Impact of biliary drainage method before pancreaticoduodenectomy on short- and long-term outcomes in patients with periampullary carcinoma and obstructive jaundice: A multicenter retrospective analysis.

BACKGROUND: The optima preoperative biliary drainage before pancreaticoduodenectomy in patients with biliary tract and pancreatic cancer remains controversial. METHODS: A total of 898 patients who underwent preoperative biliary drainage via endoscopic retrograde biliary drainage, endoscopic transnasal biliary drainage, or percutaneous transhepatic biliary drainage before pancreaticoduodenectomy for biliary tract and pancreatic cancer were included. Perioperative and long-term outcomes were analyzed. RESULTS: The Clavien-Dindo grade ≥3 morbidity rates after pancreaticoduodenectomy were higher in the endoscopic retrograde biliary drainage (21.9%; P = .001) or endoscopic transnasal biliary drainage (20.2%; P = .007) than in the percutaneous transhepatic biliary drainage (9.7%) groups. In biliary tract cancer, the frequency of dissemination after pancreaticoduodenectomy was higher in the percutaneous transhepatic biliary drainage (15.3%) than in the endoscopic retrograde biliary drainage (0.7%; P = .001) and endoscopic transnasal biliary drainage (4.1%; P = .037) groups; percutaneous transhepatic biliary drainage was an independent factor associated with worse disease-free survival (P = .04), whereas in pancreatic cancer the frequency of dissemination and survival was comparable among the 3 preoperative biliary drainage methods. Albumin <3.9 g/dL was independently associated with worse overall survival in patients with both pancreatic (P = .038) and biliary tract (P = .002) cancers, respectively. During biliary drainage, external drainage (P = .038) was independently associated with albumin <3.9 g/dL; albumin was higher in endoscopic retrograde biliary drainage group than in endoscopic transnasal biliary drainage or percutaneous transhepatic biliary drainage groups after 21 days from tube insertion. CONCLUSION: In biliary tract cancer, percutaneous transhepatic biliary drainage may carry the risk of increasing the incidence of disseminative recurrence. In pancreatic cancer, percutaneous transhepatic biliary drainage is preferable owing to fewer complications without influencing recurrence. However, if patients cannot undergo surgery immediately, endoscopic retrograde biliary drainage will be applicable to help the preservation of nutritional status, which can have an impact on survival.

Integrated Laparoscopic Management of Parastomal and Midline Incisional Double Hernias: A Staged Approach Including Hartmann's Reversal and Hernia Repair.

Parastomal hernia (PH) following Hartmann's procedure is a common late-term complication and is often combined with an incisional hernia (IH). The surgical treatment for double hernias with an end colostomy is complex and challenging. We present a 54-year-old woman with an end colostomy and combined hernias (PH and midline IH) after an emergency Hartmann's procedure for diverticular perforation of the sigmoid colon underwent staged surgery. First, laparoscopic Hartmann's reversal (LHR) and PH repair with primary suture were performed. Ten months later, "intraperitoneal onlay mesh repair (IPOM) plus" methods were implemented for IH repair. Both surgeries were successfully conducted using a laparoscopic approach, and no evidence of hernia recurrence has been observed in the 12 months after the second surgery. This case report provides valuable insights into the surgical strategy for double hernias with an end colostomy.

A case of enormous retroperitoneal liposarcoma with prolapse from the left inguinal canal following hernia repair.

