Laparoscopic closure of perforated duodenal ulcer was performed in forty patients between May 1992 and December 1999. This report compares the forty patients who underwent laparoscopic closure (LC group) and another forty-nine patients who underwent conventional open closure (OC group) between January 1988 and April 1992. Patient background was the same in both groups. Laparoscopic closure took significantly longer than open closure (p<0.01), but significantly less analgesic was required after laparoscopic closure than after open closure (p<0.01). Significantly fewer days resumption of oral feeding and significantly fewer hospital days after laparoscopic closure required than after open closure (p<0.01). The morbidity rate in the LC group was significantly lower than in the OC group (p<0.05). There were no significant differences in mortality rate, reoperation rate or rate of recurrence of duodenal ulcer between LC group and OC group. These results suggest that laparoscopic closure is not invasive and that it accelerates patient's recovery following discharge from the hospital. In conclusion, laparoscopic closure appears to be an effective procedure for the treatment of perforated duodenal ulcer.

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We conducted a prospective randomized trial to compare single-dose antibiotic administration to 2-day dose administration in 242 patients undergoing elective laparoscopic cholecystectomy with a low risk for postoperative infection. We found no statistically significant difference between single- and 2-day dose groups, except that operating time was slightly longer in the 2-day dose group. Postoperative infection was 1.7% in the single-dose group and 3.3% in the 2-day group. Infection site was one of portsite wounds among all cases with postoperative infection, and no nonsurgical-site infection was seen. No statistically significant difference was seen between groups in white blood cell or granulocyte count, CRP on first postoperative day, or postoperative hospital stay length. Findings from cultures of bile samples were positive in 9.9%, statistically higher in patients having gallbladder stones. No significant difference was seen between microbial-positive group and negative groups in postoperative infection. Almost 30% of detected microbial resisted the administered drug. We concluded that single-dose preoperative antibiotic prophylaxis was justifiable in cases of laparoscopic cholecystectomy with a low risk of postoperative infection.

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A 59-year-old man referred to our hospital for 2 gastric submucosal tumors on the fornix and the lesser curvature of the lower body, revealed by upper gastrointestinal endoscopy, was found by abdominal ultrasonography and computed tomography to have chronic cholecystitis and adenomyomatosis of the gallbladder containing sludge. Operative findings showed a diffuse fibrous adhesion in the upper abdomen, especially around the gastric lesions and gallbladder. The gallbladder wall adhered to the duodenum. Intraoperative pathological diagnosis of the 2 gastric lesions was nonmalignant xanthogranuloma. Proximal gastrectomy combined splenectomy, wedge resection of the lesser curvature of the lower body, cholecystectomy, and pyroloplasty. Histologically, tumors were granulomatous, showing proliferation of foamy and inflammatory cells. Xanthogranuloma develops in a variety of organs, but synchronous xanthogranuloma of the stomach and gallbladder is rare. Further follow-up is believed necessary because of cancer reported in cases of xanthogranuloma of the stomach or gallbladder.

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In a case of AA gastrointestinal amyloidosis with duodenal ulcer bleeding secondary to rheumatoid arthritis (RA), a 60-year-old woman who had suffered from RA for over 25 years was admitted to our institute due to bleeding from a duodenal ulcer. Several attempts at endoscopic hemostasis failed, necessitating an emergency distal gastrectomy. Histologically, the gastric specimen showed amyloid deposition confirmed by Congo-red staining and immunostaining for amyloid A protein. The patient died postoperatively due to multiple organ failure (MOF). Autopsy revealed a total amyloid lesion. RA accounts for 60% of all disease involving secondary amyloidosis. NSAIDs, often used to treat RA, are well known to cause gastroduodenal ulcers. Our case thus suggests that secondary amyloidosis be considered as a cause when gastroduodenal ulcer bleeding is seen in patients of RA.

