A retrospective review was made of 137 patients tried the breast-conserving treatment (BCT) at the Osaka Teishin Hospital since Junuary 1990 until May 1997. BCT consisted of quadrantectomy with axillary dissection. To assure complete resection of the breast cancer, we histopathologically examined three margins of the residual breast during operation. In case of a positive margin finding, mastectomy or total glandectomy was performed. One-hundred nine patients (79.6%) were successfully treated with BCT _??_group A_??_, whereas 28 patients (20.4%) required a modification of BCT in order to gain negative surgical margins _??_group B_??_. Surgical positive margins were mainly due to extensive intraductal components (EIC).
We compared the two groups in regards to their clinico-pathological futures. The patients in group B were more likely to have factors such as younger age (p<0.05), premenopousal (p<0.05), positive estrogen receptor (ER)/progesterone receptor (PgR) (p<0.05), DNA index=1.00 (p<0.05) and pathologically involved lymph nodes (p<0.05). Mastopathic change and/or atypical ductal hyperplasia (ADH) were more frequently observed surrounding the cancerous lesions of group B than of group A (p<0.0001).
There were no clinical factors that characterized the extensive intraductal component before the operation. Therefore, the rapid intraoperative pathological consultation for surgical margins and the strict patho-logical examination of the resected specimen are very important and useful in order to guarantee cancer-free surgical margins in BCT.

View full abstract

Forty-seven cases of phyllodes tumor of the breast (resected and diagosed pathologicaly at this hospital from 1994 to August 1997) were evaluated clinicopathologically. Thirty-nine patients were classified as benign, 5 as borderline and 3 as malignant. Eighty-one percent of all tumors found were 5cm or less in diameter, and 38 tumors were 2cm or less in diameter. In this study, no clinical findings characteristic of benign or malignant tumors were identified. Some tumors needed to be differentiated from breast cancer. If an adequate surgical margin can be achieved, it would appear that local excision is an acceptable form of primary surgical treatment

View full abstract

A clinical study was made on synchronous double primary cancer in patients with lung cancer who were operated on in the hospital from July 1987 to Decenber 1996. Of a series of 544 patients with primary lung cancer, 18 (3.3%) patients had double cancer. There were 15 men and three women. The organs where the another primary cancer arose in were the lung in five cases, the stomach in five cases, the large intenstine in two cases and the esophagus, kidney, liver, prostate, thyroid, and uterus in each one case. The lung cancer was the first neoplasm in eight cases and the second in 10 cases. The second cancer was commonly detected by preoperative x-ray examination or by CT during clinical observation on outpatient basis after the operation for the first cancer. The cumulative 5-year survival rates were 30.0% in 18 cases of double cancer and 37.7% in all op-erated cases of lung cancer. Therer was no great difference.

View full abstract

We investigated 59 cases of Crohn's disease treated surgically between 1967 and 1997. There were 112 operations, 10 with exclusion with mucous fistula, 86 with resection, 5 with bypass. 7 with colostomy, and 4 with other procedures. The 5-year and 10-year cumulative reoperation rates were 0 and 33.3%, respectively, for exclusion with mucous fistula, 29.3 and 57.8% for resection, 60 and 60% for bypass, and 52.4 and 52.4% for colostomy. The rate for exclusion with mucous fistula was significantly lower than that of others. Two pa-tients after exclusion with mucous fistula experienced recurrence, and one was reoperated. This method seemingly yields satisfactory results when performed on properly selected Crohn's disease patients.

View full abstract

In a recent 3-year period from January 1995 to December 1997, we performed laparoscopy-assisted colectomy for carcinoma of the sigmoid colon (LAC-S) with systematic lymph node dissection (D 3) for 25 cases. The following indications had to be satisfied for LAC-S: there was no evidence of liver metastasis and peritoneal dissemination, and tumors were not exposed on the serosal surface (MP). We performed D 3 lymph node dissection with the right side approach on the sigmoid mesocolon. It was considered that our procedure, which is different from the conventional sigmoidectomy in the right side approach on the sigmoid mesocolon, was rational in terms of dissecting lymph nodes and recognizing retroperitoneal surgical anatomies. In comparison with another 21 cases undergone open sigmoidectomy in the same period, there was no significant difference in operation time and number of dissected lymph nodes. But amount of blood loss significantly de-creased and the days for returning to normal life was significantly shortened in LAC-S group (p<0.0001, p value: Mann-Whitney U test).
In this paper, the technical aspects of our laparoscopic procedure are presented, and we conclude that LAC-S may be the possible choice in the treatment for sigmoid carcinoma by selecting patients with appropriate indication.

View full abstract

This study was carried out to clarify the relationship between the cross-sectional configuration of colorectal carcinoma and therapeutic results. We analyzed 76 cases of colorectal carcinoma that had invaded the muscularis propria and classified them into two groups based on the cross-section views; a non polypoid-growth-type (NPG) showing no polypoid growth within the mucosa, and a polypoid-growth-type (PG) exhibiting projdcting nodules or polypoid growth within it. Forty one lesion (54%) were classified as NPG, and 35 (46%) as, PG. The mean size of the NPG lesions (28.7mm) was smaller than that of the PG lesions (38.3mm). NPG occurred more frequently in the colon than in the rectum. Lymph node metastasis by NPG (37%) tended to be more frequent than by PG (14%), regardless of the degree of invasion of the muscularis propria. The recurrence rate and 5-year survival rates of NPG and PG were 13.5% and 90.8% respectively, and 9.1% and 93.8%, respectively. It is suggested that the natural history of colorectal carcinoma invaded the muscularis prop-ria differs among two groups. However, the classification of this cross-sectional configuration is not associated with therapeutic results.

