Purpose: We evaluated postoperative surveillance and long-term outcome for patients with familial adenomatous polyposis (FAP) who underwent total colectomy with ileorectal anastomosis (IRA). Materials and Methods: During the 30 years from 1970 to 2002, 72 patients with FAP underwent surgery, of whom 29 were treated by total colectomy with IRA for patients with rectal sparse polyposis without cancer. Results: The mean age of the 29 cases was 28.9 years, involving 16 men and 13 women. Mean follow-up after IRA was 19.7 years (range; 1.3-30 years). Eight of the 29 (27.6%) treated by IRA developed cancer in the residual rectum, i.e., 3 men and 5 women. All cases were diagnosed as rectal sparse polyposis, but 4 were profuse colon polyposis. Seven had an APC gene mutation (codon 348-785: 1 case, codon 658-1283:3 cases, codon 1099-1700:3 cases). Mean follow-up between initial and second surgery was 15.0 years (range; 1.3-30). Five of 7 developed advanced cancer, and 2 died of cancer of the residual rectum, but all received regular follow-up at least once a year. Conclusions: These cases suggest that we conduct the restorative proctocolectomy with ileal J-pouch anal canal anastomosis (IACA) or ileal J-pouch anal anastomosis (IAA) for FAP patients, and should be careful to undertake lifelong surveillance.

View full abstract

Purpose: We studied the clinical significance of direct invasion to adjacent organs in locally advanced colorectal cancer. Method: Subjects were 323 consecutive patients who underwent curative surgery for colorectal carcinoma, pT3-4, from 1992 to 1998. We studied the relationship of pathologic invasion to adjacent organs of tumors to other clinicopathological factors and its contribution to prognosis in clinical staging. Results: Of the 323 pT3-4 tumors, 28 (8.7%) showed pathologically defined invasion to adjacent organs (pT4). A significant difference was seen in tumor size, frequency of mulivisceral resection and blood transfusion, operative blood loss, and operation time between pT3 and pT4 tumors (p<0.0001). Patient survival of pT4 tumors was almost the same as that of pT3 tumors in JGR stage II-IIIa tumors (n=261)(p=0.9591). However, a significant difference was seen in patient survival when they were divided by lymph node status (p<0.0487). No difference was observed when survival of patients with a TNM stage II tumor (n=177) that was node-negative was compared between stage IIA (pT3) and IIB (pT4)(p=0.8069). Multivariate analysis showed that only lymph node metastasis (p=0.0043) and blood transfusion (p=0.0223) were significant prognostic factors in patient survival in pT3-4 colorectal cancer. Conclusion: Pathological invasion to adjacent organs is less significant than lymph node metastasis as a prognostic factor in locally advanced colorectal cancer after curative resection. It significantly affects perioperative factors and patient prognosis may be worsened indirectly through blood transfusion and other factors. These findings should be recognized when treating colorectal cancer with invasion to other organs.

View full abstract

A 60-year-old man followed up for 20 years with gastric polyposis underwent unsuccessful medical treatment including supplementary iron therapy, lansoprazole administration, and Helicobacter pylori eradication therapy. Total gastrectomy was attempted for chronic iron deficiency anemia and hypoproteinemia. Numerous polyps were found throughout the stomach and hypertrophic folds observed from the gastric body to the fundus. No obvious familial history was demonstrable for oral or circumoral pigmentation, congenital baldness, or nail ab normality. Pathological findings for the resected specimen led to a diagnosis of juvenile polyposis limited to the stomach, a rare condition. Only 20 cased have been reported in Japan since 1979. Of these, 9 included coexistent adenocarcinoma. Total gastrectomy is thus advisable in a case of juvenile polyposis of the stomach with complications such as anemia and hypoproteinemia.

View full abstract

A 78-year-old woman admitted for an intra abdominal tumor was found in computed tomography to have a 18 cm tumor in the right hypochondrium and a metastatic tumor of the lateral liver lobe. Endoscopic examina tion showed no mucosal lesion. We suspected a mesenchymal tumor with liver metastasis. The tumor grew extraluminally from the posterior wall of the stomach and was fed by the right gastric and gastro epiploic arteries. Distal gastrectomy with B-II reconstruction was done. The tumor was diagnosed as well-differentiated iposarcoma of the stomach. Primary gastric liposarcoma is rare and only 29 cases have been described in the English and Japanese literature. Although liposarcoma is considered to have a good prognosis, primary gastric liposarcoma with hepatic metastasis have a poor prognosis.

