Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association)
Online ISSN : 1882-5133
Print ISSN : 1345-2843
ISSN-L : 1345-2843
Volume 59, Issue 10
Displaying 1-50 of 51 articles from this issue
  • Ikuya OOSHIMA, Takamitsu ARIGA, Takashi MARUYAMA, Hirohisa KINOSHITA, ...
    1998 Volume 59 Issue 10 Pages 2459-2463
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A retrospective study was made of 40 cases of perforated duodenal ulcer experienced at the hospital from July 1991 to March 1997 to evaluate indications of therapies for the disease. There were 2 cases of conservative therapy, 13 cases of laparoscopic simple closure (LSC), 9 cases of open simple closure (OSC) and 16 cases of subtotal gastrectomy (SG). Durations from the onset of the disease until the operation were 7.3 hours in LSC, 34.2 hours for OSC and 27.5 hours in SG. The opration times were 1.4 hours in LSC, 1.2 hours in OSC and 2.8 hours in SG. The hospital stay amounted to 13.7 days in LSC, 18.8 days in OSC and 29.3 days in SG, whereas over 30 days in conservative theray. As to the medical cost on the health insurance, LSC amounted to 67, 326, OSC to 90, 434, the conservative method to 91, 492, SG to 116, 222 points Recurence of duodenal ulcer appeared in 38.5% of patients undergoing simple closure more than one year after the operation, but all such patients were treated by medication.
    From these findings, we think that the conservative therapy should be indicated for aged patients or inoperable patients with poor risk; and LSC is indicated first if there are no shock findings, then SG is indicated if duodenal stenosis is confirmed, and finally OSC should be selected if shock state or severe complications are confirmed.
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  • Toshiaki WATANABE, Masao MATSUDA, Takeshi UEMICHI, Kenji MIZUNO, Hiros ...
    1998 Volume 59 Issue 10 Pages 2464-2469
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Ultrasonography has been performed in diagnosing diverticulitis of the cecum and ascending colon as a convenient and useful imaging technique. Sixteen patients who were ultimately demonstrated having diverticulitis were subjected to this study and the sonographic findings of the disease were evaluated. The findings are summarized as follows. (1) An oval or irregularly shaped mass protruding from the colonic wall was seen. (2) The mass had a hypoechoic margin. (3) It had a central hyperechoic focus. Spotty high echoes were frequently observed. But hyperechoic speckle or linear high echo or strong echoes with acoustic shadow were also visualized. (4) Hyperechoic area existed surrounding the diverticulum. (5) Thickening of the colonic wall adjacent to the diverticulum was detected. (6) Sometimes a small amount of ascites was found. The direct findings (1), (2) and (3) were seen in all patients (100%). Finding (4) was present in 14 of the 16 patients (87.5%), (5) in 10 patients (62.5%), and (6) in 4 patients (25%). Our study suggests that sonography is very useful for the diagnosis of diverticulitis.
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  • Masahiko OHATA, Isamu KOYAMA, Haruyuki ANZAI, Shutaro OZAWA, Nobuji OG ...
    1998 Volume 59 Issue 10 Pages 2470-2476
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    In a recent one decade, we experienced 461 cases of advanced colorectal cancer, 22 cases (4.5%) of which had small colorectal cancer (SCR) less than 20min in size. A clinicopathological study was made to compare SCR and ordinary colorectal cancers (OCR) over 21mm in size. There were no significant differences in the male-to-female ratio and location of the lesions between both groups. The mean age was young and the invasion depth of mp was common in SCRs compared to OCRs. Rates of vascular invasion and lymph nodes metastases were significantly lower in SCRs. Curative resection rate was higher in SCRs and the prognosis was significantly better in SCRs than OCRs.
    Another analysis of SCRs was conducted. As for the macroscopic type, 10 lesions were elevated type and 12 lesions were depressed type. As for the growth form, five lesions were PG type and 17 lesions were NPG type. In most of the invasive lesions, elevated type and PG type were inner circlar propria muscle. In most of the invasive lesions, depressed type and NPG type were deeper than outer longitudinal propria muscle. Lymphnode metastasis was found in 3 cases in which macroscopic type and growth form were all depressed type and NPG type. Recurrence occurred in two of those three cases.
    We conclude that depressed type and NPG type SCRs have a malignant potential. But as a whole, the prognosis of SCRs was better than OCRs. It is important to find out these small colorectal cancers (SCRs) .
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  • Michito MORI, Kohji MIYAZAKI, Ken SATO, Kenji KITAHARA, Nobuo TSUTSUMI ...
    1998 Volume 59 Issue 10 Pages 2477-2483
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Seventy-eight resected cases of hepatocellular carcinoma were subjected to a study of the correlation between prognosis and prognostic factors which are prescribed in the General Rules for the Hepatic Cancer Study, and in this paper, the strategy of treatment for hepatocellular carcinoma in our institution is also described. In an analysis of the cumulative survival rates, the prognosis was correlated with 8 tumor factors including preoperative AFP value, maximum tumor diameter, number, histologic differentiation grade of the tumor, fc-inf, vp, vv, and im. Besides these 8 factors, it correlated with two background factors including the presence of liver cirrhosis and necrosis rate in tumors by TACE. Moreover, in the disease free survival rate, prognosis was correlated with 7 factors including preoperative AFP value, maximum tumor diameter, number, vp, im, the presence of liver cirrhosis and necrosis rate of the tumor. Adjuvant treatments such as arterial injection chemotherapy might be necessary when the poor prognostic factors (more than 5cm in maximum tumor diameter, vp and im) existed at the initial operation. As for the treatment of recurrent cases, an improvement of the prognosis was obtained only by reoperation when the recurrence had occurred more than 2 years after the initial operation and when the tumors had been restricted in the functionally resectable segment(s). Multimodal treatments including TACE, PEIT and arterial infusion chemotherapy may be needed when the recurrence occurs within two years after surgery.
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  • Shun KUDO, Jin-ichi KAMEYAMA, Akira SUZUKI, Yousuke SAKAI, Shigeo HASE ...
    1998 Volume 59 Issue 10 Pages 2484-2488
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    It is exceedingly important to know the degree of inflammation or adhesion of the cystic duct in conducting the laparoscopic cholecystectomy (LC). In this study, we investigated the significance and usefulness of herical three dimensional CT imaging of the cystic duct for deciding the indication and for assessment of the difficulty in LC.
    Seventy patients who were tried LC were classified into three groups according to the difficulty of LC, converted group (n=4), performed with an effort group (n=20), and performed without an effort (control) group (n=46). And morphological differences of the cystic duct from the bifurcation to gallbladder neck reconstructed by herical three dimensional CT imaging were compared among three groups.
    As a result, common tendencies seen in the converted group and performed with an effort group, were absence of herical appearance of Heister's valves of cystic duct, acute angle of cystic ductcommon bile duct, and having moth-eaten appearance of the gall bladder neck.
    It is indicated that herical three dimensional CT imaging is useful for deciding the indication of LC and for preoperative assessment of the difficulty in LC.
