Blood levels of CEA and SCC antigen were measured in 52 patients after surgery for esophageal cancer. The CEA and SCC antigen positive rates and the time course of each antigen level were analyzed in relation to tumor recurrence. Furthermore, the usefulness of a combination assay, involving both atnigens, was assessed. For the 23 cases, in which there was tumor recurrence after surgrey, CEA had a sensitivity of 56.5%, a specificity of 89.7% and an accuracy of 75.0%. SCC antigen had a sensitivity, specificity and accuracy of 60.9%, 93.1%, 87.8%, respectively. The combination of the two antigens had a sensitivity, specificity and accuracy of 78.3%, 86.2% and 82.7%. Thus, the sensitivity was increased by combining the two parameters. Preoperative positive rates were low (CEA: 15.6% or 7/45; SCC: 13.5% or 5/37). In 5 cases, where both antigens were positive preoperatively and a tumor recurred postoperatively, the antigen levels normalized for a time after surgery and rose again upon tumor recurrence. There were 11 cases in which CEA was negative preoperatively but became positive upon tumor recurrence and 8 cases in which SCC antigen followed a similar course. In two cases, antigen levels reflected the response of recurrent tumors to treatment. Measuring both CEA and SCC antigen appears to be useful in following up patients after surgery for esophageal cancer.

View full abstract

To elucidate the significance of preserving the pyloric branch of the vagus nerve in pylorus preserving gastrectomy (PPG). We prepared 3 groups of dogs: a control with no treatment, a PPG group, and a group receiving PPG combined with truncal vagotomy (PPG-TV). Gastroduodenal motility and gastric emptying were observed in each group for comparative evaluation. During the fasting period, there was no significant difference in the gastroduodenal motility of the 3 groups. In the postprandial period, however, deterioration in the motility of the PPG-TV group was particularly notable, with a significant drop (p<0.05) in the motor activity of the pyloric ring compared with that of hte PPG group. The time required for reemergence of the postprandial interdigestive migrating contractions of the PPG-TV group was 358 minutes, which was significantly longer than the control and the PPG group (295 minutes, 319 minutes) respectively. In the gastric emptying test by the acetaminophenmethod, the delay in the PPG-TV group was again significant (p<0.05) in comparison with the other 2 groups. Pyloric branch vagotomy performed in association with PPG causes a postoperative deterioration gastroduodenal motility and a dalay in gastric emptying, indicating the importance of preservation of pyloric branch of the vagus nerve.

View full abstract

Eight hundred twenty-three gastric cancer patients who underwent gastrectomy between 1985 and 1995, when we aggressively treated even advanced stomach cnacer in aged patients were evaluated. These cases were devided into 3 groups according to age. One group was 69 years and younger (n=482), the second group was between 70 and 79 (n=258), and the third group was 80 years and older (n=83). The relationship between patient's risk factors and hospital mortality rate, showed that there are specific risk factors in gastrectomy for aged patients. According to the hospital mortality rate, the risk factors were as follows: (1) Those related to the preoperative status were PS (Performance Status) 3 or above, a decreased will to live including dementia, and inability to walk. (2) Those related to preoperative complications were respiratory disorders, hypoproteinemia and anemia. (3) Those related to surgical issues were H, P, N4 factor and total gastrectomy. In the group 69 years and younger, these risk factors did not influence the hospital mortality rate. The group between 70 and 79, only the risk (1) increased the hospital mortality rate. For the group 80 years and older, in these risk factor positive cases, the hospital mortality rate was high (1) 30.8%, (2) 21.4-27.3%, (3) 16.7-50.0%, while in the risk factor negative cases, it was (1) 5.7%, (2) 7.5%-10.5%, (3) 1.9%, showing a significant difference.

