Purpose: We prospectively studied whether preoperative cardiopulmonary function reinforcement training improved maximum oxygen uptake per minute (VO₂max) and the training effect on psychological surgical stress in patients with esophageal cancer. Methods: Subjects were 23 patients with esophageal cancer undergoing curative esophagectomy with two- or three-field lymph node dissection via right thoracotomy. Preoperative cardiopulmonary function reinforcement training was conducted at 50-70% maximum heart rate reserved using a bicycle ergometer. We evaluated VO₂max, pulmonary spirometry and right lower-limb muscular strength before and after training. Using the state-trait anxiety inventory (STAI) questionnaire, we also evaluated trait and state anxiety. Results: Preoperative cardiopulmonary function reinforcement training significantly improved VO₂max and lower-limb muscular strength (p<0.05). Anxiety scores decreased (65.2%) after training, although trait anxiety scores did not change. First independent sitting, standing and postoperative walking were earlier than that in the control group (p<0.05). Conclusions: Results suggest that preoperative cardiopulmonary function reinforcement training improves VO₂max, pulmonary function, and lower-limb muscular strength while decreasing preoperative anxiety. Such preoperative training may thus help reduce pulmonary complications following esophagectomy for esophageal cancer.

View full abstract

Pectus excavatum is generally asymptomatic, but chest pain and cardiopulmonary dysfunction have been reported. Pectus excavatum may also be a risk for complications in extended thoracic surgery, such as esophagectomy with lymph node dissection. A 61-year-old man undergoing esophagogastroduodenoscopy was found to have a type 2 esophageal tumor 34-39 cm from the incisor teeth, confirmed in biopsy to be squamous cell carcinoma, stageIIA (T3, N0, M0) based on International Union Against Cancer (UICC) classification. We therefore administered 2 courses of 5-FU/cisplatine as a standard FP regimen in neoadjuvant chemotherapy. Chest computed tomography (CT) showed the distance between the breast bone and thoracic vertebrae to be 4 cm, making radical subtotal esophagectomy through a right thoracotomy unduly risky. Following the Ravitch procedure and abdominal manipulation a subtotal esophagectomy was done simultaneously with two-field lymph node dissection through a right thoracotomy. The perioperative field was well exposed. The postoperative course was uneventful, and the man was discharged on the postoperative day 22.

View full abstract

A 56-year-old man with a history of chronic type C hepatitis admitted due to advanced gastric cancer with esophageal invasion underwent neoadjuvant chemotherapy, followed by total gastrectomy with lower esophagus resection. Postoperatively, refractory massive ascites not controllable with diuretics necessitated concentrated ascites reinfusion therapy starting on postoperative day (POD) 43. After 12 treatment cycles, ascites decreased somewhat but remained refractory, necessitating Denver peritoneovenous shunt surgery on POD 88. Abdominal distention ceased and laboratory data improved markedly. He was discharged on POD 98. Numerous interventions for medically refractory ascites, such as concentrated ascites reinfusion therapy, peritoneovenous shunt, and transjugular intrahepatic portosystemic shunt, have been applied to relieve the symptoms of massive ascites. Few reports have been made of refractory postoperative ascites successfully treated by peritoneovenous shunt. For patients with refractory postoperative ascites with a background of cirrhosis, however, the efficacy and risk of treatment must be thoroughly understood to select appropriate intervention, and timing.

View full abstract

We report a rare case of a foreign body in the gallbladder. A 66-year-old woman was found during a hepatic workup in computed tomography (CT) to have a gallbladder wall perforation due to a metal foreign body. A side from cesarean section and uterine myoma surgery, the woman had no history of epigastric surgery. Blood tests on admission showed no inflammation, and no abnormal abdominal findings were seen. Upper gastrointestinal endoscopy showed no evidence of foreign body exposure. In cholecystectomy, we observed the gallbladder and gastroduodenal walls, but found no inflammation or foreign body. A 15-mm-long metal wire pierced the gallbladder mucosa. The woman was discharged without complication on post operative day 9. Although we could not precisely identify the route to the gallbladder, we speculated that she had somehow imbibed the metal foreign body by mistake, after which it penetrated the duodenal wall.

