagnosed Preoperatively and Excised Laparoscopically

We report on a case of torsion of an accessory spleen occurring in a 19-year-old female. She was admitted with a three-day history of left-upper quadrant pain that became slowly aggravated. On physical examination, left-side abdominal tenderness was observed, most markedly in the left upper quadrant, but no rebound tenderness was noted. Contrast-enhanced computed tomography (CT) scan showed a non-enhancing mass with a tubular vascular pedicle and normal enhancing spleen in the left upper abdomen. Doppler ultrasound showed no vascular flow within the hypoechoic mass in the left upper abdomen. Torsion of an accessory spleen was suspected, and emergent laparoscopic exploration was performed. Laparoscopic exploration showed a large rounded violet mass with a tw isted vascular pedicle, located anterior to the normal spleen. The mass was excised laparoscopically and then removed through a 2.5 cm extended incision of the left-sided trocar incision. Postoperative recovery was normal and she was discharged on the fifth postoperative day.

Torsion of an Accessory Spleen; Diagnosed Preoperatively and Excised Laparoscopically

We report on a case of torsion of an accessory spleen occurring in a 19-year-old female. She was admitted with a three-day history of left-upper quadrant pain that became slowly aggravated. On physical examination, left-side abdominal tenderness was observed, most markedly in the left upper quadrant, but no rebound tenderness was noted. Contrast-enhanced computed tomography (CT) scan showed a non-enhancing mass with a tubular vascular pedicle and normal enhancing spleen in the left upper abdomen. Doppler ultrasound showed no vascular flow within the hypoechoic mass in the left upper abdomen. Torsion of an accessory spleen was suspected, and emergent laparoscopic exploration was performed. Laparoscopic exploration showed a large rounded violet mass with a tw isted vascular pedicle, located anterior to the normal spleen. The mass was excised laparoscopically and then removed through a 2.5 cm extended incision of the left-sided trocar incision. Postoperative recovery was normal and she was discharged on the fifth postoperative day.

Laparoscopic transabdominal extraperitoneal mesh repair of lumbar hernia / 대한외과학회지

Lumbar hernias are rare posterolateral abdominal wall defects that may be congenital or acquired. There are two types of lumbar hernia, the superior lumbar hernia through Grynfeltt triangle, and the inferior lumbar hernia through Petit triangle. Many techniques have been described for the surgical repair of lumbar hernias including primary repair, local tissue flaps, and conventional mesh repair. But these open techniques require a large skin incision. We report a case of superior lumbar hernia, which was successfully repaired using a laparoscopic approach.

Iatrogenic Gallbladder Perforation during Gastric Endoscopic Mucosal Resection

With the exception of accidental perforation during a laparoscopic Cholecystectomy, An Iatrogenic Gallbladder Perforation Is Quite Rare. Several Cases Have Been Reported As A Complication Of Interventional Or Endoscopic Procedures. Although A Case Of Gallbladder And Stomach Perforation During Gastric Endoscopic Mucosal Resection (Emr) Has Been Reported, We Encountered A Case Of Gallbladder Perforation During Gastric Emr Without Evidence Of A Perforation Of The Stomach, Which Has Not Been Reported In The Literature.

A Rare Ileal Intussusception Caused by a Lipoma of the Ileum

Adult intussusception is a rare disease and it differs from childhood intussusception in its presentation, cause and treatment. Most of the cases have an underlying lesion within the intussusception that requires surgical resection. Making the diagnosis can be delayed because of the nonspecific and chronic symptoms, and many cases are diagnosed during performance of emergency laparotomy for treating the obstructive symptoms. A computed tomography (CT) scan is most useful for making the diagnosis of adult intussusception and is helpful in revealing the underlying lesion, although a barium enema can help to diagnose colonic intussusceptions. Surgical resection remains the recommended treatment for nearly all cases, but there is controversy about whether or not the intussusception should be initially reduced before resection. Gastrointestinal lipomas are rare benign tumors that can occur anywhere along the gut, and the small bowel is the second most common site for gastrointestinal lipomas after the colon. Intussusception of the ileum by a lipoma is very rare. We report here on a case of ileo-ileal intussusception that was caused by a lipoma of the ileum in a 35-year-old man who complained of abdominal pain of one week duration. The diagnosis of an ileo-ileal intussusception caused by a lipoma of the ileum was suspected preoperatively according to the typical CT findings, so we tried to initially reduce the intussusception during laparotomy. But manual reduction was impossible due to the edema of the lesion, and an ileum of some length had to be resected.

