Ken Hanyu

Internal hernia through a peritoneal defect in the pouch of Douglas: Report of a case.

INTRODUCTION Internal hernia is a rare entity which can cause intestinal obstruction. The most common type of internal hernia is the paraduodenal hernia which accounts for 53% of cases, and the internal hernia within the pelvis account for 7%. Perineal hernia, which is classified as pelvic hernia, usually occurs due to weakening of the pelvic floor musculature and thus, should be distinguished from the internal hernia caused by peritoneal defects in the pelvic cavity. PRESENTATION OF CASE We present a case of 28-year-old female who presented intestinal obstruction. Conservative therapies failed and she required emergency laparotomy. The operative findings revealed a peritoneal defect of 2cm in diameter in the pouch of Douglas, through which the ileum was incarcerated and strangulated. The incarcerated bowel was reduced, and the intestinal color quickly returned to normal. Therefore a primary closure of the peritoneal defect was performed and the postoperative course was uneventful. DISCUSSION A PubMed search for the case of internal hernia through a defect in the pouch of Douglas revealed only three, making this an extremely rare condition. CONCLUSION Because of rarity of this hernia, the etiology is unknown. However, our patient is a young female with no history of pregnancy, abdominal surgery, or trauma, therefore the cause of the peritoneal defect is considered congenital.

Repair of Bochdalek hernia in an adult complicated by abdominal compartment syndrome, gastropleural fistula and pleural empyema: Report of a case

INTRODUCTION Bochdaleks diaphragmatic hernia (BDH) rarely developed symptomatic in adulthood but mostly required an operation. In adult BDH cases, long-term residing of the massive intraabdominal organs in the thoracic cavity passively causes loss of domain for abdominal organs (LOD). PRESENTATION OF CASE A 63-year-old man presented at our institution complaining of sudden left upper quadrant abdominal pain. Chest radiography showed a hyperdense lesion containing bowel gas in the left pleural space. Computed tomography revealed a dilated bowel above the diaphragm and intestinal obstruction suggestive of gangrenous changes. These findings were consistent with the diagnosis of incarcerated BDH and an emergency laparotomy was performed. Operative findings revealed the hypoplastic lung, lack of hernia sac, and location of the diaphragmatic defect, which indicated that his hernia was true congenital. Organs were reduced into the abdominal cavity, and large defect of the diaphragm was repaired with combination of direct vascular closure and intraperitoneal onlay mesh reinforcement using with expanded polytetrafluoroethylene (ePTFE) mesh. On the postoperative day 1, the patient fell into the shock and was diagnosed to have abdominal compartment syndrome (ACS). Conservative therapies were administered, but resulted in gastropleural fistula and pleural empyema, which required an emergency surgery. Mesh extraction and fistulectomy were performed. DISCUSSION A PubMed search for the case of ACS after repair of the adult BDH revealed only three cases, making this very rare condition. CONCLUSION In dealing with adult BDH, possible post-repair ACS should be considered.

Large gastrointestinal stromal tumor and advanced adenocarcinoma in the rectum coexistent with an incidental prostate carcinoma: A case report

INTRODUCTION Gastrointestinal stromal tumors (GISTs) are the leading mesenchymal neoplasia in the gastrointestinal tract, but GIST arising from the rectum is rare. When a secondary neoplasia coexists in the vicinity of a rectal GIST, more aggressive treatment strategies may be needed to cure the diseases. PRESENTATION OF CASE We herein describe a 76-year-old man with a large gastrointestinal stromal tumor along with an advanced adenocarcinoma in the rectum that coexisted with prostate carcinoma. Preoperative examination revealed an advanced adenocarcinoma of the upper rectum and a large pelvic mass suggestive of a GIST or a neuroendocrine tumor arising from the anterior wall of the lower rectum. To eradicate the tumor, total pelvic exenteration with ureterocutaneous fistula was carried out after obtaining written informed consent. Immuhistochemical studies revealed the concurrence of an advanced rectal cancer (T3, N1, M0) and a malignant GIST (c-kit-positive, CD34-positive, vimentin-positive, and CAM5.2-negative), and an incidental prostatic acinar adenocarcinoma. The patient was given adjuvant chemotherapy with imatinib and remains disease-free as of 12 months after surgery. DISCUSSION A PubMed search for the case of coexistence of GIST with two other malignancies revealed only four cases, making this very rare condition. CONCLUSION Radical surgery with perioperative adjuvant chemotherapy using tyrosine kinase inhibitors is the choice for treatment of large GISTs with a malignant potential. Our report suggests that aggressive surgical approach would be feasible, when a secondary tumor is present near the GIST.

