Sacrococcygeal teratomas: a case-based review from the perspective of individual multidisciplinary experts.

PURPOSE: Sacrococcygeal teratoma (SCT) is a rare congenital tumor originating from a variant of extragonadal germ cell neoplasm. Herein, we present three cases of neonatal SCTs undergoing surgical resection and reconstruction. We also review the literature to discuss the importance of proper perinatal management and timely surgical intervention depending on the tumor type and maturity to prevent malignant transformation and recurrence and ensure functional outcomes. METHODS AND RESULTS: Three cases of SCT were retrospectively analyzed. All infants underwent complete surgical resection of the SCT and coccygectomy during their neonatal/infancy period, followed by pelvic floor and buttock reconstruction while minimizing buttock contour deformity and undesirable skin scar. Two of the cases were histopathologically diagnosed as predominantly cystic mature teratomas of Altman types I and IV, and the third was a mature teratoma of Altman type II. There were no complications or tumor recurrence during the average follow-up period of 5.3 years. CONCLUSIONS: This case-based review highlights the role of multidisciplinary team approaches, including prenatal monitoring, oncologic resection, and adequate reconstruction according to the type of tumor and anomaly. Optimal perinatal evaluation allows promising oncologic and functional outcomes in terms of timely intervention to eliminate tumor recurrence and malignant transformation. Complete oncologic surgical resection of SCTs should also include proper functional preservation strategies, such as the reconstruction of the pelvic floor, cosmetic buttock contouring, and preservation of bladder and bowel sphincter function.

Amyand's hernia combined with contralateral recurrent inguinal hernia: A case report.

INTRODUCTION: Amyand's hernia (AH)-where the appendix becomes incarcerated within the inguinal hernia (IH) sac-is rare, particularly if detected and operated concurrent with a contralateral recurrent IH. PRESENTATION OF CASE: A 65-year-old man presented with symptomatic bilateral IH; the left IH was recurrent. Abdominopelvic computed tomography (CT) revealed a right IH with appendiceal herniation and left recurrent IH with omental fat. Using the prolene hernia system (PHS) mesh, the left recurrent IH underwent operation, followed by the right AH. The patient was in a good state with no recurrence 16 months postsurgery. DISCUSSION: If AH is accidentally encountered during surgery, the procedure should differ depending on the inflammatory state of the appendix. Simultaneously operating AH and contralateral recurrent IH is complicated; it is necessary to preoperatively decide which side to operate on first and whether to use an anterior or laparoscopic posterior surgical approach. If the planned operation is unattainable, alternative surgery should be considered. Fortunately, herein CT was performed prior to surgery, and the surgical plan was properly established. CONCLUSION: Prior to simultaneous AH and contralateral recurrent IH surgery, the surgical plan should be established. If the planned surgical technique for recurrent hernia repair is not feasible, an alternative should be performed. In AH repair, different surgical methods are required depending on the presence and severity of inflammation of the appendix.

Squamous cell carcinoma arising from a huge buttock epidermal cyst without skin lesion: A case report.

INTRODUCTION: Epidermal cysts are common lesions on the surface of the body. However, squamous cell carcinomas (SCCs) arising from epidermal cysts are rare and even rarer without skin lesions, such as ulcers. PRESENTATION OF CASE: A 66-year-old male presented with a 10-cm sized mass on the left buttock without skin lesions. The patient was aware of the existence of the lesion 10 years prior. However, recently, the mass increased in size causing pain. Surgical resection was decided based on the suspicion of an epidermal cyst. Histopathological examination revealed SCC arising from an epidermal cyst. Additional complete resection was performed. No recurrence was observed 1 year after the surgery. DISCUSSION: The clinical and pathophysiological characteristics of malignant transformation of epidermal cysts have not yet been fully elucidated. However, the lesions are characterized by long-lasting and rapid growth later, with the presence of a keratinous cystic tissue structure similar to an epidermal cyst. Part of the tumor is non-malignant, which is adjacent to the area of atypical cell proliferation. The present case had all the above four characteristics and was therefore diagnosed as SCC arising from an epidermal cyst. CONCLUSION: Even if a palpable mass shows benign findings on physical examination, malignant transformation should be considered if the mass grows rapidly in size and is accompanied by symptoms such as pain.

Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study.

PURPOSE: Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. METHODS: A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. RESULTS: A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. CONCLUSION: There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.

Primary Grynfeltt's hernia combined with intermuscular lipoma: A case report.