View full abstract

We report a rare case of coexisting malignant lymphoma and adenocarcinoma occurring as a collision tumor in the stomach with malignant lymphoma of the tonsil. A 62-year-old man reporting swelling of the left tonsil was diagnosed with malignant diffuse large B cell lymphoma of the left tonsil. Gastric carcinoma was found in a systemic checkup following this diagnosis. A depressed lesion was found at the posterior wall of the lower body of the stomach, and endoscopic biopsy showed well differentiated adenocarcinoma, necessitating distal gastrectomy combined with D2 lymph node dissection. Histologically, the resected specimen showed a collsion tumor in which carcinoma (tub1, m) contacted malignant lymphoma (diffuse large B cell type, sm2), but without nodal metastasis. The postoperative course was uneventful. A CyclOBEAP regimen (cyclophosphamide, vincristine, bleomycin, etoposide, doxorubicin, prednisolon) for malignant lymphoma of the left tonsilwas conducted elsewhere 1 month after surgery, after which the man entered complete remission. The patient remains alive with recurrence-free 14 months after surgery.

View full abstract

We report 3 cases of paraduodenal hernia diagnosed preoperatively. Case 1: A 49-year-old man admitted for abdominal pain and vomiting was found in upper GI series and abdominal CT to have clustered smallintestinal loops between the stomach and left kidney, necessitating emergency surgery under a diagnosis of left paraduodenal hernia. Case 2: An 80-year-old woman referred for abdominal pain persisting for 7 days was found to have a tender soft mass palpated in her right abdomen and diagnosed with paraduodenal hernia based on abdominal CT. Because her condition rapidly deteriorated, we conducted emergency surgery. Case 3: A 53-year-old woman admitted for abdominal pain and vomiting persisting for about 3 months required emergency surgery under a diagnosis of paraduodenal hernia based on abdominal CT. The postoperative courses of all 3 patients were uneventful, and symptoms were alleviated. In patients without a history of abdominal surgery, paraduodenal hernia should be considered as a possible cause of repeated intestinal obstruc tion.

View full abstract

We report a case of primary biliary cirrhosis (PBC) associated with colon cancer. A 58-year-old woman referred for general malaise and icterus was found in laboratory studies to have high serum biliary enzymes. HBS antigen and HCV antibody were negative. Antimitochondrial antibody was positive. She was diagnosed as having PBC. Colonoscopy and barium enema were done for general evaluation. Biopsy of a tumor detected in the sigmoid colon showed adenocarcinoma. Hepatic impairment normalized after medication was started. igmoidectomy with D2 lymph node dissection and liver biopsy were done, and the postoperative course was uneventful. Macroscopically, the 40×37 mm type 3 tumor was ocated in the sigmoid colon. Histopathologically, the tumor was moderately differentiated adenocarcinoma with invasion to the subserosal connective tissue. No node involvement was seen. The histological stage was II. Histological features on liver biopsy indicated stage 2 according to Scheuer's classification. Patients with PBC sometimes have extrahepatic malignant tumors. Reports of colorectal cancer coexisting with PBC are few. We review similar cases in the Japanese literature. Patients with PBC should be examined carefully for extrahepatic malignancies, including the gastrointestinal tract, in diagnosis and follow-up.

View full abstract

A 75-year-old man with hepatocellular carcinoma repeatedly undergoing TAE and PEIT war referred for tumor recurrence. He underwent TAE once more, but the tumor did not decrease in size, and he was readmitted. On the day of admission, he reported tarry stool followed by upper abdominal pain and nausea upon evacuation. His hemoglobin decreased to 8.3 g/dl. Ultrasonography and CT showed an intrabile duct tumor thrombus at the lateral segment of the liver and dilatation of the peripheral bile duct. Angiography showed a slight tumor stain at the lateral segment of the liver. Percutaneous transhepatic cholangiography did not show the left bile duct, but showed filling defects in the common bile duct. Based on a diagnosis of hepatocellular carcinoma with hemobilia from an intrabile duct tumor thrombus. We conducted left hepatic lobectomy and incision of the common bile duct with removal of coagula. Pathology revealed poorly differentiated hepatocellular carcinoma with sarcomatous changes.

View full abstract

A 73-year-old woman admitted for epigastric pain and hematemesis and having a 10-year history of aspirin in-gestion was found in abdominal CT to have a 68×74 mm cystic lesion in the pancreatic tail. The lesion con-tained a slightly high-density area with a low-density area in the center. The CT number of each was 17HU, 75HU, and 45HU. ERCP showed a dilated main pancreatic duct and the cyst communicating with a pancreatic duct branch in the tail. MRI suggested hemorrhage into the pancreatic cyst, but we could not exclude malig-nancy due to the elevated tumor marker. A distal pancreatectomy showed clotted blood but no elevated le-sion, suggesting neoplasm within the cyst. Histological examination showed the cyst wall to be lined with co-lumnar epithelium, leading to a final diagnosis of cystadenoma of the pancreas. The postoperative course was uneventful and she was discharged on postoperative day 22.

