High-Output Stoma Leading to the Diagnosis of Antiphospholipid Syndrome.

Diverting stoma (DS) is widely created in colorectal surgery. High-output stoma (HOS) is a major complication of DS, which can lead to dehydration and thrombosis. Additionally, antiphospholipid syndrome (APS) is a risk factor for thrombosis, and it rarely occurs in men. Herein, we describe a case of multiple thromboses caused by chronic dehydration after HOS. A 48-year-old man visited our hospital with fever and lower abdominal pain; he was diagnosed with sigmoid diverticulitis. He underwent laparoscopic high anterior resection for relapsing diverticulitis and diverting ileostomy during the same operation. On postoperative day 1, an output of 3,000 mL/day was observed from the ileostomy. The stoma output exceeded 2,000 mL/day, which was diagnosed as HOS, and chronic dehydration persisted despite supplementation and restriction of oral water intake. Three months postoperatively, a computed tomography scan before ileostomy closure showed multiple thrombi in the inferior vena cava, right common iliac vein, and pulmonary artery. After antithrombotic therapy, ileostomy closure was performed. As lupus anticoagulant was positive twice and APS was diagnosed, antithrombotic therapy was changed from warfarin to direct oral anticoagulants. Thrombosis did not recur 6 months postoperatively. This is the first report of a case wherein APS was present in the background of thrombosis caused by HOS or chronic dehydration. It is important to be cautious about APS when there is thrombosis after HOS to select appropriate therapeutic agents.

Clinical indicators for the incidence of postoperative ileus after elective surgery for colorectal cancer.

BACKGROUND: The occurrence of postoperative ileus leads to increased patient morbidity, longer hospitalization, and higher healthcare costs. No clear policy on postoperative ileus prevention exists. Therefore, we aim to evaluate the clinical factors involved in the development of postoperative ileus after elective surgery for colorectal cancer. METHODS: We retrospectively analyzed patients who underwent elective surgery involving bowel resection with or without re-anastomosis for colon cancer between April 2015 and March 2020. The primary readout was the presence or absence of postoperative ileus. Univariate and multivariate analyses were used to identify pre- and intraoperative risk factors, and the incidence of postoperative ileus was assessed using independent factors. RESULTS: Postoperative ileus occurred in 48 out of 356 patients (13.5%). In multivariate analysis, male sex poor performance status, and intraoperative in-out balance per body weight were independently associated with postoperative ileus development. The incidence of postoperative ileus was 2.5% in the cases with no independent factors; however, it increased to 36.1% when two factors were observed and 75.0% when three factors were matched. CONCLUSIONS: We discovered that male gender, poor performance status, and intraoperative in-out balance per body weight were associated with the development of postoperative ileus. Of these, intraoperative in-out balance per body weight is a controllable factor. Hence it is important to control the intraoperative in-out balance to lower the risk for postoperative ileus.

Mixed neuroendocrine-non-neuroendocrine neoplasms of ascending colon: A case report.

INTRODUCTION: Neuroendocrine tumor (NET) that develops in the right-sided colon is relatively rare. Coexistence of adenocarcinoma and NET is extremely rare, and such cases are called mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN). PRESENTATION OF CASE: Colonoscopy in an 85-year-old woman for an anemia examination indicated laterally spreading tumor-nongranular (LST-NG) in the transverse colon. Colonoscopy and endoscopic ultrasonography (EUS) showed that the depth of the tumor invasion was deep submucosal. The tumor localization was diagnosed as transverse colon close to the hepatic curvature by enema. Computed tomography (CT) showed no obvious lymph node or distant metastasis. Based on these findings, laparoscopic transverse colectomy with D2 lymphadenectomy was performed. Pathologically, most of the tumor was well-differentiated tubular adenocarcinoma, but some solid follicles of polygonal tumor cells with poor nuclear atypia were observed. Immunostaining was positive for synaptophysin and diagnosed as NET G1. This tumor consisted of adenocarcinoma and neuroendocrine tumor, so we diagnosed it as MiNEN and classified the tumor as fT1N0M0 fStage I (TNM Classification of Malignant Tumors, 8th Edition). Since it was an early stage cancer, postoperative adjuvant therapy was not performed. No recurrence has yet been noted. DISCUSSION: Although MiNEN is extremely rare, the detailed pathological specimen observation and diagnosis are important because long-term follow-up after surgery is needed, as is the adequate selection of postoperative adjuvant therapy. CONCLUSION: It is important to elucidate the mechanisms involved in the coexistence of NET and adenocarcinoma and to apply these findings to future medical care.

