Recently, video assisted thoracoscopic surgery (VATS) has become widespread surgical method because the patients can have less injury and pain than those with the traditional operation.
We have experienced a series of 156 cases of VATS from July 1992 to July 1998. When they were classified by the purpose of performing the procedure, 144 cases underwent VATS for treatment and remaining 12 cases for the diagnosis. The former 144 cases of the treatment included 74 cases of lung partial resection, 33 cases of pneumothorax, 18 cases of mediastinal tumor, 12 cases of lung lobural resection, four cases of intrapleural hyperthermo-chemotherapy and three cases of pleural tumor.
In 7.7% of these cases, thoracootomy was seeded and in 3.8% of these cases, minor complications have occured.
In this paper we present a study on VATS cases in our institution as well as VATS cases in the institutions of Kyusyu area analyzed by quentionnaire survey conducted in 1996.

View full abstract

Objective: Bronchioloalveolar carcinoma (BAC) develops along intact alveolar walls characterized by overgrowth of bronchiolar-type epithelium. Few studies have related the prognosis for BAC to their macroscopic characteristics and outcome after surgical treatment.
Methods: Sixteen resected BAC with aerogenous dissemination was studied with special reference to the relationship between cell type, growth patten and surgical outcome.
Reseuts: BAC has the following three subtypes. Goblet cell type, Clara cell type and type II alveolar epithelial cell type. Ten cases were calssified as goblet cell type, 3 as Clara cell type, and 3 as type II alveolar epithelial cell type. All type I BAC cases, whose tumors were localized within one segment, were alive, one type II BAC case, whose tumor's extent was limited to one lobe, was dead with intrapulmonary tumor recurrence for 67 months after operation, and another case was alive with intrapulmonary tumor recurrence 23 months after operation.
Conclusion: The prognosis of BAC was determined by intrapulmonary tumor extent. Goblet cell type of type II showed poorer prognosis than that of the remaining two subtypes. BAC limited to one lobe should be surgically resected, and therapy for intrapulmonary metastasis after operation is important in order to prolong the survival period.

View full abstract

Clinicopathological study was performed to know the adequate extent of dissection of regional lymph nodes for t₂ and t₃ gastric cancers. Positive ratio of the ly3 was higher in undifferentiated type and that of venous invasion was higher in differentiated type. As No.3 lymph node showed high possibility of metastasis, proximal ressection seemed to be out of indication for advanced cases. No.10 lymph node should be dissected for cancers in the MC portion located in the greater curvature or posterior wall and se cancers in the M portion. Correct dissection of No.1 lymph nodes is required even for mp cancers in the A portion. These results show that adequte dissection of regional lymph nodes is required for advanced gastric cancer considering the location and depth of invasion of the tumor.

View full abstract

Clinicopathologic evaluation was made on cases of early gastric mucosal cancer with lymph node metastasis for the purpose of defining the indications of endoscopic mocosal resection. In a series of 744 cases of gastric mucosal cancer, nine (1.2%) cases with positive lymph nodes were subjected to the evaluation. The characteristic features of these nine cases included younger than 70 years old, a mixed gross appearance, undifferentiated type cancer, and larger in size of the tumor. Ulceration in the cancerous lesions was found in six (67%) of nine cases. We conclude that mucosal cancers without ulceration in the lesions less than 40mm in diameter for elevated type of gross appearance, and less than 20mm in diameter for depressed type of gross appearance seldom have lymph node metastasis. For successful curative endoscopic treatment of mucosal cancers, it is essential that the primary lesion should be completely removed.

View full abstract

This study of 43 cases of curative hepatectomy for colorectal metastases over the past 15 years in our institution reports an analysis of resectable rate, morbidity, mortality, survival rate, and quality of life (QOL) of surgical therapy for recurrences after hepatectomy. Recurrence was seen in 25 patients: hepatic recurrences in 20 patients, pulmonary recurrences in nine, peritoneal dissemination in six, lymph node metastasis in three, pleural dissemination in two, local recurrences of abdominal wall in two, and bone metastasis, brain metastasis, intrapelvic recurrence in one patient each. We performed repeated hepatectomy nine times for six patients, pulmonary resection five times for three patients, and abdominal wall resection one time for one patient. During repeated hepatectomy, pulmonary metastases were resected in two patients. The median duration of postoperative admission for all 13 operations for seven recurrent patients was 15 days and there was no morbidity or mortality. There was no case of death within six months and the five-year survival rate was 71%. All patients were able to return to their normal lives. Repeated resection of recurrences after hepatectomy is shown to achieve a short hospital stay, early recovery of QOL, and an excellent survival rate. We conclude that repeated surgical therapy is an adequate procedure for recurrent metastases from colorectal cancer.

View full abstract

Splenic tumors irrespective of primary or metastatic lesion, are relatively rare. Thirteen patients with splenic tumor who were treated at the hospital were subjected to a clinical study. Eleven patients had primary splenic tumor. There were four cases of lymphangioma, one case of hemangioma, one case of hamartoma, three cases of malignant lymphoma and two cases of angiosarcomas. The remaining two patients had metastatic splenic tumor, and their primary lesions were ovarian cancer and gastric cascer respectively. Of six patients with benign primary splenic tumor, four patients were asymptomatic and the remaining two patients who had a huge lymphangioma complained of upper abdominal discomfort because of splenomegaly and a rupture of a hemangioma. Subjective symptoms were noted on all five patients with malignant primary splenic tumor. Two patients with metastatic splenic tumor were found due to elevated levels in serum tumor markers. We could not rule out probable malignant tumor on four out of six patients with benign primary splenic tumor. Actual preoperative diagnosis was made on four out of five cases of malignant primary splenic tumor and all two case of metastatic splenic tumor. Splenic tumors prenent difficulty in preoperative diagnosis, and there are some cases showing shock resulting from spontaneous rupture of the tumor. So we consider that all patients with splenic tumor are possible candidates for opreation.