View full abstract

We investigated the significance of apoptosis in advanced gastric cancer and its relation to the expression of bcl-2 oncoprotein, S-phase fraction and DNA ploidy. We examined apoptosis by the TUNEL method using flow cytometer, bcl-2 oncoprotein by immunohistochemistry and clinicopathological features in 101 resected advanced gastric carcinomas, which were not treated by preoperative chemotherapy or radiotherapy. DNA ploidy and S-phase fraction were also determined by flow cytometry. Among these factors, only the S-phase fraction showed a correlation with the histological stage of gastric carcinoma. The expression of bcl-2 oncoprotein was significantly correlated with a low apoptotic positive cell fraction and frequently observed in undifferentiated cell type carcinoma than differentiated type. The S-phase fractions of undifferentiated cell type were greater than those of differentiated cell type and showed a tendency of a reverse correlation with apoptosis. These results indicate that apoptosis which is regulated bcl-2 has some influence on the proliferative activity of gastric carcinoma.

View full abstract

We studied the effect of portal embolization (PE) on compensatory hypetrophy, especially under the condition of cholestasis. For this study, we developed a rabbit model of partial hepatectomy, PE, bile duct ligation (BL) and PE+BL. ³H-thymidine incorporation (in vitro) into the untreated lobe after PE was enhanced mildly but continuously from Day 1 to 7, (Day 7; 229.1± 72.0%) and this enhancement was not suppressed by partial biliary retention in the embolized lobe (205.4±52.5). Atrophy of the embolized lobe after PE was greater under the condition of cholestasis, and the Day 14 weight of the untreated lobe was heavier with partial cholestasis (2.18±0.06%/body weight) than without cholestasis (1.14±0.04%). In the embolized and cholestatic lobe, DNA synthesis in vitro showed a peak at Day 5 (Peak value; 356.2± 68.2%), which was thought to indicated a high regeneration potential. But in vivo, actual regeneration (bromodeoxyuridine labelling index) was strongly suppressed. Therefore, we concluded that the effect of PE was not suppressed by the biliary retention in the embolized lobe. And the biliary drainage of the embolized lobe was thought not to be an advantage for regeneration of the untreated lobe.

View full abstract

We studied surgical treatment for hepatocellular carcinoma with hepatic vein involvement. The number of surgical cases with hepatic vein involvement (HV group) was 442. The numbers of Vv3, Vv2 and Vv1 in Japanese Liver Cancer Group's rule were 3, 13 and 3. Portal vein involvement (67%) and intrahepatic metastasis (73%), were observed in the HV group, a percentage witch was statistically higher than that of the non HV group (p<0.001). There was no statistically difference in age, sex, associated liver cirrhosis, tumor size or recurrence site between ther HV group and the non HV group. The cumulative survival rate 5 years postoperatively (31%) for the HV group was not statistically significantly different from that (49%) for the non HV group. The cumulative survival rate did not differ significantly according to the degree of hepatic vein involvement (Vv1, Vv2, Vv3). Portal vein involvement influenced the cumulative survival rate in the HV group, and 5 the patients, in the 8 patients in the HV group without portal vein involvement have been alive for over 3 years after the operation. It is considered that single hepatic vein involvement is not a prognostic factor.

View full abstract

The hourly and total volumes of bleeding in 36 patients with traumatic splenic injuries were determined by ultrasonography (US). Patients were classified into either group a (10 patients who managed conservatively), group B (9 patients who had undergone splenorraphy or partial splenectomy) and group C (17 patients who had undergone total splenectomy). The volume of bleeding estimated by US was compared to the bleeding by US was compared to the bleeding volume determined at operation, and the hourly volume loss was calculated. The mean estimated amount of bleeding was 727.3 ml in group A, 1077.8 ml in group B, and 1585.3 ml in group C, with a significant difference between groups A and C (p<0.05). The amount of blood loss estimated by US was compared with the blood loss measured at operation in the 26 patients who had undergone surgery. There was a good correlation (R=0.748, p<0.01) between the estimated and measured amounts of bleeding. The mean amount of bleeding was 12.7 ml/h for group a, 256.2 ml/h for group B and 258.5 ml/h for group C. The difference between grpoups A and C was significant (p<0.05). In conclusion, the estimated amount of bleeding in the abdominal cavity caused by injury of the spleen can be used as a criterion in the determination of surgery. Surgical treatments should be considered if the total amount of bleeding is estimated to be more than 1000 ml or if the rate of bleeding is higher than 150-200 ml/h.