Large hydrocele of the canal of Nuck diagnosed and treated using conventional and laparoscopic methods.

A 49-year-old woman presented to the hospital with a right inguinal swelling. On examination, we suspected hydrocele of the canal of Nuck (HCN) or an appendiceal or retroperitoneal tumor. Surgery for diagnosis and removal of the mass revealed that it was large and located in the preperitoneal cavity, extending into the inguinal ring; so, it was difficult to observe the entire outline of the mass solely using the laparoscopic approach. Therefore, we added the conventional approach with an inguinal incision. This combination of conventional and laparoscopic approaches helped in safe removal of the tumor. The HCN is an unusual developmental condition in women among whom it might cause an inguinal swelling infrequently. In a case with a large HCN, a combined approach using conventional and laparoscopic methods is suggested for better observation of the abdomen and successful resection without perforation of the mass than when using a single approach.

Multiple peritoneal dissemination of T2 colorectal cancer without lymph node metastases: a case report.

Most cases of peritoneal dissemination of colorectal cancers are from T3 or T4 tumors. A 61-year-old woman was admitted for examination of a positive fecal occult blood test. Colonoscopy showed an ascending colon tumor that was diagnosed as an adenocarcinoma with massive submucosal invasion. Imaging modality revealed numerous nodules throughout the abdominal cavity. Peritoneal dissemination of the ascending colon or ovarian cancer and pseudomyxoma peritonei were considered in the preoperative differential diagnoses, and laparoscopic ileocecal resection was performed. Intraperitoneal observation revealed numerous white nodules in the peritoneum, omentum and Douglas fossa. Both the nodules and tumor were diagnosed as mucinous carcinoma based on a pathology report. The tumor invasion depth was limited to muscularis propria, and no regional lymph node metastasis was detected. Peritoneal dissemination of the ascending colon cancer was considered. We report a rare case of multiple peritoneal dissemination of T2 colorectal cancer without lymph node metastases.

Inguinal bladder hernia treated using transabdominal preperitoneal approach: A case report.

INTRODUCTION: Inguinal bladder hernia (IBH) is a rare condition that is difficult to diagnose preoperatively based only on physical examination; 16% of IBHs are diagnosed postoperatively due to complications. PRESENTATION OF CASE: We report the case of a 56-year-old man who presented with left inguinal swelling and increased frequency of urination since eight years. Physical examination demonstrated a 6 × 4 cm non-reducible left inguinal bulge with mild tenderness on palpation. Computed tomography revealed a left inguinal hernia containing a portion of the urinary bladder. He was diagnosed with IBH and transabdominal preperitoneal (TAPP) repair was performed. We confirmed a left internal inguinal hernia and incised the peritoneum from the outside of the left inguinal ring. The preperitoneal space was dissected toward the Retzius space, and the prolapsed bladder was examined. The adhesion with the surroundings was carefully dissected and the bladder was reduced into the abdomen. Indigo carmine was injected through a urinary catheter, which confirmed that no bladder damage had occurred. After the mesh was positioned to cover the myopectineal orifice, it was fixed to the Cooper's ligaments, interior side, lateral side, and ventral side. The postoperative course was uneventful, and the patient is now free of symptoms and recurrence two months after surgery. CONCLUSION: TAPP repair is a useful treatment for IBH. Preoperative diagnosis of IBH is important to lessen postoperative complications.