View full abstract

Benefits of ultrasound on diagnosis of specific intestinal obstruction exclusive of due to adhesion, carcinomatosis, paralysis, and unknown origin were investigated in 65 patients in a recent 7-year period. Tumors were seen in 60 percent of patients in cases of colorectal cancers, however, dilatation of the colon were seen in almost cases of those patients. Aspect of colonic dilatation gives us a clue of colorectal cancer. Dilatation of the small intestine and protruded intestine to extraabdominal wall indicated external hernia. Invagination cases were diagnosed easily by multiple concentric sign. Small intestinal anisakiasis were diagnosed with relatively large amount of ascites and corn sign in all cases. Afferent loop obstruction was diagnosed with dilatation of the afferent loop and bile duct. Conversely, we could not obtain any diagnostic clue in internal hernia and volvulus of colon.
Ultrasound is very useful in diagnosis of specific intestinal obstruction except for internal hernia and volvulus of colon.

View full abstract

We present a 64-year-old man with sepsis due to Aeromonas hydrophila.The patient underwent a pyloruspreserving pancreatoduodenectomy for papillary carcinoma. On the first postoperative day, he was in sudden illness with high fever, chills and tachycardia. On laboratory tests, WBC counts was 1, 900/mm³, CPK was 6, 026IU/l, and arterial blood gas levels under room air breathing were; pO₂ of 62.6mmHg, and pCO₂, of 30mmHg. A chest x-ray film showed alveolar infiltrates located at the left pulmonary base. We diagnosed that he was under septic condition, DIC, and ARDS so that he was treated by intensive care. Thereafter, the findings of chest x-ray film gradually became better and the artificial support for respiration was not needed after 4th day following admission to intensive care unit. Aeromonas hydrophila was cultured from blood specimens. Aeromonas sepsis is a relatively rare entity but when it is experienced, the condition might significantly deteriorate within a short time. It is important to remark the possibility of Aeromonas hydrophila sepsis in compromised hosts. Furthermore, since Aeromonas hydrophila is low sensitive to pencillins and the first and second generation cephems, attention may have to be paid to postoperative infections due to the microorganism in future.

View full abstract

We report three cases of second primary carcinoma detected after breast conservation surgery that were successfully treated by conservative salvage surgery. Case 1: A 46-year-old woman had undergone right quadrantectomy (Bq) with axillary dissection (Ax) for primary papillotubular carcinoma located in section C at the age of 44 years. She underwent wide excision (Bp) for the second primary papillotubular carcinoma in right section A. Case 2: A 49-year-old woman had undergone Bq+Ax for primary papillotubular carcinoma located in left section C at the age of 44 years. She underwent Bq+Ax for the second primary tubular carcinoma in right section A. Case 3: A 46-year-old woman had undergone Bq+Ax for non-invasive ductal carcinoma located in left section AB at the age of 41 years. She underwent Bq for the second primary papillotubular carcinoma in left section A. None of the three primary carcinomas had axillary lymph node metastasis, and radiation therapy was not performed in any of the three cases after the initial surgery with negative margins. All of the second primary carcinomas were nonpalpable, low-echoic masses measuring less than 1.0cm. We believe that ultrasonography is extremely useful as a modality leading to verify small local recurrence or second primary cancer after breast conservation treatment.

View full abstract

A 68-year-old woman was admitted for a diagnostic examination of a liver tumor detected by abdominal ultrasonography during a health screening examination. Abdominal ultrasonography and computed tomography revealed a mass that occupied the retroperitoneal space from above the level of the renal veins to the level of the porta hepatis. Magnetic resonance image showed a tumor thrombus in the IVC that extended into the left renal vein. Venocavography revealed obstruction of the IVC and the left renal vein with developed collateral circulation. The preoperative diagnosis was primary vena cava tumor, and the operation was carried out. The 9.5cm tumor derived from the retroperitoneum which was situated around the IVC from above the right renal vein to the level of the porta hepatis. By amputating the left renal vein and amputating the IVC above the tumor and above the right renal vein, the tumor was resected. Pathological diagnosis of the tumor was leiomyosarcoma of IVC.

View full abstract

A case of extralobular pulmonary sequestration associated with mediastinal bronchogenic cyst is presented. A 25-year-old woman presented with sore throat and moderate fever. Chest X ray revealed a mass in the left cardio-phrenic angle. The mass was separated clearly into a high- and low-intensity area on MRI. Thoracoscopy disclosed extralobular pulmonary sequestration and mediastinal bronchogenic cyst that were closely but separately located. Both were resected with Video-Assisted Thoracic Surgery and thoracotomy.

View full abstract

Patient 1, a 56-year-old man, was seen at the hospital because of bloody phlegm. Chest CT scan revealed a nodular shadow 1.5cm in diameter with irregular margin in the right S 9. A partial resection of the lung was thoracoscopically performed. Histopathologically, there were granulation and numerous lymphatic follicles with embryonal center in the nodule. Patient 2, a 49-year-old man, was seen at the hospital because of an abnormal chest shadow at a medical checkup. Chest CT scan visulaized nodular shadows with irregular margin and the diameter of 3cm in the right S 8 and 1cm in the right S 4, respectively. Thoracoscopy-aided partial resection of the lung was performed for both lesions. In the resected nodules, lymphatic follicles with embryonal center were formed. Inflammatory pseudotumor of the lung is a relatively rare entity, and presents difficulty in preoperative diagnosis because it lacks characteristic clinical findings and imagings. In these cases which revealed nodular shadows with irregular margin and converged peripheral vessels on chest CT imaging, we had great difficulty in differentiating them from adenocarcinoma of lung field type. The disease usually has good prognosis and so we must try to preserve the pulmonary function at surgery as possible as we can. We think that thoracoscopy-aided operation which is less invasive is of value in the diagnosis and treatment of inflammatory pseudotumor of the lung.

