We retrospectively made a clinicopathological study on 128 breast cancer patients with tumor 2cm and smaller who were received more than axillary lymph node dissection during recent two decades in our hospital. The results were as follows: 1) Comparative analysis between recurrent nine patients and not-recurrent 13 patients who had node positive breast cancer tumor 2cm and smaller showed that the former had more frequency than the latter of scirrhous cancer, lowgrade histologic differentation, fatty invasion, positive vascular invasion and lymph node metastases. 2) Metastasizing rate to lymph nodes of T1 breast cancers was sig-nigficantly higher tumors more than 16mm in diameter than those less than 15mm (p<0.05). 3) Recurrent TO·Tl-breast cancer patients had more than four lymph node metastases in tumors less than 15mm, and the patients with one lymph node metantasis had recurrence in tumors more than 16mm. We conclude that tumor size and lymph node metastasis are especially significant an the prognostic factors in TO·Tl-breast cancers and we must perform postoperative adjuvant therapy to the patients with breast tumor less than 15mm and more than four lymph node metastases, tumor more than 16mm and positive lymph node metastasis.

View full abstract

This study is to define the risk factors of leakage of esophagojejunoanastomosis after total gastrectomy and to prevent and to cope with it. Subjects were 161 patients with gastric cancer undergoing a total gastrectomy. These patients were classified into leakage group (+), and no leakage group (-). Relationship were determined between leakage and pre and intraoperative factors and postoperative clinical findings. We could find out the new index for leakage, (D=7.27038-1.61155×Albumin (Alb)-0.00051×total lymphocyte count (TLC), above 0.04982=high risk group. p<0.05). In the leakage group, each four of nine patients had a previous history of long term use of steroid, liver chirrosis, or progressive cancer. Mean postoperative duration of SIRS was significantly prolonged in (+) group that was 4.60±2.37 days compared with (-) groupthat was 2.05±2.12 days. These facts mean that preoperative and early postoperative enteral nutrition is needed for patients with liver chirrosis, receiving steroid for a long time multiple liver metastasis and peritoneal dissemination and showing with high score of D (above 0.04982). In the patients whose postoperative state of SIRS lasts over 4 days, a potential risk for leakage of the anastomosis or other complications can be the thought.

View full abstract

We carried out an analysis of para-aortic lymph node dissection in stage IIIVa advanced gastric cancer to evaluate the extended surgery. The subjects were 32 patients undergoing para-aortic lymph node dissection (D₄), and 77 patients undergoing Group 2 and 3 lymph node dissection (D_{2, 3}) which were conducted at the department from 1988 to 1995. No patients with double cancer, liver metastasis, and peritoneal dissemination were involved in the subjects. In case of stage IIIIIb advanced gastric cancer, the 5-year survival rate of patients with D₄ (79.5%) was significantly higher than that of patients with D_{2, 3} (p<0.05). But, as to the prognosis in cases of stage IVa gastric cancer, no statistical differences were found between D₄ and D_{2, 3}. Even in cases of stage IIIIIb advanced gastric cancer with n_{1, 2} involvement, the 5-year survival rate of patients with D₄ was significantly higher than that of patients with D_{2, 3} (p<0.05). These results suggest that D₄ dissection is indicated for stage IIIIIb advanced gastric cancer with n₂ involvement.

View full abstract

Twenty-six cases of gastrointestinal advanced cancer (11 gastric, two intestinal and 13 colonic cancers) were examined for serosal invasion by spraying with a 0.1% methylene blue dye under magnifying microscope or laparoscope. Methylene blue staining showed fine structures of serosal surface and small areas of nodular blue staining were observed in some cases. After marking these areas with permapent ink under microscope, they revealed cancer invasion to the serosa in the histological cross sections. Judging from the staining, nine cancers were invading and 15 were not invading the serosa. These results obtained in these cases were in agreement with those of histological diagnosis except two cases. In about half cases of this series, serosal invasion could be hardly diagnosed macroscopically. Identification of serosal invasion with methylene blue dye is a very easy and rapid technique with a higher sensitivity and specificity than the surgeon's clinical diagnosis. More precise diagnosis with this technique could contribute to the decision-making of intra and post-operative adjuvant treatments.

View full abstract

Intrahepatic advance pattern of solitary metastatic liver tumor from colorectal cancer was considered on the basis of the classification according to pre- and intra-operative information in a series of 33 resected cases at the hospital. Small nodule; less than 3cm in tumor diameter, large nodule; more than 3cm, and proliferat-ing nodule; macroscopic existence of marginal proliferating form were defined, and the tumors were classi-fied into the following three types. 1) Small nodular type (S): both 3- and 5-year survival rates were 38%. Remnant liver recurrence was so high in the synchronously metastasized patients, whereas good prognosis in the metachronously metastasized patients. 2) Large nodular type (L): 3- and 5-year survival rates were 66 %and 54% respectively, and no prognostic difference about the distinction of metastasized period was seen. Mean diameter of the tumors specimen was 4.2±1.7cm (mean±S.D.). 3) Proliferating large nodular type (PL): the prognosis was as extremely poor as 1- and 2-year survivals were 33% and 0% respectively. The diameter of the tumor was 9.2±3.5cm, thus PL was considered as the clinically advanced type of L. We believe, that the intrahepatic advance pattern of solitary metastatic liver tumor from colorectal cancer can be pre-dicted pre- and intraoperatively by our classification, and the prediction is properly useful to the therapeutic planning.

View full abstract

In September 1992, the first laparoscopic cholecystectomy (LC) was performed at the Municipal hospital of Nomura in a mountainous district of Ehime-Prefecture, Japan.
Thereafter, 82 cases of cholelithiasis or cholecystitis among a total of 320 cases undergone operation under general anesthesia in a recent 9 years were subjected to a study of surgical methods, and the following conclusions were drawn;
1. In our hospital in mountainous districts, LC has been standardized and increasing recently as a surgical procedure for cholelithiasis and cholecystitis.
And also since 1994, LC has been performed in all of elective cases and in cases after drainage for acute cholecystitis, meaning that LC has now become a standardized surgical method for cholelithiasis and cholecystitis.
2. In hospitals like ours located in mountainous districts, acute cholecystitis often occurs in elderly and poor-risk patients. We think that, for such patients with acute cholecystitis, LC following drainages including PTGBD and PTGBA is preferred rather than take a risk of laparotomy.