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  • THE EFFECT OF STENT TUBE OBTAINABLE INTERNAL AND EXTERNAL BILIARY DRAINAGE
    Naoto FUKUDA, Junji ISHIYAMA, Hisashi KASUGAI, Tatsuo YAMAKAWA
    1998 Volume 59 Issue 10 Pages 2489-2494
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Effect of percutaneous dilatation technique using a stent tube obtainable internal and external biliary drainage indwelling for management of postoperative bengin biliary strictures was evaluated in this study. Among 24 cases of postoperative benign biliary stricture encountered in Teikyo university hospital at Mizonokuchi for the past 15 years, 19 cases treated with percutaneous dilatation technique were involved in this study. The route for percutaneous cholangioscopy were PTBD fistula in 15 cases (87.9%) and T-tube fistula in four cases (21.1%). In the patients with biliary fistula, the stent tube was in place after mechanical dilatation of the fistula under fluoroscopy. Dilatation of stricture site was also mechani-cally performed along a guidewire inserted under an endoscopic control. The size of the stent tube used ranged from 12 Fr to 18 Fr in diameter. The mean period of indwelling time of the stent tube was 125.1 days. Regarding complications, two patients had liver dysfunction and one patient had cholangitis, but the former two patients were treated conservatively. Two patients with re-stenosis and one patient of repeated cholangitis required surgical treatment. The remaining 16 patients (84.2%) had been leading a normal social life without any symptom of stenosis of the biliary duct. In conclusion, percutaneous biliary dilatation technique using a stent tube obtainable internal and external biliary drainage seemed to be an effective procedure for postoperative benign biliary strictures, because it can be treated without any foreign body left behind.
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  • Takahiro OKABAYASHI, Noriaki TANAKA, Kunzo ORITA
    1998 Volume 59 Issue 10 Pages 2495-2500
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    In this study, we focused on 24 patients with obstructive jaundice due to malignant disease of the biliary tract who underwent biliary drainage such as percutaneous transhepatic cholangio-drainage (PTCD). We analyzed the effect that administration of a Kanpo medicine, Inchinko-to, had on reduction of bilirubin level after biliary drainage. After biliary drainage, subjects were randomly allocated into a drainage-only (control) group, or a drainage/Inchinko-to combination group (Inchinko-to combination group). The Inchinko-to combination group was given a total of 7.5g per day of inchinko-to, either for four weeks, or before the surgery. During this period, changes in liver function parameters and subjective symptoms were observed and compared between the two groups. Thirteen patients were randomized into the control group and 11 into the Inchinko-to combination group. Of the latter, one patient was not evaluable due to failure in taking the medicine. No significant differences in background factors were seen between the two groups.
    The bilirubin reduction rate (b)s, indicating the effectiveness in improving the patient's jaundice were -0.057±0.019 for the control group and -0.079±0.021 for the Inchinko-to combination group in T-Bil., and -0.058±0.024 for the control group and -0.078±0.022 for the Inchinko-to combination group in D-Bil. In both cases, the Inchinko-to combination group had significantly (p<0.05) lower values than those of control group, confirming that administration of Inchinko-to significantly improved the patient's jaundice following biliary drainage. Using Inchiko-to in combination also improved such subjective symptoms as loss of appetite and general fatigue.
    Compared with drainage-only, the administration of Inchinko-to after biliary drainage shortened the time needed for jaundice to improve in patient with obstructive jaundice, suggesting a possibility that it may consequently reduce postoperative risks such as liver impairment.
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  • Seung Jin KIM, Yoshikazu MAEURA, Nobuhisa UEDA, Mafumi SAITO, Seiichi ...
    1998 Volume 59 Issue 10 Pages 2501-2505
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We experienced a case of oxyphilic adenoma of the parotid gland. A 52-year-old man was admitted to our hospital because of a right parotid tumor. The tumor was elastic hard with a clear margin and 1.7×1.8cm in diameter. Ultraosonography visualized the tumor as a cyst with free internal echo level, however, CT scan demonstrated a solid mass with low-density area. FNA revealed foamy cells without nuclear pleomorphism, and the tumor was thought to be benign pleomorphic adenoma. After exploration of the tumor in the superificial lobe, the histological examination showed that the tumor consisted of large cells with eosinophilic granular cytoplasm and without infiltration into the normal gland, and that the tumor was oxyphilic adenoma. Oxyphilic adenomas of the parotid gland are very rare and represent 0.1-0.2% of all parotid tumors. Only 27 cases including this case have been reported in Japan.
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  • Hisayuki MATSUSHITA, Masahiro ISOGAI, Keiichiro KONDO, Yoshitaka FUKUN ...
    1998 Volume 59 Issue 10 Pages 2506-2508
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Transrectal administration of thyroid hormone was successfully performed for a patient who could not take any drugs from oral route due to anastomotic leakage. A patient had received a subtotal colectomy for familial polyposis and a total thyroidectomy for a cancer. One year after the operation, the patient underwent a resection of the small intestine for desdmoid. Because of the leakage of anastomosis, oral administration of thyroid hormone became to be impossible. The serum T3 and T4 levels decreased. So she was given levothyroxine sodium in a form of suppository. The serum T3 and T4 levels increased to normal range. For transrectal admininstration, the patient needed thyroid hormone preparation at a dose of 200-300mg which might be equivalent to 2 to 3 times the oral dose. It should be considered not only that the trasrectal absorption of the drug is simply inferior to that per oral route, but also that the metabolism in postoperative patients is accelerated. This patient repeated constipation and diarrhea that might participate with her requirement of large dose in suppository form. Transrectal administration of suppository close form of thyroid hormone seems to be useful for a hypothyroidism patient who can not take oral route administration.
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  • Kazuki KOIDE, Youngjin PARK, Miyoji WAKABAYASHI, Tetsuro UEDA, Muneyuk ...
    1998 Volume 59 Issue 10 Pages 2509-2513
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A case of primitive neuroectodermal tumor (PNET), so-called Askin tumor arisen from the breast in a 14-year-old girl is reported. The patient was admitted to the hospital because of a left breast tumor. The tumor extended the entire left breast and the swelling was remarkable. Chest CT revealed internally heterogeneous tumor shadow with concomitance of low-density area which might be necrosis. And metastatic foci in the bilateral lung fields and lymph nodes of the left armpits were revealed. Under a suspicion of malignant breast tumor, a standard radical mastectomy was performed. The resected breast tumor was 25×25×20cm in size and 3.9kg in weight. The light microscopic findings disdosed remarkable increase in small round cells with rosette formation partially on HE staining, and granules of glycogen on PAS staining. Immunohistochemically, neuron specific enolase (NSE) and S-100 protein staining showed negative. Electromicroscopic finding showed tumor cells poor in small organs, and some amount of junctional complex and neuro-secretory granules. Therefore, she was diagnosed as having a peripheral PNET.
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  • Teruhisa SAKURAI, Takaomi SUZUMA, Shinichiro MIYOSHI, Hirokazu TANINO, ...
    1998 Volume 59 Issue 10 Pages 2514-2517
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A rare case of noninvasive carcinoma of the male breast with bloody nipple discharge is reported. The patient was 68-year-old and came to our hospital with a chief complaint of bloody nipple discharge and a right breast mass. The tumor was diagnosed as carcinoma of the breast by aspiration cytology. The ultrasonography findings were various ill-defined, internal echos and a relatively low-echoic multi-cystic tumor with small length-to-breadth ratio. Ductography demonstrated dilation of the ducts and intraductal filling defects. Based on findings, we suspected a noninvasive carcinoma. Tumorectomy was performed first. After rapid intraoperative pathological examination, a diagnosis of non-invasive ductal carcinoma was made, and total mastectomy was performed. The patient is healthy, without adjuvant therapy, as of 42 months postoperatively.
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  • Hiroshi NISHIE, Kiyoaki MIZUSAWA, Haruaki OGAWA
    1998 Volume 59 Issue 10 Pages 2518-2522
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Intracystic breast cancer is a relatively rare entity. This time we have experienced a case of male intracystic breast cancer with a hepatocellular carcinoma.