Rectal Arteriovenous Malformation Treated by Transcatheter Arterial Embolization.

An 86-year-old man who presented with frequent hematochezia with mild anemia on blood tests was admitted to our hospital. Colonoscopy exhibited a submucosal tumor-like lesion in the lower rectum. CT and MRI showed blood flow into the lesion, but not tumor component. Angiography of the superior rectal artery and left internal iliac artery showed vascular hyperplasia and nidus. Thus, rectal arteriovenous malformation was diagnosed. If bleeding from arteriovenous malformation was out of control, surgical resection was necessary. However, due to the age of the patient, we performed transcatheter arterial embolization and abdominoperineal resection was not needed. Embolization from the left superior rectal artery, middle rectal artery and inferior rectal artery was performed to control the bleeding and to avoid surgery. After embolization, he was followed up for 10 months in our hospital without recurrence.

A Rare Case of Pylephlebitis as a Complication of Cholecystocolonic Fistula.

Pylephlebitis is defined as a septic thrombophlebitis of the portal vein and its tributaries that is associated with multiple suppurative abdominal infections. We report a case of pylephlebitis associated with a cholecystocolonic fistula (CCF). A 41-year-old man presented with upper abdominal pain and anorexia for 1 month. Abdominal contrast-enhanced computed tomography (CT) revealed thrombosis in the left and anterior branch of the portal vein and thickening of the walls of the portal vein and periside portals. The gallbladder was collapsed and pneumobilia was seen in the biliary tract. Blood culture was positive for Streptococcus anginosus. A diagnosis of thrombophlebitis of the portal vein associated with CCF was made, and the patient was immediately managed with an intravenous broad-spectrum antibiotic and anticoagulation. After the portal vein thrombosis (PVT) propagation and inflammation had subsided, cholecystectomy and partial resection of the transverse colon were performed. Pylephlebitis is rare but is a life-threatening complication of intra-abdominal infection. A high index of suspicion is required, and a CT scan should be performed immediately for an early diagnosis and appropriate treatment.

Acute diffuse peritonitis due to spontaneous rupture of a primary gastrointestinal stromal tumor of the jejunum: A case report.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Overt peritonitis caused by GIST rupture is very uncommon. Three types of GIST rupture have been described: closed perforation due to abscess (abscess type), hemoperitoneum leading to rupture of the hematoma capsule in the tumor (hemoperitoneum type), and perforation of the digestive tract via a fistula leading to central necrosis of the tumor (bowel perforation type). This report describes a patient with spontaneous tumor rupture and diffuse peritonitis, a variant of the bowel perforation type of GIST rupture. PRESENTATION OF CASE: A 74-year-old man presented with symptoms of vomiting and abdominal pain. Computed tomography (CT) scan revealed an approximately 10×7-cm mass in the pelvis with free air and fluid collection. Emergency laparotomy revealed a tumor in the jejunum, which was ruptured with a hole measuring 5mm in diameter. The tumor and part of the jejunum were resected. Immunohistochemically, the mass was diagnosed as a GIST originating from the gastrointestinal tract. Despite chemotherapy with imatinib mesylate, the patient died 22 months after surgery. CONCLUSIONS: This report describes a patient with acute diffuse peritonitis due to spontaneous rupture of a primary GIST of the jejunum.

A colovesical fistula with a persistent descending mesocolon due to partial situs inversus: A case report.

