Background/Aims: We clinicopathologically evaluated carcinoma of the remnant stomach reconstructed by the Billroth I method. Patients and Methods: Subjects were patients with remnant gastric cancer after distal gastrectomy reconstructed by the Billroth I method and undergoing a second surgery at our hospital. The primary disease was benign in 20 (benign group) and malignant in 52 (malignant group).
Result: The average age at the second surgery was 60.5±12.1 years old in the benign group and 67.0±11.0 in the malignant group. Mean time between initial and remnant gastrectomy was 15.4 years in the benign group and 8.2 years in the malignant group. The male-to-female ratio was 17:3 in the benign group and 35: 17 in the malignant group. In the benign group, 70%had remnant cancer in a nonanastomotic area, as did 80.8% in the malignant group. The benign group had 6 cases (30.0%) of early remnant cancer and the malignant group 24 cases (46.2%). Pathologically, well-differentiated adenocarcinomas were observed in 12 (60.0%) in the benign group and 35 (67.3%) in the malignant group. In the benign group, 70.0% showed lymph node metastasis, compared to only 28.8% in the malignant group. Nodal metastasis was high at No.1, 3, and 7 in the benign group and at No.2 and 11 in the malignant group. Six of 7 patients undergoing previous surgery for multiple gastric cancer had remnant stomachs resected within 6 years. The rate of advanced remnant cancer was 70.0% in the benign group and 53.8% in the malignant group. Conclusion: Why the interval between initial and subsequent resection was shorter in the malignant group was apparently because invisible multiple gastric cancer remained at the gastric remnant. It is therefore important to follow patients up annually by endoscopy after initial gastrectomy to detect the remnant gastric cancer at an early stage.

View full abstract

Purpose: We evaluated the reliability of the Mannheim Peritonitis Index (MPI) in predicting the outcome of patients with peritonitis. Method: Subjects were 108 patients operated on for intraabdominal infection and excluded subjects with appendicitis. Results:Overall mortality was 5.3% in men and 15.2% in women, with death occurring only in patients older than 50 years. A comparison of MPI and mortality showed patients with a MPI score of 26 or less to have mortality of 3.8%, whereas those with a score exceeding 26 had mortality of 41.0%. Establishing the cutoff point at 26 on the MPI, resulted in sensitivity of 77.7%, specificity of 97.9%, and accuracy of 88.8%. We also evaluated the revised MPI added the score of renal failure to MPI. The revised MPI was superior to MPI, resulted in sensitivity of 88.8%, specificity of 93.9%, and accuracy of 92.6%. Conclusion: MPI is a simple, useful prognostic index for assessing the severity of peritonitis without the need for extensive laboratory data. The reliability of the index may be improved by including complications associated with multiple organ failure or severe chronic health problems.

View full abstract

Purpose: To improve the accuracy of correlation between converted ICGR₁₅ from ^99mTc-GSA Scintigraphy (LHL15, HH15) and ICGR₁₅, we searched for the formula based on the characteristic of LHL15 and HH15. Materials and Methods: Preoperative hepatic function reserve was evaluated by converted ICGR₁₅, calculated with a formula acquired from the correlation between HH15 and ICGR₁₅, or the correlation between LHL 15 and ICGR₁₅. Subjects were 144 patients undergoing hepatectomy after ^99mTc-GSA scintigraphy and indocyanine green retention test from June 1995 to September 2002. Results: Based on the fact that LHL15 is correlated with ICGR₁₅ in cases with better hepatic function reserve, and HH15 is correlated with ICGR₁₅ in cases with poorer hepatic function reserve. Two separate formulas were found in Liver Damage A and Liver Damage B to improve the correlation coefficient. ICGR₁₅=114-108× LHL15 was found in cases with Liver Damage A, and ICGR₁₅=-41+103× HH15 in cases with Liver Damage B. Conclusion: ICGR₁₅ converted from these formulas related better to ICGR₁₅ than that from the formula acquired from all cases.

