Forty cases of gastrointestinal surgery in patients over the age of 80 who were treated at our hospital between April 1992 and March 1999 were studied in terms of changes in pre and postoperative activity of daily life (ADL) and the degree to which the patients were bedridden. Preoperative abnormalities in laboratory data and underlying disorders were confirmed in 90% of the subjects. Except for cases of emergency operation and those of palliative surgery for malignancy, none of the cases undergoing elective surgery experienced severe complications and all cases were able to tolerate the surgeries. However, when changes in ADL were reviewed in 30 patients who had been discharged, some deterioration in movement and excretion were observed in six patients (20%). Two patients experienced a significant deterioration, from ‘independent’ to ‘bedridden’.
Surgical intervention should be minimized in elderly patients, and the possibility of a postoperative deterioration in ADL should be considered in addition to the patient's ability to tolerate the operation. Systems offering postoperative support and care should also be established.

View full abstract

In order to investigate whether the preoperative serum c-erbB-2 protein level correlates with the prognosis in patients with primary breast cancer, we measured serum c-erbB-2 protein level in 226 patients with primary breast cancer before surgery. The subjects did not include patients with noninvasive cancer and those in Stage IV. The level of serum c-erbB-2 protein was determined by means of sandwich Radioimmunometric assay kit (ErbB-2 IRMA'EIKEN'). The mean level of serum c-erbB-2 protein was 3.6±2.01ng/ml. Forty-seven patients experienced a recurrence (the median follow-up: 60 months). In a multivariate analysis of all patients, the number of lymph node metastasis and serum c-erbB-2 protein level were independent prognostic factors for recurrence. According to measured serum c-erbB-2 protein level, the patients were classified into low level group; tumors with the level less than mean value and high level group; tumors with the level more than mean value. The low level group revealed a better prognosis than high level group in node-negative patients. There was no significant difference in prognosis between the high and low level groups in node-positive patients. Our data suggest that serum c-erbB-2 protein level correlated with the prognosis in patients with primary breast cancer and can be a prognostic factor in patients with node-negative breast cancer.

View full abstract

Thymic carcinoma deriving from the thymic epithelium is a relatively rare malignant tumor. Recently clinical cases of the disease have been increasingly reported. In this study, a series of 13 cases of thymic carcinoma treated in our hospital from April 1988 to December 1999 was clinically studied. They were 46 to 76 years old, with a mean of 60, and tha male-to-female ration was 6:7. These tumors were accounted for 14% of all thymic tumors treated in the same period. Seven cases have any symptoms. The histological subtypes were squamous in six cases, undifferentiated in five cases, small cell in one case and adenocarcinoma in one case. The operative procedures included extended thymectomy in four cases, thymectomy in two cases and partial resection or open chest biopsy in seven cases. Eight cases were in stage 4b and revealed poor prognosis. Six cases were performed complete resection with good prognosis. It is suggested we must carefully select candidates for operation from patients group in stage III or IV, and also consider to add pre-and postoperative irradiation and chemotherapy. At present, no nationwide protocol for treatment of the disease has been established as yet and consequently we employ therapies of our own. We think that some nationwide attempts to develop more efficacious therapy are necessary.

View full abstract

We sometimes encounter wedge-shaped defects (WD) on computed tomography during arterial portography (CTAP), which are densely enhanced on CT during hepatic arteriography (CTHA). This study was made to elucidate possible causes of unexplained wedge shaped defects and their relationships with underlying conditions. Subjects were 41 patients with liver metastasis of colorectal cancer who underwent angio CT for detailed estimation of hepatic metastatic foci. Twelve wedge-shaped defects were observed in eight patients with synchronous hepatic metastases of colorectal cancer. The average interval of time between primary resection and CTAP was significantly shorter in patients with WD than in those without WD (p=0.0004); this prevalence was same for synchronous hepatic metastases, which was shorter in patients with WD (p=0.030). In three patients with WD whose specimens were pathologically confirmed, intrahepatic portal thrombi in one patient and regenerative nodular hyperplastic change, which indicates the temporary cessation of portal supply, in another one patient were pathologically proven. Unexplained wedge-shaped defects were found out in the early time after resection of primary lesions in patients with synchronous hepatic metastases of colorectal cancer. Based on these findings, WD was considered to be due to manipulation in primary resection of colorectal cancer.

View full abstract

Inguinal hernioplasty after mesh plug method was performed under local anesthesia in a series of 24 adult patients since March 1998. Surgical procedure was completed under local anesthesia in all patients. The stable respiratory and hemodynamic conditions during the operation were noted without any toxicity of anesthetics. Some of these patients had surgical risks, such as postoperative cardiac valve replacement followed by anticoagulant therapy, postoperative left pulmonary lobectomy, bronchial asthma and chronic renal failure. We experienced no problems in the intraoperative management for such high risk patients and the elderly patients over 85 years of age. No patients had postoperative complications including headache. Few patients needed the urethral catheterization just after the surgery. Patients could walk and take meals soon after the surgery, and the pain of would was controlled by nonsteroidal anti-inflammatory drugs. So the day surgery for inguinal hernia is considered to be feasible. A questionnaire survey was conducted after discharge from the hospital on the satisfaction of intraoperative anesthesia. The results indicated that local anesthesia was favorable by the majority of those patients. Local anesthesia for inguinal hernioplasty in adult patients is useful, especially for those with risk factors such as advanced age, under anticoagulant therapy, and severe underlying diseases.

View full abstract

A long-term survivor without recurrence after resection of cranial metastasis following hepatic resection for hepatocellular carcinoma is reported. A 59-year-old woman had undergone a subsegmentectomy of the liver for hepatocellular carcinoma in November, 1992. She was diagnosed as to have cranial metastasis in February, 1994. The cranial metastasis decreased in size tremendously by oral administration of Carmoful, but enlarged again rapidly after withdrawal of Carmoful due to side-effects. Resection of the cranial metastasis following transcatheter arterial embolization of the feeding arteries was performed successfully in December, 1996. There have been no signs of recurrence as of June, 2000.
The prognosis of hepatocellular carcinoma with bone metastasisis generally poor, however, resection of the bone metastatic foci might be one of the options in case the patient has no other metastases.