INTRODUCTION: Situs inversus viscerum, a congenital condition in which the visceral organs are a mirror image of their normal physiological positions, could be total or partial. Persistent descending mesocolon (PDM) is a congenital anomaly that is asymptomatic because of its short length. PDM causing intestinal obstruction is a known clinical complication. PRESENTATION OF CASE: A 74-year-old woman presented with pneumaturia and enteruria for two months, and recurrent cystitis for a month. An enhanced computed tomography (CT) showed air in the bladder along with sigmoid colonic diverticula adherent to it, suspecting a fistula. The CT also showed partial situs inversus with the common hepatic artery, and left colic artery arising abnormally from the superior mesenteric artery (SMA). Minimally invasive endoscopic closure using the over-the-scope clipping system was difficult because of thickening and scar tissue due to chronic inflammation from diverticulitis. Thus, a sigmoidectomy was performed to close the fistula. Intraoperatively, we noted an abnormally fixed descending mesocolon. An emergency reoperation was performed on the sixth postoperative day owing to an anastomotic leak. Suture failure was attributed to these congenital abnormalities due to insufficient blood flow from an absent marginal vessel and a high endocolonic pressure by adhesions. Sigmoid colon re-resection and maturation of an ileostomy was performed. The patient had no specific postoperative complications, and the ileostomy was closed after three months. CONCLUSION: We report an extremely rare case of colovesical fistula due to a PDM in a patient having partial situs inversus with abnormal branches originating from the SMA.

A case of pancreatic schwannoma showing increased FDG uptake on PET/CT.

INTRODUCTION: Schwannomas are neoplasms originating from Schwann cells in nerve sheath, but pancreatic schwannomas are rare. PRESENTATION OF CASE: A 59-year-old female incidentally pointed out a 2-cm-sized solid mass in the pancreas head by computed tomography (CT) which was performed for other reasons. Magnetic resonance imaging (MRI) showed a mass with hypointensity on T1-weighted images and a heterogenous hyperintensity on T2-weighted images. Magnetic resonance cholangiopancreatography (MRCP) showed no abnormal findings in the main pancreatic duct. The mass of the pancreas head showed a significantly increased uptake on fluorin-18 fluorodeoxyglucose positron emission tomography CT (FDG-PET/CT). Based on the radiological findings, a malignant potential tumor was preliminarily considered. Subtotal stomach-preserving pancreatoduodenectomy (SSSPD) was performed to make a definite diagnosis. The resected specimen showed a well-encapsulated circumscribed mass, measuring 2.0cm, in the pancreas head. Histopathological examination revealed proliferation of spindle cells showing interlacing and palisading patterns in the tumor. The proliferating cells showed no atypia and few mitoses. Immunohistochemically, the spindle cells were positive for S-100 protein. The Ki67 labeling index was approximately 2%. Based on these findings, a diagnosis of benign schwannoma of the pancreas was made. CONCLUSION: Although pancreatic schwannoma is a rare neoplasm, it is important to take into account this tumor in the differential diagnosis of pancreatic tumors. In addition, we should be aware that FDG-PET/CT shows abnormal accumulation in a benign pancreatic schwannoma.

A mesocolonic lymphangioma in an adult with peritonitis: a case report.

Cystic lymphangiomas of the mesocolon are very rare in adults. They are usually asymptomatic, but can present with an acute abdomen. We report an adult patient with cystic lymphangioma of the mesocolon that manifested with peritonitis. A 33-year-old man presented with fever and severe pain with muscle guarding in the left abdomen. Laboratory data indicated high-grade inflammation. Enhanced computed tomography (CT) showed multiple low-density masses with peripherally enhancing rims, strongly suspicious for cysts, in the left abdomen. Based on a diagnosis of peritonitis, emergency surgery was performed and revealed many cysts in the descending mesocolon. Histopathological examination findings indicated a cystic lymphangioma. The post-operative course was uneventful, and 1-year follow-up CT showed no recurrence. This case demonstrates that cystic lymphangiomas of the mesocolon in adults can present with acute peritonitis, although this is extremely rare. Complete resection is required for accurate diagnosis and for preventing recurrence.

Laparoscopic operation after pre-operative reduction of an intussusception-induced inflammatory fibroid polyp.