View full abstract

Aim: We evaluated the usefulness of serum hyaluronic acid (HA) levels as a predictor of postoperative complications. Methods: Serum HA and α₁-antitrypsin (AT) was measured perioperatively in 29 patients un-dergoing hepatic resection. Patients were divided into 2 groups, high-level group (HH group, n=14) and normal-level group (HN group, n=15), based on the preoperative serum HA. The change in these two groups was compared by considering gastric resection group (GX group, n=10) as contrast. Furthermore, changes were compared between with and without postoperative complications. Results: Preoperative serum HA correlated significantly with liver function. Moreover, in the histological degree of hepatic fibrosis, the signifi-cant difference was showed between HH group and HN group (p<0.01).Postoperative complications oc-curred in 8 patients from the SIRS case of HH group. Pre-and postoperative serum HA was significantlyhigher in patients with postoperative complications than in those without (p<0.05).Patients with postopera-tive complications had significantly lower serum AT after POD 3, compared to those without complications (p<0.05).Preoperative serum HA correlated well with serum AT on POD 3. Conclusions: The function of sinusoidal endothelial cells is falling at the patient with preoperative high serum HA level. And postoperative production of AT is falling at such a patient. Furthermore, it was possible that it was easy to develop from SIRS to the postoperative complications at such a patient. Consequently, an occurrence of postoperative comp-lications could be predicted by the perioperative serum HA levels.

View full abstract

This study reviews a consecutive series of patients who underwent stapled hemorrhoidectomy using a circular stapler (PPH (R) Johnson & Johnson Company) for prolapsing hemorrhoidal disese. Methods: Subjects were 100 patients (61 males; age, 56.6±15.3 years) undergoing stapled hemorrhoidectomy between March 2000 and September 2001. Data on surgery, early postoperative results, anorectal manometry, and follow-up were evaluated in January 2002. Follow-up was obtained by questionaire. Results: Some 27 patients (27%) experienced anal swelling, 7 (7%) had bleeding (3 had surgical treatment), 8 (8%) felt severe pain, one (1%) felt lower abdominal pain. and 2 (2%) had urinary retention during hospitalization. Five (5%) had anal pro-lapse. Two (2%) had bleeding (1 had surgical treatment), 2 (2%) experienced stenosis of the anastomosis, and 4 (4%) had fecal incontinence 1 month after surgery. Three had reoperation, 1 for prolapse and 2 for stenosis. Maximum resting pressure, first sensation, and maximum tolerable volume decreased at two weeks postoperatively (P<0.05) but recovered with 1 month postoperatively. Conclusion: Stapled hemorrhoidec-tomy using a circular stapler is safe and effective, but long-term results must be evaluated because this fact must be kept in mind in dealing with such not in good patients.

View full abstract

A 71-year-old man admitted for tarry stool on July 30, 1999, was found in upper gastrointestinal series and gastric endoscopy to have two protruding lesions in the stomach and biopsy of each showed leiomyosarcoma. Abdominal computed tomography (CT) showed a 30×25mm mass in the right adrenal gland.
Ultrasonography-guided needle biopsy was done and right adrenal metastasis from gastric leiomyosar-coma diagnosed. We partially resected the stomach on September 13. Subsequent CYVADIC chemotherapy consisting of cyclophosphamide, vincristine, adriamycin, and dacarbazine dramatically reduced the metastatic adrenal lesion after one course. The lesion, estimatable in computed tomography, was reduced to 60% in size. After transcatheter arterial embolization on November 10, the lesion was reduced to 80% in size. No metasta-ses were identified in other organs, enabling right adrenalectomy on March 1, 2000. No viable cell were found pathologically in the adrenal lesion. The man remains alive and recurrence-free 3 years and 3 months after the second surgery.
CYVADIC chemotherapy and transcatheter arterial embolization are thus effective in treating advanced gastric leiomyosrcoma.

View full abstract

A 77-years-old-man admitted for body weight loss was found to have an elevated ulcerative tumor located in the papilla of Vater. Histological examination of a biopseid specimen showed undifferentiated adenocarcinoma. We conducted pancreaticoduodenostomy with regional lymph node dissection. The resected specimen showed an intra-ampullary tumor within the oddi muscle layer. Histopathologically, the tumor consisted of solid nests of atypical argyrophilic cells, with adenocarcinoma replacing mucosa. Immunohistochemical analysis showed positive staining for NSE and chromogranin A. The final diagnosis was adenoendocrine cell carcinoma of the papilla of Vater. Adenoendocrine cell carcinoma may originate from adenocarcinoma characterized by high-grade malignancy and yielding a dismal prognosis. The patient died from multiple liver metastasis 14 months after surgery. To the best of our knowledge, this is the 14th case of adenoendocrine cell carcinoma of the papilla of Vater reported in Japan, indicating the rarity of such case so.