    A 65-year-old man who was under observation after undergoing an ethanol infusion therapy for a hepatocellular carcinoma in January, 1997 was seen at the hospital because of a tumor formation in the left breast in July, 1997. Ultrasonographic study of the breast tumor revealed a papillary lesion in a cyst. Bloody content was aspirated by needling. Cytology revealed solid-tubular carcinoma, and a modified radical mastectomy (Bt+Ax) was performed. No positive lymph nodes were involved and estrogen receptor was positive. After the operation, an endocrine therapy with oral tamoxifen was started and has been maintained up to now.
    Some bibliographical comments about male intracystic breast cancer and its simultaneous occurrence with hapatic cancer are also presented here.
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  • Masatoshi ISHIZAKI, Norio AKIYAMA, Shigebumi TANAKA, Kiyotaka OSAWA, K ...
    1998 Volume 59 Issue 10 Pages 2523-2526
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A relatively rare case of spindle cell carcinoma of the breast in pregnancy and lactation is reported. A 23-year-old woman had noticed a right breast tumor in the 7th month of pregnancy but did not consult any doctors. She was admitted to the hospital because of enlargement of the tumor during lactation. A 6 cm×4cm tumor was palpated at the lower outer quadrant of the right breast and an azuki bean-sized lymphnode swelling in the right axilla. The tumor was diagnosed as solid tubular carcinoma (T3a, N1a, M0, Stage IIIa). Modified radical mastectomy was performed.
    Postoperative histopathological examination revealed spindle cell carcinoma and immunohistochemically, Keratin and EMA were positive but CEA and Vimentin were negative. Both ER and PGR were negative. The patient has been free from recurrence, as of 3 years after the operation.
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  • Nobuyuki TANIDA, Osamu YASUDA, Kazuhisa ONISHI, Nobuyuki KAIHATSU, Aki ...
    1998 Volume 59 Issue 10 Pages 2527-2530
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    The most common complications after cardiopulmonary resuscitation (CPR) are fractures of the ribs and sternum, but pneumoperitoneum after CPR is infrequent.
    An 80-year-old man arrived at the hospital by an ambulance because of respiratory failure. He had been given intratracheal intubation in another hospital. During the transport to the hospital, external cardiac massage and artificial respiration by an Ambu bag were performed by an ambulance-man for 5 minutes. Subcutaneous emphysema was noted immediately after CPR. On admission, chest X-ray and CT examination showed subcutaneous emphysema, pneumomediastinum, retroperitoneal air and pneumoperitoneum. There were no pneumothoraces. Bronchoscopy demonstrated a mucosal disruption of the left main bronchus. We assumed that the rupture of the left main bronchus had occurred at the time of CPR and the air dissected to the mediastinum and retroperitoneal space and entered the peritoneal cavity.
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  • Tetsuji KASAMATSU, Yuko YAWATA, Miho KURAHASHI, Shinji KURATATE, Seigo ...
    1998 Volume 59 Issue 10 Pages 2531-2535
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    It is believed that leiomyosarcomas of the inferior vena cava have a relatively low growth rate and a low malignant potential, but few cases of the disease are able to be resected surgically. We present a case of leiomyosarcoma of the inferior vena cava with bone metastasis which was successfully resected.
    A 73-year-old woman was admitted to the hospital because of back pain. Chest X-ray examination revealed a tumor shadow and osteolysis at the right 6th rib. CT, magnetic resonance imaging (MRI), and angiography revealed a tumor about 3 cm in size in the vicinity of the inferior vena cava. Operative procedures included resection of the inferior vena cava including the tumor, reconstruction of the vein using Goatex graft with a ring 20 mm in diameter, and then resection of the right 6th rib.
    Histopathologically, leiomyosarcoma of the inferior vena cava and its metastasis to the rib were identified. There have been no signs of recurrence, as of 7 months after the operation.
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  • Yasushi SAKAMAKI, Akinori AKASHI, Shuichi OHASHI, Takeshi ORIYAMA, Hir ...
    1998 Volume 59 Issue 10 Pages 2536-2539
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 77-year-old man with emphysema who had suffered from dyspnea on exertion (DOE) since 20 years before was admitted to the hospital because of the DOE gradually advanced despite of oxygen therapy during the last four years. The pulmonary function tests suggested that he had both obstructive and restrictive respiratory dysfunction and his arterial blood gas data showed that he was severely hypercapnic with PaCO2 of 62.8 mmHg on room air. Both a chest CT and a pulmonary ventilation-perfusion scintigram suggested that he had clearly left-side dominant lesions and thus, a unilateral thoracoscopic volume reduction surgery which consisted of stapling and laser ablation was performed on his left lung. After the operation, both the symptoms and pulmonary function were remarkably ameliorated and hypercapnia was resolved with PaCO2 of 40.9 mmHg on room air.
    Our experience suggested that the unilateral thoracoscopic volume reduction surgery could be a reliable therapeutic option for some severe emphysema patients with unilateral-dominant lesions.
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  • Tatsunori KIMURA, Takashi MIYAMOTO, Koichi TANAKA, Takashi MIURA, Masa ...
    1998 Volume 59 Issue 10 Pages 2540-2543
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We have experienced two cases of solitary fibrous tumor arisen in the visceral pleura. Case 1 involved a 69-year-old woman. She was pointed out a tumor shadow in the left lower lung field on a chest X-ray film at a medical checkup. A tumor of the chest wall was suspected on a chest CT scan, but no definite diagnosis was made even by magnetic resonance imaging (MRI) and percutaneous needle biopsy. So a thoracoscoy aided operation was performed, and it was revealed that the mass was solitary fibrous tumor arising from the visceral pleura of left lower lobe. Case 2 involved a 29-year-old man. He was pointed out a tumor shadow in the right lower lung field on a chest X-ray film at another hospital where he visited for an injury in a traffic accident. Although there was no increasing tendency of the tumor, the patient was seen at the hospital with his hope for a thoracoscopic operation. No definite diagnosis was made by chest CT, MRI, and percutaneous needle biopsy, but a thoracoscopic operation was performed. It was found that the tumor was a solitary fibrous tumor arisen in the visceral pleura of the right lower lobe.
    Solitary fibrous tumor of the pleura is a relatively rare entity that has been called circumscribed fibrous pleural mesothelioma so far. It often presents difficulty in preoperative diagnosis, but surgical resection of the tumor can provide a relatively favorable prognosis.
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  • Hiroshi YAMASHITA, Susumu SHINOURA, Hidekazu NAKAGAWA, Junichi GANGI, ...
    1998 Volume 59 Issue 10 Pages 2544-2549
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Localized primary pleural tumors are relatively rare and are often asymptomatic. Recently we experienced a patient with giant pleural tumor who manifested specific symptoms relating to the tumor such as hypoglycemia and hypertrophic pulmonary osteoarthropathy including arthralgia and clubbed fingers.
    A 58-year-old woman was emergently admitted to the hospital because of an attack of hypoglycemia on February 26, 1997. Chst X-ray film revealed an abnormal shadow occupying the left middle lower lung. Chest CT and magnetic resonance imaging (MRI) demonstrated a giant tumor occupying the entire left thoracic cavity. A sternal midline incision, a thoracotomy between the left 3rd and 7th ribs, and an incision of costal cartillage were conducted to remove the tumor. During operation, the dorsal side of the tumor most firmly adhered to the chest wall, and adhesions to the diaphragm, left 6th rib, and a part of left lower lobe of lung were also present. So the definite diagnosis of primary tumor of the pleura parietalis was made. The tumor was 24×16×9.5cm in size and about 2, 900g in weight. Pathologically it was localized firous tumor of the pleura. After the removal of the tumor, hypoglycemia and hypertrophic pulmonary osteoarthopathy disappeared.
