Diagnostic ability of type I collagen cross-linked N-telopeptide (NTx) against bone metastasis or bone invasion of breast cancer was evaluated in comparison with type I collagen cross-linked C-telopeptide (I CTP). Subjects were 30 female patients with breast cancer having bone metastasis or bone invasion. As the number of bone lesions increased, both NTx and I CTP levels increased. Levels of I CTP correlated better to the number of bone metastatic foci than those of NTx. Each biochemical marker showed higher levels in patients with bone metastasis than in those without bone lesions. Ratios of the patients with above the cut-off level of the biochemical marker were 16.7% in NTx and 56.7% in I CTP. Patients with poorly controlled bone metastasis showed twice the levels than those with well controlled lesions in I CTP, and 1.7-fold the levels in NTx. However, the average of the NTx was smaller than the cut off level even in patients with progressive bone metastasis. In conclusion, I CTP is a more useful biochemical marker than NTx in the diagnosis of bone metastasis in breast cancer.

View full abstract

We followed 54 patients who underwent curative hepatectomy for metastasis from colorectal carcinoma at the hospital from January 1990 to October 1995, and investigated their outcomes prospectively. The patients divided into three groups as hepatic arterial infusion (HAI) group (n=14) was given intermittent 5-FU at 1000mg/body via the hapatic artery for 4 hours every 2 week for over 6 week; L-5FU group (n=22) was given 2-week course of continuous 5-FU intravenous infusion at 500mg/body for 5 days a week, followed by leucovorin (30mg/body, day 1) injection; and control group (n=18) was given UFT orally. There was no significant difference in the cumulative 5-year survival rate among 3 groups which were 41% in HAI group, 46% in L-5FU group, and 36% in control group. The disease free survival period in HAI group for both of the lung (P=0.048) and multiorgan (P=0.049) was significantly longer than in control group whereas was no significant difference between L-5FU group and control group. The resection rate in HAI group (57%) for residual liver recurrence was highest among 3 groups (L-5FU group; 14%, control group; 30%). These data indicate that, although HAI and L-5FU therapies contribute little to survival period, anticancer activity for the metastasis of the lung and multiorgan as well as for multiple recurrence of the residual liver in HAI therapy can be expected.

View full abstract

This study deals with the indication and significance of surgical therapy for recurred hepatocellular carcinoma in terms of comparison of prognoses by modes of recurrence and long-term therapeutic results after re-hepatectomy. Subjects were 79 recurred cases after hepatectomy. For comparison, the survival rates after recurrence were calculated by the following five items; time from operation to recurrence, the existence of extrahepatic growth, mode of recurrence in the remnant liver, recurred site in the remnant liver, and therapy after recurrence. As a result, significantly better prognoses were noted in recurrences after 2 years of time lapse following hepatectomy, no extrahepatic growth, solitary cases, and re-resected cases. No significant difference was observed between the sites of recurrence in the remnant liver, namely isolateral and counterlateral lobes. In 11 re-resected cases which involved only three cases suspected of heterochronous multicentric carcinoma, a mean survival time after re-resection of solitary recurrence in the remnant liver was as good as 5.2 years. And five patients of them have not experienced re-recurrence for 5 years after the re-resection.
It is thought that re-resection can be considered aggressively in patients with two factors, namely, recurrence after 2 years following hepatectomy and solitary recurrence in the hepatic remnant. And the re-resection which provides favorable prognosis appears to be significant for such cases.

View full abstract

To review the significance of the indocyanine green dye retention rate 15 minutes after injection of 0.5mg/kg (ICGR15) for the evaluation of the liver functional reserve, relationships between ICGR15 and other liver function tests in 200 patients with hepatocellular carcinoma, and between ICGR15 and histological fibrosis (F0-3) in 40 patients of chronic hepatitis, were evaluated. Furthermore, correlations between liver functional parameters including ICGR15 and postoperative liver function were studied in patients who had undergone right lobectomy or extended right lobectomy. Although statistically significant correlations were found between ICGR15 and the values of serum albumin, cholinesterase, prothrombin time, GOT, platelet count, and portal pressure, these data distributed with some widths. Degrees of histological fibrosis distributed from 0 to 3 even in about same ICGR15, regardless with a statistically significant correlation between ICGR15 and the degree of fibrosis. Between patients groups which were divided based on their postoperative course, there found statistically significant differences in regard with their preoperative values of Alb, ChE, GOT, and ICGR15. However, a multivariate regression analysis of correlation between the postoperative course and values revealed a significance for only ChE and ICGR15. These results demonstrate the importance of ICGR15 in preoperative evaluation of liver function. However, when there is a gap between the values of ICGR15 and other parameters, liver function should carefully be appreciated.

View full abstract

“The low union hepatic duct” implies mainly the one traditionally called accessory or aberrant hepatic duct, but it includes the main right and left hepatic ducts joining at low position. In this study the incidence of anomalous union of this low union hepatic duct with the cystic duct and the hepatic portions drained by the low union hepatic ducts concerned in this anomaly were examined in 857 patients who underwent operative procedures for the extrahepatic bile duct system. The incidence of the anomaly in which the cystic duct drained into the low union hepatic duct was 1.5% and of the anomaly in which the low union hepatic duct drained into the cystic duct was 0.6%. The hepatic portions drained by these low union hepatic ducts were all right lobe and the extent of the hepatic portion varied from subsegment to all right lobe. These results indicate that it is natural to consider that both the extrahepatic bile duct anomaly called accessory or aberrant hepatic duct and the one in which the main right and left hepatic ducts join at low position belong to the same category.

View full abstract

Biliary injuries in laparoscopic cholecystectomy (LC) have etiological factors, type of injury, and clinical course caused by specific characteristics of LC. This paper deals with clinical characteristics and appropriate therapies of seven cases of biliary injury in LC, including three cases of amputation, three cases of laceration, and one case of clipping. The diagnosis of injury was made in four cases during surgery, and each one case on the first, third and 29th postoperative day. For these injuries, operative repairs were performed in six cases, including cholangiojejunostomy in one case, end-to-end anastomosis of the bile duct in two cases, primary suture in two cases, and removal of a clip in one case. Postoperative biliary narrowing occurred in one case of end-to-end anastomosis for amputation of the bile duct and one case of primary suture for rupture of the bile duct. RTBD tube had been indwelt for 19 and 37 days respectively and the narrowing appeared 8 and 14 months later respectively. So long-term observation including indwelling time of a stent tube would be mandatory in LC cases undergone end-to-end anastomosis of the bile duct or primary suture.