View full abstract

We clinically investigated 158 patients with prostatic carcinoma in whom the diagnosis was histologically confirmed. The patients were divided into a first-half group and a second-half group in relation to the 5-year period of the study. These was no difference in age between the two groups, but the clinical manifestations in the second-half group included of less urinary retention and more marked dysuria. In addition, the clinical stage C was significantly increased in the second-half group while G 1 showed a significant decrease. In regard to treatment, 153 patients (97%) received antiandrogenic therapy. Patients in the second-half group were less freqently treated by castration puls hormone administration, and LH-RH analogue therapy was used instead.
As the clinical stage progressed, the grading significantly increased, however, there were no differences the clinical staging and grading according to the clinical manifestations. The survival rate of G 1 patients was significantly higher than in the other three grades, but there were no differences in survival rate among G 2, G 3, and G 4. No cancer mortalities occurred in patients of clinical stage A, and there were no defferences in survival rate among the patients wirh clinical stage A, B, and C disease. Nevertheless, the survival rate in the clinical stage D patients was significantly lower than in the other three groups.
The presence or absence of metastasis was appeared to affect the prognosis of prostatic carcinoma.

View full abstract

We have experienced a case of delivery after mastectomy and adjuvant LH-RH agonist treatment for a breast cancer. The patient was a 29-year-old woman who underwent a pectral muscle-preserving mastectomy for multiple breast cancer in the right breast. The pathological stage was t₁n₀m₀nomo in Stage I. Tamoxifen was ad-ministered as postoperative adjuvant endocrine therapy, which was changed to LH-RH agonist on halfway. During the course, the patient wished to havw a bady and the endocrine therapy was discontinued 2 years after the surgery. About 3 months after the final administration of LH-RH agonist, normal menstration was comfirmed and the patient became pregnant after further 7 months. She delivered a healthy boy. While pregnancy and delivery after breast cancer surgery are dealt with differently depending on the case or indivisual surgeon, we consider that positive cooperation with sufficient explanation and consent is one of the way provided that there is no problem in the postoperative course.

View full abstract

A 40-year-old woman was admitted to the hospital because of a rapidly growing tumor of the left breast for the last 3 months and high fever. She had noticed the breast tumor 2 years before admission, but had not consulted any hospital. On admission the tumor in the left breast was huge, elastic soft and formed skin ulceration with bleeding and odor. No regional lymph nodes were palpated. The tumor was diagnosed as phyllodes tumor. Emergency simple mastectomy was performed because a risk of septicemia due to high fever was thought. The resected tumor revealed sponge like structure and had a large quantity of hematoma in the inner part. Histopathologically papillotubular adenocarcinoma was found in only the periphery of the tumor. We report this rare case which had an unusual clinical history leading to make a misdiagnosis of breast cancer.

View full abstract

A 52-year-old woman was reffered to the hospital for investigation of a left axillary mass. A biopsy of the left axillary nodes taken 3 months prior to admission had confirmed the presence of metastasis from epithelial carcinoma; however, preoperative physical findings and radiographic studies revealed no malignant disease anywhere in the body. The patient underwent a modified radical mastectomy for the left breast and the obtained specimen was cut longitudinally at intervals of 5mm. Small lesions, 8mm×5mm and 5mm×3mm in diameter, were detected in the area C, the pathological findings of which were identical to those of the left axillary lymph nodes that had been resected preoperatively. The patient was treated with adjuvant chemotherapy for 14 months and no evidence of recurrence has been found as of 14 months after the operation. This case report serves to demonstrate that the patient with occult breast carcinoma presenting with an axillary mass should undergo the treatment for the ipsilateral breast, such as mastectomy and/or radiation with chemotherapy, due to the high possibility of this lesion being a focus of metastasis.

View full abstract

A 45-year-old woman with a previous history of undergoing a modified radical mastectomy with adjuvant chemotherapy for a right breast cancer in February 1992 was admitted to the hospital because of lower ab-dominal pain and vomiting in July 1997. Barium enema and endoscopic examination revealed multiple stenoses of the colon. On laparotomy, these tumors were found not only in the colon but also in the small intes-tine. A right hemicolectomy, a partial resection of the small intestine, and a sigmoid colostomy were per-formed. Pathological findings showed metastases from the breast cancer. After 6 courses of adjuvant CMF chemotherapy, she is alive 10 months after the operation. It has been reported that gastrointestinal metastases represent 8.9% of all metastases from breast cancer in 135 autopsied cases, but we rarely encounter such a case of gastrointestinal metastases clinically.

View full abstract

A 58-year-old woman undergone an extended radical mastectomy for a left breast cancer in Stage IIIa in 1985 had been followed postoperatively with every 3 months analyses of blood chemistries and tumor markers, and with annual ultrasonography or an ambulant basis. The patient became to complain of epigastralgia in September 1995. In December, 1995, she was admitted to the hospital because of an abnormal mass, showing a bull's eye sign in the left lobe of the liver (S4) on ultrasonography. With a diagnosis of possible liver metastasis of breast cancer, Hro (S4) was perfomed in July, 1996. No obvious postoperative complications were noted. A microscopic histological examination revealed solid tubular adenocarcinoma of the liver, metastatic breast cancer. The patient received chemotherapy with CAF postoperatively. The patient is disease free and remains alive for 12 years after the initial breast surgery or for 2 years and 3 months after the liver surgery.
Metastases of breast cancer to the liver often appear in multiple lesions and are associated with other organ metastases. In general, these hepatic metastases are uncommonly indicated hepatectomy. And there have been no such cases as 1 solid liver metastasis occurs after a 10-year disease free interval. We think, however, that aggressive hepatectomy is a useful option for the liver metastases, if it is possible, and that a long-term follow-up after curative mastectomy is important, even if more than 10 years elapse.

View full abstract

We report a case of subacutely developed constrictive pericarditis with hemopericardium. A 67-year-old man was admitted to the hospital because of chest discomfort at the inspiration and edema of the lower ex-tremities one month after catheter ablation therapy for WPW syndrome (type A). According to UCG and chest CT findings, cardiac tamponade with hemopericardium was suspected and a removal of hematoma was planned. Operative inspection, however, reveald that the heart was strangulated by thick epicardium, causing disturbance of cardiac dilatation. Then a epicardiectomy was performed. The cardiac function was improved and the postoperative course was uneventful. This case was diagnosed as effusive constrictive pericarditis. The possibility of constrictive pericarditis must be considered in cases of subchronic cardiac tamponade.