INTRODUCTION: Grynfeltt's hernia (superior lumbar hernia) is a rare posterolateral abdominal wall defect and is often misdiagnosed as an abdominal wall lipoma. I recently experienced a case of primary Grynfeltt's hernia combined with intermuscular lipoma that was managed surgically. PRESENTATION OF CASE: A 79-year-old man presented with a left flank mass. In the seated position, when the abdominal pressure was raised by deep breathing after left flank extension, the mass became clearer. Abdominal computed tomography (CT) findings showed herniated perirenal fat via the superior lumbar triangle and a surrounding intermuscular lipoma. After intermuscular lipoma removal, the hernia defect was closed with primary simple interrupted sutures. Currently, at 5 months postoperatively, no recurrence has been observed. DISCUSSION: On physical examination of Grynfeltt's hernia, it may be difficult to identify the distinct mass because of the relatively large overlaying of the latissimus dorsi muscle. Thus, Grynfeltt's hernia can be misdiagnosed as soft tissue tumors, such as lipomas. Abdominal CT findings may provide an accurate diagnosis and reveal the anatomical structures and additional lesions. Proper surgical treatment should be planned based on the etiology, size of the hernia defect, condition of the surrounding structures, and presence of additional lesions. CONCLUSION: Grynfeltt's hernia should be considered when a mass is palpable on the posterolateral abdominal wall and in cases where the size of the mass changes when changing position. CT examination of the abdomen may help make an accurate diagnosis, observe additional lesions, and develop a surgical-treatment plan.

Solitary jejunal cavernous hemangioma causing intermittent melena: A case report.

INTRODUCTION AND IMPORTANCE: Hemangioma of the small intestine is a rare disease that causes acute and chronic intestinal bleeding and is difficult to diagnose before surgery. This report presents a case of a cavernous hemangioma confined to the jejunum of a man with intermittent melena. CASE PRESENTATION: A 38-year-old man presented with an episode of melena one and a half month ago. He had similar symptoms a year ago and had undergone esophagogastroduodenoscopy, colonoscopy, and abdominopelvic computed tomography, but the results were normal. Abdominopelvic computed tomography performed after hospitalization showed a small intraluminal protruding mass in the jejunum. A jejunal hemangioma was found during laparoscopy and was successfully treated with intestinal resection. CLINICAL DISCUSSION: It is difficult to identify the cause of gastrointestinal bleeding preoperatively in patients with normal esophagogastroduodenoscopy, colonoscopy, and abdominopelvic computed tomography results. Small bowel tumors, especially small hemangiomas, should be considered as a cause. Laparoscopy may be one option for finding and treating lesions of the small intestine in hospitals where capsule endoscopy or double-balloon intestinal enteroscopy is not available. CONCLUSION: This report presents a case of a cavernous hemangioma localized in the jejunum of a 38-year-old man with intermittent melena that was successfully treated with laparoscopy and intestinal resection, thereby emphasizing the usefulness of laparoscopy in hospitals where capsule endoscopy or double-balloon intestinal enteroscopy is not available.

Tuberculosis of Cystic Duct Lymph Node Associated with Cholecystitis.

Tuberculosis of the cystic duct lymph node is very rare. Only four cases have been reported in the literature. This paper presents the case of a young male patient with a tuberculous cystic duct lymph node and chronic cholecystitis, who was diagnosed with cystic duct stones and a gall bladder polyp preoperatively.

The Management of Retained Rectal Foreign Body.

PURPOSE: Because insertion of a foreign body (FB) into the anus is considered a taboo practice, patients with a retained rectal FB may hesitate to obtain medical care, and attending surgeons may lack experience with removing these FBs. We performed this study to evaluate the clinical characteristics of Korean patients with a retained rectal FB and propose management guideline for such cases based on our experience. METHODS: We retrospectively investigated 14 patients between January 2006 and December 2018. We assessed demographic features, mechanism of FB insertion, clinical course between diagnosis and management, and outcomes. RESULTS: All patients were male (mean age, 43 years) and presented with low abdominal pain (n = 2), anal bleeding (n = 2), or concern about a retained rectal FB without symptoms (n = 10). FB insertion was most commonly associated with sexual gratification or anal eroticism (n = 11, 78.6%). All patients underwent general anesthesia for anal sphincter relaxation with the exception of 2 who underwent FB removal in the emergency department. FBs were retrieved transanally using a clamp (n = 2), myoma screw (n = 1), clamp application following abdominal wall compression (n = 2), or laparotomy followed by rectosigmoid colon milking (n = 2). Colotomy and primary repair were performed in four patients, and Hartmann operation was performed in one patient with fecal peritonitis. No morbidity or mortality was reported. All patients refused postextraction anorectal functional and anatomical evaluation and psychological counseling. CONCLUSION: Retained rectal FB is rare; however, colorectal surgeons should be aware of the various methods that can be used for FB retrieval and the therapeutic algorithm applicable in such cases.

Pediatric Adenocarcinoma in Korea: A Multicenter Study.

