Background: We determined factors contributing to increased signal intensity in the reconstructed jejunal loop in patients undergoing pancreatic resection, frequently observed on magnetic resonance cholangiopancreatography following intravenous injection of secretin (S/MRCP). We also evaluated the possible roles of S/MRCP in assessing the patency of pancreatojejunal anastomosis and the secretory function of the remnant pancreas.Methods: Subject were 44 patients undergoing several types of pancreatic resection. Baseline output and response to secretin of the remnant pancreas were measured after surgery. S/middot;MRCP and pancreatic function diagnostant (PFD) tests were conducted preoperatively, and in early and late periods after surgery.Results: Baseline pancreatic output was 1.2±0.7ml/10-min, and increased after secretin load to a maximum 9.0±6.6ml/10-min in 10 min. Signal intensity of the jejunal loop increased in 2 patients versus 40 patients (95%) during the early versus late postoperative periods. During the late period, PFD was significantly higher in patients with increased signal intensity than in those without. PFD correlated well with cumulative pancreatic output following secretin loading (r=0.820).Conclusion: A major factor responsible for increased signal intensity in S/MRCP of the jejunal loop was increased pancreatic output. The increase in signal intensity was a definitive sign of patent pancreatojejunal anastomosis. S/MRCP thus seems to have a potential for evaluating the secretory function of the remnant pancreas.

View full abstract

Introduction: We investigated the risk factors for ovarian metastasis of colorectal cancer and examined the significance of prophylactic oophorectomy. Materials and Methods: 552 women who had undergone a surgical resection for colorectal cancer within the past twenty years were studied. The characteristics of ovarian metastasis and reasons for oophorectomy were examined. Risk factors for ovarian metastasis were identified by multivariate analysis, and the prognosis was investigated.Results: Ovarian metastasis, including recurrence, was found in 26 cases (4.7%). Metastasis was observed in 14 of 38 cases (36.8%) showing morphological abnormalities of the ovary. Metastasis was found in case (8.3%) in which an ovary showing no abnormal morphology was resected because the contralateral ovary showed suspected metastatic findings. A multivariate analysis using a logistic regression method identified the following risk factors as being significantly associated with ovarian metastasis of colorectal cancer: age (p<0.0001), morphological abnormalities of the ovary (p=0.0164), depth of tumor invasion (se, a2, si, ai;p=0.0366), and peritoneal metastasis (p= 0.0004). The odds ratio was 0.9063 for age, 4.5499 for morphological abnormalities of the ovary, 3.1641 for depth of tumor invasion, and 8.1080 for peritoneal metastasis. The 5-year survival rate of all cases with ovarian metastasis was 29.1%. The 5-year survival rate of cases with metastasis to the ovary only was 67.5%. None of the patients who had distant metastasis to sites other than the ovary survived for 5 years, and a mainly palliative approach is recommended for these cases.Conclusion: The present results suggest that a prophylactic oophorectomy is of little significance in patients who do not have distant metastasis or morphological abnormalities of the ovary at the time of the primary resection, because of the low risk of ovarian metastasis.

View full abstract

Background: Liquid type fibrin glue should, in principle, be prepared immediately before use. We studied the feasiblity of dissolving fibrin glue in advance of surgery.Materials and Methods: Solutions A and B were prepared using Beriplast^® (Aventis Pharma Co. Ltd., Tokyo, Japan). The viscosity of solitions A and B was measured throughout the time course;tensile strength was measured using the swine skin section method, and the potency of fibrinogen, thrombin, and factor XIII after preparation were also examined;and bacteria reproduction in both solutions was studied under the following 3 conditions: at room temperature (20 to 25°C), preserved in a cold place (6°C), and at 37°C.Results: (1) The tensile strength was maintained for 10 days under all of the above conditions, without reduction.(2) The viscosity of solution A did not change markedly immediately after dissolution to 3 days after dissolution at any temperature. The viscosity of solution B did not change immediately after dissolution and even 10 days after dissolution.(3) Time-course changes in fibrinogen and factor XIII activity were mild, whereas thrombin activity decreased to 48.9-63%at 3 days in all samples, and activity continued to decrease gradually.(4) Tests conducted immediately and 10 days after preparation demonstrated the sterility of both solutions.Conclusion: It is feasible to prepare fibrin glue in advance of use, given its effectiveness as a biological adhesive.