View full abstract

Transperitoneal approach is most widely accepted in surgical repair of infrarenal abdominal aortic aneurysm (AAA). This approach, however, has postoperative problems such as prolonged paralytic ileus. Twenty-one patients who underwent an aortic replacement for infrareanl AAA with transperitoneal approach were subjected to a study. Seven patients of them were administered a chines herb medicine ‘Dai-kenchu-to (Da-Jian-Zhong-Tang)’ (Dai-kenchu-to group) and other seven patients were administered Panthenol (Panthenol group) and the remaining seven patients were served as control. Dai-kenchu-to, which is effective to relieve ileus simplex by intestinal adhesion, was given through nasogastric tube for the seven patients on and after the first postoperative day and only warm water for the other seven patients in the same manner. Panthenol was administered intravenously. There were no significant differences in operative time, aortic clamping time and intraoperative water balance in each group. Flatus, disappearance of intestinal wind were significantly prolonged in the control group compared with other two groups (P<0.05). There was no significant difference in the date of flatus between Panthenol group and Dai-kenchu-to group. Disappearance of intestinal wind were significantly prolonged in the Panthenol group compared with Dai-kenchu-to group (p<0.05). No adverse side effect of Dai-kenchu-to was seen. These results suggest that Dai-kenchu-to is useful for early recovering from temporary paralytic ileus after surgery for AAA.

View full abstract

Spindle cell carcinoma (SPCC) is a relatively rare breast tumor. Most SPCC has been reported as a relatively large and advanced cancer. We experienced a case of early SPCC of the breast, measuring less than 2cm in diameter. The patient was a 73-year-old woman with a chief complaint of palpable left breast mass. The tumor measured 1.9cm in diameter by mammography. Also no radiographic evidence of lymph node metastasis or distant metastasis was revealed. The tumor was localized in the mammarygland by intraoperative findings. Breast conserving surgery and axillary lymph nodes dissection were performed.
Histologically, the tumor consisted of two components: squamous cell carcinoma in an area of less than 3mm in diameter, and spindle-shaped cell in an area comprosing most of the remaining tumor. A transitional zone between the two components was observed. These findings suggested the following: (1) that only a small area of a carcinoma could transition to SPCC, and (2) that SPCC had gained a higher degree of proliferative activity, thus, it occupied most of the tumor.

View full abstract

We seldom encounter metastatic breast cancer from other organs. Placental site trophoblastic tumor (PSTT) is the rarest type of gestational trophoblastic tumor. We document a case of very rare isolated metastasis of PSTT to the mammary gland.
A 40-year-old woman was seen at the hospital because of right breast mass in February 17, 1998. There was a previous history of undergoing an abdominal total hysterectomy for PSTT in July, 1993. The patient had been disease free after postoperative chemotherapy until the breast mass was noticed. On admission the tumor was cystic and effusion from it was detected. Repeated punctures of the mass revealed that the effusion was not malignant. Since no decrease in effusion was attained, a partial resection of the right breast was performed for curative therapy as well as etiological exploration on July 30, 1998. Pathological examination revealed it was the metastasis of PSTT. On systemic examination, no other metastasis was detected.

View full abstract

A Case of a foregut cyst of the posterior mediastinum in a 5-year-old boy is reported. The patient was admitted to the hospital because of fever and abdominal pain. Chest x-ray films revealed an egg-shaped tumorous shadow on the left side of the posterior mediastinum. Esophagography visualized a left anterior displacement of lower third of the esophagus. Chest CT revealed a 7.5×5.8cm tumor with a low density center in the left posterior mediastinum adjacent to the pericardium, esophagus, and aorta. With a diagnosis of cyst of the posterior mediastinum, an operation under left thoracotomy was performed. The cyst which adhered to the esophageal wall was freed from the esophagus and excised. The excised tumor was 5×6cm in size, oval in shape, and unilocular, and contained brown serous liquid. Histologically, the cyst wall was not lined with epithelium, and contained one muscle layer. There was no cartilage. We diagnosed the cyst as foregut cyst.

View full abstract

Low-grade fibromyxoid sarcoma presented as a mediastinal tumor is so rare that no cases have been reported.
A 37-year-old woman was seen at the hospital because of shortness of breath and dyspnea. The chest roentgenogram, computed tomographic scan and magnetic resonance imaging revealed that the tumor occupied the anterior mediastinum invading the innominate veins and oppressing the bronchi.
A thoracotomy via a hemi-clamsell approach was carried out and the tumor was resected together with the innominate veins, followed by graft implantation.
Microscopically, characteristic alternating fibrous and myxoid areas with a whorled pattern were detected. The tumor was well-circumscribed, but a true capsule was present, and was characterized by poor cellularity, composed of uniform spindle cells with small, uniform nuclei that contained fine chromatin and small nucleoli.
Immunohistochemically, the tumor cells were focally positive for vimentin and contained alphasmooth muscle actin.

View full abstract

A 68-year-old woman, who was scheduled to undergo operation for bilateral gonarthritis under general anesthesia in September 1998, was detected having an about 1.5cm circular shadow in the right lower lung field on a chest simple x-ray film taken preoperatively. She was admitted to the hospital for close examination and treatment, when no particular abnormalities in physical and blood biochemical data were observed. Chest CT scan revealed a demarcated tumor shadow with homogeneous center in the right S8, but no pleuralimpaction nor lymph nodes swelling was presented. Bronchoscopy revealed no anomalies. Since a possibility of malignant tumor could not be still ruled out, a thoracoscopy-aided partial pneumonectomy was performed for the purpose of examination and treatment. Pathological diagnosis was sclerosing hemangioma of the lung. Sclerosing hemangioma of the lung which commonly occurs in the pulmonary peripheries is a relatively rare benign tumor. We often have great difficulty in preoperative diagnosis of the disease, even by intraoperative frozen section diagnosis. For such cases, this thoracoscopic operation that is minimal invasive can be recommended to treat and also to make the definite diagnosis of the disease.

