tsutomu kumamoto

The patient was an 87-year-old man. Computed tomography (CT) performed 8 years prior revealed a cystic lesion 2 cm in size in a branching duct in the intraductal papillary mucinous neoplasm (IPMN) on the anterior surface of the pancreatic body. At this time, he was admitted for sudden upper abdominal pain. His laboratory data showed marked increases in white blood cell count and C-reacted protein level. Enhanced CT revealed a multilocular cystic lesion with a dirty fat sign at the pancreatic body and large amounts of ascites. We conducted an emergency operation under the diagnosis of peritonitis caused by rupture of the IPMN. Laparotomy findings indicated large amounts of dirty ascites and omental bursa with pus. Intraoperative ultrasonography revealed a 3-cm multilocular cystic lesion in the pancreatic body, connected to the omental bursa. Abdominal drainage and distal pancreatectomy were performed. The pathological diagnosis was noninvasive intraductal papillary mucinous carcinoma. As IPMN rupture is rare, we present this case along with a literature review.

症例は44歳の男性で,下部消化管内視鏡検査で下部直腸に粘膜下腫瘍を認め,内視鏡的粘膜切除が施行された.病理検査で,Carcinoid,pSM,垂直断端陽性であり,追加切除目的で当院紹介となった.術前画像検査では異常は認めなかった.術中所見で膀胱直腸窩腹膜に限局的な黄白色の小結節の集簇を認め,術中迅速病理検査で,高分化型乳頭状中皮腫(well-differentiated papillary mesothelioma:以下WDPM)疑いと診断された.小結節は限局していたため,膀胱直腸窩の腹膜を一括切除し,その後,予定通りに腹腔鏡下低位前方切除術を施行した.永久病理検査では,腹膜切除検体はWDPMの診断であり,直腸検体は切除断端陰性であった.WDPMはまれな低悪性度の腫瘍とされ,多くは術中に偶然発見される.本邦での報告は少なく,限局したWDPMに対して腹腔鏡下に完全切除しえた報告はない.(著者抄録)

A 44-year-old man with no history of asbestos exposure was diagnosed with rectal carcinoid tumor and underwent endoscopic mucosal resection. Histological examination showed a positive vertical margin. Therefore, he was admitted to our hospital for additional surgery. On admission, he was asymptomatic, and all preoperative examinations were within normal limits. During laparoscopic surgery, yellow miliary nodules were observed on the peritoneum. Since intraoperative pathology revealed well-differentiated papillary mesothelioma (WDPM), laparoscopic peritonectomy together with low anterior resection was performed. The patient's postoperative course was uneventful.

We present a case of early neuroendocrine carcinoma of the gallbladder with bile duct extension. A 70-year-old woman with a chief complaint of appetite loss was admitted to our hospital with a diagnosis of obstructive jaundice caused by a gallbladder tumor. Abdominal CT showed the gallbladder wall was irregularly thickened and the extrahepatic bile duct was contiguously filled with the tumor. Tumor biopsy under endoscopic retrograde cholangiography revealed neuroendocrine carcinoma. We performed extrahepatic bile duct resection and cholecystectomy with choledochoduodenostomy. Immunochemical examination revealed synaptophysin (+), chromogranin A (+) and an MIB-I labeling index 70%, which confirmed large cell neuroendocrine carcinoma as defined by the WHO classification, 2010. The final diagnosis was fT1 (fm, pHinf0, pBinf0, pV0, pA0), N0 (0/1), INFα, ly1, v0, pN0, H0, P0, M (–) Stage I. The postoperative course of the patient was uneventful and she was recurrence free 14 months after the operation.

A 34-year-old man had an 8-year history of systemic lupus erythematosus (SLE) controlled by oral prednisolone. He had abdominal pain and underwent colonoscopy 3 years after the initial diagnosis. Colonoscopy revealed an ulcerative lesion and stenosis in the rectosigmoid colon. He was treated by prednisolone enema, because colonic inflammation associated with SLE was diagnosed. He obtained symptomatic relief for a period, but he developed abdominal distension again after 1 year. The lesions were eventually diagnosed as ulcerative colitis as a complication of SLE. Despite the introduction of oral mesalazine, the stenosis did not show significant improvement and he was referred to our hospital for surgical treatment. Laparoscopic low anterior resection was performed without perioperative complications, after 5 years from the first abdominal pain. Pathological results revealed that the stenosis was a result of thrombosis caused by anti-phospholipid antibody and lupus vasuculitis. Stenosis of the large intestine due to SLE is a very rare entity and only 4 cases have been reported in the literature. To the best of our knowledge, this is the first case report of laparoscopic colectomy for stenosis of the large intestine due to SLE.