View full abstract

Forty-three resected materials of invasive ductal adenocarcinoma of the pancreas were examined for the expression of p 53 protein and the cell proliferating activity in comparison with the clinicopathological factors and prognosis. Anti-p 53 antibody (DO-7) and anti-Ki-67 antibody (MIB-1) were used as the primary antibody. Although a univariate analysis revealed significant variants including pancreatic cut end (pw). and p 53 protein expression (p<0.05), none of these were independent prognostic indicator according to a multivariate analysis. With regard to the clinicopatholigical factors, p 53 protein expression was significantly associated with tumor size (ts), arterial invasion (a), venous invasion (v), intrapancreatic nerve invasion (ne), lymph node metastasis, invasion to the dissected pancreatic tissue (ew), and pw (p<0.05). Furthermore, p 53 expression was correlated with the cell proliferating activity (p=0.039). With regard to the recurrent pattern, p 53 protein expression was associated with the recurrence as hepatic metastasis (p=0.041). As a result, while the significance of p 53 protein expression was not important as a prognostic indicator, the involvement of p53 protein expression with the local progression, proliferating activity, and hepatic metastasis was suggested in invasive ductal adenocarcinoma of the pancreas.

View full abstract

The prognosis of undifferentiated thyroid cancer is extremely poor, and usual postoperative adjuvant therapies including chemotherapy and radiotherapy are almost ineffective. We have given anticancer drugs to such a patient according to the results of chemosensitivity test (SDI method) using highly purified (90%) tumor cells. A 73-year-old woman was admitted to the hospital because of a tumor on the right side of the neck. With a diagnosis of undifferentiated thyroid cancer based on a biopsy, a complete thyroidectomy and lymph nodes dissection were performed. Further extensive surgery was employed for a recurrence. From the excised material, tumor cells were purified up to 90%, for which SDI method was conducted. CDDP and ADM showed higher inhibition rates than other chemotherapeutics. Therefore, intravenous administration of 60mg/m² of CDDP on the day 1 followed by 40mg/m² of ADM on the day 4 was designated as one course; and four courses a month were given to the patient for three months. The patient survived for 11 months af-ter the initial operation.
It is suggested that appropriate chemotherapeutics selected according to the results of chemosensitivity testing may contribute to improve the prognosis of patients with undifferentiated thyroid cancer.

View full abstract

Fibroadenoma is a common benign tumor of the breast and demands to be differentiated from breast cancer. Most fibroadenomas can be diagnosed by palpation and image procedure, and are often observed the clinical course without resection. Through it is very rare, cases of breast cancer in fibroadenoma have been reported in the world. This paper deals with our experience with a case of minute breast cancer arisen in a fibroadenoma that is the 20th case report in Japan, together with a review of the literature. A 43-year-old woman underwent a biopsy for a breast tumor. Preoperative diagnosis was fibroadenoma. At operation the tumor was found to be fibroadenoma except a small part that was invasive ductal carcinoma.

View full abstract

A case of breast cancer associated with von Recklinghausen's disease is reported. A 43-year-old woman was seen at the hospital because of a right breast mass 5.0×4.0cm in size and back pain. Fine needle aspiration cytology offered a diagnosis of breast cancer. Bone scintigraphy revealed multiple bone metastases and computed tomography of the head showed brain metastases. The patient underwent a right muscle preserving mastectomy (Br+Ax, Kodama method) with systemic chemotherapy. Histologically, the tumor was solidtubular carcinoma with axillary lymph nodes metastases.
Von Recklinghausen's disease is often associated with neurogenic malignant tumors. However, its correlations with epithelial malignant tumors have not been clarified. To our knowledge, only 31 cases of breast cancer with von Recklinghausen's disease have been reported in the Japanese literature. In such cases, the detection of breast cancer is prone to be delayed both subjectively and objectively because it is skin tumor in nature. Care must be taken not to overlook mistake breast cancer, especially for skin tumor which is felt on surface in case of von Recklinghausen's disease.

View full abstract

A 53-year-old woman underwent an extended radical mastectomy for left breast cancer in March, 1992 which was t3n0m0 and in Stage II. She was admitted to the hospital because of a chest wall recurrence of the breast cancer in March, 1995. And a part of the left upper chest wall was resected, including the 1st and 2nd ribs and sternum. The defect was repaired with a left latissimus dorsi musculocutaneous flap. She was readmitted to the hospital because of chest wall rerecurrence of the breast cancer in April, 1997. In July of the year, more part of the left lower chest wall including the 4th, 5th, 6th and 7th ribs and sternum was resected. The left chest wall was reconstructed with the double sheets of Dexon mesh^R and rectus abdominis muscle flap. After the operation, the respiratory function has been kept in normal range.

View full abstract

A 76-year-old woman, she had undergone a Halsted's radical mastectomy for a left breast cancer 26 years before, was admitted to the hospital beause an anterior chest mass was found. It was proved to be sternal tumor by imaging methods. Incisional biopsy was performed and pathological examination revealed adenocarcinoma. Histology of the tumor was similar to that of breast carcinoma. The patient had gastric cancer simultaneously. A distal subtotal gastrectomy was performed for the gastric cancer, and radiation therapy was performed for the sternal metastatic tumor. Chemotherapy and endocrine therapy were given for the sternal metastatic tumor. She has been disease free for five years after completion of the radiotherapy with continuous endocrine therapy.

