Michio Tanaka

A metastatic melanoma of the small intestine diagnosed by single- balloon enteroscopy

A 67-year-old woman presented at our hospital with lower abdominal pain. Her medical history included radiation therapy three years previously for the treatment of a malignant melanoma of the nasal sinuses. On examination, tenderness in the lower abdomen was observed, but no palpable mass was identified. The patient’s laboratory data were normal except for the presence of anemia (hemoglobin, 10.0 g/dL). Gastroscopy and colonoscopy were performed, but no significant findings were obtained. Enhanced computed tomography revealed a circumscribed wall thickening of the small intestine with significant dilation on the oral side of the lesion. Single-balloon enteroscopy was performed. A circumferential whitish and partially grayish tumor was observed in the ileum 90 cm from the Bauhin valve (Figure 1). Biopsy confirmed the mass as malignant melanoma, and the specimen was positive for S-100, vimentin and HMB45 and negative for cytokeratin. Based on these results and the patient’s past medical history, the tumor was diagnosed as metastatic malignant melanoma of the small intestine.

Pulmonary edema after laparoscopic hepatectomy in a patient with Budd-Chiari syndrome-associated hepatocellular carcinoma.

An 84‐year‐old man diagnosed with Budd–Chiari syndrome (BCS) developed a 20‐mm hepatocellular carcinoma. We performed laparoscopic hepatectomy without complications, but the patients percutaneous oxygen saturation gradually worsened and pulmonary edema was detected 50 minutes after extubation. He was subsequently re‐intubated and received diuretic therapy. He was discharged on postoperative day 32. Patients with severe BCS have been reported to have an expanded plasma volume. In addition, pneumoperitoneum during laparoscopic surgery has been reported to decrease the venous flow in the portal vein and/or renal vein, the collateral pathways in BCS. The cause of pulmonary edema in the present case may have involved increased venous return following decompression of pneumoperitoneum pressure under the state of an expanded plasma volume. This case suggests that clinicians should pay special attention to achieving volume control in patients with BCS, particularly during laparoscopic surgery and minimizing the duration of pneumoperitoneum.