Gallbladder Torsion with Accompanying Acute Appendicitis

Gallbladder torsion is a rare clinical entity and it is a difficult condition to diagnose preoperatively. About 500 cases of gallbladder torsion have been reported since 1898, when Wendel first described gallbladder volvulus. This condition most commonly occurs in elderly women and the symptoms of this disease are largely non-specific and they mimic those of acute cholecystitis. Even with the recent advances of radiologic imaging modalities, making a preoperative diagnosis of gallbladder torsion is difficult and most cases are diagnosed at the time of surgery. An early diagnosis and prompt cholecystectomy for this disease are important in order to avoid the complications of gangrene and perforation, and to reduce mortality. A high index of suspicion of gallbladder torsion on the basis of the clinical situation and the specific findings on the radiologic images, usually ultrasonography and computed tomography (CT) scanning, can make the correct preoperative diagnosis possible. Gallbladder torsion is a rare disease, and gallbladder torsion with accompanying acute appendicitis is extremely rare. We report here on a case of gallbladder torsion with accompanying acute appendicitis in an 89-year-old woman and we review the clinical aspects of gallbladder torsion. Unfortunately, the diagnosis of gallbladder torsion was missed in this case, so we retrospectively reviewed and correlated the CT findings with the surgical findings.

A Retroperitoneal Foregut Duplication Cyst: A Case Report

Retroperitoneal foregut duplication cyst is an extremely rare congenital malformation. Pathologically, this lesion contains both gastric mucosa and respiratory type mucosa; radiologically, it is often challenging to differentiate it from the other cystic neoplasms that present a similar appearance. We report here on a case of retroperitoneal foregut duplication cyst that was lined by both gastric and pseudostratified ciliated columnar epithelium, and it was also accompanied by a pancreatic pseudocyst. Initially, it presented with peripancreatic and intrapancreatic cystic masses in an asymptomatic 30-year-old man, and this man has since undergone surgical resection.

Mesenteroaxial Volvulus in the Stomach Associated with Paraesophageal Hernia: Case Report

Gastric volvulus can either present as an acute or chronic symptoms according to the degree of gastric rotation and subsequent obstruction. The diagnosis of gastric volvulus is often difficult and is mainly based on imaging studies. We describe a case of mesenteroaxial gastric volvulus associated with paraesophageal hernia, well demonstrated on upper gastrointestinal (UGI) series and coronal reconstructed CT image.

Outcome of the Liver Resection of the Hepatocellular Carcinoma under Milan Criteria

PURPOSE: Liver resection (LR) has been the treatment of choice for hepatocellular carcinoma (HCC), but resection and survival rates remain low, and recurrence is common in cirrhotic patients. This study was designed to evaluate the outcome after resection of potentially transplantable early HCCs and compare it with that for liver transplantation (LT) as reported in the literature. METHODS: We studied 109 patients with HCC under the Milan criteria who underwent LR at Kyungpook National University Hospital from September 1997 to May 2002. The patients were divided into two groups: group A had a single tumor and group B had two or three tumors. RESULTS: The mean age was 56.1+/-8.1 years and the male-to-female ratio was 4.7: 1. Most of the patients had chronic liver disease due to viral hepatitis, but had preserved hepatic function. Overall survival rates (SR) at 1, 2, 3, and 4 years were 86.7, 69.4, 44.8, and 13.3%, respectively, and the corresponding disease-free survival rates (DFSR) were 74.2, 53.8, 41.6, and 23.7%. SR and DFSR were not significantly different between the two groups, although group B tended to have lower SR and DFSR. At a median follow-up of 25.3 months, 52 patients experienced recurrence, most of whom had intrahepatic recurrence within 2 years after resection. At the time of the diagnosis of recurrence, 34 patients were considered eligible for LT. CONCLUSION: Although most of the patients had preserved hepatic function, LR of early HCC showed low survival rates and high recurrence rates compared with those after LT reported in the literature and in our experiences. Therefore, in the absence of limiting factors, LT may be the better option for surgical treatment of patients with early HCC, even when preserved hepatic function is maintained.

The Effect of Preoperative Transcatheter Arterial Chemoembolization in Hepatocellular Carcinoma (prospective study) / 한국간담췌외과학회지