BACKGROUND: Liposarcomas represent ~9.8-16% of soft tissue sarcomas, with the extremities and retroperitoneum being the primary sites of occurrence. While liposarcoma in the inguinal region is uncommon, few reported cases originate from the retroperitoneum and protrude into the scrotum through the inguinal canal. Here, we present a case of a retroperitoneal liposarcoma with prolapse from the left inguinal canal into the scrotum following hernia repair with a mesh plug. CASE PRESENTATION: A 55-year-old male patient underwent a CT scan for a suspected recurrent inguinal hernia, which revealed a sizeable adipose-dense tumor by the left kidney extruded through the left inguinal canal surrounding the scrotum. The patient had undergone mesh plug repair for a left inguinal hernia at another hospital one year ago and noticed ipsilateral inguinal swelling after the hernia repair. The patient was referred to our hospital. The tumor resection was completed with combined resection of potentially involved organs: left side colon, left kidney, and left adrenal gland. Also, complete excision of the tumor was accomplished through surgical resection of the posterior wall of the inguinal canal, the mesh plug, and the tumor extending into the scrotum. Given the nearly complete absence of the inguinal canal's posterior wall and the anterior wall's torn state, sutures were employed to close the external obturator tenosynovitis. Additionally, the inguinal ligament was closed using a tension-free incision technique. Only a mesh was subsequently placed. The resected tumor measured 47 × 30 × 15 cm and 7.5 kg in weight. After surgical resection, a retroperitoneal liposarcoma diagnosis was established. After 2 years and 6 months following the surgical resection, no recurrence has been observed for either liposarcoma or inguinal hernia. CONCLUSION: The previous inguinal hernia in this case must be a prolapse of retroperitoneal liposarcoma. Thus, it is recommended to conduct a preoperative examination, which should include a CT scan, since the presence of a fatty mass within the hernia may indicate the presence of a retroperitoneal liposarcoma. Even if a preoperative diagnosis cannot be made, a long-term prognosis can be expected if the retroperitoneal liposarcoma can be completely resected at reoperation.

Simultaneous resection of a neuroendocrine tumor in an incidental Meckel's diverticulum with transabdominal preperitoneal hernial repair: a case report.

BACKGROUND: As laparoscopic surgery becomes more prevalent worldwide, Meckel's diverticula are increasingly being discovered incidentally during surgery. There is no consensus on whether to follow up or resect such diverticula, which are usually asymptomatic. In cases of transabdominal preperitoneal inguinal hernia repair, resection of such a diverticulum might add the risk of mesh infection. Thus, it is unclear whether simultaneous intestinal resection is advisable. CASE PRESENTATION: A 64-year-old man diagnosed with a left indirect inguinal hernia underwent laparoscopic inguinal hernia repair, during which a 2-cm Meckel's diverticulum located contralateral to the mesentery of the ileum approximately 30 cm from Bauhin's valve was detected incidentally. Because of the potential risk of future complications such as hemorrhage, diverticulitis, or tumor development, wedge resection of the ileum was performed extracorporeally through an extended umbilical port site after completion of the hernia repair. Pathological examination revealed a neuroendocrine tumor (G1) in Meckel's diverticulum, which was successfully resected without any mesh infection or postoperative complications. DISCUSSION: Our patient's clinical course raises two important issues. First, a Meckel's diverticulum detected incidentally during laparoscopic surgery should be resected promptly because malignant tumors within such diverticula have frequently been reported. Second, simultaneous resection with hernia repair using mesh seems to be as safe as other clean-contaminated surgery. CONCLUSIONS: Management of incidental Meckel's diverticula should be selected by appropriate assessment for the risk of malignancy and complications.

Feasibility of Surveillance for Mucinous Cystic Neoplasm of the Pancreas: A Multi-Institutional Retrospective Study of 328 Patients by the Japanese Pancreatic Society.