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  • Keiji UCHIDE, Hitoshi SHIOZAKI, Kentarou MARUYAMA, Masatomo INOUE, Mas ...
    1998 Volume 59 Issue 10 Pages 2550-2554
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We experienced a case of esophagobronchial fistula secondary to mediastinitis caused by endoscopic perforation. A 53-year-old woman was admitted to the our hospital because of chest pain and cough. 7 months after the perforation, we cut off the fistula, but it was not closed. Then an endoscopic therapy was tried using fibrin bond and histoacryl, but the fistula did not closed. 7 weeks after the first operatin, the second operation was performed and the esophagobronchial fistula was cured by removing the primary side of fistula after cut off the fistula. We discussed the therapies of esophagobronchial fistula from our experience with the case as well as from a review of the literature. It is thought that we should not stick to conservative treatment but select operation primarily for esophagobronchial fistula, because the disease often intractable by medical treatment. And in case of operatin, we surgions have to confirm the fistula exactly and the fistula should be removed at a border with the esophagus in principle.
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  • Noriaki TEZUKA, Shozo FUJINO, Shuhei INOUE, Keiichi KONTANI, Satoru SA ...
    1998 Volume 59 Issue 10 Pages 2555-2558
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A case of esophageal leiomyoma with remarkable calcification is presented.
    A 67-year-old man was admited to the hospital because of a remarkably calcified mass in the mediastinum on a chest X-ray film which was found during clinical observation for hypertension, Chest CT revealed a 3×3cm calcification covering from the anterior to left side wall of the esophagus and under the bifurcation of the trachea, and a portion of it looked like to protrude into the esophagial lumen. Esophagography visualized a clearly demarcated and elevated lesion with calcification. Endoscopy showed a protruding lesion about 4cm in diameter over the anterior wall of the esophagus. The tumor was found to originate from the esophageal submucosa without involvement of the mediastinal organ by endoscopic ultrasonography. Enuculeation of the tumor was performed. The resected material revealed a hard and clamp-like tumor, 4×2×1.5cm in size. The tumor was diagnosed as leiomyoma histologically.
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  • Naoto YAMAMOTO, Youichi WATABIKI, Akio KOSAKA
    1998 Volume 59 Issue 10 Pages 2559-2563
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 68-year-old man was seen at the hospital because of hematemesis. Castroendoscopic examination revealed no evidence of bleeding, but a flat and slightly elevated lesion in the middle of the intrathoracic esophagus, diagnosed as squamous cell carcinoma by the biopsy specimen and an elevated lesion in the posterior wall of the lesser curvature of the upper part of the gastric body, diagnosed as well differentiated adenocarcinoma. Total thoracic esophagectomy and a total gastrectomy with regional lymph node dissection were performed. Pathologically the esophageal lesion was partially covered with a normal squamous cell epithelium and presented wide submucosal spreading but remained in the submucosal layer. And the carcinoma was composed of squamous cell carcinoma and adenocarcinoma which has a d-PAS and alcian-blue positive mucin. Therefore the diagnosis of mucoepidermoid carcinoma of the esophagus was made. There was n2 lymph node metastasis (stage III). The gastric lesion presented slight submucosal invasion and was diagnosed as well differentiated adenocarcinoma (stage Ia). Immunohistochemically, p53 was positive in almost all cells of the gastric cancer, but negative in both squamous cell carcinma and adenocarcinoma components. Adjuvant chemotherapy and radiation therapy were not performed. The patient is alive 1 year after the operation.
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  • Shinya ADACHI, Naohide ISAKA, Tsunehiko MARUYAMA, Satoshi INAGAWA, Kat ...
    1998 Volume 59 Issue 10 Pages 2564-2567
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We investigated overnight pH monitoring in six patients undergone proximal gastrectomy for gastric cancer. Three types of reconstructions were performed. Round lifting group: anastomosis at anterior wall of the residual stomach with round lifting (n=4). His angle plasty: at anterior wall with His angle plasty (n=1). Lesser curvature: simply esophagogastrostomy at lesser curvature (n=1). Overnight pH monitoring was performed at 3rd week, and endoscopic study was done at 6th month after surgery. The mean pH levels of the residual stomach in round lifting group were 3.50, 1.24, 1.32 and 7.56, and those of the esophagus were 5.63, 2.87, 6.21 and 6.95. In the His angle plasty case, the mean pHs were 7.36 at the residual stomach and 6.91 at the esophagus. In the lesser curvature case, 7.69 and 8.04, respectively. Three patients complained of heartburns, and they were revealed reflux esophagitis by endoscopic study. We considered that the pHs of the residual stomach of the patients undergone proximal gastrectomy were different from each other, therefore, we have to measure the pH for recognizing whether the residual stomach is acid or alkaline and cure the patients with reflux esophagitis with adequate medicine.
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  • Shuji SAITO, Masahiko FUKANO, Hirotoshi AKIYAMA, Masahiro SHINJO, Yosh ...
    1998 Volume 59 Issue 10 Pages 2568-2572
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 61-year-old woman was admitted to the hospital because of epigastric pain. Upper gastrointestinal series revealed a huge barium defect with irregular margin and barium spots in the center extending from the upper body to cardiac part of the stomach. Endoscopy of the upper G1 tract showed a huge elevated lesion with multiple ulcers in the upper body of stomach. Biopsy indicated no malignancy. Since the patient's general condition gradually deteriorated, a total gastrectomy with lymph nodes dissection (D2) was conducted with a suspicion of malignant submucosal tumor of the stomach. The resected material revealed an 11×10×5cm tumor with ulcer at the cardiac part of the stomach, and multiple ulcers other than that in the tumor. Histopathologically, the tumor was a remarkable thickening due to fibrosis extending from submucosal layer to serosa, to where eosinophilic leukocytes diffusely infiltrated. No nest of histionic cytes was demonstrated and no granuloma was formed.
    It is very rare that eosinophilic gastritis formed a huge tumor. We report this rare case of eosinophilic gastritis which presented difficulty in differentiation from malignant tumors.
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  • Masaru MURATA, Toshiyuki OHTA, Kazuyuki ODA, Kunitaka SHIBATA, Yasuki ...
    1998 Volume 59 Issue 10 Pages 2573-2577
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    An 82-year-old woman was admitted to the hospital because of a gastric cancer in the antrum. Distal gastrectomy was uneventfully performed. Preoperative serum AFP and CA 19-9 levels were as high as 1100ng/ml and 220U/ml, respectively. Histopathologically, the primary lesion was classified as moderately to poorly (solid type) differentiated adenocarcinoma, and the metastatic lymph nodes as poorly (solid type) differentiated adenocarcinoma. Immunohistochemically, AFP positive cancer cells were detected in some parts of tube2 of the primary lesion, and in major parts of porl of the metastatic lymph nodes. CA19-9 positive cancer cells were detected in both the primary lesion and the metastatic lymph nodes extensively. An AFP producing gastric cancer with different histological feature in the primary and the metastatic lesions is considered to be rare, and this case is highly suggestive in relation to multiple differentiation of AFP producing gastric cancer.
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  • Masaru SAKUSABE, Hiroshi YOSHIOKA, Makoto NIWA
    1998 Volume 59 Issue 10 Pages 2578-2581
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    The incidence of cardiac involvement by gastric cancer is 2.4% to 7.7% in autopsy. However it is only rarely diagnosed clinically. We report a case of cardiac tamponade caused by gastric cancer after surgical treatment.