View full abstract

A 71-year-old woman who noticed an abnomal mass in her neck was admitted to the hospital. There was a previous history of undergoing a right nephrectomy for right renal cell carcinoma 10 years earlier. Ultrasonography and Computed Tomography of the neck revealed a tumor mass in the right thyroid gland. ²⁰¹T1 scanning showed defuse uptake by the right thyroid gland. The result of an aspiration cytology was class II. We suspected an adenomatous goiter of the thyroid gland, but could not rule out a possibility of malignancy. Right hemithyroidectmy was performed. Histological examination of the resected specimen showed clear cell carcinoma, and the possibility of a primary thyroid tumor was ruled out by immunohistochemical stainig for thyroglobulin. Thus, metastasis of renal cell carcinoma to the thyroid gland was diagnosed. There were no lesions in the other organs by pre-and postoperative close examination. Solitary metastasis of renal cell carcinoma to the thyroid gland was definitely diagnosed. Solitary metastasis of renal cell carcinoma to the thyroid gland is extremaly rare, and to the best of our knowlegde, this is the 13th case in the Japanese literature.

View full abstract

Primary carcinoid tumor of the breast is quite rare, and there have been only 31 operated cases in the Japanese literature. A 45-year-old woman had a palpable tumor 1.5×1.0cm in size in the A region of the left breast. Ultrasound examination showed an irregular shaped low echoic tumor, and in the left anterior chest wall, a CT scan demonstrated a round shaped tumor which was separated from mammary gland tissues. Excisional biopsy was performed. Hematoxylin and eosin (HE) stains showed a carcinoid like appearance, because the tumor was composed of small cells arranged in solid nests or in a trabecular pattern. Grimelius technique demonstrated numerous argyrophillic granules in the cytoplasm of many tumor cells, and chromogranin A stain was positive. From these figures of the tumor cells, carcinoid tumor was diagnosed. We had still difficulty in differential diagnosis between primary carcinoid tumor of the breast and metastatic carcinoid tumor to the breast. Wide excision was performed. Histologically foreign body granuloma was seen and atrophic mammary gland tissues were seen in the vicinity of the granuloma. At last we diagnosed the case as primary carcinoid tumor of the breast.

View full abstract

A 45-year-old woman was seen at the hospital because of pain of the breast, when an irregular shaped hard mass 17mm in diameter was found in the A area of left breast. Mammography revealed a tumor shadow with an irregular margin associated with minute calcification. Ultrasonography visualized an irregular, segmental hypoechoic tumor with heterogeneous inner structure. Malignancy was strongly suspected clinically, however, a needle biopsy cytology gave Class IV. So the tumor was extirpated. Histologically, it was a solid tumor 1.5cm in diameter in which two parts existed concomitantly; a part surrounded by large type myoepithelium around epithelium of lactiferous ducts showing ductal vacancy formation, and another part in which only myoepithelium formed cystic foci. The ductal epithelium was epithelial membrane antigen positive, and the myoepithelium was α-smooth muscle actin positive. Adenomyoepithelioma (AME) of the mammary duct was diagnosed.
A total of 30 cases including this case were analyzed. These lesions were predominantly found in the lateral side of the breast in middle to elderly woman over 50 years old. They manifested clinical findings suggestive of carcinoma and hence it is important not to make overdiagnosis. Four patients experienced local recurrence, but did not have distant metastasis. We think that partial excision of the breast may be an appropriate operative produre.

View full abstract

A 41-year-old woman was seen at the hospital because of a gradually enlarging tumor in the CD area of the left breast on April 6 1998, for which she first noticed in November 1997. On palpation, an 1.5×1.5cm elastic hard tumor with a slightly obscure border in the CD area and a 2.0×1.7cm well-defined elastic soft tumor in the AC area of the left breast were felt. Intraoperative frozen section pathological study could not differentiate whether both lesions were benign or malignant, and consequently the operation was discontinued. A pathological study of the permanent preparation disclosed that the tumor in the CD area was clear cell hidradenoma which is unexpected in the breast and another tumor in the AC area was hamartoma. The hamartoma was histologically confused with breast cancer, because sclerosing adenosis like histologic feature was associated and fatty tissues were partially involved.
In the case of breast tumor for which intraoperative frozen section diagnosis is questionable, it is important to wait the pathological result of the permanent preparation to avoid excessive surgery.

View full abstract

A 50-year-old premenoposal woman was seen at the department because of a left breast tumor. A soft tumor measuring 2cm in diameter in A-area of the left breast and soft lymph nodes in the left axilla were palpable. We recognized the tumor as TlNlaMX and performed a modified radical mastectomy (Bt+Ax). Histological findings revealed that the tumor was 1.5×1.2cm, invasive ductal carcinoma, solid tubular, f+, tlnOMX. Estrogen receptor and progesterone receptor of the tumor were not able to be examined. Postoperative chemotherapy with 5-FU and toremifene was conducted, but she had recurrent nests near the operation scar 10 months after the operation. She was treated with electron therapy. Systemic bone scintigraphy performed just after this treatment revealed multiple bone metastases. Chemotherapy with 5-FU, epirubicin and cyclophosphamide was started. Severe headache, conscious disorder and convulsion developed and she was re-admitted to the hospital 13 months after the operation. Although head CT images revealed no specific findings, neck stiffness became apparent and meningeal tap revealed meningeal carcinomatosis. Her general condition rapidly deteriorated and she died of recurrence of the breast cancer 9 days after the second admission.

View full abstract

This paper presents a case of invasive ductal carcinoma of the breast with ovarian metastasis developed 13 years after mastectomy in a 51-year-old woman. There were previous histories of undergoing a radical mastectomy for invasive ductal carcinoma of the right breast at the age of 38 (T2, NO, MO, Stage II), and of receiving CMF regiment for bilateral lung metastases of breast cancer and carcinomatous pleurisy at the age of 49 in the hospital. She was admitted to the hospital again because of abdominal fullness and massive ascites. Cytodiagnosis of the ascites gave Class I, but left ovarian metastasis of breast carcinoma was diagnosed due to increased levels of tumor markers and a tumor of the left ovary.
She was consented for oophorectomy. Resected specimen showed a lobulated and capsulated tumor 15×10×9cm in size, and its cut surface was white-grayish and solid. Pathological diagnosis was ductal carcinoma showing the same findings as seen in the specimen of breast carcinoma resected 13 years ago. Postoprative course is uneventful without any symptoms suggestive of recurrence, although chemotherapy is still going on.

