Introduction: Metachronous hepatic metastasis following radical surgery for advanced colorectal cancer has a decisive influence on prognosis, thus screening of high risk patients is important. Osteopontin (OPN) is a phosphorylated glycoprotein with a cell adhesion sequence that is associated with tumor metastasis and proliferation.In the present study, we investigated the relationship between the incidence of hepatic metastasis and OPN expression using a immunohistochemical method in patients with colorectal cancer. Subjects and Methods: Patients with advanced colorectal cancer who underwent radical surgery were divided into 3 groups: those with synchronous hepatic metastasis (n=30), those with metachronous hepatic metastasis (n=17), and nonmetastatic cases (n=54). Immunohistochemical staining was performed using anti-OPN, CD68, and CD105 antibodies. Results: OPN expression was mainly observed in tumor associated macrophages (TAM) that had infiltrated the tumor surrounding the stroma, whereas it was not seen in the tumor cells. The ratios of OPN-positive TAM (OPN/TAM) and microvessel density (MVD) were determined for each location. As a result of univariate analysis in the metachronous hepatic metastasis group, significant differences were observed for the following 3 factors: MVD in the central area of the cancer stroma, and OPN/TAM ratios in the marginal and central areas. Results of multivariate analyses of those 3 suggested that the OPN/TAM ratios in the marginal and central areas of the cancer stroma might be risk factors for metachronous hepatic metastasis. Discussion: We concluded that OPN/TAM ratios in the cancer stroma in the marginal and central areas of excised colorectal specimens are useful for screening patients with a high risk of postoperative hepatic metastasis.

View full abstract

The patient was a 50-year-old man with the chief complaints of abdominal distention and general malaise nine months after total gastrectomy with a Roux-Y reconstruction for gastric cancer. Abdominal computed tomography and ultrasonography revealed marked dilatation of the afferent loop, and the patient was diagnosed as having afferent loop syndrome. The stoma of the jejuno-jejunostomy, which had been reconstructed by the stapling technique at the time of total gastrectomy could not be identified by upper gastrointestinal endoscopy using a scope equipped with a lucid cap. Therefore, dilatation of the anastomotic stricture could not be carried out using an endoscopic procedure. Exploratory laparotomy under general anesthesia revealed an obstruction of the jejuno-jejunostomy. We resected the obstructed anastomotic portion, and reconstructed the jejuno-jejunostomy. Histopathological examination revealed that the obstruction had been caused by extension of mucosa and muscular layer. It is thought that further modification is needed to improve the stapling technique during formation of the Roux-Y loop. In patients presenting with abdominal distention after total gastrectomy and Roux-Y reconstruction, it is necessary to keep in mind this rare complication, as early recognition of dilatation of the afferent loop is important.

View full abstract

An 18-year-old man whose father had died of gastric cancer was admitted for ileus due to carcinomatous peritonitis from advanced gastric cancer. Ileus was due to gastric cancer invading the transverse colon, necessitating ileosigmoidostomy. He then underwent chemotherapy as an outpatient, finally died. Since he had notbeen diagnosed with cancer on initial examination, he had gone untreated for 5 months, which underscores the importance for high-risk patients to be regularly examined without preconception.

View full abstract

A 46-year-old man undergoing low anterior protectomy for rectal cancer sufferd shock due to acute hemorrhage on postoperative day POD 10 days after surgery. Gastrointestinal investigation showed an ulcer of the bulbar duodenum that was not a confirmable source of hemorrhage. Although he appeared to recover after the ulcer was clipped, he fell into shock again the next day. In emergency laparotomy, we diagnosed postbulbar duodenal ulcer hemorrhage and conducted pancreatoduodenectomy. Leakage from the pancreatojejunostomy and subsequent perforation of an arterial aneurysm of the right colonic artery then occurred. We ligated the artery surgically. The man discharged 81 days after the pancreatoduodenectomy. This is, to our knowledge, the first report of successful pancreatoduodenectomy in a patient with an acute massive ulcer hemorrhage in postbulbar duodenum therapy.

View full abstract

There have been a few reports of hepatocellular carcinoma (HCC) in cases with primary biliary cirrhosis (PBC). In particular, resection of HCC in PBC patients has been rarely reported. We report a case of HCC in a 79-year-old male patient with stage-II PBC, in whom successful curative liver resection was performed. Preoperative abdominal CT revealed a heterogeneously enhancing tumor, 13cm in diameter, occupying the left lateral sector. Serum tumor markers including alpha-fetoprotein and des-gamma-carboxy prothrombin were eleated. The patient was diagnosed as having HCC and underwent resection of the left lateral sector in March 2004. Microscopic examination of the resected left lateral sector revealed moderately differentiated HCC, and a tumor-free area showing evidence of stage-II PBC. There have been nine reported cases of resected HCC associated with PBC. Eight of the nine patients were alive more than one year postoperatively. The patient in this report is alive and well without recurrence until now, 28 months after the surgery. Early detection of HCC by close follow-up of patients with PBC may facilitate curative tumor resection and lead to improved survival.