OBJECTIVE: We aimed to elucidate the feasibility of surveillance of patients with mucinous cystic neoplasm (MCN). METHODS: We performed a retrospective, multi-institutional study of 328 patients who underwent surgery for MCN at 18 Japanese institutions. Patients with MCN were divided into an immediate surgery group and a surveillance group, which underwent surgery after surveillance. RESULTS: The median surveillance period until surgery in the surveillance group was 27 months (range, 7-165 months). Compared with the immediate surgery group, the surveillance group showed smaller tumor diameter (46 vs 50 mm, P = 0.01), more frequent laparoscopic approach (58% vs 37%, P < 0.01), and less frequent malignancy (7% vs 15%, P = 0.03). The new appearance of mural nodules and elevation of serum tumor markers were associated with malignancy in the surveillance group. Two patients in the surveillance group experienced postoperative recurrence, although there was no significant difference in recurrence or disease-free survival between the two groups. In the surveillance group, the 1-, 5-, and 10-year cumulative incidence rates of malignant MCN were 0.8%, 5.6%, and 36.5%, respectively. CONCLUSION: As the risk of progression to malignant MCNs increases over the long term, MCNs should be resected rather than subjected to unnecessary surveillance.

Clinical Impact of Radical Resection of Synchronous and Metachronous Peritoneal Metastases from Colorectal Cancer.

BACKGROUND: According to some case series, patients with colorectal cancer (CRC) who underwent radical resection of synchronous peritoneal metastases (PM) with the primary tumor had better survival than patients who underwent non-surgical treatment. However, little evidence exists regarding the significance of radical resection for metachronous PM. OBJECTIVE: This study aimed to evaluate the clinical significance of surgical intervention for isolated PM from CRC, with a particular focus on time to PM. METHODS: A total of 74 consecutive patients with isolated PM from CRC, including 40 and 34 patients with synchronous and metachronous PM, respectively, treated between 2007 and 2018 were retrospectively analyzed. The primary outcome measure was overall survival (OS) from diagnosis, and the OS was compared between radical resection and palliative chemotherapy. RESULTS: Five-year OS was 39.7% for all patients. Patients with radical resection had significantly better 5-year OS compared with those with palliative chemotherapy (62.8% vs. 11.0%; p < 0.0001). According to time to PM, patients with radical resection had significantly better 5-year OS compared with those with palliative chemotherapy for both synchronous PM (47.6% vs. 0%; p = 0.019) and metachronous PM (77.2% vs. 15.2%; p < 0.0001). Multivariable analysis stratified by time to PM revealed that surgical intervention is a significant favorable prognostic factor only in patients with metachronous PM (hazard ratio 0.117, 95% confidence interval 0.020-0.678; p = 0.017). CONCLUSIONS: Patients with radical resection of PM had good survival compared with those with chemotherapy alone, especially for metachronous PM. Surgical intervention should be considered for isolated metachronous PM when radical resection is feasible.

Impact of fundus-first laparoscopic cholecystectomy for severe cholecystitis.

BACKGROUND: The Tokyo Guidelines 2018 proposed fundus-first laparoscopic cholecystectomy (FFLC) as a bailout surgery. This study investigated the clinical impact of FFLC for severe cholecystitis. METHODS: This study reviewed 772 patients who underwent laparoscopic cholecystectomy (LC) between 2015 and 2018. Of these patients, 171 patients were diagnosed with severe cholecystitis according to our difficulty scoring system. FFLC was not prevalent in our faculty for the first 2 years [early period group (EG)], whereas FFLC was predominantly used for the last 2 years [late period group (LG)]. There were 81 patients (47%) belonging to the EG and 90 patients (53%) in the LG. The clinical data and the surgical outcomes of these patients were retrospectively analyzed. RESULTS: The difficulty score did not differ between the two groups (11 vs. 11 points, p = 0.846). Patients underwent FFLC significantly more frequently in the LG (63% vs. 12%, p = 0.020). Laparoscopic subtotal cholecystectomy (LSC) was done in 10 patients (11%) of the LG, which was significantly low compared to that in the EG (n = 20, 25%) (p = 0.020). In all patients, LC was safely achieved without bile duct injury or conversion to laparotomy. The incidence of choledocholithiasis was significantly low in the LG (0 vs. 4, p = 0.048). The median postoperative hospital stay was significantly shorter in the LG (6 vs. 4 days, p < 0.001). CONCLUSION: After the introduction of FFLC, there were significant improvements in the surgical outcomes of LC for severe cholecystitis, including the rate of LSC, incidence of choledocholithiasis, and duration of postoperative hospital stay.