View full abstract

We report a case of adenocarcinoma in the accessory duct of the pancreas and its difficulty in preoperative diagnosis. A 69-year-old man admitted for nausea and vomiting was found in endoscopic examination to have stenosis at the descending duodenum with edema and redness of the mucosa. Biopsy showed no malignancy, and physical examination and blood tests were unremarkable. Duodenography showed irregularity in the wall of the duodenal bulb. CT showed a tumorous leision at the head of the pancreas. The common bile duct and main pancreatic duct was normal on MRCP. We conducted a pylorus resecting pancreatoduodenectomy, because intraoperative rapid histopathological examination of the shrinkage at the head of pancreas indicated adenocarcinoma. The tumor was localized between the submucosa of the duodenum and the head of the pancreas. The cut surface of the specimen showed that invasion to the duodenum was greater than to the pancreas. Pathological study showed that the main pancreatic duct was normal, but adenocarcinoma was localized in the accessory pancreatic duct. The Accessory pancreatography with contrast medium in the resected specimen showed stenosis due to adenocarcinoma.

View full abstract

A 80-year-old woman admitted for hypochondoralgia was found in abdominal computed tomography to have a heterogenous mass 9 cm in diameter in the right hepatic lobe. Surgery was conducted for a suspected mesenchymal tumor arising from the abdominal wall or originating in the liver. Operative findings showed that the tumor originated in the diaphragm. We resected the tumor. Histologically, the tumor consisted of spindle and pleomorphic cells. Mitotic cells were seen 8/10 HPF, and atypical mitosis was sporadically present. Immunohistochemical testing was positive for CD34, vimentin, and glycogen, and negative for S-100 and desmin, identifying the tumor as a malignant solitary fibrous tumor of the diaphragmatic peritoneum. Eight months post operatively, the patient is doing well, without evidence of recurrence.

View full abstract

A 49-year-old man presented at our hospital with right lower quadrant abdominal pain and fever. Because the examination showed tenderness and muscular guarding, we suspected local peritonitis due to acute appendicitis or diverticulitis of the ascending colon. Ultrasonography and computed tomograpy showed severer in-flammatory change in the terminal ileum than in the ileocecal region, and local peritonitis caused by perforation of acute appendicitis could not be ruled out. At surgery an inflammatory mass was found in the ileocecal region, and there was slight inflammatory swelling of the appendix. The terminal ileum and cecum containing the inflammatory mass was resected. The mass was disclosed to be mesenteric abscess secondary to perforation of the terminal ileum, 3 cm proximal to the ileocecal valve. The pathological diagnosis was mesenteric abscess caused by a penetrated diverticula of the terminal ileum. Since we have had little experience with diverticulum of the ileum, because of their rarity, we report this case of penetration of an ileal diverticulum.

View full abstract

We report a case of multiple perforations of the transverse colon induced by a nonsteroidal antiinflammatory drug (NSAID), which is quite rare in Japan. A 31-year-old man admitted for chronic tonsillitis was administered 75-112.5mg/day of diclofenac sodium tablets and 50-100mg/day of suppository as painkiller after tonsillectomy. Thirteen days postoperatively, he suffered sudden severe epigastralgia. Abdominal computed tomography showed free air and ascites in the abdominal cavity, leading to a diagnosis of panperitonitis caused by gastrointestinal tract perforation, necessitating emergency surgery. Multiple perforations at the transverse colon necessitated partial transverse and ascending colectomy. Histological findings showed that multiple perforated ulcers with necrosis masses and fibrin at the transverse colon, presumed to be nonspecific inflammatory findings. He recovered well, and was discharged on postoperative day 22.

View full abstract

Case 1: A 68-year-old woman with esophageal cancer (stage IV) was treated with FP chemotherapy (5-FU at 750mg/day for 5 days+CDDP at 80mg/day for 1 day). On day 5 of administration, she suffered a consciousness disorder, convulsions, and hyponatremia (109mEq/L), and was diagnosed with inappropriate secretion of antidiuretic hormone (SIADH). Case 2: A 60-year-old woman with pancreatic head cancer (stage IVA) was treated with FP chemotherapy (5-FU at 250 mg/day by continuous arterial infusion+CDDP at 10mg third a week by arterial infusion). After the fourth cycle of chemotherapy, she suffered myelosuppression (Grade 4) and hyponatremia (123mEq/L). Judging from urine Na of 125mEq/L, 24-hour urine Na of 525mEq/day, and serum ADH of 7. 9pg/mL, she was diagnosed with SIADH. Frequent measurement of serum Na appears to be useful for the early detection and treatment of SIADH. These are, to our knowledge, the first cases of SIADH reported in patients with gastrointestinal solid cancer apparently induced by CDDP.

View full abstract