BACKGROUND/AIMS: The effect of preoperative Transcatheter Arterial Chemoembolization (TACE) in the management of Hepatocellular carcinoma (HCC) has remained controversial and lack of prospective study. To investigate the impact of preoperative TACE, we have performed a prospective study in HCC patients with tumor size below 5 cm. METHODS: From November 1998 through March 2002, 126 patients with HCC who had been referred for surgical resection were prospectively allocated to Group I (preoperative TACE, n=42) and Group II (simple hepatic angiography only, n=38). Patients who were underwent noncurative hepatic resection (n=4) were excluded and the groups with large tumor mass (above 5 cm) with or without TACE (n=64) were excluded from this analysis due to insufficient number. The impact of preoperative TACE on incidence of complication as well as long term overall and disease free survival rate were analyzed. RESULTS: Preoperative demographics and intraoperative data were compatible between two groups. There were no difference in complication rates between two groups. The 3 year survival rate of Group I and Group II were 88.10% and 58.32% respectively. The 3 year disease-free survival rate of Group I and Group II were 40.14% and 34.89% respectively. The 3 year overall rate was significantly high in Group I (p=0.0348), disease-free survival rate did not show difference between two groups (p=0.6132). CONCLUSION: Preoperative TACE can be done safely and showed improved overall survival rate in this prospective study, however fruther prospective study with longer period of follow up will be necessary to prove the effect of preoperative TACE.

Heterotopic Mesenteric Ossification Following Intraabdominal Surgery

Heterotopic mesenteric ossification is a very uncommon disorder that is characterized by new bone formation in the mesentery, which does not normally undergo ossification. A 52-year-old female experienced a small bowel obstruction 12 days after a segmental resection of the small bowel following a trauma. A laparotomy was performed 16 days after the initial operation, and a 2 cm hard mass was detected in the small bowel mesentery, with severe fibrous adhesions around the mass, involving the jejunum, which required resection. Postoperatively, the patient developed an intraabdominal abscess, followed by intestinal fistulation. The patient gradually recovered by conservative management, and left hospital 70 days after the first operation. Microscopic examination of the mass showed well oriented trabeculae of the osseous tissue, osteoid formation, with fine calcification and osteoblastic activity, but there was no formation of mature lamellar bone or clear evidence of the "zone phenomenon" that is classically described in heterotopic ossification. These findings appeared consistent with an early stage of heterotopic ossification. The etiology and pathogenesis are unknown; the heterotopic mesenteric ossification was thought to be associated with the trauma (intraabdominal surgery). The previous literature on heterotopic mesenteric ossification is reviewed, and a new case reported.

Heterotopic Mesenteric Ossification Following Intraabdominal Surgery

Heterotopic mesenteric ossification is a very uncommon disorder that is characterized by new bone formation in the mesentery, which does not normally undergo ossification. A 52-year-old female experienced a small bowel obstruction 12 days after a segmental resection of the small bowel following a trauma. A laparotomy was performed 16 days after the initial operation, and a 2 cm hard mass was detected in the small bowel mesentery, with severe fibrous adhesions around the mass, involving the jejunum, which required resection. Postoperatively, the patient developed an intraabdominal abscess, followed by intestinal fistulation. The patient gradually recovered by conservative management, and left hospital 70 days after the first operation. Microscopic examination of the mass showed well oriented trabeculae of the osseous tissue, osteoid formation, with fine calcification and osteoblastic activity, but there was no formation of mature lamellar bone or clear evidence of the "zone phenomenon" that is classically described in heterotopic ossification. These findings appeared consistent with an early stage of heterotopic ossification. The etiology and pathogenesis are unknown; the heterotopic mesenteric ossification was thought to be associated with the trauma (intraabdominal surgery). The previous literature on heterotopic mesenteric ossification is reviewed, and a new case reported.

Implication of the Accessory Left Hepatic Artery in Curative Surgery for Gastric Cancer

We designed this study to identify the anatomic variations of the accessory left hepatic artery and to identify the influence on the hepatic function when this vessel is sacrificed during a systematic lymphadenectomy for gastric cancer. The surgical records of 100 patients who underwent curative surgery for gastric cancer, including ligation of the left gastric artery at its origin, were reviewed. The liver function was assessed by measuring the serum glutamic oxaloacetic transaminase, the glutamic pyruvic transaminase, and the alkaline phosphatase activities preoperatively and on the seventh postoperative day. The frequency of metastasis in the lymph nodes around the left gastric artery was reviewed. In 44 of the 100 cases, an accessory left hepatic artery was encountered. The accessory left hepatic artery joined with the left hepatic artery before reaching the liver in 21 of 44 cases and ran into the left lobe of the liver without confluence in 23. The diameter of the accessory left hepatic artery was greater than that of the left hepatic artery in only 17% of the cases. Metastasis in the lymph nodes around the left gastric artery was identified in 11 cases. The observed hepatic dysfunctions 7 days after operation were mild and transient, even after sacrifice of the accessory left hepatic artery. There were no postoperative complications related to the decreased liver function in these patients. These data suggest that ligation of the left gastric artery at its origin, irrespective of the presence of an accessory left hepatic artery, is necessary to improve the oncological quality of surgery without significant complication during curative surgery for gastric cancer.