View full abstract

We report a case of small cell carcinoma of the extrahepatic bile duct. A 80-year-old man admitted for appetite loss was found in CT to have a dilated intrahepatic bile duct and a slightly high-density mass at the middle of the extrahepatic bile duct. On endoscopic retrograde cholangiopancreatography (ERCP), magneticresonance cholangiopancreatography (MRCP) and cholangiography via percutaneous transhepatic biliary drainage (PTBD), we found a round tumor at the middle of the extrahepatic bile duct, and biopsy showed poorly differenciated adenocarcinoma. Cholangioscopically, superficial spread of the cancer was not detected. Under a diagnosis of papillary middle bile duct cancer, we resected the common bile duct. Microscopic examination of the tumor showed small cell carcinoma (pure type) by HE staining and immunological staining with chromogrannine A. Superficial spread of the tumor was not detected at the common bile duct. The postoperative course was favorable, and the patient was discharged on postoperative day 19.
Only 11 cases of small cell carcinoma of the bile duct, including our case, have, to our knowledge, been reported. Papillary bile duct cancer with a preoperative diagnosis of poorly differentiated adenocarcinoma, we should suspect a tumor of small cell carcinoma of the bile duct.

View full abstract

A 68-year-old woman with abdominal pain and dark urine consulted a local practitioner. She was referred to our hospital for further examination with the possible diagnosis of pancreatic tumor and obstructive jaundice. Abdominal enhanced computed tomography (CT) showed a heterogeneous tumor measuring 4.0cm in its maximum diameter at the head of the pancreas and a neighboring cystic tumor adjacent to the portal vein. Cholangiography showed the complete obstruction of the common bile duct at the end. Angiography showed a marked tumor stain and a 4.0cm-long stenosis of the portal vein. An operation was performed because malignancy could not be ruled out. We noticed an elastic hard tumor measuring 4.0cm in diameter at the head of the pancreas and a neighboring tumor measuring 3.0cm in diameter protruding from the pancreas toward the liver with severe adhesion to the portal vein. We could not detach the tumor from the portal vein and performed pancreatoduodenectomy with a concomitant segmental excision of 4.0cm of the portal vein, followed by reconstruction. The histological diagnosis was serous cystadenoma of the pancreas and there was no evidence of malignancy. The postoperative course was excellent. Previously, serous cystadenoma of the pancreas was considered to be a benign tumor and this is an extremely rare case because concomitant excision of the portal vein was necessary for the resection of this tumor, in addition to its morphological specificity.

View full abstract

A 71-year-old man with a back bruise had been diagnosed with splenic rupture 20 years earlier, but no surgery or interventional radiological therapy was done at that time. He experienced no severe trauma. He had taken an anticoagulant drug, aspirin, for atrial fibrillation since 1999. He suffered cerebral infarction in January 2002. On July 4, 2002, the splenic cyst was detected by CT and he was admitted a week later for upper left abdominal pain and shock. We diagnosed spontaneous rupture of the splenic cyst and hemoperitoneum, which necessitated emergency surgery. We found a large amount of clotted blood and bloody ascites in the peritoneal cavity and a splenic cyst and severe adhesion around the spleen. Histological findings showed posttraumatic changes and splenic infarction containing both relatively new and old necrosis with bleeding. In this case, splenic infarction appeared to be the primary cause of splenic rupture, which may also have been affected by posttraumatic changes and the anticoagulant drug.

View full abstract

A 62-year-old man underwent thoraco-abdominal esophagectomy for esophageal cancer, and sigmoidec-tomy and lateral segmentectomy of the liver for sigmoid colon cancer. In spite of a good postoperative course for the first 28 days postoperation, he complained of abdominal pain due to an intestinal obstruction. However, as conservative therapy showed no remission, a reoperation was performed 37 days after the first operation. About one meter of the ileum was resected including four narrow segments of the ischemic intestine. Histopa-thological finding showed a constrictive ischemic inflammation of the small intestine. Even in the state of anti-coagulant therapy for esophagectomized patients, constrictive ischemic inflammation of the small intestine is observed rarely, so early diagnosis and surgery may be necessary for such patients with severe surgical stress