View full abstract

A 54-year-old man was seen at the hospital in December 1995, because he had noticed a left precordial tumor in August 1995. There was a previous history of undergoing a left pectoral muscle -preserving mastectomy (Bt+Ax) for a left breast cancer (T1N0M0, stage I) at another hospital on September 30, 1987. This time the patient had no distant metastasis nor mediastinal invasion and was diagnosed as having local recur-rence to the chest wall. On January 30, 1996, a resection of the chest wall with reconstruction was performed that resulted in curative resection. The resected material revealed the same mucinous carcinoma as the primary lesion and positive responses to both estrogen and progesterone receptors. Adjuvant chemotherapy and hormonal therapy were added. There have been no signs of recurrence 3 years since operation.
We have gained a favorable result by performing a resection of the chest wall for solitary nodule type local recurrence to the chest wall in a male patient after an 8-year disease free period following the initial operation. In male breast cancers, aggressive surgery for chest wall recurrence appears to promise better prognosis like in female breast cancers, if there are no distant metastasis nor mediastinal invasion.

View full abstract

We report herein a rare case of desmoid tumor of the chest wall in a 39-year-old woman. She was admitted to the hospital beacause of an abnormal shadow on a chest X-ray film. Chest CT and MRI revealed the soft tissue of the chest wall at the left apical portion. She underwent a surgical resection of the tumor through thoracotomy with video-assisted thoracoscopy. The tumor arose from 1st intercostal muscle, and was resected combined with the 1st rib. The tumor was 4×3×2cm in size. Histological examination revealed findings of desmoid type of fibromatosis. A local recurrence of the tumor without any symptoms was found 17 months after the surgical resection. Radiotherapy was administered at a dose of 50 Gy to the recurrent desmoid tumor that resulted in no more growth of the tumor in size so far. The patient is followed on an ambulant basis.

View full abstract

A 63-year-old woman was admitted to the hospital because of presenting with cough, feeling of heaviness in the chest, and dyspnea. She had a past history of undergoing a left pulmonary upper lobectomy for lung cancer 1 year and 2 months previously. Chest roentgenography showed left pleural effusion. Chest computed tomography (CT) showed the mediastinal shift to the right and the abnormal mass in left thorax. The old bloody pleural effusion was aspirated and its examination revealed that Hb was 4.0g/dl. The pleural effusion was aseptic and cytodiagnosis was class I. She underwent surgery by left thoracotomy and about 2, 000ml old blood was discharged. The bleeding point was not exactly revealed. Pathologically, the pleural biopsy showed that it had collagenous tissue with deposits of hemosiderin and many clusters of iron-laden macrophages. Eleven months after the operation, chest roentgenography and chest CT revealed no abnormal findings and dyspea was diminished. Expanding hematoma rarely occurs in patients with previous history of undergoing thoracotomy or artifitial pneumothorax. It is inferred that the disease often proceeded to chronic or organic pyothorax, if it is left in place for longtime. This case whitch was quickly treated resulting from manifestation of symptoms in a subacute phase of the disease is reported.

View full abstract

There are not few opportunities to insert the chest tube for hemopneumothorax at our daily procedure. The probables of hemopneumothorax include blunt thoracic trauma, spontaneous hemopneumothorax, and pleuritis. Anyway we are necessary to drip infusion, inhale oxygen, and insert a chest tube for hemopnemot-horax.
The aims of the drainage are: to improve pulmonary circulation by reducing intrapulmonary pressure; to improve hypoxia by increasing pulmonary compliance and decreasing pulmonary shunt; and to make monitering system for air leak and intrathoracic bleeding. On the other hand, chest tube drainage has compli-cations such as hemorrhage due to injuries of posterior intercostal and internal thoracic artery, and pulmonary edema. We have recently operated on two patients with spontaneous hemopneumothorax who went into shock immediately after chest tube drainage. This paper presents pithalls of the drainage for spontaneous he-mopneumothorax, together with a review of the literature.

View full abstract

The risk of developing malignancies is high in a recipient of renal transplantation due to administration of immunosuppressants for a long time. In these malignancies, lung cancer had been rarely reported.
We reported a resected case of squamous cell carcinoma of the lung detected 6 years after a living-related kidney transplantation in a 58-year-old woman. The patient who had been managed by hemodialysis for chronic renal failure due to gestosis for 9 years received a living-related renal transplantation from her sister as a donor in April, 1990. Thereafter, she had been treated by oral administration of azathiopurine and ciclosporin for 6 years. She was pointed out an abnormal shadow on a chest X-ray film and was diagnosed as having a lung cancer in December, 1996. A left upper lobectomy with mediastinal lymph node dissection was performed. The pathological diagnosis was squamous cell carcinoma with p-T2 N2 MO stage IIIA. The postoperative course was uneventful and she was discharged from the hospital on 20th postoperative day.

View full abstract

A 64-year-old woman was admitted to the hospital because of a large asymptomatic tumor of the anterior chest wall which was slowly growing up for 5 years. The tumor was occuping an upper half of the sternum and was about 9×7cm in diameter with palsation. Preoperative suspicious diagnosis of neuro-endocrine cell tumor was obtained by excisional biopsy of the cervical lymph node. En bloc resection of the tumor including both anterior portion of the clavicles and bilateral heads of 1, 2 ribs was carried out. A difect in the chest wall which measured 12×9cm was simply closured by single skin and muscle flap sutured without any prosthesis. Pathological examination of the tumor revealed “metastatic tumor from the thyroid carcinoma”, and then a total thyroidectomy with modified radical neck dissection was performed.

View full abstract

Esophageal cyst is a rare congenital cystic disease that usually occurs in the posterior mediastinum. Recently we experienced a case of esophageal cyst which was removed under thoracoscopic surgery. A 36-year-old man was admitted to our hospital because of an abnormal electrocardiogram, and pointed out an abnormal shadow on his chest roentgenogram. Chest CT showed a 4.8×3.2cm oval-shaped tumor in the left posterior mediastinum. Magnetic resonance imaging of the chest revealed that the tumor had iso signal intensity on T1-weighted image and had low to iso signal intensity on T2-weighted image. We surgically removed the tumor with suspicion of neurogenic tumor. The tumor was 6.0×4.0×3.5cm in size with smooth surface. The tumor had 0.5-2.0mm thick wall and structure of unilocular cyst. The content of the tumor was brown dreg-like. Pathologically, the tumor was diagnosed as an esophageal cyst lined by squamous epithelium ovelying double smooth muscle layers.