View full abstract

A 57-year-old woman underwent a total gastrectomy and a pancreatectomy associated with splenectomy for gastric cancer (por, se, n2, and stage IIIb) in September 1998, resulting in curability B. Chemotherapy was given to the patient for peritoneal dissemination six months after the operation. After a temporal disappearance of the intraabdominal tumor, the patient was seen at the hospital because of a rapidly enlarging tumor of the right breast on the seventh month after the operation. On physical examination, it was a 5.8×4.8cm elastic hard and unmovable tumor occupying the entire right breast. Breast metastasis of the gastric cancer was suspected and a radical mastectomy was performed. Immunohistologic exploration of the resected material revealed breast metastasis of the gastric cancer. The patient died of aggravation of peritoneal dissemination of gastric cancer two months after manifestation of breast metastasis. It was suggested that lymphogenous metastasis from gastric cancer had occurred.

View full abstract

Descending Necrotizing Mediastinitis (DNM) resulting from oropharyngeal infection, spreading to mediastinum, is a serious life threatening infection. We have experienced two patients with DNM. One patietn with DNM (Case 1) whose lesion spreaded of the anterior mediastinum, was cured by cervical drainage alone. The other patient with DNM (Case 2) whose lesion spreaded to the posterior mediastinum was cured by open drainage of the mediastinal abscess through thoracic cavity. Since both patients were confirmed to have massive pleural effusion with atelectasis, thoracic drainage was performed to treat and prevent atelectasis and pulmonary infection. An appropriate drainage for the extent of the abscess is important for the treatment of DNM.

View full abstract

Upper body deep venous thrombosis is comparatively rare and accounts for about 14% of all deep venous thrombosis. We have experienced six cases of upper body deep venous thrombosis. The male-to-female ratio was 1:5. Patients had some underlying disease including breast cancer, gastric cancer, sigmoid colon cancer, overian cancer, or bronchial asthma. There were two patients with hypercoagulable disorders, three with lower extremity deep venous thrombosis, and two with pulmonary embolism. We propose that anticoagulation therapy for upper body deep venous thrombosis is necessary because pulmonary embolism was detected in 9.636% of all patients with the disease. It is necessary to place a superior vena cava filter for high risk patients in such circumstances as contradiction to or failure of anticoagulation therapy, recourence or proximal or wide range thrombosis, and pulmonary embolism. We recommend patients with upper body deep venous thrombosis must undergo further examination to detect possible association of malignancy that occurs in a high incidence.

View full abstract

A 73-year-old man was admitted to the hospital because of an abdominal pulsatile mass and a hepatic tumor. With close examination, abdominal arterial aneurysm (AAA) and hepatocelular carcinoma (HCC) were diagnosed. A preorerative gastroscopy revealed gastric cancer. The patient underwent a Y graft replacement and a distal gastrectomy, simultaneously. Thereafter, transcatheter arterial embolization and percutaneous ethanol injection therapy against HCC were started on the 29^th day following the initial surgery. We concluded that in the treatment of AAA accompanied with malignancy of the digestive organs, surgical strategy should be decided on the consideration of the progression of the diseases.

View full abstract

Background: Several recent clinical studies have suggested that induction therapy can improve the histologically poor resectability and survival of patients with lung cancer in stage IIIA and IIIB. A 70-year-old man was seen at the hospital because of a cough. An abnormal shadow in the left hilus was pointed out on a chest X-ray film. Close examination showed a squamous cell carcinoma originated in the left upper lobe which invaded left pulmonary artery 1.5cm from pulmonary trunk (cT4N2M0, cStageIIIb). The patient was treated with two courses of induction chemotherapy (CDDP 80mg/m²+VDS 3.5mg/m²). Extreme reduction in size of the tumor and lymph nodse was seen with disappearance of the invasion to left pulmonary artery. Left pneumonectomy with mediastinal lymph node dissection resulted in curative resection (pT0N1M0, pStageIIa). Histologic exploration of the resected material disclosed metastasis of poorly differentiated squamous cell carcinoma to peribronchial lymph nodes and a partial involvement of tunica external of the pulmonary artery; however, there were no tumor cells in the center of the tumor foci. Histologic effect of the preoperative chemotherapy was rated Ef. 2. Postoperative course was uneventful. There has been no sign of recurrence as of 3 years after the operation. It is thought that the induction chemotherapy greatly contributes to local control of the primary foci as well as control of minute metastatic foci in the patients with far advanced non-small cell lung cancer.

View full abstract

We report a case of stage IVb invasive thymoma according to Masaoka's classification which was resected after successful neoadjuvant chemotherapy, radiotherapy and hyperthermia.
A 33-year-old woman was admitted to the hospital because of a right upper chest tumor. Chest computed tomographic scan and magnetic resonance imaging revealed that the tumor occupied the anterior mediastinum invading to the pericardium, superior vena cava, sternum and diaphragma, and was associated with lung metastases. Pathological diagnosis of the needle biopsy specimen was mixed cellular type of thymoma. Combination chemotherapy (Cisplatin, Doxorubicin, Vincrestin, Etoposide; CODE regimen), radiation and hyperthermia preoperatively reduced the size of thymoma. With a diagnosis of invasive thymoma, an extended thymothymectomy and a partial resection of the right lung, pericardium and diaphragm were performed. Histologically, most tumor cells were hyalinized.

View full abstract

Mesothelioma is originated from mesothelial cells. We experienced a case of malignant mesothelioma of the pleura showing localized form grossly. A 57-year-old man was admited to the hospital because of an elevated right hemidiaphragma on a chest X-ray film. Prospective possible diagnosis was diaphragmatic tumor, for which we planned a thoracoscopic resection. Intraoperative frozen section diagnosis was malignant tumor with invasion into the right lung and diaphragm, and a complete extirpation of the tumor with partial resections of the right lower lung and right diaphragm was performed. Microscopically. the tumor was diagnosed as malignant mesothelioma. Immunohistochemical stainings showed cytokeratin (+), vimentin (+), and CD34 (-). Thereafter the patient experienced recurrence twice and underwent a total removal of the tumor and chemotherapy. He is strictly followed in the clinic. Malignant mesothelioma presents difficulty in diagnosis in that immunohistochemical examination is helpful to differentiate it from other diseases. No effective therapies are available to treat the disease and its prognosisis is very poor. Definite differential diagnosis would be required in order to search for a new efficancious therapy.