View full abstract

A 69-year-old woman was admitted because of an abnormal solitary round shadow in the right lower lung on chest X-ray. However we could not make an accurate preoperative diagnosis using either transbronchial lung biopsy or CT guided needle biopsy. Since intraoperative thoracoscopic needle biopsy revealed malignant findings, right middle lobectomy with R 2_a lymph node dissection was performed. Histological examination determined pulmonary mucoepidermoid carcinoma originating from the peripheral bronchus of B 5_b.
Pulmonary mucoepidermoid carcinoma commonly occurres in the bronchial glands of the central bronchus, and gradually invades the pulmonary parenchyma. Since mucoepidermoid carcinoma of the peripheral bronchus is very rare, the clinical features of this casewere reported.

View full abstract

A case of Morgagni's foramen hernia involving only the greater omentum which was preoperativery diagnosed by angiography is reported. A 64-year-old woman was referred to the hospital with a suspicion of having a mediastinal tumor at a mass screening medical examination. Chest x-ray film revealed a fist-sized tumor shadow at a corner of diaphragm in the right heart. Chest CT visualized a tumor shadow of fat density adjacent to the right side of cardiac shadow behind the sternum. On sagittal plane of chest magnetic resonance imaging (MRI), a tumor shadow of fat density which was adjacent to the pericardium and anterior thoracic wall and communicated with the abdomen was confirmed. Morgagni's foramen hernia was suspected, but a possibility of mediastinal tumor could not be ruled out. So an angiography was performed and an omental branch of the right gastroepiploic artery along the tumor shadow was revealed. From these findings, the patient was diagnosed as having Morgagni's foramen hernia containing only the greater omentum and was operated on. At operation, the greater omentum was reduced by an abdominal approach, and the hernial openning was closed after the hernial sac was resected from the abdominal cavity. In the diagnosis of the disease, angiography is very valuable.

View full abstract

A 24-year-old woman with Prader-Willi syndrome (PWS) underwent a vertical banded gastroplasty (VBG), which is one of surgical procedures for extreme obesity, because she was extremely obese and developed diabetes mellitus as well. During perioperative period, no severe complications occurred. The body weight decreased to 60.0kg at 7th postoperative month from preoperative weight of 75.0kg. Fasting blood sugar was almost normalized around 5 months after the operation. However. thereafter the body weight converted to increase and the control of blood sugar level became poor again. The reasons may include that a total food intake has increased due to abnormal feeding behavior characteristic of PWS as well as a temporal withdrawal of medication, and she favors to eat high caloric foods. Since extreme obesity with diabetes mellitus in PWS has complicated factors compared with those of simple of extreme obesity, further investigation about therapies of PWS are necessary.

View full abstract

A 34-year-old woman was admitted to the hospital because of epigastralgia, vomiting and abdominal full-The elevation of diaphragma has been pointed out since childhood. She had experienced admission because of same complaints in 1992, when symptomatic remission had been attained by nasogastric suction. But she often suffered from stomachache. In November 1997, severe epigastralgia, vomiting and abdominal fullness were revealed after much eating. Plain chest X-ray and UGI study showed remarkably dilated stomach, displacement of the esophago-gastric junction to caudal-ventral side and upside-down stomach. Mesenteroaxial gastric volvulus was diagnosed. By nasogastric suction she became asymptomatic. She underwent percutaneous endoscopic gastrostomy fixation of her gastric volvulus. There have been no sign of recurrent gastric volvulus and she has been asymptomatic.

View full abstract

We report a case of heterotopic gastric mucosa in the gallbladder. The patient was a 69-year-old woman who visited another clinic because of nausea. Abdominal ultrasonography revealed a high-echoic polypoid lesion and CT revealed an enhanced mass at the neck of the gallbladder. The patient was referred to the hospital for further examination. Drip infusion cholangiography showed a filling defect 10mm in size at the neck of ballbladder. Since a possibility possibility of malignant tumor could not be ruled out, a cholecystestomy was performed and no malignant findings were found by intraoperative frozen pathological examination. The polypoid lesion was diagnosed as heterotopic gastric mucosa which consisted of gastric fundic glands and pyloric glands, and was located at the mucosa extending to muscular layer of the gallbladder by postoperative pathological examination of the fixed section.
Heterotopic gastric mucosa of the gallbladder is rare. This case is tenth report in the Japanease literature. We report this case here with a review of the literature.

View full abstract

We experienced a case of local recurrence after total gastrectomy for gastric cancer, which was successfully resected by the left thoraco-abdominal approach. A 62-year-old man complained of dysphagia 6 years and 9 months after total gastrectomy for gastric cancer although neither macroscopic nor microscopic cancer cells were found at the oral surgical margin of the resected stomach. Endoscopy showed an irregular narrowing of the esophagojejunostomy, and recurrence of gastric cancer was diagnosed pathologically by biopsy. The patient refused operation and underwent chemotherapy, however, after 1 year and 4 months, resection was performed successfully. That specimen removed the same pathological findings as the first resection, mucinous adenocarcinoma with signet ring cell carcinoma. No recurrence has been found 6 years and 5 months after the second operation.

View full abstract

A 67-year-old man was seen at the hospital because of a painless tumor in the left antebrachial region about 4 months following an operation for advanced gastric cancer. On palpation, a movable elastic hard tumor was palpated in the left antebrachial region. Ultrasonographic study of the legion revealed a relatively well-demarcated and hypoechoic mass in the muscle. The mass was removed with a diagnosis of tumor of the left antebrachial region. The tumor was present in the carpal extensor muscle. The removed tumor was 2.9×1.7×1.5cm in size and was covered with thin capsule. The cut surface was milk white in color. Histopathologically, poorly to moderately differentiated adenocarcinoma in the muscular tissue was demonstrated. Metastasis of the gastric cancer to the muscular layer was diagnosed. After the removal, an exploration of the whole body including the lung and liver revealed no other recognizable metastatic foci. About 2 months later, however, recurrence in the musculature of the left forearm as well as a similar tumor in the right chest (in the right anterior serratus muscle) was confirmed. These tumors were removed again. Histopathologically, recurrence of muscular metastasis was diagnosed.
In a review of 17 cases of muscular metastasis of gastric cancer including this case in the Japanese literature, the muscular metastasis commonly occurs in the lower extremities and has no certain propensity for histologic type.