View full abstract

We report a rare case of gastric stromal tumor causing hemoperitoneum.
A 60-year-old woman was admitted to the hospital because of genital bleeding. No gynecological disease was pointed out. A tumor about 10cm in diameter was found at patient's left hypochondriac region by an abdominal ultrasonography. Extra gastric submucosal tumor was diagnosed, and an extirpation of the tumor was performed. Microscopic diagnosis was leiomyosarcoma of the stomach. Immunohistochemically, the tumor showed negative responses for α-SMA (smooth muscle actin) and desmin (both are markers of muscular origin), slightly positive responses for S-100 and NSE (neuron specific enolase) (both are markers of neurogenic origin), and strongly positive responses for CD 34 (marker of non epithelioid region). Then, the definite diagnosis was gastric stromal tumor.
We consider the mechanisms of hemoperitoneum from this stromal tumor, arising as genital bleeding, and resulted in death due to peritoneal dissemination.

View full abstract

We report a case of early ampullary carcinoma in an 81-year-old female surgically treated by local excision. Distal gastrectomy and diabetes melitus were revealed in her past history. Ampullary carcinoma was detected during treatment for acute cholecystitis complicated by liver abscess and formation of fistula between the gallbladder and jejunum. Local excion of ampulla Vater was done because it seemed too risky to perform pancreatoduodenectomy. The resected specimen was 1.7cm, polypoid-type tumor.
Histopathologically, it was diagnosed as well-differentiated tubular adenocarcinoma limited to the mucosa. The postoperative clinical course was good, and there has been no recurrence to date 16 months after the operation. Among the 25 cases of locally resected ampullary carcinoma reported in Japan, there were no recurrences or mortality in the 13 cases of early ampullary carcinoma (mean observation period: 17 months), in which the carcinoma remains within the sphincter of Oddi muscle. Among the 9 advanced cases, 6 patients died of the cancer (mean survival time: 25 months). Local resection of the ampulla should be considered the procedure of choice for the patients of ampullary adenoma or early ampullary carcinoma with severe concomitant disease.

View full abstract

A case of retrograde intussusception into Braun's anastomosis is reported.
A 59-year-old man was admitted to the hospital because of sudden epigastric pain, distention and hematemesis. He had a previous history of undergoing a distal gastrectomy with gastrojejunostomy and Braun's anastomosis for gastric ulcer 37 years before admission.
There were distention and tenderness in the upper abdomen. With a diagnosis of intussusception based on an abdominal CT scan, an emergency operation was performed. Upon laparotomy, the jejunum retrogradely invaginated into the Braun's anastomosis. A resection of the jejunum including the Braun's anastomosis was carried out. The postoperative course was uneventful, and the patient was discharged from the hospital 16 days after the operation.
Anastomotic intussusception after gastrectomy is a rare postoperative complication, especially that into Braun's anastomosis. Most intersussuseptions occur within one month after operation, but some like in this case occur suddenly after elapsing for more than 10 years. Diagnostic endoscopy, upper GI series, abdominal CT and ultrasonography are useful, and in this case, abdominal CT that revealed layer structure and target sign in the extremely dilated intestine was very valuable.

View full abstract

An 83-year-old woman was referred to the hospital because of abdominal pain and vomiting. She had undergone a gastrectomy for gastric ulcer at the age of 42 years, and had been admitted to our hospital for ileus, iron deficiencyt anemia and hypoproteinemia at the age of 79 years. The time she was admitted with a diagnosis of ileus, and a long tube was inserted for decompression of the intestine. On the second hospital day, she complained of severe abdominal pain and an abdominal X-ray film revealed free air. Under a diagnosis of pan-peritonitis, an emergency operation was performed. Little adhesion and dirty ascites were seen in the peritoneal cavity. There was a perforation in the saccular dilated ileum, and there was neither adhesion nor strangulation around the perforated intestine. Resection of the saccular dilated ileum, with end to end anastomosis was performed. The dilated part of the resected specimen was filled with foods, and multiple irregular shaped shallow ulcers with a perforation were seen on its mucosa. The histological diagnosis was chronic hemorrhagic multiple ulcers of the small intestine. We present the case of the disease which can cause obtruction or perforation of the small intestine, though it is rare.

View full abstract

A case of adult intussusception by a leiomyosarcoma of the small intestine diagnosed by angiography is reported.
An 85-year-old woman was seen at the hospital because of nausea and vomiting. She was followed without treatment until she was seen at the hospital again because of repeated nausea and vomiting. Among graphic examinations, angiography was the only one that led to a diagnosis of intussusception of the jejunum induced by a tumor. It demonstrated branches of the vaso recti of the proximal jejunum underneath of the distal jejunum and the tumor staining peripheral to these. Partial resection of the jejunum including the tumor was performed. Macroscopic findings revealed that a submucosal tumor measured 3.0×3.0×1.5cm in size and ulceration at its center measuring 1.3×1.0cm in size.
Histologically it was a leiomyosarcoma. Malignant tumor of the small intestine causing intussusception in adults is a rare pathology, and its preoperative diagnosis often fails. Our experience suggests that angiography is the most useful diagnostic tool not only for tumor of the small intestine but also for intussusception in adults.

View full abstract

We report a case of Burkitt like lymphoma of the small intestine. A 69-year-old man was admitted to the hospital because of intesinal obstraction. During operation, intussusception with a 7×5.5×4cm tumor in the lead was found in the ileum 160cm oral side from the Bauhin valve. Partial resection of the small intestine in-cluding the intussusception was carried out. The tumor was diagnosed as Burkitt like lymphoma by histopa-thological findings. Postoperative chemotherapy was not added. Three months later, recurrence was recog-nized in the mesentery and chemotherapy was started.