View full abstract

Aortic aneurysm due to BehÇet's desease has a high risk of abrupt enlargement causing rupture. Fot this, operative procedure in often the treatment of choice, but complications at anastomosed portion occur in a relatively high frequency and the operative results are poor. This paper deals with our successful attempt of omental flap coverage for such an abdominal aortic aneurysm.
A 56-year-old man originally diagnosed as complete type Behçet's disease in 1967, was admitted to our hospital because of an aortic abdominal aneurysm disclosec by CT and DSA. The aneurysm consisted of a large thrombus, and a punched-out lesion was found on the aorta (φ 20mm) beneath the thrombus. The aneu-rysm was replaced by an 16×8mm woven dacron graft and the graft was wrapped in omental pedicle flap to prevent potential anastomotic complications of development of false aneurysms at the site of anastomoses, in-fection, delayed healing, and graft occlusion. Pathologic examination revealed that the patient had vasculo-Behçet's syndrome.
The patient has been followed for over 5 years and has had no further complications either from his un-derlying disease or from his aortic dissection and aneurysm. Omental flap coverage is essential for effective treatment of abdominal aortic aneurysm in Behget's disease.

View full abstract

A 44-year-old woman was admitted to the hospital for exploration of an abnormal chest shadow which was pointed out at a clinical survey. Chest CT revealed two tumorous shadows less than 1cm in diameter adjacent to the lateral pleura of right lower lobe. An operation was performed. Two lesions black in color were seen on the surface of right lower lobe and a partial excision of the lung was conducted under thoracoscopic surgery. Histopathologically, in both two nodules, granulation tissues comprizing of colonies of coal dust phagocytic macrophages and lymphocytes were formed. The definite diagnosis of pulmonary anthracosis was made.
Pulmonary anthracosis is commonly seen in adults, but the disease which forms a tumor to demand operation is relatively rare. The patient did not have any histories of smoking nor working to treat coal dust, but she had worked at ironworks where she exposed to a low concentration of dust that might cause deposit of coal dust. The disease presents difficulty in differentiation from pulmonary cancer on imaging methods. For making the definite diagnosis, thoracoscopic operation would be useful.

View full abstract

We report a case of diaphragmatic hernia presenting with an obstruction of the small intestine, which oc-curred one month after a thoraco-lumbar compression fracture.
A 76-year-old woman, with a ten-year history of steroid therapy for chronic arthritis, was admitted to the hospital for thoraco-lumbar compression fracture due to a tumble on a mat. After one month hospitalization, the symptoms of strangulated hernia occurred. Chest X-ray showed an intestional gas shadow and a pleural effusion in the left lung field. On laparotomy, there was a defect of 2cm in diameter at the central tendon around the esophageal hiatus. The small intestine escaped into the thoracic cavity through the defect with bloody pleural effusion. After the small intestine changed to the pinkish color, the defect of the diaphragm was repaired with interrupted sutures. Re-expansion pulmonary edema occurred 3 hours after the surgical repair, and was improved to re-inflate with positive pressure ventilation.
It is important to pay attention to the possibility of diaphragmatic hernia designated as the late phase in the patient with blunt injury.

View full abstract

We report a relatively rare case of diaphragmatic hernia after esophagectomy without thoractomy. A 62-year-old man was admitted to the hospital because of severe abdominal pain. He had a history of heavy drink-ing and had undergone an esophagectomy about 15 months before admission. Chest X ray, computed tomography (CT), and magnetic resonance imaging (MRI) revealed diaphragmatic hernia and its resultant intestinal obstruction. Emergency surgery was performed. During the surgery, the small intestine and transverse colon were found to be invaginated from an esophageal hiatus, which had expanded into the thorax as a results of the esophagectomy. The small intestine and transverse colon were returned to the abdominal cavity, and a Marlex mesh patch was placed over the expanded esophageal hiatus. In this case, the cause of the diaphragmatic hernia was determined to be repeated high abdominal pressure caused by vomiting after drinking. The recurrent pressure had caused the esophageal hiatus to become fragile to the point of rupture. We conclude that heavy drinking is a risk factor in diaphragmatic hernia after esophagectomy without thoracotomy.

View full abstract

A 55-year-old man was admitted to the hospital because of epigastralgia and was found having a tumor of the esophagus by upper gastrointestinal endoscopy. It was a yellowish white elevated lesion 30mm in size covered with normal esophageal mucosa and placed at Ei portion of the posterior wall of the esophagus. Endoscopic ultrasonography demonstrated a normoechoic mass with homogenous internal echo in the submucosal layer. Endoscopic resection was impossible because of its size. It was resected under laparotomy. Histologically, the resected tumor was made from many foamy cells having amount of eosinophilic cytoplasm which showed positive reaction for S-100 protein. NSE and PAS stains. The diagnosis of granular cell tumor was made. In Japan 152 cases of esophageal granular tumor have been reported in detail. Follow-up, endoscopic resection and/or surgical resection were performed for these tumors. We confirm that endoscopic resection in the first choice for esophageal granular cell tumor, considering its size, histological depth of invasion and the sign of malignancy.

View full abstract

We performed dilatation of a benign esophageal stricture with an expandable metallic stent (EMS). The patient, a 64 year old man, had attempted suicide by injesting hydrochloric acid. Dysphagia resulted from benign esophageal stricture followed by corrosive esophagitis.
Repeated dilatation of the stricture with balloon catheters had only minimal, short lasting effect. Given this patient poor physical and psychological condition, surgical intervention was considered too great a risk. The decision to try EMS to relieve the stricture proved successful. Until now, reports on EMS for esophageal stricture have primarily described obtaining better quality of life for patients with malignant tumors. However, when applying EMS for a benign esophageal stricture under such poor condition as our case, facilitating nutrition prior to surgery should be considered a favorable and safe option.