View full abstract

We experienced a rare case of dedifferentiated chondrosarcoma of the rib, which was widely resected with chest wall reconstruction. A 44-year-old man complaining of an anterior chest mass with pain was referred to the hospital with a diagnosis of chondrosarcoma. Resections of the 5th, 6th and 7th ribs and an extraction of the tumor were performed. Because the direct infiltration of the tumor extended to the lingula of the lung, diaphragm and pericardia, the mass was removed en bloc. The 16×15cm defect of chest wall was fixed by sutures with silk threads and a chest wall reconstruction was performed using Marlex mesh. The extirpated tumor was measured 12×8×11cm and diagnosed as dedifferentiated chondrosarcoma. Histologically, the tumor consisted of chondrosarcomatous component juxtaposed to fibrosarcomatous component. Postoperatively, the pulmonary function, and mobility of the upper extremities were not reduced. But he died of local recurrence 5 months after the operation.

View full abstract

We experienced a patient with spontaneous esophageal rupture who was saved by suture of the ruptured site and lavage of the mediastinum and left thoracic cavity. A 53-year-old man who had been treated as alcoholic liver cirrhosis developed shock, following hematemesis consumption of alcohol. He was brought to a nearby hospital and was treated with a diagnosis of hemorrhagic gastric ulcer. Chest CT scan and esophagography performed on the 4th day after admission disclosed spontaneous rupture of the esophagus. As his general condition was stable, conservative therapy was started. But the patient's condition gradually deteriorated and he was referred to our hospital 13 days after the onset of acute symptoms. An emergency thoracotomy was performed. The lower esophagus showed a perforation of approximately 3cm on the left side. The rupture was directly sutured, and the left thoracic cavity was lavaged. Continuous lavage of the mediastinum and left thoracic cavity was performed during ten days after the surgery. Postoperative course was uneventful and he was discharged on foot on the 38th postoperative day. The lavage of the mediastinum and thoracic cavity appeared to benefit the patient in controlling possible infection despite his surgical therapy for spontaneous esophageal rupture was delayed.

View full abstract

A case of upside down stomach type esophageal hiatal hernia and congenital absence of gallbladder associated with choledocholithiasis is reported. A 76-year-old woman was admitted to the hospital with a diagnosis of cholelithiasis. A chest X-ray film showed air-fluid level in the mediastinum. An upper gastrointestinal series showed an upside down stomach with an esophageal hiatal hernia. No gallbladder was demonstrated by abdominal ultrasonography and computed tomography. Endoscopic retrograde cholangiography demonstrated stones in the common bile duct and obstruction of the cystic duct. With a diagnosis of upside down stomach, choledocholithiasis and severe atrophic gallbladder, the patient was operated on. The esophageal hiatal hernia in which the entire stomach prolapsed, the dilated common bile duct and stones in the duct were found. But the gallbladder and cystic duct were absent. Resection of the hernia sac, reduction suture of the esophageal hiatus, fixation of the fundus of the stomach to the diaphragm, choledocholithotomy and choledochoduodenostomy were performed. No postoperative complications occurred. The patient was discharged from the hospital on the 18th postoperative day.

View full abstract

Metastatic gastric cancer from breast cancer is relatively rare. We report such a case together with a review of the literature. A 54-year-old woman complaining of epigastralgia was referred to the hospital with a diagnosis of gastric cancer. There was a history of undergoing a modified radical mastectomy for left breast cancer in 1993. Radiological and endoscopic examinations showed an elevated lesion with erosion in the body of the stomach. The pathological findings of biopsy specimen revealed poorly differentiated adenocarcinoma. Distal gastrectomy was performed under a diagnosis of primary gastric cancer. Histological examination showed the tumor mass mainly invaded the submucosal layer and it histological features were similar to those of the breast cancer. Thus we thought that the gastric cancer resulted from the previously operated breast cancer.

View full abstract

We report a case of early gastric cancer resembling submucosal tumor due to marked venous infiltration. A 68-year-old man was pointed out an abnormality of the stomach in a medical checkup. Radiological findings revealed a submucosal tumor-like lesion measuring about 1.5cm with central concavity in the body of the stomach. We diagnosed the case as early gastric cancer and performed a segmental gastrectomy. Histologically the tumor was diagnosed as poorly differentiated adenocarcinoma {porl, pT1 (SM), med, INF α, ly0, v3, and pNO}. The submucosal tumor-like appearance was due to marked venous infiltration in the submucosa. The postoperative course was uneventful. The patient is living and well as of 10months after the operation.

View full abstract

A 60-year-old man was seen at the hospital because of appetite loss lasting for about one month and recent association of nausea and vomiting. Physical examination revealed edema of the extremities and ascites. A small fist-sized tumor was palpable in the upper abdomen. Blood biochemical study revealed mild anemia and prominent hypoproteinemia. Gastric fluoroscopy and endoscopy visualized a giant segmented and protruded tumor with irregular surface, 10cm in the maximum diameter, on the greater curvature covering from the gastric body to pyloric part. Biopsy of the tumor revealed poorly differentiated adenocarcinoma. Proteins were supplied but hypoproteinemia did not improve. Advanced gastric cancer of I+IIa type with protein-losing gastroenteropathy was diagnosed, and a pancreaspreserving total gastrectomy with associated splenectomy and dissection of second group of lymph nodes were performed. It was 12×10×5cm segmented protruded tumor. Histopathologically the tumor was signet ring cell carcinoma which was associated with interstitial growth and had eosinophilic cytoplasm with poor differentiating tendency. It was ss, ly3, v1, infγ, n2, in stage IIIA. Postoperative course was uneventful, however, the patient died of tumor as of one year six months after the operation.

View full abstract

We report two rare cases of gastrectomy for gastric cancer with leukemia. Patient 1, a 51-year-old man, was pointed out having chronic myelocytic leukemia (CML) when he was addmited to the hospital for operation of early gastric cancer. After the therapy for CML, during a chronic phase, we performed a gastrectomy. Patient 2, a 72-year-old man, was pointed out having advanced gastric cancer when he was admitted to the hospital for chemotherapy for recurrence of acute myelocytic leukemia (AML). Because the recurrence was in the early phase and no bleeding tendency was revealed, a gastrectomy was preceded to the treatment for AML. Postoperative courese was uneventful without any complication in both cases Generally, operation is possible for patients in a stage of remmision of AML, and those in a chronic phase of CML, especialy in the early phase of recurrent AML like case 2. In the case of gastric cancer with leukemia, an application and a timing for operation should be seriously determined.