View full abstract

Biliary cystic tumors, rare hepatic neoplasms, were recently divided into two groups based on the presence or absence of ovarian mesenchymal stroma and luminal communication with the bile duct. We present three cases of biliary cystic tumor. Case 1: A 21-year-old woman seen for cholangitis and found to have a biliary cystic tumor underwent extended right hepatectomy. She was definitively diagnosed with cystadenoma. Case 2: A 39-year-old woman with epigastralgia and found to have a hepatic multilocular cystic tumor with septations underwent left hepatectomy. She was also definitively diagnosed with cystadenoma. Case 3: A 61-year-old man found to have a cystic lesion with intrahepatic bile duct dilation in abdominal ultrasound testing during a regular physical checkup underwent left hepatectomy. He was definitively diagnosed with cystadenocarcinoma. All three cases showed luminal communication to the bile duct. Case 2 alone had ovarian mesenchymal stroma. The clinicopathological features of cases 1 and 3 resembled those of intraductal papillary neoplasm of the bile duct, which could be regarded as a biliary counterpart of pancreatic intraductal papillary mucinous neoplasm.

View full abstract

A 75-year-old man with cold agglutinin disease (CAD) who had undergone laparoscopic cholecystectomy was admitted for jaundice and fever, diagnosed as cholelithiasis and choledocolithiasis, and cholecystectomy was planned. CAD is a form of autoimmune hemolytic anemia. Autoantibodies, usually immunoglobulin M, cause red blood cell agglutination and hemolysis at a decreased body temperature. Because perioperative hypothermia is by far the most common perioperative thermal disturbance, special consideration is required in surgical subjects with CAD. Our perioperative approach was to (1) treat CAD medically, (2) avoid a cool environment, (3) consider plasmapheresis, (4) administer erythropoietin, (5) prepare for transfusion, and (6) keep the body temperature to 37°C. These procedures, excluding plasmapheresis, enabled us to safely conduct laparoscopic cholecystectomy for a subject having CAD.

View full abstract

A 63-year-old man with a left renal tumor and a gallbladder tumor found in abdominal ultrasonography, and diagnosed preoperatively with double cancer. Underwent left nephrectomy and expanded cholecystectomy. The solid gallbladder tumor was pendunculated. Histopathologically, both the renal and gallbladder tumors had a morphology of clear cell carcinoma, diagnosed primary renal cell carcinoma and metastatic renal cell carcinoma of the gallbladder. Interferon was adoministrated in postoperative therapy and the man was discharged on postoperative day 30. To our knowledge, metastatic renal cell carcinoma of the gallbladder is rare, with only 35 reports, including our case, in the Japanese and Euroamerican literature. These literature said that the pathological examination was absolutely imperative to make a definite diagnosis. It means these cases are impossible to diagnose preoperatively as metastasis or primary gallbladder tumor. To prevent the residual carcinoma, we should do radical surgery for primaly gallbladder carcinoma.

View full abstract

We report a case of local cystic duct cancer recurrence resected after curative resection. A 81-year-old-man underwent resection of the gallbladder and the extrahepatic bile duct with lymph node dissection for cystic duct cancer in August 2005. In March 2007, serum AFP and CA19-9 became elevated and dynamic computed tomography (CT) showed a 5 cm mass at the gallbladder fossa. Local recurrence of cystic duct cancer was suspected and the tumor was resected together with liver segment S4a and 5 and the jejunum wall around the tumor near the hepaticojejunostomy. The resected specimen was pathologically diagnosed as the expected local recurrence invading into the liver and the jejunum wall. The tumor had immunoreactivity to AFP. The patient has been free from recurrence in the 24 months following the second surgery.