View full abstract

We ebcountered two cases of basaloid (-squamous) carcinoma of the esophagus. In Case 1, a 64-year-old man was operated on. The resected material showed an ulcerative and localized lesion measured 6.0×3.0cm and an erosive lesion at 0.5cm anal side from it. The histological diagnosis was basaloid (-squamous) carcinoma with moderately differentiated squamous cell carcinoma in a stage-grouping of a2, ly 2 (+), v 1 (+), n 4 (+), stage IV. Pleural effusion, ascites and multiple liver metastases were detected by ultrasonography and computed tomography four months after the surgery. He died of recurrence of esophageal cancer six months after the operation. At autopsy, systemic wide-spread recurrence of basaloid (-squamous) carcinoma was recognized. In Case 2, a 73-year-old man was operated on. The resected material revealed a 5.0×4.5cm protruding tumor and a 4.0×4.5cm protruding tumor and a 4.0×7.0cm ulcerative and infiltrated lesion. Histological diagnosis of the protruding tumor was basaloid (-squamous) carcinoma while that of the ulcerative and infil-trated tumor was moderately differentiated squamous cell carcinoma in a staging-grouping of al, ly3 (+), v1 (+), n3 (+), stage IV. He died of recurrence of esophageal cancer 15 months after the operation. Basaloid (-squamous) carcinoma of the esophagus is thought to have a high malignant potential. Therefore, more detailed studies of factors causing this high malignant potential are needed. Some bibliographical comments on 56 cases reported in Japan including our two cases are also presented to elucidate characteristic findings of the disease.

View full abstract

We experienced a case which was assumed to be‘true carcinosarcoma’ of the esophagus. The patient was a 59-year-old man complaining of epigastric pain and dysphagia. The lesion was present in the middle intrathoracic esophagus, and was a giant polypoid lesion. A total excision of the thoracic esophagus with three regional dissection was performed. Histopathologically, it was diagnosed as carcinosarcoma of the esophagus. On HE staining, the tumor was mostly composed of sarcoma comprizing of mainly spindle cells, with nest like coexistence of well-differentiated squamous cell carcinoma with keratinization, but no transitional area between two components were seen. Immunohistochemical stainings clearly distinguished the two portions, namely the squamous cell carcinoma portion as positive for keratin and EMA versus the sarcoma portion as positive for α-SMA. Based on these findings together with electron microscopic findings, the tumor was considered to be‘true carcinosarcoma’ of the esophagus.

View full abstract

An 82-year-old woman complaining of epigastric discomfort was referred to the hospital, because a sub-mucosal tumor covering from the cardiac part to upper body of stomach was revealed by an upper gastrointestinal endoscopy at another hospital in May, 1997. After admission, upper gastrointestinal fluoroscopy revealed a hemicyclic elevated lesion on the lesser curvature ciovering from the cardiac part to upper body of stomach, which formed a cavity communicating with the lumen of the syomach. Abdominal CT showed a tumor with cavity about 10cm in size at the same site. Abdominal angiography revealed vascuralization and accumulation of contrast material at the peripheral branches of the left gastric artery. On June 13, 1997, a total gastrectomy was conducted with a consideration of gastric leiomyosarcoma, but in histopathological study of postoperation, it was schwannoma of the stomach.
This paper presents the rare case of gastric schwannoma with cavitation in the tumor communicating with the lumen of stomach.

View full abstract

Continuous epidural analgesia is getting common for post operative pain relief. However, postoperative suppression of pain can hide painful pathological responses that will alart abnormallities in the body.
A 71-year-old man, 48kg in wight, 158cm in height had a cancer of the sigmoid colon and a right inguinal hernia and underwent a resection of the sigmoid colon and a right herniorrhaphy. He had massive hematemesis and bloody stool on the 7th postoperative day that required a gastrectomy. Anesthesia for the first operation was general anesthesia combined with thoracic epidural analgesia and he had been treated post operative analgesia through this epidural catheter by using infuser (Baxter infusion pump, 1.0ml/h, for 5 days), which contained 0.125% bupivacaine 60ml and 10mg of morphine. Postoperative analgesia was perfect and the patient did not have any discomforts at all. This situation led to mask stress gastric ulcer until massive hemorrhage occurred on the 7th postoperative day.

View full abstract

A case of stone of the common bile duct caused by ingested fish bone with an ampulla carcinoma of vater is reported. A 74-year old woman was admitted to the hospital because of a fever which lasted for one month. Abdominal ultrasonography revealed a 30×10mm stone of the common bile duct. Endoscopy also revealed an ampullamass lesion of vater which was diagnosed as adenocarcinoma. Then under a diagnosis an ampulla carcinoma of vater with primary common bile duct stone, a pancreticoduodenectomy was performed. The common bile duct stone was explored. The elongated stone, containing a fish bone 30mm in length was detected and removed. Foreign bodies in the common bile duct are rare especially fish bone. Such a case like ours that the common bile duct stone was formed around an ingested fish bone as a core associated with the ampulla carcinoma of vater has not been reported so far. This is the first case in the computer-aided search of the literature in 1997.

View full abstract

The use of sodium polyacrylate by scattering to refractory labial fistulas of the jejunum with high output dischrge successfully provided the protection for the skin and exposed intestine surrounding fistulas. A 55-year-old man who had undergone a distal gastrectomy developed panperitonitis due to anastomosis leakage resulting in large exposure of the intestine (8×4cm) with labial fistulas and surrounding skin erosions, 6 months after the operation. After he was transferred to our hospital, various commercial products for stoma care were used to treat the wounds but were not effective. Sodium polyacrylate, which is usually added to chemical products and is safe in humans, was inevitably administered for protection of the exposed intestine and skin with the patient's approval. The treatment provided remission in the local and systemic symptoms. The patient was able to undergo a radical surgery 4 months after the treatment.