View full abstract

A case of esophageal perforation due to reflux esophagitis treated by conservative therapy is reported.
An 82-year-old man had been undergoing treatment for reflux esophagitis, but had not been seen during the past year. On 23rd January, 1999, he developed vomiting, chest pain and high fever. The next day he was admitted because of an increase in white blood cells and C-reactive protein. After admission, an upper gastrointestinal fiberscopic examination revealed esophageal perforation with multiple esophageal ulcers of the lower esophagus. Computed tomography (CT) of the chest showed mediastinitis and mediastinum emphysema.
Because of degeneration of his performance status, conservative therapy including total parenteral nutrition, injection of antibiotics, and medication of proton pump inhibitor and aluminium hydroxide gel through a gastric tube were conducted. After treatment, his laboratory tests results improved and his temperature returned to normal. Also, CT of the chest showed improvement of mediastinitis and mediastinum emphysema on the 15th day after admission. Upper gastrointestinal fiberscopic examination revealed no perforation of the esophagus on the 37th day after admission.

View full abstract

A 53-year-old man was admitted to our hospital because fo a superficial cancer of the cervical esophagus. He had been well before the tumor was found during endoscopy one year after subtotal thoracic esophagectomy for a type O-IIa+IIc cancer (a squamous cell carcinoma confined to the mucosa without lymph node metastasis) with esophagophasty using a part of the terminal ileum and the right colon. The tumor in the cervical esophagus was estimated to be a superficial and protruding type (type O-Isep) submucosal cancer with neither lymph node metastasis, nor distant organ metastasis. Histological studies on bite-biopsy specimens revealed undifferentiated carcinoma of small-cell type.
A major part of the cervical esophagus and a part of the terminal ileum, which had been pulled up to the the neck was resected with lymph node dissection on the left side of the neck. Thereafter, anastomosis between the remnant cervical esophagus and the terminal ileum was carried out. Histological studies on the resected specimens revealed a small-cell carcinoma cofined to the submucosa without lymph node metastasis, however, severe cancer invasions into the small venules were recognized. Postoperative chemotherapies were conducted using CDDP and VP-16. Massive and multiple liver metastases which compressed the inferior vena cava were noted 15 months after the cervical esophagectomy. Chemotherapies through a catheter placed in the proper hepatic artery was effective. He is alive 21 months after cervical esophagectomy.

View full abstract

We present a rare case of massive incarcerated type III paraesophageal hernia with gastric volvulus which has been successfully treated by laparoscopic surgery. An 84-year-old woman was admitted to the hospital because of hematemesis. Oozing from lacerated mucosa at the esophagogastric junction was detected by an emergency esophagogastrofiberscopy. Esophagogastrogram revealed entirely incarcerated organoaxial volvulus of the stomach. It was judged from findings of an endoscopy that blood supply to the stomach was not compromised. So an operation was performed after the general condition of the patient improved with total parenteral nuturition for three weeks. The operative procedures involved reduction of the hernia, mobilization of the esophagogastric junction, crural repair and floppy Nissen fundoplication with anchoring sutures. At the 8th-month follow-up, the patient is asymptomatic and has had no evidence of recurrence.

View full abstract

An asymptomatic 37-year-old man underwent gastroscopy for health screening, which revealed a protruded lesion at the upper part of the corpus on the lesser curvature of the stomach. He was referred to our hospital for close inspection. Computed tomography and endoscopic ultrasonography showed an extragastric and well-defined cystic lesion. We performed an operation with a presumed diagnosis of submucosal tumor of the stomach. At laparotomy a large mass on the anterior wall of cardia and a small mass on the anterior wall of the middle part of the corpus were found in the subserosal space, and both of them could be easily enucleated. Because histologic examination of the resected material revealed that they are composed of mucosal layer, proper muscle, subserosal layer, and the serosa, a diagnosis of duplication of the stomach was made. Gastric duplication cyst is a kind of gastrointestinal tract duplications, which are congenital anomalies and have been found in various organs from tongue to large intestine. Even though the duplication of the stomach is rare, we must keep this disease in mind on differential diagnosis of the submucosal tumor of the stomach, because its frequency will increase with recent advances in imaging modalities.

View full abstract

Plasma cell granuloma is a granulomatous disorder of unknown origin that is histologically composed of plasma cell predominant cell infiltrate and fibrous connective tissue. This time we experienced a case of plasma cell granuloma arisen in the stomach.
A 45-year-old man was admitted to the hospital because of appetite loss and epigastric pain. Gastric endoscopy revealed ulcerative lesion surrounded with irregular mucosa in the pyloric antrum. Biopsy yielded no definite diagnosis. Non-epithelial malignant tumor was suspected, and a gastrectomy was performed. Histopathologically, the difinite diagnosis of plasma cell granuloma was made.
In this case, we were able to observe the morphological changes in ulcerative lesion of plasma cell granuloma with time. Domestic cases of gastric plasma cell granuloma are numbered only ten, and the clinical features of the disorder are still obscure. Some bibliographical comments in terms of the clinical features are also presented here.

View full abstract

We curatively removed recurrence of early gastric cancer to the regional lymph node along the common hepatic artery 23 years after gastrectomy for the primary foci. A 79-year-old man was admitted to the hospital because of a tumor in the right upper abdomen with mild epigastralgia. There was a history of undergoing a distal gastrectomy for early gastric cancer at the age of 53. The tumor was 7cm in diameter, although it had been 5cm in diameter 18 months before admission in the previous hospital. Graphic examinations revealed that an expansively growing egg-shaped tumor was located on the anterosuperior side of the pancreatic head. The tumor was removed with careful dissection, because it adhered to the common hepatic artery and head of the pancreas. A histological examination showed that the tumor in thick fibrous capsule was occupied with cells of poorly differentiated adenocarcinoma. Metastatic lymph node from the gastric cancer was diagnosed. The clinical course was uneventful and no relapse has been observed for postoperative 12 months. Since lymph node recurrence of gastric cancer usually occurs within 5 years after initial surgery with poor prognosis, this case is very rare.