View full abstract

A 76-year-old man was seen at the hospital because of tarry stool and a huge tumor at the left upper abdomen was found by abdominal CT. With close examination gastrointestinal stromal tumor (GIST) of the stomach with liver metastasis, early gastric cancer and gallbladder stone was diagnosed. A total gastrectomy, a distal pancreatectomy, a splenectomy, a partial hepatectomy and a cholecystectomy. The size of GIST was 23×12×11cm, the liver tumor was 1.2×1.1cm, and IIc type gastric cancer was 1.2×1.1cm. The histological findings of GIST and liver metastasis were uncommitted type, and gastric cancer was moderately differentiated adenocarcinoma limited in the mucosal layer.
In the Japanese literature, 17 cases of GIST of the stomach were reported. this suggestive case is presented together with some bibliographical comments.

View full abstract

A 53-year-old woman who had been suffering from a gastric discomfort was admitted to the hospital for close examination of an elevated lesion in the duodenum which was defected at a medical check up. Upper GI series of a group examination showed a tumor (50×20mm in size) which developed from the duodenum. Hypotonic duodenography showed a pealike elevated lesion at the 2 nd portion of the duodenum. The tumor was transformed by the compression, that is, soft and its mobility was good. Abdominal CT findings showed a clear, round and low density lesion (28×21mm in size) in the duodenum. CT scan disclosed a tumor with a radiographic density similar to adipose tissue (100 HU of CT number). The duodenal lesion was correctly diagnosed as lipoma according to these findings. Judging from the form (no peduncle) and the size (large) of the tumor, endoscopic polypectomy was considered to be impossible because of the risk of perforation. An extirpation of the tumor with a duodenotomy was performed. The resected tumor was 50×30mm in size, widebased and covered with duodenal serosa. It means endoscopic polypectomy will come to perforation. The resected specimen was pathologically diagnosed as lipoma.

View full abstract

A 69-year-old man was admitted to the hospital because of lower abdominal pain and constipation. Handgrip-sized mass was palpable at the left upper quadrant of the abdomen. CT scan of the abdomen revealed about 16×10cm solid tumor at the same region. After some other examinations small intestinal tumor derived from non-epithelial lesion was suspected. Upon laparotomy tumor grew extramurally from the third portion of duodenum and the peritoneum showed several disseminated nodules. A partial resection of the lesion with reconstruction by side to side anastomosis between the defect and jejunum was carried out. Postoperative histopathological findings on H-E staining revealed compact proliferation of round or spindle shaped cells with epitheloid arrangement. Immunohistochemiccal analysis showed positive staining for vimentin, and negative for smooth muscle actin, CD 34 antigen, S-100 protein. From these findings, this tumor was diagnosed as epitheloid leiomyosarcoma of the duodenum. This patient was predicted malignant because of tumor size and high miotic ratio (more than 1 mitose per one HPF). He died from the disease 18 months after the operation.
Epidermoid leiomyosarcoma of the duodenum is so rare that only 17 cases including ours have been reported in the Japanese literature as far as we could review.

View full abstract

We report the case of a 75-year-old woman presenting with a depressed early cancer (IIc) in the duodenal 2nd portion above the ampulla of Vater. A pylorus preserving pancreaticoduodenectomy was performed. The surgical specimen showed a type IIc tumor measuring 13×5mm in diameter. The histological diagnosis was well differentiated tubular adenocarcinoma with the invasion limited to the mucosal layer. This is the 23rd case of depressed type early carcinoma of the duodenum reported in Japan.

View full abstract

Percutaneous endoscopic gastrostomy (PEG) is commonly performed in patients who cannot ingest and need long-term nutritional support.
We experienced an adult intussusception caused by gastrostomy tube after PEG.
A 76-year-old woman was seen at our hospital because of diarrhea and vomiting. Plain abdominal radiograph showed that a gastrostomy tube tip had advanced into the small intestine; it was pulled back to in a stomach. Follow-up CT examination showed the intestinal tract had multilayers and thickened walls, and a diagnosis of intussuscepion was made.
Physicians should consider intussusception a complication of PEG.

View full abstract

Aortoenteric fistura in a special case of rupture of the abdominal aortic aneurysm. Rupture of the abdominal aortic aneurysm occurs at the third portion of the duodenum in most cases. The prognosis of the aortoenteric fistula in poor because io causes hematemesis, melana and sepsis. We report a rare case of aortoenteric fitula. A 67-year-old woman was seen at the hospital because of hematemesis and melena. In the abdomen, there was a pulsatile abdominal mass which measured was 7.0×7.0cm. Abdominal CT scan and angiography revealed an aortoenteric fistuula, and an emergency operation was performed. At laparotomy, the abdominal aortic aneurysm was seen below the left renal vein and was recognized to adhere to the jejunum strongly. The aortoenteric fistula was located at 5cm distal to the ligament of Treitz. Aneurysmectomy, partial resection of the duodenum and jejunum including the aortoenteric fistula, abdominal aortic replacement using a Y graft and doudenojejunostomy were performed. Her postoperative course was uneventful and there was no complications related to graft infection. Gastrointestinal series and angiography after the operation revealed no remarkable findings and she was discharged from the hospital on the 50 th postoperative day.

View full abstract

A case of intussusception due to an invaginated Meckel's diverticulum is reported. A 37-year-old woman was admitted to the hospital because of right lower abdominal pain, diarrhea which lasted for about one month, and recent intermittent colic. Physical examination revealed tenderness of her lower abdomen, however tumor was not palpable. Abdominal ultrasonography (US) and computed tomography (CT) showed target-like appearance on the right lower abdomen. A fluoroscopic examination of the small intestine revealed a bird's beak-like stenosis. These findings suggested intussusception of the small intestine by tumor. Intraoperatively, an invaginated Meckel's diverticulum which led to enteric intussusception was identified. Partial resection of the ileum with end-to-end anastomosis was performed. Histological examination of the resected specimen revealed Meckel's diverticulum containing ectopic pancreato tissue. We reviewed 45 cases of Meckel's diverticulum leading to intussusception and discussed the clinical features.