View full abstract

Duodenal diaphragm is a congenital disease and is usually diagnosed in infancy. A rare case of adult duodenal obstruction caused by a web is reported. A 23-year-old man complaining of vomiting was referred to the hospital with a suspicion of duodenal stenosis. With examinations including an upper gastrointestinal series and endoscopy, duodenal diaphragm was diagnosed. Thorough examinations such as cholangiography were performed in order to identify the opening of the bile duct. At the time of operation, although string surrounding duodenum was found and excised, the duodenal web was not apparent. Eventually, perioperative endoscopy revealed the menbranous stenosis at the entirely same location as the string. Since the membrane was pretty thick and bile run out of it, we performed a duodenoduodenostomy instead of excising the diaphragm to avoid injuring the papilla of Vater. The postoperative course was uneventful.
It is not always easy to identify the exact position of the membrane. Intraoperative endoscopy are helpful to make the definite diagnosis for the disease.

View full abstract

We experienced a rare case of gastrointestinal stromal tumor (GIST) with von Recklinghausen's Disease. A 53-year-old woman was admitted to the hospital because of abdominal pain on April 21 1998. With a diagnosis of cholecystlithialis, a laparoscopic cholecystectomy was performed and during the operation, a tumor about 1.5cm in diameter was confirmed in the vicinity of the duodenum. Subsequently a needle biopsy was performed and immunohistochemical examination revealed that it was negative for smooth muscle antin but positive for CD34. This tumor was diagnosed as GIST. Abdominal CT scan demonstrated the existence of the tumor in the vicinity of the duodenum. The clinical course had been observed at the patient's request for 1 year and 4 months, and then a local resection of the duodenum was performed. Immunohistochemically the tumor was diagnosed as GIST, uncommitted type. So far we have encountered case reports of von Recklinghausen's disease assochiated with non-epitherial tumor in the literature, however, there are few reports on the disease with GIST, a comparratively new concept of disease. Ours is the sixth case in the Japanese literature.

View full abstract

A 56-year-old man was transferred and admitted to the hospital because of jaundice. A tumor in the pancreatic head was detected by an abdominal CT scan. Cholangiography revealed obstruction of the common bile duct with tapering at the intrapancreatic level. Marked stenosis in the upper 2^nd portion of the duodenum was observed by upper endoscopic examination and upper gastrointestinal series. The biopsy specimen obtained from this site revealed moderately differentiated adenocarcinoma. Preoperative serum levels of CA19-9 were high (500U/ml), while the levels of CEA witin normal range (3.3ng/ml). The patient underwent a pancreatoduodenectomy after reducing jaundice by biliary drainage. Macroscopically, the resected specimen showed duodenal tumor in the upper 2^nd portion, which invaded in the pancreas head. Microscopically, the specimen revealed moderately differentiated adenocarcinoma of the duodenum, which invaded in the pancreas from duodenal mucosal layer. This finding showed that the tumor arose not from the pancreas but from the duodenum. All cancer cells were strongly stained by immunohistochemical staining against CA19-9, while normal duodenal mucosal cells were not. Serum CA19-9 levels decreased within normal range, postoperatively. The disease recurred in 8 months after the operation, and CA19-9 levels increased in association with a progression of the recurrence. It is suggested that CA19-9 might be one of the indicators for diagnosis or follow-up of the duodenal carcinoma.

View full abstract

We often encounter intestinal obstruction in daily clinical scenes. Ischemic enteritis can cause the condition, though it is rare. Recently we have operated on two patients with ischemic enterits in an acute phase. This paper presents these two cases together with 48 cases reported in the Japanese literature. Both two patients were elderly men. The patient I underwent an emergency operation because inguinal ileus could not be denied on various examinations. The patient 2 underwent an emergency operation due to worsening tendency of the general condition in his clinical course. In two patients ischemic change was noted on the distal ileum and the Iwsions were resected.
Ischemic enteritis presents with abdominal pain and gastrointestinal bleeding and causes intestinal obstruction. Although temporal remission is noted, it progresses to stricture to provoke recurrence of intestinal obstruction. In the acute phase, the desease lacks in characteristic findings but it can be diagnosed by CT which is most useful among imagings by entertaining the characters of the disease. In instances in which strangulation can not be denied, or in instances in which it gives adverse effects on general condition of the patient, emergency operation is required. However, it would be ideal to perform conservative therapy in acute phase followde by laparoscopic or laparoscopy-aided resection of the intestine before next onset of intestinal obstruction.

View full abstract

We report here a case of a 78-year-old woman who was strongly susupected to have nonocclusive mesenteric ischemia (NOMI) which is relatively rare in Japan. She underwent a posterior pelvic exenteration for anastomotic recurrence that grew after an operation for rectal cancer. A laparotomy was done for stoma necrosis on 6th postoperative day, when locally necrotic lesions in two areas of the jejunum and in one area of the ileum were seen. We renewed stoma and performed a partial resection of the small intestine. On the resected specimen, stoma necrosis was revealed to be caused by thrombotic obstruction of the left branch of middle colic artery. As for the small intestine, NOMI was suspected, since three necrosed portions of the small intestine showed no vascular obstructive findings and no serial lesions. A continous arterial infusion with papaverine from the superior mesenteric artery is thought to be effective for early stage of NOMI. But the mortality rate is prominently high due to a failure to find out the lesion earier. In this case, she died of poor general codition on 74th postoperative day. From now on we must recognize the exsistence of NOMI and find out some means for early detection.