View full abstract

A case of cancer of the remnant stomach with afferent loop syndrome 23 years after gastric resection is reported, together with some bibliographical comments. A 75-year-old man was seen at the hospital because of abdominal pain and vomiting. There was a previous history of undergoing a Billroth II gastrectomy for gastric ulcer 23 years before admission. Dilation of the afferent loop was detected with computed tomography. Afferent loop syndrome was suspected and the patient was operated on. At laparotomy, the afferent loop was almost completely obstructed and extremely dilated due to a cancer of the remnant stomach. And the transverse colon also narrowed by the tumor invasion. Subtotal gastrectomy with resection of the transverse colon was performed. The tumor was 8.0×7.0×4.0cm in size and was histologically diagnosed as signet-ring cell carcinoma. After 9th postoperative day, the patient became to take foods by mouth, but he died 3 months after the operation.
Remnant gastric cancer with afferent loop syndrome is rare and only eight cases including ours have been reported in the Japanese literature. Almost all cases were in advanced stage with invasion into other organs and might have a poor prognosis.

View full abstract

A 61-year-old woman was admitted to the hospital because of obstructive jaundice due to recurrence of gastric cancer to the pancreatic head region one year and 4 months after a gastrectomy. Expandable metallic stent (EMS) was inserted following percutaneous transhepatic biliary drainage, which resulted in maintaining normal bilirubin level for about a year. Ten months after biliary stenting, however, severe duodenal stenosis occurred because of a further extension of the disease. Then another EMS was placed between gastric outlet and proximal duodenum, which made her intake diet, and she was discharged from the hospital. Aggressive application of EMS remarkably improved her quality of life. The use of EMS for biliary strenosis has been established. On the other hand, successful uses of EMS for gastrointestinal organs other than the esophagus have been increasingly reported recently, though those indications have not been approved by the Japanese health insurance. We think that EMS therapy for gastrointestinal tract as well as biliary system is a promising modality for patients with malignant stenosis.

View full abstract

Gastroepiploic artery aneurysm is a rare entity and presents a great deal of difficulty in preoperative diagnosis. Most cases of the disease which been reported so far presented with some symptoms due to the rupture. This time, we experienced a case of unruptured right gastroepiploic artery aneurysm, which was incidentally detected during preoperative examinations for a gallbladder tumor and successfully resected together with the gallbladder under laparoscopy.
A 51-year-old man was admitted to the hospital for the treatment of a gallbladder tumor which was found at a medical chekup. Abdominal angiography revealed aneurysm cystic aneurysm in 1cm diameter in the right gastroepiploic artery. So a laparoscopic cholecystectomy was performed, followed by a removal of the aneurysm after intraoperative frozen section diagnosis of the gallbladder tumor was confirmed to be benign.
The disease in which the artery can be exposed easily would be a good indication for laparoscopic surgery. Since the laparoscopic surgery is generally used, is less invasive, and can be easily accepted by patients, the procedure might be the therapy of choice for unruptured gastroepiploic artery aneurysm.

View full abstract

This paper report a case of recurrent minute carcinoid of the duodenum after operation in a 44-year-old woman. The patient had undergone a partial resction of the duodenum for minute carcinoid (5mm in size, sm) in the descending part of the duodenum in 1993, and then was followed up in the outpatient clinic. In January, 1997, she was found having a Yamada's type 2 tumor about 1cm oral from the duodenal papilla. With a biopsy, carcinoid was diagnosed. The patient was admitted to the hospital for operation with a diagnosis of recurrence of duodenal carcinoid. At operation, an ill-defined indulation about 2cm in size infiltrating into the pancreatic head was seen, and a pancreatico duodenectomy was performed.
In general, carcinoids of the duodenum which are less than 20mm in size and submucosal or shallower in tumor invasion are indicated local resection. In our case, however, despite the primary duodenal tumor was 5mm in size with the depth of tumor invasion of sm which fulfilled the conditions, the recurrece had occurred after operation, that was thought very rare. We decide that local resection can be indicated for minute carcinoids, but preoperative close examination of the depth of tumor invasion, intraoperative exploration of lymph nodes, and postoperative clinical observation may be important.

View full abstract

A case of papillary carcinoma with complete type of unfused pancreatic duct system is reported.
A 58-year-old man was admitted to the hospital because he was pointed out having jaundice at another hospital. With a diagnosis of obstructive jaundice and papillary carcinoma of the pancreas, the patient was operated on. An exploration of the excised material revealed that the main pancreatic duct did not unite with the common bile duct and opened at 2cm oral side from the papilla. The definite diagnosis of papillary carcinoma with complete type of unfused pancreatic duct system was made.
In a review of the Japanese literature, only two such cases including our case have been reported so far.

View full abstract

A 76-year-old man was referred for the evaluation and treatment of pancreatic head cancer. Preoperative angiography showed the presence of atherosclerotic occlusion of the celiac axis and demonstrated a compensated blood supply through the enlarged anterior pancreatoduodenal arcade originating from the superior mesenteric artery. A modified pancreatoduodenectomy with the careful separation of the anterior pancreatoduodenal artery from the tumor mass was performed and the tumor was successfully resected. The blood supply for the celiac viscera was well maintained by preserving the asterior pancreaticoduodenal artery. The postoperative course was uneventful.

View full abstract

A case of posteroinferior pancreaticoduodenal artery aneurysm with a deficiency of the common hepatic artery is reported. A 72-year-old woman was admitted to the hospital because of lumbago. Abdominal simple X-ray film demonstrated two pieces of signet-ring calcification in the upper abdominal region and laboratory data showed increased serum level of CA19-9. A pancreatic tumor was suspected. Celiac angiogram demonstrated that a deficiency of the common hepatic artery was present and blood flow of he proper hepatic artery was supplied by left and right gastric artery arcades. The origin of the superior mesenteric artery was obstructed. An aneurysm was found to be located on collateral artery of the posteroinferior pancreaticoduodenal artery. After a diagnosis of posteroinferior pancreaticoduodenal arterial aneurysm was made, an operation was performed. An aneurysmectomy was carried out and great saphenous vein graft was used to replace the posteroinferior pancreaticoduodenal arterial aneurysm, which extended from the aortic artery to superior mesenteric artery. This aneurysm was attributed to arteriosclerosis. The postoperative course was uneventful, and serum level of CA19-9 decreased within normal limits. The patient has been well as of 5 years after the operation.