View full abstract

We experienced a case of perforated jejunal diverticulum with Recklinghausen disease.
The case involved a 51 year old man who had been diagnosed as having Recklinghausen disease at the age of 23. He received a neurosurgical operation for his brain tumors on December 17, 1996. The postoperative course was uneventful, but he had sudden onset of abdominal pain on January 8, 1997. His abdomen was elastic hard. Tenderness and defence were recognized. Abdominal X-ray film showed no significant remarks, but abdominal CT showed free air on upper abdomen. With the diagnosis of panperitonitis, the patient was op-erated on at same day. Intraoperative findings showed a jejunal diverticulum packed with food residue and its perforated point. A partial resection of the jejunum and dranage were performed with the diagnosis of pan-peritonitis due to perforated jejunal diverticulum.
The pathological findings demonstrated that the cause of the jejunal diverticulum was a neurofibroma associated with Recklinghausen disease.

View full abstract

Two cases of tumor of the small intestine presented with liver metastasis are reported, together with some bibliographical comment.
Patient 1, a 32 year-old man, was seen at the hospital because of pressure sensation of the abdomen. Ab-dominal CT revealed multiple tumors with central necrosis in the liver. A suspicion of liver metastasis of leio-myosarcoma was arisen. Pelvic CT and an intestinal fluoroscopy visualized the primary lesion in the ileum. The lesion was surgically removed and the definite diagnosis of tumor of the small intestine was made.
Patient 2, a 57 year-old-woman, was seen at the hospital because of epigastric discomfort. Abdominal ultrasonography and an abdominal CT revealed multiple liver tumors. Intestinal fluoroscopy showed a narrowing of the jejunum. So an excision of the small intestine was performed with a diagnosis of liver metastasis of cancer of the small intestine. After the operation the definite diagnosis was attained.
Tumors of the jejunum or ileum represent 0.3-0.5% of all malignant tumors of the gastrointestinal or-gans, and are believed to have poor prognosis. On exploration of hepatic lesions, the tumor of the small intestine must be kept in mind as a probable diagnosis, though it is rare.

View full abstract

A 36-year-old man was admitted to the hospital because of abdominal pain after eating fresh sushi, and he was diagnosed as having intestinal obstruction. His symptoms disappeared by the conservative treatment. But abdominal pain recurred repeatedly when he began oral intake.
Contrast X-ray examination of the small intestine showed a segmental stenosis in the jejunum. On the 52nd hospital day, a laparotomy was performed and a whole circumferential stenosis of the jejunum about 7cm in length at about 120cm distant from the Treiz ligament was confirmed. The jejunum oral to the stenosis was remarkably distended. A partial resection of the small intestine was performed. Based on macroscopic and microscopic findings of the resected material specimen, the diagnosis of ischemic stenosis of the small intestine was made.
Ischemic enteritis uncommonly occurs in the small intestine and such enteritis causing intestinal stenosis is rarely encountered. This paper describes a case of ischemic enteritis causing small bowel stenosis with a review of the literature

View full abstract

A case of adenocarcinoma of the small intestine in a young woman in described. A 24-year-old woman was referred to the hospital for further investigation and treatment of episodic abdominal pain. Abdominal ultrasonography demonstrated a low echoic mass adjacent to the right ovary, approximately 5×4cm in size. Small intestinal barium enema study showed a filling defect in the terminal ileum, and a colonoscopy confirmed a hemorrhagic tumor in the same region. Radical iliocecal recection with mesenteric lymph nodes dissection was performed. No tissue invasions or lymph nodes metastases were found in frozen sections intraop-eratively. The histopathological diagnosis was adenocarcinoma. The patient showed an uneventful recovery and has survived without any signs of recurrences or metastases.
Malignant tumors of the small intestine are rare, especially in a young generation. In the treatment of the disease, surgical resection is mandatory, however, no definite criteria for regional lymph nodes dissection have been established as yet. We think that intraoperative frozen section diagnosis is very helpful to improve the radicality of surgery.

View full abstract

We report here the case of an 81-year old male referred to our hospital with abrupt onset severe abdominal pain. Physical examination showed severe abdominal tenderness with mild rebound tenderness and rectal tumor was palpable on digital examination. Abdominal computed tomography revealed ascites with a thickened small intestinal wall and gas in the hepatic portal venous system. Superior mesenteric arteriography revealed irregular strictures without arterial occlusion. A diagnosis of ischemic enteritis was determined, and an emergency laparotomy was performed. Resection of a 100cm long segment of necrotic ileum, and a looped colostomy of the sigmoid colon were perfomed. The patient was discharged on the 61th postoperative day after receiving radiation therapy for rectal cancer.
We made the diagnosis of non-occlusive mesenteric ischemia from the findings of arteriography. No evidence of arterial diseases was found in the resected specimens. Indications for operation should be carefully decided because portal venous gas accompanys ischemic bowel, as well as other diseases.

View full abstract

A 58-year-old man underwent an emergency operation under the diagnosis of perforated appendicitis in May 1994. The appendix was hard and swollen, and small white nodules were observed in Douglas'pouch, suggesting peritoneal dissemination. Appendectomy and drainage were performed and some of the small nod-ules were resected. Pathological examination revealed poorly differentiated adenocarcinoma in the appendix and the small nodules, indicating metastasis from other organs. Postoperative gastrointestinal endoscopic ex-amination revealed Borrmann type-4 gastric cancer, diagnosed by biopsy specimen as poorly differentiated adenocarcinoma, similar to that found in the appendix. Twenty-four days after appendectomy, distal gastrec-tomy was perfored under the diagnosis of gastric cancer with appendiceal metastasis. Intraoperative findings were H 0 P 3 T 3 N 2 and pathological diagnosis was por2, se, n2(+). Three years and 2 months after gas-trectomy, the patient died due to peritonitis carcinomatosa. Appendiceal metastasis of gastric cancer is rare; only 16 cases have been reported in the Japanese literature. Most of them were found after surgery for secon-dary acute appendicitis, whereas this case was found an perforated appendicitis before the diagnosis of gas-tric cancer. When operating for appendicitis (especially after surgery for gastric cascer), intraoperative care-ful observation and postoperative pathological examination are very important.

