Intra‐abdominal desmoid tumor after laparoscopic low anterior resection for rectal cancer: A case report

Desmoid tumors are monoclonal fibroblastic proliferations arising from soft tissue classified as intra‐abdominal, extra‐abdominal and abdominal wall types. We present a patient with an intra‐abdominal desmoid tumor diagnosed 20 months after laparoscopic resection of rectal cancer. A 70‐year‐old woman with hematochezia was diagnosed with advanced rectal cancer. Preoperative chemoradiotherapy followed by laparoscopic low anterior resection was performed. During follow‐up, a nodular soft‐tissue density measuring 28 mm was detected in the presacral region. Metastasis from rectal cancer was diagnosed and four courses of chemotherapy were given, including capecitabine, oxaliplatin and bevacizumab. Computed tomography scan showed that the mass slightly decreased in size and surgical resection was performed. Histopathological examination revealed a proliferation of spindle‐shaped cells and collagenous stroma diagnosed as a desmoid tumor. This report highlights the possibility of a desmoid tumor in the differential diagnosis of an intra‐abdominal mass found during follow‐up after resection of colorectal cancer including following laparoscopic resection.     

腹部韧带样型纤维瘤病临床特点及治疗探讨

目的探讨腹部韧带样型纤维瘤病（desmoid-type fibromatosis,DTF）的临床特点及治疗方法。方法对我院2006年4月～2011年4月收治的26例腹部DTF临床资料进行回顾性分析。结果本组自行发现或体检时偶然发现腹部肿块24例（92.3%）,腹部不适2例（7.7%）。有腹部手术史10例（38.5%）。术前确诊DTF2例（7.7%）,诊断为腹壁肿瘤20例（76.9%）,余4例分别误诊为原发性肝癌、结肠癌、小肠肿瘤、盆腔肿瘤各1例（各占3.8%）。26例均行手术切除并经病理检查确诊,术后均恢复良好,无术后并发症发生,随访未见肿瘤局部复发及转移。结论 DTF多见于经产妇女,好发于既往有手术史者,以腹壁发病率为最高,肿瘤病理表现虽为良性,但临床上具有浸润性生长和易复发的特点,多发生于深部软组织,手术为该病主要治疗方法。     

High-intensity focused ultrasound treatment for intra-abdominal desmoid tumors: a report of four cases

Desmoid tumors are rare clonal fibroblastic proliferations that can arise at abdominal or extra-abdominal sites. Complete surgical resection is the primary treatment for resectable desmoid tumors, but a high rate of local recurrence has been reported even after complete resection. For patients with a recurrent tumor, the goals of treatment are to control the recurrence, maintain quality of life, and prolong survival. Radiofrequency ablation, radiotherapy, chemotherapy, and other medical therapies can be used as alternative methods, but there are considerable controversies over the roles of these methods in the management of desmoid tumors. High-intensity focused ultrasound (HIFU) is a minimally invasive and effective method for treatment of solid tumors. We used HIFU to treat four patients with intra-abdominal desmoid tumors from June 2011 to September 2013. Post-procedural pain was seen in all patients. One patient had an intra-abdominal abscess and another suffered a slight injury to the femoral nerve. The patients were followed up for 19–46 months (mean 34 months) until April 2015. The tumor in one patient disappeared, and no tumor progression was observed in the other patients.     

Successful laparoscopic extirpation of a large omental lipoblastoma in a child

Omental lipoblastoma is extremely rare among benign tumors. We herein report the case of a child who underwent laparoscopic extirpation of a large omental lipoblastoma. A 4‐year‐old girl was diagnosed with an intra‐abdominal solid tumor. Abdominal imaging revealed a fat density mass that was well encapsulated and measured 18 × 15 × 7.5 cm in size. Considering the MRI findings and movability of the tumor, we strongly suspected that the lesion was an omental lipoblastoma. We initially decided to perform laparoscopic exploration and, if possible, extirpation of the solid tumor sequentially. A total of five trocars were used, and the tumor was found to originate from the omentum. We successfully performed complete resection of the tumor laparoscopically. A histological examination revealed lipoblastoma. For large abdominal tumors in children, the laparoscopic approach is recommended as the first procedure when the tumor is preoperatively considered to be benign and resectable.     