    A 42-year-old man who had undergone curative gastrectomy for gastric cancer in December 1990 was admitted because of abdominal distention and poor appetite. A diagnosis of cardiac tamponade was made by echocardiography, and the pericardial effusion showed class V cytology. Local infusion of MMC and OK432 into the pericardiac cavity was performed after drainage and it was effective in preventing reaccumulation of the pericardial effusion. The patient died of dyspnea on the 102nd day after the diagnosis. Rapid and appropriate treatment of cardiac tamponade is essential. Cardiac involvement by gastric cancer must be considered in patients with gastric cancer.
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  • Masahiko KAWAMOTO, Shuji SHIMIZU, Kazuo CHIJIIWA, Koji YAMAGUCHI, Masa ...
    1998 Volume 59 Issue 10 Pages 2582-2586
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A case of ampullary carcinoma with a jumping metastasis to the paraaortic lymph node is presented. A 51-year-old woman was admitted to the hospital because of epigastrial discomfort. Liver dysfunction had been noticed since one year before without a history of jaundice. CA 19-9 level elevated. Intrahepatic bile duct dilatation was detected by ultrasound and computed tomography. Hypotonic duodenography showed a protruded mass, 4cm in size, which was well differentiated adenocarcinoma by endoscopic biopsy. There was no ascites, liver metastasis or peritoneal dissemination on laparotomy. An elastic hard tumor was palpable at the second portion of the duodenum without any invasion to the serosa. A pylorus-preserving pancreatico-duodenectomy was performed with extended lymph node dissection including paraaortic regions, and with intraoperative radiation. The mass was an exposed protruding type, invading the submucosa of the duodenum. The only one paraaortic lymph node was metastasized of all 55 dissected lymph nodes. We conclude that there is a direct stream of lymph from the papilla to paraaorta and that the paraaortic lymph node dissection would be mandatory for surgery of ampullary carcinoma even in an early stage.
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  • Joe MATSUMOTO, Tetsufumi KOJIMA, Tetsuya SHIMIZU, Satoshi HIRANO, Hiro ...
    1998 Volume 59 Issue 10 Pages 2587-2591
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We experienced a case of malignant stromal tumor of the ileum. A 59-yer-old women complaining of abdominal pain, abdominal fullness and vomiting was referred to the hospital with a diagnosis of intestinal obstruction. She was treated by a long tube to release the obstruction. Thereafter, upper gastrointestinal series, ultasonography, CT, magnetic resonance imaging, and angiography revealed a tumor which was 11cm in diameter, well-delineated and hypervascular, and developed extramurally at the ileum. Under the diagnosis of leiomyosarcoma, a partial resection of the ileum including the tumor was performed.
    Histologically, the tumor was mainly composed of proliferated spindle cells and partially epithelioid cells which have mitotic figure 6/10 high power field. Immunohistologically, the tumor was not stained for α-smoogh muscle actin, desmin and S-100 protein, but for NSE and CD34. Though the tumor was positive for NSE, the differentiation to the nerve was not found. Therefore, it was diagnosed as uncommitted type of malignant gastrointestinal stromal tumor (GIST) of the ileum. GIST is a relatively new concept, and hence, further studies on the prognosis, mode of recurrence, frequency, and differences in imaging methods according to sub-classification of GIST would be needed.
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  • Seiichiro TSUCHIHASHI, Naoto KURIHARA, Toshiharu FURUKAWA, Toshiharu F ...
    1998 Volume 59 Issue 10 Pages 2592-2596
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    An 80-year-old woman was emergently transferred to the hospital because intermittent abdominal pain around the navel became lasting. Plain abdominal X-ray film revealed small intestinal gas due to obstruction. An exploration of the small intestine by gastrograffin showed a filling defect 4cm in diamter and smooth margin in the small intestine. Abdominal ultrasonography and computed tomography showed a calculus in the small intestine measuring 4cm in diameter. Natural discharge of the obstruction was difficult and surgical treatment was conducted with a diagnosis of the excrement stone or foreign body of hte small intestine. A change in color in a part of ileum, which was in the same location of the lump, was recognized inthe distance of 110cm from the terminal ileum. Partial ilectomy was performed. the lump was 4cm in diameter, 25g in weight, and dark brown in color, and a profit side presented an annual rign structure. The enterolith consisting of bile acid element is rare.
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  • Sugiko NAKAYAMA, Toshihiko SAWADA, Kazuhiro MURAMOTO, Atsushi INAYOSHI ...
    1998 Volume 59 Issue 10 Pages 2597-2602
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    From April 1984 to December 1997, a series of nine operated cases of malignant lymphoma of the small intestine were experienced at the institution. Of these nine cases, preoperative ultrasonography (US) was performed in eight cases and the tumor was successfully detected in five out of eight cases, a tumor detecting rate being 63%. These five cases in which US detected the tumor preoperatively were subjected to a study of comparing US findings with pathological findings on those resected materials.
    On US, there were two cases of intussusception type presenting multicentric ring sign; one case of wall thickening and strictured lumen type visualized as hypoechoic, whole-circumferential wall thickening with a narrowing of the lumen, and the remaining two cases of wall thickening and lumen patent type presenting hypoechoic whole-circumfential thickening of the wall with maintained lumen longitudinally. Macroscopic types of resected materials were compared with US findings based on classification advocated by Ota and coworkers referring the Wood's classification. Results with US well corresponded to those by Ota's classification, namely, tumor type corresponded to intussusception type, stricture type to wll thickening and lumen stricture type, wall thickening type to wall thickening and lumen patent type, respectively.
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  • Nobuhiko TANIAI, Masayoshi HASHIMOTO, Masahiko ONDA, Noritake TANAKA, ...
    1998 Volume 59 Issue 10 Pages 2603-2606
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Meckel's diverticulum is silent in the clinical course in most cases, and is often detected incidentally at laparotomy. It sometimes causes some complications which include perforation due to a foreign body in a lowest frequency. This paper reports a rare case of perforation of Meckel's diverticulum due to a fish bone.
    A 60-year-old man was referred to the hospital with a diagnosis of acute appendicitis from another hospital. With a diagnosis of perforative peritonitis due to acute appendicitis, an emergency operation was conducted. It revealed that a foreign body was stipping a 3×5 cm Meckel's diverticulum at 70 cm oral side from the ileocecal region. We made a diagnosis of perforation of the Meckel's diverticulum due to the foreign body, and performed a resection of the diverticulum. The foreign body was a sharp fish bone, 3.5 cm in length and 1.5 mm in diameter. It was comfirmed as a salmon's bone that was inferred from the menu he ate. Pathological study indicated true diverticulum with infiltration of inflammatory cells extending the full thickness. No aberrant tissue, however, was demonstrated.
    There have been only ten cases of perforation of Meckel's diverticulum due to a fish bone in the Japanese literature so far. This case is thought very rare.
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  • Tsuyoshi ENOMOTO, Shinya ADACHI, Naohide ISAKA, Toru KAWAMOTO, Takeshi ...
    1998 Volume 59 Issue 10 Pages 2607-2610
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 67-year-old man was diagnosed with bullous pemphigoid, and after treatment with steroid semipulse therapy he developed massive melena and went into shock.
    Emergency angiography revealed a vitelline artery and extravasation, and we diagnosed massive bleeding from Meckel's diverticulum and preformed coil embolization immediately.
    After the coil embolization, we performed plasmapheresis because of deterioration of the bullous phemphigoid. The skin eruption resolved after plasmapheresis, and it became possible to reduce the steroid dose. We then performed safe partial resection of the ileum.