View full abstract

Clinicopathological features of colorectal cancer patients with obstruction were compared with those of patients without obstruction, and surgical treatments and indications for an emergency operation for obstructive colorectal cancer were studied. The study group consists of 252 patients with carcinoma of the large bolwel, 31 of them (12.3%) with obstruction, between 1976 and 1994. In the group with obstruction there was a significantly higher incidence of bowel obstruction in males. Macroscopically, the incidence of type 3 cancer of the circumferential type was higher than in the non-obstructive cases. Histologically, the incidence of a lesion showing depth of invasion of the sub-serosa (ss) or deeper invasion of a lesion of n (+), ly (+) and v (+) was higher than in non-obstructive cases. Depending on the advance of the lesion, a significantly higher incidence of hepatic metastsis, peritoneal dissemination and stage IIIa or more severe cancer, was found in the obstructive group. The rates of resection and curative resection in the obstructive group were lower than those of the non-obstructive group. However, those rates were higher in the primary resection cases with obstruction. Our hospital's first treatment is primary curative resection with anastomosis by tube drainage. However, some patients with left-side colorectal cancer required emergency surgery because of severe obstruction. The emergency surgery in our hospital follows these criteria: 1) after 7 days of ileus complication; 2) accompanying strong pain or pressure discomfort; 3) non-effective tubal drainage up to 4 days. In addition, high-risk patients have to have a staged operation with colostomy. In low-risk patients, a one-stage operation with anastomosis is necessary.

View full abstract

We studied the survival rate of the patients (n=62) with left side colon and rectal cancer with para-aortic lymph node metastases in order to investigate the indication and significance of para-aortic lymph node dissection. There was no significant difference of the survival between the patients with n3 and n4, but the survival rate of the patiens undergoing curative operations with no residual tumor was better than that with residual tumor (p<0.0001). Furthermore, we studied the survival rate of the patients (n=40) undergoing curative operations with no residual tumor. The survival rates of the patients with left colon and Rs rectal cancer (p=0.021), or with a small number of metastatic lymph nodes (p=0.0035) were better, but no significant differences were noted between the patients with n3 and n4, in preoperative CEA level, and with or without complete para-aortic lymph node dissection. From these results, complete para-aortic lymph node dissection causing impotence may be indicated for patients with left colon or Rs rectal cancer, except poorly differentiated adenocarcinoma, and a comparatively small number of metatatic lymph nodes. But intensive therapy for the whole body is necessary for these far advanced cancers because of the high recurrence rate in the lung, general lymph nodes and bone.

View full abstract

The patient is a 66-year-old man who has complained of post-gastrectomy-dumping syndrome after breakfast for the past seven years. His major symptoms each morning were palpitation of the heart, a fainting spell, and feeling of fatigue. In this debilitative condition, the patient periodically would involuntarily lapse into a deep sleep for a period of up to 15 minutes. Prior attempts to treat this patient with drugs, diet, and exercise have been unsuccessful. On December 18, 1995, a right SBG was performed. This method was successful, and the patient experienced no symptoms of post-gastrectomy-dumping syndrome on the morning after the treatment. A left SGB was performed that day. For the past ten weeks, since the initial series of injections, the patient has remained free of discomfort.