View full abstract

Desmoid tumor of the small bowel mesentery is rare, most often occurring in patients with histories of fa-milial polyposis coli, operation, trauma, and pregnancy. We report a case of desmoid tumor of the mesentery of the small intestine. A 58-year-old man reporting an abdominal tumor and abdominal pain was referred to us based on a diagnosis of abdominal tumor. He had undergone surgery for esophageal cancer at age 56. Abdomi-nal ultrasonography, CT, magnetic resonance imaging, and angiography showed a relatively discrete tumor in the mesentery of the small intestine. Solid tumor of the small bowel mesentery was diagnosed and the 110×65×58mm tumor was removed. The tumor histologically consisted of differentiated fibroblasts and copious collagen fibers, without karyomitosis. Collagen fibers stained blue in Masson staining and were positive for Vimentin staining, confirming a desmoid tumor. It is often difficult to preoperatively diagnose mesenteric tu-mors. When we encounter solid mesenteric tumor without tumor vascular imaging as in this case, desmoid tu-mor should be considered a possibility.

View full abstract

A 63-year-old woman was refered to our clinic for the evaluation of a right hypogastric pain. Ultra-sonography and computed tomography examinations revealed a cystic mass in the appendix. A right hemi-colectomy with D3 lymph node dissection was performed. Histological examination revealed a poorly differen-tiated adenocarcinoma of the appendix. Eighteen months later, an oophorectomy was performed because of ametastasis to the right ovary. The patient has shown no further signs of recurrence or metastasis for 2 yearsand 9 months since the first operation.

View full abstract

A 53-year-old woman was admitted complaining of right lower abdominal pain. Colonoscopy and a computed tomography scan of the abdomen showed a tumor of the ascending colon. Enhanced T1-weighted magnetic resonance imaging revealed a thrombus in the right internal iliac vein. We considered that a prophylactic strategy was necessary for the prevention of a pulmonary embolism before the resection of the advanced ascending colon cancer. Under preoperative placement of the inferior vena cava (IVC) filter, a right hemicolectomy was performed. Intra- and post-operative courses were uneventful. There was no recurrence of the tumor and further development of the venous thrombi 10 months after the operation. Internal iliac vein thrombosis is a rare disease, but it causes a pulmonary embolism. In patients who have an iliac vein thrombosis before major abdominal surgery, it may be useful to insert the IVC filter preoperatively for prevention of a pulmonary embolism.

View full abstract

A 58-year-old female was diagnosed as having dilatation of the common bile duct on abdominal ultrasound. MRCP and upper abdominal CT showed no abnormal findings, but blood chemistry findings revealed that the CA19-9 was 160 U/ml. Because the CA19-9 levels became higher and higher, we performed CT again. It showed a presacral tumor shadow. A barium enema demonstrated the posterior wall of rectum pressed outwards. Endoscopic ultrasonography of the rectum demonstrated a polycystic tumor, which we suspected as being a submucosal tumor of the posterior wall of the rectum. The tumor was resected by a transsacral operation and lower rectum circle resection. The pathological diagnosis was a tailgut cyst. After the operation, the levels of CA19-9 normalized.

View full abstract

A 71-year-old woman taking 10 mg/day of predonisolone for rapidly progressive glomerulonephritis wasadmitted for severe abdominal pain. Temperature was 38.8°Cand she had a muscular rigidity with tenderness in the lower abdomen. Abdominal X-ray and CT showed intraperitoneal free air and a large amount of feces inthe rectouterine pouch. Under a diagnosis of rectal perforation, we partially resected the rectum and con-structed a terminal colostomy. The patient was returned to the intensive care unit and treated on an artificial respirator with continuous hemodiafiltration. The postoperative course was satisfactory until postoperative day (POD) 7. Eight days after surgery, she suddenly reported general fatigue and ventricular tachycardia oc-curred in electrocardiography. The ST segment was elevated in leads II, III, aV_F, and V₂-V₆. Ultrasound car-diography showed asynergy of apical akinesis and basal hyperkinesis with a significant pressure gradient of 60-130 mmHg. She was diagnosed with “takotsubo” cardiomyopathy. The left ventricular function improved to almost normal within the next 3 weeks. This possibility showed thus be kept as a potential complication af-ter gastrointestinal surgery.

View full abstract