Blumgart anastomosis with polyglycolic acid felt reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: A propensity score analysis.

Polyglycolic acid (PGA) felt has been used to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). However, there has been no related research on Blumgart anastomosis. Therefore, this study aimed to investigate the practical significance of Blumgart anastomosis with our new method involving PGA felt to prevent CR-POPF following PD. Data from 133 consecutive patients who underwent Blumgart anastomosis during PD between June 2015 and November 2021 were reviewed. We applied PGA felt to 35 of these patients starting from July 2020. Surgical outcomes were analyzed by propensity score matching. Thirty-five (35.7%) of the 98 patients in the without-PGA group were matched with an equal number from the with-PGA group after adjusting for covariates. CR-POPF was found in 17 patients (49%) in the without-PGA group and two patients (6%) in the with-PGA group (P < .001). The multivariate analysis results indicated that male sex, pancreatic duct size <3 mm, soft pancreatic texture, and nonuse of PGA were independently associated with CR-POPF after PD. In conclusion, Blumgart anastomosis with our new penetrating method for PGA felt reduces the incidence of CR-POPF after PD.

Prognostic factors for the successful conservative management of nonocclusive mesenteric ischemia.

BACKGROUND: The criteria for deciding upon non-operative management for nonocclusive mesenteric ischemia (NOMI) are poorly defined. The aim of this study is to determine the prognostic factors for survival in conservative treatment of NOMI. METHODS: Patients with bowel ischemia were identified by searching for "ICD-10 code K550" in the Diagnosis Procedure Combination database between June 2015 and May 2020. A total of 457 patients were extracted and their medical records, including the clinical factors, imaging findings and outcomes, were analyzed retrospectively. Diagnosis of NOMI was confirmed by the presence of specific findings in contrast-enhanced multidetector-row CT. Twenty-six patients with conservative therapy for NOMI, including four cases of explorative laparotomy or laparoscopy, were enrolled. RESULTS: Among the 26 cases without surgical intervention, eight patients (31%) survived to discharge. The level of albumin was significantly higher, and the levels of lactate dehydrogenase, total bilirubin, C-reactive protein, and lactate were significantly lower in the survivors than the non-survivors. Sepsis-related Organ Failure Assessment (SOFA) score was significantly lower in the survivors than the non-survivors. The most reliable predictor of survival for NOMI was SOFA score (cutoff value ≤ 3 points), which had the highest AUC value (0.899) with odds ratio of 0.075 (CI: 0.0096-0.58). CONCLUSIONS: The SOFA score and several biological markers are promising predictors to determine a treatment plan for NOMI and to avoid unnecessary laparotomy.

How to Establish the Bipolar Forceps Dissection Method in Robotic Inguinal Hernia Repair.

The number of robotic inguinal hernia repair (RIHR) surgeries performed by younger surgeons and surgical residents has been growing worldwide. As a result, there has been growing interest in the pace at which surgeons develop their competencies. In Japan, the number of robotic surgeries with the double bipolar technique for gastric cancer is increasing. We devised an RIHR technique for a right-hand-dominant surgeon. This article describes the procedure and step-by-step instructions for this technique. We also assessed the learning curve of a surgeon experienced in the laparoscopic transabdominal preperitoneal (TAPP) approach and robotic gastrectomy. This was a retrospective review of 31 inguinal hernia patients (40 lesions) between December 2018 and April 2021 operated by a single surgeon. The cumulative summation technique (CUSUM) was used to construct a learning curve for robotic proficiency by analyzing the times for peritoneal flap creation, mesh placement, and peritoneal closure. The postoperative course, namely, the length of hospital stay, 30-d complications, and 30-d readmission rates, was evaluated. The CUSUM graph for the total time for each phase indicated an initial decrease at lesion 12 and another decrease at lesion 36, generating three distinct performance phases: learning (n = 12 procedures), competence (n = 24), and mastery (n = 4). Between the early and late periods, no significant differences in patient characteristics or surgical outcomes were found. The learning curve for this technique was divided into three performance phases, and the technique was safely achievable in 36 procedures by a surgeon with previous experience in laparoscopic TAPP.