Parasitic leiomyoma in the trocar site after laparoscopic myomectomy: A case report

BACKGROUNDLaparoscopic myomectomy is increasingly used for resecting gynecological tumors. Leiomyomas require morcellation for retrieval from the peritoneal cavity. However, morcellated fragments may implant on the peritoneal cavity during retrieval. These fragments may receive a new blood supply from an adjacent structure and develop into parasitic leiomyomas. Parasitic leiomyomas can occur spontaneously or iatrogenically; however, trocar-site implantation is an iatrogenic complication of laparoscopic uterine surgery. We describe a parasitic leiomyoma in the trocar-site after laparoscopic myomectomy with power morcellation.CASE SUMMARYA 50-year-old woman presented with a palpable abdominal mass without significant medical history. The patient had no related symptoms, such as abdominal pain. Computed tomography findings revealed a well-defined contrast-enhancing mass measuring 2.2 cm, and located on the trocar site of the left abdominal wall. She had undergone laparoscopic removal of uterine fibroids with power morcellation six years ago. The differential diagnosis included endometriosis and neurogenic tumors, such as neurofibroma. The radiologic diagnosis was a desmoid tumor, and surgical excision of the mass on the abdominal wall was successfully performed. The patient recovered from the surgery without complications. Histopathological examination revealed that the specimen resected from the trocar site was a uterine leiomyoma.CONCLUSIONClinicians should consider the risks and benefits of laparoscopic vs laparotomic myomectomy for gynecological tumors. Considerable caution must be exercised for morcellation to avoid excessive tissue fragmentation.     

Laparoscopic reduced port surgery for schwannoma of the sigmoid colon: A case report

A 74‐year‐old woman who developed schwannoma of the sigmoid colon was referred to our hospital for colonography to determine the cause of her stool occult blood. Colonoscopy revealed a submucosal tumor, which measured 3 cm in diameter, in the sigmoid colon. Endoscopic ultrasonography revealed a low echoic, homogeneous and demarcated submucosal tumor that continued into the fourth layer of the colonic wall. Gastrointestinal stromal, myogenic or neurogenic tumor was suspected, and thus, laparoscopic sigmoidectomy was carried out. We used two ports during the operation, a SILS Port in the umbilical region and a 12‐mm port in the right lower abdominal wall, and performed sigmoidectomy with D2 lymph node dissection. Histological findings revealed spindle‐like tumor cells with multiform nuclei. The tumor was diagnosed by immunostaining as benign schwannoma of the sigmoid colon. The conventional surgical treatment for schwannoma of the digestive tract is partial resection, but if preoperative diagnosis is unknown, radical resection with lymphadenectomy is acceptable for submucosal tumors in the digestive tract. In this case, laparoscopic reduced port surgery using only one or two ports may be more feasible and beneficial with regard to cosmesis and reduced postoperative pain than conventional laparoscopic colectomy.     

Laparoscopic surgery for an esophageal duplication cyst using a near‐infrared indocyanine green fluorescence system: A case report

We herein describe a case of laparoscopic surgery for an esophageal duplication cyst using a near‐infrared indocyanine green fluorescence system. A 64‐year‐old woman with a cystic tumor adjacent to the esophagogastric junction was referred to our hospital for treatment. Esophagogastroduodenoscopy and abdominal CT revealed a 70‐mm submucosal tumor derived from the abdominal esophagus. We performed laparoscopic resection and then evaluated the tissue perfusion of the abdominal esophagus by using a near‐infrared indocyanine green fluorescence system. A Dor fundoplication was performed to prevent postoperative gastroesophageal reflux disease and reinforce the mucosal layer defect. The postoperative course was uneventful, and pathological evaluation confirmed that the tumor was an esophageal duplication cyst. The patient did not develop recurrence in the 24 months after surgery. We have demonstrated that laparoscopic resection of an esophageal duplication cyst may be performed effectively with intraoperative assessment of tissue perfusion using a near‐infrared indocyanine green fluorescence system.     