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  • Satoru KAWAI, Hitoshi KUBOTA, Toshio UEMATSU, Yutaka KUROYANAGI, Hidea ...
    1998 Volume 59 Issue 10 Pages 2611-2615
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    It is rare that Crohn's disease is associated with a psoas abscess, and there have been only nine such cases in Japan as far as we could review. A case of Crohn's disease presented with a psoas abscess is reported, together with a review of the literature.
    A 29-year-old man undergoing an ambulatory treatment for a pain of the right hip joint at another hospital was referred to the hospital because of strong tenderness in the right lower abdomen. The patient was diagnosed as having a psoas abcess by a CT scan, and underwent drainage and an appendectomy. After the operation, exacerbation of the abscess was confirmed. Re-laparotomy and drainage were conducted, but an efflux of intestinal fluid from the drain was noted. Barium enema study revealed a severe stricture and abscess vavity at the terminal ileum, and so Crohn's disease of the small intestine was a most likely diagnosis. After conservative therapy was unsuccessful, an excision ofthe ileocecal region was performed. The excised material showed longitudinal ulcer. The definite diagnosis of Crohn's disease was made.
    In the treatment of psoas abscess when exacerbation of the abscess or fistula formation is confirmed, Crohn's disease should be actively suspected, and once the diagnosis of Crohn's disease is obtained, the excision of the lesion would be desirable.
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  • Hideki ITANO, Kazutoyo SHIRAKAWA, Takashi OHYA
    1998 Volume 59 Issue 10 Pages 2616-2620
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Familial adenomatous polyposis (FAP) is thought to be caused by abnormality of APC gene on 7q chromosome and has the property of autosomal-dominant heritage.
    We have experienced an operated case of FAP with diverse extracolonic manifestations. A 26-year-old man was referred to the hospital because of anal bleeding. Colonfiberscopy and barium enema study demonstrated colorectal polyposis.
    On family history, it was outstanding that paternal brothers died at relatively younger age due to rectal cancer, and moreover his younger sister was proved to have colorectal polyposis. Consequently, his family was thought to be FAP family line.
    In this case, apart from colorectal polyposis, we detected many complications including abnormal dentition, congenital hypertrophy of retinal pigment epithelium, and mesenteric desmoid as extracolonic manifestations of FAP.
    When prophylactic total colectomy and ileo-rectostomy were performed, desmoid of mesenteric-origin involving terminal ileum, caecum and retroperitoneum was resected concurrently.
    It is said that the desmoid usually develops after prophylactic colectomy in most cases of FAP, and so preoperative development of desmoid as this case seems to be relatively rare.
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  • Yoshinori MUNEMOTO, Yoshiro KASAHARA, Takeshi MITSUI, Yasuyuki ASADA, ...
    1998 Volume 59 Issue 10 Pages 2621-2624
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Pyoderma gangrenosum is relatively rare non-infectious skin disease which is often associated with ulcerative colitis. We here report two cases of ulcerative colitis associated with pyoderma gangrenosum.
    Case 1: A 37-year-old woman was seen at the hospital because of fever and nodulus in the face and right leg. At the same time, diarrhea and anal bleeding occurred. Laboratory examination revealed leucocytosis and positive C-reactive protein. X-ray and endoscopic examination revealed left sided ulcerative colitis. Histological examination of the biopsy specimen from the nodule in the face showed pyoderma gangrenosum.
    Case 2: A 40-yer-old woman who had a long standing ulcerative colitis was seen at the hospital because of diarrhea and anal bleeding. Her condition of the colon worsened. At the same time, she noticed an ulcered nodule of the right leg. Histological examination of the biopsy specimen from the nodule of the leg showed pyoderma gangrenosum. She was diagnosed as exacerbation of ulcerative colitis and pyoderma gangrenosum, and was successfully treated by prednisolon, 20mg per rectum and 40mg intravenously.
    In these cases pyoderma gangrenosum appeared when ulcerative colitis was exacerbated, that might greatly contribute to the courses of both disease as well as to responses to treatments. Careful treatments are needed because ulcerative colitis is essentially a benign disease.
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  • Kouki IDO, Kyotaro TOSHIMITSU, Keiichi KIMURA, Hideki NAGANO
    1998 Volume 59 Issue 10 Pages 2625-2628
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 40-year-old man was admitted to the hospital because of left lower abdominal pain. Severe tenderness and muscular guarding were noted in the left lower quadrant of the abdomen. Ultrasonography revealed thickening intestinal wall and hypoechoic masses containing spotty hyperechoic lesions protruded from the wall at the point of tenderness. The intestinal lesions were thought to be diverticulitis of the colon. The intestine was connected to the transverse colon via hepatic flexure and thought to be the right colon. Abdominal CT revealed the same findings. We diagnosed the case as right colonic diverticulitis complicated with a mobile cecum and treated with conservative therapy. Barium enema performed after discharge from the hospital confirmed the diagnosis. Right colonic diverticulitis is frequently misdiagnosed with acute appendicitis due to the resemble symptoms and signs. The diagnosis would be more difficult when the mobile cecum coexisted because the area of abdominal tenderness would migrate. Ultrasonography and CT scan are useful in the diagnosis of right colonic diverticulitis with a mobile cecum, because they can visualize the pathological change and location of the lesion.
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  • Kouichi HIROKAGA, Hideaki KAWASHIMA, Sayuki YAMAZAKI, Takashi HARA, Ma ...
    1998 Volume 59 Issue 10 Pages 2629-2632
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 69-year-old woman was admitted to the hospital because of epigastralgia. She had been treated for pulmonary tuberculosis 35 years before admission. A barium enema examination showed an elevated lesion 5 cm in diameter in the ascending colon, ahaustral appearance and multiple pseudo-diverticula of the cecum and ascending colon. Colonoscopic examination demonstrated an elevated lesion in the ascending colon and multiple ulcer scars in the cecum and ascending colon. Biopsy specimens of this lesion revealed well-differentiated tubular adenocarcinoma. Right hemicolectomy was performed. Macroscopic findings revealed that the tumor was 4.5×4.0cm in size. Histologically, the tumor was mainly mucinous adenocarcinoma invading the serosal layer. The nonspecific inflammatory changes were seen in the cecum and ascending colon, but no tuberculous granuloma or atypical epithelium was observed. There has been no evidence of disease as of 1 year after the operation.
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  • Yoshihiro NAKAKUBO, Hitoshi INOMATA, Tohru NISHIYAMA, Hiroshi KUBOTA, ...
    1998 Volume 59 Issue 10 Pages 2633-2636
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We experienced a case of undifferentiated carcinoma of the ascending colon found out after removal of a brain metastasis.
    A 47-year-old man underwent a removal of a metastatic brain tumor which was histolosically small cell carcinoma but no lesions in the lung and thyroid were seen. One month later he developed intestinal obstruction that led to detecting a Borrmann III type cancer in the ascending colon. A right hemicolectomy was performed.
    Histopathologically it was undifferentiated carcinoma presenting histological morphology resemblant to pulmonary small cell carcinoma. From these findings, it was thought that the brain tumor was metastasis from the colonic undifferentiated cancer.
    Undifferentiated cancers rarely arise in the large intestine, especially those metastasizing to the brain alone which has not been reported so far. We have to keep this very rare mode of metastasis manifesting histologic morphology like small cell carcinoma.