View full abstract

Postoperative pulmonary embolism (PE) is a serious complication that has a high mortality rate. The majority of emboli are derived from deep vein thrombosis (DVT). Because the incidence of postoperative DVT and PE in Japan is low, prophylaxis for DVT and PE is not a common procedure. We have assessed the risk of DVT and PE using a preoperative original risk score system, and adapted Intermittent Pneumatic Compression (IPC) for all surgical patients since Dec. 1998. We compared the frequency of postoperative DVT and PE between the 109 patients treated without IPC who were operated on between August 1997 and November 1998 (non-IPC group) and the 216 patients treated with IPC who were operated on between December 1998 and March 2001 (IPC group). In the non-IPC group, four patients suffered from DVT or PE (3.7%), while only one patient experienced a PE attack in the IPC group (0.5%). This difference was statistically significant (p=0.045, Fisher's exact test). Logistic analysis revealed that IPC decreased the risk of DVT or PE tenth. No side effects of IPC were experienced. As two patients with mean or low risk scores developed DVT or PE, it was difficult to predict the occurrence of DVT and PE. IPC is an effective prophylaxis for DVT and PE and is both safe and easy to perform. Thus, IPC should be performed in all opertive patients.

View full abstract

We reported a case of spontaneous esophageal rupture treated using a covered stent. A 45-year-old man experienced vomiting and hematemesis after drinking, followed by sudden left poststernal back pain on February 6, 2000. He was admitted to an emergency hospital. The next day, he reported dyspnea, diagnosed by scanning as spontaneous esophageal rupture, and he was transferred our hospital. We chose conservative therapy because percutaneous drainage was expected to be sufficient. We waited until his general condition improved, then inserted a covered stent on day 3 after admission. His general condition improved dramatically, diet was started on day 17 after admission, and he was discharged on day 76 after admission.

View full abstract

We report a case of esophageal carcinoma that manifested hypercalcemia and leukocytosis with the production of parathyroid hormone related protein (PTHrP) and G-CSF. A 72-year-old man had a type 2 tumor from Ut to Mt 6 cm in diameter. Blood cell count on admission showed leukocytosis (WBC 12, 100 mm³) but calcium was within normal limits (Ca⁺⁺7.4c 1.21mmol/l). Staging by imaging study was T3N2M0 Stage III. Subtotal esophagectomy was conducted on June 10, 1999. WBC count became normal after surgery. Hypercalcemia appeared on POD 69 accompanied by re-elevated WBC count. Parathyroid related protein in blood was 306 pmol/l and supernatant of cloned culture esophagus carcinoma was 272 pmol/l. Further immunohistochemical study showed positive staining of PTHrP and G-CSF in tumor cells. This is the first case, to our knowledge, in which simultaneous production of PTHrP and G-CSF was proved directly from esophageal squamous cell carcinoma cells.

View full abstract

A 50-year-old woman complaining of a left upper quadrant pain was admitted to hospital. The patient's past medical history included a subtotal gastrectomy with a D2 lymphadenectomy for advanced carcinoma of the stomach 39 months previously and a bilateral oophorectomy for Krukenberg tumor 16 months before admission. The histopathological findings revealed a moderately differentiated adenocarcinoma (type 3 macroscopic findings, SE, INFγ, ly1, v0, N0). On admission, biochemical investigations showed an elevation of carbohydrate antigen 72-4. An abdominal ultrasonography and a computed tomography revealed a solitary splenic tumor approximately 5 cm in diameter. A barium enema examination demonstrated an ulcerative lesion of the descending colon and a narrowing of the entire circumference of the transverse colon. Under a diagnosis of metastatic splenic tumor of gastric carcinoma, a splenectomy with resection of the colon and diaphragm was performed. The cut surface of the resected specimen showed a yellow-white elastic hard tumor in the spleen that had invaded the colon and diaphragm. The histological findings of the splenic tumor were compatible with those of a metastatic carcinoma with invasion into the colon and diaphragm, originating from the gastric carcinoma. The patient is alive and has been free of recurrence for thirteen months after the operation.