View full abstract

A 31-year-old woman was admitted to the hospital because of severe abdominal pain, nausea and vomiting. She had been diagnosed as having Crohn's disease since 10 years before admission. Severe tenderness and rebound soreness were present in the abdomen, and pan-peritonitis was suspected. An abdominal X-ray showed free air under the bilateral leaf of the diaphragm. The patient was operated on immediately under a diagnosis of acute peritonitis due to perforation of the gastrointestinal tract. The intestinal wall covering from about 1m to 1m70cm distal to the Treitz' ligament and the mesentery were very thick. Perforation about 3mm in diameter was observed in the ileum 1m60cm distal to the ligament of Treitz. An 80cm segment of the ileum, including the perforation site, was resected and end to end anastomosis was carried out. The postoperative course has been satisfactory. At present, 5-aminosalicylic acid and elemental diet are administered to the patient. Perforation of the small intestine due to Crohn's disease is rare, but it is necessary to remember Crohn's disease as a probable cause of acute abdomen. And in the case, some appropriate operation would be needed.

View full abstract

We report a case of multiple lymphomatous polyposis (MLP) of the small intestine. A 65-year-old man was admitted to the hospital because of right lower abdominal pain. Intestinal fluoroscopy visualized stenosis of the terminal ileum and a tumor of the jejunum. With a diagnosis of malignant lymphoma of the small intestine, the ileocecum and the jejunum were resected. The resected specimen showed a spread of polyposis in the entire small intestine and histologically, the lesion revealed non-Hodgkin's malignant lymphoma (diffuse medium cell type, B cell type). In case of MLP in the long gastrointestinal tract involving not only from the stomach to the large intestine but from the esophagus to the large intestine, the entire garstrointestinal tract should be examined.

View full abstract

This paper deals with a successful total hepatic vascular exclusion (THVE) for hepatic injury of IIIb+IVC according to the classification by the Japan Traumatic Association.
A 19-year-old man in hemorrhagic shock state was transferred to the center after diagnosed as having hepatic injury of type IIIb due to a traffic accident at another hospital. While an aortic occlusion baloon catheter (AOBC) was inserted to maintain blood pressure, a laparotomy was performed. There existed asteroid rupture in the right hepatic lobe, and circulatory blockade at the hepatic hilar region was performed by means of Pringle method. When the right lobe was turned to resect the right lobe, massive venous bleeding from the posterior surface of the liver was found. Inferior vena cava (IVC) injury was suspected. IVC was interrupted at the top and bottom of the liver to make THVE, the IVC injury was repaired under non-hemorrhagic field, and a right lobectomy was performed. A total ischemic time came to 56 minutes, including 15 minutes for Pringle method alone and 41 minutes for continued THVE. No particular problems in hepatic function arose after the operation and the patient was discharged from the hospital on 22nd hospital day. As an adjuvant treatment for hepatic injury of IIIb+IVC, THVE associated with AOBC that can be done safely and easily appears to be of great value.

View full abstract

We experienced a case of giant hemangioma of the liver with an extrahepatic growth. A 58-year-old woman was admitted to the hospital because of an abdominal tumor. She complained of that the tumor had moved like a pendulum which swung left and right. Ultrasonography and CT scan of the abdomen revealed a liver tumor with an extrahepatic growth. The pendulum-like movement was confirmed in CT. The findings of angiography showed “cotton wool appearance”, which was charasteristic of hemangioma of the liver, at the lateral inferior segment and the medial segment. Operation was performed because it was supposed that the movement caused spontaneous rupture or laceration. The excised tumor was 14×11×4cm in size and 480g in weight. Histopathologically, it was diagnosed as cavernous hemangioma. Hemangiomas with an extrahepatic growth are rare. Our case was the 29th, as far as we could review in the Japanese literature.

View full abstract

A 70-year-old man was referred to the hospital because of an upper abdominal pain, fever and jaundice. Laboratory data showed mild jaundice (T-Bil 4.0mg/dl, D-Bil 3.1mg/dl) and high levels of bile duct enzymes, CRP and CA19-9 (340U/ml). CT revealed a cyst, 9×8cm in size, in the segment 4 of the liver, atrophy of the lateral segment and dilatation of the left intrahepatic bile duct. MRCP revealed the compression of the left hepatic duct by the cyst and a dilatation of the bile duct in the lateral segment. ERCP revealed no communication between the bile duct and cyst, and the left hepatic duct retracted downwards and obstructed by compression of the cyst. Portography via superior mesenteric arteriogram did not demonstrated the left portal branch. After improvement of jaundice and inflammation, a left hepatic lobectomy including the left caudate lobe was performed. The cyst was filled with 500cc of serous fluid, and its wall was smooth. The bile duct in the lateral segment was filled with biliary sludge. Histological examination showed that the cyst wall had single layer of cuboidal epithelium without any malignancy.

View full abstract

Among hepatocellular carcinomas (HCCs) advancing into the right atrium (RA), there are some cases which can be performed removal of tumor emboli and hepatectomy. A 70-year-old man was admitted to the hospital because of an 11cm HCC in the right lobe of the liver. Imaging diagnosis showed a large hypervascular mass advancing into the RA. Right hepatic lobectomy by anterior approach and removal of tumor emboli by total hepatic vascular exclusion (THVE) were performed without bypass procedures. THVE time was 15 minutes, operative time was 9 hours and 10 minutes and operative blood loss was 3450g. The resected specimen showed an 11cm massive tumor with intrahepatic metastases and tumor emboli in the right hepatic vein, inferior vena cava and RA. Histologically, hepatic tumors and tumor emboli were moderately differentiated HCC. His postoperative course was uneventful. He is alive and well without recurrence 26 months after the operation.

View full abstract

A 60-year-old man was admitted to the hospital because of constipation in July, 1993. With a diagnosis of rectal cancer (Rs) with synchronous multiple liver metastases (H3), an abdominal resection of the rectum, a right hepatic lobectomy and partial liver resections of the segment 3 and 4 were performed. After while, partial liver resections were performed twice for recurrences in the segment 4 of the liver in June, 1994 and September, 1995. In September, 1997, a left lateral segmentectomy of the liver and a partial resection of the gastric wall were performed for recurrence in the residual liver which directly invaded the stomach. At that time, No. 6 lymph node metastasis was observed. Histologically, the surgical margin of the stomach was positive, and a distal gastrectomy with D1 lymph nodes dissection was carried out in October, 1997.
It is rare that metastatic tumor directly invades the stomach. We report the patient who is surviving for 5 years after the initial operation with aggressive liver resection.