PURPOSE: Adenocarcinoma is an extremely rare malignancy in the pediatric population. Research regarding pediatric adenocarcinoma is very rare in Korea. This study aimed to investigate the clinical features of pediatric adenocarcinomas of various primary organ sites in Korea. MATERIALS AND METHODS: Pediatric patients under 18 years, diagnosed with adenocarcinoma of various sites between January 1995 and December 2016, were included. We retrospectively reviewed patient and tumor characteristics and calculated survival estimates, reported as 5-year survival rate and 95% confidence interval. RESULTS: Of 80 patients (median age, 15 years; range, 10 to 17 years), 37 (46.3%) were men, and 24 (30%) had a family history of cancer or underlying disease relevant to malignancy. The cancer locations were the colon and rectum (n=32), ovaries (n=18), stomach (n=15), lung (n=4), small bowel (n=1), and other sites (n=10). Totally, 54.8% patients (42/77) had stage 3 or 4 disease. The median follow-up period was 2.0 years (range, 0 to 20.4). The 5-year overall survival estimate for all patients, and for those with stomach, colorectal, ovarian, and other cancer sites were 57.9%±11.5%, 58.2%±25.7%, 41.5%±18.2%, 87.5%±16.2%, and 64.0%±34.4%, respectively. The 5-year survival rate differed significantly between categories of adenocarcinomas into gastrointestinal (GI) (44.7%) and non-GI adenocarcinomas (78.8%) (p=0.007). The 5-year survival rate also differed significantly according to carcinoembryonic antigen level (69.3% in < 3 ng/mL, 23.8% in > 3 ng/mL; p < 0.001). CONCLUSION: In pediatric patients, adenocarcinomas arise from various organs and are often diagnosed at advanced stages. Large, prospective studies for their accurate clinical characteristics and prognostic factors are needed.

Differentiation of gallbladder adenomyomatosis from early-stage gallbladder cancer before surgery.

BACKGROUNDS/AIMS: This study aimed to compare the perioperative and clinical outcomes in patients undergoing laparoscopic cholecystectomy for gallbladder adenomyomatosis (GBA) or early-stage gallbladder cancer (GBC). METHODS: The perioperative and clinical outcomes of 194 patients diagnosed with GBA and 30 patients diagnosed with GBC who underwent laparoscopic cholecystectomy in our institution from January 2011 to December 2017 were retrospectively compared. RESULTS: There were no significant differences between the GBA and GBC groups in sex (male:female ratio 1.0:0.8 vs. 1.0:0.7, p=0.734), BMI (23.9±3.4 vs. 24.0±3.8 kg/m2, p=0.916), or preoperative liver function tests. Patients in the GBC group were significantly older (50.5±14.1 vs. 65.9±10.6 years, p<0.001) and had a higher ASA grade (40.3 vs. 63.4% grade II or III, p=0.043) than patients in the GBA group. Although there was no significant difference in preoperative diagnostic methods (p=0.442), the GBC group showed a significantly higher rate of misdiagnosis on preoperative imaging compared with postoperative histopathologic findings (30.9% vs. 53.3%, p=0.011). There were significantly more patients with gallstones in the GBA group than in the GBC group (68.6% vs. 40.0%, p=0.004). CONCLUSIONS: In older patients hospitalized for biliary colic without gallstones but with a thickened gallbladder wall with inflammation on preoperative diagnostic exam, the possibility of early-stage GBC should be considered.

Clinical Manifestations of Superior Mesenteric Venous Thrombosis in the Era of Computed Tomography.

PURPOSE: Thrombosis of the portal vein, known as pylephlebitis, is a rare and fatal complication caused by intraperitoneal infections. The disease progression of superior mesenteric venous thrombosis (SMVT) is not severe. This study aimed to determine the clinical features, etiology, and prognosis of SMVT. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 41 patients with SMVT from March 2000 to February 2017. We obtained a list of 305 patients through the International Classification of Disease-9 code system and selected 41 patients with SMVT with computed tomography. Data from the medical records included patient demographics, comorbidities, review of system, laboratory results, clinical courses, and treatment modalities. RESULTS: The causes of SMVT were found to be intraperitoneal inflammation in 27 patients (65.9%), malignancy in 7 patients (17.1%), and unknown in 7 patients (17.1%). Among the patients with intraperitoneal inflammation, 14 presented with appendicitis (51.9%), 7 with diverticulitis (25.9%), and 2 with ileus (7.4%). When comparing patients with and without small bowel resection, the differences in symptom duration, bowel enhancement and blood culture were significant (P=0.010, P=0.039, and P=0.028, respectively). CONCLUSION: SMVT, caused by intraperitoneal inflammation, unlike portal vein thrombosis including pylephlebitis, shows mild prognosis. In addition, rapid symptom progression and positive blood culture can be the prognostic factors related to extensive bowel resection. Use of appropriate antibiotics and understanding of disease progression can help improve the outcomes of patients with SMVT.

Thrombolytic Therapy Using Urokinase for Management of Central Venous Catheter Thrombosis.