View full abstract

An 8-year-old boy was admitted to our hospital because of nausea and a right lower abdominal pain. The patient was diagnosed as having acute appendicitis, and an emergency laparotomy was performed. An appendectomy and drainage of the abdominal cavity was conducted. On the 5^th postoperative day, the boy developed a temperature of 40.0°C. A computed tomography (CT) examination showed a subcutaneous abscess caused by a wound infection. Open drainage was performed, and the patient became afebrile. However, a high fever recurred on the 8^th postoperative day. On the 13^th postoperative day, a CT examination showed a pyogenic abscess, measuring 13th in diameter, in the right lobe of the liver. US-guided percutaneus catheter drainage of the liver abscess was immediately performed. About 300 ml of the purulent fluid was drained, and a γ-streptococcus species was isolated. After 14 days of drainage, the abscess cavity of the liver resolved and the drainage catheter was removed. The patient remained febrile for two weeks, but his clinical symptoms gradually improved and he was discharged on the 46^th postoperative day. Only a few reports of pyogenic liver abscesses after an operation for acute appendicitis during childhood have been made.

View full abstract

A 73-year-old woman underwent a sigmoidectomy April 30, 1999, after being diagnosed with sigmoid colon cancer. The histopathological diagnosis was moderately differentiated adenocarcinoma (se, INF β, ly2, v1, n0). After the first operation, the serum CEA value increased a second time, and a tumor to the cranial side of a hepatic cyst with a diameter of 10 cm and transformation around the cyst was observed by CT in January 2000. An exploratory aspiration and biopsy of the tumor showed a high CEA value in the cystic fluid (38, 900ng/ml) and a moderately differentiated adenocarcinoma was identified. A right lobectomy, including the hepatic cyst, was performed on March 25. Macroscopically, the tumor measured 6×5cm and was located in segment 8. It pressed against the hepatic cyst. Microscopically, the cancer cells had infiltrated the tissue near the cystic wall but were not found inside the cyst. The serum CEA value decreased to 3.7ng/ml six months after the second operation, and no signs of recurrence have been observed. The relation between serum and hepatic cyst CEA values may be of interest in cases of hepatic metastasis of colon cancer.

View full abstract

We report a case of hypoplastic gallbladder associated choledocholithiasis. A 62 year-old woman with Symptom-Free liver dysfunction was found by abdominal ultrasonography to have choledocholithiasis and referred to our hospital for surgery. On admission to the hospital, laboratory data were within the normal range. Drip infusion cholangiography showed dilatation of the common bile duct and choledocholithiasis. The gallbladder could not be seen clearly. Abdominal computed tomography (CT) showed no problem but was stillunable to picture the gallbladder. We operated under a diagnosis of choledocholithiasis and atrophic cholecystitis. The gallbladder was hypoplastic, and we conducted cholecystectomy and choledocholithotomy. A congenital absence of the gallbladder or a hypoplastic gallbladder are relatively rare, but should be considered, if the gallbladder cannot be seen.

View full abstract

External pancreatic fistula remains a critical complication after pancreaticoduodenectomy. We report a case of intractable pancreatic fistula after pancreaticoduodenectomy successfully treated by interventional internal drainage. A 73-years-old woman underwent pylorus-preserving pancreaticoduodenectomy for bile duct carcinoma. Pancreatic juice started descharging from drains on postoperative day 7, but halted and the fistula healed spontaneously, upon which the woman was discharged. Two months later, her pancreatic fistula relapsed and she was readmitted. Fistulography showed no communication between the main pancreatic duct and jejunum. Reoperation was considered. Canulation into the jejunal lumen on the opposite site was accomplished and an endoprosthesis was placed to connect the main pancreatic duct and jejunal lumen. The course after internal drainage was good, and she was discharged 4 weeks after internal drainage. She remains well and able to proceed with daily activity at the last follow-up, 1 year and 5 months later.