View full abstract

A case of blind pouch syndrome after polysurgery is reported. A 58-year-old woman was admitted with abdominal pain. She had previously undergone colectomy for colon cancer at 21 years old of age in 1958. After the operation, she had undergone laparotomy due to adhesional ileus three times between 1961 and 1978. In 1996, after 17 years from the last operation, she had had severe abdominal pain and fullness. She was diagnosed as adhesional ileus and received conservative therapy, including IVH without meal, with little or no improvement in clinical symptoms. She was referred to our department for surgical therapy and underwent operation. The surgical findings showed one side-to-end anastomosis, two side-to-side anastomoses and shunt ileum. The blind ileal end secondary to side-to-side ileosigmoid anastomosis was 20cm long and dilated. The diagnosis was blind pouch syndrome. Each anastomosis was reconstructed to an end-to-end anastomosis and the blind portion was resected. Symptoms were improved after the operation. The blind pouch syndrome is defined as a series of symptoms associated with formation of a blind pouch secondary to side-to-side intestinal anastomosis, and should be distinguished from blind loop syndrome.

View full abstract

A 67-year-old woman was diagnosed as having acute appendicitis and underwent an appendectomy. The appendix was significantly red in color and swelled which were compatible with acute phlegmonous appendicitis macroscopically. Postoperative histology demonstrated that goblet-cell-like tumor cells extensively infiltrated to the submucosa with perineural invasion. These cells were mucin-producing and were diffusively shown as argyrophilic. Since the same treatment as in advanced cancer was considered appropriate, a right hemicolectomy with lymph node dissection and bilateral oophorectomy were added. No metastasis or residue was observed, but a minor ovarian papillary cystic tumor of borderline malignancy was noted. Goblet cell carcinoid of the appendix is known to be almost as malignant as cancer. Metastasis to the ovary is often found in patients with goblet cell carcinoid of the appendix, but concomitant primary ovarian tumor seems rare like in this patient.

View full abstract

Primary carcinoma of the vermiform appendix is a rare disease. It presents difficulty in diagnosis preoperatively and postoperative histopathologic examination ofen offers the definite diagnosis for the first time. We have experienced four cases of primary carcinoma of the vermiform appendix. Preoperative diagnoses were ileocecal tumor in case 1 and 3, ovarian cancer in case 2, and pseudomyxoma peritonei arising from the appendix in case 4. We performed an appendectomy in case 1, ileocecal resection and extirpation of the uterus and ovary in case 2, ileocecal resection in case 3, and appendectomy and peritoneal levage (with 2, 500ml of 5% dextorose water) in case 4. At laparotomy, case 2 and 4 showed psuedomyxoma peritonei. Pathological diagnoses were mucinous cystadenocarcinoma in case 1, 2 and 4, and adenocarcinoma in case 3. After the surgical resection of the tumor, intraperitoneal administration of cisplatin and intravenous injection of pirarubicin and cyclophosphamide were executed in case 2, and peritoneal lavage and intraperitoneal administration of 5-FU were executed in case 4. All patients are still alive.

View full abstract

We present two cases of pneumatosis cystoides intestinalis (PCI) found by intraperitoneal free air.
Case 1: A 73-year-old woman was seen at the hospital because of right lower abdominal pain. Intraperitoneal free air was detected by chest and abdominal roentgenograms. Pneumatoid changes of the cecum, splenic flexure, descending and sigmoid colon were observed during laparotomy. Because of the risk of perforation ileocecal resection was carried out, but no evidence of perforated intestine was found.
Case 2: A 73-year-old woman with Parkinson's disease was seen at the hospital because of chest pain. Intraperitoneal free air was detected by chest roentgenogram, and abdominal CT scan demonstrated pneumatosis of the colonic wall. After the patient was treated with hyper oxygen, the intraperitoneal free air disappeared completely.
We concluded that abdominal CT scan should be employed for a patient without abdominal muscle guarding but with intraperitoneal free air by roentgenogram, and that hyper oxygen therapy should be the treatment of choise at first when the diagnosis is PCI.

View full abstract

We experienced a case of perforation of the sigmoid colon associated with chronic renal failure. A 66-year-old man who had been under hemodialysis was admitted to the hospital because of lower abdominal pain. Physical examination on admission showed tenderness, rebound tenderness and muscle guarding at the lower abdomen. Plain chest X-ray and abdominal CT showed intraperitoneal free air. Under the diagnosis of perforation peritonitis, an emergency laparotomy was carried out. During the laparotomy, a perforation, 4cm in size, was found at the sigmoid colon. Any tumor was not found at the sigmoid nor descending colon. A drainage of the peritoneal cavity and a sigmoidectomy were performed.
In a histological study, diverticulum was found at the perforated site of the sigmoid colon. The postoperative course was uneventful, and he was discharged on the 32nd postoperative day. In case of emergency operation on patients associated with chronic renal failure, intensive care on the perioperative management is indispensable. In this case, by means of CHDF (continuous hemodiafiltration), a stable cardio-circulatory status could be maintained. It is suggested that CHDF is effective in the perioperative management of the patient associated with chronic renal failure.

View full abstract

Gardner's syndrome is known to have many chances of developing neoplasm and total colectomy is generally employed for prophylactic purpose. This time we treated a patient with Gardner's syndrome by polypectomies and resections of cancer lesions for 17 years, without total colectomy. A patient with polyposis of the rectum and colon was diagnosed as having Gardner's syndrome in 1982. Nine early cancers had developed in the colon and rectum in this patient and he had been treated with three times of colectomy and seven times of polypectomy without prophylactic total colectomy for 17 years based on informed consent. Finally he was able to have 25cm length of colon and began to take sulindac as a chemoprevent agent. After the sulindac therapy for one year no polyps could be identified by colonoscopic examination.
In this report we would emphasize a possibility of colon conserving therapy by colonoscopic mucosal resection and colectomy for early cancer of Gardner's syndrome (familial adenomatous polyposis).
We have also demonstrated disappearance of colonic polyps after the sulindac therapy.