View full abstract

A 60-year-old man seen elsewhere for nausea and upper abdominal pain and admitted for obstructive jaundice based on laboratory data was found in abdominal computed tomography (CT) to have two tumors in the head and tail of the pancreas, which were not enhanced. Abdominal angiography showed that the tumors involved the splenic artery and vein. We operated based on a preoperative diagnosis of pancreatic double cancer. A few granulomatous nodules, not diagnosed as peritoneal dissemination, were seen on the mesentery of the small intestine, and the total pancreas was sclerosed by tumors, which invaded the superior mesenteric vein, necessitating total pancreatectomy with superior mesenteric vein resection. Postoperative pathological findings showed that epithelioid granulomas with multinucleated giant cells had formed in the pancreas, yielding a diagnosis of granulomatous pancreatitis. We conducted further examinations to rule out other granulomatous diseases, making a definitive diagnosis of tumor-forming pancreatitis with severe granuloma. No such case has, to our knowledge been reported in Japan.

View full abstract

We report a case of pancreatic cancer with intraductal papillary-mucinous tumor (IPMT). A 67-year-old man admitted with brown urine and jaundice was found in computed tomography (CT) to have a low-density area suggesting pancreatic cancer in the pancreatic head. MRCP showed a multicystic lesion in the pancreatic head and two enlarged cystic masses in the pancreatic body and tail. He underwent total pancreatectomy with splenectomy. The pathological diagnosis was invasive ductal carcinoma with intraductal papillarymucinous adenoma in the pancreatic head and multiple intraductal papillary-mucinous adenomas in the pancreatic body and tail.

View full abstract

We report a case of rectal splenosis with transverse colon carcinoma. A 68-year-old man who had undergone splenectomy 20 years earlier due to splenic injury reported constipation. A large bowel series showed transverse colon cancer. Contrast-enhanced abdominal computed tomography (CT) and Magnetic resonance imaging (MRI) showed a sub mucosal tumor (3cm in diameter) in Douglas. pouch. We diagnosed transverse colon cancer and submucosal rectum tumor. The mass was found in laparotomy to be upon the surface of the rectum and was removed, followed by curative colectomy. Pathological studies showed splenic tissue, with splenosis as the definitive diagnosis. We concluded that splenosis is one of differential diagnoses possible, especially in patients with a history of surgery for splenic injury.

View full abstract

A 55-year-old male who had been treated by continuous ambulatory peritoneal dialysis (CAPD) for chronic renal failure for the past 8 years developed intestinal obstruction. The CAPD was discontinued, and hemodialysis was instituted. Encapsulating peritoneal sclerosis (EPS) was diagnosed in 2002 and treated surgically by total intestinal enterolysis. Small bowel obstruction recurred 9 months later, and recurrent EPS was diagnosed. Conservative treatment was effective at once, it was ineffective at second time and reoperation was indicated. Intraoperatively, a thick, firm membrane covered the entire intestine the same as observed during the first operation, and postoperative adhesions were also noted. All of the membranes were peeled off, and the adhesions were detached from the entire intestine. Peristalsis was confirmed after the enterolysis. An ileostomy was created for protection against ileal injury. The patient regained full oral intake. The surgical treatment for postoperative recurrence of EPS seems to be safe and effective.

View full abstract

We report a patient with severe ulcerative colitis who underwent repeated ileal pouch-anal anastomosis with a new ileal J-pouch due to intractable perianastomotic abscess after initial ileal pouch-anal anastomosis. A 32-year-old man, who underwent staged restorative proctocolectomy for severe ulcerative colitis, suffered perianastomotic cuff abscess, pointed out in pouchography before ileostomy closure. Septic complications did not improve, despite three attempts at transanal repair, including curettage, unroofing, partial muscular cuff resection, and reanastomosis. The ileal J-pouch anal anastomosis was finally excised and a new ileal J-pouch-anal anastomosis was constructed from an abdominoperineal approach. The postoperative course after stoma closure was good and the patient experienced satisfactory anal function except for nocturnal soiling.