View full abstract

We report a case of alpha-fetoprotein (AFP)-producing gastric cancer with the distant components of liver metastasis and portal tumor thrombi. A 52-year-old man was admitted to our institute for Borrmann 3 type gastric cancer of the cardia, and his serum AFP level was extremely elevated to 818.5 ng/ml. The distant components were found in the postero-superior segment of the right hepaticlobe and within the right branch of the portal vein. Total gastrectomy and right lobectomy of the liver were carried out, followed by thrombectomy of the portal tumor. These three lesions were histologically analogous and consisted of poorly differentiated adenocarcinoma. AFP was also demonstrated in the respective cytoplasm of these tumor cells by immunohistochemical staining. The serum AFP level ofthe patient had declined to 33.3 ng/ml after surgery. It is reportedly very rare for a patient with gastric cancer to have liver metastasis and portal tumor thrombi concurrently. However, when we attend the patients with high serum levels of AFP who have a space-occupying lesion of the liver and portal tumor thrombi, we should also bear in mind the possibility of AFP-producing gastric cancer as their origin.

View full abstract

A 66-year-old woman was admitted to our hospital because of abdominal distention and pain. Abdominal computed tomography (CT) and ultrasonography (US) revealed a well-defined heterogeneous giant tumor which compressed the stomach, pancreas and intestines. Neither CT 18 months before admission nor an upper gastrointestinal barium series 4 months before admission revealed abnromal findigns. We suspected that the tumor had enlarged rapidly. Angiography showed a tumor stain and dilatation of the gastroepiploic arteries. The tumor was supplied mainly by the left gastroepiploic arteries. An operation was performed under the diagnosis of an omental malignant tumor. The tumor originated from the greater omentum was resected with a block of the greater omentum. The resected tumor measured 30×25×10cm and weighed 3600 g. The histological diagnosis was leiomyosarcoma. The tumor was composed of the proliferation of spindle-shaped cells with pleomorphism and active mitoses, which suggested its rapid growth. It is difficult to find an omental tumor in the early stage, because it has no specific signs or typical symptoms earlier. The prognosis is very poor according to the literature. Therefore we suggest more aggressive investigation in cases of omental leiomyosarcoma to improve its curability.

View full abstract

A case of a resected hepatocellular carcinoma (HCC) with sarcomatous change that recurred in an early period as a huge tumor of the abdominal wall is reproted. A 65-year-old man was admitted in our hospital complaining of upper abdominal pain. He was found to have a tumor, 4.0 cm in diameter at the lateral upper segment of the liver by imaging diagnosis. He was diagnosed as having HCC, poorly differentiated type, and underwent partial hepatectomy. Histologically, the tumor consisted mostly of spindle cells or giant cells, growing medullary, and was diagnosed as HCC with sarcomatous change. There was local recurrence in the abdominal wall with hemorrhage around the resected liver 1 month after hepatectomy. This tumor grew rapidly and became about 20 cm in diameter 2 months after hepatectomy. The doubling time of this tumor was 11.9 days. We suggest that it is necessary to perform hepatectomy as much as possible in HCC with sarcomatous change, which has high malignancy.

View full abstract

An extremely rare case of malignant mixed tumor of the liver in an adult with hepatocellular carcinoma is reported. A 74-year-old man was admitted with a liver tumor that had been discovered by ultrasound scanning in another hospital. Abdominal enchanced computed tomography (CT) revealed a well-circumscribed low density area with peripheral enhancement in the left lateral segment, and abdominal portal CT revealed shadow defects in the left lateral segment and the right anterior segment. Hepatic angiography revealed a hypervascular lesion with a tumor stain. Biopsies teken from the lesion in the left lateral segment showed cholangiocarcinoma, and in the right anterior segment showed hepatocellular carcinoma. Because of severe liver cirrhosis, subsegmentectomy was performed in the left anterior lateral segment, and percutaneous ethanol injection therapy was performed for the tumor in the right anterior segment after surgery. A macroscopic view of the resected specimen showed a white solitary tumor of 4.3×3.2 cm in size. Microscopic examination revealed that the tumor consisted of epithelial and mesenchymal elements. The mesenchymal cells were spindle shaped and proliferated over the whole tumor in which hepatocellular carcinoma and cholangiocarcinoma were scattered. The pathologic diagnosis was malignant mixed tumor of the liver in an adult with hepatocellular carcinoma. Twenty-four cases of malignant mixed tumor of the liver in adults reported in the Japanese literature were reviewed.