View full abstract

Leiomyosarcoma of the small intestine is an extremely rare entity. We hardly encounter such acase and subsequently apt to fail in performing appropriate treatment that must be done by keeping the disease in mind. This time we experienced by patient with small bowel leiomyosarcoma which was discovered by anal bleeding befor adomission to the hospital for early gastric cancer.
A 47-years-old man visited another hospital because of epigastric pain on a fasting stomach which started in early May, 1997, and was referred to the hospital because two lesions in the stomach, a type IIc and a type IIc+IIa at the angular notch, were revealed on upper gastrointestinal series. Anal bleeding occurred during a standby period. On admission, amovable and infant's fist-size abdominal tumor was palpated. CT and echography revealed an association of leiomyosarcoma of the small intestine which was found to be the bleeding site. A distal gastrectomy with associated resection of the small intestine was performed. There have been no signs of recurrence as of one year after the operation and the patient is followed on an ambulant basis. It is important to investigate whole body examination if the patient fad a known sickness.

View full abstract

We experienced a case of ileosigmoid knot following a gastrectomy. A 69-year-old man was seen at the hospital because of severe abdominal pain when he was already associated with severe peritoneal signs. There was a previous history of undergoing a gast rectomy for a gastric cancer. Abdominal Xp on left side decubitus revealed air fluid level formation in the duodenum and sigmoid colon. Abdominal CT scan showed a dilated sigmoid colon. Since the abdominal pain was so severe, an emergency operation was performed with a diagnosis of ileus combined intestinal necrosis. The small intestine involving about 1m became red in color and edematous. The small intestine was strangulated by the sigmod colon like it was wrapped due to counterclockwise volvulus of the sigmoid colon. When the colon was turned clockwise, the strangulation was relieved and then the circulation to the sigmoid colon and small in testine was restored. Both the colon and intestine were not resected. The clinical course was uneventful and the patient was discharged from the hospital on 21 st hospital day. Mechanisms of onset of ileosigmoid knot in clude an ingestion of large volume of foods in an empty stomach. In gast rectomized patients, the food retension ability of the stomach decreased and a large volume of food is liable to flow in the intestine at once that might cause the disease in this case.

View full abstract

A case of Crohn's disease with an ileovesical fistula is reported. The patient was a 44-year-old man. He had undergone a fistula-in-ani operation, and Crohn's disease was diagnosed in 1980. He had complained of “fecaluria”, and had medical therapy since 1992. Five years later, he was admitted to the hospital because of high fever and back pain. Urinalysis revealed numerous leucocytes and Enterococcus was identified by urine culture. Barium enema showed ileo-colonic fistula and stenosis. Hydronephrosis and right ureter stenosis were revealed by nephrography. CT showed a bubble in the bladder.
He underwent an operation, including right-hemicolectomy and ileo-vesical fistula resection. Postoperative course was satisfactory. He is followed in our outpatient clinic without recurrence of fistula. The authors consider that entero-vesical fistula due to Crohn's disease requires surgical treatment, because it is difficult to be cured by only medical therapy in 94 cases seen in the Japanese literature. The importance is the time when surgical treatment should be performed for the patient's QOL.

View full abstract

Mucinous cystadenoma of the appendix is a relatively rare disease. We report a case of mucinous cystadenoma of the appendix accompanied by high level of CEA in serum in an aged patient, together with a review of the literature.
An 82-year-old woman, who had a past history of undergoing a gastrectomy for stomach cancer 10 years before admission, was referred to the hospital for surgical treatment because of high level of CEA in serum and a right lower quadrant mass of the abdomen. CT scan showed an egg sized tumor between the cecum and uterus. Ultrasonogram showed an unechoic cystic tumor. Operation was performed with a suspicion of ovarian cyst or Krukenberg's tumor. During surgery, it was found that the tumor derived from the appendix and an ileo-cecal resection was carried out because a possible malignancy could not be ruled out. Pathologically it was diagnosed as mucinous cystadenoma of the appendix. The CEA level in serum immediately decreased to normal level after the operation.
Ultrasonogrphic findings such as cystic tumor in the right lower quadrant of the abdomen are specific for this disease.

View full abstract

Nonclostridial gas gangrene, the etiology is obscure, is often accompanied by a malignancy in an immunosuppressed patient.
A 71-year-old woman was reffered to our hospital with the symptom of a swelling and a painful dermatitis on the right lower abdomen to the lumber tlunk associated with redness, vesicles and necrosis. A Plain reontgenogram and a computed tomogram revealed gases in the subcutaneous tissue and muscularis, and the debridment was carried out under the tentative diagnosis of the gas gangrene. The bacterial culture revealed the diagosis of a nonclostridial gas gangrene. Then the antimicrobial treatment and the hyper oxygen therapy were done on the patient. Subsequent skin transplantation failed followed by parietoretroperitoneal fistula. Total colonoscopic examination showed no malignancy. As the fistula was resistant to the treatment, laparotomy was performed. At operation, an appendiceal carcinoma with penetraring to retroperitoneum was identified.
Nonclostridial gas gangrene of unknown etiology is often accompanied by some malignancy, especially colonic carcinoma, in immunosuppressed patients. The nonclostridial gas gangrene with Appendiceal carcinomma is rare, and we reported this case with a review of the literature.

View full abstract

A 46-year-old man was admitted to the hospital because of abdominal distention, upper abdominal pain, and fever. There were previous histories of undergoing operations twice for intestinal obstruction, though details were lacked. Preoperative abdominal x-ray film, CT scan, and barium enema study revealed megacolon covering from the transverse to descending colon, and a tumorous shadow in the colonic mesentery at its oral side. A laparotomy was performed, when remarkable dilatation covering from the transverse to descending colon was seen and deep ulcer lesion was palpated at the hepatic flexure of the transverse colon. A partial resection of the colon including the ulcer was performed. On histopathological study of the resected material, the ulcer revealed findings of non-specific ulcer. It was concluded that the ulcer in this case was simple ulcer originated in the vicinity of megacolon due to some unknown mechanisms. The patient was discharged without any serious problems after the operation, and is followed on an ambulant basis.
The etiology of simple ulcer has been still controversial. And there has been no another case of simple ulcer associated with megacolon other than our case as far as we could review. This uncommon case together with some bibliographical comments is presented.