View full abstract

A 52-year-old man with a 1-year history of pancreatic pseudocyst was admitted for melena in July, 1999. Colonoscopy showed a little coagulation near the splenic flexure, but no fresh bleeding. Abdominal computed tomography (CT) showed the 4 cm cyst including the gas in the pancreas tail. The cyst showed a mosaic pattern in ultrasonography. Endoscopic retrograde cholangiopancreatography (ERCP) revealed irregularity and stenosis of the main pancreatic duct and contrast media leaked from the end of the duct. Angiography showed an aneurysm of the splenic artery. Following these findings, we diagnosised as the pancreatic pseudocyst fenestrating into the colon. Therefore, the pancreas tail, the spleen, and the transvers colon was resected. Pathological examination revealed the fistula between the pseudocyst and the colon, and a splenic artery had ruptured into the cavity of the pseudocyst, forming the pseudoaneurysm. The postoperative course was uneventful. A pancreatic cyst fenestrating into the colon is a very rare case, which has been reported in 4 cases including ours in the Japanese literature.

View full abstract

A 70-year-old man consulted a private physician about upper abdominal pain. The patient was referred to our hospital with a diagnosis of pancreatic head tumor. Abdominal ultrasonography (US) and dynamic computed tomography (CT) revealed a tumor in the head of the pancreas and defective pancreatic body and tail. Celiac angiography showed neither hypervascularity nor pooling sign in the pancreatic head region. Endoscopic retrograde cholangiopancreatography (ERCP) showed disruption of the main pancreatic duct and endoscopic US in the second portion of duodenum revealed a tumor of the pancreatic head and low echoic lesion spreading to the muscle layer of the duodenum. Based on these clinical findings, we preoperatively diagnosed pancreatic cancer and undertook total pancreatectomy. Pathological findings revealed the tumor to be chronic pancreatitis with a pseudotumor. Immunostaining for anti-pancreatic polypeptide (PP) showed the islets of Langerhans in the tail of pancreas containing few PP cells. Accordingly, the resected specimen had dorsal anlagen and the final diagnosis was chronic pancreatitis with a pseudotumor associated with dysplasia of the pancreatic body and tail.

View full abstract

An accessory spleen is found in 10-30% of necropsies, but seldom gives rise to symptoms and very rarely involves torsion. We treated a patient with such torsion. A 23-year-old man was admitted due to intermittent abdominal pain and fever. Laboratory findings showed leukocytosis. Abdominal ultrasonography, computed tomography, and magnetic resonance imaging revealed a solid tumor in the left upper abdominal quadrant. Preoperative diagnosis was an abdominal tumor. Explorative laparotomy showed a solid tumor in the greater omentum, 8.0×7.2×4.8cm. It had a long twisted pedicle connected to the gastroepiploic artery and vein. Macroscopically, the tumor was homogenous, dark red, and solid tumor. Microscopically, it contained splenic tissue with necrosis and fibrosis. The final diagnosis was torsion of an accessory spleen with infarction, causing abdominal pain. It should be considered in the differential diagnosis of intraabdominal mass with abdominal pain in adolescents.

View full abstract

We report two cases of small intestinal GIST causing gastrointestinal bleeding. Case 1: An 80-year-old man presented with tarry stools. A barium roentogenography and abdominal CT examination revealed a submucosal tumor in the jejunum, 10cm away from Treitz's ligament. We suspected that the tumor was causing gastrointestinal bleeding and operated. The histopathological diagnosis of the tumor was a low-grade malignant GIST;immunohistochemically, a tendency toward smooth muscle cell differentiation was observed. Case 2: A 73-year-old man presented with melena. An abdominal CT revealed an encapsulated tumor connecting with the small intestinal wall. A gastrointestinal scintigram demonstrated bleeding in the small intestine, and surgery was performed. A histopathological diagnosis of malignant GIST was made;immunohistochemically, a tendency toward neural cell differentiation was observed. Only 9 cases of small intestinal GIST have been reported in the Japanese literature, including the present cases. Of these 9 cases, 6 were malignant or suspected to be malignant. Small intestinal GIST should be recognized as a high risk group of malignancy requiring careful follow-up after operation.

