Small Bowel Obstruction Caused by Type IV Hiatal Hernia.

Type IV hiatal hernia of the esophagus is characterized by herniation of the stomach and associated organs, such as the spleen, large and small bowel, and pancreas, through the esophageal hiatus. It is a relatively rare form of hiatal hernia that sometimes requires emergency surgery due to gastric incarceration, volvulus, and strangulation. Of these, small bowel obstruction is extremely rare and requires surgery. We report the case of an 83-year-old woman who was admitted to the hospital for small bowel obstruction caused by an ileum that had incarcerated the esophageal hiatus; emergency laparoscopic surgery was performed.

Adrenalectomy in a Patient With Recurrent Hepatocellular Carcinoma in the Adrenal Gland: A Case Report.

Hepatocellular carcinoma recurrence in the adrenal gland is clinically rare, for which there are no clear criteria for examination or treatment. A 70-year-old man underwent laparoscopic low anterior resection seven years prior and was diagnosed with rectal cancer stage 1 (T2N0). Right hepatic resection for suspected hepatocellular carcinoma in his liver six years and nine months prior was performed. Thereafter, the patient was diagnosed with hepatocellular carcinoma stage 3 (T3N0). During the follow-up period, elevated alpha-fetoprotein levels were detected, indicating hepatocellular carcinoma recurrence. Follow-up computed tomography in the delayed phase detected a heterogeneous 5 cm mass in the left adrenal gland. Therefore, we diagnosed the patient with recurrent hepatocellular carcinoma in the adrenal gland, for which we performed an adrenalectomy with a favorable prognosis.

Methotrexate-associated lymphoproliferative disease detected as a colorectal mass lesions: a case report.

Methotrexate-related lymphoproliferative disorder (MTX-LPD) is a rare but serious complication that occurs in patients treated with methotrexate (MTX); although MTX-LPD has been reported recently, the incidence in the colon is very low. A 79-year-old woman who had been receiving MTX for 15 years came to our hospital complaining of postprandial abdominal pain and nausea. Computed tomography scan showed the dilation of the small bowel and a tumor in the cecum. In addition, numerous nodular lesions were seen in the peritoneum. Ileal-transverse colon bypass surgery was performed for small bowel obstruction. Histopathological findings of both the cecum and the peritoneal nodules revealed the diagnosis of MTX-LPD. We report MTX-LPD occurring in the colon; it is important to consider MTX-LPD when intestinal symptoms occur during MTX therapy.

A Case of Torsion of Meckel's Diverticulum.

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. Histologically, it is a true diverticulum comprising all four layers of the intestinal tract. The complications associated with Meckel's diverticulum include bleeding, bowel obstruction, and intussusception. Torsions are an extremely rare complication. The patient was a 15-year-old boy who presented to the emergency department with acute-onset lower abdominal pain and was admitted to the hospital for a follow-up of abdominal pain due to nonspecific imaging findings. The symptoms of the patient worsened 12 hours after admission, and he underwent emergency laparoscopic surgery. A large Meckel's diverticulum with torsion and necrosis was observed 30 cm proximal to the ileocecal valve. The diverticulum was twisted around the base of the neck. Subsequently, wedge resection of the small intestine, including the diverticulum, was performed. Stem torsion is a rare complication of Meckel's diverticulum. As definitive preoperative diagnosis was difficult to obtain through imaging studies, early laparoscopic surgery was considered effective.

Bowel Perforation in a Patient with Hepatocellular Carcinoma during Lenvatinib Treatment.

We present a case of severe bowel perforation during lenvatinib treatment for advanced hepatocellular carcinoma. Although the Hartmann's procedure was performed, the patient died 48 h after the operation. The histopathological findings suggested that lenvatinib was involved in the etiology of bowel perforation in this case.

An incidentally identified 15 cm cavernous hemangioma of the small intestine: Case report and literature review.