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An unusual case of hepatic tuberculoma misdiagnosed as a metastasis of advanced gastric cancer is reported. A 78-year-old woman was admitted to our University Hospital with tuberculosis of the skin. An advanced gastric cancer and hepatic tumor were detected by gastrointestinal examinations and imaging studies. Computed tomography revealed a hypodense hepatic mass without calcification. Magnetic resonance imaging (MRI) showed a hypointense mass in the liver on T1-weighted spin echo images and a hyperintense area on T2-weighted spin echo images. Contrast-enhanced dynamic MRI visualized the liver mass as a rimenhanced area. A diagnosis of liver metastasis from gastric cancer was made, and distal gastrectomy and partial resection of the liver were performed. After the operation, a definitive diagnosis of hepatic tuberculoma was made based on histopathological studies that revealed both epitheloid cells and Langhans giant cells with caseous necrosis in the liver specimen. Although several cases of hepatic tuberculoma have been reported, the typical imaging findings of this tumor have never been described making it difficult to distinguish hepatic tuberculoma from the other primary or secondary liver tumors without liver biopsy. In our case, the liver tumor was misdiagnosed as a metastasis from gastric cancer, and palliative surgery was performed. Because preoperative liver biopsy is unusual cases of hepatic tumor and cancer, the definitive diagnosis of hepatic tuberculoma required intraoperative biopsy.

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A71-year-old male was hospitalized for malaise and pyrexia, which were alleviated antibiotics. The patient was referred to us due to a tumorous hepatic lesion about 5 cm long, from hepatic S1 to S4-8, detected by abdominal computed tomography (CT). CT during arterialportography (CTAP) showed both arterial and portal blood flow in the lesion and CT during arteriography (CTA) showed uneven dark stains in the phase where the arterial blood flow was dominant. Uneven stains were also seen in the anaphase region. Magnetic resonance imaging (MRI) showed the mixed presence of unbalanced iso and low intensities in T1WI and a somewhat high intensity in T2WI, indicating cholangiocellular carcinoma. We excised the enlarged hepatic left lobe and caudate lobe. Postoperative pathological examination showed the lesion to be a nonmalignant solid tumor, leading to a diagnosis of inflammatory pseudotumor evidencing increased growth of fibrous cells and the mixed presence of inflammatory cells. The patient's postoperative couse was favorable, and he was released on postoperative day (POD) 12.

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A 27-year-old woman was treated for fibrolamellar hepatocellular carcinoma (FLC), which is very rare in Japan. The patient was admitted because of a huge liver tumor with no signs of liver cirrhosis. Virus antigen and antibody tests for hepatitis were negative. Although the serum AFP was within a normal range, the PIVKA-II was slightly elevated to 108 mAU/ml. US and plain CT examinations revealed a 10 cm mass in the right hepatic lobe. In the early phase of a contrast-enhanced CT, the tumor was well enhanced. In the delayed phase, the septums and capsule of the tumor were enhanced, but the central part of the tumor was not enhanced. An angiography revealed a tumor stain and invasion to the right portal vein. No signs of a tumor were seen in the alimentary tract. The patient was diagnosed with a primary hepatocellular carcinoma, and then extended right hepatectomy was performed. Post-operative histopathological examination confirmed the presence of FLC. According to previous reports, FLC developed solitarily in a young adult with no signs of liver cirrhosis. In those cases, the AFP level was not elevated, and the prognosis after resection was comparatively good.

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Three (6.6%) of 45 patients with hepatocellular carcinoma (HCC) treated surgically at our institution between 1995 and 1999, had bile duct thrombi. On initial examination, the chief clinical presentation of these three patients was not jaundice, but did have abdominal pain or fever. CT scanning and ultrasonography revealed the presence of liver tumors, and cholangiography revealed the bile duct thrombi. Biliary drainage was performed preoperatively to control the cholangitis. Successful hepatectomy was performed in all the cases. Histopathologically, these tumors were diagnosed as HCC with invasion in the bile duct. HCC with bile duct thrombi has been termed “ icteric-type hepatoma ”, which is associated with a high frequency of obstructive jaundice and a low survival rate. In our series, however, none of the patients showed clinical jaundice. Advances in radiological diagnostic techniques probably enabled us to detect and treat these patients at an earlier stage, before obstructive jaundice could develop.