View full abstract

It is most probable that hepatic cyst with high levels of both CA19-9 and CEA in the cystic fluid is cystadenocarcinoma. A 57-year-old woman was admitted to Chunichi hospital because of a cystic mass in the middle segment of the liver. At first, she was diagnosed as having a cystic mass of the liver, which was 5cm in diameter. In 10 months the size of the cyst increased to 10cm in diameter. Although the patient had undergone an injection of absolute ethanol into the cyst through a catheter after US-guided drainage before admission, the cyst continued to increase in size. A laparoscopic deroofing operation was therefore performed. No pathological finding of malignancy was found in the wall of the cyst. Six months later, another cystic lesion in the middle segment of the liver with high level of CA19-9 was noticed again by ultrasonography. She underwent a left lobectomy of the liver in Aichi Cancer Center hospital. The pathological diagnosis of the tumor was cystadenocarcinoma. The patient had high levels of CA19-9 and CEA in the cyst fluid and also had high level of CA19-9 in serum. From this clinical course, the patient is considered to have had biliary cystadenocarcinoma which was derived from the simple cyst through cystadenoma. This case may serve as a paradigm that suggests the importance of following such cysts and of indicating laparoscopic surgery precisely.

View full abstract

A 63-year-old woman with no symptoms and no past history of infection was detected to have Salmonella typhi by bacteriological examination of the feces. We determined that she was a healthy biliary carrier of Salmonella typhi, because of a 2cm-sized gallbladder stone that was demonstrated by ultrasonography. We thought it would be impossible to achieve radical cure with only conservative therapy, so a laparoscopic cholecystectomy was performed no November 18, 1998. The postoperative course was good, and Salmonella typhi was not detected in any culture thereafter, so she was discharged on December 17. Our review of the literature, fuond on case report of laparoscopic examination in a healthy typhoid carrier with biliary stone, except our case. We regard this case as a good indication for the laparoscopic approach.

View full abstract

We experienced a series of 1831 cases of laparoscopic cholecystectomy betwwen February 1991 and November 1998, of which six cases were left-sided gallbladder. The purpose of this study was to discuss problems of preoperative diagnosis and laparoscopic technique for left-sided gallbladder. Six cases of left-sided gallbladder in which patients underwent laparoscopic cholecystectomy were studied retrospec-tively. Four cases were successfully diagnosed preoperatively. Ultrasonography (US) showed right-sided umbilical portal vein in five cases. Computed tomography (CT) revealed the gallbladder located in the left side of the round ligament in four cases. Cholangiography was not helpful in all cases. In all cases, usual French style laparoscopic cholecystectomy was performed. The port below the xyphoid was inserted in the right side of the round ligament in the usual method. First approach of dissection was from the triangle of Calot in the ealier two cases, but it was difficult to keep a good operative field, and so the gallbladder was dissected first from the liver bed in the later four cases. As for intraoperative complications, bleeding from the feeding vessel from the liver bed near the round ligament occurred in two cases. No anomalous bile duct was found by intraoperative cholangiography in any of these six cases.

View full abstract

A 63-year-old man complaining of fever and epigastric pain was admitted to the hospital because of mild jaundice and cholangitis which were pointed out at another hospital. Symptomatic remission was attained by conservative therapy, but 3 months later he was re-admitted because of similar symptoms. Endoscopic retrograde cholangiography revealed a filling defect at the hepatic hilar region which changed in morphology due to pressure, and a tumor shadow with marginal irregularity at the bifurcation of the common bile duct. Transendoscopic cholangioscope revealed a flat elevated lesion with granular surface associated with yellowish white mucus. Bile duct cancer at the hepatic hilar region was diagnosed. A left lobectomy of the liver and a resection of the caudate lobe were performed. Histopathological study revealed papillary adenocarcinoma, early bile duct carcinoma of invasion depth of fm without lymph node involvement. It was inferred that mucus produced by the tumor caused repeated bile duct obstruction, namely the tumor was mucin-producing bile duct cancer. In this case, a cholecystectomy was performed at the hospital 4 years before admission, when the bile duct cancer had been already present which could be seen on an intraoperative cholangiography taken at the time when we reviewed. Although the mucin-producing bile duct cancer is a rare entity, a relatively good prognosis can be promised by adequate operation. The disease must be kept in mind at close examination of the bileduct.

View full abstract

We have encountered a case of slow growing bile duct cancer with eleven years survival after operation inspite of residual cancer at the resected margin.
A 53-year-old woman with a previous history of bile duct resection for upper and middle bile duct cancer was absolute noncurative resection for residual cancer at the bilateral resected margin. After eleven years, the level of CA19-9 increased, and abdominal CT scanning revealed a tumor 1.5cm at the pancreas head. Endoscopic retrograde cholangiopancreatography showed a papillomatous tumor of the papilla of Vater, thus, a pancreatoduodenectomy was performed. Surgical findings revealed invasional growth from the resected margin of residual cancer to the papilla of Vater. Histologically, the tumor proved to be recurrent moderately differentiated adenocarcinoma. Growth of the residual cancer at the resected margin was considered. DNA ploidy pattern, which is regarded as a valuable parameter of malignancy of bile duct cancer, showed a DNA aneuploidy pattern.

View full abstract

We have experienced a case of gallbladder carcinoma growing inside the bile duct. The patient was a 47-year-old woman with a chief complaint of right hypochondrial pain. Slight dysfunction of the liver was noted at the time of admission. Abdominal CT, US and MRI showed a tumor in the gallbladder, that seemed to grow inside the bile duct. The gallbladder, adjacent segment of the bile duct and liver were resected en bloc, and a Roux-en-Y choledochojejunostomy was performed. Intraoperative findings confirmed the tumor's growth in the bile duct. Histologic analysis revealed well-differentiated adenocarcinoma of the gallbladder. Although the tumor had infiltrated the muscle layer of the cervical region of the gallbladder, no cancerous involvement of the bile duct was detected.
She died of metastasis of liver 3 years after surgery.