View full abstract

We experienced a case of Clonorchis sinenesis diagnosed as a proliferated disease of gallbladder. A 60-year-old man admitted our hospital under the diagnosis of gallbladder polyp. He complained a weight loss without any other symptom. Ultrasonic examination showed a polypoid lesion in the gallbladder which was 30mm in diameter. By the Computed Tomography, only a small low dencity area was observed. Malignancy could not be ruled out and the patient underwent surgery. Hematoma was found in the gallbladder without any pathological lesion. Ova of Clonorchis sinensis were found by the pathological examination after surgery. Stool sample wlas examined and it was positive for ova. Praziquantel (80mg/kg) was administrated. Tow weeks later, ova was negative in stool. Clonorchis sinensis infection is usually diagnosed by the abdominal symptom, such as abdominal pain or liver enlargement. It is very rare that this infection was found as a polypoid lesion in gallbladder without any abdominal symptom.

View full abstract

The patient was a 72-year-old male who had undergone endoprosthesis of the Strecker-stent for stenosis of the commonbile duct after surgery of the gastric cancer. Lateral segmentectomy with hepatico-jejunostomy underwent for recurrence of obstructive jaundice following the prosthesis. He was admitted to our hospital complaining of fever, back pain and general fatigue. Endoscopic retrograde cholangiography demonstrated stenosis of the intrapancreatic bile duct and periampullary dilatation. A computed tomography (CT) had revealed minimally progression in linear measurement for the tumor during 10 months after admission. Stenosis and deviation of the hepatic inflow vessels and inferior vena cava were noted on the angiogram. Because it was diagnosed that stenosis of the common bile duct was not caused by the cancer but the primary bile duct cancer, the patient underent extended pancreaticoduodenectomy with combined vana cava. Histological findings of the tumor were mucinous adenocarcinoma, which involved the pancreas head and invaded the duodenum. Ten months after the operation, liver metastasis of the tumor was detected by CT, but it became indetectable after the percutaneus ethanol injection therapy (PEIT). The patient is achieving a tumor-free survival for 14 months with a better quality of life. Mucinous adenocarcinoma of the common bile duct is not so common in literature. In the therapy of the mucinous histological subtype, active surgical approach may improve the prognosis of advanced common bile duct cancer.

View full abstract

A rare case of asymptomatic cholangiocellular carcinoma with hepatitis B virus infection with atrophy of the right lobe of the liver and tumor embolus in the right main branch of the portal vein is described. A 59-year-old man visited our hospital with an elevation of biliary enzymes that was detected during an annual medical examination. Abdominal ultrasonography (US) showed an isoechoic massmeasuring 76×51mm in the right lobe of the liver. The diagnosis was confirmed with computed tomography (CT), endoscopic retrograde cholangiography (ERC) and angiography. No primary malignant focus was found in other organs. A curative operation, which included right trisegmentectomy with caudate lobectomy and common bile duct resection with regional lymph node dissection, was performed. The intrahepatic bile duct of the lateral segment was reconstructed to the jejunum by a Roux-en-Y procedure. Microscopic examination of the tumor revealed moderately differentiated tubular adenocarcinoma compatible with cholangiocellular carcinoma. These results suggest that screening with US may reveal liver dysfunction even in asymptomatic cases. For better prognosis, aggressive surgery may be an effective treatment even in advanced cases.