View full abstract

A 56-year-old woman was admitted to the hospital for close examination and treatment of cecal tumor. According to the results of barium enema, colonoscopic fiber, and abdominal CT and MRI examinations, the patient was diagnosed as a case of mucocele of the appendix and she underwent an ileocecal resection with lymph node dissection.
Mucocele of the appendix is categorized histologically as non-neoplasm, benign tumor, or malignant tumor. It is difficult to get a histological diagnosis before operating. Many reports mention that the first treatment for mucocele of the appendix is an appendectomy because the chance of malignancy is 10 percent and lymph node metastasis is rare. Because the appendix is easily perforated, and not only malignant tumors but also benign tumors may develop into pseudomyxoma peritonei, this case demonstrates that all patients diagnosed with mucocele of the appendix should undergo an ileocecal resection.

View full abstract

Perforation of the digestive tract by an ingested fish bone is relatively rare, and presents difficulty in pre-operative diagnosis. In this paper, three operated cases of perforation of the digestive tract by ingested fish bones are clinically studied. In Case 1, CT revealed a tumor in the subhepatic space and a laparotomy was performed for probable cystic tumor. A fish bone was found in the resected tumor. The definite diagnosis of abdominal abscess caused by perforation of the transverse colon due to the fish bone was made. In Case 2, an ingested fish bone was visualized as well defined linear structure on ultrasonography (US) and CT. Preopera-tive diagnosis of ileocecal tumor caused by perforation of the intestine due to the fish bone was successfully made. In Case 3, an emergency laparotomy was performed because intraabdominal free air was noted. During operation, a fish bone about 7cm in length was present in the Douglas'pouch, but perforated site was obscure. Two out of three patients underwent a laparotomy for unknown cause, however, it was possible to diagnose retrospectively based on CT that revealed a linear density in them.

View full abstract

A recently operated case of chronic idiopathic pneudo-ileus in an adult is reported with some bibliographical comments.
A 27-year-old man who had had no abnormal bowel movements in his childhood had been taking cathartics for constipation and abdominal distention for these 15 years. And the patients was seen at the hospital because constipation was aggravated and his bowel movements became once a month. On admission the abdomen remarkably distended and abdominal x-ray film and CT revealed the dilated sigmoid colon with the diameter to 22cm and a large quantity of coprostasis. Barium enema study revealed no narrow segment in the rectum and a colonoscopic fiber visualized an infant's head sized coprolith. Rectal biopsy demonstrated the presence of ganglion cells. From these findings, the diagnosis of chronic idiopathic pseudo-ileus of the large intestine was made and an operation was performed. Upon laparotomy, a significant dilatation of the colon with maximum diameter of 35cm extending about 50cm in length from the turning point of peritoneum to descending colon was confirmed. An excision of the intestine by 50cm starting at 5cm oral side from the peritoneal turning point was performed, with an end-to-end anastomosis. Histo-pathologically, a mild degeneration in ganglion cells was noted. Postoperative course was uneventful. As of 1.5 years after the operation, he has bowel movements on an once-a day basis and the abdominal distention disappeared.

View full abstract

38 year-old woman visited another hospital because of anal pain in February 1996, who had noticed erosion around the anal area about 5 years before but had not consulted with any hospitals. The patient was referred to the department of dermatology in our hospital with a diagnosis of perianal Bowen disease on pathological study. After admission, the patient was transferred to the department because infiltration of the anal lesion into the rectal area was strongly suspected.
The reasons were: (1) the lesion did not invade the dented line; (2) no lymph node metastasis, inguinal lymph node, was obtained with preoperative examination; and (3) she did not hope strongly that the rectum amputation procedure was employed.
A pathological study revealed that the tumor cells did not destruct to the basal layer. There have been no signs of recurrence as of more than 2 years after the operation. The patient can have a good prognosis after operation, if surgical margin of more than 5 mm is held. Therefore, when the tumor dose not invade the dented line, we should not choice the rectum amputation procedure as possible as we can. And the local excision is the best conceivable for the purpose of definition of diagnosis and treatment.

View full abstract

A case of inflammatory pseudotumor of the liver, which was able to be diagnosed based on characteristic images, is reported.
A 57-year-old woman with a previous history of undergoing a choledoco-jejunostomy was under clinical observation at the department. The patient was seen because of fever. Ultrasonography revealed a low echogenic tumor 3.5cm in diameter in the posterior segment of the liver. Simple CT also revealed a low density area. Enhanced CT visualized an accumulation of a constrast material in the center of the tumor with low density margin. In the early phase on CT of the hepatic artery, the entire tumor became a high density area, and in the late phase the margin was left as high density area, but the center came to low density aree. From these findings, the diagnosis of inflammatory pseudotumor was made and a liver biopsy was conducted. Histopathologically, fibrous tissues with infiltration into lymphocytes and plasmocytes were confirmed. The definitive diagnosis of inflammatory pseudotumor was mode. There after we observed her clinical course without any treatments and a decreasing in tumor size was recognized, only fibrous tissue being seen on CT eventually.

View full abstract

We have experienced a resected case of intrahepatic cholangiocellular carcinoma of peripharal type oc-curred 9 years after an operation for synchronous double cancer of the stomach and pancreas.
A 74-year-old man revealed an increase in level of a tumor marker (CA 19-9:267IU/ml) during medical ovservation following the operation for the double cancer on an ambulant basis. Abdominal CT scanning visu-alized a tumor 3cm in diameter presenting an irregular low density area in the anterior and superior segment of the right lobe (S 8) of the liver. From findings of CT, ultrasonography, and angiography, we found a great deal of difficulty in differentiating whether the hepatic tumor was metastatis of the former gastric or pancreatic cancer or intrahepatic cholangiocellular carcinoma. But we first considered it as intrahepatic cholangiocel-lular carcinoma because it was solitary and 9 years had elapsed after the inital operation, and performed a segmentectomy (S 8) of the liver. The resected material also demonstrated intrahepatic cholangiocellular carcinoma of peripheral type, histopathologically.
It is very rare that metachronous triple cancer appears in such combination as early gastric cancer, pan-creatic cancer and intrahepatic cholangio-cellular carcinoma, and hence this case is presented here.