View full abstract

This paper deals with a case of signet ring cell carcinoma of the large intestine recurred 6 years after operation in a 53-year-old man. The patient had been undergone a right hemicolectomy for signet ring cell carcinoma of the ascending colon, which had been detected by close examination for ileus symptoms in March 1992. Thereafter the patient had been asymptomatic for about 6 years after postoperative chemotherapy with CDDP and UFT, until jaundice occurred in October 1998. With close examinations, a signet ring cell carcinoma in the vicinity of the hepatoduodenal ligament was demonstrated that was diagnosed as local recurrence of the signet ring cell carcinoma of the ascending colon. We judged that any radical operations were impossible, and employed a relief of obstructive jaundice by internal fistulization and chemotherapy, with a good quality of life for the patient.

View full abstract

An 81-year-old man was seen at the hospital because of abdominal distention and severe constipation. An elastic hard tumor was palpable by the digital examination and it was downward with an increase in abdominal muscular pressure. Barium enema showed an intussusception of the sigmoid colon and made it release successfully. Total colonoscopy showed two tumors (Ip, Is) in the rectum, two (type 2, Ip) in the sigmoid colon, one (Ip) in the descending colon, one (Is) in the transverse colon and two (Ip, Is) in the ascending colon. Three of them were diagnosed as adenocarcinoma in their biopsy specimen. We performed low anterior resections for them and local resection for the other tumors under colonoscopy during operation. Pathohistological examination revealed adenocarcinamas in four lesions, with different depth of invasion each other (m, sm. mp, and ss). Other lesions were tubular or tubulo-villous adenoma with cellular atypia ranging from moderate to prominent.
It has recently been reported that the hereditary factor seems to be involved in the etiology of multiple colorectal cancer. It is important to interview the patient about their family history and several gene analysis would be required for the patient with risk factors. In the case of multiple colorectal cancers, it is sometimes difficult to decide the extent of colectomy; partial or total colectomy in the number of lesions. Intraoperative colonoscopy is convenient and supportive technique in determining more adequate partial colectomy in the patients with low number of lesions.

View full abstract

A case of heterochronous triple cancer with multiple colon cancer in an 80-year-old woman is described. She underwent a right hemicolectomy and a right hepatic lobectomy for cancer of the ascending colon and liver metastasis in 1985 when she was 68 years old. Subsequently, she was operated on for right breast cancer, descending colon cancer, transverse colon cancer and gastric cancer in 1987, 1989, 1994 and 1997, respectively. Moreover her mother, brother and sister had rectal cancer. Additionally her son had brain tumor and gastric cancer. Therefore we diagnose this family as hereditary non-polyposis colorectal cancer (HNPCC) group.

View full abstract

A 60-year-old woman, who was followed in the outpatient clinic after a sigmoidectomy for advanced cancer of the sigmoid colon on November 19, 1992, was admitted to the hospital because of metachronous solitay metastasis in the spleen. She underwent a splenectomy on June 12, 1994. After the operation she had been administered anticancer drug perosly on an ambulant basis. But she died of live failure due to multiple liver metastasis 15 months after the reoperation. Splenic metastasis from colorectal cancer is extremely rare. It is believed that metachronous solitary splenic metastasis, that is seen only in the spleen with lapse of over a year after the first procedure, may have a good prognosis. However, there are some cases with poor prognosis, like our case. Although the splenectomy must be an effective therapy for them. it is important to detect splenic metastasis as soon as possible for improving the prognosis. And we must be careful not only for local recurrence, liver metastasis, and lung metastasis but also for possible splenic metastasis after operation for colorectal cancer.

View full abstract

Human T-cell lymphotropic virus type I (HTLV-1)-associated myelopathy (HAM) is considered as autoimmune disease secondary to HTLV-I virus infection. We experienced a patient with HAM who was diagnosed as having stercoral ulcer due to anal bleeding by barium enema and colonoscopy. and was cured by conservative therapy. The patient was 66-year-old woman who had been suffering from HAM since 58 years of age, and was under treatment for chronic progressive spastic paraparesis, neurogenic bladder and constipation. She noticed dark red melena at evacuation in January, 1997, and was seen at the hospital. Colonoscopy and barium enema revealed a large and deep ulcerative lesion about 3cm in diameter at the left side of the upper rectum. The patient was successfully treated with conservative therapy. As this large ulcerative lesion was healed with scar after two months, this lesion was thought to be stercoral ulcer with the penetration into the mesorectum.

View full abstract

So far we are obliged to perform colostomy temporarily for rectal stenosis due to Schnitzler metastasis from gastric cancer. This time we were able to manage a case of the disease by placement of an expandable metallic stent (EMS).
A 64-year-old woman who had been followed clinical course after the operation for gastric cancer was admitted to the hospital because of abdominal distension and general fatigue. Intestinal obstruction due to rectal stenosis was suspected. Fluoroscopy of the rectum revealed a stenosis at the RS of the rectum. One year and 4 months after the operation, an EMS was placed at the same site. Thereafter gradual symptomatic remission was attained. The patient started to eat and was discharged from the hospital.
This EMS method can be easily and safely performed and appears to be very helpful to improve the quality of the patient.

View full abstract

Carcinoma associated with anal fistula is a cancer that arises in complicated chronic anal fistulae. And cancer located in a part of fistulae, which divide and fuse in complex manners in the pelvis, presents a great deal of difficulties in diagnosis. This time we performed various imaging studies preoperatively in a patient with typical carcinoma associated with anal fistula and obtained MRI findings which were considered to be characteristic of the disease. In T2-weighted images, the lesion was visualized as an aggregation of granular markedly high-intensity areas. Since carcinomas associated with anal fistula are often mucinous adenocarcinoma, this finding is considered to represent mucus lakes characteristic of the disease. Therefore, T2-weighted images on MRI are considered to be useful for differential diagnosis of carcinoma associated with anal fistula from complicated chronic anal fistula. They are considered to be also useful for the diagnosis of postoperative intrapelvic recurrence.
In T1-weighted images, the lesion was delineated as a low-intensity area in adipose tissues that normally appears as high-intensity areas, and the complex courses of the fistulae in the pelvis could also be determined. T1-weighted images allow evaluation of three-dimensional extent of the lesion and are considered to be useful for determination of surgical procedure.