View full abstract

We report the long-term survival in a case of endocrine cell carcinoma of the cecum. A 45-year-old man was admitted for an abdominal mass in the ileocecal region and closer examination showed a submucosal tumor of the cecum. In March 1998, right hemicolectomy was done and endocrine cell carcinoma was diagnosed by histological examination. On December 1998, abdominal paraaortic lymph node metastases were found in CT and PE and CVA chemotherapy were conducted. The evaluation was PR in December 1999 and NC in August 2000. CT showed adrenal and paracommon hepatic artery lymph node metastases in March 2001 and pararenal artery lymph node metastases in September 2001. Radiation therapy was done for metastases and both evaluations were PR. A liver metastasis was detected in February 2002, for which CDDP and CPT-11 chemotherapy was done and which subsequently disappeared. In September 2002, weakness in the lower limb muscles occurred and MRI showed spinal cord metastasis on the thoracic level necessitating laminectomy. Lower limb paresis was complete in February 2003, and palliative care was begun. He died in October 2003, 67months form initial surgery. This case suggested that multidisciplinary treatment including chemotherapy and radiation is effective at least short-term in those with endocrine cell carcinoma of the colon.

View full abstract

Appendiceal carcinoma is relatively rare. Between 1991 and 2005, we have encountered 5 cases of appendiceal carcinoma. The mean age of these patients, consisting of one man and four women, was 68.0 years. The diagnosis of appendiceal carcinoma could not be made preoperatively. In any of the cases; four of the five cases were diagnosed as acute appendicitis, while the one was diagnosed as carcinoma of the cecum. Regarding the histologic type, the tumor was well-differentiated adenocarcinoma in 3 cases, and mucinous carcinoma in 2 cases. The tumor depth was classified as ‘ss’ in 2 cases and ‘ss’ in 3 cases, thus the depth was greater than ‘ss’ in all cases. About Case 3 and 4, the patients died 19 month later and 37 month later respectively. Appendiceal carcinoma is very difficult to diagonose preoperatively, and many patients are diagnosed as case of acute appendicitis. The clinical stage is usually advanced when the diagnosis was made, and the prognosis is bad. Thus in patients with right lower abdominal pain in whom tumor is diagnosed, appendiceal carcinoma should be borne in mind.

View full abstract

The patient was a 32-year-old female with abdominal pain. Abdominal X-ray and CT clearly demonstrated free gas in the abdominal cavity. While the patient reported mild spontaneous pain neither muscular guarding nor sigh of peritoneal irritation were detected by palpation. Since there were no sign of peritoneal irritation, idiopathic pneumoperitoneum and cystic emphysema of the intestine were suspected, however, we performed diagnostic laparotomy because perforation of the digestive tract could not be excluded. The patient was diagnosed as having rectal perforation based on the presence of pus on the serous membrane and mesenteric hematoma in the rectum (Rs), and laparotomy was performed. Since the peritonitis was localized, and edema and inflammation of the wall of the rectum were very mild, we simultaneously performed anterior excision in the low position and drainage after sufficient rinsing of the abdominal cavity. The postoperative course was good, and the patient was discharged from the hospital 11 days after the surgery. Idiopathic perforation and rupture of the large intestine are most often observed in the sigmoid colon (70-80%), and is rare in the rectum. However, perforation of the rectum causes high invasion and severe inflammatory symptoms, and the patients often develop septic shock. Therefore, the postoperative outcome is generally poor in these cases.

View full abstract

A 59-year-old man, who had been taking oral gefitinib for five months for unresectable lung cancer after receiving chemotherapy for three years and also oral predonisolone for three months for interstitial pneumonitis caused by gefitinib, presented with a 2-week history of anal pain. After initial incision and drainage for a perianal abscess, the patient was hospitalized for persistent pain extending from the perianal region to the left buttock and the posterior side of the left thigh after two days. Pelvic computed tomography showed the swelling of subcutaneous soft tissue and presence of gas in the muscle layers. Extended incisions, lavage, debridement and Seton drainage were immediately performed under the tentative diagnosis of the Fournier's gangrene. Abscess fluid cultures yielded Staphylococcus epidermidis and E. coli. Split-thickness skin transplantation was performed on the open wound 35 days later. Since Fournier's gangrene is rarely caused by relatively minor wounds such as a perianal abscess in patients under steroid therapy, caution must be exercised when steroids are given to patients with underlying malignancy associated with depressed immunity.

View full abstract

A 67-year-old Japanese man with myelodysplastic syndrome admitted for right inguinal swelling and pain and diagnosed with incarceration of a right inguinal hernia was found to have an irreducible round 3. 5-cm mass with tenderness. Laboratory findings indicated pancytopenia, necessitating emergency surgery under general anesthesia. The patient was diagnosed with right external inguinal hernia. The hernia sac contained the vermiform appendix. The apex of the vermiform appendix was dark red and evidenced apparent ischemic change due to strangulation. We conducted appendectomy and hernioplasty using a mesh plug. Pathological examination showed erosion in the mucosa and severe serositis at the incarcerated portion of the apex of the vermiform appendix. The postoperative course was uneventful and the patient was discharged on postoperative day 8. Inguinal hernia containing the vermiform appendix, known as Amyand's hernia, is relatively rare.Despite the high risk of infection due to myelodysplastic syndrome, our patient was successfully treated without wound infection.

View full abstract