View full abstract

A 65-year-old man complaining of right upper quadrant discomfort and fever was seen at the hospital. Serum T. Bil. and transaminases were elevated. Abdominal ultrasonography and CT showed a dilatation of the common bile duct, but no apparent stones or tumors were seen. ERCP revealed a round filling defect in the lower bile duct. A diagnosis of choledocholithiasis was made, and a laparotomy was performed. Choledochotomy and intraoperative cholangioscopy failed to reveal any gallstones, but a papillary tumor was found in the lower bile duct. The histological diagnosis of a biopsy specimen of the tumor was papillary adenoma, and a pylorus-preserving pancreatoduodenectomy was performed. Histological examination of the resected mate-rial showed benign papillary adenoma without invasion or lymph node metastasis.
Although benign tumors of the extrahepatic bile ducts are rare, there have been a case of cancer in ade-noma of the lower bile duct and a case of recurrence of lower bile duct adenoma following local resection in the Japanese literature. Thus, we think that adenoma of the bile duct should be resected radically.

View full abstract

Granular cell tumor of the biliary tract is a rare entity. A case of granular cell tumor of the cystic duct with a cancer of the ascending colon is reported. An 83-year-old woman was seen at the department of internal medicine in our hospital for examination of anemia, and was transferred to the department because a cancer of the ascending colon was found. Preoperative examinations revealed slight increases in biliary enzymes and swollen gallbladder. A right hemicolectomy was performed for the colonic cancer. During the operation, the gallbladder was explored to be tense and distended, and a hard nodule was found in the cystic duct. The mass of the cystic and the gallbladder were excised and submitted for pathologic examination. Frozen section examination showed that the cystic mass was a granular cell tumor and the distal margin of the cystic duct was involved. Therefore, the common bile duct was resected and the biliary tree was reconstructed with a Roux-en-Y hepatodochojejunostomy. Permanent sections confirmed that the lesion was a benign granular cell tumor of the cystic duct. The postoperative course was uneventful, and the patient has been doing well and recurrence free.

View full abstract

We experienced a case of huge cholangiocellular carcinoma with an extrahepatic growth. An 89-year-old woman was admitted to the hospital because of an abdominal mass and abdominal discomfort. The tumor markers showed marked increases, CEA and CA 19-9 were 1.275ng/ml and 4.950U/ml, respectively. Abdominal echo visualized a huge tumor with a well defined margin, which was growing expansively from the right lobe of the liver. Abdominal CT revealed that the tumor was so huge as to reach to the pelvic cavity. Angiography showed that the tumor was fed from a 5 and a 6 arteries of the liver and no parasitic vessels were detected. Curative operation was performed with limited resection of segment 5 and 6 of liver. The excised tumor was 15×10×8cm in size, and 1, 300g in weight. Histopathologically, the tumor was diagnosed as well differentiated tubullar adenocarcinoma with some papillary proliferation.
This case is very rare, since the huge cholangiocellular carcinoma with an extrahepatic growth have been reported in only two cases in Japan.

View full abstract

We experienced a case of duct-islet cell carcinoma which was diagnosed by a histological study after op-eration with a suspicion of cancer of the body and tail of the pancreas. A 62 year-old man was admitted to the clinic because of weight loss. Laboratory tests revealed no unremarkable findings, except for a fasting blood glucose level of 196mg/dl. Abdominal CT, Ultrasonography and Magnetic resonance imaging revealed a tu-mor mass of the pancreas body. Endoscopic retrograde cholangio-pancreatography showed an obstruction of the pancreatic duct in the body, but an angiography revealed no abnormality. Distal pancreatectomy with splenectomy was performed with a suspicion of pancreatic cancer. The pancreatic tumor was 48×25×25mm in size and was histologically proved to be duct-islet cell carcinoma of the pancreas. Despite of the unfavorable size of tumor, it was succeessfully resected without significant invasion. Duct-islet cell is very rare. To our knowledge, few reports are available.

View full abstract

A 63-year-old woman was admitted to the hospital because of dyspnea due to a blunt trauma at a traffic accident. As she was showing the flail chest due to bilateral multiple rib fractures and left hemothorax, tracheal intubation for internal pneumatic stabilization and left thoracic drainage were conducted. Although a persistent blood loss from a thoracic drain was not remarkable and we observed conservatively, a chest com-puted tomography revealed a traumatic rupture of the left diaphragma with a hernia and a splenic injury. Suture of the ruptured diaphragma and a splenectomy were carried out through the abdominal approach. The omentum and spleen protruted through the diaphragmatic rent into the pleural cavity and the ruptured spleen was strangulated with little bleeding. No bleeding in the abdominal cavity was seen. The mechanism that the bleeding from the splenic injury showed only hemothorax was considered rare.

View full abstract

An extremely rare case of primary liposarcoma of the greater omentum is reported.
A 51-year-old man was seen at the hospital because of abdominal distention. As a result of close examinations, the patient was diagnosed as having an intraabdominal tumor and was operated on. Upon laparotomy, a large volume of ascites was noted. The tumor was mainly present in the greater omentum, but a large number of small tumors with the diameters of 1 to 2cm were confirmed in the entire abdomen. The tumors were extirpated as possible as we could. The histopathological diagnosis was well differentiated liposarcoma partly with myxoid change. The prognosis was poor. The patient experienced recurrence four months after the operation and died after unsuccessful chemotherapy.