View full abstract

A 69-year-old woman was found in enhanced abdominal computed tomography and magnetic resonance imaging to have a tumor congesting the gallbladder tail and body, a swollen lymph node 20 mm in diameter beside the gallbladder neck and another lymph node 85 mm in diameter posterior to the pancreatic head, showed a disrupted cystic duct and a compressed common bile duct. Angiography showed portal vein irregularity suggestive of swollen lymph node invasion. Based on a diagnosis of advanced gallbladder carcinoma with lymph node metastasis invading the portal vein and the pancreatic head, we conducted surgery, but intraoperative findings showed no portal vein invasion, so we conducted pancreatoduodenectomy, extended cholecystectomy, and common bile duct excision with regional and paraaortic lymphadenectomy. Histopathological examination showed papillary adenocarcinoma, depth ss, with lymph node Nos. 12c and 13a positive and stage III. A pancreatic fistula was identified postoperatively. The woman was discharged on postoperative day 36, is doing well, and shows no signs of recurrence 6 years later.

View full abstract

A 57-year-old Japanese woman complained back- and upper left abdominal pain. Computed tomography (CT) analysis revealed an pancreatic tail cancer, 10 cm in diameter, with direct invasion into the spleen and gastric wall. A peri-splenic abscess was formed. The patient underwent distal pancreatectomy, splenectomy, and partial gastrectomy. Pathological analysis with multiple samplings revealed that the tumor was pure squamous cell carcinoma with a marked central degeneration/necrosis. Postoperative whole-body examination showed no other primary tumors, indicating that the tumor was not a metastatic focus from other organs. After undergoing one course of postoperative chemotherapy, this was ceased due to adverse side effects. The patient remains alive without recurrence or distant metastasis 3 years and 1 month after the surgery. Pancreatic squamous cell carcinoma is an extremely rare subtype of pancreatic cancer of ductal origin, with a usually dismal prognosis. Our case is typical in its radiological and pathological findings. Despite its advanced stage, the patient showed a long-term disease-free follow-up. In this sense, the present case is important for clarifying the biological significance of pancreatic squamous cell carcinoma.

View full abstract

Aggressive surgery should be considered when interventional radiology (IVR) is difficult in postpancreatectomic pseudoaneurysm. A 61-year-old man undergoing pancreatoduodenectomy for pancreatic-head cancer suffered massive hemorrhaging through an abdominal drainage tube due to postoperative pancreatic fistula and circulatory shock on postoperative day (POD) 10. Emergency abdominal superior mesenteric artery (SMA) angiography showed a pseudoaneurysm 10 mm in diameter at the SMA root. IVR hemostasis was technically difficult, so we conducted emergency laparotomy, ligating and suturing the SMA and conducting right common iliac artery-SMA bypass using a left great saphenous vein graft following remnant total pancreatectomy. The man recovered from shock and CT on POD 21 confirmed intestinal blood flow to be supplied by the iliac artery alone via the graft.

View full abstract

We report a case of torsion of a wandering spleen with mesenterium commune. A 47-year-old mentally retarted woman admitted for anorexia, slight fever and nose bleeds was found on palpation to have a lower abdominal mass. Laboratory data showed disseminated intravascular coagulation. Abdominal computed tomography showed a spleen with torsion in the pelvic space and mesenterium commune due to ascending colon absence in the right abdomen. In emergency surgery based on a preoperative diagnosis of disseminated intravascular coagulation due to splenic infarction we found the spleen enlarged with 4 twisted rotations and a splenic pedicle adhering to the pelvic space, and mesenterium commune in which the duodenum, pancreas, ascending colon, descending colon, and rectum were not fixed to the retroperitoneum. Splenectomy was conducted.