View full abstract

A 68-year-old man was admitted to the hospital because of right lower abdominal pain 3 months after a lobectomy for a lung cancer. Barium enema study revealed extrinsic filling defects in the ascending and transverse colon. Colonoscopy showed multiple submucosal tumor-like lesion with deep ulceration about 2cm in size in the hepatic flexure. With a diagnosis of metastatic colonic cancer from the lung cancer, a right colectomy was performed. Resected material revealed that the metastatic foci formed a tumor 7cm in size on the mesentery size centering the hepatic flexure with ulcer on the mucosa. The incidence of the metastasis to the colon from lung cancer is 2_??_4%. However, clinically confirmed colonic metastasis from lung cancer in extremely rare, and only 27 cases have been reported in Japan.

View full abstract

This paper deals with a case of abscess of the iliopsoas muscle an intractable external fistula of the rectum caused by adiation proctitis. In a 68-year-old man. There were previous histories of undergoing an A-C bypass operetion for coronary stricture 10 years before; and undergoing aportial resection of the bladder with radiation therapy for urinary bladder cancer, flowed by colostomy for hemorrage and stricture of the rectumu for rdiation froctitis 2 year before admission. In April, 1997 when he had been treated at outpatient clinic, exudmation of pusfrom the sacurred that was diagnosed external fistula of the rectum on a fistulography and he was continuously treated on an ambulant basis. On november 17, 1997, the patient had a temprature 38.7°C, the while blood cell count increased to 35×10⁴/ml, inflammation reactiom increased, and unconsiouzsness appeared. An emergency CT revealed retention of fluid in the retroperitoneum covering from the fistulation through the iliopsoas musucle to peivis. An abscess of the ileopsoas muscle was diagnosed. It was detrmined that any operations under general anesthesiawere impossible due to poor general condition, and an emergency incision drainage was perfomed under local anesthesia. There after, the patient developed MRSA septicemia which demanded redrainage and stric general management, but he was successfully freed from the management. Although the intractable fistula in persistently present, he was discharged after a resection of sequestrum and is followed on an ambulant basis.

View full abstract

Although a few cases of granulocyte colony-stimulating factor (G-CSF) producing tumor have been reported recently, hepatocellular carcinoma (HCC) that produces G-CSF remains a rarity. At the same time, HCC with a solitary mediastinal lymph node metastasis in seldom observed. This is a report of a valuable case of HCC in which both of these peculiarities co-existed. A 68-year-old man visited a physician with pyrexia and general fatigue, and was referred to the nospital with a diagnosis of hepatic tumor. The elevation of serum α-fetoprotein level and the results of various imaging studies ledus to the diagnosis of HCC. After admission, further evaluation was carried out to identify the cause for the high fever exceeding 38°C and leukocytosis, and serum G-CSF level was found to be overtly elevated, hence the diagnosis of G-CSF producing HCC. Following an extended left hepatolobectomy, the pyrexia became convalescent and leukocyte-count decreased until the 7th postoperative day, when the fever and leukocytosis resumed. Further imaging studies revealed acute enlargement of a solitary mediastinal lymph node, and it was eventually diagnosed as node metastasis. Which had not been detected preoperatively. There being no evidence of other metastatic lesions, re-operation was performed to resect the metastatic node. Once again, the patient recovered from pyrexia and leukocytosis postoperatively. Histological examination of the liver tumor revealed poorly differentiated HCC, and the mediastinal node was confirmed to have been the metastasis. Furthermore, the immunostaining using anti-G-CSF antibody was positive not only for the primary liver tumor, but also for the metastatic node. These findings confirmed that the HCC secreted G-CSF and elicited pyrexia and granulocytosis.

View full abstract

A rare case of cholecystolithiasis causing hepatic cholecystoduodenal fistula is presented.
A 61-year-old woman, who had been pointed out having cholecystolithiasis 3 years before but left it alone because it was asymptomatic, was seen at the hospital because of right hypochondralgia which was recently felt sometimes. No impaired liver function was revealed by laboratory tests, but a ultrasonography showed cholecystolithiasis and a dilatation of the intrahepatic bile duct. On ERC, the hepatic side bile duct including the confluence of three ducts did not visualized. PTC revealed an interruption of the hepatic duct at the porta hepatis and fistulization toward the duodenum was confirmed. Endoscopic examination disclosed that the fistula opened at oral side of the descending part of duodenum. With the diagnosis of hepatic cholecystoduodenal fistula due to cholecystolithiasis, a cholecystectomy and an excision of the bile duct associated with closure by suture of the duodenal fistula were performed on June 9, 1997.

View full abstract

We experienced a case of microcarcinoid of the gallbladder which was diagnosed by histological study after operation under a diagnosis of cholecysto-choledocholithiasis.
An 83-year-old man was seen at the hospital because of right hypochondralgia. Abdominal ultrasonography and CT scan revealed stones in the gallbladder and common bile duct, but no tumor was demonstrated. After a cholecystectomy, T-tube drainage was performed. Close exploration of the resected material revealed a tumor located in the neck of the gallbladder, measuring 4×2mm. The tumor was diagnosed histologically as classical carcinoid because the tumor cells were composed of small, round and uniform nuclei forming acinar structures, and no mitotic appearance was seen. Besides, the carcinoid tumor had positive reaction to Grimelius staining and immunohistologic Chromogranin A staining. He is doing well without any signs of recurrence 11 months after the cholecystectomy, choledocholithotomy and T tube drainage.
Carcinoid tumors of the gallbladder are very uncommon. There have been only 13 cases in the Japanese literature during the past five years. Among them, we could not find any case report except ours that the tumor was too diminutive to detect preoperatively. Accordingly, close examinations are needed not to overlook microcarcinoids in case of severe cholecystitis.