View full abstract

A 49-year-old man was first seen at the hospital in July, 1995, with a 2-year history of pus discharge and bleeding from the perianus. This was considered to be a horseshoe type perianal abscess and was treated by surgical drainage. Two months later, he underwent debridement and tight seton under the diagnosis of complex fistula ani. The patient remained symptom-free for 2 years thereafter. He was again seen at the hospital in October, 1997, with a 2-month history of bleeding from the wound. Examination revealed an ulcerative left side perianal lesion and a left inguinal lymph node swelling. Proctoscopic examination revealed no mucosal lesion in the anal canal and rectum. Biopsy of the perianal mass showed an adenocarcinoma. Miles operation with left inguinal lymph nodes dissection was performed. The carcinoma was histologically diagnosed as mucinous adenocarcinoma with inguinal lymph node metastasis. First manifestations of carcinoma of the anal canal resemble those of benign hemorrhoidal diseases, and hence histological diagnosis is required for all cases not to make misdiagnosis. In this case, if we had performed histological examinations and carcinoma had been present, we had to make the correct diagnosis at the first visit. This case that has emphasized the importance of histological diagnosis and should be noted in daily clinical scenes is presented here.

View full abstract

A case of gastic cancer revealed 5 years after a duodenum preserving pancreas head resection is reported.
A 52-year-old man visited a local practitioner because of heart burn, and was referred to the hospital for operation with a diagnosis of gastric cancer. There was a previous history of undergoing a duodenum preserving pancreas head resection (choledocho-duodenostomy, side to side pancreatico-jejunostomy) for chronic pancreatitis. Endosocopic examination and barium meal study of the gastrointestinal tract revealed a type 4 lesion of the stomach. A total gastrectomy with reconstruction of ρ-Roux-en-Y fashion was performed. Pathological diagnosis was sig, ss, INFγ, ly0, v0, ow (-), aw (-), n1 (+), in stage II and curability A. There has been no sign of recurrence and the patient is strictly followed up on an ambulant basis. It is inferred that the digestive function preserving operations will be increasingly performed, in that postoperative follow up of the preserved organs should not be neglected. In case of malignancy after the digestivoe function preserving operation, management of curativity and the preserved function is important at surgery.

View full abstract

We experienced four cases of tumor forming pancreatitis. In this paper two out of four cases are presented with some notes on differential diagnosis from pancreatic cancer. Case 1, A 54-year-old man was admitted to the hospital with a doubt of pancreatic cancer with obstructive jaundice. Abdominal US, EUS, and ERCP revealed specific findings, and so we diagnosed the patient as having tumor forming pancreatitis. Case 2, A 53-year-old woman was admitted to the hospital with a suspicion of pancreatic tumor. The patients was diagnosed as tumor forming pancreatitis on EUS and ERCP. We studied the images of four patients of tumor forming pancreatitis retrospectively, and found that the most reliable image for diagnosis was ERCP, followed by US, and EUS. CT and angiography were comparatively poor in diagnosis. The reason might lie in that CT was uncapable of offering relieable differentiation of the density between the lesion and surrounding pancreas, and that angiography was not most appropriate for differentiation between hypovascular (pancreatic cancer) and isovascular areas (tumor forming pancreatitis).

View full abstract

A case of acinar cell carcinoma of the pancreas which was indistinguishable from extramucosal tumor of the stomach is reported. A 71-year-old woman was admitted to the hospital because of epigastralgia. A very movable tumor was palpated in the upper abdomen. Ultrasonography revealed a large mass as well as the compressed splenic vein and portal vein on dorsal position, but not on sitting position. Upper gastrointestinal X-p and gastric camera showed the compression extraluminally from the posterior wall of pylorus with mucosal ucleration. Abdominal CT showed a mass with high and low density areas. These findings offered a suspicion of extramucosal tumor of the stomach. Upon laparotomy, the tumor seemed to infiltrate into the transverse colon and pancreas head. So a pancreatoduodenectomy and a partial resection of transverse colon were performed. It was pancreas tumor with an extrapancreatic growth on cross section, but the main pancreatic duct and bile duct in pancreas were intact. The pathological diagnosis of the excised tumor was acinar cell carcinoma.

View full abstract

A 33-year-old woman was trasported to the hospital after being involved in a steering wheel injury. She was diagnosed as having injuries in the lateral segment of the liver and the upper pole of the spleen by CT and echo. All her vital signs were stable and she was treated conservatively.
A follow-up CT on hospital day 9 revealed a highly enhanced lesion in the spleen. It became larger and was diagnosed as pseudoaneurysm with thrombi on day 16. The patient had a successful arterial embolization on day 23. And after that she had an uneventful recovery. Ten months later, just a small low density lesion could be identified at the spleen.
Intraspleic pseudoaneurysm, one of the causes of delayed rupture of the spleen, can be managed with embolization by meticulous follow up before rupture, if conservative therapy or spleen preserving operation is selected for splenic injuries.

View full abstract

It is rare that intestinal obstruction caused by internal hernia arisen in a defect of the broad ligament of the uterus, especially that operated on laparoscopically which has not been reported in Japan as far as we could review. This paper reports a case of hiatus hernia of the broad ligament of the uterus diagnosed and treated by laparoscopic procedure.
A-73-year-old woman was performed a laparoscopic surgery with a diagnosis of adhesive intestinal obstruction which had been resisted conservative therapy. Exploration of the abdomen revealed that a portion of the ileum about 15cm in length located about 1m from the ileum end incalcerated into a defect of the broad ligament of the uterus from ventral to dorsal, forming an internal hernia. The incalcerated ileum was reddish violet in color, but it recovered in color after reduction of the hernia. So no intestinal resection was carried out and the hiatus was closed. Postoperative course was uneventful. In the treatment of the disease which often present difficulty in preoperative diagnosis with resultant intestinal resection due to poor blood flow in the in-calcerated intestine, laparoscopic procedure which has been increasingly indicated in wider range of diseases in recent years appears to be an excellent method for both diagnosis and treatment.