View full abstract

We report a case of mesenteric schwannoma excised in laparoscopic surgery. A 53-year-old woman referred for epigastralgia was found in abdominal computed tomography (CT) and endoscopy to have a hard submucosal tumor on the horizontal duodenum. We preoperatively diagnosed gastrointestinal stromal tumor (GIST) originating from the duodenum and conducted laparoscopic excision. The tumor was located in the small intestine mesentery and could be excised of tumor without partially resecting the jejunum. Immunohistochemically, tumor cells were diffusely positive for S-100 protein but negative for c-kit and CD34. These findings were compatible with a benign mesenteric schwannoma. The patient's postoperative course was satisfactory and no recurrence has occurred in the 12 months since surgery. Mesenteric schwannoma is relatively rare, so preoperative diagnosis may be difficult. Laparoscopic surgery is considered useful minimally invasive treatment for these tumors.

View full abstract

A previously healthy 23-year-old man admitted for abdominal pain, frequent diarrhea, and vomiting, was found in abdominal computed tomography (CT) to have an ileo-colonic intussusception without a mass lesion at the leading point. Aggravated abdominal pain necessitated emergency operation that day. After manually fixing the intussusception, we performed ileocecal resection because the cecum was very edematous, solid, and appeared malignant. Histopathological cecal features included edematous focal wall thickening and nonspecific colitis. The postoperative diagnosis of Shigella flexneri and Campylobacter jejuni was made by preoperative and postoperative stool cultures. The cause of enterocolitis-induced intussusception mainly concerned leading point formation by acute inflammatory change, abnormal peristalsis, and anatomical factors. This case demonstrated intussusception as a complication of enterocolitis, underscoring that enterocolitis is in fact a potential cause of intussusceptions, and some reports reveal the feasibility of conservative therapy for enterocolitis-induced intussusception without surgical intervention.

View full abstract

A 66-year-old man referred for lower right abdominal pain, and markedly elevated white blood cell count and CRP in blood tests was found in abdominal computed tomography (CT) to have an ascending colon lesion and ileocecal dilation 10 cm in diameter containing pneumatosis, and mesocolon swelling, necessitating semi emergency surgery based on a diagnosis of perforation of ascending colon carcinoma. Laparotomy disclosed a cecum dilated and greenly necrotic. A soft half-circular mass 60 mm in diameter was found at the anal side of Bauhin's valve. Right hemicolectomy was done based on a diagnosis of pericecal abscess and necrosis secondary to perforation by ascending colon cancer. Histological findings showed tubulovillous adenoma carcinoma of the ascending colon and ischemic colitis. Many calcified schistosomiasis japonica ova were seen in the veins in the submucosal cecal layer. These findings and the fact that the man had fished in a local Toyama river when young led to the pathogenesis of this case being identified as ischemic colitis caused by venostasis.

View full abstract

We report the case of rare primary mixed small cell carcinoma and mucinous cystadenocarcinoma of the appendix. An 86-year-old men seen for obstipation and flatulence was found in colonoscopy to have a cecal tumor. Computed tomography showed multiple metastases in both hepatic lobes necessitating emergency ileocecal resection with D2 lymph node dissection based on a diagnosis of ileus due to cecal cancer. The tumor mainly occupied the appendix. The major tumor component was small cell carcinoma. The partly tumor component was mucinous cystadenocarcinoma showing gland formation with focal mucin production. The definitive diagnosis was primary mixed small cell carcinoma and mucinous cystadenocarcinoma of the appendix. The postoperative course was uneventful but, cachexia progressed rapidly, and the men died on postoperative day 54. Histologically the resected tumor was a biphasic lesion consisting of small cell carcinoma mixed with mucinous cystadenocarcinoma. Immunohistochemically, the adenocarcinoma lesion was stained strongly for synaptophysin suggesting that the adenocarcinoma had the potential to become small cell carcinoma.