View full abstract

A 41-year-old man was admitted with a diagnosis of acute enterocolitis due to epigastralgia, vomiting and diarrhea that lasted 3 days. Computed tomography (CT) showed intussusception of the ileum into the ascending colon, which included a heterogeneous fatdensity mass in the center. We diagnosed intussusception caused by lipoma of the ileum. At laparotomy, we found intussusception that could not be restored, and partially resected the ileum. The protruding lesion of the resected ileum had a mushroom shape and lipoma-like yellow stump, leading to a macroscopic diagnosis of lipoma. Histologically, the lesion was the inverted wall of the ileum with ectopic mucosa of the stomach. Central adipose tissue of the lesion led to the mesntery, so we diagnosed intussusception caused by inverted Meckel's diverticulum involving adipose tissue on the serosa. Meckel's diverticulum occasionally inverts involving dipose tissue, so we must be careful to distinguish between inverted Meckel's diverticulum and lipoma.

View full abstract

A 73-year-old man brought to our hospital with to severe abdominal pain and vomiting of sudden onset had a history of apoplexy, arrhythmia, and surgery for lung cancer. The next day, he was referred to our department with progressive abdominal pain and muscular defense. He was in agony with slight bulging, severe tenderness, and spontaneous pain and muscular defense in the abdomen. Abdominal Xray film taken laterally revealed dilation of the small intestine and niveau. Computed tomography (CT) of the abdomen revealed gas in the mesenteric vessels but not in the hepatic portal vein. Nevertheless, we suspected hepatic portal venous gas and operated immediately. He had purulent ascites and necrosis of the duodenum on the oral side and jejunum on the anal side, so we resected the necrotic intestine and instituted drainage. CT thus proved useful in preoperative diagnosis of bowel necrosis.

View full abstract

We report a case of Clostridium difficile (CD) enterocolitis succsessfully treated with vancomycin (VCM) administered via long intestinal tube. An 82-year-old man was refer to the hospital because of obstructive jaundice. He was diagnosed as hilar cholangiocarcinoma by endoscopic retrograde cholangiography. For acute obstructive suppurative cholangitis, we attempted percutaneous transhepatic bile duct drainage, but failed, necessitating a laparotomy for drainage. RTBD tubes were inserted into the left and right hepatic ducts through the stricture of the hilar bile duct and bile juice was drained extracorporally. On postoperative day 8, excessive diarrhea was observed and toxin A of CD was positive from stool specimens. Oral VCM (2.0g/day) was started, but severe abdominal pain and distension occurred 4 days thereafter. Abdominal X-ray showed paralytic ileus. We inserted a long intestinal tube to administer. The man's condition improved dramatically the next day, and the tube was removed after 6 days. Oral administration with VCM is effective in treating CD enterocolitis, but in paralytic ileus, orally administered VCM does not reach the site of interstinal inflammation, long intestinal tube may thus present a viable alternative in refractory CD enterocolitis.

View full abstract

We report a rare case of advanced synchronous triple cancer of the colon. A 69-year-old man was admitted to our hospital for bloody stool. Barium enema and colon fiberscopy revealed 3 protruding lesions, 1 in the cecum, 1 in the transverse colon, and 1 in the sigmoid colon. The sigmoid lesion was resected by D3 lymphadenectomy and the cecum and transverse lesions extirpated by D2 lymphadenectomy. Histologically, all 3 tumors were moderately differentiated adenocarcinoma. The sigmoid and transverse lesions had invaded to the subserous level and the cecal lesion to the muscularis propria. No regional lymph node metastasis was seen in any of the tumors. We applied comparative genomic hybridization (CGH) to investigate carcinogeneses cytogenetically and found loss of chromosome arm 17p in all 3 lesions. p53 is located in 17p13, and this suppressor gene plays an important role in the transition from adenoma to carcinoma. Our finding is consistent with the hypothesis that multiple carcinoma of the colon develops in conjunction with the adenoma-carcinoma sequence.