View full abstract

A 54-year-old man underwent pylorus preserving pancreatoduodenectomy for lower bile duct cancer. At the beginning of oral intake after surgery, the discharge from the drain changed from a serous fluid to a milky one and increased in volume. Because the triglyceride concentration was 2700mg/dl of the discharge, we diagnosed the fluid accumulation as chylous ascites. In spite of dietary restriction of fat and intravenous hyperalimentation, the discharge did not decrease. Then a reoperation was performed. In that operation, a stream of milky fluid was found, coming from the stump of the intestinal lymphatic trunk of the radix mesenterii. A transfixing suture was used to close it. Because chylous ascites due to operative injury is uncommon, its management is not yet established. As in this case, surgical treatment should be performed without persistence of conservative treatment when a milky discharge from the drain increases immediately after the operation.

View full abstract

We experienced a patient with a somatostatinoma of thepancreas. A 65-year-old woman, who had no clinical symptoms except impaired glucose tolerance, visited our hospital for detailed examination of the pancreas head tulnor. An abdominal ultrasonogram, CT scan and celiac angiography revealed a hypervascular lesion corresponding to that of the pancreas head. As we suspected a hormone-producing tumor of the pancreas, the concentrations of somatostain, insulin, glucagon, gastrin, vasoactive intestinal polypeptide etc. in the periphreal blood were measured by immunoassay. Only somatostatin appeared in an excess amount of 50pg/ml which was 4 times higher than the normal range (1-12pg/ml). Fromthose results, we were able to diagnose the case as pancreatic somatostatinoma preoperatively and pancreatoduodenectomy was performed. The resected specimen revealed a spherical tumor of the pancreas head measuring about 3 cm in diameter. This tumor was a benign islet-cell tumorhistologically, and stained by anti-somatostatin antibody, not by antibodies against glucagon, insulln and vasoactive intestinal polypeptide immunohistochemically. The patient was discharged after the operation and has been well without recurrence for 8 months postoperatively. To date, only 16 patients, includlng ours, with somatostatinoma of the pancreas have been reported in Japan. Their clinico-pathological features were reviewed in this study.

View full abstract

Renal cell carcinoma commonly matastasizes to the lung, bone and liver. However, metastasis to the pancreas is rare and often multiple, so diagnosis and treatment are difficult. Wereport a case of multiple pancreatic metastases from renal cell carcinoma 4 years after nephrectomy and resection of metastases to the brain and thyroid. A 52-year-old woman was admitted to our hospital with the chief complaint of bloody stool. Barium enema and colon fiberscopy revealed a tumor at the sigmoid colon. Abdominal CT and angiography demonstrated multiple hypervascular tumor at the pancreatic head and tail. Total pancreatectomy and sigmoidectomy were performed under the diagnosis of metastaticpancreatic tumor and carcinoma of the sigmoid colon. Histological examination confirmed it to be clear cell type renal cell carcinoma that had metastasized to the pancreas. Chemotherapy and radiation are not effective, and therefore, total pancreatectomy, when possible, could be the most useful treatment for this metastatic lesion.

View full abstract

A 75-year-old man attended our hospital complaining of right lower abdominal pain and fever following aplastic anemia. He had tenderness and rebound pain at the right lower abdomen. The CT and US findings of swelling in the intestine from the terminal ileum to the ascending colon suggested neutropenic enterocolitis. In emergent laparotomy, swelling of intestines as shown at CT and US examination and necrotized cecum were resected and anastomosis was performed end to side using a stapling device. After operation, the patient recovered with an increasing neutrophil count due to the effect of antibiotics and granulocyte colony stimulating factor. Generally neutropenic enterocolitis only attacks the immunocompromised patients with neutropenia. Where neutropenia is present, early detection of neutropenic enterocolitis is essential when a patient complains of clinical symptoms such as abdominal pain, fever or diarrhea.

