Shiro Fujihata

A post operative complication of foramen of Winslow hernia with left to right herniation of the small intestine: An extremely rare case report

Highlights • A foramen of Winslow hernia is rare and difficult to diagnose.• We report a post operative complication of foramen of Winslow herniation from left to right.• There are no previous reports of a foramen of Winslow hernia with this presentation.• It has been thought that closure of the foramen is not necessary.• However, as there are no reports about the complications due to closing the Foramen of Winslow, the foramen should be closed, whenever possible.

A Giant Duodenal Leiomyoma Showing Increased Uptake on 18F-Fluorodeoxyglucose Positron Emission Tomography

Background Although 18F-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) is now widely used in their differential diagnosis, it is sometimes difficult to distinguish between benign and malignant diseases. Case Presentation A 44-year-old woman was found to have abnormalities on health screening. Magnetic resonance imaging for detailed examination showed an intra-abdominal tumor measuring 12 cm in the major axis near the cranial end of the uterus. Upper gastrointestinal tract endoscopy showed a tumor with an ulcer in the third part of the duodenum, involving half the circumference. Heterogeneous uptake was observed within the tumor on FDG-PET/CT. Based on these findings, the patient underwent surgery for suspected primary malignant lymphoma of the duodenum or gastrointestinal stromal tumor. Laparotomy revealed a 12 cm tumor in the third part of the duodenum. Partial duodenectomy and end-to-end duodenojejunostomy were performed. Pathological findings showed a solid tumor growing from the muscle layer of the duodenum to outside the serous membrane; based on immunostaining, it was diagnosed as a leiomyoma. Conclusions Duodenal leiomyomas are originally benign; to date, there have been no reports of uptake in duodenal leiomyomas on FDG-PET/CT; therefore, our case is rare. Leiomyomas should be considered in the differential diagnosis of duodenal neoplastic diseases.

Arteriovenous malformation in the sigmoid colon of a patient with Cowden disease treated with laparoscopy: a case report

BackgroundCowden disease is a genetic disorder associated with a mutation of the PTEN gene and is known to be easily complicated by generalized vascular malformations and malignant tumors. However, only a few reports have investigated the relationship between Cowden disease and vascular malformations. We present a case of Cowden disease along with a review of the literature.Case presentationThe patient was a 48-year-old man who visited our hospital complaining of fresh blood in his stools and shortness of breath. Hematological tests showed the patient had severe anemia. On physical examination, white papules—several millimeters in size—were observed between the patient’s eyebrows. White papules were also observed on the left corner of his mouth and buccal mucosa. An upper gastrointestinal endoscopy showed densely-packed, white, flat protrusions in the esophagus. While lower gastrointestinal endoscopy revealed a mass accompanied by arterial pulsation in the sigmoid colon. A diagnosis of Cowden disease was confirmed and a laparoscopic sigmoidectomy was performed to address the arteriovenous malformations in the sigmoid colon. Post-surgery, the patient had an unremarkable recovery and was discharged 7 days later.ConclusionsWe present a very rare case of Cowden disease with arteriovenous malformations occurring in the colon. Surgical resection is believed to be the first choice for treating congenital arteriovenous malformations of the intestines. However, the arteriovenous malformations in the colon in our patient were treated under laparoscopic guidance, making ours the first report describing laparoscopic treatment of colonic arteriovenous malformations occurring in the inferior mesenteric artery. Thus we demonstrate that laparoscopic treatment of arteriovenous malformations in the intestines is a minimally invasive and can be successfully applied in such cases.

Technique of totally robotic delta-shaped anastomosis in distal gastrectomy

Background: We aimed to clarify the utility of delta-shaped anastomosis (Delta), an intracorporeal Billroth-I anastomosis-based reconstruction technique used after laparoscopy-assisted distal gastrectomy (LADG), in robot-assisted distal gastrectomy (RADG). Methods: RADG was performed in patients with clinical Stage I gastric cancer, and reconstruction was performed using Delta. The Delta procedure was the same as that performed after LADG, and the operator practiced the procedure in simulated settings with surgical assistants before the operation. After gastrectomy, the scope and robotic first arm were reinserted from separate ports on the right side of the patient. Then, a port on the left side of the abdomen was used as the assistant port from which a stapler was inserted, with the robotic arm in a coaxial mode. The surgical assistant performed functional end-to-end anastomosis of the remnant stomach and duodenal stump using a powered stapler. Results: The mean anastomotic time in four patients who underwent Delta after RADG was 16.5 min. All patients were discharged on the post-operative day 7 without any post-operative complications or need for readmission. Conclusions: Pre-operative simulation, changes in ports for insertion of the scope and robotic first arm, continuation of the coaxial operation, and use of a powered stapler made Delta applicable for RADG. Delta can be considered as a useful reconstruction method.

Retroperitoneal and Mediastinal Pancreatic Pseudocyst Accompanied by Pancreas Divisum

症例は 68歳のアルコール多飲歴のある男性で,呼吸困難を主訴に近医を受診し,右胸水貯留を指摘さ れ,当院紹介となった.当院初診時の単純 CTで右胸水貯留に加え,後腹膜から縦隔内の低吸収域,膵石 を認めた.胸水中のアミラーゼは高値であった.胸水ドレナージ後の造影 CTで,後腹膜から縦隔内の低 吸収域は囊胞性病変と判断した.また,膵体尾部頭側には膵仮性囊胞を認めた.以上から,慢性膵炎に伴 う,後腹膜・縦隔内膵仮性囊胞と診断した.膵管癒合不全のため,ERCPで縦隔内,肝背側囊胞への内瘻 を描出できなかったが,MRCPでは膵体尾部頭側の囊胞から後腹膜囊胞への内瘻の存在を疑った.脾合併 膵体尾部切除術を施行し,術後 4か月の CTでは後腹膜,縦隔内囊胞は消失した.膵管癒合不全のため, 縦隔内膵仮性囊胞への内瘻が ERCPで確認困難な症例であったが,MRCPではその存在を疑うことがで き,治療方針の決定に有用であった.