INTRODUCTION: Hemangiomas of the small intestine are rare, usually present with symptoms such as anemia, gastrointestinal bleeding or abdominal pain and are resected. We report resection of an incidentally identified cavernous hemangioma of the small intestine that did not present symptoms referable to the hemangioma. Although it was a large lesion, it was resected using laparoscopy and a mini-laparotomy. PRESENTATION OF CASE: A 29-year-old otherwise healthy man was referred for evaluation of ileal wall thickening found on a contrast-enhanced computed tomography scan obtained for the workup of chronic diarrhea. Double balloon enteroscopy (DBE) showed a cavernous hemangioma of the small intestine. The lesion was 15 cm and resected using laparoscopy and a mini-laparotomy to prevent future bleeding. The histopathological diagnosis was a cavernous hemangioma of the ileum. DISCUSSION: Though there have been no reports of the asymptomatic patients of the disease, the recent spread of double balloon enteroscopy and capsule endoscopy will allow us to diagnose more asymptomatic hemangiomas like this patient. Also, this large lesion was able to be resected through a small incision due to its compressible nature. CONCLUSION: Future studies in asymptomatic patients of the disease may help to determine the optimal management for these patients. Even large hemangiomas are compressible, facilitating minimally invasive resection.

Laparoscopic appendectomy for metastatic cervical cancer presenting as appendicitis.

BACKGROUND: Metastatic lesions to the appendix are rare. They usually present with acute appendicitis or remain asymptomatic and are diagnosed incidentally. Metastases to the appendix have been reported from a number of primary tumor sites including ovary, colon, gastric and lung. We report a laparoscopic appendectomy for a metachronous metastatic lesion to the appendix from the uterine cervix. CASE PRESENTATION: A 68-year-old woman, who underwent radical hysterectomy for cervical cancer 16 years previously, presented with nausea and gradually worsening right lower quadrant abdominal pain. Abdominal computed tomography scan showed an enlarged appendix and periappendiceal fat stranding. She was diagnosed with appendicitis and underwent laparoscopic appendectomy. Pathological findings showed adenocarcinoma in the submucosa and muscularis propria. Gastrointestinal endoscopy and positron emission tomography with computed tomography (PET-CT) did not show other lesions. Immunohistochemical analysis showed cytokeratin 7 (CK7) positive, cytokeratin 20 (CK20) negative, estrogen receptor (ER) 70-80% and progesterone receptor (PgR) 40-50%. The ER and PgR expression was similar to the cervical lesion 16 years previously, and the diagnosis was a metastatic lesion to the appendix from the uterine cervix. CONCLUSIONS: Metastasis to the appendix from cancer of the uterine cervix is a rare lesion.

Gastric perforation secondary to an incarcerated paraesophageal hernia.

BACKGROUND: Paraesophageal hernias are usually asymptomatic; however, they can cause serious complications such as necrosis or incarceration-induced perforation. Necrosis usually occurs in the incarcerated portion of the hernia. Here, we report the case of a patient with gastric necrosis secondary to an incarcerated paraesophageal hernia in which the necrotic lesion was outside the hernia sac. CASE PRESENTATION: A 91-year-old woman presented with severe abdominal pain and vomiting. A physical examination showed hypotension and a diffusely tender and rigid abdomen. Computed tomography showed a paraesophageal hernia, massive ascites, and free air around the stomach. A laparotomy was performed to treat the upper gastrointestinal perforation. The stomach was incarcerated within the paraesophageal hernia sac. After reducing the stomach, we identified a large perforation on the posterior wall of the gastric fundus. Full-thickness necrosis involving part of the stomach necessitated total gastrectomy. She remained physiologically unstable and her condition deteriorated; she died 2 days postoperatively. CONCLUSIONS: A hiatal hernia can be associated with an ischemic gastric perforation outside the hernia sac.

Laparoscopic subtotal cholecystectomy for Mirizzi syndrome: A report of a case.

INTRODUCTION: Mirizzi syndrome is a rare complication of gallstone disease. The purpose of this report is to describe the utility of laparoscopic subtotal cholecystectomy for Mirizzi syndrome. PRESENTATION OF CASE: A 53-year-old female presented with dark urine and right upper quadrant pain. Blood tests revealed elevated liver and biliary enzyme levels. Magnetic resonance cholangiopancreatography showed a narrowed common hepatic duct compressed by a large gallstone, consistent with Mirizzi syndrome. Semi-urgent laparoscopic cholecystectomy was planned. At operation, circumferential dissection of the gallbladder neck was difficult. The fundus of the gallbladder was opened and a 2 cm stone extracted. The gallbladder neck was sutured and a drain placed. The postoperative clinical course was uneventful. DISCUSSION: After laparoscopic cholecystectomy in patients with Mirizzi syndrome, complication rates, including bile duct injuries, is high. In patients with Mirizzi syndrome, removal of the responsible stone is the main purpose of treatment. CONCLUSION: Laparoscopic subtotal cholecystectomy is a useful technique for patients with Mirizzi syndrome to avoid bile duct injury.