View full abstract

A 21-year-old woman, who had undergone a right nephrectomy for a Wilms tumor of the right kidney and a partial hepatectomy for its multiple hepatic metastasis at the age of 10 (1987), was admitted to the hospital for the treatment of recurrent tumors in June 1997. Until 1994, at 18 years of age, she had partial hepatec-tomies with microwave coagulation therapy twice, pulmonary resection, paraaortic lymph node dissection, neoadjuvant chemotherapies for recurrent tumors, and auto bone marrow transplantation. In March 1996, a cystic lesion in the right lower lobe of lung was detected on CT. In June 1997, another tumor in the posterior segment of the liver was detected, and a thoracoscopic resection of the lung tumor and transdiaphragmatic microwave coagulation therapy for the liver tumor were successfully performed. The patient have maintained a good quality of life for 10 years since the initial therapy with subseqent multimodal therapies.

View full abstract

The authors present a case of ‘teratomatosis peritonei’, originated from an immature ovarian teratoma (G 1) which was completely cured by six operations in five years with a recurrence free 12 year-period as the first case. Repeated recurrent disseminations were usually treatoma comprizing of three germ layers, and maturation (G 0) was confirmed in the resected materials after fourth operation.
The disease is similar to but quite different from gliomatosis peritonei among peritoneal disseminations in terms of morphology and biology. The authors wound claim to give some independent criterion for the condi-tion which obliged us to call ‘teratomatosis peritonei’ among peritoneal disseminations. We present the case as an important and basic case and emphasize the necessity of repeated and aggressive extirpation of tumors and adjuvant intensive therapy in abdomen.

View full abstract

Internal hernias are not common cause of intestinal obstruction. Among of those hernias, a very rare internal herniation through an abnormal defect in the broad ligament of the uterus is reported. A 54-year-old woman was admitted to the hospital because of abdominal pain and vomiting. She was treated conservatively with a long tube, but no symptomatic remission was obtained except evacuation. As a stenosis of the ileum was detected on a long tube enterogram, an operation was performed on the 11th hospital day. At laparotomy, the ileum, approximately 25cm proximal to the ileocecal valve, was herniated through an abnormal defect in the broad ligament of the uterus. Following a reduction of the incarceration, the hiatus was sutured. This disease presents difficulty in preoperative diagnosis. When we encounter multiparous patient with intestinal obstruction without any previous surgical history, a possibility of this disease must be kept in mind.

View full abstract

A 22-year-old woman who had been admitted to the department of psychiatry in our hospital with anorexia nervosa had a sudden onset of severe pain and cyanosis on her left lower extremity. She was referred to the department of surgery. Emergency angiography showed a complete obstruction of the left femoral artery. Embolectomy was performed according to the angiographic findings. Histological findings of this embolus revealed fungus embolus. After the operation, blood flow on her left lower extremity was recovered. Her consciousness level was, however, down suddenly in spite of intensive treatment. Twenty-seven days after the operation, she died of brain abcess. Infectious fungal endocarditis of mitral vulve was found by autopsy. These results suggest that acute fungal embolism was derived from infectious fungal endocarditis of the mitral vulve. Prognosis of systemic fungal infection is very poor and so we should examine the whole body and treat carefully.

View full abstract

We experienced a case of synchronous double cancer, an undifferentiated esophageal carcinoma and an early gastric cancer, which were treated by esophagectomy with reconstruction followed by endoscopic mucosal resection, respectively.
A 66-year-old man was admitted to the hospital with a diagnosis of ulcerative type of cancer in the lower thoracic esophagus. He underwent an esophagectomy together with 3-field lymph node dissection and reconstruction using the stomach through posterior mediastinum on 9 th November, 1994. Pathological study revealed that the lesion was undifferentiated carcinoma invading adventitia with lymph node metastasis. The patient was followed up without any adjuvant therapy. Seven months after the surgery, a superficially elevated lesion was detected in posterior wall of the antrum endoscopically. The gastric lesion was treated by endoscopic mucosal resection, which was found to be curative, because the lesion was well differentiated tubular adenocarcinoma limited in the mucosa and without vascular invasion. There have been no signs of recurrence 32 months after the surgery.
Undifferentiated esophageal carcinomas are uncommon among esophageal tumors. It is believed that the patients with the disease can not expect to survive for more than one year after operation. However, an improvement of prognosis may be afforded by strict follow-up of clinical course and early detection and treatment of the second malignancy.

View full abstract

We present the case of a 80-year-old male, who fad surgery for rectal cancer in 1994. Histological examination revealed well differentiated adenocarcinoma of a1, ly1, n0, ow(-), aw(-). In January, 1998, he noticed a tumor in the left breast, and was seen at the hospital. Ultrasonography and incisional biopsy indicated a breast cancer. Mastectomy with preservation of the pectoral muscle was carried out. Histologically it was hard carcinoma, T3, N1 α, M0, and in stage III. There has been no recurrence or metastasis after the operation. Male breast cancer rarely occurs, with a frequency of about 1% of all breast cancers. Male breast cancer has been believed to have a poor prognosis compared to other breast cancers. However, recently similar case have been reported. This rare case is the 6th occurrence double cancer involving male breast and colon, and the 2 nd occurrence involving male breast and rectum in the Japanese literature.

View full abstract

A 54-year-old man was seen at the hospital because of epigastralgia. Endoscopic and upper gastrointesti-nal x-ray examinations revealed a cancer of the stomach. Abdominal ultrasonography and CT scan detected a tumor at superior segment of the left kidney which was diagnosed as renal cell carcinoma by magnetic resonance imaging (MRI) and renal angiography.
Based on a consideration that this synchronous double cancer could be successfully resected on an onestep approach, total gastrectomy with D₂ lymph node dissection, cholecystectomy, distal pancreatectomy, splenectomy and radical nephrectomy were performed. Histopathologically, the gastric cancer showed poorly differentiated adenocarcinoma (SS, ly₃, ow(-), aw(-), n₂(+), stage IIIa) and the renal cell carcinoma was clear cell subtype (G2, INFα, pT2, pN0, pM0, pV0, stage II) . In addition, it was found that the gastric cancer showed aneuploidy, while renal cell carcinoma was diploidy by DNA analysis.
Postoperative course was uneventful, and now he is healthy without any recurrence signs.

View full abstract