View full abstract

An 80-year-old woman developed myxedema megacolon. Thyroid function but not abdominal symptoms, mproved after thyroid hormone replacement for 3 months. Measurement of colonic motor function using radiopaque markers showed megacolon in the left colon from the splenic flexure to be irreversible. The patient was treated successfully by setting a transverse colostomy. Myxedema megacolon is rare. It should be treated with thyroid hormone replacement and surgical approaches are contraindicated. There have been no discussion about surgical treatment. In the 5 Japanese cases of myxedema megacolon reported to date, 2 had effective surgical treatment. Surgical approaches may be an attractive option for irreversible myxedema megacolon.

View full abstract

A fifty-two-year-old female with familial adenomatous polyposis (FAP) underwent a total colectomy in 1981. She was diagnosed as having an intraabdominal desmoid tumor in 1985 and was successfully treated by oral administration of Tamoxifen and Sulindac. In 1995, she underwnet an endoscopy and was diagnosed as having three duodenal cancer-in-adenomas at the opposite side of the major papilla, accompanied by multiple duodenal adenomas. She underwent a laparotomy in September 1995, but pyloric-preserving pancreatico-duodenectomy (PPPD), initially proposed as the treatment of choice, was considered impracticable because of extensive mesenterial invasion by he desmoid tumor that would have prevented the reconstruction procedures. Consequently, removal of the tumors and coagulation of less prominent lesions were performed through duodenostomy. Although duodenal lesions are commonly found in patients with FAP, multiple cancerous lesions not arising from the periampullary region have rarely been reported. Desmoid tumor, another commonly found tumor in FAP patients, can interere with a surgical treatment for such a duodenal lesion, and calls for meticulously planned treatment strategies.

View full abstract

Abdominal actinomycosis is rare, and its diagnosis is difficult to make preoperatively. We report a case of abdominal actinomycosis which was successfully diagnosed preopratively. A 44-year-old man was admitted to our hospital because of an abdominal mass and mild fever. Physical examination revealed a hard, nontender, fixed mass in the left lower abdominal quadrant. Laboratory data showed leucocytosis, thrombocythemia and an elevated CRP level. CT scan demonstrated an infiltrating mass in the anterior left abdomen, extending to the rectal muscle. ⁹⁷Ga scintigraphy showed strong uptake of RI in the mass. Thus it was suspected to be an inflammatory mass, and the patient was treated with antibiotics (SBT/ ABPC) intravenously. He improved with this treatment. CT scan on the 15th hospital day revealed a clear straight line with high density in the shrunk mass. Excisional biospy was performed on the 22nd day, and a diagnosis of abdominal actinomycosis was established by hisotopathtological examination. Resection of the mass carried out on the 35th day. At surgery, the sigmoid colon was adherent to the mass and also a fish bone was found embedded in the mass. We thought that this case was caused by a fish bone penetrating thorough the sigmoid colon. The postoperative course was uneventful, and he discharged on the 14th postoperative day.

View full abstract

Two cases of rectal cancer with stele prolapsing through the anus are reported. Case 1 was a 51-year-old man who was admitted with a complaint of tumor prolapsing through the anus. Barium enema showed a tumor 5cm from the anal verge, about 4cm in diameter. Low anterior resection with lymph node dissection was performed. Pathological examination revealed that the prolapsing tumor was adenocarcinoma in adenoma. Case 2 was a 68-year-old woman who was admitted with complaints of anal bleeding and a tumor prolapsing through the anus. Barium enema showed a tumor 3 from the anal verge, about 6cm in diameter. endoscopic ultrasonography showed no evidence of propria muscularis invasion. The tumor was resected at the stele. Pathological examination revealed that the tumor was localized inside the submucosa and the distal edge of the stele was not invaded. There are two ways in which rectal cancer prolapses through the anus: only tumor with stele prolapses or tumor prolapses with rectal prolapse. In the former, there is a good possibility that the tumor is early cancer, regardless of its size. Both cases reported here were the former.