View full abstract

A 66-year-old woman seen for lower abdominal pain and endometrial cytology findings of Class V was not found to have any abnormal findings in the uterus or ovaries in radiological examination, although she did have an appendiceal mucocele. The appendiceal tumor found in surgery was filled with mucin and multiple peritoneal nodules, diagnosed as mucinous cystadenocarcinoma of the appendix with peritoneal dissemination, so we operated right hemicolectomy, examined cytodiagnosis of cancer, and did open biopsy of the disseminated nodules. Histopathological examination showed differences in pathological structures between the appendiceal tumor and disseminated nodules, definitively diagnosed as synchronous mucinous cystadenocarcinoma of the appendix and primary peritoneal carcinoma. She underwent postoperative adjuvant chemotherapy for primary peritoneal carcinoma. This is, to the best of our knowledge, the first report of synchronous mucinous cystadenocarcinoma of the appendix and primary peritoneal carcinoma.

View full abstract

We report a very rare case of rectum and anus collision cancer. A 48-year-old man seen for anal pain was found in colonoscopy to have a 3 cm polypoid mass in the lower rectum, part of which was suspected to have invaded the anal epithelium. Biopsy yielded a diagnosis of moderately to highly differentiated adenocarcinoma. Imaging studies, including ¹⁸F-fluorodeoxy-glucose positron emission tomography (FDG-PET)/CT, did not show any clear distant metastasis. Under a diagnosis of rectal cancer with anal canal invasion, we conducted abdominoperineal resection and lymph node dissection (D3). Resected specimens showed a type 1 mass above the dentate line. Cross-sections contained a tumorous lesion in the wall continuous with the mass. The histological diagnosis of the type 1 mass was moderately to highly differentiated adenocarcinoma originating in the rectum. The histological diagnosis of the tumorous lesion was adenocarcinoma mainly with poor differentiation and originating in the anal canal. The patient, thus had collision cancer of the rectum and anal canal. Some collision cancer cases have been seen in the lungs and stomach, but, to the best of our knowledge, only 16 large intestine cases, including ours, have been reported in Japan.

View full abstract

Although surgical resection is viewed as the most effective therapy for locally recurrent rectal cancer (LRRC), surgical stress and sacral nerve damage accompanied by high sacral resection often yield a dismal result. Despite efficacy similar to that of surgery, indications for carbon ion radiotherapy (C-ion RT) are limited by gastrointestinal toxicity. We report a case of LRRC resected combined with preoperative C-ion RT. A 62-year-old man undergoing low anterior resection for rectal adenocarcinoma with D2 lymphadenectomy in November 2003 was diagnosed pathologically with moderately differentiated adenocarcinoma, SS, N0, Stage II, R0, operative curability A. Admitted for sacral pain in February 2008, he was diagnosed by endoscopic biopsy as having recurrent rectal cancer. Imaging analysis showed recurrent sites at the anastomosis and sacral bones 2 to 4. Because sacral bone metastasis could not be resected, C-ion RT (73.6 Gray equivalent) was started for both lesions in April 2008. After the completion of C-ion RT, the man underwent abdominoperineal resection combined with sacral (S5), coccygeal, and partial resection of the small intestine. Histologically, resected specimens showed no residual caner cells, i.e., grade 3 based on the Japanese radiation therapy criteria. He was discharged on postoperative day 46 without severe complications and remains alive with no sign of recurrence in the 13 months since surgery.

View full abstract

In seven cases of anastomotic leakage causing pelvic abscess after laparoscopic low anterior resction treated by transanal drainage, anastomotic leakage was diagnosed by enema, the fistula was dilated by forefinger, and abscess cavities were drained into the rectum, avoiding surgical intervention including percutaneous drainage and/or laparotomy and/or diverting ileostomy. In one case, transanal drainage was ineffective and diverting ileostomy was performed. The patient's general condition must be good, however, and the abscess limited to within the presacral space not expanded into the abdominal cavity. Cases of peritonitis and septicemia due to leakage should be excluded. Transanal drainage can be one of the therapeutic options for the anastomotic leakage following laparoscopic low anterior resection.

View full abstract