View full abstract

A 34-year-old man was admitted to the hospital because of melena and abdominal pain. He had developed melena twice before admission, but any cause for the hemorrhage had not been identified. ^99mTc-HSA scintigraphy showed an abnormal accumulation in the left lower abdominal region. Angiography of the superior mesenteric artery demonstrated an extravasation of contrast medium from the peripheral branch of ileal artery. After embolizing the arterial branch superselectively using a microcoil, an emergency lapalotomy was performed. At surgery, the bleeding site was identified at 50cm proximal to the ileocecal valve by using a radiographic device. Partial resection of the ileum was performed and the resected specimen revealed a clearly demarcated ulcer in which an exposed vessel was included. Histological examination confirmed that the lesion was non-specific ulcer, suggestive of simple ulcer of the ileum.
Small intestinal hemorrhage is difficult to be diagnosed by routine radiographic or endoscopic examination. The present case suggests that scintigraphy and angiography may be useful strategies not only for diagnosis but also for treatment of intestinal hemorrhage from unknown origin.

View full abstract

A 59-year-old man was referred to the hospital because of anal bleeding. There were previous histories of undergoing a gastrectomy with Billroth II reconstruction for gastric ulcer 35 years earlier, and undergoing a left upper lobe lobectomy with rib resection and postoperative radiation therapy for poorly differentiated adenocarcinoma of the left lung (p-T3N0M0, stage IIIA) 13 months earlier. Upper gastrointestinal endoscopy showed ulcer formation with bleeding at the efferent tract near the gastrojejunal anastomosis. The biopsy specimen was diagnosed as adenocarcinoma. At laparotomy, a jejunal tumor about 7cm in size located 20cm distal from the Treitz ligament was demonstrated which involved the transverse colon. Partial resection of the jejunum with the transverse colon and stomach enbloc was performed. Histopathologically, the jejunal tumor was diagnosed as poorly differentiated adenocarcinoma, which was consistent with small bowel metastasis from lung cancer. The patient remains alive without any signs of recurrence 23 moths after the surgery for small bowel metastasis, and is strictly followed in the outpatient clinic.

View full abstract

A 79-year-old woman was admitted to the hospital because of right lower abdominal pain and constipation. We suspected acute appendicitis and a cecal tumor by an abdominal CT scan and other imagings. After symptomatic remission was attained by conservative treatment, we performed more close examination. CT scan of the abdomen showed dilatation of the vermiform appendix and a cecal mass. Colonoscopy demonstrated an easily bleeding protruded lesion with central depression at the end of the cecum, and the orifice of the appendix was undetected. Histological examination of the biopsy specimens from the cecal tumor demonstrated tubulovillous tumor, Group 4. Under a diagnosis of appendiceal adenocarcinoma, an ileocecal resection was performed. Pathological examination showed well differentiated adenocarcinoma in tubulo-villous adenoma with submucosal invasion. No lymph node metastasis was recognized. In instances in which carcinoma of the vermiform appendix is suspected, we should perform colonoscopy, and in instances in which circular fold, elevated lesion and a mass similar to submucosal tumor at the end of the cecum are recognized, we should suspect carcinoma of the vermiform appendix.

View full abstract

A case of mucinous cystoadenocarcinoma of the appendix with pseudomyxoma peritonei, concomitant with synchronous multiple colorectal cancer is described. A 68-year-old Japanese man was seen at the hospital because of anal bleeding. Colonoscopy showed a type 2 tumor in the rectum, type 2 and Isp tumors in the sigmoid colon. During operation, pseudomyxoma peritonei arising in the appendix was found, and we performed a Miles operation and an appendectomy. Histologically, the resected appendix revealed mucinous cystoadenocarcinoma, and the type 2 tumor in the rectum, type 2 and Isp tumors in the sigmoid colon were all well-differentiated adenocarcinoma, with the invasion depth of the tumors of mp, se, and m, respectively. Replication errors in DNA, which are found by an analysis of microsatellite instability in paired normal and tumor DNAs, were not observed in this case. To our knowledge, synchronous colorectal cancers consisting of an appendiceal cancer assosiated with pseudomyxoma and colorectal cancers are extremely rare, and have been peviously twice reported in Japan.

View full abstract

Two cases of intramesenteric penetration of diverticulum of the sigmoid colon with a fecal mass in the mesocolon are reported. Patient 1, an 86-year-old woman, was admitted to the hospital because of abdominal pain and nausea. An abdominal CT scan revealed free air and a massive fecal mass outside of the intestine in the pelvic cavity. An emergency operation was performed with a diagnosis of perforation of the sigmoid colon. A large fecal mass was found not in the free cavity but in the sigmoid mesentery, and a Hartmann's operation was performed. Patient 2, a 75-year-old man, was brought into the hospital by ambulance because of acute abdominal pain. An abdominal CT scan revealed a fecal mass outside of the intestine in the pelvic cavity. We diagnosed the case as panperitonitis due to perforation of the sigmoid colon and an emergency operation was performed. Same as the patient 1, much stool was found in the sigmoid mesentery and a Hartmann's operation was performed. Both cases were histologically diagnosed as penetration due to sigmoid diverticulitis. Postoperative course was uneventful in them. Intramesenteric penetration of sigmoid diverticulum is rare. Since the inflammation is relativery locarized in the pelvic cavity in these cases, good prognosis can be expected if early and appropriate surgical treatment is performed.

View full abstract

A 33 year-old woman was referred to our hospital complaining of a pain in the sacral region that had lasted for 6 months. She had been diagnosed as having ulcerative colitis by another hospital at the age of 27. Thereafter, she had been repeatedly transferred to different hospitals. After admission to our hospital, a close examination revealed multiple hepatic metastases, ulcerative colitis, and rectal cancer (Rs-b). A pancolectomy, abdomino-perineal resection of the rectum, superior D3 and lateral D2 lymph node dissection, and an ileostomy were performed. The rectal cancer was 10cm in length, appeared to be a type 3 cancer, and had directly invaded the ileum. Histopathologically, the tumor was identified as a moderately differentiated adenocarcinoma, ly2, v3, and n2, with areas of associated dysplasia surrounding the tumor. Ulcerative colitis involving the entire large intestine was also diagnosed. General chemotherapy with 5FU and MMC was started on the 23rd postoperative day, and the patient was discharged after 2 courses of chemotherapy. However, a cerebral metastasis was detected on the 140th day, and she died on the 203rd postoperative day.
Our experience with this case emphasizes the need to monitor the presence of dysplasia by periodic colonofiberscopy in patients with a long-term history of ulcerative colitis to enable the diagnosis and treatment of cancer at an early stage.