View full abstract

We report a case benign main pancreatic ducatal stenosis which was difficult to differentiate from a small pancreatic cancer.
A 73-year-old woman complaining of chest pain was admitted to our hospital. Abdominal CT scans showed dilatation of the main pancreatic duct. ERP and EUS showed main pancratic ductal stenosis in the pancreas head, and dilatation of the tail portion of the pancreatic duct. However, no pancreatic tumor was detected. Abdominal angiography also preseted no evidence of malignancy. A small pancretic cancer was suspected and duodenum preserving pancreas head resection was performed.
The pathological findings revealed pancreatic tissue with fibrosis of the pancreatic duct and without chronic pancreatitis.

View full abstract

A 47-year-old man, who received continuous vibration to the abdomen by an Air-breaker during construction work, visited our hospital because of left hypochondralgia. Abdominal computed tomography (A-CT) scan showed wall thickening of the colon in the splenic flexure and edematous fatty tissue. Barium enema study revealed narrowing with marginal serration of this portion and colonoscopy showed slightly edematous mucosa, suggesting the colon was involved with extra-colonic cancer or inflammation. However, no signs of malignancy were found at all. His pain was reduced and he stopped coming to the hospital. One year later, he had pain again and was admitted to the hospital. Colonic stricture had gone at this point, however, A-CT scan showed pancreatic cyst and splenic aneurysm near the splenic hilus. From his occupational history, we diagnosed post-traumatic pancreatitis with pancreatic pseudocyst and splenic pseudoaneurysm caused by continuous vibration to the abdomen. Distal pan-createctomy and splenectomy were performed. The mesocolon around the splenic flexure and the splenocolic ligament had a scar contracture probably due to pancreatitis, which suggested the colonic stricture one year previous might have been followed by post-traumatic pancreatitis. In cases of unknown original colonic stenosis, we must consider possible latent pancreatitis.

View full abstract

A case of acute pancreatitis caused by hyperlipidemia during pregnancy is reported.
A 27-year-old pregnant woman of the 32nd week gestation was seen at the hospital because of vomiting and upper abdominal pain. The abdomen was entirely distended, and the upper margin of the gastated uterus was palpated three fingers above the navel. There was tenderness centering the region of the epigastric fossa, but no rebound tenderness nor muscle guarding was presented. Laboratory data on admission revealed increased white blood cell count of 18, 410/mm³. Biochemically, total cholesterol, neutoral fat, serum amylase, and urinary amylase levels were as abnormally high as 749mg/dl, 5, 632mg/dl, 9, 411U/L, and 4, 724U/L, respectively. Abdominal ultrasonography visualized the pancreas which swelled generally and had an obscure margin. Conservative therapy was started under a diagnosis of acute pancreatitis of mild degree. On the next day, some alterations were seen in the fetus and the fetus was delivered by a cesarean section. Simultaneously, intraperitoneal and pancreas bed drainage were performed. Postoperative course was uneventful. Blood biochemical data were normalized and the general condition improved as well. The patient was discharged from the hospital on 45th hospital day. Both the patient and her baby have been in good health, as of 3 years and 4 months.

View full abstract

Splenic tuberculosis is secondary to milliary tuberculosis in most cases. Solitary tuberculosis of the spleen is extremely rare.
A 55-year-old woman with rheumatoid arthritis was seen at the hospital because of weight loss. Abdominal computed tomography and sonography revealed splenic mass lesions with moderate splenomegaly. Splenectomy was carried out, because these findings were suggestive of splenic neoplasm such as malignant lymphoma. Mutiple whitish nodules varying from 0.5-3cm in diameter were found in the resected spleen. Histopathological exmanination of the spleen showed the typical tuberculoma. No abnormal findings were found in any other organs after the operation, and so the patient was diagnosed as having solitary tuberculosis of the spleen. Antituberculous chemotherapy was given for 6 months.
Tuberculosis is decreasing in these days, but splenic tuberculosis should be included in probable differential diagnoses of splenic tumor or abscess.

View full abstract

A case of giant retroperitoneal hematoma due to the appearance of coagulation factor VIII inhibitor is reported.
A 69-year-old man was admitted to the hospital because of hematemesis, and was operated on with a diagnosis of early cancer of the cardiac part of the stomach. After the operation, hemorrhage from ulcer at the anastomosed site occurred which demanded reoperation. Thereafter the patient had hematemesis again but was conservatively managed. Two months later, however, a giant hematoma was abruptly formed at the retroperitoneum and shock occurred. On a coagulation test, a prolongation in APTT alone was noted. Exploration revealed that it was bleeding tendency due to the appearance of the factor VIII inhibitor. The cause was obscure, but the APTT level was normalized for a time after starting the prednisolone regimen. An immunological analysis of the inhibitor demonstrated that it was IgG type autoantibody and IgG1 and IgG4 as IgG subclass.
Bleeding tendency due to the appearance of coagulation factor VIII inhibitor often causes severe hemorrhagic symptoms like in this case, with a high mortality rate due to hemorrhage. So the recognition and rapid treatment of the disease are of importance.

View full abstract

A 52-year-old man was seen at the hospital because of a right latus tumor. A tumor 20mm in diameter was palpable in the right latus abdominal wall. Excision biopsy was performed under local anesthesia and malignant fibrous histiocytoma was suspected. However, no definite diagnosis could be made. General examinations revealed no other tumor lesion. Half a year later, another tumor recurred in the same site of the abdominal wall. The tumor was 26mm×32mm in size. A partial resection of the abdominal wall was performed implemented with a normal margin under epidural anesthesia. The tumor was present in adipose tissue of the abdominal wall and adjacent to the rectus anterior sheath partially. It was diagnosed as malignant fibrous histiocytoma with HE, fat, and immunological stainings. A gene protein test presented no abnormal findings. Malignant fibrous histiocytoma (MFH) is the most frequent tumor of soft tissue malignant tumors. MFH is common in the extremities or retro peritoneum but otherwise in the abdominal wall is rare. It is believed that the tumor is often associated with local recurrence, metastasis, and second malignant tumor, and hence resection of the tumor with a sufficient normal margin and clinical observation would be demanded.