View full abstract

Mesenteric panniculitis of the small intestine is a rare entity causing nonspecific inflammation disease in the mesenterium and its differential diagnosis and treatment have not been established as yet. We herein describe a case of mesenteric panniculitis of the small intestine successfully treated by laparoscopy assisted operation and discuss the relevant literature. A 78-year-old man was admitted to the hospital because of ileus symptoms. Double contrast radiography of the small intestine revealed narrowing segment of the small intestine. An abdominal CT scan disclosed thickened wall of the small intestine, and a low density mass in the mesentery near the thickend portion which was enhanced by contrast medium. On laparoscopy, serosa of the small intestine at 1m apart from the Treitz's ligament was spotted reddish edematously in 10cm length, and the mesenteric fat tissue appeared yellow-white in color and hard. We diagnosed it mesenteric panniculitis of the small intestine, and a surgical resection was performed by mini laparotomy at 6cm left pararectus abdominal skin incision. Pathological findings revealed multiple small erosion in the small intestinal mucosa, and hemorrhagic necrosis or granulated change in the mesenteric fat tissue.

View full abstract

We report two cases of retroperitoneal schwannoma which were difficult to diagnose preoperatively. The first patient, a 56-year-old man, was seen at the hospital because of pollakiuria. CT scan showed a large mass which occupied almost the entire pelvic cavity accompanied by a low density portion in its central part. Tumor extirpation was perfomed under a diagnosis of retroperitoneal tumor. The tumor was 21×12×6.5cm in size and 1, 180g in weight with a thick capsule. Histological diagnosis was schwannoma. The second patient, a 73-year-old man, was found having a pelvic tumor incidentally, when he underwent a close examination for rectal cancer. Magnetic resonance imazing (MRI) showed a large mass in the presacral space, which had a central necrosing part. Abdominoperineal excision of rectum and an extirpation of the tumor were perfomed. The extirpated tumor was 9.2×7.4×7.0cm in size and 230g in weight. It had a white and thick capsule. Histological diagnosis was benign schwannoma composed of two different types, Antoni-A and B. Schwannoma often presents difficulty in preoperative diagnosis. It has been reported that malignant change of the remnant tumor or metastasis from it can occur after operation. We must attempt to remove the tumor completely.

View full abstract

A 58-year-old man was admitted to the hospital because of a painless tumor on the left lumbar region. The patient had been diagnosed as having Ehlers-Danlos syndrom 4 years before admission. The tumor was 10×9cm in size, palpable at the left superior lumbar triangle and easy to mamiputate. Computed tomography revealed a left lumbar hernia. We perfomed a hernioplasty with 2 sheets of Marlex Mesh bacause the tissue forming around the hernia opening was too fragile to suture. The lumbar region has the superior and inferior lumbar triangles as anatomical resistance alleviating portions, where are extremely rare sites for hernia. And Ehlers-Danlos syndrome is arare entity that is characterized by overextension of the skin and joints. This case of lumbar hernia was assosiated with Ehlers-Danlos syndrome as an underlying disease. Thirty nine cases of lumbar hernia have been reported in Japan, but this is the first case complicated by Ehlers-Danlos syndrome.

View full abstract

Case 1: A 65-year-old man was admitted to the hospital because of dorsal pain. Abdominal CT and ultrasonography visualized multiple liver tumors and a left kidney tumor. Colonoscopic fiber revealed a type 2 tumor in the sigmoid colon, and a biopsy findings indicated adenocarcinoma. A sigmoidectomy and a left nephrectomy were simultaneously performed. The histopathological diagnosis was cancer of the sigmoid colon with liver multiple metastasis and left renal cell carcinoma. In spite of systemic chemotherapy, he died of liver dysfunction on 8th month after the operation. Case 2: A 74-year-old woman was admitted to the hospital because occult blood test was positive at a medical checkup. Colonoscopic fiber revealed a type 2 tumor in the rectum. Ultrasonography and abdominal CT visualized a left kidney tumor. A high anterior resection and a left nephrectomy with a splenectomy were simultaneously performed. The histopathological diagnosis was rectal cancer and renal cell carcinoma. After discharge, no relapse has occurred for postoperative 18th month.
With recent medical progress as well as the aging of the population, the incidence of the double cancer has been increasing. Therefore we should be careful not to overlook the presence of second cancer in preoperative diagnosis.

View full abstract

We have recently encountered two cases of synchronous double superficial cancer of the esophagus and stomach. Patient 1 was a 65-year-old man, who had synchronous double cancer of the esophagus (Im, sm, ly1, v1, n2) and stomach (in the lower portion of the gastric body, sm, ly1, v1, n0). Subtotal esophagectomy, total gastrectomy, splenectomy, cholecystectomy, and lymph nodes dissection were performed, in which reconstruction was made by using the right hemicolon. Patient 2 was a 56-year-old man, who had early esophageal cancer (Iu-Ei, 15cm in total length, sm, ly1, v1, n0) and multiple cancer of the gastric mucosa (m, ly0, v0, n0) simultaneously. Subtotal esophagectomy, lymph nodes dissection, resection of the gastric mucosa were performed, in which reconstruction was made by using gastric tube. For treatment of simultaneous cancer of the esophagus and stomach, especially the superficial type, making an appropriate choice of either endoscopic or surgical therapy is important in terms of both the invasiveness and radicality. We selected surgery for treatment of the superficial double cancers, and used different organs for reconstruction, namely the right hemicolon in the patient 1 and gastric tube in the patient 2, because the lymph node dissection depends on the degree of invasion and location of the gastric cancer. In this report, we discussed the surgical approach to the superficial double cancers, with special reference to the importance of the preoperative assessment.

View full abstract