View full abstract

Recently we experienced an adult case of postoperative intussusception probably caused by an indwelt ileus tube. A 70-year-old man was admitted to the hospital for adhesive ileus which developed 85days after having undergone a distal gastrectomy for early gastric cancer. Conservative therapy under indwelling ileus tube was inffective. An operation was performed on the 17th hospital day and adhesions were separated, but an ileus tube was left in the jejunum for postoperative bowel decompression. The ileus tube was removed immediately on the third postoperative day, when intermittent vomiting and upper slight abdominal pain occurred and persisted. From findings of a roentogenogram on the 7th postoperative days (POD), and abdominal CT on the 8POD, intussusception was suspected and another operation was performed on the 10POD. Antegrade intussusceptions located 10 and 120cm from the Treitz ligament were found during surgery, and they were resected because the intussusceptions were associated with ischemia and necrosis. It should be considered that intussusception can occur when a long tube is used for aspiration or prevention of postoperative ileus, though it is uncommon.

View full abstract

This paper presents a case of rectal cancer with metastasis to left adrenal cortical carcinoma.
A 47-year-old woman complaining of abnormal bowel movements and bloody stool was admitted to the hospital for operation after rectal cancer was pointed out by a colonofiberscopy at another hospital. CT scan performed before operation revealed a left adrenal tumor. On July 29, 1998, a low anterior resection of the rectum, a resection of the left adrenal tumor, a hysterectomy, and bilateral adnexectomies were performed. Operative findings included RaRs, circ, 3 type, Si (uterus), N₄(+), P₂, H₀, M (-), and Stage IV. Since periaortic lymph nodes metastasis was prominent, complete dissection was impossible and the operation resulted in D₂ Cur C of palliative operation. Postoperative pathologic study disclosed that the left adrenal tumor was adrenal cortical carcinoma, and in the adrenal tumor, metastatic foci of the rectal cancer was confirmed. After receiving postoperative immunochemical therapy with CDDP, 5FU and PSK, the patient was discharged from the hospital and is strictly followed in the outpatient clinic.

View full abstract

We recently experienced two patients with amebiasis whose clinical courses presented a remarkable contrast each other. Patient 1, a 65-year-old man, was a retired teacher. He had a high fever and upper abdominal pain in November, 1998. Ultrasonography and a CT scan of the abdomen revealed an abscess around the ileocecal lesion and the liver. Ileocecal resection and a drainage of the liver abscess were performed. Histological examination of the specimen showed non-specific ulcer with abscess. The patient died of liver failure 5 months after the operation. Postmortem examination showed liver abscess with amebiasis. Patient 2, a 54 year-old man, was a farmer, who had a high fever, mucous and bloody stool, and right upper abdominal pain in November, 1999. CT scans of the abdomen showed a solitary abscess in the right lobe accompanied by hepatomegaly. US-guided percutaneous transhepatic drainage was carried out. The pus drained from the liver abscess was anchovy sauce appearance. Serological tests for Entamoeba histolytica were positive but we could demonstrate the parasite neither in the stool nor the liver abscess pus. He was administered metroidazole at a daily dose of 2.0g for 14 days. For that, the abscess cavity shrank and high fever was normalized. The patient was discharged from the hospital. In the diagnosis of amebiasis, serological test is valuable. Once the diagnosis of amebiasis is made, very effective amebicide is available. We have to consider the serological tests for Entamoeba histolytica for intractable hepatic abscess. The survival of the patient with amebiasis including liver abscess depends on early diagnosis and prompt appropriate treatment.

View full abstract

A 78-year-old woman, who had undergone a subtotal thymectomy and radiation therapy for invasive thymoma in another hospital at the age of 77, was admitted to the hospital because abdominal CT study revealed a liver tumor in S4 segment in September 1999. Abdominal magnetic resonance imaging (MRI) and abdominal angiography showed a solitary tumor. Percutaneous needle biopsy revealed hepatic metastasis of the thymoma. In Nobemver, a left lobectomy of the liver was performed; the resected tumor was a 3.9×3.5×2.7cm solid tumor. Histopathologically the tumor was the same mixed thymoma as the original thymoma tissue. The patient is living and well as of 8 months after the operation. It has been known that invasive thymoma rarely metastasizes to extrathoracic sites. The prognosis of the patients with distant metastasis is poor, however, a few patients who survived for three years after treatment have been reported. It is suggested that multidisciprinary treatments including resection and adjuvant chemotherapy are required for the disease.

View full abstract

Splenic hamartoma is a relatively rare disease and there have been about 50 reported cases in Japan. We recently treated a patient with splenic hamartoma by a laparoscopic splenectomy. A 40-year-old man was found to have a splenic tumor at a physical checkup and was admitted to the hospital.
Abdominal ultrasonography and computed tomography showed a hypoechoic and low dencity solid mass in the spleen. The magnetic resonance image showed a low intensity mass on T1 and T2-weighted images. Splenic angiograms showed a hypovascular tumor. Because it was difficult to make the final diagnosis and to rule out a possible malignant tumor, we performed a laparoscopic splenectomy. The histological diagnosis was red pulp typed hamartoma. Splenic hamartoma presents difficulty in preoperative diagnosis because it has diverse histologic types with resultant diverse imaging findings. However, we must consider conservative therapy for the disease that is naturally benign, if the definite diagnosis can be made before operation. So we selected laparoscopic splenectomy for the patient to minimize the surgical stress.

View full abstract

A 53-year-old woman was admitted to the hospital because of a left adrenal tumor which was discovered by abdominal CT scan during close examination for other disease in other hospital. Endocrinological examination of the adrenal gland revealed no extraordinary findings. She was diagnosed as having a left adrenal tumor, incisional hernia of the abdominal wall and varicose veins by close examination in our hospital, and was operated on. The resected adrenal mass was well circumscribed, covered with a thin capsule, and measured 7.5cm in diameter. Microscopically, the tumor tissue consisted of mainly adipose tissue with hematopoietic cells. Myelolipoma of the adrenal gland was diagnosed. Postoperative course was uneventful. We report the case together with a review of the literature.