PURPOSE: The management of central venous catheters (CVCs) and catheter thrombosis vary among centers, and the efficacy of the methods of management of catheter thrombosis in CVCs is rarely reported. We investigated the efficacy of bedside thrombolysis with urokinase for the management of catheter thrombosis. MATERIALS AND METHODS: We retrospectively reviewed data from patients who had undergone CVC insertion by a single surgeon in a single center between April 2012 and June 2014. We used a protocol for the management of CVCs and when catheter thrombosis was confirmed, 5,000 U urokinase was infused into the catheter. RESULTS: A total of 137 CVCs were inserted in 126 patients. The most common catheter-related complication was thrombosis (12, 8.8%) followed by infection (8, 5.8%). Nine of the 12 patients (75%) with catheter thrombosis were recanalized successfully with urokinase. The rate of CVC recanalization was higher in the peripherally inserted central catheter (PICC) group (87.5%) than the chemoport group (50%). Reintervention for catheter-related thrombosis was needed in only 2.2% of patients when thrombolytic therapy using urokinase was applied. Age <60 years (P=0.035), PICC group (P=0.037) and location of the catheter tip above the superior vena cava (P=0.044) were confirmed as independent risk factors for catheter thrombosis. CONCLUSION: Thrombolysis therapy using urokinase could successfully manage CVC thrombosis. Reintervention was rarely needed when a protocol using urokinase was applied for the management of CVC thromboses.

Comparison of clinical outcomes and hospital cost between open appendectomy and laparoscopic appendectomy.

PURPOSE: Laparoscopic appendectomy has been recognized to have many advantages such as greater cosmetic results, less postoperative pain and shorter hospital stays. On the other hand, the cost of laparoscopic procedures is still more expensive than that of open procedures in Korea. The aim of this study is to compare clinical outcomes and hospital costs between open appendectomy and laparoscopic appendectomy. METHODS: Between January 1, 2010 and December 31, 2010, 471 patients were diagnosed with acute appendicitis. Of these, 418 patients met the inclusion criteria and were divided into two groups of open appendectomy (OA) group and laparoscopic appendectomy (LA) group. We analyzed the clinical data and hospital costs. RESULTS: The mean operation time for laparoscopic appendectomy (72.17 minutes) was significantly longer than that of open appendectomy (46.26 minutes) (P = 0.0004). The mean amounts of intravenous analgesics for OA group (2.00 times) was greater than that of LA group (1.86 times) (P < 0.0001). The complication rate was similar between the two groups (OA, 6.99% vs. LA, 10.87%; P = 0.3662). The mean length of postoperative hospital stay was shorter in LA group (OA, 4.55 days vs. LA, 3.60 days; P = 0.0002). The mean total cost covered by the National Health Insurance was more expensive in LA group (OA, 1,259,842 won [Korean monetary unit] vs. LA, 1,664,367 won; P = 0.0057). CONCLUSION: Clinical outcomes of laparoscopic appendectomy were superior to that of open appendectomy even though the cost of laparoscopic appendectomy was more expensive than that of open appendectomy. Whenever surgeons manage a patient with appendicitis, laparoscopic appendectomy should be considered as the procedure of choice.

Clinical characteristics of primary epiploic appendagitis.

PURPOSE: Primary epiploic appendagitis (PEA) is a rare cause of an acute abdomen. It can be clinically misdiagnosed as either diverticulitis or appendicitis on clinical examination because the clinical symptoms and signs of PEA are non-specific. The present study was performed to describe the clinical characteristics of PEA and to assess the differences between PEA and diverticulitis. METHODS: We reviewed the clinical records and radiologic findings of 31 consecutive patients with PEA and compared them with those of patients with diverticulitis without complications. RESULTS: In most cases, abdominal pain was localized to the right (13 cases, 41.9%) or left (13 cases, 41.9%) lower quadrants. Gastrointestinal symptoms such as nausea and vomiting were infrequent, and localized tenderness without peritoneal irritation was common. All patients were afebrile, and only 4 patients (12.9%) showed leukocytosis. In all cases except one, a pericolic fatty mass with a hyperattenuated ring was observed on computed tomography. Patients with left PEA were younger than those with diverticulitis (41.4 ± 11.9 vs. 69.7 ± 13.3, P < 0.001), and the mean body mass index was higher in patients with left PEA (26.4 ± 2.9 vs. 22.6 ± 3.4, P = 0.01). Whereas one patient (6.7%) with left PEA showed leukocytosis, the incidence of leukocytosis in patients with diverticulitis was 80% (8/10) (P < 0.001). CONCLUSION: In patients with an acute abdomen showing localized tenderness without associated symptoms or leukocytosis, a high index of suspicion for PEA is necessary. For correct diagnosis and proper management, it would useful for surgeons to be aware of the computed tomographic findings and the natural course of the disease.