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Peritoneal dissemination of hepatocellular carcinoma (HCC) is rare, and its prognosis is extremely poor. A case of long-term survival after postoperative adjuvant immuno-chemotherapy for peritoneal dissemination of HCC and the autopsy findings are reported. A 71-year-old woman who underwent a lateral segmentectomy for HCC in 1989, and a medial segmentectomy for an HCC recurrence in 1996 was admitted to our hospital after she identifed tumor in her abdomen. Fine needle aspiration cytology was performed, and peritoneal recurrence of HCC was suspected. A laparotomy was performed, and ascites and several metastatic nodules were identified in the greater omentum and mesenterium. The metastatic nodules were suspected to have arisen from the peritoneal dissemination of HCC. An intraperitoneal infusion of Mitomycin C via an intraperitoneal reservoir was given for about one year, and the prescription of UFT and PSK was continued until the last admission. Although the patient died 30 months after her 3rd operation, she was able to be treated on an outpatient basis and maintain a good quality of life for more than 27 months. No intrahepatic metastases or indications of a progressive disseminated tumor were found at the time of autopsy. This may suggest that it is possible to live for a long term under a good quality of life by a reduction surgery of tumors and adjuvant chemotherapy, even if peritoneal dissemination has arisen from HCC.

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Choledochoduodenal fistula complicating duodenal ulcer disease is a rare occurrence. We report such a case in a 25-year-old man admitted to our hospital with chief complaint of vomiting and upper abdominal pain. Abdominal ultrasonography showed pneumobilia in the ballbladder and intrahepatic bile ducts. Upper gastrointestinal contrast radiography showed bulbar stricture and bulbar dilatation but no evidence of a fistula. Percutaneous transhepatic cholangiography (PTC) showed a choledochoduodenal fistula slightly proximal to the bulbar stricture. The patient was successfully treated by distal gastrectomy by the Billroth II method leaving the ulcer intact (Finsterer-Bancroft operation) and by hepaticojejunostomy to decompress the duodenal stump. Medical management with recent anti-ulcer drugs for choledochoduodenal fistula has also been reported to yield good results. Our patient, however, required surgery because of the bulbar stricture and the location of the choledochoduodenal fistula.

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A 42-year-old man who had first noticed a tumor around the navel three years earlier was admitted because the tumor had grown larger. Abdominal X-ray CT scanograms revealed a large iso-density tumor 15 cm×10 cm in size on the abdominal aorta. It was also visualized as an area of significant RI uptake on a Ga⁶⁷ scintigram. We suspected a malignant lyphoma of the mesentery and performed open laparotomy to obtain a tissue specimen. The diagnosis was B-cell type follicular lymphoma (small cleaved cell type). Chemotherapy with ten cycles of CHOP was given, and the patient is still doing well two years later.

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A 67-year-old man was admitted to our hospital because of abdominal distention and pain. On physical examination, a mass was palpated in the lower abdomen. Ultrasonography, an abdominal CT scan, and magnetic resonance imaging revealed a mesenteric tumor 4.0 cm in diameter, and a superior mesenteric arteriogram showed a hypovascular tumor. Small bowel radiography depicted a submucosal tumor 1.8 cm in diameter with defined margins. At surgery, an ileal tumor was observed, and a mesenteric tumor 4.0 cm in diameter was noted close to the terminal ileum where the mesentery was retracted. Approximately 100 cm of the distal ileum was resected, and examination of the resected specimen revealed 8 ileal tumors ranging in size from 0.2 cm to 1.8 cm. Pathologically, the ileal tumors were diagnosed as carcinoid tumors, with a depth ss, and the mesenteric tuomor was identified as a metastatic lymph node. Chromogranin staining was strongly positive, and electron microscopic examination demonstrated numerous neurosecretory granules. Ileal carcinoid tumor is rare. In this case multiple synchronous tumors were observed, and the mesenteric tumor was much larger than the primary lesion and led to the detection of the primary carcinoid tumor.

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