View full abstract

An 82-year-old woman was admitted to the hospital because of abdominal pain and vomiting. There were slight tenderness in the abdomen and accelerated intestinal murmur. Simple abdominal x-ray examination revealed gaseous distention of the small intestine which extended to the right upper abdomen over the transverse colon partly and was seen at the hight of from the 12th thoracic vertebra to 1st lumber vertebra. On abdominal CT scan, the dilated intestine was situated dorsal to the stomach and ventral to the pancreas; cord which might be mesenteric vessel in fatty tissue ran upward on the right side of the duodenum and transversely ran dorsally to the liver and hepatoduodenal mesentery; and the continuity to the dilated intestine was confirmed. A hernia through the foramen of Winslow was diagnosed. At laparotomy, a part of the ileum about 30cm in length 200cm distant from the terminal ileum incarcerated in the omental bursa through foramen of Winslow; and the small intestine strongly adhered to duodenal flexure. Operative procedures included a repair of the incarcerated intestine and an excision of the small intestine including the adhered portion, and the foramen of Winslow which opened up to two fingers was not sutured for reduction. Postoperative course was uneventful. The disease lacks in characteristic symptoms and simple abdominal x-ray examination and CT are useful for preoperative diagnosis. Favorable prognosis can be expected for the disease by early diagnosis and early treatment.

View full abstract

Spigelian hernia is rare in all abdominal wall hernia. We report a case of Spigelian hernia with a review of the literature. A 73-year-old woman who had undergone a Casearean section was referred to our hospital because of bulge and pain at the left lower quadrant. Physical examination revealed a 7×7cm soft tender mass at the left quadrant which could not be reduced. The hernia opening, 3×3cm in size, locoted at the aponeurosis between lateral side of the rectal muscle. Computed tomography showed the aponeurosis under the bulge was defected and intra-abdominal content was protruded through this defect. Barium enema study revealed this abdominal content was the sigmoid colom. Under the diagnosis of Spigelian hernia, we carried out the reduction of the incarcerated colon and closed the hernia opening using a Marlex mesh. For 5 months after the operation no signs of recurrence have been detected. Only 18 cases including our case has been reported in Japan. However, no case with incarceration of the colon has been reported. In this case, CT scanning and barium enema study were useful for preoperative diagnosis.

View full abstract

Spigelian hernia is extremely rare among primary abdominal wall hernias. This report describes a case of Spigelian hernia in a 78-year-old woman, with a review of the literature. At the level of 4cm below the umbilicus, a soft bulge was observed by the lateral border of rectus abdominis muscle. By abdominal computed tomography, the aponeurosis according with the region of the bulge was defected. A Spigelian hernia was diagnosed and the patient was operated on. The hernia sac was found under the aponeurosis of external oblique muscle and reduced into the abdominal cavity. The sac and hernia opening were closed by nonabsorbable suture and the fragile portion was reinforced with a Marlex^® mesh. Spigelian hernia is an abdominal hernia occurs between the semilunar line and the lateral border of rectus, and only 15 cases have been reported in the domestic literature. For the diagnosis of this disease, a confirmation of the presence of the aponeurotic defect using computed tomography is useful. For the method of treatment, a closure of the hernia opening with prosthetic meshes is available.

View full abstract

Obturator hernia commonly occurs in aged thin women, and there have been 300 cases in the japanese literature so far. The preoperative correct diagnosing rate is as low as 30.5%, and resection of the intestine at operation is performed in about 60% of such cases. This time we experienced a case of metachronous bilateral obturator hernia, which is rare, with advanced gastric cancer.
A 69-year-old woman was admitted to the hospital because of lower abdominal pain and pain extending down the inner surface of her right thigh to the right knee (Howship-Romberg sign). On admission, she was very thin and weighed 36kg. X-ray contrast examination showed obstruction of the small intestine at the site of right obturator foramen. Under a preoperative diagnosis of right obturator hernia, an emergency operation was performed. At laparotomy the ileum was incacerated into the right obturator foramen. Postopertive course was uneventful and she was discharged on the 16th postoperative day. She returned to the hospital complaining of vomiting with abdominal pain 3 years after the first operation. She lost 2kg and weighed 37kg on the readmission. Pelvic CT scan showed an incarceration of the left obturator hernia. The second operation required no resection of the intestine. She complained of dysphagia 3 months after the second operation. Panendoscopic observation revealed a 3'typed advanced gastric carcinoma located at the cardia.
In a review of the Japanese literature metachronous bilateral obturator hernias have been reported in only five cases including this case. In four previous cases, an obturator hernia on the contralateral side occurred within 21 weeks after reduction of the initial hernia.
This relativly short interval from the reduction until the onset of contralateral hernia might be explained by a fact that fatty tissue covering the contralateral obturator decreased dut to the first operation and fasting. In this case, the contralateral obturator hernia occurred after long interval of 3 years that might be caused by emaciation secondary to the development of gastric cancer. We must entertain aprobable association of malignancy in case of metachronous bilateral obturator hernia with long interval between two operations.

View full abstract

An 89-year-old woman was admitted to the hospital because of vomiting and high fever. Abdominal reontogengram showed intestinal obstruction. Definite diagnosis of bilateral obturator hernias was made by a pelvic CT. Emergency operation was performed. The ileum incarcerated into the right obturator foramen 55cm from the terminal ileum. It was easily reduced, and the right hernia hilum was closed with direct suture. On the left side, a peritoneal concave shape, suspected of being an empty hernial sac, was found. The porta was closed in a similar fashion. Twelve cases of bilateral obturator hernias can be seen in the Japanese literature. It is characteristic of this disease to repeat incarceration and reduction. The contralateral obturatory foramen should be inspected during laparotomy, even if preoperative diagnosis by CT is lateral.

View full abstract

Three cases of strangulated obturator hernia repaired by the inguinal approach under local anesthe-sia (IALA) are described. Patient 1, an 81-year-old woman, was diagnosed as having left strangulated obturator hernia. Complicated with chronic respiratory failure and cor pulmonale, the patient was operated on by IALA. Patient 2, an 84-year-old woman, was also diagnosed as having left strangulated obturator hernia. Since she developed sepsis and acute renal failure during the clinical course, the operation by IALA was choiced. Patient 3, an 85-year-old woman, was diagnosed as having right strangulated obturator hernia. An operation by IALA was employed because she was in hypovolemic state.
Obturator hernia occurs in old, highly emaciated women complicated with intestinal obstruction, and hence less invasive and more suitable operation is required. The operation by IALA is thought to be more appropriate procedure for strangulated obturator hernia.

View full abstract