Intussusception occurs mainly in children but rarely in adults. About 80-90% of adult cases of intussusception are due to benign or malignant neoplasms as a lead point. One of the causes is an inflammatory fibroid polyp (IFP), a rare, benign entity that occurs more frequently in the stomach than the ileum. We describe an uncommon case of a patient who presented with intussusception-induced IFP of the ileum. A 35-year-old woman presented with a 2-day history of abdominal pain. A computed tomography scan demonstrated ileocolic intussusception. During colonoscopy, reduction by pressured air easily released intussusception, and we suspected a submucosal tumour of the ileum. Successful pre-operative colonoscopic reduction was helpful for performing laparoscopic ileocecal resection 2 days later. Results of the histopathological examination confirmed a large IFP. The patient's post-operative course was uneventful. Pre-operative reduction by colonoscopy is effective for the diagnosis and treatment of intussusception-induced IFP.

Sphincter-saving resection by cluneal arched skin incision for a gastrointestinal stromal tumor (GIST) of the lower rectum: a case report.

BACKGROUND: Planning the surgical strategy for a gastrointestinal stromal tumor (GIST) at the posterior wall of the lower rectum is difficult, as the procedures for the lower rectum are hampered by poor visualization and may cause anal dysfunction or discomfort. We report a novel procedure to resect a submucosal tumor of the rectum. CASE PRESENTATION: A 75-year-old woman presented with metrorrhagia. Endovaginal ultrasonography showed a low echoic tumor. Computed tomography showed an enhanced tumor, measuring 5.3 × 4.2 cm, behind the rectum. Magnetic resonance imaging revealed a submucosal tumor of the rectum, measuring 5.3 cm at its greatest dimension. Colonoscopy showed that the distal tumor margin was 1 cm above the dentate line. Core needle biopsy of the tumor revealed the rectal GIST. After receiving neoadjuvant imatinib treatment, the tumor size decreased to 3.5 cm. During the operation, we approached the rectum and resected the posterior rectal wall, including the 3.5 × 3.5 cm tumor with a safety margin, making an arched incision at the buttocks to form a skin flap with the patient in a jackknife position. The histopathological diagnosis was GIST of the rectum. Her anorectal sphincter function was well preserved. No recurrence was seen during the 2-year follow-up. CONCLUSIONS: This novel approach improves the operative field visibility in resecting a tumor with a safety margin and preserves a patient's anorectal sphincter function.

A mixed adenoneuroendocrine carcinoma of the pancreas: a case report.

A tumor consisting of an adenocarcinoma component and a neuroendocrine carcinoma component, with each component accounting for at least 30% of the tumor, is defined as a mixed adenoneuroendocrine carcinoma (MANEC). We report a case of MANEC of the pancreas. A 63-year-old man presented with hyperglycemia and was referred to our hospital for further examination. Abdominal contrast-enhanced computed tomography (CT) revealed a mass of 2 cm in size in the pancreas head with portal vein narrowing. Fluorin-18 fluorodeoxyglucose-positron emission tomography (FDG-PET) CT revealed increased accumulation in the mass of the pancreas head. Endoscopic retrograde cholangiopancreatography (ERCP) showed severe narrowing of the main pancreatic duct. Cytological analysis by endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) suggested a neuroendocrine tumor. Under the diagnosis of neuroendocrine tumor, pancreaticoduodenectomy with portal vein resection and regional lymph node dissection was performed with curative intent. Histological examination revealed that the tumor consisted of two cell populations. One was well- to moderately differentiated tubular adenocarcinoma. This cell component accounted for 45% of the whole tumor. The second component was non-adenocarcinoma cells arranged in a nest, and the cells had round nuclei, abundant cytoplasm, and coarse chromatin. The Ki67 labeling index was 40%. Immunohistochemically, the adenocarcinoma cells were positive for CEA but negative for chromogranin A (CgA) and synaptophysin (Syn), while the non-adenocarcinoma cells were positive for the expression of CgA and Syn but negative for CEA. Based on the findings, a diagnosis of MANEC of the pancreas was made. Postoperatively, lymph node metastasis and peritoneal dissemination developed rapidly and he died the 6 months after the operation. Due to the small number of reported cases of MANEC of the pancreas, its clinical behavior remains unclear and a standardized management protocol has not been established. Further investigation of more cases of this rare entity is necessary.