View full abstract

A 29-year-old woman, who visited another hospital because of lower abdominal pain but could not get symptomatic remission after treatment with analgesics and i. v. infusion therapy, was seen at the department of gynecology in our hospital. The patient was conservatively treated with a suspicion of intrapelvic peritonitis, however, the symptoms were aggravated. So the patient was referred to the department of surgery. Abdominal CT scan offered a suspicion of strangulated ileus due to a band which was present between a uterine leiomyoma and the excavatio vesicouterina. An emergency operation was performed. During operation, we confirmed the band which was present between the uterine leiomyoma and bladder, severe inflammation at the ileocecum, and small intestinal necrosis covering about 110cm in length to the terminal ileum. The band existed between the uterine leiomyoma and bladder that connected the uterine with bladder, the excavatio vesicouterina became a hernia opening, that might cause the strangulated ileus. It is inferred that the band had been left in the excavation vesicouterina when paramesonephric duct had fused to form broad ligament of the uterus.

View full abstract

A 77-year-old man was seen at the hospital because of abrupt onset of abdominal pain and vomiting. With an abdominal CT scan, strangulated ileus was diagnosed and an emergency operation was performed. Upon laparotomy, the ileum was found to be incarcerated into an abdominal hiatus on the ileocecal mesentery and to be twisted and necrotized. The ileum about 250cm in length was resected. Postoperative course was uneventful.
Hiatal hernia of the small intestinal mesentery belongs to the internal hernia and is a relatively rare entity. A total of 81 cases of the disease reported in the Japanese literature since 1972 were analyzed.

View full abstract

A 41-year-old woman was admitted to the hospital because of upper abdominal pain, fever 38.5°C and watery diarrhea. On the next day after admission, an exploratory laparotomy was performed because of progressive peritoneal stimulant sign and a tumor like density on a CT scanning. It revealed a fist-sized tumor extended from the transverse colon to mesocolon. It was thought that cancer of the trasverse colon had ruptured between the leaves of the mesentery, and had formed granulation. The jejunum was edematous with stenotic state due to the pressure by this mesocolic granulation. The transverse colon with intramesocolic granulation was resected and drainage was performed. Macroscopic findings of the resected specimen showed 3 type cancer of the transverse colon and penetration of intramesocolic granulation 3.0cm in diameter from the bottom of ulcer. Histological examination revealed well differentiated adenocarcinoma and no invasion to the root of mesentery. It is rare that intramesenteric granulation occurs by penetration of colon cancer. We think it is necessary to bear the disease in mind as a probable differential diagnosis of acute abdomen.

View full abstract

A 52-year-old woman was referred to the hospital for close examination because she was pointed out a retroperitoneal tumor at a medical checkup. Abdominal ultrasonography revealed a tumor with relatively homogeneous internal echo in the vicinity of the uncus of the pancreas. Abdominal CT scan visualized a relatively demarcated tumor with center necrosis at dorsal to the horizontal portion of the duodenum. With a suspicion of retroperitoneal lymphoma, the patient was operated on. Upon laparotomy, the tumor was contiguous to dorsal to the duodenum and anterior to the vena cava inferior and fibrous adhesion was confirmed. The adhesion was easily freed and the tumor was removed. Histopathologically it was hyaline vascular type Castleman's lymphoma with the side of 6×8.5×3cm. There were no obvious malignant features nor lymph node metastases. Postoperative course was uneventful and there have been no signs of recrrence up to now. The patient is followed in the outpatient clinic.
Castleman's lymphoma is a tumor forming benign lesion and its hyaline vascular type is believed to have a good prognosis. However, some cases of recurrence have been reported and further careful observation of the clinical course would be required.

View full abstract

A 52-year-old woman was admitted to the hospital because of right hypochondrial and back pain. There was a previous history of undergoing a cholecystectomy. Laboratory data were unremarkable except a slight elevation in C-reactive protein. Computed tomography and magnetic resonance imaging demonstrated a huge mass of heterogeneous density, approximately 15cm in diameter, anterior to the right kidney. Angiography revealed a hypervascular mass mainly supplied by the middle colic and replaced hepatic branches of the superior mesenteric artery. Barium enema showed an extrinsic compression on the hepatic flexure of the colon. At laparotomy, the tumor was proved to be arising from the perirenal soft tissue. It was well circumscribed and capsulated but accompanied by several daughter nodules around the right kidney and inferior vena cava. The main tumor and daughter nodules were extirpated en-block with the right kidney, colonic wall of the flexure and inferior vena caval wall, and histologically diagnosed as malignant fibrous histiocytoma, inflammatory type. Local recurrence and lymph node metastasis occurred around the aorta 8 months after the operation. Multiple hepatic and pulmonary metastases were also noted and the patient died 2 months later.

View full abstract

A 75-year-old woman was seen at the clinic because of an epigastric mass. The tumor was about egg-sized and elastic soft with mild tenderness. We thought that the tumor was a ventral hernia because it enlarged with abdominal pressure. It penetrated the linea alba and reached under the skin on abdominal ultrasonography and CT. We diagnosed the case as a median ventral hernia. Upon laparotomy, there were herniated preperitoneal fat and a hernial sac from the linea alba. We peeled them off, excised the sac, repaired the linea alba with two layers, and laid Marlex mesh on the linea alba. It is thought that principles of the operation are resection of hernial sac and the herniorrhaphy. Some were reported as the operative methods: simple closure of the hernial gate, suturing an incision line upon the sheath of rectus abdominis muscle, and suturation two layers of anterior and posterior sheaths of rectus abdominis muscle. Median epigastric hernia is comparatively rare in Japan. We present 50 cases including our case, of which details have been clearly reported in this country, with some bibliographical consideration.

View full abstract

A 51-year-old man was seen at the hospital because of a right inguinal tumor which became gradually large for 7 to 8 years while he let it alone to cause difficulty in physical movement. When he was first seen, a 40cm-sized, elastic hard mass with smooth surface extending from the right inguinal region to genital area was formed. No abnormal dermal findings such as ulcer and erosion were observed. CT scan and magnetic resonance imaging visualized it as a well surcumscribed, internally heterogenous, and extramural tumor. Since a possible malignancy could not be ruled out, as well as to recover the function, the tumor was excised. During operation, the tumor adhered to the testicular cord partially, but it was an encapsulated, sharply demarcated and well movable tumor. The excised tumor was 40×28×15cm in size and 12.5kg in weight and the section was yellowish white in color. Histopathologically it was spindle cell lipoma. Postoperative course was uneventful. There have been no signs of recurrence. Giant spindle cell lipoma like this case is uncommon. This rare case is presented together with some bibliographical comments.

View full abstract