View full abstract

Emphysematous cholecystitis that is caused by gas-producing bacteria is a reratively rare entity in which the gallbladder or gallbladder wall contains gas. This paper presents a case emphysematous cholecystitis associated with pneumobilia and intraabdominal free air, together with a review of the literature. An 81-year-old man was admitted to the hospital because of appetite loss and abdominal fullness. Blood studies showed severe inflammation and jaundice without liver injury. There was no tenderness nor muscle gurding. Abdominal CT scan showed gas in the gallbladder, intrahepatic bile duct and right subphrenic space. With a diagnosis of acute emphysematous cholecystitis, an emergency operation was done because the patient was in a preseptic state and the wall of gallbladder was thin and weak. Histological examination of the gallbladder showed necrosis without cholecystlitiasis. Postoperative course was uneventfull, and the patient was discharged from the hospital 16 days after the operation.

View full abstract

Acute emphysematous cholecystitis is a serious disorder with high mortality and morbidity. We report a case of emphysematous cholecystitis with pneumobilia managed by laparoscopic cholecystectomy (LC) following percutaneous transhepatic gallbladder drainage (PTGBD).
A 63-year-old woman was admitted with a chief complaint of the right hypochondralgia and diagnosed as acute cholecystitis. Gall stones and thicking of the gall bladder wall was detected by ultrasonography (US). On the third day after admission, the presence of gas in the gall bladder and biliary tract was detected by US, plain abdominal X-ray and CT scan. The patient appeared clinically unwell, so PTGBD was carried out. Cholangiography after PTGBD showed a remarkable stenosis of the common bile duct. On the 6 th day after PTGBD, laparoscopic cholecystectomy was performed.
The postoperative course was good and the patient was discharged on the 14 th day after surgery.
We consider PTGBD and LC useful procedures for treating acute emphysematous cholecystitis.

View full abstract

It is important to diagnose the precise localization of the tumor because the first choice for the treatment of insulinoma is the surgical resection. We report a case of insulinoma that was diagnosed by selective calcium arterial stimulation and venous sampling and successfully resected. A 41-year-old woman was admitted to the hospital because of general fatigue. There were no characteristic findings for insulinoma on general and endocrinological examinations. Ultrasonography, CT, Magnetic resonance imaging and angiography revealed a tumor with the size of 1cm in diameter at the body of the pancreas. Selective calcium arterial stimulation and venous sampling disclosed a marked increase in insulin level near the splenic and great pancreatic arteries. We successfully operated on with the diagnosis of insulinoma in the body of the pancreas.
We were able to obtain accurate information about localization of the insulinoma by means of superselective arterial injection of calcium from the great pancreatic artery. It is suggested that further technical improvement would lead to more precise diagnosis of the localization.

View full abstract

We report a case of metastatic solid cystic tumor (SCT) of the pancreas to the liver eight years after operation. A 79-year-old woman was admitted to the hospital because of a right hypochondrial mass in 1997. There was a previous history of undergoing a distal pancreatectomy with splenectomy for SCT in 1989. Radiological findings revealed that a 6cm sized encapsulated tumor projected out of the lower edge of the liver, and that the tumor was composed of solid and cystic portions concomitantly with hemorrhage. With a diagnosis of hepatocellular carcinoma or liver metastasis of SCT, a partial hepatectomy was performed. Postoperative course was uneventful, and the definite diagnosis of liver metastasis of SCT was made by histopathological study. SCT of the pancreas is known to occur in young women, and usually to have favorable prognosis without metastasis and recurrence. However, some controversial problems have still remained. This paper presents a clinico-pathological features of 25 cases of SCT with liver metastasis where is the most common site for metastasis of SCT, including this case, reported in the Japanese literature so far.

View full abstract

A 50-year-old woman was admitted to the hospital because of a slight abdominal pain. Abdominal computed tomography and ultrasonography showed a solid mass 4-cm in diameter in the body of the pancreas with swollen lymph nodes around it. Endoscopic retrograde cholangiopancreatography disclosed a stenosis of the main pancreatic duct with a branch joining it. Angiography showed a slight compression of the splenic artery. With a suspicion of anaplastic carcinoma or malignant lymphoma of the pancreas, a distal pancreatectomy was performed. The resected tumor was solid and 4×4×3cm in size. The pathological and immunohistochemical studies indicated diffuse large cell type (B cell) non-Hodgkin's lymphoma. On the 28th postoperative day, abdominal computed tomography revealed swollen abdominal lymph nodes and metastases in the liver, and the patient was transferred to another hospital for chemotherapy.

View full abstract

A 78-year-old man was admitted to the hospital because of anal bleeding. CT scan showed a mixed density tumor at the body of the pancreas and varices around the tumor. Angiography (arterial phase) revealed the hypervascular tumor with irregular border. And co-lateral vessels developed around the tumor at venous phase. Endiscopic retrograde pancreatography was performed unsuccesfully. Leiomyosarcoma of the pancrease was suspected and a laparotomy was performed in Januuary 1997.
The tumor infiltrated into the multiple organs, including stomach, spleen, transeverse colon, left adreanal gland and capsule of left kidney, and extended to the main pancreatic duct. Thus a distal pancreatectomy and a resection of the invaded organs were performed. The main tumor was 9×8×3cm in size and the extending tumor to the duct was 4.5cm in length.
Histologically, the tumor was an islet cell tumor with evident trabecular and ribbon-like structures. The immunochemical stainings for chromogranin A, Glimerius, insulin, glucagon and somatostatin were negative, and hormonal concentrations measured in the operation were normal. Finally this tumor was diagnosed as non-functional islet cell carcinoma. No recurrence has been detected in a year and eight month since the operation.

View full abstract

A 46-year-old man underwent a resection of middle and lower lobes of the right lung with a diagnosi of right lung cancer. Histopathologic ally, it was adenosquamous call carcinoma (t 4 n 2: Stage IIIb). In March 1998 when 11 months had elapsed after the operation, CEA and CA 19-9 started to increase and a CT scan revealed a right adrenal tumor. Solitary adrenal metastasis of the lung cancer or primary adrenal tumor was suspected, and a right adrenalectomy was performed. At surgery, CEA and CA19-9 levels were as high as 50.4ng/ml and 1, 511U/ml, respectively. Histopathological diagnosis was adrenal metastasis of lung cancer. Elevated Cae and CA 19-9 levels rapidly decreased into the normal ranges after the right adrenalectomy. Half-lives of CEA and CA 19-9 calculated were about 5 days and about 4 days, respectivery.
We think that solitary metastasis of lung cancer to the adrenal gland should be activery resected, if the patient's general condition permits it.