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  • Kiyotaka KURACHI, Makoto OHARA, Yoichi WATAHIKI, Akio KOSAKA
    1998 Volume 59 Issue 10 Pages 2637-2641
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 64-year-old woman was admitted to the hospital because of unpleasant feeling in her anal region. digital examination revealed an elastic hard tumor on the lateral wall of the rectum. Barium enema and colonoscopy revealed a semipeduculated polypoid lesion 13mm in diameter with a central depression in the rectum. Endoscopic ultrasonography revealed the tumor limited with in the submucous layer. In this case, a possibility of malignancy could not be reled out because of central depression. So a low anterior resection with lymph nodes dissection was performed. Histologically, the tumor was confined to the submucous layer, and pararectal lymph node metastasis was observed.
    Her postoperative course has been good without recurrence for 13 months after discharge.
    Only 17 cases of rectal carcinoid which is smaller than 20mm in size and is confined to the submucous layer have been reported in the Japanese literarure so far. We must take a careful attitude to select therapies of the disease in case of central depression and vascular invasion, even if the tumor is small size.
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  • Tadashi NOZAWA, Yoshimasa OTANI, Yukihito KOKUBA, Atsushi IHARA, Yoshi ...
    1998 Volume 59 Issue 10 Pages 2642-2645
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We have experienced a case of minute carcinoid (2mm) of the rectum with vascular invasion demanded a laparotomic radical operation.
    A 65-year-old man was admitted to the hospital because of a SMT in the rectum Rb which was diagnosed as carcinoid on January 24, 1997. There were previous histories of undergoing polypectomies 7 times for colorectal polyps since 57 of age. On admission hormone levels in the blood and urine were in normal range. On february 6, 1997, an excision of the rectal tumor was conducted through transanal endoscopic microsurgery (TEM). Pathologically, it was a 0.2×0.2cm carcinoid of sm, ly1 . v2, Ki67 (+), and PCNA (+) with negative surgical stumps. From these pathological findings, we determined that an additional operation was needed. On March 12, an abdominoperineal excision of rectum with D3 superior lymph nodes dissection was performed. Postoperative course was uneventful and the patient was discharged from the hospital on April 9.
    This experience with the case has made us have a new understanding of that the malignancy of carcinoids should not be determined by the size of tumor and that we have to give careful consideration to select therapies.
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  • Eiji CHIKAMATSU, Takamasa NAGASHIMA, Yasunobu MINAKAMI, Koji IKUTA, Mu ...
    1998 Volume 59 Issue 10 Pages 2646-2649
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A case of endometriosis of rectum associated with familial polyposis coli which presented difficulty in differentiation from colonic malignant tumor is reported.
    A 21-year-old woman was seen at the hospitl because of lower abdominal pain and anal bleeding, and was admitted for close examination. Preoperative examinations revealed multiple rought nodular polyps and a submucosal tumor like elevation in the sigmoid colon where narrowed. In addition, a solid tumor occupying the small pelvic cavity, a left ovarian cyst, and left hydronephrosis were confirmed. No malignancy was revealed on a biopsy of the rectum. From these findings, an operation was performed with a suspicion of rectal tumor or endometriosis. Intraoperative frozen section diagnoses of the polyps and submucosal tumor indicated no malignancy. A low anterior resection of the rectum, left oophorectomy and stent indwelling for the left ureter were performed. Histopathologically the definite diagnosis of emdometriosis of rectum was made. This case presented a very rare finding that infiltration of intimal tissue extended into the proper muscle layer of rectal polyps.
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  • Jouji TAKADA, Masanobu SAITOU, Kazuhito MISAWA, Kunihiko MANABE, Yoshi ...
    1998 Volume 59 Issue 10 Pages 2650-2654
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 74-year-old man was seen at our hospital because of bloody stools who had undergone aggressive radical cystectomy for cancer of the bladder followed by radiation therapy 21 years before. A barium enema showed a rectal tumor, and Mile's operation was performed. Histological examination revealed radiation colitis and moderately differentiated adenocarcinoma (ss, ly1, v1, n0, stage II). It was inferred that the major etiologic factor in this case may have been irradiation for the first cancer because (1) the first cancer had been cured, (2) the interval between irradiation and the second cancer was long, and (3) rectal tumor was with in the radiation field.
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  • Tatsuro OISHI, Seiji YANO, Yasunari KAWABATA, Shoichiro SUMI, Yoshinor ...
    1998 Volume 59 Issue 10 Pages 2655-2660
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We experienced a relatively rare case of localized primary sclerosing cholangitis (PSC) of extrahepatic bile dut type in which an excision of the lesion successfully provided a recurrence free 6-year postoperative period.
    A 69-year-old man was admitted to the hospital because of nausea and upper abdominal pain. On imaging methods, a dilatation of the intrahepatic bile duct and a tumor shadow at the confluence of the right and left hepatic ducts were revealed. Choledochography disclosed a stricture of the bile duct at the porta hepatis. With a diagnosis of hilar bile duct cancer, an excision of the bile duct at the porta hepatis and associated resection of the right hepatic artery were conducted. Histopathological examination, however, showed only inflammatory lesion with fibrous change and no tumor findings were seen. The definite diagnosis of PSC was made.
    Diffused type of PSC is most common in those patients with PSC and medical treatments are generally employed for them. As to localized type of PSC, we often have difficulty in differential diagnosis from bile duct cancer and those patients experience recurrence after excision of the lesion in a low frequency. Accordingly we think that aggressive surgical resection would be a reasonable therapy.
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  • Satoshi KOBAYASHI, Akihiro YAMAGUCHI, Masatoshi ISOGAI, Akihiro HORI, ...
    1998 Volume 59 Issue 10 Pages 2661-2664
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 71-year-old man who had undergone a choledocholithotomy 4 years previously was found having dilatation of the intrahepatic ducts by abdominal ultrasonography during clinical observation for diabetes mellitus. After percutaneous transhepatic biliary drainage was performed. a cholangiography showed a stenosis extending to the left hepatic duct and a bifurcation of branches of anterior and posterior segments from the hilus. Percutaneous transhepatic portography showed a stenosis of the left portal vein. With a diagnosis of hilar cholangiocarcinoma, an extended left lobectomy combined with caudate lobectomy, dissection of lymph nodes including paraaortic lymph nodes, and reconstruction with hepatico-jejunostomy were performed. Exproration of the resected specimen showed no malignancy but sclerosing cholangitis.
    Sclerosing cholangitis was classified into primary group or secondary group. This case is classified into secondary group becase of a past history of biliary surgery. Sclerosing cholangitis, especially the localized type like ours, presents difficulties in differentiation from cholangiocarcinoma. We have to take care in diagnosing sclerosing cholangitis.
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  • Tomohiko IKEYA, Motoharu TSUDA, Tetsuyuki UEDA
    1998 Volume 59 Issue 10 Pages 2665-2668
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We experienced a case of perforation of the acalculous gallbladder, so called “idiopathic perforation of the gallbladder”. A 94-year-old woman who was admitted to the hospital because of severe pain of the upper abdomen. Spontaneous pain and tenderness were recognized in the epigastric region. On admission neither laboratolry nor abdominal X-ray examination revealed abnormality. Both abdominal sonography and CT revealed a slight thickness of the gallbladder wall and a small quantity of ascites. Because no symptomatic remission was attained with conservative treatment and muscle defence became terrible gradually, panperitonitis was suspected. The patient was operated on 14 hours after the onset of symptoms. During surgery bilialy ascites was found in the perineal cavity and a black-colored change 0.6cm in size at the fundus of the gallbladder and leakage of bile juice from the site were noted. Cholecystectomy and abdominal drainage were performed. There were no stones in the gallbladder and culture of the bile juice was negative for bacteria. Histologically, an autolysis of the wall in the perforated site was seen but no infiltration or arterial thrombus existed. The difinitive diagnosis of ideiopathic perforation of the gallbladder was made.