腹壁韧带样纤维瘤影像学诊断(附3例报告)

目的探讨韧带样纤维瘤的影像学表现。方法结合文献分析3例韧带样纤维瘤的病理起源、临床特点与影像学表现。结果典型的韧带样纤维瘤表现为较均质的、沿着肌纤维生长的单发病灶。CT表现为肌肉密度均质肿块,增强后病灶不规则强化,境界较清。MRI信号较复杂,但对病灶周围组织的侵犯及改变的评估具有优势。结论韧带样纤维瘤的CT和MRI表现具有一定的特征性,结合临床病史可以作出诊断,MRI对手术切除范围的评估具有优势。     

Single‐incision laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor arising from the duodenum

We report a case involving a minimally invasive single‐incision laparoscopic and endoscopic cooperative local excision of a duodenal gastrointestinal stromal tumor. A 59‐year‐old man presented with a 35‐mm lesion located in the second portion of the duodenum. A local resection was performed via single‐incision laparoscopic and endoscopic cooperative surgery. Intraluminal endoscopic dissection of the duodenal mucosa and submucosa was performed circumferentially around the tumor. The resection was then completed by laparoscopic dissection of the seromuscular layer around the tumor. The tumor was retrieved laparoscopically. After confirming that the resection achieved clear surgical margins, we closed the duodenal wall with a laparoscopic stapling device. There were no postoperative complications, including stenosis. Single‐incision laparoscopic and endoscopic cooperative surgery can be safely and effectively performed for a duodenal submucosal tumor.     

Un fibrome desmoplastique du tibia proximal révélé par une fracture pathologique : un cas rare

Desmoplastic fibroma or desmoid bone tumor is a rare tumor described for the first time by Jaffe in 1958. It accounts 0.3% of all benign bone tumors. Histology is required for certain diagnosis of desmoid fibroma. The tumor is composed of sparse fibroblasts in a rich background of collagen fibers, a histological presentation exactly the same as soft tissue desmoid fibroma. Histological study of this tumor may be difficult. Pathological fracture represents a rare revealing. We report a case of a desmoplastic fibroma of the proximal tibia revelated by a pathological fracture. The observation illustrates differents diagnosis and therapeutic aspects of this tumor. The rate of local recurrence is high in the event of partial resection. Surgery is the optimal treatment, with tumor resection as wide as possible depending on the localization, cimentoplasty and internal fixation.     

Laparoscopy assisted middle‐segment–preserving pancreatectomy for multiple pancreatic neuroendocrine tumors: Report of a case

For multiple low‐grade malignant tumors located in the pancreatic head and tail, middle‐segment–preserving pancreatectomy (MSPP) is sometimes indicated. However, MSPP has rarely been performed laparoscopically. Here we report the first case of laparoscopic MSPP for multiple pancreatic neuroendocrine tumors diagnosed preoperatively under an endoscopic ultrasound‐guided fine‐needle aspiration biopsy. A 70‐year‐old man had multiple small tumors located in the pancreatic head, body and tail. Endoscopic ultrasound‐guided fine‐needle aspiration biopsy with immunohistochemical staining made a definitive diagnosis of a pancreatic neuroendocrine tumor (G1). To preserve the 5‐cm pancreas body, we successfully performed laparoscopic MSPP: subtotal stomach‐preserving pancreaticoduodenectomy followed by distal pancreatosplenectomy. Pathological examination revealed negative surgical margin after resection. Postoperative course was uneventful, and at 14 months after the operation, the patient remains tumor‐free. The patient has discontinued insulin supplement therapy but does use an oral hypoglycemic agent. Laparoscopy‐assisted MSPP, with reconstruction through a 6‐cm transverse incision, can be safely performed for selected cases of borderline and malignant lesions.     

腹壁韧带样瘤切除Dacron补片修补11例

目的：总结腹壁韧带样瘤的外科治疗经验。方法：11例腹壁韧带样瘤的患者，采用肿瘤广泛切除，Dacron补片修补。结果：11例手术治愈，无手术死亡、严重并发症的术后肿瘤复发。结论：腹壁韧带样瘤需行广泛切除，用人造材料修补腹壁缺损。这种手术方法简单，安全有效，可减少术后肿瘤复发的机会。     

Desmoid tumors of the abdominal wall.

Desmoid tumors are musculo-aponeurotic fibromatoses which most commonly occur in the abdominal wall. They do not metastasize but local recurrence is common. The treatment of choice is wide local excision of the mass and surrounding normal tissue. We have described a rare desmoid tumor which involved the abdominal wall as well as small and large bowel. En bloc intestinal resections were required for complete tumor extirpation.     