View full abstract

Parkinson's disease is a chronic progressive disease with the triad of tremor, rigidity and akinesia. It is difficult to manage after the gastrointestinal operation for parkinsonis. We performed gastrointestinal surgery in three patients with parkinsonism. Two patients had the complication of paralytic ileus and one needed a tracheostomy for respiratory management. The postoperative course and the management of these cases of parkinsonisms are described. it is important to give high enough doses of anti-parkinsonisms agents to control the symptoms of parkinsonism, and to prevent the complications of respiratory disease and paralytic ileus.

View full abstract

The usefulnes of diagnostic laparoscopy (DL) under general anesthesia was studied to determine the most appropriate treatment. Eighty-one patients with blunt abdominal trauma were hospitalized over 5 years starting in 1989. All patients underwent abdominal X-ray, and ultrasonography. Sixty-eight patients also underwent CT scanning. In addition, DL was performed in 17 patiens, because it could not be determined whether laparotomy was indicated. Further laparotomy was indicated in 13 and contraindicated in 4 patients. On DL findings, laparotomy was indicated for progressive intraperitoneal bleeding in 7 patients, slight intestinal fluid retention in 4, and slightly hemorrhagic ascites accompanied by an increased amylase level in 2. Seven of these patients were negative for Blumberg's sign. Laparotomy was contraindicated in 2 patients with peritoneal hematoma (pelvic fracture) and in 2 with abdominal wall hematoma, on DL findings. Blumberg's sign was noted in all of these patients. In addition, ascites was revealed by CT scanning in 2 of them. DL has the advantage that organ damage can be observed under direct vision and a qualitative diagnosis can be made which is unobtainable from clinical examination, X-ray, US, or CT. DL is a very useful tehcnique for determining the indications for laparotomy.

View full abstract

Fifty-seven patients with non-ruptured abdominal aortic aneurysms (AAA) seen between 1991 and 1994 were reviewed. Six patients had a histologically proven gastrointestinal malignancy with AAA. The most common site of the cancers (Ca) was the stomach (4 cases), in the other two cases it was the sigmoid colon and the rectum. Three patients underwent resection of the Ca first, one the AAA first, and two the Ca only. When both Ca and AAA are diagnosed preoperatively, Ca should be resected first. For asymptomatic AAA with a diameter more than 5 cm, grafting at proper intervals following surgey is preferred. These patients were examined for preoperative risk factors, diameter of AAA, progression of Ca, complications and long-term survival. All patients were dischaged uneventfully. There were three late deaths. One of the patients died of acute cardiac failure 6 months following surgery. This patient had ischemic heart disease (IHD), anemia, renal dysfunction and pulmonary dysfunciton preoperatively. Of the other two patients, one died of carcinomatosis 7 months after surgery, the other one died of recurrence 2 years and 2 months following surgery. Both of them undewwent resection of the Ca only, because of the asymptomatic small aneurysm. Three patiens are still alive. We conclude that a two-stage operation should be performed, but that patients with progressive cancer or risk factors such as IHD need to be followed up strictly.

View full abstract

Clinical study of three different local excision procedures for rectal tumors was undertaken to evaluate the new local excision procedure using an E retractor and a stapler (minimally invasive transanal surgery, MITAS). Forty-three patients underwent local excision for rectal tumors. Twenty-four of them were operated on by MITAS for 25 lesions, 17 by peranal local excision (PAE) for 17 lesions and two by transsacral local excision (TSE) for two lesions. The maximum diameter of the lesions was not different among the three procedures, but the distance from the anal verge to the proximal margin of the tumor in patients receiving MITAS was significantly longer that in those treated by the other procedures. The mean operative time and blood loss were 28 minutes and 25g in MITAS, 41 minutes and 47g in PAE, and 73 minutes and 45g in TSE. The times for starting oral intake and discharge afte MITAS were shorter than those after the other procedures. Two anastomotic leakages were observed after PAE, and one transient bleeding aftr MITAS, and there was no trouble after TSE. MITAS was considered to be a minimally invasive local excision procedure which enables an approach to a more proximal lesion than the other local excision procedures.

View full abstract