Laparoscopic complete excision of an enormous simple hepatic cyst occupying the entire abdomen in a child: a case report and literature review.

BACKGROUND: Simple hepatic cysts are common lesions in adults, but rare in children. Because of their benign nature, simple hepatic cysts may not be detected until they grow too large to be diagnosed and resected in a minimally invasive manner. CASE PRESENTATION: An 18-month-old girl presented with an enormous cyst occupying the entire abdomen. The beak sign on computed tomography revealed the hepatic origin of the cyst. The cyst was decompressed through the umbilicus, which was opened by the three-triangular-skin-flap technique, thus creating a working space that enabled laparoscopic surgery. The cyst was excised en bloc together with the attached hepatic parenchyma. CONCLUSIONS: Giant simple hepatic cysts occupying the entire abdomen are rare in children. Of 14 reported cases, only 1 underwent laparoscopic treatment. We have herein reported another case of a giant simple hepatic cyst in which the beak sign on imaging and the three-triangular-skin-flap umbilical opening technique were useful for its diagnosis and laparoscopic excision, respectively. Complete excision is desirable because there is a possibility of recurrence or other diseases that require total removal, including hydatid cysts and mesenchymal hamartomas.

Prenatally diagnosed biliary cysts: A spectrum from congenital biliary dilatation to biliary atresia from the same origin.

Kato and colleagues present prenatal cases with transitional features between congenital biliary dilatation and biliary atresia. They propose that all prenatal biliary cysts originate from choledochal cysts with a narrow segment, but present on a spectrum from congenital biliary dilatation to biliary atresia depending on the severity of reactive biliary sclerosis.

Long-term results of laparoscopic Hassab's procedure for esophagogastric varices with portal hypertension.

INTRODUCTION: Recent reports have shown laparoscopic gastric devascularization and splenectomy (Hassab's procedure) to be a safe and effective treatment for esophagogastric varices with portal hypertension. However, the long-term postoperative results remain unclear. METHODS: Between 2009 and 2015, 17 patients with portal hypertension and esophagogastric varices underwent laparoscopic Hassab's procedure at our institution. Two patients were lost to long-term follow-up (at least 2 years) and excluded. The remaining 15 patients' data and endoscopic findings were retrospectively reviewed. RESULTS: The median postoperative follow-up period was 56 months. The median spleen volume, operation time, blood loss, and length of postoperative hospital stay were 651 (320-1,265) mL, 305 (275-547) minutes, 347 (24-1,131) mL, and 20 (8-41) days, respectively. According to the endoscopic findings 1 year after surgery, the esophagogastric varices disappeared in three patients and improved in 12 patients. The median platelet count was significantly higher 1 year after surgery (19.7 × 104 /dL) than before surgery (5.5 × 104 /dL) (P < .001) and remained stable 2 years after surgery. Two patients died of liver disease. The remaining 13 patients, with a median postoperative follow-up of 57 months, were alive without bleeding from esophagogastric varices. CONCLUSION: Laparoscopic Hassab's procedure is a feasible treatment for esophagogastric varices with portal hypertension in terms of both short- and long-term results.

Current status and future perspectives of robotic inguinal hernia repair.