A case of the geniculate artery pseudoaneurysm after total knee arthroplasty: search for preventive measures by evaluation of arterial anatomy of cadaver knees.

This article presents an 80-year-old man with pseudoaneurysm of the inferolateral geniculate artery after total knee arthroplasty (TKA). The aim is to report this case and review possible preventive methods of pseudoaneurysm formation after TKA by investigating the relationship between knee arterial anatomy and the TKA procedure. Cadaveric evaluation demonstrates that the superomedial and inferomedial geniculate arteries are difficult to visualize. The anatomical position of the inferolateral artery makes it vulnerable to the surgical procedure during cutting of the tibia or while retracting soft tissue from the tibial edge, especially with minimal invasive surgery. In conclusion, careful subperiosteal release around the geniculate arteries is recommended. However, early recognition of pseudoaneurysm formation is even more essential than prevention.

[Effectiveness of systemic chemotherapy of GEM+CBDCA+5-FU/LV and hepatic arterial infusion of CDDP in a case of advanced, combined hepatocellular-cholangiocarcinoma with multiple lung metastases].

This patient is a male in his 30's. He was diagnosed as hepatitis B virus-related huge primary liver cancer, 10cm in diameter, located in segment 4, accompanied with left portal thrombus and multiple lung metastases. Ten months after repeating systemic chemotherapy using gemcitabine (GEM)+carboplatin (CBDCA)+5-FU/leucovorin (LV) and hepatic arterial infusion chemotherapy with cisplatin (CDDP) 4 times, extended left lobectomy with caudate lobe could be successfully performed because of marked reducion of the huge tumor. The pathology revealed almost entirely necrotic changes of the main tumor, and the remaining, viable tumor nests showed combined hepatocellular and cholangiocarcinoma. Systemic chemotherapy was repeatedly given afterwards, which kept the pulmonary metastases stable without growth. The present case suggests that systemic chemotherapy using GEM+CBDCA+5-FU/LV may be useful in the multimodal treatment for the combined hepatocellular and cholangiocarcinoma with distant metastases.

Ovarian vessel dilatation with ovarian mass on MR images: influence of pelvic venous plexus dilatation.

PURPOSE: We assessed the value of analyzing visualization of the ovarian vessels in relation to the features of ovarian masses using MR images. MATERIALS AND METHODS: 74 patients with 91 masses (61 benign lesions and 30 malignant lesions) were evaluated. Ovarian masses were classified using the following features: 1) benignancy, 2) characterization, and 3) maximum diameter. We assessed the relationship between visualization and the diameter of the ipsilateral ovarian vessels and the features of ovarian masses. In addition, we assessed the relationship between visualization and the diameter of ovarian vessels and pelvic venous plexus (PVP) dilatation. RESULTS: Regardless of tumor laterality, 82% of ovarian vessels were visualized (121/148 vessels) on MR images. There was a significant relationship between the average diameter of ovarian vessels and dilatation of PVP (p<0.001). In patients without dilatation, there was a stronger relationship between ovarian vessel average diameter and benignancy (p=0.007), and the character of ovarian mass (solid versus cystic; p<0.05, mixed versus cystic; p<0.01). CONCLUSION: We confirmed a strong relationship between the diameter of ovarian vessels and dilatation of PVP. If ovarian vessels are dilated in patients without dilatation of PVP, we could suggest the possibility of malignant ovarian tumor.