    Post operative course was unevenful. The patient was discharged from the hospitl two weeks after the operation.
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  • Mamoru KANAZAWA, Norichika MATSUI, Takashi NAKAMURA, Tomoaki MORITA, T ...
    1998 Volume 59 Issue 10 Pages 2669-2673
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A case of pancreas divisum which was discovered as LDA of the pancreas head and performed ventral pancreatectomy was reported. A 74-year-old woman, was admitted to the hospital because of epigastric pain. She had been treated for diabetes mellitus for 25 years with a good control. After admission, a abdominal ultrasonography revealed LDA of the pancreas head. ERCP revealed that the pancreatic duct was interrupted in site of 5 cm apart from the Vater papilla orifice. Computed tomography revealed only dilatation of the main pancreatic duct. From these findings, pancreas divisum and SOL of the ventral pancreas were diagnosed.
    Ventral pancreatectomy was performed under the diagnosis of tumor of the pancreas head associated with pancreas divisum. Histological diagnosis was hyalinization and calcification of Langhans' cells. Therefore, it was presumed that the degeneration of Langhans' cells was visualized as LDA of the pancreas head on echography.
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  • Mitsunori MAEDA, Naoki KONAGAI, Hiroshi SUDO, Tatsuhiko KUDO, Shin ISH ...
    1998 Volume 59 Issue 10 Pages 2674-2677
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We report two cases of spontaneous splenic rupture in patients receiving anticoagulant therapy after valve replacement. Case I: A 65-year-old man, who had been receiving anticoagulant therapy after aortic valve replacement, was admitted to the hospital because of abrupt onset of left upper abdominal pain and a fever. Four days after admission he developed severe abdominal pain, and went into shock. Case 2: A 50-year-old man, who had been receiving anticoagulant therapy after a mitral valve replacement, was admitted to the hospital because of abrupt onset of left upper abdominal pain. In both cases, an emergency body CT revealed a hematoma in the spleen. Emergency exploratory laparotomies were undertaken soon after splenic rupture was indicated, and splenectomies were performed. The postoperative courses were uneventful and the patients recovered their social activities. On pathological examination, only the hematoma of the spleen was present and there were no findings of infection, inflammation, hematologic abnormalities, vascular disease, nor any causative underlying diseases such as neoplasm. These cases were diagnosed as spontaneous splenic rupture. Spontaneous splenic rupture should be considered in the differential diagnosis of acute abdominal pain in patients receiving anticoagulant therapy after valve replacement.
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  • Shigeo FUJITA, Toyokazu AONO, Jun HIGAKI, Yasushi TANAKA, Seiko ENDO, ...
    1998 Volume 59 Issue 10 Pages 2678-2681
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    We here report two cases of spontaneous rectus sheath hematoma. Case 1 involved a 72-year-old man, who had been in our hospital for purpose of PTCA for ischemic heart disease and underwent anticoagulant therapy. There was a previous history of undergoing an appendectomy. After repeated coughs, suddenly he complained of severe right hypogastric pain. Abdominal palpation, laboratory data and abdominal CT did not lead us to make the correct diagnosis. We performed an operation under general anesthesia. suspecting some of acute abdomen and found a huge hematoma in the musculus rectus abdominis. Case 2 involved a 66-year-old woman who had suffered from liver cirrhosis and diabetes meliltus. After repeated coughs, like in Case 1, suddenly she complained of a severe left hypocondrial pain. We could easily diagnosed her as having a spontaneous rectus sheath hematoma from abdominal CT, abdominal ultrasonography and the experience with case 1, and performed drainage of the hematoma under local anesthesia. Spontaneous rectus sheath hematoma is a relatively rare entity and often present difficulty in differentiation from acute abdomen because of its abrust onset and severe pain. It is thought that the difficulty in diagnosis of the disease may depend on that we have experienced the case of the disease or not. We have to entertain the presence of the disease as a probable diagnosis.
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  • Hiroshi OMORI, Atsuo SAITO, Kazuya KAWABATA, Takahiro OKAZAKI, Yoshino ...
    1998 Volume 59 Issue 10 Pages 2682-2685
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    A 49-year-old woman was referred to the hospital because of lower abdominal pain on March 31, 1997 which appeared 6 days before, and was treated with a suspicion of acute enteritis on an ambulant basis. She had a 24-year history of systemic lupus erythematosus (SLE) and had been recently controlled by prednisolone at a dose of 5-10mg a day at another hospital. On April 14, the patient was emergently admitted to the hospital because a collection of ascites was suspected, though the abdominal pain was slightly relieved. Abdominal CT on admission revealed a large volume of ascites and intestinal edema. We had a conference with medical doctors based on the nature of ascites and blood analysis data (low CHSO and high anti DNA antibody), and diagnosed the case as lupus peritonitis caused by angitis and serositis of mesentery associated with exacerbated SLE. According to the diagnosis, a steroid pulse therapy was started and symptomatic remission as well as improvement in laboratory data were attained.
    It is not uncommon that the patients with SLE have gastrointestinal symptoms, but sometimes, there have been sporadic reports that described the difficulty in differentiation of those GI symptoms from acute abdomen in the literature. We surgeons have a great difficulty in diagnosis and treatment of the symptoms, because it directly relates with SLE itself rather than as complication. We should recognize that SLE is not an unrelated disease to surgeons.
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  • Masao YANO, Yasuo SHIRAKI, Masataka INOKUCHI
    1998 Volume 59 Issue 10 Pages 2686-2689
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Paraganglioma is a relatively rate tumor. There has been no case of paraganglioma presented with intraabdominal bleeding so far. In this paper, a case of giant paraganglioma with intraabdominal bleeding is reported.
    A 48-year-old woman was transferred to the hospital because of intraabdominal bleeding and hemorrhagic shock. Abdominal ultrasonography and CT scan revealed intraabdominal bleeding and a huge tumor in the right subhepatic space. Angiography visualized a hypervascular tumor but no active bleeding was seen. With a suspicion of angiosarcoma, an operation was performed, when inveterate hemorrhage and clots were demonstrated in the abdomen. The tumor was a 14×10×8cm retroperitoneal tumor. It adhered to the right subhepatic space and a rupture of the liver in the vicinity of the adhesion was noted where was thought to be the bleeding site. Histopathologically it was paraganglioma.
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  • Toshihiro MORITA, Yasuhiko SUMI, Takashi SUHARA, Shin YAMADA, Masahiro ...
    1998 Volume 59 Issue 10 Pages 2690-2694
    Published: October 25, 1998
    Released on J-STAGE: January 22, 2009
    JOURNAL FREE ACCESS
    Hernia uteri inguinalis in male hermaphroditism is rare and there have been only 54 other similar cases in Japan. We present a case of hernia uteri inguinalis in male hermaphroditism. A 52-year-old man was admitted to the hospital because of painful swelling involving the scrotal sac and right inguinal region. Abdominal CT scan and magnetic resonance imaging (MRI) revealed a tumor shadow and intestinal gas extending from the scrotal sac to right inguinal region. The preoperative diagnosis was incarceration of hernia inguinalis of the intestinal tract. Radical operation for hernia inguinalis was performed. Hernia sac contained the sigmoid colon and two ovary-like, two salpinx-like and uterus-like structures were found in the right inguinal canal. Histopathologically, the ovary-like structure was the testis and the uterus-like structure was the urerus. The chromosomes and hormonal examinations were normal.
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