Gastric plexiform fibromyxoma: A case report

BACKGROUNDPlexiform fibromyxoma (PF) is a rare mesenchymal tumor of the stomach. The clinical features of PF frequently include upper abdominal pain, abdominal discomfort, hematemesis, melena, pyloric obstruction and an upper abdominal mass. We herein report a case of PF resected by laparoscopic radical distal gastrectomy plus Roux-en-Y gastrojejunostomy.CASE SUMMARYThe patient was admitted to hospital, due to a 1-wk history of an abdominal space-occupying lesion identified during a health examination. He underwent complete resection by laparoscopic radical distal gastrectomy plus Roux-en-Y gastrojejunostomy. During the operation, the tumor was located in the anterior wall of the gastric antrum (approximately 7 cm × 6 cm × 5.5 cm) and did not show evidence of invasion of the serosa. Histology showed that the tumor cells were oval fibroblast-like and spindle-shaped cells, with numerous thin-walled blood vessels and abundant myxoid stroma. Cellular atypia and mitosis were both rare. Immunohistochemistry showed that the tumor cells were immunoreactive for smooth muscle actin, S-100 and CD-10, but were negative for CD-117, CD-34, DOG-1, and ALK. In this case, S-100 was positive and no significant disease was observed during the follow-up period.CONCLUSIONThe fact that PF is a rare tumor with only a few cases in this region can lead to misdiagnosis of this entity and pose a real diagnostic challenge for general surgeons and pathologists when encountering such patients and differentiating PF from other primary tumors of gastric mesenchymal origin. Our report may help increase awareness of this rare, but important new disease entity.     

Case report of perineal hernia after laparoscopic abdominoperineal resection

Perineal hernia (PH) is a rare complication following laparoscopic abdominoperineal resection (APR) for rectal cancer. We present a case report of perineal hernia after laparoscopic APR and discuss its management. The patient was a 77‐year‐old man who was diagnosed with lower rectal cancer. He underwent laparoscopic APR and bilateral lateral lymph node dissection. Two months after the surgery, pain and bulging in the perineal region developed, and PH was diagnosed by CT. Repair with a polypropylene mesh was performed using a combination of laparoscopic abdominal and transperineal approaches. Reportedly, the incidence of secondary PH after APR has increased along with the rate of laparoscopic surgery. Treatment of secondary PH with transperineal repair alone may cause injuries to other organs because of adhesion of the pelvic viscera. In the present case, we safely repaired the hernia repair using a laparoscopy‐assisted perineal approach.     

Unusual complication in patient with Gardner’s syndrome: Coexistence of triple gastrointestinal perforation and lower gastrointestinal bleeding: A case report and review of literature

Gardner’s syndrome (GS) is a rare syndrome with autosomal dominant inheritance, which is characterized by multiple intestinal polyps, dental anomalies, desmoid tumors, and soft tissue tumors. All gastrointestinal symptoms seen in GS are associated with the underlying familial adenomatosis polyposis and abdominal desmoid tumors, with the most common symptoms being anemia, lower gastrointestinal bleeding, abdominal pain, diarrhea, obstruction, and mucous defecation. To our best knowledge, no case of GS that has presented with gastrointestinal perforation and bleeding has ever been reported in the English language medical literature. A 37-year-old male who had been diagnosed with GS five years earlier was referred to our clinic for lower gastrointestinal bleeding. Despite the absence of a bleeding focus on conventional angiography, the patient was operated on with laparotomy, due to the persistence of both signs and symptoms of mild peritonitis. On the laparotomy, the patient was noted to have areas of perforation in the duodenum, splenic flexura, and mid-rectum. The third and fourth part of the duodenum, the proximal 15 cm segment of the jejunum, a 10 cm segment of the terminal ileum, the whole colon, and the upper and middle rectum were resected, and duodeno-jejunal side-to-side anastomosis and terminal ileostomy were performed. The histopathological analysis of the large mass measuring 30 cm × 20 cm was reported as a desmoid tumor. The pathological examination of the tumor foci detected in the colonic specimen revealed poorly differentiated adenosquamous carcinoma.     