View full abstract

A 32-year-old woman was admitted to the hospital because of abdominal pain, vomiting and abdominal distension. She had suffered from cerebral palsy and mental retardation since birth. Abdominal X-ray films reverled marked dilatation of the ascending colon and transverse colon. A contrast enema demonstrated an abrupt obstruction at the distal transverse colon. A characteristic bird-beak deformity was seen, and a diagnosis of transverse colon volvulus was made. An emergency laparotomy showed the volvulus of the transverse colon with a 180°torsion. The detorsioned bowel was viable. Resection of the transverse colon with a primary end-to-end anastomosis was performed. Transverse colon volvulus is a rare disease that accounts for approximately 4% of all colonic volvuli. In a review of Japanese literature, 36 cases of transverse colon volvulus were found. Out of these cases, 14 patients (39%) had cerebral palsy or mental retardation as an underlying disease. Chronic bowel movement dysfunction predisposes an individual to volvulus, and detorsion without a colectomy has a high recurrence rate. Colonic resection should be performed to prevent recurrence.

View full abstract

We report an uncommon vesicosigmoidal fistula due to diverticulitis with prostatic abscess and sepsis. A 67-year-old man with pollakisuria and micturation pain was suspected of proctatitis and antibiotic therapy was begun in March 2000. He experienced a pneumaturia suggesting colovesical fistula in April. A barium enema showed diverticulosis of the sigmoid colon but no colovesical fistula. In August, he was admitted due to incipient poor general condition with paracolic and prostatic abscesses from comuted tomography (CT) findings. Sigmoidectomy, colostomy, and surgical drainage were conducted for the vesicosigmoidal fistula and percutaneous drainage for the prostatic abscess.

View full abstract

We describe a case of retrograde intussusception due to a sigmoid colonic polyp. A 62-year-old man admitted with lower abdominal pain had a tumor palpated in the left lower abdomen. Ultrasonography showed a double intestinal structure. Barium enema disclosed a complete beak-like obstruction of the sigmoid colon. Following the diagnosis of mechanical obstruction, we conducted a laparotomy and found the sigmoid colon invaginated retrogradely into the oral side of the colon. The resected specimen revealed a pedunculated polyp in the mucosa, and microscopic examination clarified it to be tubulovillous adenoma. Although some cases of intussusception require ultrasonography and computed tomograpy, barium enema is useful in diagnosing retrograde intussusception.

View full abstract

From 1996 to 2000, 105 patients with hepatocellular carcinoma (HCC) underwent inital surgical treatment (hepatectomy in 62 and ablation in 43) at our institute. Twelve of the 105 suffered extrahepatic metastasis. Nine of the 12 had intrahepatic metastasis, and 6 were controlled by various treatment to liver (TAE, CAI, MCT, RFA and resection). Metastatic sites of the 12 with multiple organ recurrence were lung (7), peritoneum (5), lymph node (4), adrenal gland (3), bone (1), brain (1), and stomach (1). These extrahepatic lesions were treated by resection in 15, systemic chemotherapy in 6, and radiation in 3 (overlapping occurred). The 1-year survival of the 12 was 67% and 3-year survival was 39%. The 3-year survival of those with resected extrahepatic metastasis (69%, n=7) was significantly better than that of unresected (0%, n=5, p=0.0045). In those with resected extrahepatic metastasis, intrahepatic recurrence was controlled of all. These results suggest that extrahepatic HCC metastasis should be resected if the lesion is completely resectable and intrahepatic recurrence is controlled.

View full abstract