With more than 5500 da Vinci Surgical System (DVSS) installed worldwide, the robotic approach for general surgery, including for inguinal hernia repair, is gaining popularity in the USA. However, in many countries outside the USA, robotic surgery is performed at only a few advanced institutions; therefore, its advantages over the open or laparoscopic approaches for inguinal hernia repair are unclear. Several retrospective studies have demonstrated the safety and feasibility of robotic inguinal hernia repair, but there is still no firm evidence to support the superiority of robotic surgery for this procedure or its long-term clinical outcomes. Robotic surgery has the potential to overcome the disadvantages of conventional laparoscopic surgery through appropriate utilization of technological advantages, such as wristed instruments, tremor filtering, and high-resolution 3D images. The potential benefits of robotic inguinal hernia repair are lower rates of complications or recurrence than open and laparoscopic surgery, with less postoperative pain, and a rapid learning curve for surgeons. In this review, we summarize the current status and future prospects of robotic inguinal hernia repair and discuss the issues associated with this procedure.

Laparoscopic Hartmann's reversal combined with interval lymphadenectomy after emergency surgery for perforated colon cancer: A case report.

A 55-year-old man underwent Hartmann's procedure for generalized peritonitis caused by perforation of sigmoid colon cancer, which was histologically diagnosed as tubular adenocarcinoma penetrating the muscularis propria (T3). The extent of lymph node dissection was insufficient for the advanced cancer, according to the concept of complete mesocolic excision. Two months after surgery, he underwent laparoscopic Hartmann's reversal, combined with interval lymphadenectomy. En bloc resection of the colostomy, rectal stump and associated mesentery was performed with high ligation of the inferior mesenteric artery. Subsequently, the intestinal continuity was restored by end-to-end anastomosis. The postoperative course was uneventful except for infection at the stoma site. No lymph node metastasis was found by histological examination of the resected specimen, with no evidence of cancer recurrence 8 months after the initial surgery.

Which is the best predictor of clinically relevant pancreatic fistula after pancreatectomy: drain fluid concentration or total amount of amylase?

AIM: Drain fluid amylase concentration (DFAC) has been reported as a predictor of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatectomy. However, the clinical significance of measuring the total drain fluid amylase amount (DFAA) considering the daily drainage volume of CR-POPF remains unclear. METHODS: Data from 216 consecutive patients who underwent pancreaticoduodenectomy (PD) (n = 126) or distal pancreatectomy (DP) (n = 90) between August 2014 and November 2020 were reviewed. All drains were closed but not suctioned. DFAA was calculated by multiplying the DFAC and daily drainage fluid volume. DFAC and DFAA were recorded on d 1 and 3 after pancreatectomy. The cutoff value of CR-POPF was determined using the receiver operating characteristic curve. RESULTS: CR-POPF was found in 75 patients (35%) (PD: 30%, DP: 41%, P = .111); the mortality rate was zero. The cutoff value of DFAC-day 1 was 1757 U/L (sensitivity [SE]: 84%, specificity [SP]: 62%, and accuracy [AC]: 69%). The cutoff value of DFAA-day 1 was 139 U (SE: 71%, SP: 72%, and AC: 71%). The cutoff value of DFAC-day 3 was 1044 U/L (SE: 73%, SP: 79%, and AC: 78%). The cutoff value of DFAA-day 3 was 21 U (SE: 68%, SP: 72%, and AC: 70%). Multivariate analysis indicated that a nondilated pancreatic duct and high DFAC-day 3 were independently associated with CR-POPF after PD, indicating that a prolonged operative duration, massive blood loss, and high DFAC-day 3 are independently associated with CR-POPF after DP. CONCLUSION: DFAC is more reliable than DFAA for predicting CR-POPF after both PD and DP.

A case of resected hepatocellular carcinoma with gallbladder metastasis.