Metastatic colon cancer derived from a diverticulum incidentally found at herniorrhaphy: a case report.

BACKGROUND: There are few reports of metastases from colon cancer to an inguinal hernia sac, and few reports of colon cancer originating in diverticula. We report a patient with carcinoma of the sigmoid colon arising in two diverticula, who presented with peritoneal seeding to an inguinal hernia sac, and a review of the literature. CASE PRESENTATION: A 55-year-old male underwent open herniorrhaphy for a left inguinal hernia. At operation, a nodule in the inguinal hernia sac was resected and histologic examination revealed adenocarcinoma, which was suspected to be a metastasis from a distant primary lesion. Postoperative evaluation included colonoscopy and positron emission tomography which showed two suspected lesions in sigmoid diverticula. Laparoscopic subtotal colectomy was performed, and pathology revealed adenocarcinoma in two sigmoid diverticula. CONCLUSIONS: If a nodule is found in an inguinal hernia sac, especially in older patients, peritoneal metastases should be considered. Resection of the nodule with histopathologic evaluation is essential. Colon cancer arising in a diverticulum should be considered as a possible site of the primary lesion.

Ductal Carcinoma in situ of the breast in sclerosing adenosis encapsulated by a hamartoma: A case report.

INTRODUCTION: Ductal Carcinoma in situ (DCIS) of the breast can develop in areas of sclerosing adenosis. The radiographic finding of sclerosing adenosis is a spiculated mass and can look like invasive ductal carcinoma. We report a patient with DCIS in sclerosing adenosis encapsulated by a hamartoma, with imaging findings quite different from the typical findings of sclerosing adenosis. PRESENTATION OF CASE: A 73-year old woman, with no previous mammography, presented with a palpable mass in the left breast. Mammography showed a 36 mm well-defined mass with fat density in the middle outer quadrant of the left breast. Ultrasonography showed a well-defined mass in the same area which was composed of hypoechoic and hyperechoic areas. The histological diagnosis by core needle biopsy was sclerosing adenosis. We considered the patient's age and tumor size and performed a partial mastectomy for both diagnosis and treatment. Final pathology showed DCIS in sclerosing adenosis in a hamartoma. DISCUSSION: This patient had DCIS in an area of sclerosing adenosis, encapsulated by a hamartoma. DCIS can develop in areas of sclerosing adenosis, and can appear similar to invasive ductal carcinoma, so we must avoid misdiagnosis or over-treatment. Malignant transformation of a hamartoma is rare, but can occur since it contains epithelial tissue. Definitive biopsy should be performed due to the possibility of a malignancy inside the hamartoma. CONCLUSIONS: When diagnosing a hamartoma, the presence of atypical findings on imaging studies, should suggest the possibility of malignancy. Although rare, a malignant tumor may be present inside the hamartoma.

Treatment of Complete Anal Stricture after Diverting Colostomy for Fournier's Gangrene.

Background. Anal stenosis is a rare but serious complication of anorectal surgery. Severe anal stenosis is a challenging condition. Case Presentation. A 70-year-old Japanese man presented with a ten-hour history of continuous anal pain due to incarcerated hemorrhoids. He had a history of reducible internal hemorrhoids and was followed for 10 years. He had a fever and nonreducible internal hemorrhoids surrounding necrotic soft tissues. He was diagnosed as Fournier's gangrene and treated with debridement and diverting colostomy. He needed temporary continuous renal replacement therapy and was discharged on postoperative day 39. After four months, severe anal stenosis was found on physical examination, and total colonoscopy showed a complete anal stricture. The patient was brought to the operating room and underwent colostomy closure and anoplasty. He recovered without any complications. Conclusion. We present a first patient with a complete anal stricture after diverting colostomy treated with anoplasty and stoma closure. This case reminds us of the assessment of distal bowel conduit and might suggest that anoplasty might be considered in the success of the colostomy closure.

Idiopathic omental hemorrhage: A case report and review of the literature.