View full abstract

Fournier's gangrene is a specific type of necrotic fascitis. It is a fulminating infection characterized by a rapid progress of necrosis of subcutaneous tissue covering from the lower abdomen to the scrotum. It is necessary to detect the disease as early as possible and to perform incision, drainage snd debridement completely and without hesitation. A 51-year-old man who had a past history of diabetes mellitus was seen at our hospital because of pain, swelling, and redness of the perianal area and perineum to the right upper leg. Computed tomography revealed a widespread low-density area, from the perianal lesion to the right thigh. Colonoscopic examination showed type 2 advanced cancer in the lower portion of the rectun. Debridement of necrosed tissue was performed. Leakage of contrast material from the rectum into the pelvic cavity was detected on fluoroscopic study after surgery, suggesting that penetration of the rectal cancer might have caused the disease in this patient.

View full abstract

An asymptomatic 38-year-old woman was admitted to the hospital because of liver tumors which were found at a medical check-up. On admission she had mild anemia. Physical examination indicated a hen egg sized abdominal mass in the left upper quadrant of the abdomen. Computed tomography showed three liver tumors and a soft tissue density tumor in the left upper abdominal cavity. A biopsied specimen of the liver tumors demonstrated hepatocellular carcinoma. Right hepatic lobectomy with total caudate lobectomy and partial resection of the left hepatic lobe where a tumor was found and partial resection of the small intestine including the mesenteric tumor were preformed. A pathological study revealed paraganglioma with liver and lymph node metastases. Postoperatively, examination of a preoperatively stored serum sample showed that serum level of catecholamines such as adranaline and noradranaline were within normal limits, whereas the serum dopamine level was elevated to 850pg/ml. The patient is well and has been free from recurrence two years after the surgery.

View full abstract

We report a 65-year-old man who developed sclerosing encapsulating peritonitis (SEP) 15 months after converting from continuous ambulatory peritoneal dialysis (CAPD) to hemodialysis because of intraabdominal hemorrhage following a traffic accident. In January 1999, he suffered acute abdominal pain and vomiting. He was referred to our hospital from a nearby clinic with suggested adhesional intestinal obstruction. Physical examination showed a palpable mass in the lower abdomen. He underwent an emergency operation with a diagnosis of strangulated intestinal obstruction. The laparotomy revealed a large amount of bloody ascites and dense fibrous adhesions that entrapped the small intestine in a thick membrane. We resected the loop of the ileum because separation of the bowel mass, simulating cocoon, seemed impossible. The diagnosis of SEP was made postoperatively. He was started on oral prednisolone therapy after the operation.
SEP is a rare and serious complications of CAPD, and develops even after CAPD has bees discontinued. The diagnosis of SEP should be kept in mind in CAPD patients presenting with recurrent adbominal pain or intestinal obstruction.

View full abstract

We encountered a case of intractable ascites that was treated by the filtration-concentration-IV reinfusion of ascites regimen 73 times in a period of 16 months.
A 61-year-old man was seen at the hospital because of abdominal distention, poor appetite, and general edema. Medical and alimentary therapies were started, but no symptomatic remission was obtained. So the filtration-concentration-IV reinfusion of ascites regimen was conducted. The volume of ascites in this case an average of 7, 627ml. In a review of the previous reports, an increase in the volume of ascites fluid prolonged the time requiring the regimen. The number of times the regimen was conductad in this case, was the most frequent among all cases in Japan. In this case, the urine volume remarkably increased and Ccr improved with the regimen. It is throught that an increase in abdominal pressure due to massive collection of ascites and a resultant decrease in renal blood flow might contribute to the long-term collection of ascites. Futhermore, the filtration-concentration-IV reinfusion of ascites regimen can cause severe complications in patients with hyperbilirybinemia, but in other patients, it appears to be an effective treatment of intractable ascites.

View full abstract

A 51-year-old man had bumped into the rear of a car when he was driving his car at a low speed wearing a seat belt. About one month later, the patient felt dull pain from the left hypochondrium to back, and he was admitted to the hospital because of gradual aggravation of the pain. Abdominal ultrasonography revealed hypoechoic tumors, about 6 cm and 2 cm in diameter, with homogenous center at the lower pole of the spleen and pancreatic tail, respectively. Endoscopic retrograde pancreatography (ERP) revealed a retention of contrast mediun with the diameter of about 2 cm in the pancreatic tail. With further CT scan and magnetic resonance imaging, splenic and pancreatic cysts were diagnosed. Resection of the pancreatic tail and a splenectomy were performed. Histopathologically, both splenic and pancreatic cysts were pseudocyst with deposits of hemosiderin, indicating hemorrhage. It is thought that trauma plays an important role in etiology of pseudocysts. In this case, it is inferred that compression due to the seat belt at the bumping might cause the disease. Care must be exercised for the possibility in observation of clinical course of the patient even after slight accident.

View full abstract

We have experienced a rare case of solitary brain and solitary lung metastases occurred 13 years after our operation that resulted in curative resection for a stage I lung cancer (adenocarcinona). A 74-year-old woman was admitted to the hospital because of attacks of unconsciousness and convulsions. Thirteen years prior to this admission, she had undergone a right lower lobectomy due to adenocarcinoma. T1N0M0, stage IA. A solitary brain tumor shadow was detected on a brain CT and brain MRI. and a solitary lung nodular shadow was showed in the right lung field on a chest CT. Both brain and lung tumors were resected and both were diagnosed histologically as metastasis of the lung cancer. Immunohistochemical expression of PCNA and sialyl-Lewis X antigen (sLex) were examined for three operative specimens that were primary lung cancer, brain metasitasis, and lung metastasis. For all three specimens, the expressions of both PCNA and sLex were highly positive. The patient with lung cancer that is highly expressive of PCNA and sLex would require a long-term follow up after operation for the primary lesion.

View full abstract