Akihiko Shimada

Retroperitoneal Biloma due to Spontaneous Perforation of the Left Hepatic Duct

Patient: Male, 82 Final Diagnosis: Retroperitoneal biloma due to spontaneous perforation of the left hepatic duct Symptoms: Abdominal pain • high fever Medication: — Clinical Procedure: Emergent operation Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Spontaneous perforation of the bile duct in adults is very rare, particularly in cases accompanied by retroperitoneal biloma. We report a patient with retroperitoneal biloma due to a spontaneous perforation of the left hepatic duct. Case Report: An 82-year-old man was admitted to our institution with abdominal pain and a high fever. He had tenderness at the epi-mesogastrium. Computed tomography showed several stones in the gall bladder and common bile duct (CBD) and a few ascites. A substantial amount of fluid had collected from the dorsal stratum of the duodenum and pancreas head to the right paracolic gutter and anterior side of the right iliopsoas. Laboratory examination revealed a high inflammation score. He underwent emergent laparotomy. Biliary fluid was revealed after the mobilization of the pancreas head, duodenum, and right side of the colon. Bile duct perforation was suspected. Therefore, we exfoliated the dorsal side of the CBD to the cranial side, and intraoperative cholangiography was performed. However, the perforation site could not be detected. Cholecystectomy and choledocholithotomy were performed. A retrograde transhepatic biliary drainage tube was inserted, and primary closure of the CBD incision site was achieved. Postoperative cholangiography revealed leakage from the left hepatic duct near the caudate branch. Conclusions: There are a few reports of spontaneous bile duct perforation cases in the literature, particularly on infants or children with congenital anomalies, but it is rare in adults. It usually causes bile peritonitis, although bile duct perforation should be considered in the differential diagnosis of spontaneous retroperitoneal fluid collection in adults.

A Case of Breast Cancer with Predominant Cartilaginous and Osseous Components

Primary breast cancers with cartilaginous and osseous components are quite rare. We recently treated a 51-year-old woman suffering from primary breast cancer with predominant cartilaginous and osseous components, adjacent to a component of intraductal carcinoma. We discuss the management of this tumor with a review of the literature.

Total mastectomy and chest reconstruction for a rapidly progressing giant phyllodes tumor with skin necrosis: a case report

Phyllodes tumors are rare fibroepithelial neoplasms of the breast. In the literature, borderline or malignant tumors have been reported to present with unusual characteristics including a short clinical history and extremely rapid tumor growth. Skin necrosis and infection sometimes accompanies these malignancies. Giant phyllodes tumors have a good prognosis when treated with total mastectomy, but reconstruction of the chest wall has been a challenge because of the need for a wide-range excision.We report a case of a malignant phyllodes tumor that was initially diagnosed as borderline because sudden growth of the tumor contrarily induced sparse to moderate stroma cellularity in the sections of the tumor that were biopsied. Total mastectomy without axillary lymph node resection and chest wall reconstruction using a full-thickness mesh skin graft was performed. The patient has remained free from infection and recurrence for over a year since diagnosis.

Pulmonary inflammatory pseudotumor observed by bronchoscopy and resected using video-assisted thoracic surgery

Pulmonary inflammatory pseudotumor is rare. A 34-year-old woman visited our hospital due to an abnormal chest shadow. Computed tomograhy showed a nodule in the right upper lobe. Bronchoscopy showed a polypoid endobronchial nodule obstructing most of the orifice of B2a. The nodule was white, glossy, and smooth, and it seemed to be covered with bronchial mucosa. However, transbronchial biopsy could not facilitate a diagnosis. To obtain a definitive diagnosis, we performed lobectomy of the right upper lobe using video-assisted thoracic surgery and removed the nodule completely. The pathologic diagnosis made during surgery was inflammatory pseudotumor. Immunohistochemical examination showed proliferating spindle cells were positive for vimentin and smooth muscle actin, but negative for epithelial markers. These findings were consistent with the staining pattern of inflammatory pseudotumor previously reported. Careful follow-up is necessary to detect any sign of local recurrence and distant metastases.

Cricopharyngeal myotomy for primary cricopharyngeal dysfunction caused by a structural abnormality localized in the cricopharyngeus muscle: Report of a case

Primary cricopharyngeal dysfunction (PCD) is a rare idiopathic disorder of the upper esophageal sphincter (UES), characterized by oropharyngeal dysphagia, frequent aspiration, and narrowing at the level of the UES. Cricopharyngeal myotomy (CPM) has been used to treat oropharyngeal dysphagia of different causes including anatomic, neuromuscular, iatrogenic, inflammatory, neoplastic, and idiopathic; however, the indications for CPM and predictors of its outcome are not clearly defined. We report a case of PCD with hypertonic UES caused by a structural abnormality localized in the cricopharyngeus muscle, visualized as a cricopharyngeal bar, which we treated successfully by CPM, achieving long-term relief.

Invasive Solid Papillary Carcinoma of the Nipple With Pagetoid Extension and Nodal Metastasis

We report a case of invasive solid papillary carcinoma (SPC) of the nipple with Pagetoid extension to the skin and lymph node metastasis. SPC is an uncommon primary breast cancer accounting for less than 1% of all breast cancers. Only 2 cases occurring in the nipple have been reported. However, both cases were without Pagetoid extension or lymph node metastasis. The presently reported tumor consisted of irregularly shaped solid cell nests with delicate fibrovascular cores. The tumor cells had round nuclei with low-grade atypia and eosinophilic cytoplasm. Neuroendocrine differentiation was confirmed by immunohistochemical positivity for CD56, synaptophysin, and chromogranin A. Immunohistochemistry also confirmed the absence of myoepithelial cells around the tumor cell nests. Therefore, a diagnosis of invasive SPC was made. Additionally, tumor cell deposits in the intramammary and axillary lymph nodes were identified, and these deposits had the same histological characteristics as the invasive SPC of the nipple. The invasiveness of SPC can be difficult to determine. However, the tumor cell nests in the current case exhibited a retraction artifact, which is known to be associated with invasive carcinoma and a poor prognosis, as well as morphological patterns that have been previously identified as characteristic of invasive SPC. Although SPC is widely recognized as having a favorable outcome, the existence of exceptionally aggressive cases occurring in the nipple must be recognized. Additional cases of invasive SPC of the nipple are needed to analyze the clinicopathological correlation.

Perforation of abdominal esophagus following nasogastric feeding tube intubation: A case report

Highlights • Abdominal esophageal perforation due to NGT insertion is very rare.• The cause of the perforation was suggested to be the deformity of the abdominal esophagus.• We should insert a nasogastric tube with a use of frontal and lateral radiograph view or under fluoroscopic guidance.

Duodenal rupture due to giant inguinal hernia: A case report

Highlights • Giant inguinal hernia is unusual and rarely encountered in modern clinical practice.• Retraction of its third portion into the hernia sac can perforate the duodenum.• Emergency surgery of these hernias is difficult due to postoperative complications.