INTRODUCTION: Omental hemorrhage results from rupture of the omental vessels. There are many causes of omental hemorrhage including trauma, aneurysm, and vasculitis. Idiopathic omental hemorrhage is a rare cause of an acute abdomen, which is potentially life-threatening. We report a patient with idiopathic omental hemorrhage, which may have been caused by overeating. CASE PRESENTATION: A 29-year-old man without a history of trauma, bleeding disorders, or other significant medical history, presented with left upper quadrant pain, which began after overeating the previous evening. The pain worsened and he presented to the emergency department. On physical examination, his BP was 111/69mmHg and pulse 71 and he reported tenderness and involuntary guarding in the left upper quadrant on palpation. Contrast enhanced computed tomography scan revealed intraperitoneal fluid collection with intra-omental extravasation. Significant intraperitoneal hemorrhage was suspected and emergency laparotomy was performed. On exploring the abdominal cavity, a hematoma was found in the greater omentum, adjacent to the right gastroepiploic artery. No active bleeding was seen, and partial omentectomy was performed. There were no obvious lesions suggestive of malignancy or aneurysm, supporting the diagnosis of idiopathic omental hemorrhage. On postoperative day six, the patient developed a wound dehiscence, which was surgically closed. The subsequent postoperative course was uneventful and he was discharged on fifth day after the second operation. CONCLUSION: Idiopathic omental hemorrhage is a rare cause of an acute abdomen, which may develop after eating. Omentectomy is preferred to ligation or transcatheter arterial embolization to rule out an underlying malignancy or aneurysm.

Barium appendicitis: A single institution review in Japan.

AIM: To review clinical experience with barium appendicitis at a single institution. METHODS: A retrospective review of patients admitted with a diagnosis of acute appendicitis, from January 1, 2013 to December 31, 2015 was performed. Age, gender, computed tomography (CT) scan findings if available, past history of barium studies, pathology, and the presence of perforation or the development of complications were reviewed. If the CT scan revealed high density material in the appendix, the maximum CT scan radiodensity of the material is measured in Hounsfield units (HU). Barium appendicitis is defined as: (1) patients diagnosed with acute appendicitis; (2) the patient has a history of a prior barium study; and (3) the CT scan shows high density material in the appendix. Patients who meet all three criteria are considered to have barium appendicitis. RESULTS: In total, 396 patients were admitted with the diagnosis of acute appendicitis in the study period. Of these, 12 patients (3.0%) met the definition of barium appendicitis. Of these 12 patients, the median CT scan radiodensity of material in the appendix was 10000.8 HU, ranging from 3066 to 23423 HU (± 6288.2). In contrast, the median CT scan radiodensity of fecaliths in the appendix, excluding patients with barium appendicitis, was 393.1 HU, ranging from 98 to 2151 HU (± 382.0). The CT scan radiodensity of material in the appendices of patients with barium appendicitis was significantly higher than in patients with nonbarium fecaliths (P < 0.01). CONCLUSION: Barium appendicitis is not rare in Japan. Measurement of the CT scan radiodensity of material in the appendix may differentiate barium appendicitis from routine appendicitis.

Massive Preperitoneal Hematoma after a Subcutaneous Injection.

Preperitoneal hematomas are rare and can develop after surgery or trauma. A 74-year-old woman, receiving systemic anticoagulation, developed a massive preperitoneal hematoma after a subcutaneous injection of teriparatide using a 32-gauge, 4 mm needle. In this patient, there were two factors, the subcutaneous injection of teriparatide and systemic anticoagulation, associated with development of the hematoma. These two factors are especially significant, because they are widely used clinically. Although extremely rare, physicians must consider this potentially life-threatening complication after subcutaneous injections, especially in patients receiving anticoagulation.

Afferent Loop Syndrome after Roux-en-Y Total Gastrectomy Caused by Volvulus of the Roux-Limb.

Afferent loop syndrome is a rare complication of gastric surgery. An obstruction of the afferent limb can present in various ways. A 73-year-old man presented with one day of persistent abdominal pain, gradually radiating to the back. He had a history of total gastrectomy with a Roux-en-Y reconstruction. Abdominal computed tomography scan revealed dilation of the duodenum and small intestine in the left upper quadrant. Exploratory laparotomy showed volvulus of the biliopancreatic limb that caused afferent loop syndrome. In this patient, the 50 cm long limb was the cause of volvulus. It is important to fashion a Roux-limb of appropriate length to prevent this complication.