BACKGROUND: Advanced hepatocellular carcinoma (HCC) can often spread as intrahepatic metastases. Extrahepatic metastasis (e.g., lung, lymph nodes, and bones) is rare, and gallbladder metastasis from HCC is extremely rare. CASE PRESENTATION: A 66-year-old woman who presented with right hypochondrial pain was referred to our hospital for further examination of a liver tumor. The blood chemistry data showed elevated levels of serum α-fetoprotein (AFP) (3730 ng/mL), protein induced by vitamin K absence or antagonist II (PIVKA-II) (130 mAU/mL), and carcinoembryonic antigen (CEA) (358.6 ng/mL). Hepatitis B surface antigen and hepatitis C virus antibody were negative. Dynamic computed tomography (CT) showed a tumor measuring 12 × 7 cm in the right lobe of the liver. This tumor was contrast-enhanced in the hepatic arterial phase and then became less dense than the liver parenchyma in the portal phase. A well-enhanced tumor was found in the gallbladder. No regional lymph nodes were enlarged. Contrast-enhanced magnetic resonance imaging (MRI) demonstrated that the liver tumor showed a pattern of early enhancement and washout. The gallbladder tumor was also detected as an enhanced mass. Endoscopic retrograde cholangiography (ERC) showed compression of the left hepatic duct due to the liver tumor. The patient was diagnosed with simultaneous HCC and gallbladder cancer. Right hepatic trisectionectomy and caudate lobectomy with extrahepatic bile duct resection were performed. Histopathological examination of the resected liver specimen showed a poorly differentiated HCC cell component with a trabecular and solid growth, and diffuse invasion of the portal vein. The same tumor cells were found in the gallbladder, but no continuity with the liver tumor was identified. Immunohistochemistry of the liver tumor and gallbladder was positive for AFP, Glypican 3, and CK7, and negative for CK19. The final pathological diagnosis was the gallbladder metastasis from HCC. A follow-up diagnostic image 33 months after surgery showed a mass in the upper lobe of the left lung. The patient underwent left upper lobectomy. Postoperative pathology revealed that the lung lesion was a metastasis of HCC. The patient was still alive with lung metastasis and was being treated with a molecular-targeting drug in good health 42 months after the initial surgery. CONCLUSIONS: The standard treatment for advanced HCC with extrahepatic metastases is molecularly targeted drugs, but surgery is also an option if the lesion can be resected en bloc without remnants.

Calcium bilirubinate sludge causes early onset of congenital biliary dilatation: a report of two cases.

BACKGROUND: Symptomatic congenital biliary dilatation (CBD) during early infancy is always characterized by cystic dilation of the common bile duct with a narrow segment connecting the pancreatic duct. CASE PRESENTATION: In two consecutive infants with a prenatal diagnosis of CBD, we found that biliary sludge had formed in the cyst upon the appearance of symptoms including acholic stool and hypertransaminasemia. Infrared absorption spectrometry revealed that the sludge consisted of calcium bilirubinate. CONCLUSION: We suggest that overproduction of bilirubin by neonatal hemolysis causes sedimentation of bilirubin calcium, resulting in obstruction of the narrow segment and development of symptoms.

Ruptured intra-abdominal testicular seminoma with hemorrhage shock, after inadequate surgical exploration for undescended testis: a case report.

BACKGROUND: Undescended testes are associated with an increased risk of malignancy and infertility, and surgical treatment in childhood is recommended. CASE PRESENTATION: A 35-year-old man presented to the emergency department with abdominal pain and vomiting. Despite a history of surgery for a left undescended testis in infancy, his left-sided scrotum appeared underdeveloped. Contrast-enhanced computed tomography showed a pelvic mass, involving a major axis of approximately 15 cm, with high-density ascites suggestive of hemorrhage. A ruptured gastrointestinal stromal tumor was suspected. As he was in hemorrhagic shock, an emergency laparotomy was indicated. The active bleeding mass was controlled through complete resection. A pathological evaluation of the mass revealed a seminoma arising from an undescended testis. His post-operative course was uneventful, and he was discharged on post-operative day 6. Recurrence on the retroperitoneal lymph nodes was detected 1 year postoperatively, and a retroperitoneal lymph node dissection was performed after chemotherapy. He remains well without any apparent signs of recurrence. CONCLUSIONS: Paying close attention to an empty scrotum is advisable, even postoperatively, for undescended testis because of possible subsequent potential malignancy presenting with hemorrhage, as our patient demonstrated.