Multiple gastric gastrointestinal stromal tumors treated by laparoscopic‐endoscopic cooperative surgery: A case report

The typical treatment of choice for gastrointestinal stromal tumors (GIST) is surgical resection. Here we report a case of three GIST lesions resected safely by laparoscopic‐endoscopic cooperative surgery (LECS). A 78‐year‐old woman was referred to our hospital for further treatment of an enlarging gastric submucosal tumor. Esophagogastroduodenoscopy and endoscopic ultrasonography revealed two gastric submucosal tumors. Endoscopic ultrasonography‐guided fine needle aspiration was subsequently performed. The patient underwent LECS in accordance with therapeutic guidelines for GIST. Assisted by a laparoscope and using three trocars, a full‐thickness resection was performed endoscopically for the 3‐cm lesion and its nearby submucosal tumor, which was newly detected intraoperatively. The other lesion was also resected with an autosuture device under laparoscopy. No intraoperative or postoperative complications were observed. In LECS, endoscopic observation and resection can minimize gastric deformation and preserve gastric function. To the best of our knowledge, this is the first case of LECS performed on multiple GIST.     

Ileal bronchogenic cyst: A case report and review of literature

We herein report a rare case of ileal bronchogenic cyst that was found in a 39-year-old Chinese man. He had no symptoms and the physical examination was normal. Tumor markers were within the normal range. Abdominopelvic enhanced computed tomography showed a mass in the lower abdominal cavity and the tumor had a complete capsule. Diagnostic laparoscopy was then performed, which showed that a spheroid mass with a complete capsule was located at the antimesenteric border of the distal ileum 20 cm from the ileocecal valve, measuring 6.0 cm × 6.0 cm × 5.0 cm. Considering that the malignancy of the tumor cannot be ruled out, and there is a risk of rupture during laparoscopic surgery, the patient was converted to an open surgery. Partial resection of the ileum with the tumor was performed, followed by a side-to-side anastomosis. The tumor was gray-red in color, filled with grayish yellow mucus and had no septum. The postoperative pathology revealed that the cystic wall was lined by pseudostratified ciliated columnar epithelium without cellular atypia. The wall consisted of bronchial mucous glands and smooth muscle fibers, and no abnormalities were found in adjacent ileum tissues. Thus, a diagnosis of bronchogenic cyst of the ileum was made.     

Laparoscopic dissection for pelvic lymph node recurrence of thymic carcinoma: A case report

Thymic carcinoma, a rare mediastinal neoplasm, is characterized by extensive local invasion and distant metastasis. To our knowledge, this is the first case report demonstrating the efficacy of laparoscopic dissection for pelvic lymph node metastases from thymic carcinoma. A 64‐year‐old man was found to have a mediastinal mass by CT and underwent radical resection. Six months after resection of his thymic carcinoma, follow‐up CT revealed a gluteal tumor and enlarged pelvic lymph nodes. The gluteal tumor was resected percutaneously. Two months after this procedure, PET showed that the three pelvic lymph nodes had abnormal uptake of ¹⁸F‐fluorodeoxyglucose and had enlarged further. The patient accordingly underwent laparoscopic dissection of these lymph nodes. Pathological examination of all resected specimens showed metastatic thymic carcinoma. We recommend laparoscopic dissection of pelvic lymph node metastases because it provides a clear intraoperative view and is minimally invasive.     

Laparoscopic surgery for repeated cecal volvulus with intestinal malrotation: A case report

This is the first report of laparoscopic surgery for an advanced‐age patient with cecal volvulus accompanied by intestinal malrotation. A 96‐year‐old woman who had previously undergone laparotomy for cecal volvulus underwent emergency laparoscopic surgery for recurrent volvulus. Because the cecum was about to rupture but not ischemic, we untwist the intestinal volvulus and fixed the cecum to the abdominal wall with a single suture. Five days after the surgery, the volvulus between the suture and the hepatic flexure of the colon recurred. We performed a second laparoscopic surgery in which we fixed the right side of the colon to the abdominal wall after diagnosing intestinal malrotation. Given its positioning, the sign of malrotation would not have been visible on preoperative CT images. As shown by this case, intestinal malrotation might lie behind the repeated cecal volvulus, and laparoscopic surgery may be a good option for volvulus with intestinal malrotation, even in cases with obstruction.