Preoperative Diagnosis of Adult Intussusception Caused by Small Bowel Lipoma

Adult intussusception is rare, accounting for only 5% of all intussusceptions, for which preoperative diagnosis is difficult. We herein report a preoperatively diagnosed case of adult intussusception caused by a small bowel lipoma. A 33-year-old man was admitted to our hospital with three weeks history of colicky epigastric pain. Computed tomography revealed thickening of the ileal wall suggestive of intussusception. Colonoscopy revealed an ileocolic intussusception. Barium enema for reduction of ileocolic intussusception demonstrated a small bowel tumor in the ileum 15 cm proximal to the ileocecal valve. The intussusception was reduced, and the patient underwent partial resection of the ileum encompassing the small bowel tumor. Histological findings confirmed the diagnosis of lipoma of the small bowel. The patient made a satisfactory recovery and remains well.

Topic: Perineal Reconstruction.

Background: A perineal hernia (PH) is a challenge for surgeons and may develop after conventional abdominoperineal resection (APR), Recently several different surgical approaches and techniques of repair have been reported, however, the standard technique has yet to be established. We present two cases of PH after APR; the PHs were successfully repaired with KugelTM patch (M size, 11 x 14 cm) through a trans perineal approach.

Benign retroperitoneal cyst containing a high fluid concentration of cancer antigen 125, carbohydrate antigen 19-9, and amylase. Case report

ZusammenfassungGRUNDLAGEN: Gutartige retroperitoneale Zysten sind selten, jene mit flüssigem Inhalt, der CA-125 und CA 19-9 enthält, noch seltener. METHODIK: Wir berichten über eine 38-jährige Frau mit einer Zyste zwischen Colon ascendens und rechter Niere. Der Zysteninhalt zeigte erhöhte Werte für CA 125 (2.798 U/ml), CA 19-9 (49 U/ml) und Amylase (1.283 U/ml). ERGEBNISSE: Die Zyste wurde reseziert, es fand sich eine gutartige retroperitoneale Zyste. SCHLUSSFOLGERUNGEN: Unser Fall ist der 2. einer retroperitonealen Zyste mit hohen Tumormarker-Konzentrationen und Amylase in der englischsprachigen Literatur.SummaryBACKGROUND: Benign retroperitoneal cystic masses are uncommon clinical entities, and those with high cyst fluid levels of cancer antigen 125 and carbohydrate antigen 19-9 are extremely rare. METHODS: A 38-year-old woman was admitted to our hospital due to a right abdominal cystic mass. Computed tomography revealed a unilocular cystic mass without nodule between the ascending colon and the right kidney. The cyst fluid levels of cancer antigen 125, carbohydrate antigen 19-9, and amylase were elevated to 2,798 U/ml, 49 U/ml, and 1,283 IU/l, respectively. RESULTS: The patient underwent excision of the retroperitoneal cystic mass, and histologic findings confirmed the diagnosis of benign retroperitoneal cyst. CONCLUSIONS: To the best of our knowledge, our patient is the second case of a benign retroperitoneal cyst containing fluid with a high concentration of cancer antigen 125, carbohydrate antigen 19-9, and amylase in the English literature.